Molecular profiling of osteosarcoma in children and adolescents from different age groups using a next-generation sequencing panel

Osteosarcoma (OS) is a malignant bone tumor, with a peak of incidence in the second decade of life and possibly associated with the presence of germline mutations. Besides, clinicians have pointed to a second, rarer group of patients that develops OS before 10 years old. Here we access, through next-generation sequencing (NGS) strategy, the genetic alterations present in OS and blood samples from patients diagnosed before and during the second decade of life. A custom NGS panel, designed for the main alterations described in childhood and adolescence neoplasms, named Oncomine Childhood Cancer Research Assay (OCCRA©), was used. Of all 84 OS samples investigated, 42 (50%) presented some somatic variant, with TP53, MYC, CDK4, RB1 and PDGFRA genes harboring the most observed genetic variants. MYC CNVs were more frequent in tumors from patients diagnosed before 10 years old (X²₁= 5.18, p = 0.023). Additionally, patients diagnosed during the second decade of life presented a higher percentage of somatic and germline variants. Germline variants in TP53 and RB1 were found in 5 of the 11 (45.5%) patients analyzed. Clinical variables and tumor histopathological characteristics were also collected and correlated with our molecular findings.

Angiogenic biomaker study in osteosarcoma

e21507

Background: This study represents a prospective assessment of angiogenesis genes mRNA expression in tumors and blood from patients treated with pre- and post-operative Brazilian osteosarcoma protocol (GCBTO 2006) that introduce metronomic chemotherapy (anti-angiogenic) in order to try to increase survival of osteosarcoma patients. Methods: Tumor samples from 27 patients were analyzed before and after chemotherapy to determine VEGFA, VEGFR1, VEGFR2, PDGFC, SDF1 and TSP1 genes expression profile by Quantitative Real Time PCR. Also, blood samples of these patients were investigated pre- and post-chemotherapy and at the end of high-dose chemotherapy trying to evaluate potential for proangiogenic factors and antiangiogenic factor (TSP1) which could be used to monitor treatment activity. Results: Of all six genes studied pre- and post- chemotherapy, in tumor samples, only SDF1 and VEGFR2 were underexpressed. SDF1 gene has the lowest expression at all. In tumor samples, TSP1 and VEGFA expression was higher than SDF1, VEGFR2 and PDGFC expression in biopsies and surgeries (P=0.001). VEGFR1 expression was higher than VEGFR2 expression (P=0.001). PDGFC and VEGFR1 overexpression were associated with necrosis grade I and II (Huvos score) (P=0.005). VEGFA and TSP1 were overexpressed in 96% and 92% of surgery samples, respectively. In blood samples from biopsy, surgery and end of treatment there were no statistically significant changes in the marker genes expression. Conclusions: The study suggests an association between PDGFC and VEGFR1 overexpression and lower grade necrosis. TSP1 and VEGFA were the most expressed genes in all tumor samples but TSP1 was lower than VEGFA in biopsies and VEGFA was lower than TSP1 in surgery (P=0.001). Although VEGFR2 is the primary receptor of VEGF, VEGFR1 was the most expressed VEGF receptor.

No significant financial relationships to disclose.

Fifteen years experience of the Brazilian Osteosarcoma Treatment Group (BOTG)

