Laboratory and clinical features of tumor lysis syndrome in children with non-Hodgkin lymphoma and evaluation of long-term renal functions in survivors

OBJECTIVE

The purpose of our study is to investigate the laboratory and clinical features of tumor lysis syndrome (TLS) and acute kidney injury (AKI) in childhood non-Hodgkin lymphomas (NHL) and to reveal their impact on long term kidney function in survivors.

METHODS

Our single-center retrospective study included 107 patients (0-18 years old) with NHL who were admitted and treated at our hospital between 1998 and 2020. The relationship between TLS and age, gender, histopathological subgroup, tumor stage, lactate dehydrogenase (LDH) level at presentation, bone marrow and kidney involvement were assessed. The long-term renal functions of the patients were investigated.

RESULTS

80.3% of the patients were male with a median age of 9.8 years. The most common detected histopathological subgroup was Burkitt lymphoma. Hyperhydration with or without alkalinisation, and allopurinol were used in first-line treatment and prophylaxis of TLS. Laboratory TLS and clinical TLS was observed in 30.8% and 12.1% of patients, respectively. A significant correlation was found between young age, advanced stage, high LDH level at presentation, and TLS. AKI was observed in 12.1% of the patients. When the glomerular filtration rate values of the patients at the first and last admissions were compared after an average of 6.9 years, a mean decrease of 10 mL/min/1.73 m2 was found. It was not, however, found to be statistically significant.

CONCLUSION

Lower age, advanced stage, and high LDH level at presentation were found to be risk factors for TLS in our study. Long-term renal function loss was not observed in the survivors who received early and careful prophylaxis/treatment for TLS. The survivors are still being followed up.

The relationship between preoperative CEA and CA19-9 status and patient characteristics and lymph node involvement in early-stage colon cancer

OBJECTIVE

Colon cancer is a primary human cancer that accounts for approximately one-tenth of all cancers and is one of the three most common cancers in incidence and mortality. This study investigated the relationship between serum preoperative carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9), patient characteristics and lymph node (LND) involvement in early-stage colon cancer.

PATIENTS AND METHODS

A total of 154 patients who had undergone surgery for early-stage colon cancer were included in this study. Patient demographics regarding age and gender, laboratory parameters, tumor size, and tumor laterality were recorded. CEA and CA19-9 positivity was defined as patients whose tumor markers were above the cut-off values, and patients were grouped according to CEA and CA19-9 positivity. Patients were compared according to the CEA and CA19-9 status and pathological LND involvement.

RESULTS

We found that patients in the CEA (+) and CA19-9 (+) groups were significantly older than the others. Our study detected LND involvement in histopathological examination in 25% of patients. LND pathological participation was significantly higher in the CEA (+) CA19-9 (+) group, and being age 65 years or older was found to be a risk factor for pathological LND involvement.

CONCLUSIONS

Clinicians should pay more attention to LND involvement when both CEA and CA19-9 are elevated preoperatively in early-stage colon cancer patients. Preoperative CEA and CA19-9 status of patients is important in predicting LND involvement and, as a result, the prognosis of these patients.

Central Nervous System Fungal Infections in Children With Leukemia and Undergoing Hematopoietic Stem Cell Transplantation: A Retrospective Multicenter Study

BACKGROUND

Central nervous system fungal infections (CNSFI) are seen in patients with hematologic malignancies and have high morbidity and mortality. Because of their rarity, there is limited data on CNSFI in children with no established treatment protocols or guidelines.

MATERIALS AND METHODS

In this multicenter retrospective study, 51 pediatric patients with leukemia, 6 of whom had undergone bone marrow transplantation, with proven or probable CNSFI were evaluated. Fungal infections were defined as proven or probable based on European Organisation for Research and Treatment of Cancer criteria. Proven CNSFI was diagnosed by appropriate central nervous system (CNS) imaging or tissue sample findings in combination with positive microbiological results of cerebrospinal fluid. A positive culture, microscopic evidence of hyphae, a positive result of the galactomannan assays are defined as positive microbiological evidence. Probable CNSFI was defined as appropriate CNS imaging findings together with proven or probable invasive fungal infections at another focus without CNS when there is no other explanatory condition. Data was collected by using the questionnaire form (Supplemental Digital Content 1, http://links.lww.com/JPHO/A541 ).

RESULTS

Seventeen patients had proven, 34 patients had probable CNSFI. Headaches and seizures were the most common clinical findings. The median time between the onset of fever and diagnosis was 5 days. The most common fungal agent identified was Aspergillus . Sixteen patients received single-agent, 35 received combination antifungal therapy. Surgery was performed in 23 patients. Twenty-two patients (43%) died, 29 of the CNSFI episodes recovered with a 20% neurological sequelae.

CONCLUSION

CNSFIs should be considered in the differential diagnosis in patients with leukemia and refractory/recurrent fever, headache, neurologicalocular symptoms, and a radiologic-serological evaluation should be performed immediately. Early diagnosis and prompt management, both medical and surgical, are essential for improving clinical outcomes.

Renal Ultrasonographic Abnormalities at Initial Presentation of Children Diagnosed with Acute Lymphoblastic Leukemia and Long-Term Renal Functions and Prognosis in Survivors

OBJECTIVES

The kidney is a vulnerable organ for acute lymphoblastic leukemia (ALL), by the disease, and various associated clinical pictures. This retrospective study aims to document renal ultrasound abnormalities in children with newly diagnosed ALL as well as to investigate the correlation between renal findings and clinical/laboratory/survival data.

