The association of hepatoblastoma, prematurity and cerebral palsy: Case reports

PURPOSE

Hepatoblastoma is the most common primary liver tumor in children and has a greater incidence in children with a history of prematurity and very low birth weight. To increase awareness of the association between prematurity and hepatoblastoma for health care providers who treat children with Cerebral Palsy (CP), we present two case reports.

METHODS

Two case reports of premature, very low birth weight infants with hepatoblastoma are described and a literature review of hepatoblastoma in the setting of prematurity and cerebral palsy is performed.

RESULTS

Each patient had a history of 26-28 week prematurity, very low birth weight, and CP. Both presented with worsening constipation and abdominal distension that did not respond to oral medications. Appropriate referrals to the ER were made which lead to a diagnosis of hepatoblastoma. Pediatric rehabilitation was a source of referral for diagnosis in one patient and aided in the rehabilitation course following treatment for both patients.

CONCLUSIONS

Hepatoblastoma is the most common primary liver tumor in children and has an increased incidence in children with a history of prematurity and very low birth weight. Providers who frequently care for the very low birth weight and premature children with CP should be aware of this correlation and include hepatoblastoma in the differential when managing patients with suddenly worsening constipation or abdominal distension. Pediatric physiatrists and other providers for these patients could be a source of referrals and diagnosis leading to timely treatment.

The National Physicians Cooperative: transforming fertility management in the cancer setting and beyond

Once unimaginable, fertility management is now a nationally established part of cancer care in institutions, from academic centers to community hospitals to private practices. Over the last two decades, advances in medicine and reproductive science have made it possible for men, women and children to be connected with an oncofertility specialist or offered fertility preservation soon after a cancer diagnosis. The Oncofertility Consortium's National Physicians Cooperative is a large-scale effort to engage physicians across disciplines – oncology, urology, obstetrics and gynecology, reproductive endocrinology, and behavioral health – in clinical and research activities to enable significant progress in providing fertility preservation options to children and adults. Here, we review the structure and function of the National Physicians Cooperative and identify next steps.

Pediatric and Teen Ovarian Tissue Removed for Cryopreservation Contains Follicles Irrespective of Age, Disease Diagnosis, Treatment History, and Specimen Processing Methods

PURPOSE

Fertility preservation in a pediatric and teen female population is challenging because standard technologies of egg and embryo freezing may not be possible due to premenarcheal status. Ovarian tissue cryopreservation (OTC) with the intent of future ovarian tissue transplantation or in vitro follicle growth may be the only option to preserve fertility. The purpose of this study was to add to the general understanding of primordial follicle dynamics in young patients.

METHODS

First, the unique infrastructure of the Oncofertility Consortium National Physicians Cooperative (OC-NPC) is described, which simultaneously drives clinical fertility preservation and basic research to explore and expand the reproductive options for those in need. Then, the OC-NPC research resource is used to perform a histological evaluation of ovarian tissue from 24 participants younger than 18 years of age.

RESULTS

Primordial follicles, which comprise the ovarian reserve, were observed in all participant tissues, irrespective of variables, including age, diagnosis, previous treatment history, tissue size, and tissue processing methods. Primordial follicles were present in ovarian tissue, even in participants who had a previous history of exposure to chemotherapy and/or radiation treatment regimens, which placed them at risk for iatrogenic infertility or premature ovarian failure.

CONCLUSION

Primordial follicles were observed in ovarian tissue from all participants examined, despite population and tissue heterogeneity. These results increase the understanding of human follicle dynamics and support OTC as a promising fertility preservation modality in the young female population. Future studies to evaluate follicle quality within these tissues are warranted.

