Gastrointestinal tumors in children and adolescents

Surgical management of children with Burkitt's lymphoma involving the gastrointestinal tract

PURPOSE

To investigate the clinical characteristics and surgical management of children with Burkitt's lymphoma (BL) involving the gastrointestinal tract.

METHODS

A retrospective analysis was conducted on 87 pediatric patients diagnosed with BL involving the gastrointestinal tract and treated surgically at Beijing Children's Hospital (2008-2022). All patients were histopathologically confirmed with BL and diagnosed with gastrointestinal involvement through imaging studies and surgery. Clinical data were reviewed and analyzed.

RESULTS

Among 87 patients, 79 were male and 8 were female, with an average age of 6.8 ± 3.3 years. Predominant clinical manifestations included abdominal pain (74/87, 85.1%) and abdominal mass (45/87, 51.7%). The ileocecal region (31/87, 35.6%) was the most frequent involvement site. The presence of intussusception (58/87, 66.7%) was the main indication for surgery, of which 56 (56/58, 96.6%) underwent enterectomy and anastomosis. Twenty-two (22/87, 25.3%) patients underwent surgery for abdominal mass, with 15 (15/22, 68.2%) receiving an open biopsy. During the follow-up period, 2 patients (2/83, 2.4%) experienced recurrence, 4 patients (4/83, 4.8%) required reoperation, and no deaths were reported.

CONCLUSION

The main surgical indications for gastrointestinal BL are intussusception and abdominal mass. Surgery plays a crucial role in resolving intussusception, clarifying the diagnosis, and ultimately facilitating the timely initiation of chemotherapy without delay.

Imaging of pediatric gastrointestinal tumors: A tertiary center experience over 19 years

PURPOSE

Gastrointestinal tract (GIT) tumors in children are rare and there is a scarcity of data on their imaging features. The purpose of this study was to determine thefrequency of various GIT tumor types in children and to identify key imaging characteristics.

METHODS

This retrospective, single-center study was approved by the local ethics committee. Children with histologically proven GIT tumours (malignantand benign) who had imaging available on the institutional PACS between May 1, 2000 and Dec 31, 2019 were included. Demographic data and available imaging was reviewed by two blinded radiologists.

RESULTS

In total, 90 children (45 male, mean age 9.3 ± 4.3 years) with GIT tumours were included. The final diagnoses included polyps (n = 28), lymphomas/PTLD (n = 27), neuroendocrine tumours (n = 16), adenocarcinoma (n = 6), adenoma (n = 5), gastrointestinal stromal tumor (GIST) (n = 3), inflammatory myofibroblastic tumours (n = 2) and lastly leiomyoblastoma, leiomyoma and lipoma (1 each). All GIT segments were affected, but overall the small and large bowel had most lesions. Eighty-one percent children had a single lesion while remaining 19 % had multiple lesions. The neoplastic process manifested as intra-luminal lesion (58 %) or wall thickening (42 %) on imaging. Multiple cystic areas and vascular pedicle for polyps; and hypoechogenecity of the mass or wall thickening and aneurysmal dilatation for lymphomas, were the characteristic imaging features. None of the neuroendocrine tumours affecting appendix were seen on pre-resection imaging.

CONCLUSIONS

Variety of benign and malignant tumors are seen throughout the childhood. Polyps, lymphomas and appendiceal neuroendocrine tumors are common lesions. Characteristic imaging features of juvenile polyps and lymphomas on ultrasound may help narrowing the differentials, and guide further work up.

Intestinal Intussusception Complicating an Undiagnosed Burkitt Lymphoma in a Pediatric Arab Patient

Burkitt's lymphoma (BL) is considered an aggressive form of a non-Hodgkin B-cell lymphoma, representing less than 5% of all pediatric malignancies and 30% of pediatric lymphomas. However, intestinal BL may present as a lead point, causing intussusception. Surgery continues to be the gold standard for the treatment and identification of localized tumors to ensure complete removal with proper margin. In this report, we describe a hidden BL presenting as intestinal intussusception in an eight-year-old Arab boy. A computed tomography (CT) scan of the abdomen revealed an ileoileal intussusception with multiple enlarged lymph nodes. The report discusses the role of histopathology, supported by immunohistochemistry studies, in establishing the diagnosis. It also covers the significance of proper laparoscopic surgery and chemotherapy in the management of this child.

Clinical characteristics and prognostic factors for primary pediatric and adolescent Non-Hodgkin Lymphomas of the gastrointestinal tract: a population-based study

PURPOSE

To investigate the clinical features and survival outcomes of primary gastrointestinal non-Hodgkin lymphomas (PGINHL) in pediatric and adolescent population, we conducted a population-based cohort study.

METHODS

All pediatric and adolescent patients with PGINHL diagnosed between 2000 and 2019 were identified using the Surveillance, Epidemiology, and End Results (SEER) database. Kaplane-Meier estimations were used to generate survival curves based on various criteria. To compare survival curves, the log-rank test was applied. A multivariate Cox proportional hazards model was developed to investigate the effect of each component on overall survival.

RESULTS

A total of 334 pediatric and adolescent with PGINHL patients were identified. The median age at diagnosis was 12 years (range 1.0-19 years). Tumors were most commonly found in the small bowel (47.3%), followed by the large bowel (42.8%) and the stomach (9.9%). Overall, the most common histological subtype was Burkitt lymphoma (56.9%), followed by diffuse large B-cell lymphoma (DLBCL) (27.8%). Overall survival rates for all patients were 92.2% at 5- year and 91.6% at 10- year, respectively. The Cox proportional hazard regression revealed that only chemotherapy was an important independent predictor in this model. Patients with chemotherapy have a higher survival rate than those without.

CONCLUSIONS

Our study revealed that only chemotherapy was found to be the most important predictor of the OS in pediatric and adolescent PGINHL, providing critical information for therapeutic care.

