A longitudinal study of the peripheral and central auditory pathways in individuals with acute lymphoid leukemia

OBJECTIVE

To characterize the peripheral and central auditory pathways in individuals with Acute Lymphoid Leukemia (ALL) and compare assessment results before and during chemotherapy.

METHOD

The study included 17 subjects with ALL, divided into two age groups: 3 to 6 (11 individuals) and 7 to 16 years old (6 individuals). Each subject was evaluated twice (before and 3 to 6 months after chemotherapy treatment) with the following procedures: medical history survey, otoscopy, Pure-Tone Threshold (PTA) and speech audiometry, acoustic immittance measures, Brainstem Auditory Evoked Potentials (BAEP) and Long-Latency Auditory Evoked Potentials (LLAEP).

RESULTS

PTA was normal. Tympanometry was abnormal in the second assessment in 2 individuals aged 3 to 6 years. One subject in each age group had absent ipsilateral acoustic reflexes. In high-frequency audiometry, 1 individual had abnormal results. BAEP was abnormal in 5 (first assessment) and 7 individuals (second assessment) aged 3 to 6 years and 2 (first assessment) and 1 individual (second assessment) aged 7 to 16 years. As for LLAEP, P1 latency was increased in 5 (first assessment) and 7 individuals (second assessment) aged 3 to 6 years.

CONCLUSION

No hearing loss was identified in the behavioral audiological assessment. BAEP was more affected in the 3-to-6-year-old group, with greater impairment in the lower brainstem in the first and second assessments. In LLAEP, P1 was the most impaired component in children aged 3 to 6 years, and P2 and N2 were so for those 7 to 16 years old, especially in the second assessment.

Perceptions of Health Professionals on the Implementation of Integrative and Complementary Practices at a University Pediatric Hospital in Brazil: A Qualitative Interview Study

BACKGROUND

Despite an increase in use of pediatric complementary and integrative health (PCIH), many healthcare professionals still have an inadequate understanding of such practices and consider their use inappropriate, which might thwart implementation processes. In a qualitative interview study we examined the feedback of conventional healthcare professionals about the integrative practices provided to pediatric patients by an integrative team in a pediatric oncological hospital.

METHODS

Fifteen semi-structured interviews were carried out with various conventional healthcare professionals in an university pediatric hospital in São Paulo, Brazil. The interviews were audio-recorded, transcribed and pseudonymized. DSCsoft® and MAXQDA® software assisted in a profound qualitative analysis using the collective subject discourse and thematic analysis method in order to display participants' perspectives on PCIH and the project in their hospital.

RESULTS

Interviewees acknowledged their lack of knowledge about PCIH practices and reflected on the limits of their care as well as on new possibilities PCIH could offer. PCIH was perceived by interviewees as an effective supportive tool of care to promote patients' wellbeing, assist overall compliance, strengthen cooperation between professionals, children and their relatives and hence facilitated general patient care. Since PCIH was implemented in their clinic, perceptions led interviewees to wish for increased PCIH offering and a more profound integration of its therapists into the standard of care.

DISCUSSION

The coexistence of integrative and conventional practices in the conventional healthcare setting is important to give visibility to the possibilities offered by the integrative pediatrics field. Regular and constant encounters with integrative practices, as well as information access seem crucial to reach a wider openness for PCIH and subsequently a broader application and dissemination of it.

The implementation of an online mindfulness-based program for pediatric patients at a tertiary hospital in South America: a feasibility study protocol

Background

The prevalence of chronic and complex pediatric health conditions has quickly risen over the last decades. Chronic and complex health conditions make pediatric patients and their families more susceptible to many distressing events during their lifespan. Mindfulness-based interventions have become a popular intervention for individuals living with chronic illnesses and have been adapted for pediatric populations with good results, including online versions. This study intends to report an implementation protocol of an online mindfulness-based program for adolescents to address an important gap in stress relief and health promotion for pediatric patients.

Methods

In this article, we describe the rationale and design of an implementation study of an online mindfulness-based program for pediatric patients at a tertiary pediatric hospital in South America. Participants will be recruited during one year to participate in an eight-session online mindfulness-based program. To assess our primary aim of feasibility, we will exam recruitment, retention and participation rates. Participants will also complete a symptomatology evaluation (i.e., depression, anxiety, and stress symptoms) at baseline and immediately at post-treatment and fidelity will be evaluated by a structured questionnaire.

Discussion

This study will be the first known to assess the implementation of an online mindfulness-based program for a pediatric population at a tertiary pediatric center in South America under real-life conditions. This study will establish the feasibility of a novel intervention aimed at promoting mental health and positive coping strategies among pediatric patients with chronic and complex health conditions. Evidence from this study would be useful to patients, families, clinicians, and policymakers and will help to devise strategies of health promotion for the pediatric population, as well as serve as a model for a future trial to examine efficacy of the proposed intervention.

Trial registration

This research has been registered at Ensaiosclinicos.gov.br, identifier RBR-23trp87. Registered 25 February 2022—retrospectively registered.

ATRT-06. Atypical Teratoid Rhabdoid Tumors (ATRT): results from a Single Institution in Brazil - São Paulo University

OBJECTIVES: Atypical teratoid/rhabdoid tumor (AT/RT) is a rare, highly malignant tumor of the central nervous system with poor prognosis. Nowadays, multimodal management, including surgery, chemotherapy (CMT), radiation therapy (RT) and Bone Marrow Transplantation (BMT). The aim of this study was to assess the experience and survival in a center of reference of treatment in childhood cancer in Brazil. PATIENTS AND METHODS: Medical records of AT/RT patients who underwent surgery from 2008 to 2020 at a center of childhood cancer treatment (ITACI) in São Paulo University were retrospectively reviewed and statistically analyzed. RESULTS: Eight patients (2 males and 6 females) were presented with AT/RTs. Median age during presentation was 22 months (range, 0 - 6 years). Seven patients (88%) were < 18 months and one patient were >18 months. Tumor location was supratentorial in four patients, infratentorial in 2 patients. Kidney disease as the primary diagnosis in 2 patients (25%). Surgical treatment was performed in 4 patients. Seven children underwent total CMT and 3 children were treated with RT. Only 3 patients underwent Autologous Bone Marrow Transplantation (ABMT). The chemotherapy management protocol of the patients was variable: 2 patients received the EU-RHAB protocol, 2 patients received the HEAD START III protocol, 3 patients received chemotherapy in the ICE regimen (Ifosfamide + Carboplatin + Etoposide) and 1 patient received chemotherapy in the CDDP+CTX+VCR (Cyclophosphamide + Cisplatin + Vincristine) regimen. All patients had episodes of neutropenic fever when they received chemotherapy, requiring hospitalization and use of an antibiotic treatment. Among the 8 patients analyzed, all died. CONCLUSIONS: Despite progress in treatment, AT/RT of the CNS disease or primary kidney disease associated with a lack of standardization in a regimen contributes to the dismal prognosis. There is a high mortality in patients with AT/RT, similar to that found in the literature.

