Alpha-fetoprotein (AFP) levels in normal children

Effect of maternal polycystic ovary syndrome (PCOS) on screening of aneuploidy in the first and second trimesters

BACKGROUND

Polycystic ovary syndrome (PCOS) is characterized by insulin resistance and hormonal disorder in women. This study aimed to assess the effect of maternal PCOS on screening of aneuploidy in the first and second-trimesters.

METHODS

This case-control study was conducted in Arash Hospital and Nilou Laboratory in 2017-2018. The screening test was conducted on 90 PCOS and 90 healthy mothers. Finally, the first and second-trimester screening was compared between the two groups using Chi-square, Mann-Whitney's U and students T tests and regression model by SPSS 21. P < 0.05 was considered as statistically significant.

RESULTS

Free Beta-Human Chorionic Gonadotropin (Free-β-HCG) (P = 0.04), inhibin-A (P = 0.001) and Alpha Fetoprotein (AFP) (P = 0.02) levels were higher in the PCOS women comparing to the healthy women but there was no significant difference between the mean of HCG, Plasma Protein A (PAPP-A), and Unconjugated Estriol (UE3) between the two groups. Pre-eclampsia (P < 0.001) and trisomy 18 risks in quad screening were higher in the PCOS women (P = 0.002) than the control group; however, trisomy 13, trisomy 18 and trisomy 21 risks, Smith-Lemli-Opitz Syndrome (SLOS) and Neural Tube Defect (NTD) risks were not different between the two groups. The logistic regression model showed that the first- and second-trimester screening of aneuploidywas related to PCOS.

CONCLUSIONS

There was a significant difference in the mean of free-β-HCG, inhibin-A, AFP level, and the risks of pre-eclampsia, SLOS and trisomy 18 between the two groups but no significant association was found in the mean of HCG, PAPP-A, UE3, NTD and other aneuploidies between the two groups. PCOS may affect the first- and second-trimester screening tests and pregnancy health. It may also require correction in the calculation of risks related to the first- and second-trimester screening for aneuploidy.

Development of the Serum α-Fetoprotein Reference Range in Patients with Beckwith-Wiedemann Spectrum

OBJECTIVE

To establish reference ranges for serum α-fetoprotein (AFP) at various ages in patients with Beckwith-Wiedemann spectrum (BWSp), to better predict the risk for hepatoblastoma in this population.

STUDY DESIGN

A retrospective analysis of AFP measurements collected from patients with BWSp was performed. Factors including sex, prematurity, molecular diagnosis of patients, and performing laboratory were evaluated for significant differences. In total, 1372 AFP values were collected from 147 patients and the predictive AFP values at various ages were calculated to establish reference ranges. Mixed-effects polynomial regression models were used to study various potential factors affecting log(AFP) values.

RESULTS

Overall, predicted AFP values declined to normal range for age (<10 ng/mL) by 14 months old. Patient sex and performing laboratory were found not to influence values. A significant difference was demonstrated between premature and nonpremature patients, and separate reference values were established. Significant differences in the predicted AFP value were not broadly apparent between molecular subtypes; however, interpretation was limited due to the small sample size of some of these subtypes.

CONCLUSIONS

Predictive AFP values were created for premature and nonpremature patients with BWSp to aid with interpretation and monitoring of the risk for hepatoblastoma. Further analysis is needed to determine whether AFP values differ within the less common molecular subtypes of patients with BWSsp.