A rare case of primary gastric Hodgkin lymphoma in an adolescent with Nijmegen breakage syndrome

BACKGROUND

Nijmegen Breakage Syndrome (NBS) is a rare autosomal recessive DNA repair disorder that increases risk of hematological malignancy. Primary gastric malignancies are exceedingly rare in pediatric patients and not typically high on the differential of abdominal pain.

CASE PRESENTATION

A 14-year-old male with NBS presented with persistent abdominal pain and was diagnosed with primary Hodgkin disease of the stomach.

CONCLUSIONS

In pediatric patients with predisposition to malignancies, such as those with underlying chromosome instability disorders, all symptoms must be carefully considered.

Intestinal tumor lesions leading to intussusception in children: a report of four cases and literature review

Background

Intussusception is commonly idiopathic in children. Pathologic lead points (PLP) especially intestinal tumors (IT) are extremely rare. The diagnosis of intussusception secondary to pediatric IT is difficult due to the non-specific nature of symptoms. Its management remains a challenge. We report here four pediatric cases of intussusception secondary to IT lesions in order to analyze the clinical and therapeutic characteristics of this unusual condition.

Case presentations

Four children were diagnosed and operated in our center for intussusception secondary to IT during the period from February 2017 to February 2021. Patients’ demographics, clinical presentations, investigations, operative data, and postoperative outcome were recorded and analyzed. There were three girls and one boy. Ages ranged between 1 and 8 years (average of 5.5 years). Intermittent abdominal pain with acute exacerbation and vomiting were the main clinical signs. Radiologic investigations showed the intussusception in all cases but the tumor lead point was evident only during the surgical exploration in most cases. All patients underwent surgical treatment with intussusception reduction and mass removal. Pathological examination of these masses revealed: submucosal intestinal lipoma (1 case), hamartomatous polyposis (2 cases), and Burkitt’s lymphoma (1 case). For this last case, adjuvant chemotherapy was also needed. The postoperative period was uneventful in all cases.

Conclusion

Pediatric intussusception secondary to IT lesions is an unusual and challenging condition that requires high preoperative diagnostic suspicion, considerate intraoperative judgment, and appropriate postoperative follow-up for successful outcomes.

These tumors should be considered by the pediatric surgeons as possible PLP for recurrent intussusception, especially in older children. Surgeons should be familiar with the various treatment options, because the real cause of the intussusception is often accurately diagnosed by laparotomy.

Imaging findings of gastrointestinal tract tumors in children and adolescents

Gastrointestinal (GI) tract tumors are rarely seen in children and adolescents, and can easily be misdiagnosed. Lymphoma is the most frequent GI tract tumor, and the common locations are ileum and ileocecal area. GI tract tumors may present as large heterogeneous mass lesions. For gastric and colonic tumors, increased wall thickening usually prompts the diagnosis of GI tract tumors. Computed tomography and magnetic resonance imaging might be used in clinically suspected cases for correct/appropriate diagnosis and management. Awareness as regards the most common tumors and their locations is paramount for radiologists. Likewise, the aim of this article was to define the imaging findings of primary benign and malignant GI tract tumors in children and adolescents.

Anemia induced by hemangioma at the duodenal papilla, resected by endoscopic mucosal resection

A 7-year-old ever healthy girl presented to our hospital with anemia for half-a-year, and her lowest hemoglobin level was 75g/L. She denied any hematemesis or melena, however her fecal occult blood test was positive. Computed tomography revealed an oval lesion in the descending duodenum.

Efficacy of Prednisone in Children with Acute Nonspecific Mesenteric Lymphadenitis: A Pilot Study

BACKGROUND

Acute nonspecific mesenteric lymphadenitis (ANML) is a common cause of acute abdominal pain in children with no specific treatment.

METHODS

A total of 13 patients (6 boys, 7 girls) aged 7.3 (5-13.5) years with severe acute abdominal pain were evaluated using ultrasonography and laboratory tests to establish the diagnosis of ANML. They were treated with prednisone 1 mg/kg (max 40 mg daily) for a maximum of 5 days. The intensity of abdominal pain was evaluated before and after treatment using a numeric rating scale.

RESULTS

All patients had pain scores above 6/10 before, and below 4/10 after treatment with prednisone. Intensity of abdominal pain after treatment for 1-5 days decreased significantly (p < 0.001), with no recurrence at follow-up within 3 months. All other pre-existing signs and symptoms, such as nausea, vomiting, anorexia, fever, diarrhea, and constipation were found to disappear with no adverse effects of corticosteroid therapy.

CONCLUSION

These results suggest that the treatment with prednisone in selective patients with ANML can reduce the duration of abdominal pain.

Clinical features and outcomes of bowel perforation in primary pediatric gastrointestinal lymphoma

Background

Whether surgery can improve the prognosis of patients with primary pediatric gastrointestinal lymphoma (PPGL) who experienced bowel perforation remains controversial. This study aimed to evaluate the prognosis of such patients.

Methods

Nine patients pathologically diagnosed with PPGL who experienced perforation at our center between January 2010 and December 2020 were enrolled and divided into two groups: those with perforation during (n = 4) and before (n = 5) chemotherapy. Their medical records were reviewed, and long-term follow-up was conducted by telephone in February 2021.

Results

All patients with perforation during chemotherapy were diagnosed with PPGL in the outpatient department. The mean time from outpatient visit to chemotherapy was 17.3 ± 6.1 days. Two patients experienced perforation during the first chemotherapy regimen and received conservative treatment, while the others developed perforation after multiple chemotherapy regimens and underwent surgery. All of the patients received regular chemotherapy and survived for a mean follow-up time of 3.8 ± 1.9 years. No patient with perforation before chemotherapy had a definite diagnosis in the outpatient department. Among these patients, 4 experienced perforation and underwent surgery, of whom 3 developed perforation-related complications and died; the other recurred after chemotherapy. Only the patient who received conservative treatment was diagnosed with PPGL before chemotherapy, received regular chemotherapy, and survived without a recurrence for 1.0 year.

Conclusion

Prompt diagnosis and chemotherapy improve the prognosis of PPGL. Surgery does not affect the prognosis of patients with perforation during chemotherapy but may accelerate disease progression in patients with perforation before chemotherapy.