Novel pathogenic variants and quantitative phenotypic analyses of Robinow syndrome: WNT signaling perturbation and phenotypic variability

Robinow syndrome (RS) is a genetically heterogeneous disorder with six genes that converge on the WNT/planar cell polarity (PCP) signaling pathway implicated (DVL1, DVL3, FZD2, NXN, ROR2, and WNT5A). RS is characterized by skeletal dysplasia and distinctive facial and physical characteristics. To further explore the genetic heterogeneity, paralog contribution, and phenotypic variability of RS, we investigated a cohort of 22 individuals clinically diagnosed with RS from 18 unrelated families. Pathogenic or likely pathogenic variants in genes associated with RS or RS phenocopies were identified in all 22 individuals, including the first variant to be reported in DVL2. We retrospectively collected medical records of 16 individuals from this cohort and extracted clinical descriptions from 52 previously published cases. We performed Human Phenotype Ontology (HPO) based quantitative phenotypic analyses to dissect allele-specific phenotypic differences. Individuals with FZD2 variants clustered into two groups with demonstrable phenotypic differences between those with missense and truncating alleles. Probands with biallelic NXN variants clustered together with the majority of probands carrying DVL1, DVL2, and DVL3 variants, demonstrating no phenotypic distinction between the NXN-autosomal recessive and dominant forms of RS. While phenotypically similar diseases on the RS differential matched through HPO analysis, clustering using phenotype similarity score placed RS-associated phenotypes in a unique cluster containing WNT5A, FZD2, and ROR2 apart from non-RS-associated paralogs. Through human phenotype analyses of this RS cohort and OMIM clinical synopses of Mendelian disease, this study begins to tease apart specific biologic roles for non-canonical WNT-pathway proteins.

MUSIC INTERVENTIONS IN PEDIATRIC ONCOLOGY: Systematic review and meta-analysis

BACKGROUND

Pain is a disagreeable and distressing feeling that affects human beings in multi-dimensional ways. A number of non-pharmacological interventions have had varying degrees of success in treating cancer-related pain, such as breathing and relaxation techniques, and music therapy, which have been identified as beneficial therapies for alleviating pain and anxiety.

OBJECTIVE

Identify the therapeutic effects of music interventions in psychological and physiological terms and on the quality of life of children undergoing cancer treatment.

METHOD

Systematic review of effectiveness based on the methodology of the Joanna Briggs Institute.

RESULTS

Eleven articles were included with a total of 429 children, whose ages ranged from 0 to 18 years. The mean duration of the music intervention was 30.6 (±SD 9.8) min. In a combined estimate of five studies for pain and anxiety outcomes, there were benefits to using music when compared with the control group (SMD -1.05; CI 95 % -1.70 - 0.40 N = 453 I² = 90 %). A combined analysis of five studies to assess quality of life showed that the use of music was favorable when compared with the control (SMD -0.80; CI 95 % -1.17-0.43 N = 457= I² = 71 %).

CONCLUSION

After completing this review, it was determined that there is evidence to support the use of music to reduce pain and anxiety and improve the quality of life of children undergoing cancer treatment.

Primary cardiac congenital yolk sac tumor - case report and literature review

Intracardiac tumors are rare, especially in the neonatal period. We present an infant of 1-year and 11 months old with a diagnosis of an intracardiac antenatal tumor, along with literary review on the topic. The referred tumor evolved rapidly with metastases at the time of diagnosis. A biopsy of a pulmonary metastatic lesion was performed, which showed germinative cells tumor (GCT). The patient underwent intensive care treatment, and is now in good condition, following the proposed treatment with chemotherapy for TCG.

Brainstem auditory pathway of children with acute lymphoid leukemia on chemotherapy with methotrexate

OBJECTIVE

Investigate the auditory pathway in the brainstem of children with acute lymphoblastic leukemia submitted to chemotherapy (by intravenous or intrathecal infusion).

METHODS

Fourteen children aged between 2 and 12 years with diagnosis of acute lymphoid leukemia were evaluated. The following procedures were used: meatoscopy, acoustic immitance measurements, tonal audiometry, vocal audiometry, transient otoacoustic emissions, and auditory brainstem response.

RESULTS

From the 14 children with normal auditory thresholds, 35.71% showed an alteration in auditory brainstem response, with a predominance of hearing impairment in the lower brainstem. It was found that 80% of the children with alteration had used intrathecal methotrexate less than 30 days and that 40% had the highest cumulative intravenous methotrexate doses.

CONCLUSION

Children with acute lymphoblastic leukemia submitted to chemotherapy, present auditory pathway impairment in the brainstem, with a predominance of a low brainstem.

Abstract B18: MEG3 and MEG8 aberrant methylation associated with worst prognosis in an infant with neuroblastoma

Background: Neuroblastoma (NB) is an extremely rare pediatric cancer accounting for about 12% of childhood cancer-related deaths, due to its dismal prognosis in patients diagnosed over 18 months of age with disseminated disease. However, neonates and infants with neuroblastoma are expected to have a better evolution despite their stage and even unfavorable molecular characteristics. Here, we report an unusual case of low-risk neuroblastoma (stage 2B, nonamplified MYCN) in a 9-month-old girl with unfavorable outcome despite favorable prognostic factors.

Material and Methods: We investigated the coding genes expression (mRNA) and long noncoding RNAs (lncRNAs) in primary and relapse tumors of this patient to look for genomic and epigenetic alterations that could explain the clinical evolution. The cytogenetic profiles of the primary and relapse tumor samples were also obtained. Three primary tumors from patients with neuroblastoma, all classified as stage 1 (INSS) and low-risk (below 18 months of age at diagnosis, nonamplified-MYCN, all alive and free of disease 60 months after diagnosis) were used as controls in RNA sequencing (RNA-Seq. Illumina®) and DNA methylation arrays (Illumina Infinium HumanMethylation450 BeadChip). Somatic copy number alterations were investigated in the primary and relapsed sample using the array-CGH methodology in a 180K platform (Agilent).