FDG PET/CT Evaluation of Pediatric Patients With Yolk Sac Tumor

OBJECTIVE. The objective of our study was to evaluate the clinical utility of FDG PET/CT in staging and restaging pediatric patients with yolk sac tumor (YST). MATERIALS AND METHODS. We retrospectively reviewed the data from 31 pediatric patients with pathologically confirmed YST who underwent 34 PET/CT studies for the purpose of staging or restaging. The PET/CT studies were read by two nuclear medicine doctors in consensus. Histopathology combined with clinical and imaging follow-up was taken as the reference standard. The results of PET/CT were also compared with conventional imaging and α-fetoprotein (AFP) levels when available. RESULTS. Of the total 34 studies, six were performed for initial staging and the other 28 for posttherapy evaluation. FDG PET/CT was true-positive in all six staging studies, detected only a few more metastatic foci than conventional imaging, and changed the therapeutic regimen in none of the six patients. Nevertheless, PET/CT showed high accuracy in the restaging group, with a sensitivity of 100% and specificity of 85.7%. The treatment regimen was changed in 46.4% of the patients in the restaging group according to the PET/CT study. In addition, PET/CT had higher accuracy than AFP levels in YST restaging. Overall, the per-study performance of PET/CT was a sensitivity of 100%, specificity of 85.7%, positive predictive value of 90.9%, and negative predictive value of 100%. CONCLUSION. FDG PET/CT was only slightly superior to conventional imaging in staging YST in pediatric patients. However, PET/CT of posttherapy patients with YST showed high diagnostic accuracy and had a great impact on therapeutic management.

Serum AFP levels in patients suffering from 47 different types of cancers and noncancer diseases

Alpha-fetoprotein (AFP) is a glycoprotein and belongs to the gene family of serum albumins. The serum AFP levels were found to be elevated in the sera of liver cancer patients in 1964 and were subsequently developed and used as a liver cancer biomarker. However, elevated serum AFP levels have been observed in patients suffering from other cancer and noncancer diseases. Up to date, a systematic comparison of the serum AFP levels in different diseases has not been reported. In current study, 66,682 clinical lab test results of serum AFP levels from healthy individuals and patients with 47 different types of diseases during the past 5 years were retrieved and analyzed. Based on the mean (SD), median, and p (-Log₁₀p) values, we found that patients suffering from liver, breast, esophagus, cervical, pancreatic, endometrial, gastric, lung, rectum cancers in addition to noncancer diseases cirrhosis, nephrotic syndrome, and gastritis had significantly (p<0.05) increased, whereas patients suffering from multiple myeloma, Wilms' tumor, and other 22 types of noncancer diseases had significantly decreased median serum AFP levels than that of healthy controls. Moreover, patients with liver cancer, cirrhosis, lymphoma, bone fracture, and Wilms' tumor had highest mean serum AFP levels and the biggest SD values. In summary, the increased serum AFP levels were most evident but not specific for liver cancer patients. The potential clinical use of the increased or decreased serum AFP levels for other types of cancer and noncancer diseases and the molecular mechanisms behind our current findings need to be investigated.

Half-life of alpha-fetoprotein in neonatal sacrococcygeal teratoma

BACKGROUND

Alpha-fetoprotein (AFP) is useful as a tumor marker for sacrococcygeal teratoma (SCT). We investigated the half-life of AFP in SCT.

METHODS

Neonates who underwent surgical treatment for SCT between 1997 and 2016 were included in the study, whereas patients who died before or after surgery or had malignant germ cell tumors were excluded.

RESULTS

Fifty-five non-recurrent SCT patients (M:F = 18:37) were enrolled. They underwent surgery on average 7.4 ± 4.1 days after birth. Serum AFP was measured an average 4.25 ± 2.07 times per patient. We obtained 165 half-lives following the formula (M = Mo * (1/2) ^Δt/T). A positive correlation was observed between half-life and patient age using the formula T_1/2 = 0.0597 × days +6.1643 (p < 0.001). It was different from recurrent SCT (T_1/2 = 0.1196 × days -0.0633) (p < 0.05). Half-life was different between mature SCT (T_1/2 = 0.0671 × days +4.3912) and immature SCT (T_1/2 = 0.0433 × days +8.9339) (p < 0.05).

CONCLUSION

The half-life of AFP in neonatal patients with SCT was prolonged in proportion to the age, and it was getting longer in recurrent tumor than non-recurrent tumor. The half-life of AFP was longer in immature teratoma than in mature teratoma.