METHODS

All children (age <18 years) with ALL were included in the study. An increase in size/nephromegaly (NM) or hyperechogenicity (HE) of the kidneys at first admission was accepted as a pathological renal abnormality. The clinical/laboratory findings, survival, and long-term renal functions were compared between patients with and without NM/HE.

RESULTS

The incidence of NM±HE was 12% in 163 patients. Enlargement of spleen, liver, or both and, hypercreatininemia was independently correlated with the presence of NM/HE. After the induction therapy, ultrasound findings were resolved in all patients, and NM/HE did not influence ALL prognosis. All survivors had normal renal functions in long term.

CONCLUSION

The renal ultrasound abnormalities are not uncommon in children with leukemia at admission, without a negative impact on leukemia prognosis and on long-term renal functions.

Diagnostic value of oxidative stress markers in patients presenting with primary dysmenorrhea to the emergency department

Background and Aim

Primary dysmenorrhea (PD) is a common presentation for emergency departments. This study investigates the diagnostic value of oxidative stress and ischemia markers in patients with PD.

Materials and Methods

The participants were classified into the PD group (patients with PD) and the control group (healthy volunteers). Thiol/Disulfide Homeostasis (TDH) parameters (Ds, Disulfide; NT, Native Thiol; TT, Total Thiol) and serum ischemia modified albumin (IMA) levels of the groups were measured. The Numeric Rating Scale (NRS) was used for pain assessment. Bivariate correlation analysis was performed to test the relationship between NRS and oxidative stress parameters. A P < 0.05 was considered significant.

Results

A total of 135 patients (PD group, n = 83; Control group, n = 52) were included in the study. PD group had statistically higher oxidant biomarkers (Ds level, Ds/NT ratio and Ds/TT ratio) and lower antioxidant biomarkers (NT/TT ratio) compared to the control group (p = 0.001; 0.003; 0.002, and 0.002, respectively). Serum IMA level in the PD group was higher than in the control group (P = 0.000). There was a positive correlation between IMA and NRS score (r = 0.342, P < 0.01), but no correlation was found between the other oxidative stress parameters and NRS.

Conclusions

PD is characterized by increased oxidative stress and ischemia in the endometrium, which can be detected by TDH parameters and serum IMA. NRS score in PD patients is positively correlated with serum IMA level, which suggests IMA level can be valuable to determine the severity of endometrial ischemia and pain in patients with PD.

The therapeutic outcomes of one-minute application of sodium hydroxide versus phenol in the chemical cauterization of ingrown toenails

BACKGROUND

Ingrown nails are frequently encountered in dermatology practice. The recurrence tendency of the disorder makes chemical cauterization essential during surgical procedures. In studies comparing nail matrix cauterization with sodium hydroxide (NaOH) versus phenol, phenol's application time was highly variable.

OBJECTIVE

To compare the therapeutic outcomes of matrix cauterization for a standard duration of one minute for NaOH versus phenol in stage II and III ingrown nails MATERIAL AND METHODS: The medical records of patients undergoing matrix cauterization with 10% NaOH or 88% phenol were evaluated. The primary outcome measure was the lack of recurrences on long-term follow-up. The secondary outcome measures were complete healing duration, patient-reported pain scores, and adverse effects related to the procedure.

RESULTS

Enrolled in this study were 62 ingrown toenail sides treated with 10% NaOH and 56 ingrown toenail sides treated with 88% phenol. The mean follow-up duration was 25.17 months. Recurrence was observed in four nail sides of the NaOH group (%6.45) and three nail sides of the phenol group (%5.35). The difference between the recurrence rates did not reach statistical significance. Patients treated with both methods were free of pain on the post-procedural tenth day. The visual analog scale pain scores and complete healing duration were similar between the two groups (p>0.05).

CONCLUSION

In a large group with long-term follow-up results, the short-term and long-term post-operative treatment outcomes were similar between the one-minute applications of 10% NaOH versus 88% phenol groups.

Hepatitis B Vaccination in Children With Ongoing Cancer Treatment: A Safety and Efficacy Study of Super-Accelerated Vaccination Scheme

OBJECTIVE

Children with cancer have an increased risk for hepatitis B virus (HBV) infections due to chemotherapy-induced secondary immunodeficiency and frequent blood transfusions. The aim of this study is to evaluate the efficacy and safety of hepatitis B vaccination during the intensive induction chemotherapy in children with cancer found to be seronegative for hepatitis B on admission.

MATERIALS AND METHODS

Children newly diagnosed with cancer were evaluated for the presence of hepatitis B surface antigen (HBsAg) and antibody on admission. The children negative for both were included in the study. A super-accelerated vaccination scheme (3 booster doses at days 1-5, 8-12, and 28-33) was administered to these seronegative children concurrently with induction chemotherapy. Antibody response was checked 4-8 weeks after the last vaccination and 6 months after the end of the treatment.

RESULTS

Eleven out of 122 children were seronegative for hepatitis B on admission (9%). Acute lymphoblastic leukemia, lymphoma, and solid tumors were diagnosed in 5, 4, and 2 children, respectively. Complete seroconversion was achieved in 4-8 weeks after the last vaccination with high titers of anti-HBs antibody, and all patients remained antibody-positive until 6 months after the completion of chemotherapy.

CONCLUSION

The risk of transfusion-related infections increases with a number of transfused products and donor exposures, and it is more significant for immunosuppressed children with hematologic and oncologic malignancies. Hepatitis B vaccination could safely be applied with brisk and sustained responses in this vulnerable population, based on the local epidemiological data.

