Childhood cancer in Britain: the National Registry of Childhood Tumours and incidence rates 1978-1987

Cohort profile: the United Kingdom Childhood Cancer Study (UKCCS) - a UK-wide population-based study examining the health of cancer survivors

PURPOSE

The United Kingdom Childhood Cancer Study's (UKCCS's) matched cohort was established to examine the longer term morbidity and mortality of individuals previously diagnosed with cancer before 15 years of age, comparing future healthcare patterns in 5-year cancer survivors to baseline activity seen in age- and sex-matched individuals from the general population.

PARTICIPANTS

Predicated on a national childhood cancer case-control study conducted in the early 1990s (4430 cases, 9753 controls) in England, Scotland and Wales, the case population comprises 3125 cancer survivors (>5 years), and the control population 7156 age- and sex-matched individuals from the general population who did not have cancer as a child. Participants are now being followed up via linkage to national administrative healthcare databases (deaths, cancers and secondary care hospital activity).

FINDINGS TO DATE

Enabling the creation of cohorts with minimal selection bias and loss to follow-up, the original case-control study registered all newly diagnosed cases of childhood cancer and their corresponding controls, regardless of their family's participation. Early findings based on the registered case population found marked survival variations with age and sex across subtypes and differences with deprivation among acute lymphoblastic leukaemia (ALL) survivors. More recently, comparing the health-activity patterns of the case and control populations revealed that survivors of childhood ALL experienced excess outpatient and inpatient activity across their teenage/young adult years. Adding to increased risks of cancer and death and involving most clinical specialties, excesses were not related to routine follow-up monitoring and showed no signs of diminishing over time.

FUTURE PLANS

With annual linkage updates, the UKCCS's maturing population-based matched cohorts provide the foundation for tracking the health of individuals through their lifetime. Comparing the experience of childhood cancer survivors to that of unaffected general-population counterparts, this will include examining subsequent morbidity and mortality, secondary care hospital activity and the impact of deprivation on longer term outcomes.

Guidance to develop a multidisciplinary, international, pediatric registry: a systematic review

AIM

The European Reference Network for craniofacial anomalies and ear, nose and throat disorders (ERN-CRANIO) aims to improve craniofacial care on a European scale. Within ERN-CRANIO, the cleft lip and palate (CL/P) work stream seeks to ameliorate health outcomes for patients with CL/P. This work stream acknowledged the need for a European wide registry for comparable outcome measures and therapy endpoints to achieve this goal. This review aimed to provide a scientific basis for the conceptualization of this registry by studying previous registry initiatives.

METHODS

This review performed thematic analysis on twenty-four articles through narrative synthesis. An iterative process was used to identify key-themes required for prolonged registry success.

RESULTS

Analysis of the literature resulted in twenty-one distinct headings including quantitative and qualitative data. Quantitative data including registry characteristics were visualized in a table. The analysis of qualitative data resulted in the identification of fourteen key-themes, which have been summarized and visualized in a guidance.

CONCLUSION

This review has successfully identified key-themes required for the development of an international, multidisciplinary, pediatric registry for pan-European cleft care. The guidance provided by this review applies to the goals of ERN-CRANIO, but can be used by any initiative developing a registry.

Incidence patterns of childhood non-Wilms renal tumors: Comparing data of the Nationwide Registry of Childhood Hematological Malignancies and Solid Tumors (NARECHEM-ST), Greece, and the Surveillance, Epidemiology, and End Results Program (SEER), USA

BACKGROUND

We used, for the first time, data registered in the Nationwide Registry for Childhood Hematological Malignancies and Solid Tumors (NARECHEM-ST)-Greece to estimate incidence/time trends of the rare childhood (0-14 years) non-Wilms tumors (non-WT), and compared the results of malignant non-WT to those from the Surveillance, Epidemiology, and End Results Program (SEER)-USA.

METHODS

Fifty-five cases (n = 33 malignant-only) were extracted from NARECHEM-ST (2001-2020) and 332 malignant cases from SEER (1990-2017). To allow between-country comparisons, age-standardized incidence rates (AIR) of malignant-only non-WT were calculated, and temporal trends were evaluated using Poisson and joinpoint regressions.

RESULTS

In NARECHEM-ST, malignant and non-malignant non-WT accounted for 22.6% of all renal tumors. Among malignant tumors, the AIR was 1.0/106 children in Greece, similar to that calculated for SEER, USA (AIR=0.9/106). The proportion of infant malignant and non-malignant non-WT was 27% (20% before 6 months) in NARECHEM-ST. Most common non-WT in Greece were congenital mesoblastic nephromas (CMN) diagnosed mainly in infancy (CIR=7.2/106). The proportion of infant malignant non-WT was 20% in SEER (AIRinfancy=2.5/106), mainly attributed to rhabdoid tumors (CIR=1.6/106). The male-to-female (M:F) ratio of malignant non-WT was 0.9 in NARECHEM-ST vs. 1.2 in SEER, whereas boys outnumbered girls with clear cell sarcoma in NARECHEM-ST (M:F=4.0). Lastly, significantly increasing trends in incidence rates were noted in NARECHEM-ST [+ 6.8%, 95% confidence intervals (CI): 0.5, 13.3] and in SEER (+7.3%, 95%CI: 5.6, 9.0).

CONCLUSIONS

Observed incidence, time trends and sociodemographic variations of non-WT may reflect differential registration practices and healthcare delivery patterns including differences regarding surveillance, coding and treatment practices.

Childhood cancer research in Oxford II: The Childhood Cancer Research Group

BACKGROUND

We summarise the work of the Childhood Cancer Research Group, particularly in relation to the UK National Registry of Childhood Tumours (NRCT).

METHODS

The Group was responsible for setting up and maintaining the NRCT. This registry was based on notifications from regional cancer registries, specialist children's tumour registries, paediatric oncologists and clinical trials organisers. For a large sample of cases, data on controls matched by date and place of birth were also collected.

RESULTS

Significant achievements of the Group include: studies of aetiology and of genetic epidemiology; proposals for, and participation in, international comparative studies of these diseases and on a classification system specifically for childhood cancer; the initial development of, and major contributions to, follow-up studies of the health of long-term survivors; the enhancement of cancer registration records by the addition of clinical data and of birth records. The Group made substantial contributions to the UK government's Committee on Medical Aspects of Radiation in the Environment.

CONCLUSION

An important part of the ethos of the Group was to work in collaboration with many other organisations and individuals, both nationally and internationally: many of the Group's achievements described here were the result of such collaborations.

Socio-economic patterning in early mortality of patients aged 0-49 years diagnosed with primary bone cancer in Great Britain, 1985-2008

BACKGROUND

Studies have shown marked improvements in survival between 1981 and 2000 for Ewing sarcoma patients but not for osteosarcoma. This study aimed to explore socio-economic patterning in early mortality rates for both tumours.

PROCEDURE

The study analysed all 2432 osteosarcoma and 1619 Ewing sarcoma cases, aged 0-49 years, diagnosed in Great Britain 1985-2008 and followed to 31/12/2009. Logistic regression models were used to calculate risk of dying within three months, six months, one year, three years and five years after diagnosis. Associations with Townsend deprivation score and its components were examined at small-area level. Urban/rural status was studied at larger regional level.

RESULTS

For osteosarcoma, after age adjustment, mortality at three months, six months and one year was associated with higher area unemployment, OR = 1.05 (95% CI 1.00, 1.10), OR = 1.04 (95% CI 1.01, 1.08) and OR = 1.04 (95% CI 1.02, 1.06) respectively per 1% increase in unemployment. Mortality at six months was associated with greater household non-car ownership, OR = 1.02 (95% CI 1.00, 1.03). For Ewing sarcoma, there were no significant associations between mortality and overall Townsend score, nor its components for any time period. For both tumours increasing mortality was associated with less urban and more remote rural areas.