LEVEL OF EVIDENCE

IV.

Serum α-fetoprotein in pediatric oncology: not a children’s tale

Background

Measurement of α-fetoprotein (AFP) concentrations in the serum of infants is useful for the management of testicular germ cell tumors, hepatoblastoma and hepatocellular carcinoma. Here, we provide a critical review of the available information about pediatric reference intervals (RI), focusing on their utility in interpreting AFP as an aid for cancer diagnosis.

Content

Evidence sources in the available literature were critically appraised. Out of 3873 retrieved papers, 24 were finally selected and carefully inspected, and six of them overcame exclusion criteria (i.e. methodological limitations in the study design, statistical gaps, drawbacks in traceability of the AFP assay to higher order materials and/or biased reporting of AFP results). Preterm and term infants up to the 3rd month of life exhibited the highest average AFP concentrations, but the attempt of defining RI by data pooling and partitioning for age intervals was impeded by the wide variability of data. The inability of defining robust RI in the first months of life made difficult, if not impossible, using upper reference limits for ruling out malignancies with a single AFP result. Evaluating the behavior of AFP concentrations 5 days from the baseline result, if this exceeds risk thresholds partitioned for age, according to the formula Xt=X0*2−t/HL (where: t=days elapsed for AFP retest; HL=AFP half-life according to age; X0=AFP baseline concentration, and Xt=predicted AFP concentration at day 5), could give a better information.

Summary

Novel studies defining AFP RI in infants based on robust methodology are warranted to improve the interpretation of AFP results in pediatric oncology. In the meantime, algorithms based on both serum AFP absolute concentrations and HL may aid in cancer diagnosis.

Elevated Serum Levels of Alpha-Fetoprotein in Patients with Infantile Hemangioma Are Not Derived from within the Tumor

Aims

The embryonic-like stem cell origin of infantile hemangioma (IH) and the observed elevated serum levels of alpha-fetoprotein (AFP) in patients with hepatic IH led us to investigate if this tumor was the source of AFP.

Materials and methods

We measured serial serum levels of AFP in patients with problematic proliferating IH treated with surgical excision or propranolol treatment. We also investigated the expression of AFP in extrahepatic IH samples using immunohistochemical staining, mass spectrometry, NanoString gene expression analysis, and in situ hybridization.

Results

Serum levels of AFP normalized following surgical excision or propranolol treatment. Multiple regression analysis for curve fittings revealed a different curve compared to reported normal values in the general populations. AFP was not detected in any of the IH samples examined at either the transcriptional or translational levels.

Conclusion

This study demonstrates the association of proliferating IH with elevated serum levels of AFP, which normalized following surgical excision or propranolol treatment. We have shown that IH is not the direct source of AFP. An interaction between the primitive mesoderm-derived IH and the endogenous endodermal tissues, such as the liver, via an intermediary, may explain the elevated serum levels of AFP in infants with extrahepatic IH.

Long-Term Outcomes of Sacrococcygeal Germ Cell Tumors in Infancy and Childhood

Purpose. The aim of this study was to evaluate long-term outcomes of sacrococcygeal germ cell tumors (SC-GCTs) over a 15-year period. Materials and Methods. A retrospective review was conducted of all pediatric patients treated for SC-GCTs at our hospital from 1998 to 2012. Results. Fifty-seven patients were treated for SC-GCTs with the most common in Altman's classification type I. Age at surgery ranged from one day to 5.6 years. Tumor resection and coccygectomy were primarily performed in about 84% of the cases. Pathology revealed mature, immature, malignant sacrococcygeal teratomas (SCTs), and endodermal sinus tumors (ESTs) in 41 (72%), 4 (77%), 6 (10.5%), and 6 (10.5%), respectively. Recurrence of discase occurred in 3 of 41 patients with mature teratomas (7.3%); 2 recurrences with mature teratomas and one recurrence with EST. Five of 6 malignant SCTs and 3 of 6 ESTs responded well to the treatment. Alpha-fetoprotein (AFP) level was elevated in both malignant teratomas and ESTs. No immediate patient death was noted in any of the 57 cases, but 4 patients with malignant tumors and distant metastasis succumbed at home within 2 years of the initial treatment. Conclusion. Benign SCTs have a significant recurrence rate of approximately 7%. Close follow-up with serial AFP level monitoring should be done for 5 years after initial tumor resection and coccygectomy. The survival rate for malignant SC-GCTs with distant metastasis was unfavorable in the present study.