10039

Background: This is a 15-year analysis of disease characteristics and treatment outcome from three consecutive studies of BOTG. Results from protocols III and IV were previously published (J Clin Oncol. 24:1161–8, 2006). Methods: 604 histologically confirmed high-grade osteosarcoma patients were enrolled into these multicentric studies (with 4, 5, and 20 institutions in studies III, IV, and 2000, respectively). Results: Of the 604 patients, 578 were evaluable with osteosarcoma of extremities, mean age at enrollment of 14, mean time to diagnosis of 4.4 months, advanced disease (tumors diameter > 12cm) in 45% and metastatic disease in 30% of the patients. Statistically significant prognostic factors were: tumor size, histological response (Huvos grade), presence of metastasis at diagnosis and type of surgery. Time to diagnosis was not predictable of survival. Advanced disease was associated to presence of metastasis and to a poorer histological response. During the first 5 years, 53% of the patients had conservative surgery with 19.6% of local recurrence and these numbers were 65.5% and 14% in the next 5 years and 62.3% and 11% during the last 5 years. The overall survival (OS) at 5 years was 44%, 45% and 46% respectively. In the whole cohort of patients, overall survival (OS) was 45.7% at 5 years and 43% at 10 years and event free survival (EFS) was 43% and 34%. For non-metastatic patients, OS was 56.5% and 54% and EFS was 53% and 44%, respectively. Conclusions: Over these 15 years, we were able to increase limb salvage procedures with a significant drop in local recurrence, reaching survival rates similar to some international studies. This cumulative experience enabled the expansion of the collaborative group, the identification of prognostic factors, dissemination of knowledge, and the development of the current protocol for osteosarcoma treatment, which is a multicentric, randomized study with good quality data collection over 26 sites in Latin America.

No significant financial relationships to disclose.

Outpatient administration of high-dose methotrexate for osteosarcoma treatment in Brazil

10038

Background: We describe the experience with outpatient administration of high dose methotrexate (HDMTX) and leucovorin rescue for osteosarcoma treatment at Instituto de Oncologia Pediátrica. Methods: HDMTX (12g/m2) is administered as part of the Brazilian Osteosarcoma Treatment Group Protocol in an ambulatory basis. Daily MTX serum levels and fluid controls follows until the serum level is <0,2 μ/L. Families were oriented to measure urinary pH and volume, PO intake and to adjust leucovorin dose as needed. To achieve treatment adherence, a family education program was developed. Concomitantly to HD chemotherapy, low dose oral cyclophosphamide and MTX (metronomic treatment) were provided to metastatic (M) patients. This is a retrospective analysis of the HDMTX courses administered between 2006 and 2008. Results: Out of 341 HDMTX infusions, administered to 42 patients, 42.5% had abnormal serum levels at hour 24, 8.8% at hour 48 and 33.2% at hour 72. After required interventions, 2.9% (n = 8) had serum levels >0.2 μ/L at hour 72 leading to delayed excretion. Of these, 7 had also creatinine elevation and main adverse events were mucositis, reversible transaminasis elevation and one sepsis. In the overall analysis, other toxicities included mucositis grade II (20%), nefrotoxicity (5.6%) and neutropenia grades III and IV (25.4%). Serious adverse events of seizure, allergic reaction, and Steven Johnson's Syndrome lead to suspension of future HDMTX administration in 4 patients (01 metastatic). The main differences found between M and non-M patients were 16.8% versus 8.7% of leucopenia grade IV and 12.1% versus 6.6% of anemia grades III and IV. Conclusions: Similar to other authors’ experience, outpatient administration of HDMTX lead to elevated serum levels in 42.5% of the infusions, demonstrating the importance of a well trained staff and early introduction of supportive therapies to avoid associated toxicities. To a developing country, this approach helps lowering treatment costs and infection risks and increases patient adherence to treatment, with acceptable toxicities, even with the introduction of metronomic treatment.

No significant financial relationships to disclose.

Ifosfamide, carboplatin, and etoposide as front-line therapy in patients with Ewing sarcoma family tumors (EFT): A study of the Brazil/Uruguay Cooperative Group