Clinicopathological Study of Primary Pediatric Gastrointestinal Lymphomas

Background:

Primary gastrointestinal lymphomas (PGIL) are uncommon in children and account for <5% of all pediatric malignancies. The objective of our study was to analyze the prognostic factors of pediatric PGILs with reference to its histological subtypes, stage, and outcomes using immunohistochemistry.

Materials and Methods:

Twenty cases were studied over 11 years. Clinicopathological profiles, histological details, and immunohistochemical (IHC) profiles were analyzed.

Results:

The mean age at the presentation was 6 years. Using IHC stains (CD CD10, CD19, CD20, CD3, terminal deoxynucleotidyl transferase, BCL 2 and 6, PAX 5, and MUM1), diffuse large B-cell lymphoma (DLBCL) was most prevalent (45%), followed by Burkitt lymphoma (35%) and lymphoblastic lymphoma (20%). DLBCLs (9) were classified using the Han's algorithm. Six were activated B-cell and 3 were germinal center B-cell subtypes. The cases of lymphoblastic lymphoma and those in Stage I disease had the best prognosis.

Conclusion:

Pediatric PGILs have variable presentation, outcomes, and diverse treatment modalities depending on the histological subtypes. A panel of IHC stains can be a useful adjunct for the categorization and prognosis of pediatric PGILs.

Gastrointestinal and oncologic outcomes of pediatric gastrointestinal lymphoma following upfront resection or biopsy of bowel masses

PURPOSE

Complete upfront resection of pediatric gastrointestinal lymphomas is recommended over biopsy whenever feasible, but either approach may have adverse sequelae. We sought to compare gastrointestinal and oncological outcomes of pediatric gastrointestinal lymphomas who underwent attempted upfront resection or biopsy of the presenting bowel mass.

METHODS

We retrospectively reviewed charts of children with gastrointestinal lymphomas treated on LMB89 and LMB96 protocols from 2000 to 2019 who underwent upfront gastrointestinal surgery, and compared resection and biopsy groups.

RESULTS

Of 33 children with abdominal lymphomas, 20 had upfront gastrointestinal surgery-10 each had resection or biopsy. Patients with attempted upfront resections had fewer postoperative gastrointestinal complications compared to biopsies (10% vs. 60%, p = 0.057), but longer time to chemotherapy initiation (median 11.5 vs. 4.5 days, p < 0.001). Three resection patients were surgically down-staged. Second surgeries were required in 30% and 40% of resected and biopsied patients, respectively, at median 4.6 months. Survival was similar in both groups, but better in patients on LMB96 protocol and stage II/III disease.

CONCLUSIONS

Children with upfront attempted resection had low rates of surgical down-staging, greater delay in chemotherapy initiation, but fewer gastrointestinal complications and subsequent surgeries than biopsies. Survival was similar regardless of upfront surgery, likely reflecting beneficial effects of newer protocols.

Pediatric hematolymphoid pathology in the gastrointestinal tract

Hematolymphoid processes involving the gastrointestinal tract in the pediatric and adolescent young adult (AYA) populations include processes occurring primarily within the gastrointestinal tract as well as systemic diseases with predilection for gastrointestinal involvement. Here, we present a focused review of reactive and neoplastic entities occurring in the pediatric and AYA age groups.

Neonatal Bowel Obstruction by Pseudolymphoma: A Case Report

Interstitial obstruction in newborn infants can be caused by several factors such as malrotation, meconium plug syndrome, meconium ileus, Hirschsprung's disease, atresia and stenosis. Neonates who have been diagnosed with an interstitial obstruction are in need of immediate treatment; otherwise, they can deteriorate rapidly. Surgery remains the mainstay of treatment in most cases. Pediatric gastrointestinal tumours are very rare, especially in newborn infants. Their management is usually different as compared to adults. We present the case of a newborn infant who was born with interstitial obstruction. At the 31 weeks scan, a significant dilation of the small bowel was observed and the diagnosis of interstitial obstruction was made. When born, the newborn was transferred to a specialised unit and underwent a laparotomy. The findings were consistent with a tumour causing the obstruction; the histology reported this tumour as benign lymphoid hyperplasia. Pseudolymphoma is a very rare cause of fetal interstitial obstruction, and it should be considered in the differential diagnosis.

Ileocecal Burkitt's Lymphoma Presenting as Acute Abdominal Pain

Primary gastrointestinal non-Hodgkin's lymphomas are rare tumors which account for about 0.9% of all gastrointestinal tract tumors. They are usually associated with inflammatory bowel disease, previous radiotherapy, and renal transplantation. We report a case of non-Hodgkin's lymphoma involving the ileocecal region in a 46-year-old gentleman who presented with acute abdominal pain that mandated emergency laparotomy.

Endoscopic Removal of a Single, Painless, Juvenile Polyp in the Small Intestine Causing Anemia

Juvenile polyps are the most common gastrointestinal polyps in childhood. Typically, they are located in the colon and present with intermittent and painless hematochezia. A few case reports have described juvenile polyps in the small intestine, all presenting as intussusception requiring surgery. We report an isolated juvenile polyp in the small intestine presenting with painless anemia, identified using video capsule endoscopy, and removed via enteroscopy.

Pediatric gastric adenocarcinoma: A National Cancer Data Base review

PURPOSE

We sought to compare the presentation, management, and outcomes in gastric adenocarcinoma cancer for pediatric and adult patients.

METHODS

Using the 2004 to 2014 National Cancer Database (NCDB), patients ≤21 years (pediatric) were retrospectively compared to >21 years (adult). Chi-squared tests were used to compare categorical variables, and Cox regression was used to estimate hazard ratios (HR) for survival differences.