CONCLUSIONS

This study found that for osteosarcoma, early mortality was associated with residence at diagnosis in areas of higher unemployment, suggesting risk of early death may be socio-economically determined. For both tumours, distance from urban centres may lead to greater risk of early death.

HMGA2 overexpression predicts relapse susceptibility of blastemal Wilms tumor patients

Wilms tumor (WT) is an embryonal malignant neoplasm of the kidney that accounts for 6-7% of all childhood cancers. WT seems to derive from multipotent embryonic renal stem cells that have failed to differentiate properly. Since mechanisms underlying WT tumorigenesis remain largely unknown, the aim of this study was to explore the expression of embryonic stem cell (ESC) markers in samples of WT patients after chemotherapy treatment SIOP protocol, as the gene expression patterns of ESC are like those of most cancer cells. We found that expression of ESC markers is heterogeneous, and depends on histological WT components. Interestingly, among ESC markers, HMGA2 was expressed significantly stronger in the blastemal component than in the stromal and the normal kidney. Moreover, two subsets of patients of WT blastemal type were identified, depending on the expression levels of HMGA2. High HMGA2 expression levels were significantly associated with a higher proliferation rate (p=0.0345) and worse patient prognosis (p=0.0289). The expression of HMGA2 was a stage-independent factor of clinical outcome in blastemal WT patients. Our multivariate analyses demonstrated the association between LIN28B-LET7A-HMGA2 expression, and the positive correlation between HMGA2 and SLUG expression (p=0.0358) in blastemal WT components. In addition, patients with a poor prognosis and high HMGA2 expression presented high levels of MDR3 (multidrug resistance transporter). Our findings suggest that HMGA2 plays a prominent role in the pathogenesis of a subset of blastemal WT, strongly associated with relapse and resistance to chemotherapy.

Multidrug resistance transporter profile reveals MDR3 as a marker for stratification of blastemal Wilms tumour patients

Wilms tumour (WT) is the most common renal tumour in children. Most WT patients respond to chemotherapy, but subsets of tumours develop resistance to chemotherapeutic agents, which is a major obstacle in their successful treatment. Multidrug resistance transporters play a crucial role in the development of resistance in cancer due to the efflux of anticancer agents out of cells. The aim of this study was to explore several human multidrug resistance transporters in 46 WT and 40 non-neoplastic control tissues (normal kidney) from patients selected after chemotherapy treatment SIOP 93–01, SIOP 2001. Our data showed that the majority of the studied multidrug resistance transporters were downregulated or unchanged between tumours and control tissues. However, BCRP1, MDR3 and MRP1 were upregulated in tumours versus control tissues. MDR3 and MRP1 overexpression correlated with high-risk tumours (SIOP classification) (p = 0.0022 and p < 0.0001, respectively) and the time of disease-free survival was significantly shorter in patients with high transcript levels of MDR3 (p = 0.0359). MDR3 and MRP1 play a role in drug resistance in WT treatment, probably by alteration of an unspecific drug excretion system. Besides, within the blastemal subtype, we observed patients with low MDR3 expression were significantly associated with a better outcome than patients with high MDR3 expression. We could define two types of blastemal WT associated with different disease outcomes, enabling the stratification of blastemal WT patients based on the expression levels of the multidrug resistance transporter MDR3.

Cross-space-time clustering of childhood cancer in Great Britain: evidence for a common aetiology

Previously, we identified space-time clustering in certain childhood cancers. This study aimed to determine whether there was cross-space-time clustering between different diagnostic groups. A total of 32,295 cases were diagnosed during 1969–1993. Cross-space-time clustering was analyzed by a second-order procedure based on Diggle's method. Locations were birth and diagnosis addresses. The following space-time combinations were examined: address and date of birth; address at birth and date of diagnosis; address and date of diagnosis. Cross-space-time clustering analyses considered clustering pairs of cases from two different diagnostic groups. Formal statistical significance was taken as p < 0.00067 and marginal significance 0.01 > p ≥ 0.00067. Based on address at birth and date of diagnosis, there was statistically significant cross-clustering between cases of HL and intracranial and intraspinal embryonal tumors (IIET), both aged 0–14 years (p < 0.0001). Based on address and date of birth, there was marginally significant cross-clustering between cases of lymphoid leukemia (LL) aged 5-14 years and Hodgkin lymphoma (HL) aged 0–14 years (p = 0.0019). Based on address and date of diagnosis there was marginally significant cross-clustering between cases of LL aged 1–4 years and soft tissue sarcoma (STS) aged 0–14 years (p = 0.0041). Findings from this study are consistent with possible common aetiological factors between different diagnostic groups. They suggest a common aetiology for the following pairs of diagnostic groups: HL and IIET; older cases of LL and HL; younger cases of LL and STS. The possibility of common infectious mechanisms should be explored.

Wilms' tumor: biology, diagnosis and treatment

Wilms' tumor is the commonest renal tumor of childhood affecting one in 10,000 children. It is also one of the successes of paediatric oncology with long term survival above 90% for localised disease and 75% for metastatic disease. Successful management of Wilms' tumor necessitates meticulous attention to correct staging of the tumor and a collaborative effort between paediatric oncologists, specialist surgeons, radiologists, pathologists, and radiation oncologists. Although current treatment protocols are based on risk assignment to minimise toxicity for low risk patients and improve outcomes for those with high risk disease, challenges remain in identifying novel molecular, histological and clinical risk factors for stratification of treatment intensity. Knowledge about Wilms' tumor biology and treatment is evolving rapidly and remains a paradigm for multimodal malignancy treatment. Future efforts will focus on the use of biomarkers to improve risk stratification and the introduction of newer molecularly targeted therapies that will minimise toxicity and improve the outcomes for patients with unfavourable histology and recurrent disease. The aim of this article is to summarise advances in our understanding of the biology of Wilms' tumor and to describe the current approaches to clinical management of patients.

Neonatal neuroblastoma

Neuroblastoma, an embryonal tumour arising from the sympathetic nervous system, is the most common neonatal malignancy accounting for >20% of neonatal cancers. It may present as an antenatal adrenal mass or more commonly with localised or metastatic (4s/Ms) disease, which is usually low risk with a very good clinical outcome. Around 20% of neonatal neuroblastoma presents with spinal cord compression requiring prompt diagnosis and treatment with steroids and chemotherapy to relieve the cord compression. Patients with stage Ms disease without life- or organ-threatening symptoms or adverse genetic features (MYCN amplification or segmental chromosomal abnormalities) can be safely observed for spontaneous regression which may also occur with other localised neonatal neuroblastomas. Universal mass screening for neuroblastoma is not indicated but targeted screening of infants at risk of hereditary neuroblastoma with germline ALK or PHOX2B mutations is appropriate. Future studies will be aimed at observing more patients without adverse genetics or life-threatening features.

Small-area analyses of bone cancer diagnosed in Great Britain provide clues to aetiology

BACKGROUND

The aetiology of bone cancers is poorly understood. This study examined geographical patterning in incidence of primary bone cancers diagnosed in 0-49 year olds in Great Britain during 1980-2005 to provide information on factors linked with disease development. We investigated putative associations with deprivation and population density.

METHODS

Data on osteosarcoma and Ewing sarcoma were obtained from national population-based registries. Negative binomial regression was used to examine the relationship between incidence rates and the Townsend deprivation score (and its component variables) and small-area population density.

