1
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Ziogas IA, Kakos CD, Kokkinakis S, Hills-Dunlap JL, Corkum KS, Acker SN, Diaz-Miron JL, Lovvorn HN, Roach JP, Gosain A. Management and Outcomes of Hepatoblastoma in Patients With Trisomy 18: A Systematic Review and Pooled Analysis of 70 Patients. J Pediatr Surg 2024:S0022-3468(24)00363-4. [PMID: 38955626 DOI: 10.1016/j.jpedsurg.2024.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 04/29/2024] [Accepted: 06/06/2024] [Indexed: 07/04/2024]
Abstract
INTRODUCTION Predicted 1-year survival of children with trisomy 18 (T18) has increased to 59.3%. We aimed to systematically review the characteristics, management, and outcomes of children with T18 and hepatoblastoma. METHODS A systematic literature review of the PubMed, Embase, Scopus, Web of Science, and Cochrane Library databases was performed according to the PRISMA 2020 statement (end-of-search date: 03/03/2024). RESULTS Fifty studies reporting on 70 patients were included. The median age at diagnosis was 11.5 months, 85.9% were female (n = 55/64), and 15.0% had mosaic T18 (n = 6/40). Diagnosis was made during symptom evaluation (most commonly hepatomegaly or abdominal mass) in 45.5% (n = 15/33), incidentally in 24.2% (n = 8/33), during surveillance with abdominal ultrasound in 18.2% (n = 6/33), and at autopsy in 12.1% (n = 4/33). The median tumor size was 6.4 cm, 33.3% had multiple tumors (n = 14/42), and metastasis was present in one patient (3.8%; n = 1/26). Neoadjuvant chemotherapy was administered in 42.6% (n = 26/61) and adjuvant chemotherapy in 31.6% (n = 18/57). Surgical treatment was performed in 64.2% (n = 43/67). Of the patients not diagnosed on autopsy, overall mortality was 35.5% (n = 22/62) over a median follow-up of 11.0 months. Among the 26 deceased patients (including those diagnosed on autopsy), the most common causes of death were cardiopulmonary disease (38.5%, n = 10/26) and tumor progression (30.8%, n = 8/26). CONCLUSIONS T18 does not preclude resection with curative intent for hepatoblastoma. Combination of surgery and chemotherapy should be considered in children on an individualized basis depending on tumor characteristics and underlying cardiopulmonary comorbidities. Locoregional modalities may have a role in the setting of severe comorbidities. LEVEL OF EVIDENCE Level IV evidence.
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Affiliation(s)
- Ioannis A Ziogas
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO 80045, USA.
| | - Christos D Kakos
- Department of Surgery, Aristotle University of Thessaloniki School of Medicine, 54124, Thessaloniki, Greece
| | - Stamatios Kokkinakis
- Department of Surgery, University of Crete School of Medicine, 71500, Heraklion, Greece
| | - Jonathan L Hills-Dunlap
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO 80045, USA
| | - Kristine S Corkum
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO 80045, USA
| | - Shannon N Acker
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO 80045, USA
| | - Jose L Diaz-Miron
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO 80045, USA
| | - Harold N Lovvorn
- Department of Pediatric Surgery, Monroe Carell, Jr. Children's Hospital at Vanderbilt, Nashville, TN 37232, USA
| | - Jonathan P Roach
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO 80045, USA
| | - Ankush Gosain
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO 80045, USA
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2
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Sosnowska-Sienkiewicz P, Kamińska A, Anderko I, Telman-Kołodziejczyk G, Mańkowski P, Januszkiewicz-Lewandowska D. Therapeutic Management and Outcomes of Hepatoblastoma in a Pediatric Patient with Mosaic Edwards Syndrome. Genes (Basel) 2024; 15:463. [PMID: 38674397 PMCID: PMC11049815 DOI: 10.3390/genes15040463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 03/28/2024] [Accepted: 03/29/2024] [Indexed: 04/28/2024] Open
Abstract
The mosaic form of Edwards syndrome affects 5% of all children with Edwards syndrome. The clinical phenotype is highly variable, ranging from the full spectrum of trisomy 18 to the normal phenotype. The purpose of this publication was to present the therapeutic process in an 18-month-old girl with the mosaic form of Edwards syndrome and hepatoblastoma, against the background of other cases of simultaneous occurrence of this syndrome and hepatoblastoma described so far. It appears that this particular group of patients with hepatoblastoma and Edwards syndrome can have good outcomes, provided they do not have life-threatening cardiac or other severe defects. Due to the prematurity of our patient and the defects associated with Edwards syndrome, the child required constant multidisciplinary care, but Edwards syndrome itself was not a reason to discontinue therapy for a malignant neoplasm of the liver. Regular abdominal ultrasound examination, along with AFP testing, may be helpful in the early detection of liver tumors in children with Edwards syndrome.