RESULTS

Of the 129,024 gastric adenocarcinoma cases identified, 129 (0.10%) occurred in pediatric patients. Pediatric cases presented with more advanced disease, including poorly differentiated tumors (81% vs 65%, p = 0.006) and stage 4 disease (56% vs 41%, p = 0.002). Signet ring adenocarcinoma comprised 45% of cases in the pediatric group as compared to 20% of cases in the adults (P < 0.001). Similar proportions in both groups underwent surgery. However, near-total gastrectomy was more common in the pediatric group (16% vs 6%, p < 0.001). The proportions of patients with negative margins, nodal examination, and presence of positive nodes were similar. There was no overall survival difference between the two age groups (HR 0.92, 95% Confidence interval 0.73-1.15).

CONCLUSION

While gastric adenocarcinoma in pediatric patients present with a more advanced stage and poorly differentiated tumors compared to adults, survival appears to be comparable.

TYPE OF STUDY

Retrospective cohort study.

LEVEL OF EVIDENCE

III.

Primary lymphoma of the colon: report of two cases and review of literature

BACKGROUND

Gastrointestinal tract is the most frequent site of extranodal lymphoma accounting for approximately 40% of all extranodal lymphomas; out of these, non-Hodgkin's lymphoma (NHL) comprises 4% of total cases. Primary lymphoma arising in the colon is very rare comprising only 0.2-1% of all colonic malignancy.

PATIENTS AND METHODS

We report two cases of 13- and 20-year-old boys with NHL of colon presenting with abdominal pain and weight loss and discuss the approach to colonic lymphoma after a review of world literature to provide an overview on colonic lymphoma.

RESULTS

Colonic NHL most commonly affects older age group with mean age of diagnosis being 55 years. Abdominal pain and weight loss are the two most common presentations with palpable abdominal mass as physical examination finding in half of the cases.

CONCLUSIONS

Colonic lymphoma in young adolescence is rare. Multimodality approach involving both surgery and chemotherapy is the principal mode of treatment. Radiotherapy is used in selected cases. If diagnosed preoperatively, non-surgical management can be attempted.

Aneurysmal dilation of bowel mimicking an abscess in pediatric primary gastrointestinal lymphoma

Primary gastrointestinal lymphoma, though rare, is the most common gastrointestinal malignancy in children. Signs and symptoms are nonspecific, and include abdominal pain, nausea, emesis, and a palpable abdominal mass. Imaging is therefore typically required to differentiate gastrointestinal lymphoma from other abdominal conditions. We present a pediatric case of primary gastrointestinal lymphoma involving the distal bowel that was initially misdiagnosed as an intra-abdominal abscess. This case highlights the imaging findings of primary gastrointestinal lymphoma, potential pitfalls in imaging diagnosis, and the role of accurate imaging diagnosis in expediting patient management to reduce associated morbidity and mortality.

Primary gastric Burkitt lymphoma-induced anaemia: a case report and a literature review

Background.

Primary tumours of the gastrointestinal tract are very uncommon in children. They can present with anaemia caused by gastrointestinal acute or chronic bleeding. One of the most common gastrointestinal tumours is Burkitt lymphoma. This lymphoma is a highly aggressive, rapidly growing B-cell neoplasm, making survival without treatment possible only for a few weeks. For this reason it requires immediate hospitalization and treatment.

Case report.

We report a case of a gastric Burkitt lymphoma in an adolescent girl who presented with anaemia due to gastrointestinal bleeding. She received out-patient care with iron medications orally due to suspected iron-deficiency anaemia but there was no sufficient effect. The patient was referred to Children’s Oncohematology Department with a progression of symptoms (weakness, fatigue, sound in the ears, and nausea) five months after anaemia was diagnosed in the complete blood count. The imaging tests showed a massive solid tumour with bleeding in the stomach. The final diagnosis was a histologically atypical Burkitt lymphoma. Chemotherapy treatment was started according to NHL-BFM 2004 paediatric protocol.

Conclusions.

Non-Hodgin’s lymphoma is the most common malignancy of the gastrointestinal tract in children and about 75% of these tumours are Burkitt lymphomas. They can present with anaemia in the complete blood count due to bleeding. Reticulocyte test and serum ferritin level test help to differentiate pathophysiological origin of anaemia. Combination chemotherapy according to standardized protocols is the best current standard of care and has a very good clinical response without unfavourable risk factors.

Gastrointestinal tract carcinoma in pediatric and adolescent age: The Italian TREP project experience

BACKGROUND

Gastrointestinal (GI) carcinomas are very rare in the pediatric and adolescent age range. We report the clinical features, treatment, and outcome of a series of children and adolescents with GI carcinoma prospectively registered in the Italian Tumori Rari in Età Pediatrica (TREP) project.

METHODS

The TREP project developed diagnostic and therapeutic guidelines based on recommendations currently in use for adults. Clinical data were centrally registered and reviewed.

RESULTS

Fifteen patients were registered over the years 2000-2016. Most of the tumors were colorectal carcinomas (12 cases). All but one patient had advanced-stage disease (American Joint Committee on Cancer stages III-IV), and the majority of patients had aggressive histological subtypes, i.e. poorly differentiated (G3) (five patients), mucinous (four patients), and signet ring (two patients) adenocarcinomas. Surgery was performed in 13 of 15 patients, and was radical in nine of 13 patients. Only one patient received postoperative radiotherapy. All patients received chemotherapy, with the addition of bevacizumab in two cases. Nine patients were still alive at the time of the present report, but two of them had only just completed their treatment program and one patient is still on treatment. Six patients died due to disease progression.

CONCLUSIONS

This prospective report on pediatric GI tract carcinomas confirms the rarity and biological aggressiveness of these diseases in pediatric and adolescent age. Further prospective studies are needed to explore the distinct biology of tumor in this age group in order to find new therapeutic targeted agents.

A 17-year-old male with a Small Bowel Neuroendocrine Tumor: flushing differential diagnosis

Background

Neuroendocrine tumors (NETs) are heterogeneous neoplasms that originate from cells with a secretory function. Small bowel NETs (SB-NETs) are related to serotonin hypersecretion which causes: flushing, diarrhea, abdominal pain, bronchoconstriction and heart involvement, also known as carcinoid syndrome (CS). CS can be confused with an allergic reaction and thus should be considered as a differential diagnosis in the allergy consult. We present the case of a pediatric patient initially referred under the suspicion of food allergies.

