Solid Cancers in the Premature and the Newborn: Report of Three National Referral Centers

Non-inferiority of fragmented care for high-risk pediatric neuroblastoma patients: a single institution analysis

Pediatric neuroblastoma (NB) patients receive multi-modal therapy and may experience care fragmented among multiple institutions with a significant travel burden, which has been associated with poor outcomes for some adult cancers. We hypothesized that fragmented care for pediatric NB patients is associated with inferior outcomes compared to treatment consolidated at one location. We reviewed paper and electronic records for pediatric NB patients who received ≥1 hematopoietic stem cell transplant (HSCT) at Duke from 1990-2017. Fragmented care was defined by treatment at >1 institution and grouped by 2 institutions vs. 3+ institutions. Distances were calculated using Google Maps. To compare all care groups, we used Fisher's Exact and Kruskal-Wallis tests for demographic and treatment characteristics, Kaplan-Meier for unadjusted overall survival (OS), and Cox proportional hazards for factors associated with OS. Of 127 eligible patients, 102 (80.3%) patients experienced fragmented care, with 17 treated at 3+ facilities. Kaplan-Meier analysis did not associate fragmented care with increased mortality (log-rank p = 0.13). With multivariate analysis, only earlier diagnostic decade and greater distance to HSCT remained significantly associated with worsened OS. In this single institutional study, we found fragmented care did not impact overall survival. Worsened overall survival was associated with increased travel distance for HSCT and further research should aim to improve supportive processes for patients undergoing HSCT for high-risk neuroblastoma.

Imaging of Horner syndrome in pediatrics: association with neuroblastoma

Neuroblastoma is the most common neoplasm associated with pediatric Horner syndrome. The laboratory and imaging evaluation of isolated pediatric Horner syndrome is controversial. We review the literature published in the last several decades and present the rationale for the imaging work-up in this patient cohort.

Clinical Presentation and Surgical Management of Neonatal Tumors: Retrospective Analysis

Aims:

Neonatal tumors (NTs) include a group of diverse neoplasms. In this study, we reviewed our data for clinical presentations, management options, and outcome.

Materials and Methods:

All patients from 0- to 1-month age presenting with solid tumors, from 2006 to 2018 were studied. The gender, presentation, location, type of tumor, and management were analyzed. The final diagnosis was made with histopathology in all cases. Hemangiomas and lymphangiomas were excluded from the study.

Results:

A total of 32 neonates were studied. The most common tumor was sacrococcygeal teratoma (SCT,16) followed by teratoma at other sites including two cases of fetus-in-fetu, soft-tissue sarcoma (STS, 4), mesenchymal hamartoma (2), hemangioendothelioma (2), and other rare tumors. Three tumors were diagnosed antenatally; of whom, two were neither visible externally nor palpable. Complete surgical excision was done for all except in a case of ovarian cyst where near-total cystectomy was done. No patient received chemotherapy or radiotherapy. Six patients had postoperative complications, including two who had local recurrence requiring excision. There was one mortality. All the other patients are doing well during follow-up.

Conclusion:

NTs have varied presentations. SCT and STS were the most common benign and malignant tumor, respectively. Early diagnosis and complete surgical excision are often curative for all, regardless of the pathology with the minimal role of chemotherapy or radiotherapy.

Adrenal hemorrhage in newborn: how, when and why- from case report to literature review

Background

Neonatal adrenal hemorrhage is a relatively uncommon condition (0.2–0.55%). Various risk factors have been reported in addition to birth asphyxia, such as sepsis, coagulation disorders, traumatic delivery, and perinatal injuries. Adrenal hemorrhage usually affects the right adrenal gland (about 70% of cases) while it involves the bilateral adrenal gland only in 10% of cases. In most cases, the event is asymptomatic but, in others, it may be so devastating to determine death by bleeding or adrenal insufficiency.

