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Forster VJ, Aronson M, Zhang C, Chung J, Sudhaman S, Galati MA, Kelly J, Negm L, Ercan AB, Stengs L, Durno C, Edwards M, Komosa M, Oldfield LE, Nunes NM, Pedersen S, Wellum J, Siddiqui I, Bianchi V, Weil BR, Fox VL, Pugh TJ, Kamihara J, Tabori U. Biallelic EPCAM deletions induce tissue-specific DNA repair deficiency and cancer predisposition. NPJ Precis Oncol 2024; 8:69. [PMID: 38467830 PMCID: PMC10928233 DOI: 10.1038/s41698-024-00537-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 02/08/2024] [Indexed: 03/13/2024] Open
Abstract
We report a case of Mismatch Repair Deficiency (MMRD) caused by germline homozygous EPCAM deletion leading to tissue-specific loss of MSH2. Through the use of patient-derived cells and organoid technologies, we performed stepwise in vitro differentiation of colonic and brain organoids from reprogrammed EPCAMdel iPSC derived from patient fibroblasts. Differentiation of iPSC to epithelial-colonic organoids exhibited continuous increased EPCAM expression and hypermethylation of the MSH2 promoter. This was associated with loss of MSH2 expression, increased mutational burden, MMRD signatures and MS-indel accumulation, the hallmarks of MMRD. In contrast, maturation into brain organoids and examination of blood and fibroblasts failed to show similar processes, preserving MMR proficiency. The combined use of iPSC, organoid technologies and functional genomics analyses highlights the potential of cutting-edge cellular and molecular analysis techniques to define processes controlling tumorigenesis and uncovers a new paradigm of tissue-specific MMRD, which affects the clinical management of these patients.
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Affiliation(s)
- V J Forster
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - M Aronson
- Zane Cohen Centre, Sinai Health System and Faculty of Molecular Genetics, University of Toronto, Toronto, ON, Canada
| | - C Zhang
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - J Chung
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - S Sudhaman
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - M A Galati
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - J Kelly
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - L Negm
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - A B Ercan
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - L Stengs
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - C Durno
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada
| | - M Edwards
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - M Komosa
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | | | - N M Nunes
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - S Pedersen
- University Health Network, Toronto, ON, Canada
| | - J Wellum
- University Health Network, Toronto, ON, Canada
| | - I Siddiqui
- Department of Paediatric Laboratory Medicine and Pathobiology, Division of Pathology, The Hospital for Sick Children, Toronto, ON, Canada
| | - V Bianchi
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - B R Weil
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - V L Fox
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA
| | - T J Pugh
- University Health Network, Toronto, ON, Canada
| | - J Kamihara
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - U Tabori
- The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada.
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada.
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada.
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2
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Friedman DN, Goodman PJ, Leisenring WM, Diller LR, Cohn SL, Howell RM, Smith SA, Tonorezos ES, Wolden SL, Neglia JP, Ness KK, Gibson TM, Nathan PC, Turcotte LM, Weil BR, Robison LL, Oeffinger KC, Armstrong GT, Sklar CA, Henderson TO. Impact of Risk-Based therapy on late morbidity and mortality in neuroblastoma survivors: a report from the childhood cancer survivor study. J Natl Cancer Inst 2024:djae062. [PMID: 38460547 DOI: 10.1093/jnci/djae062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 02/14/2024] [Accepted: 02/28/2024] [Indexed: 03/11/2024] Open
Abstract
BACKGROUND Early efforts at risk-adapted therapy for neuroblastoma are predicted to result in differential late effects; the magnitude of these differences have not been well-described. METHODS Late mortality, subsequent malignant neoplasms (SMN), and severe/life-threatening chronic health conditions (CHCs), graded according to CTCAE v4.03, were assessed among 5-year CCSS survivors of neuroblastoma diagnosed 1987-1999. Using age, stage at diagnosis, and treatment, survivors were classified into risk groups (low [n = 425]; intermediate [n = 252]; high [n = 245]). Standardized mortality ratios (SMR) and standardized incidence ratios (SIR) of SMNs were compared to matched population controls. Cox regression models estimated hazard ratios (HR) and 95% confidence intervals (CI) for CHC compared to 1,029 CCSS siblings. RESULTS Among survivors (49.8% male; median age 21 years, range 7-42; median follow-up 19.3 years, range 5-29.9), 80% with low-risk disease were treated with surgery alone, while 79.1% with high-risk disease received surgery, radiation, chemotherapy ± autologous stem cell transplant (ASCT). All-cause mortality was elevated across risk groups (SMRhigh=27.7 [21.4-35.8]; SMRintermediate=3.3 [1.7-6.5]; SMRlow=2.8 [1.7-4.8]). SMN risk was increased among high- and intermediate-risk survivors (SIRhigh=28.0 [18.5-42.3]; SIRintermediate=3.7 [1.2-11.3]), but did not differ from the US population for survivors of low-risk disease. Compared to siblings, survivors had an increased risk of grade 3-5 CHCs, particularly among those with high-risk disease (HRhigh=16.1 [11.2-23.2]; HRintermediate=6.3 [3.8-10.5]; HRlow=1.8 [1.1-3.1]). CONCLUSION Survivors of high-risk disease treated in the early days of risk stratification carry a markedly elevated burden of late recurrence, SMN, and organ-related multi-morbidity, while survivors of low/intermediate-risk disease have a modest risk of late adverse outcomes.