10547

Background: Chemotherapy (CT) with ifosfamide, carboplatin, and etoposide (ICE) is effective in refractory solid tumors. The aim of this trial was to determine the efficacy and safety of ICE as front line therapy for patients (pts) with newly-diagnosed EFT. Methods: Induction with 2 courses of ICE (ifosfamide 3g/m2/d ×3, carboplatin 450mg/m2 ×1, etoposide 150mg/m2/d ×3) plus 2 of VDC (vincristine 1,5mg/m2/d ×1, doxorubicin 60mg/m2/d ×1, cyclophosphamide 1,5g/m2/d ×1) was followed by surgery and/or radiotherapy. After induction, pts were allocated to low (LR) or high-risk (HR) according to LDH (<or>1,5×NL), site (pelvic/non-pelvic) and resection (complete/unresectable) or metastatic (mets). Postoperative CT included 10 alternating courses of IE and VDC for LR and 12 alternating courses of ICE and VDC for HR. Toxicity was assessed following 523, 648, 268 and 114 courses of ICE, VDC, IE and VC, respectively; 35 site visits were carried out for data quality control. Results: From 10/2003 to 10/2008, 150 of 159 enrolled pts were evaluable; median age 13y (0.2–29.3y). 44 pts were classified as LR and 101 as HR, 56 mts. Toxicity was mainly grade III-IV neutropenia, thrombocytopenia and febrile neutropenia, and was significantly higher following ICE. The 3y EFS and OS were 65% and 27% for localized pts and 80% and 43% for mets pts. 3y EFS for lung and non-lung mets were 40% and 19% (P=0.013). Multivariate analysis showed that mets disease was the only independent prognostic factor (P=0.006) for the entire group. However, when mts pts were analyzed separately, high LDH (P=0.01) and extra-lung site (P=0.016) had significant negative impact on survival. Conclusions: ICE regimen is safe and despite a high proportion of pts with advanced disease the survival are similar to larger series. Elevated LDH and the presence of extra-lung mets were significant negative prognostic factors in mets pts. Randomized trials to identify pts who may benefit from more intensive CT are warranted.

No significant financial relationships to disclose.

Clinical, serum cardiac troponin T and echocardiographic evaluation for prediction of late doxorubicin cardiotoxicity

9536

Background: To evaluate whether clinical signs or symptoms of congestive heart failure, serial assessment of systolic and diastolic cardiac function by low dose dobutamine stress echo (LDSE) and serum cardiac troponin T (cTnT) can predict doxorubicin (DOXO) cardiotoxicity. Methods: Twenty five patients with osteosarcoma enrolled in the Brazilian osteosarcoma treatment group study 2000, from january 2000 to may 2004, were studied with LDSE (>5μg/kg/min) before chemotherapy, 160 mg/m2 DOXO and after 160 mg/m2 DOXO. cTnT were measured before and during DOXO infusion. Cardiotoxicity was defined as shortening fraction (SF) less than 30% assessed by rest echo 1 to 6 months off chemotherapy. Group A comprised those without cardiotoxicity (16 patients, 10 male, 14.3 ± 4.7 years) whereas group B included those with a SF < 30% (9 patients, 6 male, 15.4 ± 3 years). Elevated serum cTnT was defined as seric levels above 0.01ng/ml. Results: Patients were submitted to a mean 3.4 LDSE and a mean of 32.5 serum cTnT. One patient (group B) presented clinical manifestation of cardiotoxicity. There was no statistical difference of elevated serum cTnT between the group B and group A (87.5% vs 46.2%; p=0,06). Left ventricular dimensions by M- MODE and transmitral Doppler inflow diastolic parameters were not significantly different between the two groups. Resting SF showed comparable values in both groups until cumulative doses of DOXO reached 160mg/m2, then the resting SF in group B was significant lower than group A (27% ± 2 and 34.1% ± 2, p<0.01). During dobutamine infusion, SF and ΔSF (dobutamine-rest) were significantly lower in group B as compared to group A at a DOXO dose 160mg/m2 (SF 36.1%±3,4 and ΔSF 2.1±2.3 vs. SF 45.2%±4.9 and ΔSF 9.4±3; p< 0.01 and p < 0.01) as well as at a DOXO dose > 160mg/m2 (30.3%±3 and 3.1±1.9 vs. 40.8%±5.9 and 7.2±4.2;p<0.01 and p<0.01). Conclusions: This study suggests that LDSE is more reliable than cTnT and clinical evaluation for predicting future subclinical cardiotoxicity,even at lower doxorubicin dose.

No significant financial relationships to disclose.