Results: The cytogenetic profiles of both samples were quite identical, with few copy number alterations. No numerical chromosomal alterations (aneuploidies) were detected; both tumors carry segmental copy number alterations in common, most of them probably present in a nonmosaic state. The differential gene expression analysis based on fold-change (≤ -2 and ≥ 2), p &lt; 0.005, and FDR &lt; 0.05 was used in RNA-seq to identified gene differential expression in primary and relapsed tumors. Interestingly, only two lncRNA, the imprinted maternally expressed genes MEG3 and MEG8, were downregulated in both primary and relapse tumors. MEG3 targets p53 by either directly interacting with p53 or indirectly suppressing the negative regulator MDM2. In the case of MEG8, their functions in cancer remain unknown. Our study then focused on MEG3 and MEG8 methylation analysis. DNA methylation status of the study groups (primary, relapse tumors, and controls) strongly suggested that DMR that covers promoters was responsible for silencing MEG3 and MEG8 genes in primary and relapse tumors, resulting in downregulation of MEG3 and MEG8. Tumor samples from the patient were also used to perform methylation-specific MLPA (MSMLPA) (SALSA® probemix, MRC-Holland). Hypermethylated probes at MEG3 were identified in primary and relapse tumors when compared with controls.

Conclusion: Furthermore, we hypothesized that the methylation gain of the MEG3 and MEG8 locus may be accentuated during cancer progression and therefore, the increased degree of MEG3 and MEG8 suppression was associated with the overall aggressiveness of neuroblastoma.

Citation Format: Estela M. Novak, Thamiris Magalhaes Gimenez, Nathalia Halley Neves, Carolina Sgarioni Camargo Vince, Ana Cristina Victorino Krepischi, Rainer Marco Lopez Lapa, Lilian M. Cristofani, Israel Bendit, Vicente Odone Filho. MEG3 and MEG8 aberrant methylation associated with worst prognosis in an infant with neuroblastoma [abstract]. In: Proceedings of the AACR Special Conference on the Advances in Pediatric Cancer Research; 2019 Sep 17-20; Montreal, QC, Canada. Philadelphia (PA): AACR; Cancer Res 2020;80(14 Suppl):Abstract nr B18.

CD56bright/CD16bright NK-cell adoptive immunotherapy in patients with concurrent CNS disease and relapsed or refractory (R/R) AML

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Background: Patients (pts) with R/R AML and concurrent CNS disease rarely respond to chemotherapy and have a dismal prognosis. Adoptive immunotherapy (AI) with haploidentical ex vivo-activated/expanded NK cells shows promise in R/R AML, but it is unknown whether the blood–brain barrier (BBB) represents an obstacle to this approach. Here we present data from 4 pts with CNS disease from a phase 1 study of 13 pts receiving NK AI for R/R AML (NCT02809092). Methods: Double bright (CD56bright/16bright) activated NK cells (DBNK) were expanded from haploidentical family donors on feeder cells expressing membrane-bound IL-21. DBNK were infused thrice weekly for six doses 3–7 days after fludarabine, cytarabine, and G-CSF (FLAG). Pts received doses ranging from 106 to 107 DBNK/kg/infusion. CNS responses at day 30 were assessed using Response Assessment in Neuro-Oncology criteria. RNA sequencing was used to compare gene expression in DBNK vs unexpanded NK cells. Results: Demographics of the 4 pts with CNS disease are shown (Table). All pts had received a prior stem cell transplant and were heavily pretreated (median 6 prior treatments), and 1 had primary refractory disease. All pts completed 6 NK-cell infusions without dose-limiting toxicities. No cytokine storm syndrome was reported. Other toxicities were manageable, including CNS hypertension symptoms. Imaging studies showed inflammation localized to disease sites. All 4 pts showed a response (Table), with complete, long-lasting resolution of CNS lesions documented in pts #1 & #5, almost complete resolution of bone and nerve root leukemic infiltration in pt #4, and a 50% reduction of CNS chloromas in pt #6. Responses were durable, lasting up to 7 months. DBNK showed upregulation of homing receptors associated with CNS trafficking. Conclusions: Multiple infusions of ex vivo IL-21-expanded DBNK were tolerable and demonstrated unprecedented CNS responses in patients with R/R AML. These data support effectiveness of DBNK across the BBB. Clinical trial information: NCT02809092 . [Table: see text]

Long-Term Evaluation of Post-transplant Lymphoproliferative Disorders in Paediatric Heart Transplantation in Sao Paulo, Brazil

We sought to better define the demographics and characteristics of post-transplant lymphoproliferative disorders (PTLD) in a cohort of paediatric OHT patients from a developing country. Data were collected from the Heart Institute, Sao Paulo, for all paediatric OHT recipients from October 1992 to October 2018. Group differences between the PTLD and non-PTLD cohorts were assessed by Fisher exact and Mann-Whitney U tests. Kaplan-Meier curves analysed the survival in each group. Data were reviewed for 202 paediatric OHT recipients. Overall 1-, 5- and 10-year survival for the entire cohort was 76.5%, 68.3% and 62.9%; 24 patients (11.9%) developed PTLD at a median 3.1 years (IQR 0.8-9.0) after OHT. Cases were evenly spread over the follow-up period, with PTLD diagnosed in 9.8% (n = 137) of patients who were alive at 3 years, 15.3% (n = 78) of patients who were alive at 5 years and 29.3% (n = 41) of patients who were alive at 10 years. The commonest form of PTLD was diffuse large B cell lymphoma (n = 9), and most patients received rituximab with immunosuppression and chemotherapy as treatment (n = 15). We identified no increased risk in mortality amongst the PTLD vs. non-PTLD cohorts in multivariate analysis (P = 0.365). PTLD after paediatric OHT had acceptable outcomes. However, risk factors for PTLD were not identified and warrant further investigation.

Abstract B13: BLM, FOXO3, FOXK2, FOXM1, FOXR1 genes as therapeutic targets to neuroblastoma

Due to heterogeneity of the neuroblastoma (NB) tumor, next-generation personalized medicine may identify therapeutic targets. Gene expression alterations of BLM (Bloom Syndrome RecQ Like Helicase) and FOX (Forkhead-box) family have been associated with an increased risk for cancer and resistance to chemotherapy drugs. Considering the potential implication of these genes on the clinical management of NB, we correlated clinical parameters, such as survival and treatments with genetic profiles of 11 NB patients stage 3 and 4 with MYCN-amplified (4 patients) or MYCN-non-amplified (7 patients) and one patient stage 2B and MYCN-non-amplified. Patients were treated with doxorubicin, etoposide, topotecan, cyclophosphamide, vincristine, and carboplatin. Targeted DNA sequencing, methylation array, and mRNA expression were performed on tumor and blood peripheral of these patients. Multiplex ligation-dependent probe amplification (MLPA). All variants considered important were validated by Sanger sequencing. Polymorphisms were identified using dbSNP138, 1000 genomes Project Consortium and NHLBI Exome Sequencing Project (ESP) databases with minor allele frequencies recorded from each database.