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Affiliation(s)
- Danielle Novetsky Friedman
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA
| | - Pamela J Goodman
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Wendy M Leisenring
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Lisa R Diller
- Department of Pediatrics, The Dana-Farber Cancer Institute, Boston, MA, USA
| | - Susan L Cohn
- Department of Pediatrics, The University of Chicago, Chicago, IL, USA
| | - Rebecca M Howell
- Division of Radiation Oncology, Department of Radiation Physics, The University of Texas at MD Anderson Cancer Center, Houston, TX, USA
| | - Susan A Smith
- Division of Radiation Oncology, Department of Radiation Physics, The University of Texas at MD Anderson Cancer Center, Houston, TX, USA
| | - Emily S Tonorezos
- Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, MD, USA
| | - Suzanne L Wolden
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Joseph P Neglia
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
| | - Kirsten K Ness
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Todd M Gibson
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD, USA
| | - Paul C Nathan
- Division of Haematology/Oncology, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Lucie M Turcotte
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
| | - Brent R Weil
- Department of Pediatrics, The Dana-Farber Cancer Institute, Boston, MA, USA
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Leslie L Robison
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Kevin C Oeffinger
- Department of Medicine, Duke Cancer Institute, Duke University, Durham, NC, USA
| | - Gregory T Armstrong
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Charles A Sklar
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Pediatrics, Weill Cornell Medical College, New York, NY, USA
| | - Tara O Henderson
- Department of Pediatrics, The University of Chicago, Chicago, IL, USA
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3
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Rich BS, Dicken BJ, Billmire DF, Weil BR, Ross J, Fallahazad N, Krailo M, Shaikh F, Frazier AL, Hazard FK, Nuño MM. Characterizing Lymphovascular Invasion in Pediatric and Adolescent Malignant Ovarian Nongerminomatous Germ Cell Tumors: A Report from the Children's Oncology Group. J Pediatr Surg 2023; 58:2399-2404. [PMID: 37699777 PMCID: PMC10872999 DOI: 10.1016/j.jpedsurg.2023.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 08/11/2023] [Accepted: 08/15/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND Lymphovascular invasion (LVI) has been identified as a poor prognostic factor for a variety of tumors; however, its significance in malignant ovarian germ cell tumors (MOGCT) in pediatric and adolescent patients is not well described. We aim to clarify the significance of LVI in the subset of patients with nongerminomatous MOGCT. METHODS Records of patients 0-20 years of age with MOGCT enrolled on Children's Oncology Group study AGCT0132 were reviewed. Patients with documented presence or absence of LVI in either institutional or central review pathology reports were included. RESULTS Of 130 patients with MOGCTs, 83 patients had of the presence or absence of LVI documented in their pathology report. 42/83 patients (50.6%) were found to have LVI present. The estimated odds of having LVI was higher in patients with stage II and III disease, 11 years and older and with the presence of choriocarcinoma. Event-free survival (EFS) and overall survival (OS) remained high in patients with LVI. Approximately 50% of patients with a documented LVI status in either institutional pathology report or central review were found to have LVI. CONCLUSIONS The presence of LVI was higher in tumors with adverse risk factors including higher stage and age greater than 11 years. While LVI was not associated with EFS or OS in the intermediate risk group, further work is necessary to determine the effect of LVI on long-term disease-free survival. We, therefore, recommend routinely incorporating LVI status into institutional pathology reports for pediatric and adolescent patients with MOGCT. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Barrie S Rich
- Division of Pediatric Surgery, Cohen Children's Medical Center, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA.