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Affiliation(s)
- Patrycja Sosnowska-Sienkiewicz
- Department of Pediatric Surgery, Traumatology and Urology, Poznan University of Medical Sciences, 60-572 Poznan, Poland; (I.A.); (P.M.)
| | - Alicja Kamińska
- University Research Hospital in Poznan, Poznan University of Medical Sciences, 60-355 Poznan, Poland;
| | - Iwona Anderko
- Department of Pediatric Surgery, Traumatology and Urology, Poznan University of Medical Sciences, 60-572 Poznan, Poland; (I.A.); (P.M.)
| | - Gabriela Telman-Kołodziejczyk
- Department of Pediatric Cardiology, Nephrology and Hypertension, Poznan University of Medical Sciences, 61-701 Poznan, Poland;
| | - Przemysław Mańkowski
- Department of Pediatric Surgery, Traumatology and Urology, Poznan University of Medical Sciences, 60-572 Poznan, Poland; (I.A.); (P.M.)
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3
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Shirane K, Yoshimi A, Masuko T, Kajikawa D, Toma M, Idesawa H, Tsukada Y, Yano Y, Kato K, Motoyama K, Asai N, Hirono K, Kono T, Otani H, Shiono J, Izumi I, Yanai T. Successful Treatment for Hepatoblastoma in Trisomy 18: A Case Report. J Pediatr Hematol Oncol 2024; 46:e83-e86. [PMID: 38063411 DOI: 10.1097/mph.0000000000002788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 09/19/2023] [Indexed: 01/04/2024]
Abstract
Children with trisomy 18 tend to develop hepatoblastoma. Since the introduction of appropriate management for organ malfunction, individuals with trisomy 18 have come to have a longer life expectancy. However, the predisposition to hepatoblastoma becomes a significant issue for the quality of a case. Here, we present a rare multifocal hepatoblastoma involving predominantly Couinaud segments 5 and 7 in a 10-month-old boy with trisomy 18. Though the first-line cisplatin monotherapy resulted in unsatisfactory tumor shrinkage, the second-line neoadjuvant chemotherapy administrating irinotecan and vincristine gave rise to significant tumor reduction in volume, leading to the completion of partial resection of the liver without the microscopic residual disease. The patient has been free from recurrence for 44 months. Because anatomical right hepatectomy can cause circulatory instability, including acute onset of pulmonary hypertension in trisomy 18 patients, physicians should balance treatment benefits and potential adverse effects. Our successful experience utilizing a combination of efficacious and less cardiotoxic neoadjuvant chemotherapy followed by the partial hepatectomy encourages physicians to treat a patient with trisomy 18 and tackle hepatoblastoma with a genetic background.
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Affiliation(s)
| | - Ai Yoshimi
- Division of Pediatric Hematology and Oncology
| | | | | | | | | | | | | | | | | | | | - Koji Hirono
- Division of General Pediatrics
- Ultrasonography Center
| | - Tatsuo Kono
- Division of Clinical Radiology, Tokyo Metropolitan Children's Medical Center, Fuchu, Tokyo, Japan
| | - Haruo Otani
- Division of Diagnostic Pathology, Ibaraki Children's Hospital, Mito, Ibaraki Prefecture
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4
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‘Teratoid’ Hepatoblastoma: An Intriguing Variant of Mixed Epithelial-Mesenchymal Hepatoblastoma. CHILDREN 2022; 9:children9040565. [PMID: 35455609 PMCID: PMC9024637 DOI: 10.3390/children9040565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 04/04/2022] [Accepted: 04/11/2022] [Indexed: 11/28/2022]
Abstract
Liver neoplasms are quite rare in childhood. They often involve 6.7 cases per 10 million children aged 18 years or younger. Hepatoblastoma (HB) is the most frequent tumor, but this neoplasm’s rarity points essentially to the difficulty of performing biologic studies and large-scale therapeutic trials. On the pathological ground, HB is separated into an entirely epithelial neoplasm or a mixed neoplasm with epithelial and mesenchymal components. This last category has been further subdivided into harboring teratoid features or not. The ‘teratoid’ HB includes a mixture of components with heterologous origin. The heterologous components include neuroectoderm, endoderm, or melanin-holding cells with or without mesenchymal components. The most important criterium for the teratoid component is neuroepithelium, melanin, and, more recently, a yolk-sac-like component and neuroendocrine components. The mesenchymal components include muscle, osteoid, and cartilage, which are most often observed mainly in ‘teratoid’ neoplasms. The teratoid component or mesenchymal components are diagnosed with biopsies. They appear more prominent after chemotherapy due to the response and shrinkage of epithelial elements and non- or low-responsive components of mixed HB. This review focuses on the clinical, radiological, and pathological findings of HB with teratoid features.
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5
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Kepple JW, Fishler KP, Peeples ES. Surveillance guidelines for children with trisomy 18. Am J Med Genet A 2021; 185:1294-1303. [PMID: 33527722 DOI: 10.1002/ajmg.a.62097] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 01/06/2021] [Accepted: 01/12/2021] [Indexed: 12/31/2022]
Abstract
Trisomy 18 is the second most common aneuploidy syndromes in live born infants. It is associated with high mortality rates, estimated to be 75%-95% in the first year of life, as well as significant morbidity in survivors. The low survival is largely due to the high prevalence of severe congenital anomalies in infants with this diagnosis. However, interventions to repair or palliate those life-threatening anomalies are being performed at a higher rate for these infants, resulting in increased rates of survival beyond the first year of life. While it is well documented that trisomy 18 is associated with several cardiac malformations, these patients also have respiratory, neurological, neoplastic, genitourinary, abdominal, otolaryngologic, and orthopedic complications that can impact their quality of life. The goal of this review is to present a comprehensive description of complications in children with trisomy 18 to aid in the development of monitoring and treatment guidelines for the increasing number of providers who will be caring for these patients throughout their lives. Where the evidence is available, this review presents screening recommendations to allow for more rapid detection and documentation of these complications.