Treatment results of modified BFM protocol in pediatric high-risk Burkitt lymphoma

BACKGROUND

Chemotherapy with high dose methotrexate is the mainstay of treatment for Burkitt lymphoma (BL), especially to manage central nervous system (CNS) disease. However, methotrexate administration requires close drug level monitoring for appropriate folinic acid rescue, which might not be readily available in all centers. In this study, we assessed the long-term treatment outcomes of a modified Non-Hodgkin lymphoma (NHL)-Berlin-Frankfurt-Munster (BFM) 90 regimen in pediatric high-risk BL without CNS involvement.

METHODS

Between 1999 and 2011, 42 patients (median age: 7 years) with advanced-stage BL were treated with modified NHL-BFM 90 regimen (methotrexate at a dose of 1 g/m2). Demographic data, stage, lactate dehydrogenase (LDH) and treatment results were retrospectively evaluated. The patients were assessed for toxicity, survival and CNS recurrence.

RESULTS

Thirty-six patients had Stage III and six had Stage IV disease, respectively. The median LDH level was 1,432 IU/L. Four patients died of infectious and metabolic complications. One patient had local recurrence at the 48 < sup > th < /sup > month of the follow-up and he is in the second remission for 72 months. In Kaplan-Meier analysis, the overall survival and event-free survival rates at 10 years were found as 90 % and 88 %, respectively. None of our patients died of treatment failure.

CONCLUSIONS

The administration of the reduced dose of methotrexate seems to not compromise treatment success nor increase the risk of CNS recurrence in high-risk BL without CNS involvement. The limitation of the study is that it is not randomized. Our treatment scheme might be considered for centers without methotrexate measurement facility.

Lesional activation of Tc 17 cells in Behçet's disease and psoriasis supports HLA-class I-mediated autoimmune responses

BACKGROUND

Behçet's disease (BD) presents with lymphocytic and neutrophilic vasculitis of unknown aetiology. HLA-B*51 ERAP1 and IL12R/IL23R are genetic risk factors. IL-23 regulates IL-17A, which controls recruitment and activation of neutrophils.

OBJECTIVES

To determine pathological changes in BD skin lesions related to the complex genetic predisposition METHODS: We characterised the expression of IL-17A and IL-23A in various cell types by immunohistological double staining of sections from papulopustular skin lesions (PPL) of acute attacks of BD and lesions of psoriasis vulgaris (PV), another HLA-class I-associated T-cell mediated autoimmune disease in which excessive T-cell derived IL-17A production promotes neutrophil activation.

RESULTS

We found that in BD lesions, as in psoriasis, actively expanding CD8⁺ T cells were the predominant source of IL-17A. IL-17A⁺ CD8⁺ T (Tc17) cells outnumbered infiltrating IL-17A⁺ CD4⁺ T cells. Unlike the epidermal localisation of CD8⁺ T cells in psoriasis, Tc17 cells in BD lesions infiltrated mainly the perivascular tissue and also the blood vessel walls of dermis and subcutaneous tissue. They colocalised with a marked IL-23A expression by CD11c⁺ dendritic cells (DCs) and CD68⁺ macrophages. IL-17A expression was associated with extensive recruitment of neutrophils around blood vessels that formed neutrophil extracellular traps (NETs).

CONCLUSIONS

In BD, the genetic predisposition may mediate antigen-specific activation and differentiation of a T_c 17 response, possibly targeting endothelial antigens. Neutrophils recruited by IL-17A in this process may enhance tissue damage by extensive NET formation (NETosis). Thus, the IL-23/IL-17 axis presumably controls neutrophilic inflammation in BD vasculitis in the context of a predominant antigen-specific CD8⁺ T-cell response.

Investigation of gamma secretase gene complex mutations in German population with Hidradenitis suppurativa designate a complex polygenic heritage

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic inflammatory disease affecting apocrine gland-bearing skin in the axilla, groin and under the breasts. Mutations of the gamma secretase gene complex, which is essential in the activation of Notch signalling pathways, were shown in some families with HS and in a few sporadic cases. Although an imbalance in Notch signalling is implicated in the pathogenesis, the exact mechanism of HS development is yet unknown.

OBJECTIVES

We aim to investigate the genetic basis of HS by determining the presence of mutations of gamma secretase gene complex in a cohort of HS patients and by searching for a disease-causing pathogenic variant in a multi-generational HS family using parametric linkage analysis.

METHODS

Thirty-eight patients clinically diagnosed with HS were included in this study. All exons and exon-intron boundaries of the genes encoding gamma secretase complex consisting of six genes: APH1A, APH1B, PSENEN, NCSTN, PSEN1 and PSEN2 were sequenced by Sanger technique. Genetic mapping with parametric linkage analysis for the patients in the family was performed with eight affected and four healthy individuals. The logarithm of odds was calculated.

RESULTS

In a sporadic patient with early-onset, severe lesions in axilla and groin, a novel single-nucleotide deletion causing frameshift in exon 1 of the NCSTN gene was identified ((NM_015331.3): c.38delG, p.(Gly13Glufs*15)). The LOD score of 1.5 was never exceeded in any region of the genome, pointing towards intricate multi-genic inheritance pattern within the affected family.

CONCLUSIONS

The gamma secretase gene complex mutations were rare in our cohort (3.2%). Besides, our analysis indicates a possible complex multi-genic inheritance in a seemingly autosomal dominantly inherited large HS family. Genetics of both familial and sporadic HS may be complicated in most cases, and the role of other potential genes such as autoinflammatory and modifier genes as well as environmental factors may influence the pathogenesis.

Cutaneous manifestations in pediatric oncology patients

BACKGROUND/OBJECTIVES

Oncology patients present with various skin manifestations related to primary disease and treatments. Although these skin toxicities are well described in adults, studies of pediatric oncology patients are limited. The objective of this study was to evaluate the cutaneous findings in pediatric oncology patients receiving chemotherapy.