| | - Bryan J Dicken
- Division of Pediatric Surgery, University of Alberta, Edmonton Canada
| | - Deborah F Billmire
- Division of Pediatric Surgery, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Brent R Weil
- Division of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jonathan Ross
- Department of Urology, Department of Pediatrics, Rush Medical College, Chicago, IL, USA
| | - Negar Fallahazad
- Children's Oncology Group, Public Health Institute, Monrovia, CA, USA
| | - Mark Krailo
- Children's Oncology Group, Public Health Institute, Monrovia, CA, USA; Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA, USA
| | - Furqan Shaikh
- Division of Haematology/Oncology, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - A Lindsay Frazier
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center Harvard Medical School, Boston, MA, USA
| | - Florette K Hazard
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Michelle M Nuño
- Children's Oncology Group, Public Health Institute, Monrovia, CA, USA; Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA, USA
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Koester TM, Chewning RH, Weldon CB, Shaikh R, Weil BR. Lymphatic Embolization for the Management of Post-operative Chyle Leaks Following Solid Tumor Resection in Pediatric Patients. J Pediatr Surg 2023; 58:2141-2148. [PMID: 37336682 DOI: 10.1016/j.jpedsurg.2023.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/16/2023] [Accepted: 05/22/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND Chyle leaks are a common post-operative complication following solid-tumor resection in pediatric patients. Current treatments for persistent chyle leaks are limited, leading many patients to experience prolonged hospitalization, nutritional deficits and/or delays in cancer therapies. Lymphatic embolization is an emerging treatment option for chyle leaks, however, limited reports exist of its use in pediatric populations. METHODS We conducted a retrospective review of pediatric patients (<18) who underwent lymphangiogram with intent for lymphatic embolization for the management of chyle leaks following solid-tumor resection between 2017 and 2022. RESULTS Seven patients underwent a total of 11 attempted lymphatic embolization procedures after current standard of care treatments failed to resolve the leak. Lymphangiograms identified a chyle leak in 6 of 7 patients and embolization had a technical success rate of 73%. The complication rate was 9% and complications were limited to one episode of inadvertent gastric wall perforation that did not result in a gastric leak. Lymphatic embolization was ultimately associated with chyle leak resolution in 100% of patients within a median of 24 days, however, repeat embolization was required in 5 of 7 patients (83%). CONCLUSION Lymphatic embolization appears to be a safe and effective treatment for persistent chyle leaks in pediatric patients, leads to a direction reduction in chyle output, and has high rates of technical and clinical success. Complete resolution of the chyle leak may require multiple embolization procedures. Further work is needed to determine whether earlier intervention may offer benefit for the management of pediatric chyle leaks. LEVEL OF EVIDENCE IV.
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Affiliation(s)
| | - Rush H Chewning
- Harvard Medical School, 25 Shattuck Street, Boston, MA, USA; Division of Interventional Radiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, USA
| | - Christopher B Weldon
- Harvard Medical School, 25 Shattuck Street, Boston, MA, USA; Department of Pediatric Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, USA; Department of Pediatric Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, USA
| | - Raja Shaikh
- Harvard Medical School, 25 Shattuck Street, Boston, MA, USA; Division of Interventional Radiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, USA
| | - Brent R Weil
- Harvard Medical School, 25 Shattuck Street, Boston, MA, USA; Department of Pediatric Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, USA; Department of Pediatric Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, USA
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5
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Weil BR, Rich BS, Madenci AL, Stambough KC, Schmoke N, Peace A, Bruny JL, Rescorla FJ, Dicken BJ, Dietrich JE, Billmire DF. Critical elements in the operative management of pediatric malignant ovarian germ cell tumors. Semin Pediatr Surg 2023; 32:151342. [PMID: 38039829 DOI: 10.1016/j.sempedsurg.2023.151342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2023]
Abstract
Performance of the appropriate operation is highly important to ensure that any patient with a suspected ovarian germ cell tumor receives optimal therapy that prioritizes cure while simultaneoulsy minimizing risk of short and long-term toxicities of treatment. The following critical elements of any operative procedure performed for a suspected pediatric or adolescent ovarian germ cell tumor are reviewed: 1. Complete resection of the tumor via ipsilateral oophorectomy while avoiding tumor rupture and spillage, and 2. Performance of complete intraperitoneal staging at the time of initial tumor resection.