Case presentation

We present the case of a 17-year-old male with evanescent non-pruriginous erythematous lesions- flushing that appeared with food consumption, associated with conjunctival injection, warmth and diaphoresis after the lesions disappeared. He denied abdominal pain, diarrhea, cough or wheezing. The 24-h urinary 5-hydroxyindoleacetic acid (5-HIAA) excretion was elevated. The CT scan showed thickening of the distal ileum and multiple lesions on both hepatic lobules and the colonoscopy revealed a tumor in the ileocecal valve. Hepatic and intestinal biopsies reported a well-differentiated NET of the ileocecal valve with hepatic metastasis. He was started on octreotide and underwent a wide hepatectomy and right hemicolectomy with improvement of symptoms.

Conclusions

NETs can present as carcinoid syndrome (flushing, diarrhea, abdominal pain, wheezing), which constitutes vague symptomatology and represents a challenging diagnosis for physicians. They can be confused with an allergic reaction and the allergist should consider it as a differential diagnosis. Accurate diagnostic tests will help to diagnose NETs earlier and potentially prevent carcinoid heart disease, bowel obstruction, and improve quality of life and mortality in these patients.

Immature enteric ganglion cells were observed in a 13-year-old colon signet ring cell carcinoma patient: A case report and literature review

RATIONALE

All the enteric ganglion cells are fully mature by 2 to 5 years of age in human. No one had reported the presentation of immature enteric ganglion cells in elder ones. Colorectal carcinoma is also rare in the adolescent population. The coincidence of these 2 rare events in a 13-year-old boy has never been reported elsewhere, which may suggest some linkage between them.

PATIENT CONCERN

A 13-year-old boy presented with progressive abdominal pain and melena for 3 months. Computed tomography (CT) scan and endoscopic ultrasonography showed significant abnormality in the transverse colon characteristic of marked mural thickening. The biopsy results indicated signet ring cell carcinoma.

DIAGNOSES

A 13-year-old male patient with advanced colon signet ring cell carcinoma. In addition, immature but not mature ganglion cells could be observed in almost all of the slices of the resected nontumorous area of the specimen.

INTERVENTIONS

The transverse colon tumor was resected and the subsequent histopathological examination confirmed the diagnosis of primary colon signet ring cell carcinoma. Then the patient received adjuvant chemotherapy and biological target therapies subsequently.

OUTCOMES

After 6 cycles of adjuvant chemotherapy and biological target therapies, metastasis was however detected within a year.

LESSONS

In this case, a 13-year-old male patient with advanced colon signet ring cell carcinoma were presented. Unexpectedly, immature ganglion cells could be observed in almost all of the slices of the resected nontumorous area of the specimen. It is critical to raise medical awareness and improve the diagnosis and treatment of the signet ring cell carcinoma. This malignancy and the immature ganglion cells may be associated, possibly caused by some unidentified genetic defects. Genome sequencing, histopathological examination, and long-term follow-up of young patients with related diseases, would help further reveal the potential relationship between tumorigenesis and ganglion cells' immaturity, contributing to understanding the molecular mechanisms.

Enteric Duplication Cyst Leading to Volvulus: An Unusual Cause of Acute Intestinal Obstruction - A Case Report

Enteric Duplication Cysts (EDC) is a rare congenital malformation, usually found in mesenteric side of Gastrointestinal (GI) tract. Generally patients present with non-specific symptoms depending on size and location of the cyst in GI tract. EDC presenting as small bowel volvulus is a rare clinical entity. Herein, we are reporting a 16-year-old adolescent girl who presented to Emergency Department (ED) with the features of acute bowel obstruction with septicemia. Patient underwent exploratory laparotomy which revealed dilated, twisted, gangrenous bowel due to a cystic lesion adjacent to the mesenteric side. Resection of the cystic lesion along with the affected gangrenous segment of bowel with an end to end anastomosis performed.

Rare Case of Primary Gastric Burkitt Lymphoma in a Child

Primary gastric tumors are very rare in children. Burkitt lymphoma is a common type of non-Hodgkin's lymphoma, and gastric Burkitt lymphoma usually occurs in the aged. When involving the gastrointestinal tract, primary gastric Burkitt lymphoma is very rare in younger childhood. Many gastric lymphomas including mucosa-associated lymphoid tissue lymphoma are associated with Helicobacter pylori infection or acute bleeding symptom. We report a seven-year-old boy who presented with only some vomiting and postprandial pain. His upper gastrointestinal endoscopy and biopsy revealed a large primary Burkitt lymphoma with no acute bleeding and no evidence of H. pylori infection. After chemotherapy, he remains in remission.

Anal Canal Carcinoma in a Child With Disorders of Sex Development

Squamous cell carcinoma of the anal canal in children is rare. To date, the etiology and outcome of this condition have been not fully understood. Here, we report an 11-year-old child with anal canal cancer who had concomitant disorders of sex development. Radiotherapy followed by salvage surgery achieved disease-free survival of 3 years. Since overexpression of cell cycle regulatory protein p16 was immunohistochemically evident in tumor tissue, human papillomavirus infection was considered as a causative factor in the carcinogenesis.

Well-differentiated neuroendocrine tumor of the stomach: A rare case at an uncommon site

INTRODUCTION

A 13-year-old African-American female presented to her primary care physician's office with fatigue, syncope, and hematemesis. After initial evaluation, the patient was referred to pediatric gastroenterology clinic for further evaluation.

MAIN CONCERNS, IMPORTANT FINDINGS

An upper gastrointestinal endoscopy was performed to evaluate the source of her bleeding. Endoscopy revealed a 3-cm mass in the lesser curvature of the stomach, and a biopsy of the mass revealed a concern for carcinoid (neuroendocrine) features.

DIAGNOSIS

She underwent an open gastrectomy. Post-surgical pathology reports confirmed a well-differentiated neuroendocrine tumor of the stomach.