In this study, we observed in a patient with 17 months, diagnosed with MYCN-non amplified (11q-,+17p,+9p) stage 3 NB, a variant in FOXO3 gene (rs201947198) and BLM gene (rs28384991) with low frequency in the population (0.001% and 1%, respectively). FOXO3 and BLM gene expressions were decreased while FOXM1 gene expression was increased. This patient received chemotherapy and 2 years after the end of therapy, NB recurred locally. Six years after the diagnosis, the patient is still alive and receives chemotherapy.

In other case, we found a patient of 13 months, diagnosed with MYCN amplified (+2p,+3p,+17q) stage 3 NB, three synonymous variants in BLM gene (rs2227933,rs2227934,rs1063147). These variants have been shown to affect protein levels and function. We also identified an important variant in FOXO3 gene (rs 111556510) with low frequency in the population. FOXM1 mutation was not found in this patient and FOXM1 RNAm was increased. This patient received chemotherapy and despite the treatment, died 6 months after the diagnosis.

As relapse with a second event, we found two variants in BLM gene (rs2227935 and rs7167216), in a patient diagnosed at 6 months, stage 2B, MYCN-non-amplified (+2p;+3p;-11q;+17) NB, who received chemotherapy but has recurred three times at the same local site, despite the treatment. These variants are polymorphism low frequency and databases of the prediction algorithms, considered the SNP p.P868L damage. The variant identified in FOXR1 gene (c.C517G:p.R173G). This variant has not been described to NB. Further, hypermethylation in the promoter region of FOXK2 was correlated with decreased FOXK2 RNAm. Many studies have shown that epigenetic silencing of FOXK2 gene increases resistance to chemotherapy drugs. Other patients (3 MYCN-amplified and 6 MYCN-non-amplified) were found only polymorphisms synonymous in the BLM gene (rs2227933, rs2227934, and rs1063147). Moreover, variants or alterations in FOXO3, FOXR1, FOXK2 expression were not found. However, FOXM1 expression was increased in these patients.

Conclusion: Many studies have shown that personalized oncology plays an important role in treatment of cancer patients. In this study, we demonstrated that variants in FOXO3, FOXR1 and BLM genes, FOXM1 expression and silencing epigenetic of FOXK2 found in 3/12 patients with refractory relapse disease may be candidate targets for personalized therapy in neuroblastoma.

Citation Format: Thamiris Magalhaes Gimenez, Nathalia Halley Neves, Andreia Rangel Santos, Fabio A. Marchi, Leslie Kulikowski, Lilian M. Cristofani, Estela M. Novak, Vicente Odone Filho. BLM, FOXO3, FOXK2, FOXM1, FOXR1 genes as therapeutic targets to neuroblastoma [abstract]. In: Proceedings of the AACR International Conference held in cooperation with the Latin American Cooperative Oncology Group (LACOG) on Translational Cancer Medicine; May 4-6, 2017; São Paulo, Brazil. Philadelphia (PA): AACR; Clin Cancer Res 2018;24(1_Suppl):Abstract nr B13.

Partnership of the Sociedade Brasileira de Oncologia Pediátrica and International Society of Pediatric Oncology to improve nutritional care for children with cancer in Brazil

The authors present a proposal of a partnership between the Sociedade Brasileira de Oncologia Pediátrica (SOBOPE) and the International Society of Pediatric Oncology (SIOP) to promote the standardization and improvement of nutritional care of kids under cancer treatment in Brazil. The results of the first meeting in Brazil as well as plans for future meetings are described.

Videolaparoscopic radical nephrectomy after chemotherapy in the treatment of Wilms' tumor: Long-term results of a pioneer group

INTRODUCTION

A high cure rate for Wilms' tumor has been achieved using a multidisciplinary approach. The natural step forward is to offer the benefits of a minimally invasive technique for surgery, which is an obligatory part of treatment. Nevertheless, some authors resist using videolaparoscopic radical nephrectomy (VRN) because of concerns about reducing the cure index.

METHODS

The present study included children with unilateral Wilms' tumor treated from December 2003 to December 2015 with neoadjuvant chemotherapy followed by VRN. Patients were selected based on the size of their tumors compared with the contralateral kidney, and on their stature.

RESULTS

VRN was performed in 24 patients of age range 10-93 months, with an average of 38.04 ± 23.37 months. The tumoral kidney's largest diameter after chemotherapy averaged 10% of a patient's height. There was no tumor rupture or spillage and no patient presented intra or immediate postoperative complications, except for prolonged ileum in two patients. One patient required intraoperative transfusion because of preoperative anemia. Another developed a late herniation in the umbilical port that required surgical correction. After an average of 6.65 years of follow-up, two patients presented relapse: one with a stage IV disease had relapse in the lung and another with a stage III, involving the liver, had local relapse because of an unwanted delay in the adjuvant treatment.

CONCLUSION

VRN can be considered a feasible alternative to open surgery in selected cases of children with Wilms' tumor. The present experience shows that besides the benefits of minimally invasive procedures and better cosmetic results, there is no evidence of increased tumor rupture or spillage, peritoneal or port site metastasis, and the long-term oncological results are the same as open procedures.

The value of anterior displacement of the abdominal aorta in diagnosing neuroblastoma in children

Objective

To determine the value of anterior displacement of the abdominal aorta, when present at any level or only at the level of the adrenal gland, contralateral to the mass, in diagnosing neuroblastoma on computed tomography or magnetic resonance imaging in children up to 7 years of age.

Materials and Methods

Imaging examinations of 66 patients were classified by consensus as for the presence of anterior aorta displacement and were compared with the pathology report.

Results

We found anterior abdominal aorta displacement in 26 (39.39%) of the 66 patients evaluated. Among those 26 patients, we identified neuroblastoma in 22 (84.62%), nephroblastoma in 3 (11.54%), and Burkitt lymphoma in 1 (3.85%). The positive predictive value was 84.62%, and the specificity was 88.24%. The displacement of the aorta was at the adrenal level, contralateral to the mass, in 14 cases, all of which were attributed to neuroblastoma.

Conclusion

When the abdominal aorta is displaced at the level of the adrenal gland, contralateral to the mass, it can be said that the diagnosis is neuroblastoma, whereas abdominal aorta displacement occurring at other abdominal levels has a positive predictive value for neuroblastoma of approximately 85%.