RESULTS

The study analyzed 2566 osteosarcoma and 1650 Ewing sarcoma cases. For females with osteosarcoma, statistically significant decreased risk was associated with higher levels of deprivation (relative risk [RR] per unit increase in deprivation score = 0.969; 95% confidence interval [CI] 0.946-0.993). For all Ewing sarcoma combined, statistically significant decreased risk was associated with greater area-level population density and higher levels of non-car ownership (RR per person per hectare increase = 0.984; 95% CI 0.976-0.993, RR per 1% increase in non-car ownership = 0.994; 95% CI 0.991-0.998).

CONCLUSIONS

Higher incidence of osteosarcoma was observed for females in areas with lower deprivation levels indicating increased risk is linked to some aspect of affluent living. Higher incidence of Ewing sarcoma occurred in areas of low population density and where more people owned cars, both characteristic of rural environments. The study adds substantially to evidence associating Ewing sarcoma risk with rural environmental exposures. Putative risk factors include agricultural exposures, such as pesticides and zoonotic agents.

The importance of time of exposure to harmful anthropogenic factors as an element of cancer risk assessment in children

This study attempted to verify whether the time of exposure to harmful factors is important for the increased risk of developing cancer. A statistical analysis of all cases of cancer in children in the period from 1995 to 2004 in the province of Silesia (Poland) was conducted, and their spatial distribution was then presented using cartographic and GIS methods. The data were then juxtaposed with the developed assessment of the degree of anthropogenic pressure in the province of Silesia with regard to: population density, the volume of produced waste and the density of road networks. The anthropogenization index, which was determined by taking into account the selected factors and the degree of impact on human health, was presented as values from 0 to 1, where 0 represents no anthropogenic pressure and 1 represents its maximum level. In the province of Silesia, the estimated values of the anthropogenization index range from 0.2 to 0.67. The study revealed significant variation in the incidence rates in certain age groups, sexes and districts. It also showed a change in incidence rate values in 2004 compared to 1995, with the largest increase (over 9-fold) occurring in boys. In girls, a decrease (almost 5-fold) in incidence rates was recorded in most cancer groups. The correlation coefficient which was determined indicates a diverse relationship between exposure time and the number of cases of cancer, but in only a few districts it is statistically significant.

Incidence of craniopharyngioma in Denmark (n = 189) and estimated world incidence of craniopharyngioma in children and adults

We studied the incidence of craniopharyngioma in Denmark during the period 1985-2004 and estimated worldwide incidence rates (IR) of craniopharyngioma based on a literature review. Craniopharyngioma patients diagnosed during the period 1985-2004 were identified from the Danish National Patient Registry, the Danish Cancer Registry and regional registries. Medical records were reviewed. Danish population data were obtained from Statistics Denmark. European and World population data were obtained from EU and WHO homepages. Prior studies providing data on craniopharyngioma IRs were identified via PubMed and, if appropriate, were included in a weighted analysis estimating overall and children's IRs of craniopharyngioma. IRs are given as new cases per million per year. We identified 189 patients with new verified (162) or probable craniopharyngioma. The overall WHO World-standardised incidence rate was 1.86 (1.60-2.14) for all ages and 2.14 (1.53-2.92) for children (age <15 years). Peak incidence rates were observed in age groups 5-9 and 40-44 years. Fifteen prior studies (including 1,232 craniopharyngioma cases) were identified. Seven and 11 studies, respectively, were eligible for weighted all-ages and childhood population IR analyses, yielding summary IRs of 1.34 (1.24-1.46) (all ages) and 1.44 (1.33-1.56) (children). We have provided a detailed survey of the incidence of craniopharyngioma in Denmark during a recent 20-year period. Overall IR of craniopharyngioma in Denmark was 1.86 (1.60-2.14) as compared to 2.14 (1.53-2.92) among children. Weighted estimates of craniopharyngioma world IRs were 1.34 (1.24-1.46) in all ages and 1.44 (1.33-1.56) among children.

Wilms' tumour: a systematic review of risk factors and meta-analysis

Wilms' tumour comprises 95% of all renal cancers among children less than 15 years of age. The purpose of this review is to examine the existing literature on perinatal and environmental risk factors for Wilms' tumour. A search for epidemiological studies that examined risk factors for Wilms' tumour was undertaken in Medline, LILACS, ISI Web of Science and Dissertation Abstracts. A total of 37 studies, including 14 cohort, 21 case-control and 2 case-cohort studies, were identified that examined environmental and perinatal risk factors. Most studies were from Western Europe and North America, and among case-control studies, 16 used randomly selected population-based controls. We observed a significantly increased risk of Wilms' tumour with maternal exposure to pesticides prior to the child's birth (OR = 1.37 [95% CI 1.09, 1.73]), high birthweight (OR = 1.36 [95% CI 1.12, 1.64]) and preterm birth (OR = 1.44 [95% CI 1.14, 1.81]), although the results regarding pesticide exposure may be subject to publication bias (Egger's test, P = 0.09). Further analyses to adjust for the heterogeneity in the results for high birthweight and preterm birth did not statistically change the significance of the results. Additionally, an increased though not statistically significant risk of Wilms' tumour was associated with maternal hypertension (OR = 1.30 [95% CI 0.99, 1.72]), and, compared with the first born, being a second or later birth was associated with a significantly decreased risk (OR = 0.82 [95% CI 0.71, 0.95]). This review suggests a role for several perinatal and environmental risk factors in the aetiology of Wilms' tumour.

Sudden unexpected death in infancy associated with an epithelial-type hepatoblastoma in a 6-month-old infant

Sudden unexpected death in infancy and childhood attributable to undiagnosed neoplasia is rare. Malignant neoplasms are very uncommon in infancy, with an age-standardized incidence rate of 118.3 per million. Primary malignant liver tumors are rare, with hepatoblastoma accounting for up to two thirds of cases. Although hepatoblastoma is the most common malignant neoplasm of the liver in childhood, it only accounts for 3.1% of childhood cancers for infants less than 12 months of age. We describe the first case of sudden death in an apparently healthy 6-month-old infant whose autopsy revealed an epithelial type hepatoblastoma with mixed fetal and embryonal patterns.

Surgical management of supratentorial ependymomas

INTRODUCTION

Supratentorial ependymomas are rare neoplasms accounting for just ten to 15 new cases in the UK per year. This article discusses the surgical management of these tumours.

MATERIALS AND METHODS

We present our experience over the past 12 years looking, in particular, at the location, histological grading, postoperative complications, survival and progression-free survival. A literature review of publications discussing the surgical management of ependymoma over the past 10 years is then presented.

RESULTS

The data shows that complete surgical resection confers a significant survival advantage. There appears to be conflicting data with respect to prognosis when comparing supratentorial to infratentorial ependymoma.

CONCLUSION

The authors suggest complete excision and advocate, where appropriate, the use of pre and intra-operative functional mapping and second-look surgery. The trade off neurological deficit in the pursuit of complete surgical excision in some instances should be considered.

Wilms tumour and paternal occupation: an analysis of data from the National Registry of Childhood Tumours

BACKGROUND

Wilms tumour is an embryonal malignant tumour that accounts for 90% of childhood kidney cancers. Parental occupational exposure has been hypothesised to be a cause of childhood Wilms tumour, in particular exposure to pesticides. However, the findings are inconsistent.

PROCEDURE

We have examined the association between paternal occupational exposures and Wilms tumour using birth registration data for cases (n = 2568) from the National Registry of Childhood Tumours (NRCT) and matched controls (n = 2,568) drawn from the general population of Great Britain. Paternal occupation, as recorded at the time of birth, was used to infer "occupational exposure" using a previously defined occupational exposure classification scheme. Odds ratios and 95% confidence intervals were generated using conditional logistic regression with exact methods to estimate the association between each paternal occupational exposure group and childhood Wilms tumour.

