The role of second-look surgery in the management of advanced germ cell malignancies

The history of ependymoma management

INTRODUCTION

The ependymomas are relatively not a common tumor. However, most clinicians agree that the radical removal of the tumor is the most important prognostic factor.

MORBIDITY OF TREATMENT

Tumor removal was not sufficient before the era of magnetic resonance imaging (MRI) and resulted in a considerable operative morbidity and mortality. As the microneurosurgical techniques and microsurgical anatomy become popular and the MRI provide more detailed anatomical information preoperatively, radical removal of this complex and complicated tumor can be more feasible. In childhood ependymoma, the treatment-related morbidity and mortality can be the special issues, which can modify the policy of management safe tumor removal and minimal adjuvant treatment, which are extremely important.

RADIATION THERAPY

Radiation treatment has been the option for disseminated disease and residual tumor. With the advancement of detailed MR anatomical information, safer and more delicate radiation becomes possible with newer radiation modalities, three-dimensional conformal radiotherapy, intensity modulating radiotherapy, and tomotherapy.

PROGNOSTIC FACTORS

Although many clinicians believe that the ependymomas are inheritably chemoresistant, the new targets for the treatment are under investigation or clinically tried. Also, the genetic alterations of ependymoma are developing and might be a promising target.

CONCLUSION

The surgical techniques and assistant modalities for tumor removal are still advancing. So, the outcome of ependymoma is still improving. Unfortunately, newer treatment modalities, such as new chemotherapeutic agent and gene modification agent, are still not promising. The history of ependymoma management is still in progress.

Complete surgical excision is effective treatment for children with immature teratomas with or without malignant elements: A Pediatric Oncology Group/Children's Cancer Group Intergroup Study

PURPOSE

To determine whether the 3-year event-free survival (EFS) of children with completely resected immature teratomas is greater than 85%.

PATIENTS AND METHODS

Patients with immature teratomas treated at Pediatric Oncology Group or Children's Cancer Group institutions were eligible. Pathology was centrally reviewed to confirm diagnosis and tumor grading. Follow-up included physical examination, measurement of tumor markers (alpha fetoprotein and human chorionic gonadotropin), and imaging. All patients were monitored for events, defined as tumor recurrence, second malignancy, or death.

RESULTS

Seventy-three children (median age, 7.8 years) with extracranial immature teratomas were enrolled on study. Primary tumor sites included ovarian (n = 44), testicular (n = 7), and extragonadal (n = 22). However, on review, 23 patients had foci of yolk sac tumor (n = 21) or primitive neuroectodermal tumor (n = 2), whereas 50 had pure immature teratomas. Twenty-five patients had increased alpha fetoprotein (n = 18), human chorionic gonadotropin (n = 5), or both (n = 2); nine had foci of yolk sac tumor on review. Pathology review identified 23 patients with grade 1, 29 with grade 2, and 21 with grade 3 immature teratomas. With a median follow-up of 35 months, the overall 3-year EFS was 93% (95% confidence interval, 86% to 98%), with 3-year EFS of 97.8%, 100%, and 80% for patients with ovarian, testicular, and extragonadal tumors, respectively. Only four of 23 patients with immature teratoma and malignant foci developed recurrence, suggesting that surgical resection followed by close observation are effective treatment. Overall, five patients had disease recurrence 4 to 7 months from diagnosis, and four (80%) are disease free after platinum-based therapy. The fifth patient has residual tumor after cisplatin, etoposide, and bleomycin treatment requiring further therapy.

CONCLUSION

Surgical excision is safe and effective treatment for 80% to 100% of children with immature teratoma.

Long-term survivors of childhood cancer. The medical consequences of cure

The late effects of cancer therapy are a significant problem and the risk can be predicted based on each individual's prior therapy. Although the use of effective therapy has led to the development of sequelae involving various organ systems, recognition of these complications has led to the design of new therapy targeted at minimizing these effects, especially in patients with good risk. Unfortunately, the risks of the late effects must be accepted in patients with cancers that are aggressive or in advanced stages to maximize the chance for cure. Continued education of cancer survivors regarding their risks of late effects is essential and gives them the ability to maintain healthy lifestyles, avoiding cancer-promoting behaviors such as smoking. It also gives survivors the opportunity to participate in screening programs to help in early recognition of the late consequences of therapy and to learn self-examination to detect second malignancies early. It is hoped that the use of early intervention will lead to an improved long-term outcome. Finally, continued surveillance of this population is essential to monitor the impact of the therapeutic modifications on late complications and potentially to detect the sequelae produced by newer treatment strategies. Because the number of childhood cancer survivors will continue to increase, it is imperative that the pediatricians and internists in the community who care for these survivors are aware of their risks for late effects so that they have access to and can benefit from early intervention.

Sacrococcygeal yolk sac carcinoma: imaging findings during treatment

Sacrococcygeal teratomas and their malignant counterparts (germ cell tumors) are the most common solid tumors in neonates. Prompt diagnosis is essential because the frequency of malignant transformation increases from 10-20 % in neonates to 67 % in patients over 2 months of age. Cross-sectional imaging has largely replaced surgical exploration for staging these tumors and assessing their response to chemotherapy. Radiologists must be familiar with changes in the imaging findings of these tumors during and after treatment so that they can advise clinicians regarding the efficacy of therapy and the presence or absence of recurrent disease. From our study, magnetic resonance imaging appears to be a better modality for assessing sacral invasion and metastases and distinguishing fibrotic masses from recurrent tumor.

A case of metastatic yolk sac tumor of testis in a child

We report a case of testicular yolk sac tumor in a child aged 3 years and 6 months with multiple bulky metastases to lung and retroperitoneum (stage IIIB2). After three courses of chemotherapy with a PVB regimen (cisplatin, vinblastine and bleomycin), complete and partial responses were obtained for lung and retroperitoneal lymph node metastases, respectively. The patient was followed-up closely. However, on the basis of a re-elevated alpha-fetoprotein (AFP) after 4 months' follow-up, he was treated with three courses of salvage chemotherapy with a modified VAB-6 regimen (cyclophosphamide, etoposide, actinomycin D, bleomycin and cisplatin), followed by retroperitoneal lymph node dissection. Histologically, only necrotic tissue was found. There is no evidence of recurrence 24 months after lymphadenectomy. There is very little information in the literature on the appropriate management of postchemotherapy residual mass in pediatric testicular tumors.