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Affiliation(s)
- Brent R Weil
- Department of Pediatric Surgery, Boston Children's Hospital, Harvard University, Boston, United State; Department of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard University, Boston, United States.
| | - Barrie S Rich
- Division of Pediatric Surgery, Cohen Children's Medical Center, Zucker School of Medicine at Northwell/Hofstra, NY, United States
| | - Arin L Madenci
- Department of Pediatric Surgery, Boston Children's Hospital, Harvard University, Boston, United State
| | - Kathryn C Stambough
- Division of Pediatric and Adolescent Gynecology, Arkansas Children's Hospital, University of Arkansas School for Medical Sciences, Little Rock, United States
| | - Nicholas Schmoke
- Division of Pediatric Surgery, Children's Hospital of Colorado, University of Colorado Anschutz Medical Center, Denver, United States
| | - Alyssa Peace
- Division of Pediatric Surgery, Children's Hospital of Colorado, University of Colorado Anschutz Medical Center, Denver, United States
| | - Jennifer L Bruny
- Division of Pediatric Surgery, Children's Hospital of Colorado, University of Colorado Anschutz Medical Center, Denver, United States
| | - Frederick J Rescorla
- Division of Pediatric Surgery, Riley Children's Hospital, Indiana University School of Medicine, Indianapolis, United States
| | - Bryan J Dicken
- Division of Pediatric Surgery, Stollery Children's Hospital, University of Alberta, Edmonton, Canada
| | - Jennifer E Dietrich
- Division of Pediatric and Adolescent Gynecology, Texas Children's Hospital, Baylor College of Medicine, United States
| | - Deborah F Billmire
- Division of Pediatric Surgery, Riley Children's Hospital, Indiana University School of Medicine, Indianapolis, United States
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Zimmerman LA, Spaan J, Weinbren N, Manokaran K, Ajithkumar A, Bogursky A, Liu E, Lillehei C, Weil BR, Zalieckas JM, Bousvaros A, Rufo PA. Efficacy and Safety of Tacrolimus or Infliximab Therapy in Children and Young Adults With Acute Severe Colitis. J Pediatr Gastroenterol Nutr 2023; 77:222-227. [PMID: 37477885 DOI: 10.1097/mpg.0000000000003824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
INTRODUCTION One-third of children and young adults admitted for management of acute severe colitis (ASC) fail intravenous corticosteroids. Infliximab (IFX) or tacrolimus (TAC) is often used to prevent urgent colectomy in these patients. However, no prior studies have reviewed the outcome of pediatric patients with ASC who were treated with either IFX or TAC. METHODS We retrospectively identified 170 pediatric patients with ASC admitted to our institution who did not respond to intravenous corticosteroids and were subsequently treated with either IFX or TAC. We compared 6-month colectomy rates, time to colectomy, improvement in disease activity indices, and adverse effects. RESULTS The mean age of patients in the IFX (n = 84) and TAC (n = 86) groups were 14 and 13.8 years, respectively. The median study follow-up time was 23 months. The rate of colectomy 6 months from rescue therapy was similar whether patients received IFX or TAC (22.6% vs 26.7%, respectively, P = 0.53). The mean decline in Pediatric Ulcerative Colitis Activity Index scores from admission to discharge in those treated with IFX (31.9) or TAC (29.8) was similar (P = 0.63). Three patients treated with IFX experienced infusion reactions. Six patients treated with TAC experienced changes in renal function or electrolytes, and 4 patients reported neurologic symptoms. CONCLUSIONS There were no significant differences in the likelihood of colectomy 6 months after initiating IFX or TAC rescue therapy. Efficacy of both agents was comparable. The types of adverse effects differed by therapy. These data support the use of either TAC or IFX in children with ASC refractory to intravenous corticosteroids.