RESULTS

All odds ratios were close to 1.00 and no statistically significant associations were observed.

CONCLUSION

The results of this study failed to support any of the previously identified associations between paternal occupation and childhood Wilms tumour.

Spatial clustering of childhood cancer in Great Britain during the period 1969-1993

The aetiology of childhood cancer is poorly understood. Both genetic and environmental factors are likely to be involved. The presence of spatial clustering is indicative of a very localized environmental component to aetiology. Spatial clustering is present when there are a small number of areas with greatly increased incidence or a large number of areas with moderately increased incidence. To determine whether localized environmental factors may play a part in childhood cancer aetiology, we analyzed for spatial clustering using a large set of national population-based data from Great Britain diagnosed 1969-1993. The Potthoff-Whittinghill method was used to test for extra-Poisson variation (EPV). Thirty-two thousand three hundred and twenty-three cases were allocated to 10,444 wards using diagnosis addresses. Analyses showed statistically significant evidence of clustering for acute lymphoblastic leukaemia (ALL) over the whole age range (estimate of EPV = 0.05, p = 0.002) and for ages 1-4 years (estimate of EPV = 0.03, p = 0.015). Soft-tissue sarcoma (estimate of EPV = 0.03, p = 0.04) and Wilms tumours (estimate of EPV = 0.04, p = 0.007) also showed significant clustering. Clustering tended to persist across different time periods for cases of ALL (estimate of between-time period EPV = 0.04, p =0.003). In conclusion, we observed low level spatial clustering that is attributable to a limited number of cases. This suggests that environmental factors, which in some locations display localized clustering, may be important aetiological agents in these diseases. For ALL and soft tissue sarcoma, but not Wilms tumour, common infectious agents may be likely candidates.

Peripheral T-cell lymphoma in childhood: population-based experience in the United Kingdom over 20 years

BACKGROUND

Peripheral T-cell lymphomas (PTCL) are very rare in children and this has prevented assessment of best treatment and prognosis.

PROCEDURE

Registry-based experience in England, Scotland and Wales over a 20-year period was studied to address these shortfalls. Anaplastic large cell lymphoma and mycosis fungoides were excluded due to recent publications describing UK experience with these disorders.

RESULTS

Twenty-five cases were identified, comprising 1.6% of non-Hodgkin lymphoma (NHL) registrations; 17 (68%) children with PTCL-unspecified (PTCL-u), 3 (12%) with angiocentric PTCL, 3 (12%) with angioimmunoblastic PTCL, and 2 (8%) with subcutaneous panniculitis-like T-cell lymphoma. Eighteen children were male, with a male/female ratio of 2.6:1. Median age was 7 (range 1-14) years. Eleven children (44%) died and actuarial survival was 76% at 1 year, 64% at 3 years and 59% at 5 years. Treatments given were subdivided between group T (regimens for T NHL or acute lymphoblastic leukaemia) or group B (regimens for B NHL). Amongst the 17 children with PTCL-u, 9/12 children in group T survived compared with 1/5 group B.

CONCLUSIONS

The Children's Cancer and Leukaemia Group recommendation that children with PTCL-u receive group T therapy is supported by this series. The numbers of children with other types of PTCL were too small to allow conclusions on best therapy.

Trends in childhood renal cancer mortality in Brazil, 1980-2000

Mortality from childhood cancers has shown substantial declines in developed countries since 1960, with smaller favourable trends in South America. This study describes mortality trends in renal childhood cancer mortality in São Paulo state, Brazil, from 1980 to 2000. The age-standardised mortality rates among the boys decreased from 0.36 per 100,000 inhabitants in 1984 to 0.09 in 1992, whereas the observed corresponding decline among girls was from 0.43 per 100,000 inhabitants in 1981 to 0.07 in 1990. Statistically significant declining trends in mortality rates were observed for boys (adjusted r(2) = 0.51, P < 0.001) and also for girls (adjusted r(2) = 0.40, P = 0.002), achieving in this group a significant reduction in age-standardised mortality rates in the period (annual percentage change = -4.21). Consistent decrease in mortality rates from childhood renal cancer was noted at São Paulo state. In the absence of changes in incidence rates, this decline could be attributed to the improvement in treatment protocols and supportive measures.

Patterns of care and survival for patients aged under 40 years with bone sarcoma in Britain, 1980-1994

The purpose of the study was to calculate population-based survival rates for osteosarcoma (OS) and Ewing's sarcoma (ES) in Great Britain during 1980–1994, determine proportions of patients treated at specialist centres or entered in national and international clinical trials, and investigate effects of these factors on survival. Data on a population-based series of 1349 patients with OS and 849 with ES were compiled from regional and national cancer registries, UK Children's Cancer Study Group, regional bone tumour registries and clinical trials. Follow-up was through population registers. Survival was analysed by actuarial analysis with log-rank tests and by Cox's proportional hazards analysis. Five-year survival rates during 1980–1984, 1985–1989 and 1990–1994 were 42% (95% CI: 37, 46), 54% (95% CI: 50, 59) and 53% (95% CI: 48, 57), respectively, for OS and 31% (95% CI: 26, 37), 46% (95% CI: 40, 51) and 51% (95% CI: 45, 57) for ES. Proportions of patients treated at a supraregional bone tumour centre or a paediatric oncology centre in the three quinquennia were 36, 56 and 67% for OS and 41, 60 and 69% for ES. In 1983–1992, 48% of OS patients were entered in a national trial; for ES, 27% were entered in 1980–1986 and 54% in 1987–1994. Survival was similar for trial and nontrial patients with OS. For ES, trial patients had consistently higher 5-year survival than nontrial patients: 1980–1986, 42 vs 30%; 1987–1992, 59 vs 42%; 1993–1994, 54 vs 43%. During 1985–1994, patients with OS or ES whose main treatment centre was a nonteaching hospital had lower survival rates. In multivariate analyses of patients diagnosed during 1985–1994 that also included age, sex, primary site, surgical treatment centre, the results relating to main treatment centre for both OS and ES retained significance but the survival advantage of trial entry for ES became nonsignificant. For both OS and ES diagnosed since 1985, patients whose main treatment centre was a nonspecialist hospital had a lower survival rate.

Space-time clustering of childhood cancer in great Britain: A national study, 1969–1993

Previous studies have provided evidence that infections may play a part in the aetiology of certain childhood cancers. The finding of space-time clustering indicates the presence of an environmental component to aetiology and is especially supportive of a role for infections. Space-time clustering occurs when excess numbers of cases of a disease are observed within small geographical locations at limited periods of time and this cannot be explained in terms of general excesses in those locations or at those times. To investigate whether infections may be involved in the aetiology of childhood cancer, we have analysed for space-time clustering using a large set of national population-based data from Great Britain for the period 1969-1993. Data were examined by a second-order procedure based on K-functions, with fixed thresholds of closeness in space (0.5-7.5 km) and closeness in time (0.1-1.5 years). Locations were addresses at diagnosis. Tests were repeated, replacing geographical distances with distances to the 19th-33rd nearest neighbours and this provided the primary result for each analysis. There were a total of 32,295 cases of childhood cancer. The analyses showed statistically significant evidence of space-time clustering for acute lymphoblastic leukaemia over the whole age range (p = 0.04), but especially for ages 1-4 years (p = 0.03). There was less statistically significant evidence for total leukaemia (p = 0.048). Significant space-time clustering was also evident for soft tissue sarcomas (p = 0.03) and osteosarcomas (p = 0.02). Results support other evidence suggesting a role for infections in the aetiology of these particular diagnostic groups.