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Affiliation(s)
| | - Kristen P Fishler
- Munroe-Meyer Institute for Genetics and Rehabilitation, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Eric S Peeples
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska, USA
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6
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Lucas DJ, Rubinstein J, Gosain A, Tiao G, Head T, Pratap JN, Williams R, Helmig S, Geller J, Langham M, Trobaugh-Lotrario A. Surgical and anesthetic management for hepatectomy in two pediatric patients with trisomy 18, pulmonary hypertension, and hepatoblastoma. Pediatr Blood Cancer 2019; 66:e27678. [PMID: 30803146 DOI: 10.1002/pbc.27678] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 02/01/2019] [Accepted: 02/02/2019] [Indexed: 11/06/2022]
Abstract
Children with trisomy 18 are surviving longer and undergoing more aggressive life-sustaining therapy. This report describes two patients with trisomy 18 and hepatoblastoma (HB) successfully resected in the setting of significant pulmonary hypertension. Forty-four previously published cases of the association between HB and trisomy 18 are reviewed. With careful multidisciplinary preoperative planning, successful resection of HB in children with trisomy 18 who have significant pulmonary hypertension is feasible. Because HB and trisomy 18 are increasing in prevalence, the need for timely liver tumor resection in the setting of pulmonary hypertension will be more common.
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Affiliation(s)
- Donald J Lucas
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Jeremy Rubinstein
- Department of Cancer and Blood Disease Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ankush Gosain
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee.,Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Greg Tiao
- Division of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Tim Head
- Department of Anesthesia, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - J Nick Pratap
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Regan Williams
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee.,Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Sara Helmig
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - James Geller
- Department of Cancer and Blood Disease Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Max Langham
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee.,Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Angela Trobaugh-Lotrario
- Division of Pediatric Hematology/Oncology, Providence Sacred Heart Children's Hospital, Spokane, Washington
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7
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Farmakis SG, Barnes AM, Carey JC, Braddock SR. Solid tumor screening recommendations in trisomy 18. Am J Med Genet A 2019; 179:455-466. [DOI: 10.1002/ajmg.a.61029] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 11/22/2018] [Accepted: 12/09/2018] [Indexed: 02/01/2023]
Affiliation(s)
- Shannon G. Farmakis
- Department of RadiologySaint Louis University School of Medicine and SSM Health Cardinal Glennon Children's Hospital St. Louis Missouri
| | - Ann M. Barnes
- The Support Organization for Trisomy 18, 13 and Related Disorders Rochester New York
| | - John C. Carey
- Department of PediatricsUniversity of Utah Salt Lake City Utah
| | - Stephen R. Braddock
- Division of Medical Genetics, Department of PediatricsSaint Louis University School of Medicine and SSM Cardinal Glennon Children's Hospital St. Louis Missouri
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8
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Inoue A, Suzuki R, Urabe K, Kawamura Y, Masuda M, Kishi K, Takitani K, Katayama H, Tomiyama H, Hayashi M, Nemoto S, Uchiyama K, Tamai H. Therapeutic experience with hepatoblastoma associated with trisomy 18. Pediatr Blood Cancer 2018; 65:e27093. [PMID: 29701292 DOI: 10.1002/pbc.27093] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 03/18/2018] [Accepted: 03/20/2018] [Indexed: 12/14/2022]
Abstract
Trisomy 18 is often fatal, but patients with this disease can now have longer survival due to proactive treatment intervention. However, hepatoblastomas may develop in these patients. In this study, we report four cases of hepatoblastoma associated with trisomy 18. All of the patients had congenital heart disease and three had undergone intracardiac surgical repair. Tumor growth was relatively slow in all cases, and there were no problems with chemotherapy tolerability and surgical resection. Three of the patients are currently disease-free and the fourth is alive with remaining of the tumor. These cases suggest that combined chemotherapy and surgical resection may be an option to treat hepatoblastoma associated with trisomy 18 when cardiac pulmonary function is relatively stable.