Establishment of the Brazilian telehealth network for paediatric oncology

A telemedicine network has been established in Brazil to support distance medical practice in paediatric oncology. ONCONET comprises a national network of universities, research institutes and medical institutions. The system is Web-based and hosted on a high-performance computing infrastructure based on clusters of computers. It is based on open-source software, designed to provide high performance, fault tolerance and high availability. The ONCONET began operation in 2004. Currently, 30 hospitals affiliated to the Brazilian Society for Paediatric Oncology are users of the ONCONET. Six hospitals are connected by broadband access through the National Education and Research Network and 24 by conventional Internet access. The Multimedia Patients Registry also became operational in 2004, and its database contains information on 3,200 patients from the 30 hospitals. The technological platform was notable for its low production cost. It thus appears to be a sustainable solution to the problem of delivering continuing medical education in a large country with widely dispersed health professionals.

Web-based patient records and treatment guidelines in paediatric oncology

We have established a Web-based system in Brazil offering health information in childhood cancer and services such as electronic patient records and treatment protocols. The system was based on open-source software. The database has records for about 3,200 patients from 30 Brazilian hospitals. An evaluation by doctors from the six hospitals comprising the Neuroblastoma Cooperative Group was positive, mainly because the system allows easy online access, but also because the electronic register performs data validation when information is inserted. Our experience shows that it is possible to use a Web-based system to provide paediatric cancer services at a distance.

Tooth abnormalities in pediatric patients submitted to antineoplastic treatment for central nervous system neoplasms

Objective: The aim of this study was to evaluate the frequency of tooth abnormalities in pediatric patients treated for central nervous system neoplasms. Material and methods: This cross-sectional study assessed thirty-one patients, median age 14.2 years (range 5 - 25), who were off therapy for at least one year, comparatively with a control group of thirty-one healthy patients matched for age with the study group. Tooth abnormalities were evaluated by panoramic radiographs. Results: There was no statistical significant evidence that patients of the study group (age range 5 - 25 years) have more frequency of tooth abnormalities comparatively with controls.   However, in children who were diagnosed before 5 years of age, microdontia was the most common abnormality with statistically significant difference (P=0.037). Root shortening grade III was observed in patients over 10 years of age at the time of radiographic examination, also with statistical significance (P=0.046). Conclusions: Tooth abnormalities frequency in patients treated for central nervous system neoplasms is directly related to the age of diagnosis and stage of odontogenesis. Microdontia and reduced root surface areas, the most common abnormalities observed, can lead to future oral health impairment due to malocclusion and less periodontal support. It is important to give parents and patients early orientation about maintenance of good oral hygiene and proper treatment by orthodontics or dentofacial orthopedics.

Long-term dental follow-up in hematological stem cells transplantation children

Objective: The aim of this paper is to update the current published content about the craniofacial long-term development disturbances of childhood hematopoietic stem-cell transplantation (HSCT) and the preparative regimens for the onco-hematological malignancies treatments. Material and Methods: Two authors independently reviewed the published articles about long-term effects of childhood HSCT that fitted in to predetermined inclusion/exclusion criteria: clear definition of exposure or intervention, standard outcomes measurement and appropriate statistical analysis. Results: Twelve papers matched all the previous established eligibility criteria and were included in this review. The children’s age at HSCT were related to a higher risk of dental development disturbances, such as agenesis, dental hypoplasia, root stunting, crown-root proportion alterations, and microdontia. Craniofacial vertical growth was impaired in the irradiated patients without antero-posterior or latero-lateral impairment. Temporomandibular joint dysfunction was found to be more prevalent in the patients who was diagnosed with graft-versus-host disease. Conclusion: The late effects of craniofacial development disturbances leads to several aesthetic and functional impairment, periodontal bone resorption with consequent impairment of chewing ability, and risk of early tooth loss often associated with life’s quality impairment. Further investigations should be performed to provide accurate information for patients, parents and health care professionals. Keywords: Dental development. Craniofacial growth. Bone marrow transplantation. Hematopoietic stem-cell transplantation. Chemotherapy. Radiotherapy.

Comparative study of quality of life of adult survivors of childhood acute lymphocytic leukemia and Wilms' tumor

Objective

To analyze and compare the health-related quality of life of adult survivors of acute lymphocytic leukemia and Wilms’ tumor amongst themselves and in relation to healthy participants.

Methods

Ninety participants aged above 18 years were selected and divided into three groups, each comprising 30 individuals. The Control Group was composed of physically healthy subjects, with no cancer history; and there were two experimental groups: those diagnosed as acute lymphocytic leukemia, and those as Wilms’ Tumor. Quality of life was assessed over the telephone, using the Medical Outcomes Study 36-Item Short Form Health Survey.

Results

Male survivors presented with better results as compared to female survivors and controls in the Vitality domain, for acute lymphocytic leukemia (p=0.042) and Wilms’ tumor (p=0.013). For acute lymphocytic leukemia survivors, in Social aspects (p=0.031), Mental health (p=0.041), and Emotional aspects (p=0.040), the latter also for survivors of Wilms’ tumor (p=0.040). The best results related to the Functional capacity domain were recorded for the experimental group that had a late diagnosis of acute lymphocytic leukemia. There were significant differences between groups except for the Social and Emotional domains for self-perceived health, with positive responses that characterized their health as good, very good, and excellent.

Conclusion

Survivors of acute lymphocytic leukemia showed no evidence of relevant impairment of health-related quality of life. The Medical Outcomes Study 36-Item Short Form Health Survey (via telephone) can be a resource to access and evaluate survivors.

New concepts and outcomes for children with hepatoblastoma based on the experience of a tertiary center over the last 21 years

OBJECTIVE

The aim of this study was to summarize the experience of a tertiary center in treating hepatoblastoma for the last 21 years.

PATIENTS AND METHODS

Fifty-eight cases were included. The tumor extent and prognosis were assessed using the PRETEXT system. The following data were analyzed: age at diagnosis, comorbidities, prematurity, treatment modalities, histopathological findings, surgical details and complications, treatment outcomes, chemotherapy schedules, side effects and complications. Treatment outcomes included the occurrence of local or distant recurrence, the duration of survival and the cause of death. The investigation methods were ultrasonography, CT scan, serum alpha-fetoprotein level measurement and needle biopsy. Chemotherapy was then planned, and the resectability of the tumor was reevaluated via another CT scan.

RESULTS

The mean numbers of neoadjuvant cycles and postoperative cycles of chemotherapy were 6±2 and 1.5±1.7, respectively. All children except one were submitted for surgical resection, including 50 partial liver resections and 7 liver transplantations. Statistical comparisons demonstrated that long-term survival was associated with the absence of metastasis (p=0.04) and the type of surgery (resection resulted in a better outcome than transplantation) (p=0.009). No associations were found between vascular invasion, incomplete resection, histological subtype, multicentricity and survival. The overall 5-year survival rate of the operated cases was 87.7%.