Incidence trends and projections for childhood cancer in Ontario

Studies of cancer incidence patterns and trends can provide useful measures of health burden and possible disease etiology, which can aid the planning of cancer care services. This report aims to characterize trends in incidence of childhood cancer, and to assess the implications of these trends by generating incidence projections to 2015. Cancer incidence data were obtained from the database of the Pediatric Oncology Group of Ontario (POGO), which has registered all cancer cases in Ontario since 1985. Annual incidence rates were calculated with census-based population estimates for the 1986-2001 period. Poisson regression models were used to analyze trends, and to calculate projected numbers of cases up to the year 2015. From 1986 to 2001, 5,163 cancer cases occurred among children aged 0-14. Leukemia, CNS tumors and lymphomas were the most common cancers. The number of incident cases increased by 14%, from 296 in 1986 to 336 in 2001. For all cancers, average annual age-standardized rates increased from 147 per million in 1991 to 157 per million in 2001. Over the next 15 years, the 0-14 year population is expected to decrease from 2.28 million in 2000 to 2.13 million in 2015. A marginally statistically significant trend in incidence was projected for all cancers combined (0.5% increase per year p < 0.10) and a statistically significant increase for lymphomas, (1.2% per year 95% CI = 0.0-3.9%). During this period, the number of cases of leukemia and CNS tumors is expected to remain relatively stable. The number of cases of all cancers is expected to increase by 8%, from the average of 320 in 1995 to approximately 347 in 2015. Understanding of these projections will facilitate health care resource planning.

Pediatric hematology and oncology in Iran

Pediatric hematology and oncology (PHO) is a rapidly expandingfield. It has been our goal to meet the needs and increasing demands for comprehensive medical care of children suffering from chronic blood diseases and malignancies. In the past decade we have been able expand and optimize the PHO services throughout Iran, in general and in respect to their prevalence and clinical importance, by trained pediatric hematologist-oncologists, pediatric surgeons and improved para clinical facilities. Major beta-thalassemics receive blood transfusion and chelation therapy according to the current standards mostly at regional blood banks centers. To curb major beta-thalassemia a premarital screening program has been enacted and abortion has been legitimized if major thalassemia is diagnosed by CVS. Hemophiliacs are supervised and treated as indicated by Iranian Hemophilia Comprehensive Care Centers (IHCCC). Screening for transfusion related complications and transmitted viral diseases (HBV, HCV and HIV) in both cohorts are carried out in regular intervals and necessary management will be then carried out as indicated at respective specialized units. Childhood malignancies are treated according to protocols adopted from accredited institutions in the USA and Europe, with almost comparable results. BMT is available for selected patients with beta-thalassemia or malignancies. By going to public we have been able to rise general awareness about chronic blood diseases and childhood malignancies and have initiated establishment of parents groups and formation of NGOs to support these children and their families. Foundation of Iranian Society of Pediatric Hamatology and Oncology (ISPHO) in the year 2000 has been another step forward to consolidate and coordinate the available manpower and facilities.

CONCLUSION

By evaluation of the country's main problems and shortcomings and conduction of collaborative studies and operation planning one will succeed to get the expected feedback and scientifically based approach to provide medical services to far reaching underdeveloped regions.

The incidence of childhood cancer in Jordan: a population-based study

BACKGROUND

Marked variations in the incidence of particular types of childhood cancer exist between countries. We report on the geographic variation in the occurrence of childhood cancer in Jordan.

MATERIAL AND METHODS

Cases were identified from the Jordan National Cancer Registry. We collected data on age, sex, type, primary site, and stage of cancer. Tumor topography and morphology were coded according to the accepted international standard. For all cases registered, 95.2% were histologically diagnosed. Incidence rates were calculated as annual rates per million population. The denominator is the 1997 estimate of the childhood population at ages 0-4, 5-9, and 10-14 years.

RESULTS

There were 646 registered primary malignant neoplasms during the three-year study period (1996-1998). The annual incidence rate for all types of cancer combined was 113 per million children. The rate among children less than 5 years of age was 134.5 per million, for 5-9 years it was 97.8 per million, and for 10-14 years it was 104.1 per million. Overall, the age-standardized annual incidence rate was 113.8 per million. The most common diagnostic group was leukemia, accounting for more than a third of all cases, followed by brain tumors and lymphoma. The highest rate was in the capital, Amman.

CONCLUSION

The pattern of childhood cancer in Jordan seems to be generally similar to other countries in the region, particularly the observed excess of lymphoma. Geographical variations in childhood cancer exist in Jordan and could be partly explained on the basis of lower detection or reporting, or both, in certain locations.

Absence of leukaemic fusion gene transcripts in preterm infants exposed to diagnostic x rays

BACKGROUND

Childhood leukaemias express novel, clonotypic fusion genes that may already be present at birth before the clinical manifestation of leukaemia. Exposure of the fetus to diagnostic x rays is reported to increase the risk of childhood leukaemia, and may do so by generating leukaemic fusion genes. Advances in neonatal medicine in the past decade that have extended the limits of viability of preterm babies down to 23 weeks of gestation have resulted in the increased use of diagnostic x rays to monitor neonatal progress.

AIM

To investigate whether exposure of very preterm infants to diagnostic x rays in the neonatal period leads to the development of leukaemic fusion genes.

METHODS

Peripheral blood samples were collected at birth from very preterm infants (23-30 weeks gestation) and following exposure to diagnostic x rays at intervals of two weeks, until discharge. Cord blood samples from normal full term infants served as controls. Total RNA was extracted from the blood and the expression of the fusion genes TEL-AML1, MLL-AF4, and BCR-ABL, characteristic of three subtypes of childhood leukaemia, was investigated in the preterm and full term infant samples using a nested reverse transcriptase polymerase chain reaction method. Serial pre- and post-x ray samples from 42 preterm babies, pre-x ray samples from an additional 46 preterm infants, and cord blood samples from 100 normal full term infants were screened for fusion gene transcripts.

RESULTS

No leukaemic fusion gene transcripts were detected in preterm infants following exposure to diagnostic x rays. A BCR-ABL transcript was identified in a single preterm infant prior to x ray exposure. TEL-AML1 transcripts were detected in cord blood samples from two full term infants. MLL-AF4 transcripts were not detected in any of the pre- or full term infants tested.

CONCLUSIONS

Exposure of the preterm infants to x rays in this small series and at the doses used for diagnostic purposes did not induce leukaemic fusion gene expression, but we cannot exclude the possibility that a small proportion of preterm infants may be unusually sensitive to x rays.

Constitutional sequence variation in the Fanconi anaemia group C (FANCC) gene in childhood acute myeloid leukaemia

The extent to which genetic susceptibility contributes to the causation of childhood acute myeloid leukaemia (AML) is not known. The inherited bone marrow failure disorder Fanconi anaemia (FA) carries a substantially increased risk of AML, raising the possibility that constitutional variation in the FA (FANC) genes is involved in the aetiology of childhood AML. We have screened genomic DNA extracted from remission blood samples of 97 children with sporadic AML and 91 children with sporadic acute lymphoblastic leukaemia (ALL), together with 104 cord blood DNA samples from newborn children, for variations in the Fanconi anaemia group C (FANCC) gene. We found no evidence of known FANCC pathogenic mutations in children with AML, ALL or in the cord blood samples. However, we detected 12 different FANCC sequence variants, of which five were novel to this study. Among six FANCC variants leading to amino-acid substitutions, one (S26F) was present at a fourfold greater frequency in children with AML than in the cord blood samples (odds ratio: 4.09, P = 0.047; 95% confidence interval 1.08-15.54). Our results thus do not exclude the possibility that this polymorphic variant contributes to the risk of a small proportion of childhood AML.