CONCLUSION

Neuroendocrine tumors of the stomach in children are rare and we presently do not have pediatric-specific diagnostic and treatment guidelines. Although adult-based The North American Neuroendocrine Tumor Society (NANETS) guidelines are helpful, they are clearly not geared toward pediatric patients. To establish pediatric guidelines and to assess effectiveness of treatments, multicenter data collection is essential. In the long run, accumulation of clinically useful treatment information and long-term follow-up guidelines should enable clinicians to improve standard of care given to children with neuroendocrine tumors.

Enteric duplication cyst as a leading point for ileoileal intussusception in an adult: A rare cause of complete small intestinal obstruction

Duplication of alimentary tract (DAT) presenting as an ileoileal intussusception is a very rare clinical entity. Herein, a case of an ileoileal intussusception due to DAT is presented. A 32-year-old woman was hospitalized due to diffuse, intermittent abdominal pain, vomiting and constipation for 3 d associated with abdominal distention. Plain abdominal X-ray revealed dilated small bowel. Abdominal computed tomography showed grossly dilated small bowel with “sausage” and “doughnut” signs of small bowel intussusception. She underwent laparotomy, with findings of ileoileal intussusception due to a cystic lesion adjacent to the mesenteric side. Resection of the cystic lesion along with the affected segment of intestine, with an end to end anastomosis was performed. The histopathology was consistent with enteric duplication cyst. This case highlights the DAT, although, an uncommon cause of adult ileoileal intussusception should be considered in the differential diagnosis of intussusception in adults, particularly when the leading point is a cystic lesion.

Carcinoid tumours of the appendix in children having appendicectomies at Princess Margaret Hospital since 1995

AIM

The diagnosis of carcinoid tumour is a relatively rare one. Our surgical approach has changed over the last two decades from predominantly open to predominately laparoscopic with a tendency to leave the mesoappendix in situ. The aim of this audit was to identify how many cases we had at PMH and to see whether the shift in surgical approach allowed us to make prognostic decisions in keeping with current best practice and whether this made any difference in further surgery requirements or outcome for patients.

METHODS

A retrospective review of all cases of carcinoid identified in our search of all appendicectomy histopathology results was conducted. Results were compared to those found in other studies. Duration of follow up and further investigations was reviewed, as was whether or not there was any recurrence.

RESULTS

Our incidence of carcinoid tumours in patients undergoing appendicectomy since 1995 was 0.35%, similar to that in other centres. None of our patients had surgery beyond an appendicectomy and our active follow up varied from none to 6 months. There were no recurrences in this time.

CONCLUSIONS

The literature review carried out suggests further meta-analysis is needed including data on long term follow up before definitive guidelines regarding extent of surgical treatment and follow up based on histopathology are created. The condition is rare and the studies small, resulting in no clear consensus on the best practice for tumours measuring between 1 and 1.5 cm in diameter. Our surgical approach to appendicectomies has changed; it is unclear whether this has resulted in a change in outcome.

Hepatic metastatic disease in pediatric and adolescent solid tumors

The management of hepatic metastatic disease from solid tumors in adults has been extensively described and resection of metastatic liver lesions from colorectal adenocarcinoma, renal adenocarcinoma, breast cancer, testicular cancer, and neuroendocrine tumors (NET) have demonstrated therapeutic benefits in select patients. However, there are few reports in the literature on the management of hepatic metastatic disease in the pediatric and adolescent populations and the effectiveness of hepatic metastasectomy. This may be due to the much lower incidence of pediatric malignancies and the higher chemosensitivity of childhood tumors which make hepatic metastasectomy less likely to be required. We review liver involvement with metastatic disease from the main pediatric solid tumors, including neuroblastoma and Wilms tumor focusing on the management and treatment options. We also review other solid malignant tumors which may have liver metastases including germ cell tumors, gastrointestinal stromal tumors, osteosarcoma, desmoplastic small round cell tumors and NET. However, these histological subtypes are so rare in the pediatric and adolescent populations that the exact incidence and best management of hepatic metastatic disease are unknown and can only be extrapolated from adult series.

Colorectal carcinoma in first decade of life: our experience

INTRODUCTION

Though the lifetime risk of colorectal carcinoma (CRC) in general population is 5-6 %, it is uncommon in pediatric age group. Here, we are reporting our experience of CRC in the first decade of life.

METHODS

From January 2010 to December 2013, seven patients with histopathologically confirmed colorectal carcinoma were treated in the Department of Pediatric Surgery, Chittagong Medical College and hospital. Age, sex, presenting symptoms, location of the primary tumor, serum CEA level, treatment modalities and outcomes were evaluated.

RESULTS

There were four male and three female patients and age ranged from 6.5 to 10.5 years. Rectum (3 patients) and rectosigmoid (2 patients) were the most common primary sites. Serum carcinoembryonic antigen level was obtained in six patients and in only one patient the level was raised markedly (137 ng/ml). Two patients of familial adenomatous polyposis had localized disease and others presented in an advanced stage. Histopathologically, poorly differentiated adenocarcinoma was noted in five patients with one signet ring cell type and well differentiated in rest of the two patients. Only one patient was surviving at the last follow up.

CONCLUSION

Advanced stage at diagnosis, aggressive histologic subtype and poor survival are the hallmarks of pediatric CRC.

Nonurological malignancies in children

Context:

Nonurological malignancies in children include a wide variety of tumors. These tumors include primary tumors of the liver, thyroid, lung, gastrointestinal tract (GIT), and adrenals; soft tissue sarcomas (STSs) like rhabdomyosarcoma (RMS) and non-RMS; and finally extragonadal germ cell tumors (GCT).

Aims:

This article aims at describing the current thinking in the management of these childhood solid tumors. This is critical in view of the recent advances in the elucidation of the molecular, genetic, and biologic behavior of these tumors and how these factors are getting integrated not only in the staging but also in developing a risk-based approach towards the management of these tumors.