Case presentation

A case of bilateral neonatal adrenal hemorrhage, with adrenal insufficiency, but with no important risk factors and favorable evolution in a male infant.

Conclusions

This case emphasizes the importance of keeping a non-interventional attitude, avoiding early surgery but carrying out a serial sonographic follow-up. Serial ultrasound monitoring is the most reliable approach during conservative management.

Electronic supplementary material

The online version of this article (10.1186/s13052-019-0651-9) contains supplementary material, which is available to authorized users.

Primary Immunodeficiency and Cancer Predisposition Revisited: Embedding Two Closely Related Concepts Into an Integrative Conceptual Framework

Common understanding suggests that the normal function of a "healthy" immune system safe-guards and protects against the development of malignancies, whereas a genetically impaired one might increase the likelihood of their manifestation. This view is primarily based on and apparently supported by an increased incidence of such diseases in patients with specific forms of immunodeficiencies that are caused by high penetrant gene defects. As I will review and discuss herein, such constellations merely represent the tip of an iceberg. The overall situation is by far more varied and complex, especially if one takes into account the growing difficulties to define what actually constitutes an immunodeficiency and what defines a cancer predisposition. The enormous advances in genome sequencing, in bioinformatic analyses and in the functional in vitro and in vivo assessment of novel findings together with the availability of large databases provide us with a wealth of information that steadily increases the number of sequence variants that concur with clinically more or less recognizable immunological problems and their consequences. Since many of the newly identified hard-core defects are exceedingly rare, their tumor predisposing effect is difficult to ascertain. The analyses of large data sets, on the other hand, continuously supply us with low penetrant variants that, at least in statistical terms, are clearly tumor predisposing, although their specific relevance for the respective carriers still needs to be carefully assessed on an individual basis. Finally, defects and variants that affect the same gene families and pathways in both a constitutional and somatic setting underscore the fact that immunodeficiencies and cancer predisposition can be viewed as two closely related errors of development. Depending on the particular genetic and/or environmental context as well as the respective stage of development, the same changes can have either a neutral, predisposing and, in some instances, even a protective effect. To understand the interaction between the immune system, be it "normal" or "deficient" and tumor predisposition and development on a systemic level, one therefore needs to focus on the structure and dynamic functional organization of the entire immune system rather than on its isolated individual components alone.

Neuroblastoma with flat genomic profile: a question of representativity?

Neuroblastoma is one of the most common paediatric malignancies. Detection of somatic genetic alterations in this tumour is instrumental for its risk stratification and treatment. On the other hand, an absence of detected chromosomal imbalances in neuroblastoma biopsies is difficult to interpret because it is unclear whether this situation truly reflects the tumour genome or if it is due to suboptimal sampling. We here present a neuroblastoma in the left adrenal of a newborn. The tumour was subjected to single-nucleotide polymorphism array analysis of five tumour regions with >80% tumour cells in histological mirror sections. This revealed no aberrations compared with a normal reference sample from the patient. Whole exome sequencing identified two single-nucleotide variants present in most tumour regions, corroborating that the tumour resulted from monoclonal expansion. Our data provide proof-of-principle that rare cases of neuroblastoma can have a normal whole genome copy number and allelic profile.

A Tumor Profile in Primary Immune Deficiencies Challenges the Cancer Immune Surveillance Concept