Feasibility and acute toxicities of outpatient ifosfamide infusions in children and adolescents with cancer

9055

Background: Ifosfamide (IFO) is very effective and widely used in pediatric oncology protocols. Patients are usually admitted to receive IFO infusions due to potential urological and neurological complications. The current study was conducted to assess the feasibility of outpatient IFO infusions in children and adolescents with cancer, the compliance of the patients and their parents, and the acute toxicities in this setting. Methods: All patients with newly diagnosed solid tumors included in protocols with at least three cycles of IFO/mesna were eligible for this study. IFO was administered I.V. over one hour. Doses varied according to the underlying malignancy and protocol from 2.5–3.0g/m2/day × 3 days to 2.7g/m2/day × 5 days. Three doses of mesna were administered intravenously in the outpatient clinic at 75% of the IFO dose divided on hours 0, 3 and 6 and a fourth dose of mesna was given as oral tablets at home 12 hours after IFO. Hydration was 2L/m2 I.V. over 5 hours in the hospital, followed by another 1L/m2 P.O. at home. Kidney function was assessed before, during, and after treatment through glomerular filtration rate; sodium, magnesium, calcium, uric acid renal excretions; urinary phosphate threshold and retinol-binding protein. Results: From November 2003 to August 2005, 30 patients received a total of 160 IFO cycles. Compliance was 100%. The incidence of grades 3 and 4 toxicities in all IFO cycles was: gastrointestinal 15%, leucopenia 92%, neutropenia 88%, thrombocytopenia 29%, hepatotoxicity 3%, and genitourinary 7%. No patient had gross hematuria, neurotoxicity or had to be admitted for chemotherapy. One third of the patients developed subclinical tubular nephropathy. Conclusions: Ambulatory infusion of IFO is safe and toxicities are comparable to the expected with inpatient administration.

No significant financial relationships to disclose.

Resource utilization and cost of episodes of febrile neutropenia in children with acute leukemias and lymphomas

The resource utilization and cost of 51 episodes of febrile neutropenia in children with leukemia and lymphomas who were admitted to the Pediatric Oncology Institute (GRAAC) of the Federal University of São Paulo were analyzed. Patients aged 60 days to 21 years with confirmed diagnoses of acute myeloid leukemia, acute lymphoid leukemia, non-Hodgkin lymphoma, or Hodgkińs disease who presented axillary temperature above 38 degrees C at least once episode, or between 37.5 degrees C and 38 degrees C on three occasions during a 24-h period, neutrophil count below 500/mm(3), or between 500/mm(3)and 1,000/mm(3) but expected to fall below 500/mm(3) were included in the study. The patients' ages varied between 1 and 15.6 years, and 67% of the patients were male. The median cost per treated episode was US dollars 2,660 (2,039). Hospitalization costs accounted for 62% of the total cost of the treatment, antibacterials accounting for 23%. Episodes in patients with documented infections had a higher median direct cost than episodes in patients with fever of unknown origin (P=0.018). There was a trend for a higher median direct cost in episodes among patients with a worse prognostic factor, such as type of underlying disease, presence of documented infection, and longer duration of neutropenia. This is the first study to evaluate the economics of febrile neutropenia episodes in Brazil, and serves as a basis for resource utilization and costs incurred in the treatment of such patients in this country.

Cecal duplication causing a disappearing abdominal mass in an infant

Duplications of the alimentary tract are rare malformations. A case of a 2-year-old girl with an intestinal intussusception caused by a cystic duplication of the cecum is presented. This case report is justified by its clinical features and the difficult diagnosis, which was only confirmed during surgery. Ultrasonography had documented an abdominal mass that then disappeared and later reappeared, leading to surgical indication. During surgery, the intussusception within the abdomen was reduced, and right hemicolectomy was performed around the mass in the interior part of the cecum and appendix, with ileocolic anastomosis. On resecting the cecum, a cystic duplication measuring 4 x 3 cm was observed, with a granular mucous layer, an ulcerated hole in its interior, and inflammatory reaction. The patient had an uneventful recovery and was discharged on the fourth postoperative day.