Materials and Methods:

Reference was made to recently published literature from the leading pediatric cancer centers of the world to make a sense of things of the most current thinking in this rapidly expanding field. This will provide surgeons and physicians taking care of these children with a working knowledge in this somewhat challenging field.

Conclusions:

Treatment results vary from center to center depending on access to resources and following different management protocols. Results have improved for these tumors with the advent of newer chemotherapeutic agents, novel delivery methods of radiation therapy (RT), and improvement in surgical technique. Due to the limited number of patients presenting with these tumors, national and international collaboration of data is critical for all and beneficial to individual treatment centers. This has resulted in better results in the past and will definitely result in still better results in the future.

Laparoscopic-Assisted Endoscopic Resection of a Gastric Leiomyoma

Leiomyomas are infrequent benign intestinal tumors that can arise at any age and location within the gastrointestinal (GI) tract. These tumors can cause symptoms including abdominal pain, obstruction, intussusception, volvulus, GI bleeding, or a mass and should be resected if symptomatic. Open surgical resection is considered the standard for removing these tumors. However, recent improvements in endoscopic and laparoscopic equipment have made it possible to utilize minimally invasive techniques of tumor removal including complete endoscopic resection or endoscopic-assisted laparoscopic resection. We present the case of an adolescent female with a large mass located at the gastroesophageal junction (GEJ) causing GI bleeding. Given the location of the mass near the GEJ and the morbidity associated with surgical resection, we performed laparoscopic-assisted complete endoscopic resection of tumor. In addition, this tumor had an unusual immunohistochemical-staining pattern, with focal expression of markers more often seen in GI stromal tumors, elucidating a gray area between these two tumor classes with potential implications for patient follow-up. Laparoscopic-assisted endoscopic resection of benign tumors is a useful technique that can be employed to facilitate resection of mucosal and subserosal masses near the GEJ with minimal morbidity.

Abdominal inflammatory myofibroblastic tumor

A 28-year-old woman was referred to our hospital because of abdominal pain, weight loss and a palpable intra-abdominal mass. A CT scan revealed a tumor with a diameter of 7 cm with sharp margins, intra-tumoral fatty components and enhancing soft tissue. After initial workup, which suggested an inflammatory myofibroblastic tumor (IMT), she underwent laparotomy with complete resection. Pathological examination indeed revealed IMT. IMT is a rare benign neoplasm and has been described in nearly the entire body. It presents with nonspecific symptoms. The therapy of abdominal IMT consists of radical surgery because of high local recurrence rates. In this case report clinical, surgical, radiological and histological features with a review of the relevant literature are described.

Ileal duplication mimicking intestinal intussusception: A congenital condition rarely reported in adult

Intestinal duplication is an uncommon congenital condition in young adults. A 25-year-old man complained of chronic, intermittent abdominal pain for 3 years following previous appendectomy for the treatment of suspected appendicitis. Abdominal discomfort and pain, suggestive of intestinal obstruction, recurred after operation. A tubular mass was palpable in the right lower quadrant. Computed tomography enterography scan identified suspicious intestinal intussusception, while Tc-99m pertechnetate scintigraphy revealed a cluster of strip-like abnormal radioactivity in the right lower quadrant. On exploratory laparotomy, a tubular-shaped ileal duplication cyst was found arising from the mesenteric margin of the native ileal segment located 15 cm proximal to the ileocecal valve. Ileectomy was performed along with the removal of the duplication disease, and the end-to-end anastomosis was done to restore the gastrointestinal tract continuity. Pathological examination showed ileal duplication with ectopic gastric mucosa. The patient experienced an eventless postoperative recovery and remained asymptomatic within 2 years of postoperative follow-up.

Inflammatory fibroid polyp: a rare benign tumor of the alimentary tract in children presenting as intussusception-case report and review of literature

Inflammatory fibroid polyp (IFP) represents a rare cause of gastrointestinal polypoid disease in childhood. Τhe lesion has been described by various names beyond the currently accepted term, including “Vanek's tumour,” eosinophilic or submucosal granuloma, gastric fibroma with eosinophilic infiltration, inflammatory pseudotumor, and hemangiopericytoma. The etiopathogenesis and origin of the mesenchymal spindle-shaped cells that comprise the polyp remains enigmatic. Recent studies have shown familial occurrence, expression of platelet-derived growth factor receptor (PDGFRA) and oncogenic PDGFRA mutations in the majority of lesions, suggestive of a neoplastic nature. We present a rare case of a 10-year-old boy with an IFP of the terminal ileum, who presented acutely with intussusception and was treated with a right hemicolectomy. Postoperative course was uneventful and the patient has been asymptomatic during follow-up. Histopathology and immunohistochemical analysis excluded inflammatory myofibroblastic tumor (negative for Alk1, desmin, smooth muscle actin [SMA]), gastrointerstinal stromal tumors (GIST) (negative for CD117) and schwannoma (negative for S100). The lesion was positive for CD34 and faintly for vimentin. Despite the classification of IFPs as a mesenchymal benign neoplasm, in the vast majority of cases, surgical excision alone was curative, and no reports exist of a malignant transformation. A cautious approach with periodic surveillance of the affected children seems reasonable though.

Obstructing apple core lesion of the rectum: a case report of inflammatory pseudotumor masquerading as colorectal carcinoma

Inflammatory pseudotumor is a rare lesion which can occur, typically in children and young adults, in many different organ systems. The tumor often clinically behaves like a cancer but without histological evidence of malignancy. This case study of a 14 year-old boy is the first report in the literature of an inflammatory pseudotumor presenting as an obstructing apple core lesion, mimicking a rectal carcinoma. A six-week course of non-steroidal, anti-inflammatory drugs (NSAIDs) led to complete resolution of the mass, and following resection of a residual stricture, the patient has been recurrence-free for seven years.

Colon carcinoma in childhood: review of the literature with four case reports

PURPOSE

Colorectal cancer (CRC) in childhood is extremely rare, and only a few case reports exist. We hereby present four cases of childhood CRC along with a literature review.