METHODS

In this prospective cohort study conducted from December 2018 to March 2020, all pediatric oncology patients were examined and patients who had a dermatologic finding at any point during their treatments were recorded. Dermatologic examinations were performed by the same dermatologists, and biopsy and microbiologic tests were performed according to clinical need. Patients were grouped according to their oncologic diagnoses and types of chemotherapies.

RESULTS

A total of 80 patients with a mean age of 9.1 ± 5.0 years were included in the study. Seventy-five (93.7%) of them developed a dermatologic manifestation during the study period. Most of the patients had hematologic malignancies (n = 48, 60%). Antimetabolites were the most frequently used class of chemotherapeutic agents. Anagen effluvium was the most common dermatologic finding (61.3%, n = 49), followed by inflammatory dermatoses (51.2%, n = 41, most commonly diaper dermatitis in 33 patients), xerosis (35%, n = 28), and nail changes (20%, n = 16, most commonly nail pigmentation in seven patients). Mucositis was seen in 13 (16.2%) patients. Five patients (6.2%) had drug-induced cutaneous hyperpigmentation, and five (6.2%) had toxic erythema of chemotherapy. The highest percentage of xerosis (45.4%) was detected in patients using antitumor antibiotics, whereas inflammatory dermatoses were observed more in patients using antimetabolites (48.6% of patients using antimetabolites), and pigmentation changes were more frequently detected in patients using alkylating agents.

CONCLUSION

Identification, diagnosis, and treatment of these reactions are important to dermatologists and oncologists so that appropriate management may be provided to pediatric oncology patients.

DICER1 Hotspot Mutations in Pleuropulmonary Blastoma: A Case Series From a Tertiary Center

Pleuropulmonary blastoma (PPB) is a potentially aggressive, rare childhood neoplasia. We investigated histopathological features, survival, and DICER1 hotspot mutations among PPB patients. Archive records at our institution were reviewed, covering a 20-year period. Thirteen children (6 males and 7 females) with a mean age of 30.5 (range 6-83) months were included. The tumor subtypes were type I in 6 (46%), type II in 4 (31%), and type III in 3 (23%). Only tumors with type II and type III histology showed anaplasia (4/7, 57%). Median follow-up was 28 (range 9-216) months. Three-year overall survival rate was 83.3% and 3-year progression-free survival rate was 25%. Progression was seen in 60% (3/5) of type I and 66.7% (4/6) of type II and type III cases. Two patients died of disseminated disease at 9 and 44 months. Hotspot missense mutations on DICER1 gene were detected in all 11 patients with available tumor tissue. We found an additional novel germline loss-of-function mutation (c.5436dupT; p.E1813*) in 1 case. To the best of our knowledge, this is the first study to investigate hotspot missense mutations on DICER1 gene among the largest series of Turkish children with PPB.

Association of pyrin mutations and autoinflammation with complex phenotype hidradenitis suppurativa: a case-control study

BACKGROUND

Hidradenitis suppurativa (HS) is a rare, debilitating neutrophilic dermatosis characterized by chronic inflammation of hair follicles. Many inflammatory conditions may accompany HS.

OBJECTIVES

To investigate the association of variants of the MEFV gene with a complex HS phenotype.

METHODS

Firstly, we identified the clinical characteristics of 119 patients with HS with a complex phenotype (Hurley stage III disease and/or additional inflammatory symptoms). Then, we searched for MEFV variants among these patients. The odds ratios (ORs) for pathogenic MEFV mutations were calculated using data from these patients with HS and 191 healthy controls.

RESULTS

The male/female ratio was higher, and the mean age of onset was earlier, in our complex HS group compared with patients with HS in general. Five of the patients with HS (4·2%) had a diagnosis of familial Mediterranean fever (FMF) with a standardized morbidity ratio of 45 [95% confidence interval (CI) 16·50-99·84, P < 0·001] when compared with the frequency of FMF in the general Turkish population. Of the patients with complex HS, 38% were positive for pathogenic variants of MEFV. The OR for carrying a pathogenic MEFV allele was 2·80 (95% CI 1·31-5·97, P < 0·001).

CONCLUSIONS

The frequency of MEFV mutations in the group of patients with complex HS was higher than that in healthy controls, suggesting that MEFV mutations may contribute to the pathogenesis of HS. Understanding the role of autoinflammation in HS is of fundamental importance for the development of novel therapies.

The Incidence of and Factors Associated with Vitamin D Deficiency in Newly Diagnosed Children with Cancer

This retrospective chart review study aimed to assess vitamin D status and identify risk factors associated with vitamin D deficiency and bone parameters in children with cancer at admission. The data of 86 (50 males and 36 females) patients between April 2013 and June 2015 were analyzed. Calcium, phosphorus, alkaline phosphatase (ALP), 25(OH)D, age, gender, diagnostic category, body mass index, duration of complaints, and season of blood sampling were recorded. Median age was 7.17 years (range 0.31-17.40) in 29 hematological malignancy and 57 solid tumor patients. According to cut-off level of 20 ng/ml, 63% of children with cancer had vitamin D deficiency at diagnosis with a median 25(OH)D of 16.75 ng/ml. The mean vitamin D value of children >10 years was significantly low in comparison to that observed in younger children [11.83, 95% confidence interval (CI) = = 8.85-14.81 ng/ml vs. 19.81, 95% CI = = 17.02-22.60 ng/ml]. Vitamin D measurement between November and May was a risk factor for vitamin D deficiency (P < 0.05). The frequency of hypocalcemia and hypophosphatemia was not different between two groups of vitamin D. Further longitudinal studies are needed to investigate whether monitoring vitamin D status and supplementation in children with cancer might prevent future complications related to vitamin D deficiency.