Meconium peritonitis presenting as abdominal calcification: three cases with different pathology

Intra-abdominal calcification is uncommon in newborns and has several causes of which meconium peritonitis is the most frequent. Three neonates with intra-abdominal calcification as a complication of meconium peritonitis are presented. The types of meconium peritonitis were cystic, meconium pseudocyst and meconium ascites. Two required surgical intervention. Meconium peritonitis should be considered in newborns with intra-abdominal calcification.

Experience with hemihyperplasia and Beckwith-Wiedemann syndrome surveillance protocol

Beckwith-Wiedemann syndrome (BWS) and isolated hemihyperplasia (IHH) are two well known overgrowth conditions that are associated with cancer predisposition. Multiple surveillance protocols have been proposed to detect the most commonly reported tumor types Wilms tumor and hepatoblastoma. We reviewed the history of our patients who were part of this monitoring protocol. Information from 63 cases was collected retrospectively while another 63 control samples for AFP measurement were obtained prospectively. Twenty-five (40%) patients had an ultrasound abnormality, the most frequent being nephromegaly/size discrepancy. Two patients had well documented cases of tumors/tumor precursor (2/63:3.2%) detected by ultrasound images. Three hundred thirty-six separate AFP values were available with values above 50,000 ng/ml seen in three patients older than 2 months, one with hepatoblastoma and two other with hemangiomas/hemangioendotheliomas. There was no clear difference in the range of AFP values between previously reported controls, our own normal population and affected patients. In conclusion, ultrasound surveillance detected renal and liver pathology including benign and malignant lesions. The known variability of AFP in normal neonates and patients with BWS makes interpretation difficult in early infancy. Very high AFP values did seem to be correlated with risk for identifiable liver lesions. Determination of the natural changes in AFP levels over time will allow more appropriate comparison.

Diagnostic criteria and tumor screening for individuals with isolated hemihyperplasia

Isolated hemihyperplasia, formerly termed isolated hemihypertrophy, is a congenital overgrowth disorder associated with an increased risk for embryonal tumors, mainly Wilms tumor and hepatoblastoma. This practice guideline will set forth the diagnostic criteria and tumor screening recommendations for children with isolated hemihyperplasia, based on the best information available. There is clinical overlap between isolated hemihyperplasia with Beckwith-Wiedemann syndrome. The majority of Beckwith-Wiedemann syndrome patients have a molecular abnormality involving the imprinted cluster of genes at 11p15.5. In contrast, the preponderance of isolated hemihyperplasia patients studied have no identified etiology. Tumors have developed in isolated hemihyperplasia patients with and without molecular abnormalities. For this reason, molecular diagnostics are not helpful in identifying the subset of isolated hemihyperplasia patients with tumor risk and all isolated hemihyperplasia patients should undergo tumor screening.

Hereditary persistence of alpha-fetoprotein

Hereditary persistence of alpha-fetoprotein (HPAFP) is a rare benign autosomal dominant disorder. Here we report a 7-year-old healthy female who was found to have elevated alpha-fetoprotein (AFP) of 55-88 ng/ml over a 2-year period. Subsequently, AFP was also determined to be elevated in another 4 out of 8 family members in three generations, consistent with an autosomal dominant inheritance pattern. Elevated AFP levels are usually related to pregnancy, congenital disorders, liver diseases, or specific malignancies. However, HPAFP should be considered in the differential diagnosis of children with unexplained elevation of AFP. This disorder can be easily confirmed by measuring AFP levels in family members or checking specific point mutations of AFP gene promoter.