Characteristics and adequacy of intravenous morphine infusions in children in a paediatric oncology setting

BACKGROUND

Pain management is central in the care of patients in paediatric oncology. Intravenous (i.v.) morphine infusion is an important treatment modality. The objectives of this study were to identify the characteristics of children who receive i.v. morphine infusions in a paediatric oncology setting and to describe the effectiveness, tolerability, and limiting side-effects of this treatment.

PROCEDURE

We prospectively collected evaluation charts for all morphine infusions in a paediatric oncology unit during a 4-year period, and reviewed the medical records of the patients. The incidence of breakthrough pain was used as a measure of the effectiveness of morphine treatment. For comparison, patients were grouped according to causes of pain; minor surgery, major surgery, tumour/disease, or treatment side-effects.

RESULTS

Overall, 72 individuals (36% of all 201 patients diagnosed in the unit) were given morphine infusions. Patients with pain after major surgery suffered from more breakthrough pain than the other patients during the 1st day of morphine treatment even though their morphine consumption was almost twice as high (0.64 vs. 0.36 mg/kg, P < 0.001); 92% of these patients had solid tumours. Common morphine side-effects were vomiting (38%), nausea (32%), and constipation (24%).

CONCLUSIONS

Patients who undergo major tumour surgery require extensive pain management to achieve acceptable post-operative pain relief. The routine of giving both a bolus dose and increasing the morphine dose at breakthrough pain should be encouraged. For the other patients studied, morphine infusions were considered to be adequate, but vomiting, nausea, and constipation might be reduced if prophylactic antiemetics and laxatives were given.

Epidemiologic studies in a population-based childhood cancer registry in Northeast Hungary

BACKGROUND

Reports on the patterns of childhood cancer incidence are rare in Eastern Europe. To compare incidence rates and trends with international data, we processed records of the regional childhood cancer registry of Northeast Hungary.

PROCEDURE

Our computerized database contains population-based information on childhood cancer cases (<15 years) diagnosed in residents of two counties of Hungary: leukaemias from 1973, non-CNS solid tumours from 1978, and CNS tumours from 1984. After a retrospective evaluation of completeness of ascertainment, descriptive epidemiologic analyses were performed for the years of operation of the registry. Age-standardized annual incidence rates and age-specific incidences were calculated. Trends were evaluated in linear regression analysis.

RESULTS

The distribution of major histologic groups was similar to those observed in the Western countries with the exception that central nervous system tumours account for a higher percentage (27.3%). Average age-standardized annual incidence rates were as follows: all types of cancer: 120.7 per million; leukaemia: 37.3; CNS tumours: 31.6; lymphomas: 12.2; sympathetic nervous system tumours: 12.5; kidney tumours: 8.8. Significant increases were observed in incidence of leukaemia (average annual percent change AAPC: 0.7%), acute lymphoblastic leukaemia (AAPC: 1.9%), and all cancer groups (AAPC: 2.6%), but not in acute non-lymphocytic leukaemia or in CNS tumours. The strongest increases in cancer incidence were detected in the age group of 10-14 years (AAPC: 4.4%) and in infants (AAPC: 12.9%).

CONCLUSIONS

Incidences and trends are in accordance with the data in the latest literature, however, the contribution of CNS tumours and the rate of increase in total cancer incidence proved to be higher. Further detailed genetic and environmental studies of cancer registries may shed light on the etiology of the observed differences whether they represent a pattern specific for this region.

Cytogenetic abnormalities and clinical outcome in Wilms tumor: a study by the U.K. cancer cytogenetics group and the U.K. Children's Cancer Study Group

BACKGROUND

Tumor genetic features reported to correlate with adverse outcome in Wilms tumor include karyotype complexity, losses of material from the short arm of chromosome 1 and from the long arms of chromosomes 11, 16 and 22 and gain of material from the long arm of chromosome 1. This study sought to test these associations in a large series of tumors studied by cytogenetic analysis. Identification of markers associated with elevated risk of relapse and fatal outcome could allow more effective treatment stratification at presentation.

PROCEDURE

Thirteen member laboratories of the U.K. Cancer Cytogenetics Group provided results from a 12-year period. Karyotype abnormalities were correlated with clinical data (age, tumor stage, and histology) and outcome data provided by the central register of the U.K. Children's Cancer Study Group.

RESULTS

Of 127 abnormal karyotypes, 78 included a reputedly "poor prognosis" feature. Univariate survival analysis showed no significant adverse effect for karyotype complexity, 1p loss or 11q loss. The poor outcome of cases with 16q loss was of borderline significance, but this effect was restricted to those tumors with unbalanced translocation der(16)t(1q;16q). The association between relapse risk and gain of 1q material was not significant. Only monosomy 22 was a significant marker of poor outcome in univariate analysis (13 cases showing 50% relapse free survival at 5 years compared to 79% survival for the remaining 114 cases, P = 0.02). In multivariate analysis, significant independent predictors of poor outcome were 1q gain (Hazard Ratio 3.4), stage IV disease (HR 5.0), and monosomy 22 (HR 5.9).

CONCLUSIONS

Loss of chromosome 22 identifies high risk Wilms tumors. The prognostic significance of 1q gain, 16q loss and unbalanced translocation der(16)t(1q;16q) is unresolved and warrants further investigation.

Case-control study of parental age, parity and socioeconomic level in relation to childhood cancers

BACKGROUND

Parental ages, parity, and social class have been found in some studies to be associated with particular childhood cancers. Further investigation is warranted because of conflicting findings, biases, and the need to test specific hypotheses.

METHODS

A case-control study was conducted (England and Wales, ages 0-14 years). Cases were ascertained from the National Registry of Childhood Tumours, and were born and diagnosed during 1968-1986. Birth record controls were matched 1:1 to cases on date of birth, sex and area. Information on variables of interest for both groups came from birth records. In all, 10 162 pairs could contribute to matched analyses.

RESULTS

The odds ratio (OR) for retinoblastoma resulting from assumed new germ cell mutations among children of fathers aged > or =45 years was 3.0 (95% CI : 0.2-41.7). The risk of childhood acute lymphoblastic leukaemia (ALL) was significantly higher among children of older mothers and fathers, and significant trends with increasing mothers' (P < 0.001) and fathers' (P = 0.002) ages were found. There was a strong and significant protective effect of increasing parity on risk of childhood ALL. The adjusted OR for parity of > or =5 (versus 0) was 0.5 (95% CI : 0.3-0.8). Children in more deprived communities had a lower risk of ALL; but this was not significant after confounders were allowed for. There was no significant effect of social class based on parental occupation on ALL risk, but the numbers were small in those analyses.

CONCLUSIONS

The associations between ALL and parental ages did not disappear when children with Down syndrome were excluded, suggesting an additional explanation beyond known links. The strong ALL association with parity may be because of an unknown environmental risk factor.

Constitutional balanced chromosomal rearrangements and neoplasm in children

A predisposition to tumor development is currently associated with some, but not all, constitutional chromosomal abnormalities. In a series of 578 children, in which conventional cytogenetic investigation was performed on material from various benign and malignant tumors, four boys and one girl were also found to have constitutional balanced chromosomal rearrangements. The figure of 5 in 578 is notable because the reported incidence of balanced rearrangements in newborns is approximately 1 in 450. Thereby suggesting that some, if not all, children with balanced constitutional chromosomal rearrangements have an increased predisposition for neoplasms developing.