CONCLUSION

In conclusion, the experience of a Brazilian tertiary center in the management of hepatoblastoma in children demonstrates that long survival is associated with the absence of metastasis and the type of surgery. A multidisciplinary treatment involving chemotherapy, surgical resection and liver transplantation (including transplantations using tissue from living donors) led to good outcomes and survival indexes.

Ototoxicity evaluation in medulloblastoma patients treated with involved field boost using intensity-modulated radiation therapy (IMRT): a retrospective review

Background

Ototoxicity is a known side effect of combined radiation therapy and cisplatin chemotherapy for the treatment of medulloblastoma. The delivery of an involved field boost by intensity modulated radiation therapy (IMRT) may reduce the dose to the inner ear when compared with conventional radiotherapy. The dose of cisplatin may also affect the risk of ototoxicity. A retrospective study was performed to evaluate the impact of involved field boost using IMRT and cisplatin dose on the rate of ototoxicity.

Methods

Data from 41 medulloblastoma patients treated with IMRT were collected. Overall and disease-free survival rates were calculated by Kaplan-Meier method Hearing function was graded according to toxicity criteria of Pediatric Oncology Group (POG). Doses to inner ear and total cisplatin dose were correlated with hearing function by univariate and multivariate data analysis.

Results

After a mean follow-up of 44 months (range: 14 to 72 months), 37 patients remained alive, with two recurrences, both in spine with CSF involvement, resulting in a disease free-survival and overall survival of 85.2% and 90.2%, respectively.

Seven patients (17%) experienced POG Grade 3 or 4 toxicity. Cisplatin dose was a significant factor for hearing loss in univariate analysis (p < 0.03). In multivariate analysis, median dose to inner ear was significantly associated with hearing loss (p < 0.01). POG grade 3 and 4 toxicity were uncommon with median doses to the inner ear bellow 42 Gy (p < 0.05) and total cisplatin dose of less than 375 mg/m² (p < 0.01).

Conclusions

IMRT leads to a low rate of severe ototoxicity. Median radiation dose to auditory apparatus should be kept below 42 Gy. Cisplatin doses should not exceed 375 mg/m².

Dental anomalies in children submitted to antineoplastic therapy

Cancer is the third most frequent cause of death in children in Brazil. Early diagnosis and medical advances have significantly improved treatment outcomes, which has resulted in higher survival rates and the management of late side effects has become increasingly important in caring for these patients. Dental abnormalities are commonly observed as late effects of antineoplastic therapy in the oral cavity. The incidence and severity of the dental abnormalities depend on the child's age at diagnosis and the type of chemotherapeutic agent used, as well as the irradiation dose and area. The treatment duration and aggressivity should also be considered. Disturbances in dental development are characterized by changes in shape, number and root development. Enamel anomalies, such as discoloration, opacities and hypoplasia are also observed in these patients. When severe, these abnormalities can cause functional and esthetic sequelae that have an impact on the children's and adolescents' quality of life. General dentists and pediatric dentists should understand these dental abnormalities and how to identify them aiming for early diagnosis and appropriate treatment.

Minimally invasive adenocarcinoma of the lung in a young patient treated for osteosarcoma

Although children with osteosarcoma have a higher incidence of a 2nd malignancy than the general population, its development in the lung is rare. The few reported cases belong to examples of carcinomas. Here we present the case of a 13-year-old boy with a primary pulmonary adenocarcinoma diagnosed 3 years after the osteosarcoma diagnosis and present a review of the literature.

Evaluation of adrenal reserve in children with acute lymphocytic leukemia treated with prednisone or dexamethasone

BACKGROUND/AIMS

The purpose of this study was to compare adrenal gland reserve in acute lymphocytic leukemia (ALL) patients 8 weeks after treatment with either prednisone (PRED) or dexamethasone (DEX) during the induction phase of therapy.

METHODS

A double-blind comparative study of patients treated with PRED and DEX was performed. Sixteen patients received PRED (40 mg/m(2)/day) and 13 patients received DEX (6 mg/m(2)/day), both for 28 days. A low-dose adrenocorticotropic hormone test (1.0 µg/m(2), IV) was performed before and weekly for 8 weeks after abrupt cessation of glucocorticoid therapy. Sixteen children without ALL were used as controls to determine the cutoff peak cortisol level (14.2 µg/dl).

RESULTS

Both groups (PRED and DEX) displayed similar mean peak cortisol levels before treatment and during the 8 weeks of evaluation (p = 0.652). No relationship was observed between the incidence of infection/stress and peak cortisol level within each group, nor was there a difference in the frequency of infection/stress between groups (p = 0.359). Although the patients presented variations in peak cortisol during the study period, no signs or symptoms of adrenal insufficiency were observed.

CONCLUSION

Patients who received PRED or DEX for 4 weeks showed similar adrenal reserves and infection rates for 8 weeks after abruptly stopping glucocorticoid therapy, suggesting that DEX, which is a better antileukemic drug than PRED, has similar adrenal suppression and recovery rates.

Effects of a combined aerobic and strength training program in youth patients with acute lymphoblastic leukemia

Cure rates of youth with Acute Lymphoblastic Leukemia (ALL) have increased in the past decades, but survivor's quality of life and physical fitness has become a growing concern. Although previous reports showed that resistance training is feasible and effective, we hypothesized that a more intense exercise program would also be feasible, but more beneficial than low- to moderate-intensity training programs. We aimed to examine the effects of an exercise program combining high-intensity resistance exercises and moderate-intensity aerobic exercises in young patients undergoing treatment for ALL. A quasi-experimental study was conducted. The patients (n = 6; 5-16 years of age) underwent a 12-week intra-hospital training program involving high-intensity strength exercises and aerobic exercise at 70% of the peak oxygen consumption. At baseline and after 12 weeks, we assessed sub-maximal strength (10 repetition-maximum), quality of life and possible adverse effects. A significant improvement was observed in the sub maximal strength for bench press (71%), lat pull down (50%), leg press (73%) and leg extension (64%) as a result of the training (p < 0.01). The parents' evaluations of their children's quality of life revealed an improvement in fatigue and general quality of life, but the children's self-reported quality of life was not changed. No adverse effects occurred. A 12-week in-hospital training program including high-intensity resistance exercises promotes marked strength improvements in patients during the maintenance phase of the treatment for Acute Lymphoblastic Leukemia without side-effects. Parents' evaluations of their children revealed an improvement in the quality of life. Key pointsPatients with ALL present low muscle strength and poor quality of life.High-intensity resistance exercises combined with moderate-intensity aerobic exercise improved muscle strength and quality of life during the maintenance phase of ALL treatment.The exercise training program seemed to be tolerable and safe in ALL patients.