Serum alpha-fetoprotein (AFP) levels in breastfed infants with prolonged indirect hyperbilirubinemia

The aim of this prospective study was to verify normal serum AFP (alpha-fetoprotein) levels in jaundiced breastfed infants with indirect hyperbilirubinemia.

METHODS

The study was conducted in clinically jaundiced breastfed infants, 20, or more, days old, referred to our outpatient ambulatory. Inclusion criteria were: birth at term after a physiologic pregnancy, with an Apgar score >7 at 1 and 5 min, no evidence of congenital anomalies or diseases, direct bilirubin <1 mg/dl, normal values of alpha-1-antitrypsin, glucose-6-phosphate dehydrogenase, thyroid stimulating hormone, triiodothyronine, tyroxine, and normal growth. 30 non-jaundiced breastfed infants age-weight-matched, were used as control group.

RESULTS

98 jaundiced breastfed infants satisfied inclusion criteria. Their mean serum concentration of AFP was significantly higher than control infants (3548 vs 1095 ng/ml, p<0.001). Serum AFP levels of jaundiced infants were directly associated with serum indirect bilirubin and gamma-glutamyltranspeptidase concentrations.

CONCLUSIONS

The most probable explanation of elevated AFP in jaundiced breastfed infants may be the presence in human milk of one or more factors which affect hepatocyte growth and/or function. Based on our finding we demonstrated that in jaundiced breastfed infants normal range of serum AFP levels are higher than previously published data for healthy infants. Our data can be useful for a right interpretation of AFP levels in breastfed infants with prolonged jaundiced and may be used to avoid unnecessary investigations.

Elevated serum alpha-fetoprotein in Wilms tumor may follow the same pattern of other fetal neoplasms after treatment: evidence from three cases

Alpha-fetoprotein (AFP) is a common tumoral marker in pediatric neoplasms; increased serum levels are usually encountered in tumors arising from tissues producing AFP during fetal life. However, elevation of such protein is rarely found in patients with Wilms tumor (WT). Three patients with WT and elevated serum AFP were studied over the course of the disease. One patient had left WT with invasion of aorto-caval lymph nodes and lung metastases. The second patient was referred to our center for abdominal recurrence of bilateral WT whereas the third showed right WT with inferior vena cava thrombosis. AFP levels demonstrated a trend parallel to decrease/increase of tumor size, with further elevation in patients with metastases. Elevated AFP serum levels in patients with WT could be related to peculiar histological features and serial dosage might be a useful diagnostic and prognostic test.

Pediatric liver tumors: initial presentation, image finding and outcome

BACKGROUND

Few reports have been carried out on the characteristics of pediatric liver tumors.

METHODS

A retrospective study of 57 patients diagnosed with liver tumors from 1989 through 2004 was conducted. They were classified into groups; 10 benign, 33 primary malignant and 14 metastatic liver tumors. Their demographics, initial presentations, laboratory data, image findings and outcomes were investigated and compared.

RESULTS

Hepatocellular carcinoma (HCC) with 91% hepatitis B virus-related, constituted 23 of 33 primary malignant liver tumors and had the poorest survival rate. Initially, 70% of patients with primary malignant liver tumors were at disseminated stages. All of HCC and 88% of hepatoblastoma had elevated serum levels of aphal-fetoprotein. However, abnormal liver function tests as alanine aminotransferase, total bilirubin, albumin and alkaline phosphatase were uncommon in patients with pediatric liver tumors. Metastatic liver tumors compared with primary malignant liver tumors showed hypo-echogenicity in abdominal ultrasound (US) exam and a lesser presence of vessel invasion and contrast enhancement in computed tomography studies (P < 0.01).