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Affiliation(s)
- Lori A Zimmerman
- From the Division of Gastroenterology and Nutrition, IBD Center, Boston Children's Hospital, Boston, MA
| | - Jonathan Spaan
- From the Division of Gastroenterology and Nutrition, IBD Center, Boston Children's Hospital, Boston, MA
| | - Nathan Weinbren
- From the Division of Gastroenterology and Nutrition, IBD Center, Boston Children's Hospital, Boston, MA
| | - Krishanth Manokaran
- From the Division of Gastroenterology and Nutrition, IBD Center, Boston Children's Hospital, Boston, MA
| | - Aravindh Ajithkumar
- From the Division of Gastroenterology and Nutrition, IBD Center, Boston Children's Hospital, Boston, MA
| | - Anna Bogursky
- From the Division of Gastroenterology and Nutrition, IBD Center, Boston Children's Hospital, Boston, MA
| | - Enju Liu
- From the Division of Gastroenterology and Nutrition, IBD Center, Boston Children's Hospital, Boston, MA
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, MA
| | - Craig Lillehei
- the Department of Surgery, IBD Center, Boston Children's Hospital, Boston, MA
| | - Brent R Weil
- the Department of Surgery, IBD Center, Boston Children's Hospital, Boston, MA
| | - Jill M Zalieckas
- the Department of Surgery, IBD Center, Boston Children's Hospital, Boston, MA
| | - Athos Bousvaros
- From the Division of Gastroenterology and Nutrition, IBD Center, Boston Children's Hospital, Boston, MA
| | - Paul A Rufo
- From the Division of Gastroenterology and Nutrition, IBD Center, Boston Children's Hospital, Boston, MA
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Shaikh R, Weil BR, Weldon CB, Chen N, London WB, Krush M, Anderson M, Gebhardt M, Church AJ, DuBois SG, Pikman Y, Spidle J, Wall CB, Feraco A, Ullrich NJ, Mack JW, Mullen E, Kamihara J, Forrest S, Shusterman S, Janeway KA, Alomari A, Padua H, Rodriguez-Galindo C, O'Neill AF. A single-institution pediatric and young adult interventional oncology collaborative: Novel therapeutic options for relapsed/refractory solid tumors. Cancer Med 2023. [PMID: 37264747 DOI: 10.1002/cam4.6026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 03/29/2023] [Accepted: 04/18/2023] [Indexed: 06/03/2023] Open
Abstract
BACKGROUND Pediatric interventional oncology (PIO) is a growing field intended to provide additional or alternative treatment options for pediatric patients with benign or malignant tumors. Large series of patients treated uniformly and subjected to rigorous endpoints for efficacy are not available. METHODS We designed a collaborative initiative to capture data from pediatric patients with benign and malignant tumors who underwent a therapeutic interventional radiology procedure. Modified Response Evaluation Criteria in Solid Tumors (mRECIST) was utilized as a measure of radiologic response and data were collected regarding improvement in pain and functional endpoints. Cumulative incidence of progressive disease was calculated using both the treated site and the patient as the analytic unit. FINDINGS Forty patients, 16 with malignant tumors and 24 with benign tumors, underwent a total of 88 procedures. Cryo- and radiofrequency ablation were the most frequently utilized techniques for both cohorts of patients. A complete or partial response, or prolonged disease stability, were achieved in approximately 40% of patients with malignant tumors and 60% of patients with benign tumors. No patients had progressive disease as their best response. Resolution of pain and improved mobility with return-to-baseline activity were demonstrated across patients from both cohorts. Only minor complications were experienced. INTERPRETATION Interventional radiology-guided interventions can serve as an alternative or complementary approach to the treatment of benign and malignant tumors in pediatric patients. Prospective, multi-institutional trials are required to adequately study utility, treatment endpoints, and durability of response.