Effects of rapamycin treatment on pancreatic fibrosis, cellular apoptosis and oxidative stress in experimental chronic pancreatitis model

PURPOSE

Rapamycin reduces hepatic fibrosis by inhibiting hepatic stellate cell activation. The present study investigated whether rapamycin treatment could modify the degree of fibrosis, cellular apoptosis and oxidative stress (OS) in an experimental model of CP.

METHODS

Fifty-five male, Sprague-Dawley rats weighing 200-400g were randomized into four groups. CP was induced by intraductal trinitrobenzene sulfonic acid (TNBS) infusion in group A (n = 15) and group B (n = 15). Group C (n = 15) received intraductal TNBS and was killed for histologic confirmation at four weeks. Group D (n = 10) received intraductal saline instead of TNBS. Group A and group D received oral rapamycin (2 mg/kg/d) for two weeks after CP was induced while group B received oral tap water instead of rapamycin. Blood and pancreatic tissue specimens were collected and oxidative stress parameters, fibrosis and cellular apoptosis were determined.

RESULTS

Tissue and blood malondialdehyde (MDA) levels were significantly lower in rapamycin treated group compared to controls (p < 0.001). Superoxide dismutase (SOD) and glutathion peroxidase (GSH-Px) activities were also significantly higher in the active treatment group (p < 0.001 for both). Tissue and blood MDA, SOD, GSH-Px measurements was similar in rapamycin group and pancreatic cannulation group (p > 0.05). Histopathologic fibrosis scores were similar in rapamycin and control groups. Apoptotic cell counts tended to be lower in rapamycin treated animals.

CONCLUSIONS

Administration of rapamycin alleviated OS and, in part, prevented apoptotic cell death in experimental CP, but did not reduce fibrosis.

Wilms' tumor: a 24-year retrospective study from a single center

Medical records of 71 children with Wilms' tumor at Sisli Etfal Education and Research Hospital between 1990 and 2014 were reviewed. Mean age at diagnosis was 3.11 years (2 days-7 years). Male to female ratio was M/F = 6/10. The incidence of associated anomaly was 16.9%. Clinical manifestations included abdominal mass (89%), hematuria (30%), hypertansion (25%), abdominal pain (15%), fever (5%), restlessness (2%), weight loss (2%), varicocele (1%). Ultrasound (USG) was the most often initial study in a child presenting with abdominal mass. Doppler USG was also made to evaluate the inferior vena cava (IVC) for the presence of tumor extension in children with renal mass. The left kidney was affected in 33 patients (46.5%), the right was affected in 31 patients (43.7%). Two patients was extrarenal (2.8%). And 5 patients (7.04%) were bilateral on the presentation. Preoperative chemotheraphy was done in 14 cases. In 63 patients with unilateral Wilm tm, unilateral radical nefrectomy is performed. In one patient with solitary kidney, nephron sparing surgery (NSS) is performed. In 3 patients with bilateral tm NSS is performed and in 2 patients with bilateral Wilms' tm NSS is performed in one side and nefrectomy on the other side. Out of 71 Wilms tumor (WT) patients, 17 of them has been out of our follow. And 4 of them are died. Ten of them has metastases. Forty children are under follow with no metastases. Patients with WT needs a multimodal, multidisiplinary treatment with the cooperation of pediatric oncologist and pediatric surgeon and needs close follow-up.

Comparison of piperacillin tazobactam and cefoperazone sulbactam monotherapy in treatment of febrile neutropenia

BACKGROUND

Monotherapy has tended to replace the combination therapy in emprical treatment of febrile neutropenia. There is no reported trial which compares the efficacy of cefoperazone-sulbactam (CS) and piperacillin-tazobactam (PIP/TAZO) monotherapies in the treatment of febrile neutropenia. In this prospective randomized study, we aimed to compare the safety and efficacy of CS versus PIP/TAZO as empirical monotherapies in febrile neutropenic children with cancer.

PROCEDURE

The study included febrile, neutropenic children hospitalized at our center for cancer. They were randomly selected to receive CS 100 mg/kg/day or PIP/TAZO 360 mg/kg/day. Duration of fever and neutropenia, absolute neutrophil count, modification, and success rate were compared between the two groups. Resolution of fever without antibiotic change was defined as success and resolution of fever with antibiotic change or death of a patient was defined as failure. Modification was defined as changing the empirical antimicrobial agent during a febrile episode.

RESULTS

One hundred and two febrile neutropenic episodes were documented in 55 patients with a median age of 4 years. In 50 episodes CS and in 52 episodes PIP/TAZO was used. Duration of fever and neutropenia, neutrophil count, age, sex, and primary disease were not different between two groups. Success rates in the CS and PIP/TAZO groups were respectively 56 and 62% (P > 0.05). Modification rate between two groups showed no significant difference (P > 0.05). No serious adverse effect occurred in either of the groups.

CONCLUSION

CS and PIP/TAZO monotherapy are both safe and effective in the initial treatment of febrile neutropenia in children with cancer.