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Affiliation(s)
- Akiko Inoue
- Department of Pediatrics, Osaka Medical College, Takatsuki, Japan
| | - Ryo Suzuki
- Department of Pediatrics, Osaka Medical College, Takatsuki, Japan
| | - Keisuke Urabe
- Department of Pediatrics, Osaka Medical College, Takatsuki, Japan
| | - Yutaro Kawamura
- Department of Pediatrics, Osaka Medical College, Takatsuki, Japan
| | - Midori Masuda
- Department of Pediatrics, Osaka Medical College, Takatsuki, Japan
| | - Kanta Kishi
- Department of Pediatrics, Osaka Medical College, Takatsuki, Japan
| | | | - Hiroshi Katayama
- Department of Pediatrics, Osaka Medical College, Takatsuki, Japan
| | - Hideki Tomiyama
- Department of General and Gastroenterological Surgery, Osaka Medical College, Takatsuki, Japan
| | - Michihiro Hayashi
- Department of General and Gastroenterological Surgery, Osaka Medical College, Takatsuki, Japan
| | - Shintaro Nemoto
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College, Takatsuki, Japan
| | - Kazuhisa Uchiyama
- Department of General and Gastroenterological Surgery, Osaka Medical College, Takatsuki, Japan
| | - Hiroshi Tamai
- Department of Pediatrics, Osaka Medical College, Takatsuki, Japan
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9
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Satgé D, Nishi M, Sirvent N, Vekemans M. A tumor profile in Edwards syndrome (trisomy 18). AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2016; 172:296-306. [PMID: 27474103 DOI: 10.1002/ajmg.c.31511] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Constitutional trisomy 18 causes Edwards syndrome, which is characterized by intellectual disability and a particular set of malformations. Although this condition carries high mortality during prenatal and early postnatal life, some of the rare infants who survive the first months develop benign and malignant tumors. To determine the tumor profile associated with Edwards syndrome, we performed a systematic review of the literature. This review reveals a tumor profile differing from those of Down (trisomy 21) and Patau (trisomy 13) syndromes. The literature covers 45 malignancies: 29 were liver cancers, mainly hepatoblastomas found in Japanese females; 13 were kidney tumors, predominantly nephroblastomas; 1 was neuroblastoma; 1 was a Hodgkin disease; and 1 was acute myeloid leukemia in an infant with both trisomy 18 and type 1 neurofibromatosis. No instances of the most frequent malignancies of early life-cerebral tumors, germ cell tumors, or leukemia--are reported in children with pure trisomy 18. Tumor occurrence does not appear to correlate with body weight, tissue growth, or cancer genes mapping to chromosome 18. Importantly, the most recent clinical histories report successful treatment; this raises ethical concerns about cancer treatment in infants with Edwards syndrome. In conclusion, knowledge of the Edwards' syndrome tumor profile will enable better clinical surveillance in at-risk organs (i.e., liver, kidney). This knowledge also provides clues to understanding oncogenesis, including the probably reduced frequency of some neoplasms in infants and children with this genetic condition. © 2016 Wiley Periodicals, Inc.
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10
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Jongmans MCJ, Loeffen JLCM, Waanders E, Hoogerbrugge PM, Ligtenberg MJL, Kuiper RP, Hoogerbrugge N. Recognition of genetic predisposition in pediatric cancer patients: An easy-to-use selection tool. Eur J Med Genet 2016; 59:116-25. [PMID: 26825391 DOI: 10.1016/j.ejmg.2016.01.008] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Revised: 01/03/2016] [Accepted: 01/24/2016] [Indexed: 02/01/2023]
Abstract
Genetic predisposition for childhood cancer is under diagnosed. Identifying these patients may lead to therapy adjustments in case of syndrome-related increased toxicity or resistant disease and syndrome-specific screening programs may lead to early detection of a further independent malignancy. Cancer surveillance might also be warranted for affected relatives and detection of a genetic mutation can allow for reproductive counseling. Here we present an easy-to-use selection tool, based on a systematic review of pediatric cancer predisposing syndromes, to identify patients who may benefit from genetic counseling. The selection tool involves five questions concerning family history, the type of malignancy, multiple primary malignancies, specific features and excessive toxicity, which results in the selection of those patients that may benefit from referral to a clinical geneticist.
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Affiliation(s)
- Marjolijn C J Jongmans
- Department of Human Genetics, Radboud University Medical Center and Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands.
| | - Jan L C M Loeffen
- Department of Pediatric Oncology, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Esmé Waanders
- Department of Human Genetics, Radboud University Medical Center and Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | | | - Marjolijn J L Ligtenberg
- Department of Human Genetics, Radboud University Medical Center and Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Roland P Kuiper
- Department of Human Genetics, Radboud University Medical Center and Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Nicoline Hoogerbrugge
- Department of Human Genetics, Radboud University Medical Center and Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
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11
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Ahmad N, Wheeler K, Stewart H, Campbell C. Hepatoblastoma in a mosaic trisomy 18 child with hemihypertrophy. BMJ Case Rep 2016; 2016:bcr-2015-211380. [PMID: 26795740 DOI: 10.1136/bcr-2015-211380] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
To date, there are 12 reported cases of hepatoblastoma in trisomy 18 patients, three of whom had a mosaic chromosome pattern. We report on an 18-month-old child who had hemihypertrophy and developmental delay, was found to have hepatoblastoma on surveillance ultrasound scan, and was subsequently diagnosed with mosaic trisomy 18 on array comparative genomic hybridisation from a peripheral blood sample and molecular cytogenetic analysis of the tumour specimen. Although hemihypertrophy has been associated with mosaic trisomies, there are only a couple of published case reports of hemihypertrophy or asymmetry in mosaic trisomy 18 patients and none in the reported cases of hepatoblastoma in a mosaic trisomy 18 setting. We have reviewed the published case reports of hepatoblastoma in trisomy 18 patients and found that they seem to tolerate the intensive treatment very well if there are no significant comorbidities.