Epiphyseal plate involvement in osteosarcoma

Fourteen boys (56%) and 11 girls (44%) 4 to 17 years of age (mean, 12.2 years) who had osteosarcoma and open epiphyseal plates were studied. A possible correlation between transepiphyseal spread of osteosarcoma and radiologic and histopathologic findings was investigated. Epiphyseal plate invasion was detected radiologically in only 11 patients (44%), whereas histopathologic examination showed transepiphyseal extension in 21 patients (84%). The authors conclude that the epiphyseal plate is not a barrier against tumor growth and strongly recommend that limb salvage surgery preserving the epiphysis be planned carefully.

Oral ciprofloxacin vs. intravenous ceftriaxone administered in an outpatient setting for fever and neutropenia in low-risk pediatric oncology patients: randomized prospective trial

BACKGROUND

Infections are one of the major complications in children undergoing chemotherapy. Monotherapy with either ciprofloxacin or ceftriaxone is safe and efficient in low-risk patients (solid tumors and stage I/II lymphomas). The same drugs may be used in an outpatient setting, decreasing costs and the risk of nosocomial infections.

PROCEDURE

Low-risk patients (N = 70) with episodes of fever and neutropenia (N = 116) were randomized to receive either oral ciprofloxacin or intravenous ceftriaxone as outpatients. Only one patient had a central venous catheter.

RESULTS

Episodes of fever and neutropenia were classified as fever of unknown origin (41% vs. 32%) or clinically documented infection (56% vs. 63%) in the ciprofloxacin and ceftriaxone groups, respectively. Most of these infections were of upper respiratory tract, skin, or gastrointestinal origin. The mean duration of neutropenia was 5 vs. 6 days. Fever persisted for 1-9 days (mean 2 vs. 3 days). Therapy was successful with no modifications in 83% vs. 75% of the episodes. Patients were admitted in 7% vs. 4% of the episodes. No bone or joint side effects were seen in either group. All patients survived.

CONCLUSIONS

Outpatient therapy with either oral ciprofloxacin or intravenous ceftriaxone for fever and neutropenia is effective and safe in pediatric patients with solid tumors and stage I/II non-Hodgkin lymphoma (low-risk patients).

Management of Wilms' tumor with intracardiac extension

We review our experience and the literature in treating 4 patients with Wilms' tumor (WT) with intracardiac extension among 92 patients with this neoplasm. Cardiopulmonary bypass with circulatory arrest and profound hypothermia was used. There were 3 boys (3 years, 4 years 5 months, and 15 years) and 1 girl (6 years). The follow-up periods were 8 months, 3 years, 2 years 6 months, and 15 years, respectively. We had no surgical complications and conclude that the preoperative diagnosis is extremely important. These patients must be transferred to institutions where concomitant cardiac procedures can be performed. In treating patients with WT, Doppler ultrasound must be used preoperatively in all cases, not only those in which clinical and radiologic signs of intravascular involvement are found. We propose that preoperative chemotherapy should be used, as it shrinks the thrombus and causes desirable adherence of the thrombus to the venous wall, reducing the probability of thromboembolism during the surgical procedure. We also find this method safer than in our 1st case, where neither cardiac arrest nor hypothermia was used. Our results agree with the literature that intracardiac extension of WT does not worsen its prognosis when a rational surgical approach is used.

Activity of intraarterial carboplatin as a single agent in the treatment of newly diagnosed extremity osteosarcoma

BACKGROUND

Chemotherapy has dramatically improved the rates of cure and survival of patients with localized and metastatic osteosarcoma. Nonetheless, the number of chemotherapeutic agents active against osteosarcoma is limited to doxorubicin, cisplatin, high-dose methotrexate, and ifosfamide. Carboplatin, a cisplatin analogue, has been tested as a single agent in patients with recurrent osteosarcoma or as part of multiagent chemotherapy in newly diagnosed patients.

PROCEDURE

We tested the activity and toxicity of two cycles of intraarterial carboplatin as a "window therapy" (600 mg/m2 per cycle) in 33 consecutive patients with extremity osteosarcoma before the start of multiagent chemotherapy. Response was based on clinical (tumor diameter, local inflammatory signs, and range of motion) and radiological parameters (plain local films and arteriographic studies prior to drug administration).