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Affiliation(s)
- Raja Shaikh
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Brent R Weil
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute/Boston Children's Cancer and Blood Disorders Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher B Weldon
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute/Boston Children's Cancer and Blood Disorders Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Nan Chen
- Department of Pediatric Oncology, Dana-Farber Cancer Institute/Boston Children's Cancer and Blood Disorders Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Wendy B London
- Department of Pediatric Oncology, Dana-Farber Cancer Institute/Boston Children's Cancer and Blood Disorders Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Morgan Krush
- Department of Pediatric Oncology, Dana-Farber Cancer Institute/Boston Children's Cancer and Blood Disorders Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Megan Anderson
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute/Boston Children's Cancer and Blood Disorders Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Mark Gebhardt
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Alanna J Church
- Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Steven G DuBois
- Department of Pediatric Oncology, Dana-Farber Cancer Institute/Boston Children's Cancer and Blood Disorders Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Yana Pikman
- Department of Pediatric Oncology, Dana-Farber Cancer Institute/Boston Children's Cancer and Blood Disorders Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Jennifer Spidle
- Department of Pediatric Oncology, Dana-Farber Cancer Institute/Boston Children's Cancer and Blood Disorders Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Catherine B Wall
- Department of Pediatric Oncology, Dana-Farber Cancer Institute/Boston Children's Cancer and Blood Disorders Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Angela Feraco
- Department of Pediatric Oncology, Dana-Farber Cancer Institute/Boston Children's Cancer and Blood Disorders Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Nicole J Ullrich
- Department of Pediatric Oncology, Dana-Farber Cancer Institute/Boston Children's Cancer and Blood Disorders Center and Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Jennifer W Mack
- Department of Pediatric Oncology, Dana-Farber Cancer Institute/Boston Children's Cancer and Blood Disorders Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Elizabeth Mullen
- Department of Pediatric Oncology, Dana-Farber Cancer Institute/Boston Children's Cancer and Blood Disorders Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Junne Kamihara
- Department of Pediatric Oncology, Dana-Farber Cancer Institute/Boston Children's Cancer and Blood Disorders Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Suzanne Forrest
- Department of Pediatric Oncology, Dana-Farber Cancer Institute/Boston Children's Cancer and Blood Disorders Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Suzanne Shusterman
- Department of Pediatric Oncology, Dana-Farber Cancer Institute/Boston Children's Cancer and Blood Disorders Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Katherine A Janeway
- Department of Pediatric Oncology, Dana-Farber Cancer Institute/Boston Children's Cancer and Blood Disorders Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Ahmad Alomari
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Horacio Padua
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Carlos Rodriguez-Galindo
- Departments of Global Pediatric Medicine and Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Allison F O'Neill
- Department of Pediatric Oncology, Dana-Farber Cancer Institute/Boston Children's Cancer and Blood Disorders Center and Harvard Medical School, Boston, Massachusetts, USA
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Dieffenbach BV, Murphy AJ, Liu Q, Ramsey DC, Geiger EJ, Diller LR, Howell RM, Oeffinger KC, Robison LL, Yasui Y, Armstrong GT, Chow EJ, Weil BR, Weldon CB. Cumulative burden of late, major surgical intervention in survivors of childhood cancer: a report from the Childhood Cancer Survivor Study (CCSS) cohort. Lancet Oncol 2023; 24:691-700. [PMID: 37182536 PMCID: PMC10348667 DOI: 10.1016/s1470-2045(23)00154-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/29/2023] [Accepted: 03/30/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND Multimodal cancer therapy places childhood cancer survivors at increased risk for chronic health conditions, subsequent malignancies, and premature mortality as they age. We aimed to estimate the cumulative burden of late (>5 years from cancer diagnosis), major surgical interventions among childhood cancer survivors, compared with their siblings, and to examine associations between specific childhood cancer treatments and the burden of late surgical interventions. METHODS We analysed data from the Childhood Cancer Survivor Study (CCSS), a retrospective cohort study with longitudinal prospective follow-up of 5-year survivors of childhood cancer (diagnosed before age 21 years) treated at 31 institutions in the USA, with a comparison group of nearest-age siblings of survivors selected by simple random sampling. The primary outcome was any self-reported late, major surgical intervention (defined as any anaesthesia-requiring operation) occurring 5 years or more after the primary cancer diagnosis. The cumulative burden was assessed with mean cumulative counts (MCC) of late, major surgical interventions. Piecewise exponential