Evidence-Based Recommendations for Fertility Preservation Options for Inclusion in Treatment Protocols for Pediatric and Adolescent Patients Diagnosed With Cancer

As survival rates improve for pediatric cancers, increased attention has been paid to late effects of cancer therapy, in particular, infertility. Fertility preservation options are available for pre- and postpubertal cancer patients; however, many providers lack knowledge regarding options. The aim of this article is to provide a comprehensive synthesis of current evidence and recommendations regarding fertility preservation options for children, adolescents, and young adults undergoing cancer treatment. A systematic search was performed to identify fertility preservation evidence. Fifty-three studies and 4 clinical guidelines were used for the review. Final recommendations consisted of 2 strong and 1 weak recommendation for both female and male fertility preservation options. The treatment team should be knowledgeable about fertility preservation so that they can educate patients and families about available fertility preservation options. It is important to consider and discuss all available fertility options with patients at the time of diagnosis.

Male reproductive health after childhood, adolescent, and young adult cancers: a report from the Children's Oncology Group

The majority of children, adolescents, and young adults diagnosed with cancer will become long-term survivors. Although cancer therapy is associated with many adverse effects, one of the primary concerns of young male cancer survivors is reproductive health. Future fertility is often the focus of concern; however, it must be recognized that all aspects of male health, including pubertal development, testosterone production, and sexual function, can be impaired by cancer therapy. Although pretreatment strategies to preserve reproductive health have been beneficial to some male patients, many survivors remain at risk for long-term reproductive complications. Understanding risk factors and monitoring the reproductive health of young male survivors are important aspects of follow-up care. The Children's Oncology Group Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancer (COG-LTFU Guidelines) were created by the COG to provide recommendations for follow-up care of survivors at risk for long-term complications. The male health task force of the COG-LTFU Guidelines, composed of pediatric oncologists, endocrinologists, nurse practitioners, a urologist, and a radiation oncologist, is responsible for updating the COG-LTFU Guidelines every 2 years based on literature review and expert consensus. This review summarizes current task force recommendations for the assessment and management of male reproductive complications after treatment for childhood, adolescent, and young adult cancers. Issues related to male health that are being investigated, but currently not included in the COG-LTFU Guidelines, are also discussed. Ongoing investigation will inform future COG-LTFU Guideline recommendations for follow-up care to improve health and quality of life for male survivors.

Ovarian tissue cryopreservation in a prepubertal girl after fertility impairing therapy

e20001

Background: Advances in cancer therapy have improved the long-term survival of patients suffering from malignancies. High doses of alkylating agents and radiation are known to cause infertility in cancer survivors. Ovarian stimulation is not an option for prepubertal females, leaving experimental ovarian tissue cryopreservation (OTC) as the only option for preserving the reproductive potential of prepubescent girls. Little data is available regarding the condition of a prepubertal ovary after cancer treatment is received. This case study demonstrates the possibility of OTC post cancer treatment in a prepubertal female. Methods: A 9-year-old girl with multiply recurrent vaginal rhabdomyosarcoma presented for fertility preservation upon local recurrence of her tumor. Prior therapy included 32,200 mg/m2 of cyclophosphamide, 9,000 mg/m2 of ifosfamide and vaginal brachytherapy after ovarian transposition. A unilateral oophorectomy was performed with therapeutic partial vaginectomy, total hysterectomy and bilateral salpingectomy. A 1 cm section of the ovary was dissected and sent to pathology. The ovarian tissue planes were separated and the cortical tissue removed from the medulla. The cortical tissue was then cut into approximately 2 cm x 0.5cm x 0.1cm strips. 80% of this tissue was cryopreserved using a slow-freeze method for the patient’s future reproductive use and 20% was provided to the Oncofertility Consortium for research as per the ovarian tissue cryopreservation protocol. Results: Follicle stimulating hormone (FSH) level prior to oophorectomy was 0.5 mIU/mL (Normal 1-6 mlU/mL).The ovary was small and fibrotic. Microscopically, primordial follicular density was 1.41/mm2. No follicles of more mature stage were noted. There was no evidence of malignancy in the tissue. Conclusions: The presence of viable follicles in the ovarian tissue suggests that fertility preservation may still be possible even in patients who have received therapy that is considered to be likely to impair fertility. For this patient, who was scheduled to have an invasive surgery, adding on ovarian tissue cryopreservation presented a very minimal risk with a potential for a great benefit.