RESULTS

Patients' age ranged between 8 and 18 years (median age 13 years). Primary tumor originated from the femur (15 patients), tibia (10 patients), fibula (4 patients), humerus (3 patients), and calcaneus (1 patient). Only 7 patients (21%) had metastatic disease at diagnosis (5 in the lung and 2 in other bones). A favorable clinical and radiological response was documented in 81% and 73% of the patients, respectively. Clinical and radiological progression occurred in 12% and 9% of the patients, respectively. Seventeen of the patients remain alive and disease-free. Survival and event-free survival at 3 years for nonmetastatic patients are 71% (SE = 9%) and 65% (SE = 9%), respectively; for metastatic patients, the figures are 17% (SE = 15%) and 14% (SE = 13%), respectively.

CONCLUSIONS

We conclude that carboplatin is an active agent in the treatment of newly diagnosed extremity osteosarcoma.

Guidelines for a therapeutic alliance between families and staff: a report of the SIOP Working Committee on Psychosocial Issues in Pediatric Oncology

This, the fifth official document of the SIOP Working Committee on Psychosocial Issues in Pediatric Oncology, develops another important topic: the Therapeutic Alliance between families and staff. This is addressed to the Pediatric Oncology Community as Guidelines that could be followed. Every parent, medical staff member, and psychosocial professional involved in the care of the child should be responsible for cooperating in the child's best interest. Everyone must work together toward the common goal of curing the cancer and minimizing its medical and psychosocial side-effects.

Fever and neutropenia in children with cancer: a therapeutic approach related to the underlying disease

Antibiotic monotherapy is increasingly an option for the initial empiric treatment of febrile neutropenic cancer patients. We noted in a previous study that response to empiric therapy was related more to disease classification (solid tumors vs. leukemia) than to the regimen chosen. In the present study we based empiric monotherapy on the underlying disease in treating 240 episodes of fever and neutropenia in 145 children. Patients with leukemia or Stage III/IV non-Hodgkin's lymphoma (higher risk group) were treated with imipenem-cilastatin, whereas those with solid tumors or Stage I/II non-Hodgkin's lymphoma (lower risk group) received ceftriaxone. The regimens were modified in 15% of lower risk and 45% of higher risk episodes. Overall successful outcomes were obtained in 93.2% of the higher risk (n = 119) and 97.5% of the lower risk (n = 121) episodes. The two groups differed significantly in duration of neutropenia, frequency of positive blood cultures and superinfection and the need for modification of the monotherapy (P < 0.05). Empiric monotherapy based on primary disease appears to be safe and effective for febrile neutropenic children with cancer at our Brazilian institution. Further studies will be needed before these findings can be generalized to patient populations in other settings.

Fever and granulocytopenia in children with cancer: a study of 299 episodes with two treatment protocols in Brazil

In Brazil, 226 children with cancer presenting 299 episodes of fever and neutropenia (< or = 500/mm3) were treated with two consecutive empirical regimens. Regimen I-Cefoxitin Amikacin-Carbenicillin; and Regimen II Ceftriaxone-Amikacin. 67.0% of the patients had leukemias or lymphomas, documented infections occurred in 47.2%, superinfections occurred in 18.7% (Reg. I) and 17.8% (Reg. II) of the episodes. The most common agents identified in Reg. I and Reg. II were, respectively, Gram negative rods (55.0%) and Gram positive cocci (52.6%). The overall rate of success with modifications (Amphotericin B, Vancomycin, Clindamycin, Metronidazole) was higher in Reg. II (93.0%) than in Reg. I (84.0%). This study shows that the appropriate formula to maximize the successful treatment of children with cancer, fever and neutropenia in developing nations includes adherence to established principles of supportive care, utilizing the optimal antibiotic agents available in the country. It is important to promote the necessary modifications along the treatment having in mind the high index of resistant agents.