CONCLUSIONS

It is important to diagnose primary malignant liver tumors before their clinical symptoms and signs develop. Children with chronic hepatitis B virus infection must be followed every 6 months by serum aphal-fetoprotein and abdominal US even when their liver function tests are normal. Image studies with abdominal US and computed tomography scan can differentiate between primary and metastatic liver tumors.

Should children at risk for familial adenomatous polyposis be screened for hepatoblastoma and children with apparently sporadic hepatoblastoma be screened for APC germline mutations?

BACKGROUND

Hepatoblastoma (HB) is the most frequent liver tumor in childhood, occurring in the first few years of life. Surgery combined with chemotherapy has resulted in dramatic improvements in prognosis. However, even today, about one quarter of affected children do not survive the disease. Compared to the general population, the risk of HB is 750-7,500 times higher in children predisposed to familial adenomatous polyposis (FAP), an autosomal-dominant cancer predispostion syndrome caused by germline mutations in the tumor suppressor gene APC. Only limited data exist about the frequency of APC germline mutations in cases of apparently sporadic HB without a family history of FAP.

PROCEDURE

In our sample of 1,166 German FAP families, all known cases of HB were registered. In addition, 50 patients with apparently sporadic HB were examined for APC germline mutations.

RESULTS

In the FAP families, seven unrelated cases of HB are documented; three had been detected at an advanced stage. In patients with apparently sporadic HB, germline mutations in the APC gene were identified in 10%.

CONCLUSIONS

These data raise the issue of the appropriate screening for HB in children of FAP patients. To date, the efficiency of surveillance for HB is unclear. In Beckwith-Wiedemann syndrome (BWS), recent studies suggest an earlier detection of both Wilms tumor and HB by frequent screening. We discuss the rationale and implications of a screening program; besides the examination procedure itself, screening for HB in children of FAP patients would have important consequences for the policy of predictive testing in FAP. In a substantial fraction of sporadic HB, the disease is obviously the first manifestation of a de novo FAP. These patients should be identified by routine APC mutation screening and undergo colorectal surveillance thereafter.

Tumour surveillance in Beckwith-Wiedemann syndrome and hemihyperplasia: a critical review of the evidence and suggested guidelines for local practice

There is strong evidence for an association between overgrowth disorders such as Beckwith-Wiedemann syndrome and the development of neoplasia. An increased cancer risk has also been observed in individuals with isolated hemihyperplasia. We critically review the evidence for tumour surveillance in Beckwith-Wiedemann syndrome and isolated hemihyperplasia and suggest local practice guidelines.

Mesenchymal hamartomas of the liver: comparison of clinicopathologic features between cystic and solid forms

Mesenchymal hamartoma (MH) of the liver is an uncommon benign lesion related to ductal plate malformation. It is usually cystic and mainly composed of myxoid mesenchymal tissue with tortuous or cystic bile ducts. In order to characterize the clinicopathological features of MH, the Korean Gastrointestinal Pathology Study Group collected a total of 17 MH cases diagnosed in 7 hospitals from 1992 to 2002 and compared the clinicopathologic findings of cystic MH with those of solid variant. Among the 17 cases, 7 (41%) were solid. The solid form showed a higher serum level of alpha-fetoprotein (AFP), the smaller bile ducts, and more frequent proliferation of vessels. Serum AFP level was related to the amount of hepatocytes. Two of seven solid cases harbored a larger amount of evenly distributed hepatocytes and proliferation of small duct with focal hepatocyte-bile duct transition. These histologic findings are similar to those of mixed hamartoma. Therefore, the mixed hamartoma and the MH of both solid and cystic types could be the variants of one disease spectrum. And hepatocytes within MH might be rather a genuine tumor component than entrapped into the tumor. In conclusion, MH can show various clinicopathological features and recognition of these features will facilitate accurate diagnosis of MH.