Under the concept of cancer immune surveillance, individuals with primary immune deficiencies would be expected to develop many more malignancies and show an excess of all types of cancers, compared to people with a normal immune system. A review of the nine most frequent and best-documented human conditions with primary immune deficiency reveals a 1.6- to 2.3-fold global increase of cancer in the largest epidemiological studies. However, the spectrum of cancer types with higher frequencies is narrow, limited mainly to lymphoma, digestive tract cancers, and virus-induced cancers. Increased lymphoma is also reported in animal models of immune deficiency. Overstimulation of leukocytes, chronic inflammation, and viruses explain this tumor profile. This raises the question of cancers being foreign organisms or tissues. Organisms, such as bacteria, viruses, and parasites as well as non-compatible grafts are seen as foreign (non-self) and identified and destroyed or rejected by the body (self). As cancer cells rarely show strong (and unique) surface antibodies, their recognition and elimination by the immune system is theoretically questionable, challenging the immune surveillance concept. In the neonatal period, the immune system is weak, but spontaneous regression and good outcomes occur for some cancers, suggesting that non-immune factors are effective in controlling cancer. The idea of cancer as a group of cells that must be destroyed and eliminated appears instead as a legacy of methods and paradigms in microbiological medicine. As an alternative approach, cancer cells could be considered part of the body and could be controlled by an embryonic and neonatal environment.

A Case of Prenatally Diagnosed Wilms Tumor Managed With Laparoscopic Nephrectomy

We present a case of prenatally diagnosed Wilms tumor, with subsequent operative approach and management. The patient was referred to our institution with an abnormal prenatal renal ultrasound. Computed tomography scan after delivery showed a multifocal enhancing left renal mass. The patient underwent an uncomplicated left laparoscopic radical nephrectomy and retroperitoneal lymph node sampling using a novel hidden incision endoscopic surgery technique. Final pathology revealed favorable histology stage II Wilms tumor. The patient underwent adjuvant chemotherapy with vincristine and dactinomycin based on the EE4A regimen. We highlight the diagnostic pathway, perioperative management, surgical approach, and early postoperative follow-up in this case report.

Neonatal tumours: A single centre review

<strong>Background</strong>: Neonatal tumours, occurring within 28 days of life, are associated with a favourable outcome in high-income countries. Limited data are available on neonatal tumours in low- and middle-income countries.<br /><strong>Aim</strong>: We aimed to create awareness of neonatal tumours in a middle-income country, by identifying the most common tumours diagnosed to determine whether there was a delay to presentation or diagnosis at the Paediatric Oncology unit, to identify possible areas of improvement and increase overall survival. Setting: Chris Hani Baragwanath Academic Hospital Paediatric Oncology unit. <br /><strong>Methods</strong>: A retrospective case series was performed collecting data on 60 neonates diagnosed with a tumour over a 25-year period (1 January 1988 to 31 December 2012). Descriptive statistical analysis using percentages and medians were used. Kaplan–Meier analysis was used to calculate survival. <br /><strong>Results</strong>: Germ cell tumours were identified as the most common neonatal tumours diagnosed 29/60 (48.3%), whereas malignant soft tissue tumours were the most common malignant tumours identified. The median delay to presentation was 7 days, the median diagnostic delay was 11 days and the median overall delay was 30 days. The overall 5-year survival rate was 67.3%, with an overall 5-year survival of 54.1% of neonates diagnosed with a malignant tumour. <br /><strong>Conclusion</strong>: A large percentage of neonates diagnosed with malignant tumours in highincome countries can be successfully treated and cured. Clinicians involved in the care of neonates need to be better acquainted with disease-specific signs of neonatal tumours to allow for early detection and referral to a Paediatric Oncology unit.

Up-To-Date Practical Imaging Evaluation of Neonatal Soft-Tissue Tumors: What Radiologists Need to Know

OBJECTIVE

The purposes of this article are to provide an up-to-date overview of neonatal soft-tissue tumors, including information regarding their unique nature, and to present practical imaging techniques and characteristic imaging findings.

CONCLUSION

Neonatal soft-tissue tumors are a unique set of neoplasms that often have characteristic clinical and imaging findings. Imaging evaluation, mainly with ultrasound and MRI, plays an important role in the initial diagnosis, staging, preoperative assessment, and follow-up evaluation. Clear understanding of practical imaging techniques combined with up-to-date knowledge of characteristic imaging findings can help the radiologist provide a timely and accurate diagnosis of these neoplasms and can lead to optimal neonatal patient care.