[Fever and neutropenia in children with cancer: a new therapeutic proposal]

Based on our previous experience treating children with cancer, fever and neutropenia we selected two different empirical regimens: Ceftriaxone once a day, for patients with solid tumors and lymphomas I-II (Low Risk group--LR) and Imipenem for patients with leukemias and lymphomas III-IV (High Risk group--HR). From Oct 1988 to Nov 1989, 121 episodes of fever (F+) and granulocytopenia (G+) in LR Group and 119 in HR Group were studied: the HR had 51.3% documented infections and the LR 58.7%. In the HR Group the following organisms were isolated from the blood cultures: Gram + 52%, Gram - 20% and fungal 28%. In the LR Group 78% of the organisms were Gram+. Positive blood cultures was 21% for the HR Group and 8.3% for the LR Group. There were 23.5% superinfections in the HR Group vs 5.7% in the LR. The mean time and the median time of granulocytopenia was 11.5 and 8 days (HR) and 6.9 and 6.0 days (LR), respectively. There were 14.5% (LR) and 45.4% (HR) modifications to the initial empirical antibiotic regimen (Amphotericin B, Vancomycin and Amikacin). The overall success rate was 97.6% (LR) and 94.2% (HR) and for documented infection the success rate was 95.7% (LR) and 91.8% (HR). We conclude that: a) The allocation of patients to two risk groups aiming to use distinguished therapy, allowed us to delineate two different populations, predominantly based on time of granulocytopenia, disappearance of fever, rate of superinfection, causative organisms and need of additional drugs to the initial scheme.(ABSTRACT TRUNCATED AT 250 WORDS)

Increased survival, limb preservation, and prognostic factors for osteosarcoma

Preoperative intraarterial (IA) cisplatin (CDP) was administered to 92 patients with nonmetastatic osteosarcoma. The ages of the patients ranged from 4 to 28 years. Sixty-four patients (70%) received 2 or 3 preoperative courses and 28 (30%) received 4 or more. Sixty-two specimens were available for pathologic examination to assess the degree of tumor necrosis. More than 90% tumor destruction was observed in 16 of 42 patients (38%) who received 1 to 3 preoperative courses as opposed to 17 of 20 (85%) who received 4 or more courses. Patients who received 4 or more courses had a 2-fold probability of achieving more than 90% tumor necrosis, and 68% underwent conservative surgery. Of those who received 3 or less courses, 23% underwent conservative surgery. Postoperatively, patients were treated with intravenous (IV) CDP alternating with doxorubicin (ADR) (Adriamycin, Adria Laboratories, Columbus, OH). Pulmonary metastases developed in 36 patients, bone metastases in 2, and local recurrence in 6. Two patients died of cardiac failure without evidence of disease. Thus, 46 patients (50%) were continuously free of disease 18 to 78 months after diagnosis. Univariate and multivariate analyses showed that male sex, low grade preoperative chemotherapy-induced necrosis, and nonosteoblastic histologic condition were prognostic factors predictive of recurrence, while male sex and large tumor size were prognostic factors predictive of death. These results are comparable with those reported by other centers and are superior to our previous experiences that yielded survival rates of 5% to 10%. A substantial number of patients also had the opportunity to achieve tumor removal with conservative surgery.

[Evaluation of antimicrobial schemes in episodes of fever and granulocytopenia in children with cancer]

The efficacy of two antibiotic regimens used as initial empiric therapy was evaluated in 299 episodes of fever and granulocytopenia in children with cancer. Of these, 148 were treated with the combination cefoxitin-amikacin-carbenicillin and the remaining 151 with ceftriaxone-amikacin. All of the patients were evaluated at the beginning and 72 hours after starting treatment with laboratory tests and based on their clinical condition. Each was classified according to the type of infection. A few modifications were made to the initial treatment plan and in accordance with the clinical condition of each patient. Over 52% of the episodes were due to fever of unknown origin and 47.2% due to infections, of which 33.8% proved to be positive blood cultures mainly for Staphylococcus aureus and Pseudomonas aeruginosa. The modifications made to the basic treatment regimens were the addition of amphotericin B, clindamycin or vancomycin. An 89.2% therapeutic index percentage was obtained, independent from the use of either antibiotic scheme. The total therapeutic index for the study was 83.6%.