Pre-operative diagnostic biopsy and surgery in paediatric liver tumours--the Amsterdam experience

AIM

To report 24 years of pre-treatment biopsy and surgical experience in primary liver tumours in children.

METHODS

Between 1979 and 2003, 53 children presented with a primary liver tumour of whom 48 who underwent surgical resection were evaluated (two died, two were unresectable, and one was transplanted). Biopsy data, per- and post-operative complications, mortality, and survival were retrospectively reviewed.

RESULTS

Benign tumours were diagnosed in eight patients. Surgical resection for a malignant tumour was performed in 40 patients (26 hepatoblastomas (HB), eight hepatocellular carcinomas (HCC) (four had fibrolamellar HCC), three rhabdomyosarcomas (RMS), one neuroblastoma, one non-hodgkin lymphoma (NHL), and one teratoma). Primary resection was performed in one HB, and four HCCs. The cumulative survival without evidence of disease was 73% for HB (median 7 years) and 88% for HCC (median 3.5 years).

CONCLUSION

The treatment results are comparable with those of larger international series except for HCC. The existing diagnostic pitfalls in differentiating between the various liver malignancies justify the use of a diagnostic biopsy.

beta-Catenin and met deregulation in childhood Hepatoblastomas

Activation of the Wnt/beta-catenin and hepatocyte growth factor/Met signaling has been implicated in various tumors. Owing to the cross-talk between these pathways and aberrant redistribution of beta-catenin in hepatoblastomas, we examined their status in this tumor. This study examined changes in beta-catenin and Met in paired pretreatment and post-treatment hepatoblastoma tissues in relation to their effects on proliferation and target genes such as c-myc and cyclin-D1. In this study we compared proliferation indices, beta-catenin staining and its known molecular targets, c-myc and cyclin-D1, and Met, a tyrosine kinase receptor for hepatocyte growth factor in pretreatment and post-treatment specimens. Pretreatment and post-treatment sections from 13 children, ages 11 weeks to 9 years, were analyzed for these markers by immunohistochemistry. All tumors (13 of 13) displayed increased proliferation and beta-catenin (cytoplasmic and nuclear) staining in pretreatment biopsies that remained relatively unaffected after treatment. Aberrant Met staining (cytoplasmic) was observed in all pretreatment samples that decreased considerably after treatment in 11 of 13 patients. A significant subset of these tumors showed increased c-myc and cyclin-D1 staining in pretreatment biopsies that decreased after chemotherapy in most cases. beta-Catenin redistribution in tumor cells corresponds to proliferation in hepatoblastomas. However, beta-catenin nuclear localization remains unaffected in viable hepatoblastoma tissue after chemotherapy. In contrast, Met undergoes a prominent decrease after treatment and thus might be important in pathogenesis of hepatoblastoma.

Alpha-fetoprotein in the early neonatal period—a large study and review of the literature

BACKGROUND

Alpha-fetoprotein (AFP) is a glycoprotein molecule, which has similarity to albumin and is produced by the fetal liver. Its biological role is unclear and factors that may influence its concentrations in neonates are only partially identified. However, it has an important role as a diagnostic marker, especially in certain tumors and liver diseases of childhood. Its normal reference values in newborns have not been well defined.

METHODS

Serum AFP concentrations were measured and characterized in 260 term and near-term newborns [gestational age (GA)> or =34 weeks, birthweight (BW)> or =1700 g] at birth [umbilical cord (UC) blood] and upon discharge from the nursery at 60+/-24 h of life (venous sample).

RESULTS

Due to the nonnormal distribution of AFP levels, it is useful to relate to reference interval for AFP concentrations at birth that was 15.7-146.5 microg/ml, based on 95% confidence interval (CI). The median value of 48.3 microg/ml is also a useful reference. However, mean AFP concentrations at birth that were 61.6+/-44.8 microg/ml are less informative due to the large standard deviation (S.D.). Upon discharge, AFP concentrations dropped to 9.7-111.9 microg/ml (95% CI) with a median of 34.2 microg/ml. A significant negative correlation was found between AFP serum levels and gestational age and to a lesser extent with birthweight. No significant differences were found between males and females.