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Affiliation(s)
- Naveed Ahmad
- Department of Paediatric Oncology, University of Oxford Hospitals, NHS Trust, Oxford, UK
| | - Kate Wheeler
- Department of Paediatric Oncology, University of Oxford Hospitals, NHS Trust, Oxford, UK
| | - Helen Stewart
- Department of Clinical Cytogenetics, University of Oxford Hospitals, NHS Trust, Oxford, UK
| | - Carolyn Campbell
- Department of Clinical Cytogenetics, University of Oxford Hospitals, NHS Trust, Oxford, UK
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12
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Motta S, Sala D, Sala A, Cazzaniga G, Giudici G, Villa N, Biondi A, Selicorni A. Hodgkin lymphoma in a patient with mosaic trisomy 18: First clinical observation. Am J Med Genet A 2015; 170:777-80. [DOI: 10.1002/ajmg.a.37504] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 11/25/2015] [Indexed: 01/03/2023]
Affiliation(s)
- Serena Motta
- Department of Pediatrics; University of Milano-Bicocca; Monza e Brianza per il Bambino e la sua Mamma (MBBM) Foundation; Monza Italy
| | - Debora Sala
- Department of Pediatrics; University of Milano-Bicocca; Monza e Brianza per il Bambino e la sua Mamma (MBBM) Foundation; Monza Italy
| | - Alessandra Sala
- Department of Pediatrics; University of Milano-Bicocca; Monza e Brianza per il Bambino e la sua Mamma (MBBM) Foundation; Monza Italy
| | - Giovanni Cazzaniga
- Department of Pediatrics; Tettamanti Research Center; University of Milano-Bicocca, MBBM Foundation; Monza Italy
| | - Giovanni Giudici
- Department of Pediatrics; Tettamanti Research Center; University of Milano-Bicocca, MBBM Foundation; Monza Italy
| | - Nicoletta Villa
- Medical Genetics Laboratory; San Gerardo Hospital; Monza Italy
| | - Andrea Biondi
- Department of Pediatrics; University of Milano-Bicocca; Monza e Brianza per il Bambino e la sua Mamma (MBBM) Foundation; Monza Italy
| | - Angelo Selicorni
- Department of Pediatrics; Pediatric Genetic Unit; University of Milano-Bicocca, MBBM Foundation; Monza Italy
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13
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Rozell JM, Catanzano T, Polansky SM, Rakita D, Fox L. Primary Liver Tumors in Pediatric Patients: Proper Imaging Technique for Diagnosis and Staging. Semin Ultrasound CT MR 2014; 35:382-93. [DOI: 10.1053/j.sult.2014.05.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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14
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Hackl C, Schlitt HJ, Kirchner GI, Knoppke B, Loss M. Liver transplantation for malignancy: Current treatment strategies and future perspectives. World J Gastroenterol 2014; 20:5331-5344. [PMID: 24833863 PMCID: PMC4017048 DOI: 10.3748/wjg.v20.i18.5331] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Revised: 12/31/2013] [Accepted: 02/27/2014] [Indexed: 02/06/2023] Open
Abstract
In 1967, Starzl et al performed the first successful liver transplantation for a patient diagnosed with hepatoblastoma. In the following, liver transplantation was considered ideal for complete tumor resection and potential cure from primary hepatic malignancies. Several reports of liver transplantation for primary and metastatic liver cancer however showed disappointing results and the strategy was soon dismissed. In 1996, Mazzaferro et al introduced the Milan criteria, offering liver transplantation to patients diagnosed with limited hepatocellular carcinoma. Since then, liver transplantation for malignant disease is an ongoing subject of preclinical and clinical research. In this context, several aspects must be considered: (1) Given the shortage of deceased-donor organs, long-term overall and disease free survival should be comparable with results obtained in patients transplanted for non-malignant disease; (2) In this regard, living-donor liver transplantation may in selected patients help to solve the ethical dilemma of optimal individual patient treatment vs organ allocation justice; and (3) Ongoing research focusing on perioperative therapy and anti-proliferative immunosuppressive regimens may further reduce tumor recurrence in patients transplanted for malignant disease and thus improve overall survival. The present review gives an overview of current indications and future perspectives of liver transplantation for malignant disease.
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15
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M Turcotte L, G Spector L. What do we know about the etiology of hepatoblastoma? Hepat Oncol 2013; 1:7-10. [PMID: 30190935 DOI: 10.2217/hep.13.2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Lucie M Turcotte
- Division of Pediatric Hematology/Oncology, University of Minnesota, 420 Delaware Street SE, MMC 484, Minneapolis, MN 55455, USA.,Division of Pediatric Hematology/Oncology, University of Minnesota, 420 Delaware Street SE, MMC 484, Minneapolis, MN 55455, USA
| | - Logan G Spector
- Division of Pediatric Epidemiology & Clinical Research, University of Minnesota, 420 Delaware Street SE, MMC 422, Minneapolis, MN 55455, USA.,Division of Pediatric Epidemiology & Clinical Research, University of Minnesota, 420 Delaware Street SE, MMC 422, Minneapolis, MN 55455, USA
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16
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Case-control study of birth characteristics and the risk of hepatoblastoma. Cancer Epidemiol 2013; 37:390-5. [PMID: 23558166 DOI: 10.1016/j.canep.2013.03.004] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Revised: 03/05/2013] [Accepted: 03/06/2013] [Indexed: 11/22/2022]
Abstract
BACKGROUND Hepatoblastoma is a malignant embryonal tumor typically diagnosed in children younger than five years of age. Little is known on hepatoblastoma etiology. METHODS We matched California Cancer Registry records of hepatoblastomas diagnosed in children younger than age 6 from 1988 to 2007 to birth records using a probabilistic record linkage program, yielding 261 cases. Controls (n=218,277), frequency matched by birth year to all cancer cases in California for the same time period, were randomly selected from California birth records. We examined demographic and socioeconomic information, birth characteristics, pregnancy history, complications in pregnancy, labor and delivery, and abnormal conditions and clinical procedures relating to the newborn, with study data taken from birth certificates. RESULTS We observed increased risks for hepatoblastoma among children with low [1500-2499 g, Odds Ratio (OR)=2.02, 95% confidence interval (CI) 1.29-3.15] and very low birthweight (<1500 g, OR=15.4, 95% CI 10.7-22.3), preterm birth <33 weeks (OR=7.27, 95% CI 5.00, 10.6), small size for gestational age (OR=1.75, 95% CI 1.25-2.45), and with multiple birth pregnancies (OR=2.52, 95% CI 1.54-4.14). We observed a number of pregnancy and labor complications to be related to hepatoblastoma, including preeclampsia, premature labor, fetal distress, and congenital anomalies. CONCLUSION These findings confirm previously reported associations with low birthweight and preeclampsia. The relation with multiple birth pregnancies has been previously reported and may indicate a relation to infertility treatments.