Serum neopterin, sialic acid and nitric oxide levels in dogs with malignant mammary tumours

Mammary cancer is one of the leading causes of death in pet population. Early diagnosis and malignancy detection is important for prognosis. The levels of neopterin, sialic acid and nitric oxide in serum of dogs with malignant mammary tumours were evaluated to investigate the importance of these biochemical parameters for malign mammary tumour. Twelve healthy dogs and twenty dogs with malignant mammary tumours were used as research materials. Blood samples were collected from both groups for neopterin analysis by enzyme-linked immunosorbent assay, whereas nitric oxide and sialic acid were measured by modified nitrate reductase method and spectrophotometry, respectively. Tissue specimens were evaluated and defined as malignant tumours. Serum nitric oxide and sialic acid levels in dogs with mammary tumours were significantly higher than those in the healthy dogs. Serum neopterin levels were not found significantly different in dogs with mammary tumours compared to healthy dogs. Malignancy of canine mammary tumours are accompained by an elevation of nitric oxide and sialic acid levels.

Assessment of hepatitis B immunization status after antineoplastic therapy in children with cancer

BACKGROUND AND OBJECTIVES

Hepatitis B is a disease that is preventable with vaccination. Antibody levels after vaccination may be affected by suppression of the immune system due to cancer therapy. Children with cancer have a high risk of hepatitis B virus (HBV) infection. We aimed to assess the pretreatment immunization status against HBV infection and the rate of continuity of immunization after therapy in children with cancer.

DESIGN AND SETTING

Retrospective case review of patients treated from 2004 to 2008.

PATIENTS AND METHODS

We reviewed the medical records of patients treated in the departments of pediatric hematology and oncology and collected data on immunization history and hepatitis B serology. Anti-HBs antibody titers were compared before and after treatment.

RESULTS

This study included 159 (99 males, 60 females) children who had a serologic examination. Antineoplastic therapy had been given for acute leukemia (n=66), non-Hodgkin lymphoma (n=27), Hodgkin lymphoma (n=20), and solid tumors (n=46). Fifty-one patients had not been immunized against HBV prior to the therapy; HBV serology was negative in 49 of these patients and HBsAg was positive in 2 patients. Anti-HBs antibody positivity was present in 99 of 108 patients with an immunization history, whereas no vaccination response was present in 9 patients. The titer of anti-HBs antibody was decreased below the protection level in 33 (33%) patients with positive anti-HBs antibody, whereas the protection level was found to be maintained in 66 (67%) patients. The most significant decrease (63.6%) was observed in leukemia patients. Posttreatment HBsAg and HBV DNA positivity was detected in two of the patients with negative pretreatment serology, whereas no HBV infection developed in the group with positive anti-HBs antibody.

CONCLUSIONS

This study demonstrated the importance of routine childhood vaccination in reducing the risk of HBV infection in patients with cancer.

Mild and Severe Anal Incontinence after Lateral Internal Sphincterotomy: Risk Factors, Postoperative Anatomical Findings and Quality of Life

<i>Aim:</i> This study aims to evaluate the risk factors for incontinence after lateral internal sphincterotomy (LIS) and assess quality of life in different levels of incontinence. <i>Methods:</i> All consecutive patients (n = 253) with chronic anal fissure who underwent LIS between 2003 and 2006 were retrospectively reviewed. All patients were questioned for possible anal incontinence according to the Wexner Incontinence Score (WIS). Demographics, vaginal delivery history, additional procedures and surgeon’s experience were evaluated as risk factors. Endoanal ultrasound (EUS) was performed in incontinent patients to assess the thickness of the remaining internal sphincter and to evaluate any injury in the external sphincter. Quality of life was questioned with SF-36. <i>Results:</i> Twenty-eight (11.7%) patients suffered from incontinence (mean WIS = 3.6 ± 2.5). The search for a risk factor was unsuccessful when continent and incontinent groups were compared. In subgroup analyses, patients were found to be suffering from mild (WIS <5, n = 19) or severe (WIS >5, n = 9) incontinence. Vaginal delivery history was found more often in the severely incontinent subgroup than in the continent group (p < 0.05). Also, vaginal delivery history and the additional procedures were more frequently observed in the severely incontinent subgroup than in the mildly incontinent subgroup. EUS did not find any external sphincter injury in these cases. WIS had negative correlations with the physical and mental component scores of SF-36. <i>Conclusion:</i> In our opinion, the threat for incontinence is unpredictable; however, vaginal delivery history may increase the risk of severe incontinence.

Apical lymph nodes at the root of the inferior mesenteric artery in distal colorectal cancer: an analysis of the risk of tumor involvement and the impact of high ligation on anastomotic integrity

BACKGROUND

What level of arterial ligation is best in left-sided colon cancer and rectal cancer remains controversial. This study aims to assess the necessity and risk of high ligation from an oncological and technical perspective.

METHODS

The lymph nodes at the origin of the inferior mesenteric artery (IMA) were separated as apical nodes in all patients operated for distal colorectal cancer in our department. The number and status of the nodes were prospectively assessed, and demographic and tumor-related variables were evaluated as risk factors for apical tumor invasion. Anastomotic leaks were also evaluated.

RESULTS

A hundred and three patients (52 [50.5%] males, 60.3+/-12.9 years old) were included. The number of non-apical lymph nodes harvested was 14.5+/-7.1 with an additional 4.4+/-3.2 apical nodes at the high ligation site. Tumor invasion of apical nodes was observed in 6 (5.8%) patients. Two of these (1.9%) had no other positive nodes (skip metastases). Although none of the variables evaluated was found significant for predicting apical node positivity, tumor invasion was detected in 8.5 and 22.2% of patients with pT3 and pN2 cancers, respectively. Among patients, who had an anastomosis (n = 84, 81.6%), anastomotic leak was observed in 7(8.3%) and 1 (1.2%) of these patients required emergency relaparotomy. There was no mortality related to high ligation.