The investigation of karyotypic instability in the high-hyperdiploidy subgroup of acute lymphoblastic leukemia

Acute lymphoblastic leukemia (ALL) of childhood has been cytogenetically well characterized, and approximately 25% of cases will have a high-hyperdiploid (51-68) chromosome complement. In a 5 year period a consecutive series of 152 presentation ALL's were karyotyped. In all cases a result was obtained and 138 (91%) had a detectable abnormal clone of which 44 (29%) were high-hyperdiploid. Within the high-hyperdiploidy group karyotypic cell to cell variation was observed in many cases. To provide further evidence of this phenomenon a dual-color fluorescence in-situ hybridization (FISH) experiment was performed on stored fixed suspension from 14 ALL's with such a karyotype. In each case 4-6 probes were investigated, employing probes to centromeres of chromosomes X, 4, 6, 8, and 10 and a locus specific probe to chromosome 21q22. It was found that the FISH produced results that were generally in good agreement with the G-banding findings and supported the notion of karyotypic cell to cell variation. FISH further showed that most of cases would have two extra copies of chromosome 21 in the majority of leukemic cells and a single extra copy in the minority. A further finding was that fewer cells contained extra copies of chromosomes 6, 8 and 10 than was expected based on the comparison of the signal number of the other probes investigated. In contrast chromosomes X, 4, and 21 seldom displayed this feature. We have demonstrated that karyotypic instability as defined by karyotypic cell to cell variation is a feature of the high-hyperdiploid subgroup in childhood ALL. It is questioned whether the underlying defect resulting in the observed karyotypic instability of this subgroup is one of the primary causative events in the formation of the leukemia.

Thyroid cancer in children and young adults in the North of England. Is increasing incidence related to the Chernobyl accident?

Population-based data on thyroid carcinomas was obtained from the Northern Region Young Person's Malignant Disease Registry to analyse the incidence of thyroid cancers in young people (<25 years) in the North of England for the period 1968 and 1997 and to assess if changes in incidence were consistent with the spatial and temporal distribution of the fallout from the Chernobyl nuclear accident. We compared incidence rates for differentiated (papillary or follicular) thyroid carcinomas 1968-1986 with those for 1987-1997. There were 75 cases of thyroid carcinoma diagnosed over the study period, of which 63 were differentiated carcinoma and 12 were medullary carcinoma. There were 26 young adults (15-24 years) diagnosed with differentiated thyroid carcinoma in the 19-year period 1968-1986 and 30 in the subsequent 11 years 1987-1997, Age standardised rate (ASR) 3.0 versus 6.5, respectively (rate ratio 2.2, 95% confidence interval (CI): 1.3-3.6). There were three children (aged <15 years) diagnosed with differentiated carcinoma in the period 1968-1986 and four in the period 1987-1997, ASR 0.2 versus 0.6 (rate ratio 2.7, 95% CI: 0.6-12.1). Regression models showed a significant increase in the incidence of thyroid cancer after the Chernobyl accident (P=0.002). In Cumbria, the area receiving the heaviest fallout in the UK, the increase in incidence was much greater (rate ratio 12.19, 95% CI 1.5-101.2). These temporal and spatial changes in incidence are consistent with a causal association with the Chernobyl accident although a greater effect in the younger rather than the older age group would have been anticipated. However, factors including improvements in ascertainment and earlier detection of tumours may also have contributed to the increasing incidence. Further collaborative international studies are needed to investigate changes in the incidence of thyroid cancer in children and young adults.

Lumbar puncture in pediatric oncology: conscious sedation vs. general anesthesia

BACKGROUND

Lumbar punctures (LP) generally have been performed with conscious sedation (CS) but are increasingly performed using general anesthesia (GA) owing to the belief that this is less distressing. The aim of this study was to compare these two methods concerning distress, discomfort, pain, well-being and security after the LP, and problems with the LP.

PROCEDURE

Twenty-five children with cancer participated in this prospective, randomized, crossover study. Children, parents, and nurses completed a visual analogue scale questionnaire to evaluate the efficacy of CS and GA. In addition, sedation and anesthesia protocols were reviewed.

RESULTS

The two methods seemed to be equivalent concerning distress, discomfort, pain, well-being and security after the procedure, and procedure problems. Most children (80%), parents (66%), and nurses (58%) preferred LP in CS. However, the LP was not performed in CS in five cases because the child did not cooperate. Younger children less often preferred CS.

CONCLUSIONS

Outcomes for CS and GA in LP were similar. Although there were failures with the CS model, most preferred it to GA. LP in CS also saved time and medical resources. An alternative approach would be to have a pediatric anesthesiologist available at the oncology ward for these elective LPs to provide the sedation or anesthesia required by each individual.

Season of birth and diagnosis of children with leukaemia: an analysis of over 15 000 UK cases occurring from 1953-95

If infections are involved in the aetiology of childhood leukaemia then seasonal variation in the birth or onset dates of the malignancy may be apparent. Previous studies that have examined seasonality of these dates have produced conflicting results. Using population-based data from the National Registry of Childhood Tumours we conducted a larger study than any to date of 15 835 cases of childhood leukaemia born and diagnosed in the UK between 1953-95. We found no evidence of seasonality in either month of birth or month of diagnosis overall or in any subgroups by age, sex, histology or immunophenotype. We did however find a significant (P = 0.01) February peak in month of birth for cases born before 1960 and a significant (P = 0.02) August peak in month of diagnosis for those diagnosed before 1962. Whilst these findings may be due to chance they are also consistent with changes over time in the seasonality of exposure, or immunological response, to a relevant infection. Changes in the seasonal variation in the fatality rate of a pre-leukaemic illness, such as pneumonia, could be another explanation.

Clinical prognostic factors in 1277 patients with neuroblastoma: results of The European Neuroblastoma Study Group 'Survey' 1982-1992

In 1982 the European Neuroblastoma Study Group (ENSG) established a prospective registry for patients with newly diagnosed neuroblastoma ('The ENSG Survey'). Clinical information was collected primarily to: (a) establish an ENSG database; and (b) investigate prognostic factors in neuroblastoma. This paper summarises the results of the survey. By 1992, 1277 patients with a median age of 26 months (range: 0-289 months), gender ratio of 1.19 M:F had been registered from 30 centres. The median follow-up of survivors is 9.7 years (range: 1-14 years). Overall 5-year survival (S) is 45% (95% CI 42-48%), and event-free survival (EFS) is 43% (95% CI 40-45%). For both survival and EFS the key established prognostic factors, stage and age, are highly significant (P<0.001). In particular, patients under 1 year of age at diagnosis, whatever the disease stage, had a more favourable prognosis than older patients; stage 2 (EFS 93% (95% (CI 85-97) versus 76% (95% CI 67-86), P=0.02), stage 3 (EFS 91% (95% CI 82-96) versus 52% (95% CI 44-60), P<0.001) and stage 4 (EFS 59% (95% CI 48-69) versus 16% (95% CI 13-19), P<0.001). Multivariate analysis established that the anatomical location of the primary tumour (i.e. abdominal versus other sites) and primary tumour volume also conferred a statistically significant difference. In stage 4 disease the 20% of patients without demonstrable bone marrow involvement had a more favourable prognosis than those with infiltrated marrow (EFS 36% (95% CI 13-19) versus 16% (95% CI 29-45), P<0.001). Urine catecholamine metabolite levels (raised versus normal), histology (ganglioneuroblastoma versus neuroblastoma) and gender had no significant effect on outcome after stage and age were accounted for. 5-year survival following first relapse is only 5.6% (95% CI 2.8-8.4). This ENSG Survey provides secure data for future comparisons with new prognostic factors and treatment programmes.

