The team approach to the management of pediatric cancer

Surgical outcome of patients considered to have "inoperable" tumors by specialized pediatric neuro-oncological multidisciplinary teams

PURPOSE

Despite the lack of evidence in literature, it is widely felt that patient outcomes will be improved by adopting a multidisciplinary team (MDT) approach to children with brain tumors. This study focuses on a series of pediatric patients treated surgically despite a MDT recommendation against surgery.

METHODS

A retrospective study was conducted on all pediatric brain and spinal cord tumor patients operated in a single center from 1999 to 2009. Of the 256 surgical patients, 47 patients (18%) had been previously seen by a MDT who had recommended against surgery. Details of preoperative treatment, diagnosis and clinical status, postoperative diagnosis, early and late outcomes, progression-free survival and overall survival, and parental satisfaction were reviewed.

RESULTS

There was a single case of surgical mortality, and 14 patients have since died from their primary disease an average of 21 months after surgery. Of the patients who are alive, only four (12.5%) have permanent neurological sequelae despite nine patients presenting in a terminal status. In ten cases, radical removal of the tumor resulted in a change in histological diagnosis, usually from a presumed diagnosis of malignancy to a more benign variety (n = 6). Not a single parent expressed regret over the decision to undergo surgery.

CONCLUSION

In the majority of patients, surgical decision making is congruent with the collective opinion of dedicated pediatric neuro-oncological MDT. However, sometimes the surgeon's opinion may be incongruous with MDT recommendation. This series demonstrates the dramatic and favorable potential long-term outcomes that may be achieved with surgery of so-called inoperable lesions.

Principles of treatment of pediatric solid tumors

Great strides have been made in the treatment of pediatric solid tumors over the last three decades. A multimodality approach involving a combination of surgery, radiation therapy, and chemotherapy is now used in the treatment of these diseases. This article reviews the principles that guide the use of these modalities and the multidisciplinary approach used to integrate them into a coordinated treatment plan. The role of each modality in the control of local and systemic disease is described. Radiation treatment planning, dose fractionation, and toxicity are also discussed.

Bone sarcoma as a second malignant neoplasm in children: influence of radiation and genetic predisposition for the Late Effects Study Group

Osteosarcoma or chondrosarcoma developed as a second malignant neoplasm (SMN) in 40 of 188 individuals with SMN whose first neoplasm occurred in childhood. A genetic susceptibility to cancer was found in 23; the SMN developed in an irradiated field in 32; both factors wer present in 16; neither in one. When a genetic predisposition was present, radiation shortened the interval to SMN. The intervals between tumors and the age at which the bone sarcomas developed in relation to genetic disease and therapy were analyzed by a two-mutation hypothesis. Studies of SMN in childhood permit us to make observation about the role of genetic factors and environmental mutagens in cancer etiology.

Thrombotic and hemorrhagic strokes complicating early therapy for childhood acute lymphoblastic leukemia

Sudden cerebrovascular insults occurred during or immediately following remission induction therapy in 4 children with acute lymphoblastic leukemia. In 3, cerebral infarction was due to thrombosis. In the fourth, an intracerebral hematoma developed representing either frank hemorrhaging or a hemorrhagic infarction. None of the patients had central nervous system leukemia or extreme leukocytosis at the time of diagnosis. Symptoms were obtundation, hemiparesis, seizures, and headache. The induction chemotherapy included L-asparaginase which causes deficiencies of antithrombin, plasminogen, fibrinogen, and factors IX and XI. These hemostatic abnormalities may explain the thromboses and bleeding observed in these children.

Acute nonlymphocytic leukemia

The discovery of cytosine arabinoside, and then the anthrocycline antibiotics, 6-thioguanine, vincristine, cyclophosphamide, and other drugs, has added to the armamentarium of known effective agents. The use of combination chemotherapy, the recognition of the need during induction for virtual marrow aplasia to obtain a remission, and recognition of the predilection of the disease for the central nervous system requiring prophylaxis constitute major advances. The impediment to long-term survival is the lack of effective maintenance therapy.

Testicular relapse in childhood acute lymphoblastic leukemia: association with pretreatment patient characteristics and treatment. A report for Childrens Cancer Study Group

Of 395 male pediatric patients with previously untreated acute lymphoblastic leukemia, 20 (5%) exhibited testicular infiltration prior to or concurrent with their first bone marrow relapse. Fourteen occurred as an isolated relapse and six occurred concomitant with bone marrow and/or central nervous system relapse. Nine of the 20 relapses were in patients who had discontinued therapy after completing three years of continuous complete remission. Factors found to be independently associated with an increased risk of testicular relapse during maintained remission included pretreatment lymphadenopathy, and to a lesser extent, initial hemoglobin level and initial platelet count. Pretreatment splenomegaly and lymphadenopathy appear to imply an increased risk of testicular relapse for those patients who have their maintenance therapy discontinued. Time from testicular relapse to bone marrow relapse or death was significantly shorter for patients with testicular involvement while receiving chemotherapy when compared to patients with testicular relapse after discontinuing therapy. In those patients achieving three years of continuous complete remission, subsequent testicular relapse occurred significantly more often in patients who discontinued therapy than a similar group who continued therapy. In a group of 76 males who received presymptomatic gonadal radiation immediately after achieving an initial marrow remission, protection appears to have been provided against the manifestation of testicular leukemia during maintained remission.

A follow-up report of long-term survivors of childhood acute lymphoblastic or undifferentiated leukemia. A report for Childrens Cancer Study Group

From an original group of 229 patients with acute lymphoblastic leukemia or acute undifferentiated leukemia diagnosed in 1963 and 1964, 15 patients who achieved greater than 2 1/2 years continued complete remission were assigned either to continue with maintenance therapy or to discontinue therapy. Five of the 15 patients have died after surviving from six to ten years from the time of diagnosis. Of the remaining ten patients, all are alive and free of disease for more than 14 years from diagnosis. No relapses or deaths have occurred in patients off therapy for greater than five years. In this small series of patients, there was no difference in survival in the continued or discontinued therapy groups. No overt adverse effects of therapy have been seen in the ten surviving patients. These encouraging data need to be extended and confirmed, utilizing patients treated with the more sophisticated therapeutic approaches employed in modern protocols for ALL/AUL. Identification of adverse effects of therapy will require appropriate and careful surveillance of large groups of successfully treated patients.