Intermediate pilomyxoid astrocytoma and diencephalic syndrome: imaging findings

Pilomyxoid astrocytoma, an entity described as a histological variant of pilocytic astrocytoma, is a rare primary tumor of the central nervous system. It is usually located in the hypothalamic-chiasmatic area, affecting children with a mean age of 10 months. It has a high rate of recurrence and cerebrospinal fluid dissemination, which may be present throughout the neuroaxis. Due to its topography, it may present developmental delay in childhood and diencephalic syndrome, characterized by extreme weight loss, lack of fat accumulation, hyperactivity, euphoria and alertness. Magnetic resonance imaging has an important role in its diagnosis, staging and follow-up of pilomyxoid astrocytoma. However, for a definitive diagnosis, anatomopathology is particularly important to differentiate it from pilocytic astrocytoma. Some cases, as in this present one, have simultaneous histological features of pilocytic and pilomyxoid astrocytomas, constituting a group called intermediate pilomyxoid astrocytoma. Surgery is the best treatment option and it usually requires adjuvant therapy.

Simultaneous occurrence of biphenotypic T cell/myeloid lesions involving t(12;13)(p13;q14) in a pediatric patient

This paper chronicles a 2-year-old girl who presented with acute leukemia/lymphoma syndrome of the T cell immunophenotype. At this time, the cytogenetic analysis of her bone marrow cells showed a reciprocal translocation between the short arm of chromosome 12 and the long arm of chromosome 13, t(12;13)(p13;q14). The immunophenotyping of bone marrow blast cells by flow cytometry revealed a population of cells positive for CD56, CD117, CD45, partial CD33, partial HLA-DR, CD13, CD7, CD2 and CD5. Therefore, a diagnosis of acute leukemia with a mixed T cell/myeloid phenotype was made. The patient had a poor response to classic T cell acute lymphocytic leukemia/lymphoma therapy; thus, her treatment was changed to a myeloid leukemia protocol, which produced a good response. She underwent a successful cord blood transplantation from an unrelated HLA partially matched donor. The coexistence of these two phenotypes prompts questions about the existence of clonal instability, which might influence the choice of therapy. The rarity of the t(12;13)(p13;q14) and the coexistence of T cell/myeloid markers suggest a nonrandom association. To the best of our knowledge, this is the first reported case in which a cell clone bearing a t(12;13)(p13;q14) translocation in a mixed T cell/myeloid lesion was detected.

[Evaluation of the main late endocrine effects in children and adolescents after treatment of malignancies]

OBJECTIVE

To report the main endocrine effects after cancer treatment in children and adolescents and associate them to the disease and its treatment.

SUBJECTS AND METHODS

Clinical and lab evaluation for endocrinopathy was performed in 320 patients after cancer therapy have been followed for six years.

RESULTS

The most prevalent endocrine late effects in patients were: 32 patients had short stature, nine of them were under growth hormone therapy. Precocious puberty was found in 14 patients, 10 of them received GnRH analog. Thyroid diseases were present in 19 patients (12 with hypothyroidism; six with thyroid nodules/cysts; one with chronic lymphocytic thyroidytis). Obesity was found in 18 patients. Six presented insipidus diabetes, five delayed puberty and three panhypopituitarism. Radiation was associated with the appearance of the aforementioned endocrinopathies.

CONCLUSION

Ninety four of 320 (30%) patients presented endocrine late effects which emphasize the importance for these patients to be regularly followed-up in order to precociously diagnose endocrine late effects and provide them a better quality of life.

Exposure to magnetic fields and childhood acute lymphocytic leukemia in São Paulo, Brazil

BACKGROUND

Epidemiological studies have identified increased risks of leukemia in children living near power lines and exposed to relatively high levels of magnetic fields. Results have been remarkably consistent, but there is still no explanation for this increase. In this study we evaluated the effect of 60 Hz magnetic fields on acute lymphocytic leukemia (ALL) in the State of São Paulo, Brazil.

METHODS

This case-control study included ALL cases (n=162) recruited from eight hospitals between January 2003 and February 2009. Controls (n=565) matched on gender, age, and city of birth were selected from the São Paulo Birth Registry. Exposure to extremely low frequency magnetic fields (ELF MF) was based on measurements inside home and distance to power lines.

RESULTS

For 24h measurements in children rooms, levels of ELF MF equal to or greater than 0.3microtesla (μT), compared to children exposed to levels below 0.1 μT showed no increased risk of ALL (odds ratio [OR] 1.09; 95% confidence interval [95% CI] 0.33-3.61). When only nighttime measurements were considered, a risk (OR 1.52; 95% CI 0.46-5.01) was observed. Children living within 200 m of power lines presented an increased risk of ALL (OR 1.67; 95% CI 0.49-5.75), compared to children living at 600 m or more of power lines. For those living within 50 m of power lines the OR was 3.57 (95% CI 0.41-31.44).

CONCLUSIONS

Even though our results are consistent with the small risks reported in other studies on ELF MF and leukemia in children, overall our results do not provide support for an association between magnetic fields and childhood leukemia, but small numbers and likely biases weaken the strength of this conclusion.

Dental approach in the pediatric oncology patient: characteristics of the population treated at the dentistry unit in a pediatric oncology brazilian teaching hospital

OBJECTIVES

The objective of this paper was to characterize the population seen at the dentistry unit of the hematology-oncology service of the Oncology-Hematology Service, Instituto da Criança at the Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo. Oral problems resulting from cancer therapy increase the risk of infection, length of hospital stay, treatment cost and negative impact on the course and prognosis of the disease.

METHOD

Of the 367 medical records of cancer patients seen from November 2007 until December 2008: 186 with a cancer diagnosis and complete clinical data were selected, while 20 with a cancer diagnosis and incomplete records were excluded; 161 medical records with only hematological diagnosis were also excluded. The following characteristics were assessed: ethnicity, gender, age, diagnosis and characteristics of the neoplasm, cancer therapy status and performed dental procedures.

RESULTS

Review of 1,236 visits indicated that 54% (n=100) of the patients had blood cancers, 46% (n=86) had solid tumors and 63% were undergoing anticancer therapy. The proportion of males (52.7%) in the study population was slightly greater. The most common cancer was acute lymphocytic leukemia (32.2%). Cancer occurred more often among those patients aged 5 to 9 years. The most common dental procedures were restorative treatment, preventive treatment and removal of infectious foci.