Congenital malformations and childhood cancer

BACKGROUND

We investigated the epidemiology of congenital malformations and childhood cancer.

PROCEDURE

By employing the cases of the Registry of Childhood Malignancies in Hokkaido Prefecture, Japan, from 1969 to 1996, the numbers of malignancies in cases (diagnosis at 0-14 years of age) with Down syndrome (DS), mental retardation (MR) excluding DS, luxatio coxae congenita (LCC), congenital heart disease (CHD) excluding DS, undescended testicle (UT), and cleft palate-lip (CPL) were calculated. Using the percentages of malignancies in the 2,349 cases without malformation, expected numbers of malignancies in the cases with the malformations were calculated. The observed numbers were statistically compared to expected ones.

RESULTS

In the DS cases, leukemia developed with a significantly high frequency, but no UT cases developed leukemia. No brain tumor was preceded by DS. This could not be explained only by early death from coexisting diseases such as CHD, insofar as the CHD cases without DS developed brain tumors more frequently than expected. The ratio of acute lymphoblastic leukemia (ALL) to acute nonlymphoblastic leukemia (ANLL) was different among the malformations. The MR cases developed ANLL more frequently than expected, whereas the CPL cases developed ALL more frequently. The distribution of the age at diagnosis for Wilms' tumor was different according to the underlying malformation.

CONCLUSIONS

Malformations might have some factors that inhibit or delay as well as promote the development of certain malignancies.

The United Kingdom Childhood Cancer Study: objectives, materials and methods. UK Childhood Cancer Study Investigators

An investigation into the possible causes of childhood cancer has been carried out throughout England, Scotland and Wales over the period 1991-1998. All children known to be suffering from one or other type of the disease over periods of 4-5 years have been included, and control children matched for sex, age and area of residence have been selected at random from population registers. Information about both groups of children (with and without cancer) has been obtained from parental questionnaires, general practitioners' and hospital records, and from measurement of the extent of exposure to radon gas, terrestrial gamma radiation, and electric and magnetic fields. Samples of blood have also been obtained from the affected children and their parents and stored. Altogether 3,838 children with cancer, including 1,736 with leukaemia, and 7,629 unaffected children have been studied. Detailed accounts are given of the nature of the information obtained in sections describing the general methodology of the study, the measurement of exposure to ionizing and non-ionizing radiation, the classification of solid tumours and leukaemias, and the biological material available for genetic analysis.

Midazolam nasal spray reduces procedural anxiety in children

OBJECTIVE

Anxiety and pain even in minor procedures are still great problems in pediatrics, not least in pediatric oncology. Conscious sedation is indicated when other means to overcome a child's fear fail. The aim of this study was to investigate whether intranasal administration of midazolam given before insertion of a needle in a subcutaneously implanted central venous port could reduce anxiety, discomfort, pain, and procedure problems.

METHOD

Forty-three children with cancer participated in this randomized, double-blind, placebo-controlled, crossover study in which nasal administration of midazolam spray,.2 mg/kg body weight, was compared with placebo. Children, parents, and nurses completed a visual analog scale questionnaire to evaluate efficacy.

RESULTS

Parents and nurses reported reduced anxiety, discomfort, and procedure problems for children in the midazolam group and would prefer the same medication at next procedure. They also reported pain reduction. Children reported reduced anxiety and procedure problems but reduction of pain and discomfort was not significant. No serious or unexpected side effects occurred. Nasal discomfort was the most common side effect (17/38 approximately 45%) and the primary reason for dropouts (8/43 approximately 19%). Anxiety varied with age but not with gender. When anxiety increased, the differences between midazolam and placebo increased.

CONCLUSION

Nasal midazolam spray offers relief to children anxious about procedures, such as insertion of a needle in a subcutaneously implanted intravenous port, venous blood sampling, venous cannulation, etc. Its use, however, may be limited by nasal discomfort in some patients for whom rectal and oral routes might be alternatives.

Uranium-235 and childhood leukaemia around Greenham Common airfield

There has been considerable publicity recently concerning the possible release of enriched uranium from the Greenham Common USAF base near Newbury in Berkshire. Evidence for the release relies on an internal report of the Atomic Weapons Research Establishment at Aldermaston, the authors of which postulated that it resulted from a fire in 1958 involving a B47 bomber standing on the runway. Their report contained a much publicised contour map of excess 235U levels estimated from the ratio of 235U to 238U in 26 evergreen leaf samples examined. The current concern of the inhabitants of Newbury centres mostly on the incidence of leukaemia, which was known beforehand to be slightly elevated in parts of West Berkshire, at least for young children. A number of cases have received considerable press publicity, with suggestions that their homes are located close to the base or the flight-path. The reports are, however, anecdotal and are not based on a complete register of cases. We have examined the evidence for this putative association by re-analysing the uranium data and determining the spatial relationship to the base of cases of childhood leukaemia diagnosed in the years 1966-87. We conclude that, although the excess uranium found has a non-random distribution, it does not support the pattern depicted by the contours and bears no relation to the incidence of childhood leukaemia for the period we examined. In any case, the increase in level of environmental radiation as a result of the putative release must be very small and is at variance with the reporting in some of the national press.

Patterns of care and survival for children with acute lymphoblastic leukaemia diagnosed between 1980 and 1994

AIMS

To document survival rates after acute lymphoblastic leukaemia (ALL) during the era of modern chemotherapy, to assess effects of prognostic factors at presentation, and to investigate the relation of survival to patterns of organisation of care.

PATIENTS

From a population based series of 5078 children diagnosed in the UK during 1980-94, 4988 remained for analysis after exclusion of nine children ascertained from death certificates alone and 81 who received no antileukaemia treatment.

MAIN OUTCOME MEASURES

Actuarial survival rates.

RESULTS

Between 1980-84 and 1990-94, the proportion of children treated at paediatric oncology centres rose from 77% to 89%, and the proportion entered into national trials rose from 59% to 82%. Each of age, sex, white blood count, immunophenotype, and Down's syndrome status had a highly significant effect on survival. Five year survival improved from 67% in 1980-84 to 81% in 1990-94, a 42% reduction in the risk of death within five years of diagnosis. Survival did not differ significantly between hospitals with different numbers of new patients per year or between paediatric oncology centres and other hospitals. Children who were entered into national trials had higher survival and this difference became greater in recent years; five year survival rates for children diagnosed during 1980-84 were 70% and 64% for trial and non-trial patients, respectively; in 1990-94 the rates were 84% and 68% for trial and non-trial patients, respectively.

CONCLUSIONS

Survival after ALL continues to improve. Nearly 50 children/year diagnosed during 1990-94 survived who would have died a decade before. Survival does not vary systematically with place of treatment but is higher for children entered into national trials.

A rise in the incidence of childhood cancer in the United States

From the early 1980s to the early 1990s, the incidence of cancer in American children under 10 years of age rose 37 percent, or 3 percent annually. There is an inverse correlation between increases in cancer rates and age at diagnosis; the largest rise (54 percent) occurred in children diagnosed before their first birthday. Rates rose for all 11 states and cities included in the analysis. A jump in cancer rates for children born in 1982-83 was followed by a drop; but another abrupt rise for the 1986-87 birth cohort has been sustained thereafter. Results indicate that the rising childhood cancer rate represents a far more serious problem in the United States than previous reports have suggested. The methodology used here adds three additional states and cities, analyzes children under 10 rather than under 15, begins the analysis in 1980 rather than in 1973, and extends the study to 1993, which may partially account for the new findings. There are no apparent explanations for these trends, suggesting that researchers should analyze the data more fully and propose hypotheses on potential causes. One possible factor, fetal and infant exposure to low-dose radioactivity, is explored here.