CONCLUSIONS

Normal reference intervals for AFP in term and near-term newborns have been defined, but need to be addressed with caution due to the wide range of normal values. AFP levels at birth decrease as gestation advances and the newborn weighs more.

Diagnostic value of alpha 1-fetoprotein and beta-human chorionic gonadotropin in infancy and childhood

This article provides a comprehensive review of the current literature and summarizes the experience of the German cooperative protocols for nontesticular germ cell tumors (MAKEI) on the use of alpha 1-fetoprotein (AFP) and beta-human chorionic gonadotropin (beta-hCG) for diagnostic evaluation in pediatric oncology. Based on this evaluation, this review proposes guidelines for the initial diagnostic work-up for children with clinically suspected secreting tumors. AFP and beta-hCG represent the characteristic tumor markers of malignant epithelial liver tumors and malignant germ cell tumors (GCT). They play an important role in the initial diagnostic evaluation as well as in the follow-up examination during therapy. Current therapeutic strategies for both tumor types include preoperative chemotherapy followed by delayed tumor resection. Therefore, it is essential for the pediatrician in charge to be aware of the broad differential diagnosis of elevated AFP and beta-hCG. In a well-defined clinical setting, these tumor markers allow clinical diagnosis without histological confirmation, but the physiologically elevated AFP serum levels in infancy or unrecognized benign conditions, such as hepatic diseases or hereditary disorders, must also be considered as differential diagnoses. Therefore, the laboratory investigations should include liver parameters in all patients to exclude hepatic disease. In addition, pregnancy must be excluded in adolescents. Careful history taking and clinical examination will further help to rule out metabolic disorders or ataxia teleangiectasia that are associated with elevated AFP levels. Having excluded these conditions, elevated AFP levels above the age-related normal range (with or without high beta-hCG), indicate malignant epithelial liver tumors in primary liver lesions. At virtually all other sites, the diagnosis of a malignant GCT with a substantial yolk sac tumor and/or choriocarcinoma component can be established. Pancreaticoblastoma should be considered in the differential diagnosis of tumors of the upper abdomen, and biopsy must be performed. Other childhood tumors are rarely associated with AFP or beta-hCG production, usually at only moderately elevated serum levels, and in most patients these tumors can be excluded by clinical and radiological examination.

Liver tumors

Liver tumors in children are rare, potentially complex, and encompass a broad spectrum of disease processes. Any age group may be affected, including the fetus. Most present with abdominal distension and/or a mass. Accurate preoperative diagnosis is usually possible using a combination of ultrasound scanning and cross-sectional imaging techniques (CT and/or MR), supplemented by liver biopsy and measurement of tumor markers. The most common benign tumors are hemangiomas, but mesenchymal hamartoma, focal nodular hyperplasia, and adenoma also are found. In Western countries, hepatoblastoma is the most common primary malignant liver tumor; disease-free survival is now possible in more than 80% of affected patients because of advances in combination chemotherapy, improved techniques of surgical resection, and the selective use of liver transplantation. In contrast, there has been less progress in the management of hepatocellular cancer, which still poses many therapeutic challenges.

Serum alpha-fetoprotein levels in Beckwith-Wiedemann syndrome

We conducted a retrospective study that compared serial alpha-fetoprotein (AFP) concentrations obtained from 22 children with Beckwith-Wiedemann syndrome (BWS) with levels established for healthy children. The AFP concentration is greater in patients with BWS and declines during the postnatal period at a significantly slower rate than what is reported in healthy children. AFP levels obtained in the course of routine tumor screening in children with BWS should be interpreted with a normal curve established specifically for BWS rather than with previously published data for healthy infants and children.