METHODS

A retrospective review of four cases from our institute was conducted, and 15 articles from PubMed describing childhood CRC were reviewed.

CASE REPORTS

Four patients ranging in age from 11 to 14 years were treated for colon cancer between the years 2000 and 2011. The presenting symptoms varied and included abdominal pain, nausea, vomiting, diarrhea, constipation, and hematochezia, with symptom duration ranging from a few days to 4 months. No patient had a predisposing disease or syndrome. All patients underwent surgical resections, with the most prevalent histology being mucinous adenocarcinoma. Despite radical surgery followed by systemic chemotherapy, the disease progressed in all patients.

LITERATURE REVIEW

A total of 239 cases were reviewed. The youngest patient was 6 years old. The most frequent predisposing conditions were hereditary nonpolyposis colorectal cancer and familial adenomatous polyposis. Most of the patients presented advanced stage, with the most common histopathologic diagnosis being mucinous adenocarcinoma, followed by poorly differentiated adenocarcinoma and signet ring cell carcinoma. Even though most of the patients underwent aggressive treatment, the overall prognosis was poor.

CONCLUSIONS

Childhood CRC has an aggressive pathology and distinct genetic features, which result in an advanced stage at diagnosis and consequently a poor prognosis. Although the incidence is very low, every physician should be aware of CRC as a possible childhood diagnosis.

Erkrankungen und Therapieformen des unteren Gastrointestinaltrakts

Duodenalatresien sind Hemmungsfehlbildungen und können proximal oder distal der Papilla Vateri entstehen, wobei die präpapillären Obstruktionen selten sind. Grundsätzlich kann zwischen einer Membranatresie und einer Defektatresie unterschieden werden. Die Unterscheidung beruht nicht nur auf embryologischen Gesichtspunkten, sondern hat auch eine klinische Bedeutung: Bei der Membranatresie kann die quergestellte, partiell offene oder geschlossene Membran weit in den distalen Duodenalanteil reichen („Windsackphänomen“), was zu diagnostischen und auch intraoperativen Problemen führen kann. Ein Pancreas anulare findet sich bei etwa 20 % aller Patienten mit Duodenalatresie.

Primary pediatric gastrointestinal lymphoma

Background:

Primary non-Hodgkin's lymphoma (NHL) of the gastrointestinal (GI) tract is the most common extranodal lymphoma in pediatric age group. Yet, the overall incidence is very low. The rarity of the disease as well as variable clinical presentation prevents early detection when the possibility of cure exists.

Materials and Methods:

We studied six cases of primary GI NHL in pediatric age group with reference to their clinical presentation, anatomic distribution and histopathologic characteristics.

Results:

All were males except one. Intestinal obstruction was the presenting feature in 50%. Half the cases showed ileocaecal involvement, while large bowel was involved in 16%. Histology showed four cases of diffuse large B-cell lymphoma (DLBCL), one case of Burkitt lymphoma, and one Burkitt-like lymphoma. Immunohistochemistry for Tdt, CD20, CD3, CD30, bcl2, bcl6 confirmed the morphological diagnosis.

Conclusion:

Pediatric GI lymphoma commonly involves the ileocaecal region and presents with intestinal obstruction. A higher prevalence of DLBCL is found compared to other series. A high proliferative index is useful in differentiating Burkitt-like lymphoma from DLBCL.

Different clinical manifestations between primary gastrointestinal malignancies and benign tumors in children

OBJECTIVE

The purpose of the present study was to review the different clinical manifestations of primary gastrointestinal (GI) malignancies and benign tumors in pediatric patients.

METHODS

The demographic data, duration to diagnosis, clinical features, laboratory data, location and pathology of the tumors, and outcomes of pediatric patients from January 1984 to December 2009 were retrospectively reviewed.

RESULTS

A total of 24 GI malignancies and 62 benign tumors were diagnosed. Patients in the benign group were mostly diagnosed in the first decade of life (73%), whereas majority of patients with malignancies were older than 10 years (79%). The most common tumor location in the benign group was the colorectum, whereas in the malignant group, tumors were distributed equally in the small intestine and colorectum. The median duration from onset to diagnosis in the benign group was longer than that of the malignant group (P>00.05). There was statistically significant increase in the presence of hematochezia in patients with benign tumor compared with those with malignancy (P<00.05). Among the malignancies, 79% presented with abdominal pain, followed by weight loss (25%), anorexia (25%), palpable mass (25%), and fever (21%), with statistically significant differences compared with the benign group (P<00.05). Anemia was found in 47% to 63% of patients in both groups (P>00.05). Two patients with polyposis subsequently developed malignancy.

CONCLUSIONS

Different manifestations of GI malignancies and benign tumors may help pediatricians to detect these early. Patients with polyposis should be aware of the risk of malignant change.

Primary Burkitt's lymphoma of the colon--an uncommon cause of acute constipation and abdominal pain

Constipation is a common problem in children and adolescents, accounting for over 25% of all visits to pediatric gastroenterologists. Approximately 95% of childhood constipation is functional in nature. Primary gastrointestinal malignancies are rare in childhood and adolescence. When present in the gastrointestinal tract, Burkitt's lymphoma is typically located in the ileocecal region. We present a case of primary Burkitt's lymphoma of the transverse colon in an adolescent presenting with acute exacerbation of constipation, abdominal pain, and later, rectal bleeding and progressive weight loss.

Torsed reactive nodular fibrous pseudotumor in an adolescent: case report and review of the literature

We describe a case of a 13-year-old girl presenting with acute abdominal pain and imaging suggesting acute appendicitis. Upon laparoscopy, she was found to have a mass attached to the jejunum that had torsed upon its blood supply. On histopathologic studies, the mass was determined to be a reactive nodular fibrous pseudotumor. This lesion is a benign neoplasm that may arise from the gastrointestinal tract and has only been recently described in the literature. Our case is unique because it is the first report of reactive nodular fibrous pseudotumor presenting as a torsed polypoid lesion and the first arising in an adolescent.