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Rosa RFM, Rosa RCM, Zen PRG, Graziadio C, Paskulin GA. Trissomia 18: revisão dos aspectos clínicos, etiológicos, prognósticos e éticos. REVISTA PAULISTA DE PEDIATRIA 2013; 31:111-20. [DOI: 10.1590/s0103-05822013000100018] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Accepted: 05/21/2012] [Indexed: 12/21/2022]
Abstract
OBJETIVO: Revisar as características clínicas, etiológicas, diagnósticas e prognósticas da trissomia do cromossomo 18 (síndrome de Edwards). FONTES DE DADOS: Foram pesquisados artigos científicos presentes nos portais MedLine, Lilacs e SciELO, utilizando-se os descritores 'trisomy 18' e 'Edwards syndrome'. A pesquisa não se limitou a um período determinado e englobou artigos presentes nestes bancos de dados. SÍNTESE DOS DADOS: A síndrome de Edwards é uma doença caracterizada por um quadro clínico amplo e prognóstico bastante reservado. Há descrição na literatura de mais de 130 anomalias diferentes, as quais podem envolver praticamente todos os órgãos e sistemas. Seus achados são resultantes da presença de três cópias do cromossomo 18. A principal constituição cromossômica observada entre estes pacientes é a trissomia livre do cromossomo 18, que se associa ao fenômeno de não disjunção, especialmente na gametogênese materna. A maioria dos fetos com síndrome de Edwards acaba indo a óbito durante a vida embrionária e fetal. A mediana de sobrevida entre nascidos vivos tem usualmente variado entre 2,5 e 14,5 dias. CONCLUSÕES: O conhecimento do quadro clínico e do prognóstico dos pacientes com a síndrome de Edwards tem grande importância no que diz respeito aos cuidados neonatais e à decisão de instituir ou não tratamentos invasivos. A rapidez na confirmação do diagnóstico é importante para a tomada de decisões referentes às condutas médicas. Muitas vezes, as intervenções são realizadas em condições de emergência, sem muita oportunidade de reflexão ou discussão, e envolvem questões médicas e éticas difíceis.
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18
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Tomlinson GE, Kappler R. Genetics and epigenetics of hepatoblastoma. Pediatr Blood Cancer 2012; 59:785-92. [PMID: 22807084 DOI: 10.1002/pbc.24213] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Accepted: 05/08/2012] [Indexed: 12/23/2022]
Abstract
A number of unique genetic features are observed in hepatoblastoma that have provided insights into the origins of hepatoblastoma. Hallmark cytogenetic changes in hepatoblastoma include the acquisition of additional copies of whole chromosomes and a recurring unbalanced translocation involving 1q. Genetic syndromes are associated with approximately 15% of hepatoblastoma and the understanding and recognition of these syndromes will be important in determining future surveillance studies needed to prevent additional cancers in survivors as well as in some case guide the care of family members. This article will review the genetic changes, both germ line and acquired, that are recurring events in hepatoblastoma, with emphasis on how these genetic changes could work together with other developmental factors and influence cancer predisposition, tumor growth, as well as aid in prognosis. Tumor-specific signatures based on transcriptional or epigenetic alterations will be reviewed that might be used in the future to better diagnose and subtype the disease as well as predict prognosis and response to therapy.
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Affiliation(s)
- Gail E Tomlinson
- Department of Pediatrics, Greehey Children's Cancer Research Institute, University of Texas Health Science Center at San Antonio, San Antonio, Texas 78229, USA.