CONCLUSION

The characteristics of the studied population were similar to those of the general Brazilian and global populations, especially regarding gender and diagnosis distributions. The aim of implementation of the dentistry unit was to maintain good oral health and patients' quality of life, which is critical to provide oral care and prevent future oral problems.

Retinoblastoma: a three-year-study at a Brazilian medical school hospital

OBJECTIVE

To present the characteristics and treatment outcomes of patients with retinoblastoma.

METHODS

A retrospective case series was conducted to review the records of all new patients diagnosed with retinoblastoma between 2003 and 2005. Eyes with early disease, or advanced disease with potential vision were treated with chemotherapy (carboplatin and etoposide) in conjunction with early local therapy (laser or cryo). Radiotherapy was used in cases where the disease did not respond to the above protocols or in recurrent cases. Eyes in the late stage of disease with no potential vision in the initial examination or eyes and where conservative treatment had failed were enucleated.

RESULTS

In total, we reviewed 28 new cases of retinoblastoma, 15 of which were unilateral and 13 of which were bilateral (46%). These data correspond to a mean of 9.3 new cases per year (0.77 case/ month). The mean age at diagnosis was 33.8 months for unilateral cases, and 19.15 months for bilateral cases (p=0.015). Leucocoria was the major presenting symptom (75%). All but one patient with unilateral disease had the affected eye enucleated due to advanced disease (mean follow-up: 39.91 months). Among the 13 bilateral cases, 13 eyes (50%) were enucleated, 11 eyes (42.4%) were saved with chemotherapy in conjunction with local therapy and 2 eyes (7.6%) were saved using external beam radiotherapy (mean follow-up: 41.91 months). In unilateral and bilateral disease, pathology data revealed choroid involvement in 50% and 30%, respectively, and optic nerve invasion in 92% and 50%, respectively.

CONCLUSION

In this population, retinoblastoma was diagnosed too late and most eyes were consequently enucleated. In cases with bilateral disease, half of the eyes were preserved.

A prevalência de perdas auditivas em crianças e adolescentes com câncer

O tratamento do câncer infantil provoca diversos efeitos colaterais, como a ototoxicidade, que é capaz de lesar estruturas da orelha interna e pode levar à perda auditiva. OBJETIVO: Estimar a prevalência de perda auditiva em crianças e adolescentes com câncer, utilizando três classificações: American Speech-Language-Hearing Association (ASHA), Pediatric Oncology Group Toxicity (POGT) e Perda Auditiva Bilateral (PAB). Forma de Estudo: Transversal. MATERIAL E MÉTODO: Analisou-se 94 pacientes atendidos entre 2003 e 2004. Os indivíduos foram submetidos à inspeção visual do meato acústico externo e avaliação audiológica. Para caracterização da amostra utilizou-se a estatística descritiva e para a análise da concordância da perda auditiva nas três classificações foi utilizada a estatística Kappa. RESULTADOS: Houve prevalência de perda auditiva de 42,5% pela ASHA, 40,4% pela POGT e 12,8% pela PAB. A concordância para POGT e PAB, e para PAB e ASHA foi fraca (respectivamente, k=0,36 e k=0,33). A concordância entre ASHA e POGT foi quase perfeita (k=0,96). CONCLUSÕES: A perda de audição é um efeito colateral importante nos pacientes com câncer. A monitorização auditiva é fundamental, pois possibilita detecção precoce e revisão do tratamento. Recomenda-se adotar uma classificação que contemple perdas auditivas leves, como proposta pela ASHA.

Measles and rubella antibody status in children after treatment for acute lymphoblastic leukemia

OBJECTIVE

To assess the vaccination history and the status of vaccine-induced protection from measles and rubella in children after treatment for acute lymphoblastic leukemia.

METHODS

Measles and rubella immunological status was assessed by the ELISA technique for 22 children previously treated for acute lymphoblastic leukemia.

RESULTS

From the total of 22 patients, 20 had been given two doses of measles vaccine and 18 had had one dose of rubella vaccine. The percentage of patients seropositive for measles and rubella were 65 and 88.9%, respectively, with no correlation with age of patient, aggression of treatment or the time passed between the end of treatment and sample collection.

CONCLUSIONS

We detected that vaccination had failed against measles and rubella in 35 and 11.1% of cases, respectively. We recommend that a measles booster be given after the completion of treatment for acute lymphoblastic leukemia and that rubella immunity status should be assessed at this point, with revaccination performed when necessary.

Development of a pilot telemedicine network for paediatric oncology in Brazil

We established a pilot telemedicine network for paediatric oncology in Brazil, linking the School of Medicine at the University of Sao Paulo in Sao Paulo City to the 'Hospital de Base' in Porto Velho, Rondonia, located in the Amazon region, 3,000 km away. The videoconferencing link used ISDN transmission at 384 kbit/s. The network was used for patient screening, follow-up, treatment monitoring and other activities. Between March 2000 and 2002, 69 videoconferences were held for 33 patients, 29 with cancer. During this period, 16 patients required transfer, 18 patients died and 11 achieved cancer remission. The main cause for patient mortality (infection) was not one that could be addressed directly by telemedicine. Using the School of Medicine as a benchmark, the average mortality rate for paediatric cancer patients in the pilot was higher. However, it was lower than previous levels observed at Rondonia (62% versus 80%).

Results of the Brazilian Osteosarcoma Treatment Group Studies III and IV: prognostic factors and impact on survival

PURPOSE

To evaluate the impact of chemotherapy and surgery on the outcome of osteosarcoma (OS) of the extremities and to identify prognostic factors in Brazilian patients.

PATIENTS AND METHODS

A total of 225 patients with metastatic and nonmetastatic OS of the extremities were enrolled and assessed in two consecutive studies designed and implemented by the Brazilian Osteosarcoma Treatment Group.

RESULTS

The 5-year survival and event-free survival rates for the 209 assessable patients were 50.1% and 39%, respectively; for the 178 patients with nonmetastatic disease at diagnosis, the rates were 60.5% and 45.5%, respectively. The multivariate analysis showed that the following variables were associated with a shorter survival: metastases at diagnosis (P < .001), necrosis grades 1 and 2 (P = .046), and tumor size (P = .0071).

CONCLUSION

The overall 5- and 10-year survival rates were lower than the rates reported in North American and European trials. A pattern of advanced disease at diagnosis was often present, with a high proportion of patients having metastases (20.8%) and large tumor size (42.9%). However, these features were not necessarily associated with longer duration of prediagnostic symptoms. These findings were considered in the strategic planning of the current Brazilian cooperative study, with the aim of improving survival and quality of life of a large number of patients with OS.