CONCLUSIONS

High ligation of IMA may be routinely performed in patients with distal colorectal cancer, since tumor invasion of apical lymph nodes is neither rare (>5%) nor predictable, and skip metastases may also occur. This is especially true in case of an advanced disease for which apical node positivity peaks. The anastomotic leak rate is less than 10%, and mortality is low after high ligation of IMA.

Diagnosis in childhood abdominal Burkitt's lymphoma

BACKGROUND

The role of surgery has changed substantially over the years in abdominal Burkitt's lymphoma. Laparotomy without total excision of the tumor does not have a positive effect on survival, might cause complications, and delays initiation of chemotherapy. Here we present our diagnostic management of patients with abdominal Burkitt's lymphoma.

MATERIALS AND METHODS

The diagnostic methods of abdominal Burkitt's lymphoma cases treated between January 1999 and December 2009 were evaluated retrospectively.

RESULTS

Of the 48 abdominal Burkitt's lymphoma patients, 13 also had extra-abdominal site involvement. Diagnosis was made with ultrasound-guided tru-cut needle biopsy of the abdominal mass (n = 11), fluid cytology (n = 7), extra-abdominal site biopsy (n = 4), bone marrow aspiration (n = 2), gastroscopy (n = 1), and laparotomy (n = 23). In patients diagnosed with laparotomy, chemotherapy was started in 4-22 days (median 7) compared with patients diagnosed with other diagnostic interventions in 2-4 days (median 2) (P < .001).

CONCLUSION

Although the most frequently used technique is laparotomy and open biopsy in our series, other methods provided quicker initiation of chemotherapy and less surgical morbidity. Especially in patients with high stages, cytological evaluation and tru-cut needle biopsy with radiological guidance is a better alternative of laparotomy.

Imipenem-cilastatin versus piperacillin-tazobactam as monotherapy in febrile neutropenia

BACKGROUND

In view of the recent trend toward monotherapy in the treatment of febrile neutropenia, we evaluated the clinical efficacy and safety of imipenem-cilastatin versus piperacillin-tazobactam as an empiric therapy for febrile neutropenia in children with malignant diseases.

METHODS

Febrile neutropenic patients received either imipenem-cilastatin or piperacillin-tazobactam randomly. Improvement without any changes in the initial antibiotic treatment was defined as "success" and improvement with modification of the initial treatment and death was defined as "failure".

RESULTS

Over 12 months, 99 febrile neutropenic episodes were treated with monotherapy in 63 patients with a median age of 5 years. At admission, median absolute neutrophil count was 50/mm(3) and in 67% of episodes, neutrophil count was under 100/mm(3). Median duration of neutropenia was 5 days. In 22% of episodes, neutropenia persisted for more than 10 days. Piperacillin-tazobactam was used in 52 episodes and imipenem-cilastatin was used in 47 episodes. There was no difference between groups in terms of age, sex, primary diseases, neutrophil count or duration of neutropenia. In the whole group, the success rate was 67% and the failure rate was 33%, whereas in the piperacillin-tazobactam group, the rates were 71% and 29%; and in the imipenem-cilastatin group they were 62% and 38%, respectively (P > 0.05). There were no deaths. No major adverse effects were seen in either group.

CONCLUSIONS

Although failure was slightly higher in the imipenem-cilastatin group, this was statistically insignificant. Both of these antibiotics can be used safely for initial empirical monotherapy of febrile neutropenia.

The effect of ribavirin on bone density in patients with chronic hepatitis C treated with interferon-ribavirin therapy

OBJECTIVE

The objective of this study was to investigate the effects of ribavirin on bone mineral metabolism in patients with chronic hepatitis C who had been treated with interferon and ribavirin.

METHODS

Twenty patients (3 female, 17 male) with chronic hepatitis C were enrolled. Age range was 6 to 15 years (mean+/-SD, 11.15+/- 2.3 years). Thirteen patients received combined interferon alpha-2b and ribavirin therapy (Group 1), and 7 patients received only interferon alpha-2b (Group 2). Both groups were treated for 12 months. Bone mineral density, z-scores and biochemical bone markers were evaluated in both groups before and after treatment.

RESULTS

There were no significant differences between the groups in age or gender. Mean lumbar vertebral bone mineral density and mean z-scores in groups 1 and 2 before and after treatment were not significantly different. In both groups, serum and urinary biochemical values and bone markers were all normal and there were no differences between the pretreatment and post-treatment values.

CONCLUSION

Contrary to studies in adults, we did not find any ribavirin-dependent changes related to bone mineral metabolism in our pediatric study groups. Further studies are needed to obtain more detailed information about the effects of ribavirin on bone mineral density.

Brain metastasis in pediatric extracranial solid tumors: survey and literature review

OBJECTIVES

Brain is a rare site of metastasis in most extracranial pediatric solid tumors. The aim of this study is to investigate the incidence, treatment, prognosis of brain metastasis in extracranial pediatric malignant tumors in a single institution and to review the literature.

METHODS

From September 1989 to December 2002, 1100 children <or=16 years of age with extracranial solid tumors including lymphomas were diagnosed and treated in the Division of Pediatric Oncology, Oncology Institute, Istanbul University. Patients with parenchymal metastases in the brain were assessed.