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Abstract
The trisomy 18 syndrome, also known as Edwards syndrome, is a common chromosomal disorder due to the presence of an extra chromosome 18, either full, mosaic trisomy, or partial trisomy 18q. The condition is the second most common autosomal trisomy syndrome after trisomy 21. The live born prevalence is estimated as 1/6,000-1/8,000, but the overall prevalence is higher (1/2500-1/2600) due to the high frequency of fetal loss and pregnancy termination after prenatal diagnosis. The prevalence of trisomy 18 rises with the increasing maternal age. The recurrence risk for a family with a child with full trisomy 18 is about 1%. Currently most cases of trisomy 18 are prenatally diagnosed, based on screening by maternal age, maternal serum marker screening, or detection of sonographic abnormalities (e.g., increased nuchal translucency thickness, growth retardation, choroid plexus cyst, overlapping of fingers, and congenital heart defects ). The recognizable syndrome pattern consists of major and minor anomalies, prenatal and postnatal growth deficiency, an increased risk of neonatal and infant mortality, and marked psychomotor and cognitive disability. Typical minor anomalies include characteristic craniofacial features, clenched fist with overriding fingers, small fingernails, underdeveloped thumbs, and short sternum. The presence of major malformations is common, and the most frequent are heart and kidney anomalies. Feeding problems occur consistently and may require enteral nutrition. Despite the well known infant mortality, approximately 50% of babies with trisomy 18 live longer than 1 week and about 5-10% of children beyond the first year. The major causes of death include central apnea, cardiac failure due to cardiac malformations, respiratory insufficiency due to hypoventilation, aspiration, or upper airway obstruction and, likely, the combination of these and other factors (including decisions regarding aggressive care). Upper airway obstruction is likely more common than previously realized and should be investigated when full care is opted by the family and medical team. The complexity and the severity of the clinical presentation at birth and the high neonatal and infant mortality make the perinatal and neonatal management of babies with trisomy 18 particularly challenging, controversial, and unique among multiple congenital anomaly syndromes. Health supervision should be diligent, especially in the first 12 months of life, and can require multiple pediatric and specialist evaluations.
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Affiliation(s)
- Anna Cereda
- Ambulatorio Genetica Clinica Pediatrica, Clinica Pediatrica Universita Milano Bicocca, Fondazione MBBM A.O, S, Gerardo Monza, Italy
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Uekusa S, Sugito K, Kawashima H, Yoshizawa S, Furuya T, Ohashi K, Ikeda T, Koshinaga T, Mugishima H. Successful treatment for hepatoblastoma in a 1-year-old boy with trisomy 18. Pediatr Int 2012; 54:428-30. [PMID: 22631576 DOI: 10.1111/j.1442-200x.2011.03528.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Shota Uekusa
- Department of Pediatric Surgery, Nihon University School of Medicine, Tokyo, Japan
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Abstract
We report a case of hepatoblastoma in a 10-year-old girl with mosaic-type trisomy 18. A comprehensive literature review reveals only 2 cases involving mosaic trisomy 18 patients. Our patient underwent an abbreviated chemotherapy course before complete surgical resection. Her hepatoblastoma did not contain cells with trisomy 18. The conservative management approach resulted in a successful outcome; she remains disease free >2 years after surgery. Along with presenting a literature review, this report demonstrates a favorable outcome in a mosaic trisomy 18 child with hepatoblastoma where tumor cells lacked a trisomy 18 karyotype.
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Abstract
PURPOSE Hepatoblastoma is a rare childhood liver malignancy with limited relevant cytogenetic data. This study aimed to discover common genomic copy-number variations (CNVs) in subjects with hepatobalstoma and its relevance to the clinical course. METHODS Gene copy-number was systemically rated by high-resolution comparative genomic hybridization (CGH) DNA oligonucleotide microarray. The study group consisted of 12 children (7 males and 5 females) with hepatoblastoma and another 20 healthy individuals (10 males and 10 females) as controls. The influence of recurrent CNVs on clinical outcomes was analyzed. RESULTS Four highly recurrent CNVs were identified in these 12 hepatoblastoma children after comparison with controls, including a gain on 1p13.3 (n = 3, 25%) and losses on 5p15.33 (n = 4, 33.3%), 16q12.2 (n = 4, 33.3%), and 19q13.42 (n = 3, 25%). The most prevalent sites of genomic deletion were 5p15.33 and 16q12.2. Zinc finger, DHHC-type containing 11 (ZDHHC11) and DHHC-type containing 11B (ZDHHC11B) were mapped to 5p15.33, which was associated with a lower rate of survival with native liver (p = 0.03). The carboxylesterase 4-like (CES4) gene that mapped to 16q12.2 was associated with smaller tumor size at presentation. CONCLUSIONS Deletions of 5p15.33 (33.3%) and 16q12.2 (33.3%) are the most frequent hepatoblastoma-related events in our patient group with 5p15.33 microdeletion as a potential biomarker for the fate of survival with native liver.
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Hepatoblastoma and prune belly syndrome: a potential association. Pediatr Nephrol 2011; 26:1269-73. [PMID: 21597971 DOI: 10.1007/s00467-011-1874-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Revised: 02/28/2011] [Accepted: 03/03/2011] [Indexed: 10/18/2022]
Abstract
Prune belly syndrome (PBS) is a congenital anomaly characterized by the clinical triad of lax abdominal musculature, bilateral cryptorchidism, and abnormalities of the kidney and urinary tract. Previous reports of malignancy in patients with PBS have been limited to germ cell tumors. Hepatoblastoma (HBL) is the most common hepatic malignancy of childhood, affecting approximately 100 children each year in the USA. We describe a set of 4 pediatric patients with PBS and HBL. All individuals were born after 2002. These subjects lacked genetic, natal, or environmental factors known to confer risk of HBL. The occurrence of PBS and HBL in these patients constitutes a novel potential association.