RESULTS

Sixteen (10 female, 6 male) of 1100 patients (1.45%) with extracranial solid tumors developed brain metastases. The median age of the patients was 10.5 (1-16) years. The diagnosis was sarcomas in 12 patients: 5 osteosarcomas, 4 Ewing's sarcoma family tumors, 1 rhabdomyosarcoma, 1 clear cell sarcoma of the soft tissue, 1 alveolar soft part sarcoma. Two patients had Wilms' tumor and two had germ cell tumors. Four patients (25%) had brain metastasis at diagnosis. Twelve (75%) developed brain metastasis during therapy or relapse at a median duration of 16 (1-70) months from initial diagnosis. All patients had metastases to various sites, mostly lung, at the time the brain metastases were detected. Treatment included surgery, followed by postoperative radiotherapy (RT) and chemotherapy (CT) in 1, S and RT in 1, S in 1, RT and CT in 6, RT in 1, CT in 1 and no treatment in 5. Only one patient with alveolar soft part sarcoma is alive with disease 20 months from diagnosis of brain metastasis. All other patients died at a median time of 2 months (2 days-6 months) from the time of brain metastasis.

CONCLUSIONS

Children with metastatic cancer who develop headaches or any other neurologic symptom should be investigated for possible brain metastasis. Although, the outcome for these patients is dismal in this series and in the literature; reports of long term survival in a few cases with Wilms' tumor, osteosarcoma and alveolar soft part sarcoma who had isolated brain metastasis, suggest that a subset of patients may benefit from therapy.

Evaluation of the patellofemoral joint with kinematic MR fluoroscopy

OBJECTIVE

The aim of this study was to evaluate the diagnostic effectiveness of kinematic magnetic resonance fluoroscopy (KMRF) on patients with patellofemoral incongruency. MATERIALA AND METHODS: 17 patients (20 knees) and 10 healthy volunteers (20 knees), all men (mean age 29.4 years, S.D. 9, range 16-50), were included to our study. Only male subjects were studied because of potential biomechanical differences between sexes. KMRF was used to perform kinematic MR imaging of patellar alignment and tracking in 10 healthy subjects and 17 patients with a provisional clinical diagnosis of abnormal patellofemoral joints. The patellofemoral joints were examined with the knee in different angles of active flexion. At each knee position, real time kinematic and axial MRF image was used to focus on the sagittal plane, followed by an axial image focused through the middle of the patella. Three angles were measured: patellar tilt angle (PTA), sulcus angle (SA) and congruence angle (CA).

RESULTS

Five patterns of malalignment were identified and studied. Two patellofemoral joints were normal, 10 had lateralization of the patella, 2 had patellar tilt, 2 had lateralization and patellar tilt (i.e. excessive lateral pressure syndrome) and 4 had medialization of the patella.

CONCLUSION

KMRF is an effective method in evaluating patellofemoral incongruency. Short time duration of investigation, ability to get nearly real time images, suitable temporal contrast resolution and investigation from very different angles of knee are important advantages of the method.

The role of L-arginine and neutrophils on incisional wound healing

Although arginine plays an important role in many aspects of inflammation and wound healing, the mechanism is not clear. We aimed to evaluate the effect of L-arginine administration on wound healing and neutrophil activity and on the interaction of these effects. Sixteen rats were divided into two groups: control group and L-arginine group. L-arginine was given intraperitoneally. The rats underwent incisional wounding and were killed on the 7th day of wounding. Blood neutrophil counts, neutrophil adhesivity index, tensile strengths and hydroxyproline level of skin were determined, histopathological and electron microscopical evaluation of healing was performed. Wound scores in the control group were significantly lower (p < 0.05). Hydroxyproline and collagen levels of skin were significantly increased in the L-arginine group (p < 0.05). Blood neutrophil counts and neutrophil adhesivity index in the L-arginine group were significantly increased (p < 0.05), as were the inflammatory cells in the skin. L-arginine may be used during the first phase of healing to induce inflammation in high risk patients.

The effectiveness of systemic antibiotics in preventing postoperative, intraabdominal adhesions in an animal model

OBJECTIVE

Postoperative intraabdominal adhesions can be prevented by antibiotic lavage. We assessed whether systemic antibiotics could prevent adhesion formation in a rat model.

METHODS

Cecal abrasion was performed in the peritoneal cavities of 40 Wistar albino rats. Twenty rats were treated with a 5-day course of cefepim and metronidazole; the remaining animals were given saline injections. The animals were sacrificed 14 days after surgery. Adhesion severity scores and histopathologic findings were compared.

RESULTS

The median adhesion severity score was 2 (0-3) in the antibiotic group and 2.5 (1-4) in the controls (P = 0.03). In tissue specimens from controls, the adhesions were marked by mature collagen bundles. In treated rats, the adhesions were immature, characterized by early inflammatory cells, less collagen formation, and no collagen bundles.

CONCLUSIONS

Postoperative systemic antibiotics slow adhesion formation and reduce the severity of the adhesions.

A trial of reducing adhesion formation in a uterine horn model

For the prevention of postoperative adhesion formation, one of the most common causes of infertility, none of the adjuvants had been proven uniformly effective. In this study we evaluated the effectiveness of sodium carboxymethylcellulose (SCMC) and disodium cromoglycate (DSCG) in postoperative adhesion prevention in a rat uterine horn model. Thirty female Sprague-Dawley rats were used. After uterine horn abrasion, in 10 rats 10 ml 0.9% saline, in 10 rats 10 ml of 2% SCMC, and in 10 rats 10 ml DSCG were administered intraperitoneally. Two weeks later, all animals were sacrificed and adhesion formation was assessed. All the pieces of the peritoneum biopsies were stained with Luna's mast cell stain to assess the mast cell degranulation. The mean adhesion scores were 2.1, 2.0 and 1.5 for saline, SCMC and DSCG groups respectively. There were no significant differences among all groups. In the pathologic examination, mast cell degranulation was less in the DSCG group than the other groups.