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Multifocal hepatoblastoma in a 6-month-old girl with trisomy 18: a case report. J Med Case Rep 2009; 3:8319. [PMID: 19830224 PMCID: PMC2726543 DOI: 10.4076/1752-1947-3-8319] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2008] [Accepted: 01/22/2009] [Indexed: 01/08/2023] Open
Abstract
Introduction Edward's syndrome (trisomy 18) is a rare entity with a reported incidence of 1/3000 to 1/7000 births. Less than 10% of patients survive beyond the first year of life, which may influence the fact that malignant tumors are rarely reported in association with this syndrome. Case presentation The authors report a rare case of a 6-month-old girl with trisomy 18 and multifocal hepatoblastoma. The course of the disease, autopsy results and review of the literature are presented. Conclusion Our case represents the seventh published case of hepatoblastoma in a patient with trisomy 18. All of the seven published cases were women, possibly due to the high preponderance of females among the children with Edward's syndrome and longer survival of females with trisomy 18 compared to males. Since both trisomy 18 and hepatoblastoma are rare conditions, the probability that a child with trisomy 18 will independently develop a hepatoblastoma is very low. Therefore, we believe that the existence of these cases in children with trisomy 18 indicates a significant association. It can be assumed that trisomy 18 potentiates the development of hepatoblastoma. Careful clinical and post-mortem studies are needed to recognize the real frequency of hepatoblastoma in children with trisomy 18, who might die from different causes with unrecognizable hepatoblastoma.
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Ganmore I, Smooha G, Izraeli S. Constitutional aneuploidy and cancer predisposition. Hum Mol Genet 2009; 18:R84-93. [PMID: 19297405 DOI: 10.1093/hmg/ddp084] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Constitutional aneuploidies are rare syndromes associated with multiple developmental abnormalities and the alterations in the risk for specific cancers. Acquired somatic chromosomal aneuploidies are the most common genetic aberrations in sporadic cancers. Thus studies of these rare constitutional aneuploidy syndromes are important not only for patient counseling and clinical management, but also for deciphering the mechanisms by which chromosomal aneuploidy affect cancer initiation and progression. Here we review the major constitutional aneuploidy syndromes and suggest some general mechanisms for the associated cancer predisposition.
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Affiliation(s)
- Kenichi Maruyama
- Department of Neonatology, Gunma Children's Medical Center, Gunma, Japan.
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Scheil S, Hagen S, Brüderlein S, Leuschner I, Behnisch W, Möller P. Two novel in vitro human hepatoblastoma models, HepU1 and HepU2, are highly characteristic of fetal-embryonal differentiation in hepatoblastoma. Int J Cancer 2003; 105:347-52. [PMID: 12704668 DOI: 10.1002/ijc.11082] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Using comparative genomic hybridization (CGH), we present a genome-wide screening of a mixed mesenchymal-epithelial hepatoblastoma, its recurrence and 2 novel hepatoblastoma cell lines raised from the ascites, 18 (HepU1) and 23 (HepU2) months after diagnosis of a hepatoblastoma in a 35-month-old boy. Both cell lines were also characterized by GTG-banding, multicolor-fluorescence in situ hybridization (M-FISH) and multicolor banding (M-Band). On the basis of CGH, we compared the cytogenetics of histologically different tumor areas of the parental tumor and its recurrence with the hepatoblastoma cell lines. We found different CGH profiles in the parental tumor rev ish enh(1q31-q32,8p,12,17,20,X), dim(4q34-q35,18q23)[cp] and its recurrence rev ish enh(8q24,17,Xq26-q28), dim(7q11.2-q21,13q34)[cp]. Although both epithelial cell lines were obtained at different times and the clonal ancestor of HepU2 had been exposed to a higher cumulative dose of chemotherapy, HepU1 and HepU2 have an identical karyotype: 48-56,XY,+Y,dup(2)(q32-q34),t(3;4)(q21;q34),+8,+12,+13, +17,+t(18;19)(q21;q?),+20[cp] and identical CGH profiles: rev ish enh(2q24-q33,8,12,13q,17,20), dim(4q34-q35,18q22-q23). In common with previously described hepatoblastoma cell lines, HepU1 and HepU2 demonstrate a gain of chromosome 20. The in situ aberrations most closely resembling that of HepU1 and HepU2 were found in areas of fetal-embryonal differentiation of the primary tumor. Interestingly, both cell lines mimic this histology in their three-dimensional growth pattern in vitro. HepU1 and HepU2 are thus cytogenetically and phenotypically highly characteristic of fetal-embryonal hepatoblastoma.
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Affiliation(s)
- Stefanie Scheil
- Institute of Pathology, University Hospitals of Ulm, Germany.
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Kisato Y, Nishikubo T, Uchida Y, Kuwahara I, Minowa H, Kamitsuji H, Kanehiro H, Park YD, Sasaki F. Hepatoblastoma in a low-birthweight infant complicated with cleft palate, Dandy-Walker malformation and chronic lung disease. Pediatr Int 2002; 44:698-701. [PMID: 12421276 DOI: 10.1046/j.1442-200x.2002.01617.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Yoriko Kisato
- Neonatal Intensive Care Unit, Perinatal Medical Center, Nara Prefectural Hospital, Japan
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