regression models with calculation of adjusted rate ratios (RRs) evaluated associations between treatment exposures and late, major surgical interventions. FINDINGS Between Jan 1, 1970, and Dec 31, 1999, 25 656 survivors were diagnosed (13 721 male, 11 935 female; median follow-up 21·8 years [IQR 16·5-28·4]; median age at diagnosis 6·1 years [3·0-12·4]); 5045 nearest-age siblings were also included as a comparison group. Survivors underwent 28 202 late, major surgical interventions and siblings underwent 4110 late, major surgical interventions. The 35-year MCC of a late, major surgical intervention was 206·7 per 100 survivors (95% CI 202·7-210·8) and 128·9 per 100 siblings (123·0-134·7). The likelihood of a late, major surgical intervention was higher in survivors versus siblings (adjusted RR 1·8, 95% CI 1·7-1·9) and in female versus male survivors (1·4; 1·4-1·5). Survivors diagnosed in the 1990s (adjusted RR 1·4, 95% CI 1·3-1·5) had an increased likelihood of late surgery compared with those diagnosed in the 1970s. Survivors received late interventions more frequently than siblings in most anatomical regions or organ systems, including CNS (adjusted RR 16·9, 95% CI 9·4-30·4), endocrine (6·7, 5·2-8·7), cardiovascular (6·6, 5·2-8·3), respiratory (5·3, 3·4-8·2), spine (2·4, 1·8-3·2), breast (2·1, 1·7-2·6), renal or urinary (2·0, 1·5-2·6), musculoskeletal (1·5, 1·4-1·7), gastrointestinal (1·4, 1·3-1·6), and head and neck (1·2, 1·1-1·4) interventions. Survivors of Hodgkin lymphoma (35-year MCC 333·3 [95% CI 320·1-346·6] per 100 survivors), Ewing sarcoma (322·9 [294·5-351·3] per 100 survivors), and osteosarcoma (269·6 [250·1-289·2] per 100 survivors) had the highest cumulative burdens of late, major surgical interventions. Locoregional surgery or radiotherapy cancer treatment were associated with undergoing late surgical intervention in the same body region or organ system. INTERPRETATION Childhood cancer survivors have a significant burden of late, major surgical interventions, a late effect that has previously been poorly quantified. Survivors would benefit from regular health-care evaluations aiming to anticipate impending surgical issues and to intervene early in the disease course when feasible. FUNDING US National Institutes of Health, US National Cancer Institute, American Lebanese Syrian Associated Charities, and St Jude Children's Research Hospital.
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Affiliation(s)
- Bryan V Dieffenbach
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA; Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - Andrew J Murphy
- Department of Surgery, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Qi Liu
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Duncan C Ramsey
- Department of Orthopedics and Rehabilitation, Oregon Health and Science University, Portland, OR, USA
| | - Erik J Geiger
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Lisa R Diller
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - Rebecca M Howell
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kevin C Oeffinger
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Leslie L Robison
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Yutaka Yasui
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Gregory T Armstrong
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Eric J Chow
- Clinical Research and Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Brent R Weil
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA; Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA.
| | - Christopher B Weldon
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA; Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA; Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
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9
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Weil BR, Murphy AJ, Liu Q, Howell RM, Smith SA, Weldon CB, Mullen EA, Madenci AL, Leisenring WM, Neglia JP, Turcotte LM, Oeffinger KC, Termuhlen AM, Mostoufi-Moab S, Levine JM, Krull KR, Yasui Y, Robison LL, Armstrong GT, Chow EJ, Armenian SH. Late Health Outcomes Among Survivors of Wilms Tumor Diagnosed Over Three Decades: A Report From the Childhood Cancer Survivor Study. J Clin Oncol 2023; 41:2638-2650. [PMID: 36693221 PMCID: PMC10414738 DOI: 10.1200/jco.22.02111] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/29/2022] [Accepted: 12/09/2022] [Indexed: 01/25/2023] Open
Abstract
PURPOSE To evaluate long-term morbidity and mortality among unilateral, nonsyndromic Wilms tumor (WT) survivors according to conventional treatment regimens. METHODS Cumulative incidence of late mortality (≥ 5 years from diagnosis) and chronic health conditions (CHCs) were evaluated in WT survivors from the Childhood Cancer Survivor Study. Outcomes were evaluated by treatment, including nephrectomy combined with vincristine and actinomycin D (VA), VA + doxorubicin + abdominal radiotherapy (VAD + ART), VAD + ART + whole lung radiotherapy, or receipt of ≥ 4 chemotherapy agents. RESULTS Among 2,008 unilateral WT survivors, 142 deaths occurred (standardized mortality ratio, 2.9, 95% CI, 2.5 to 3.5; 35-year cumulative incidence of death, 7.8%, 95% CI, 6.3 to 9.2). The 35-year cumulative incidence of any grade 3-5 CHC was 34.1% (95% CI, 30.7 to 37.5; rate ratio [RR] compared with siblings 3.0, 95% CI, 2.6 to 3.5). Survivors treated with VA alone had comparable risk for all-cause late mortality relative to the general population (standardized mortality ratio, 1.0; 95% CI, 0.5 to 1.7) and modestly increased risk for grade 3-5 CHCs compared with siblings (RR, 1.5; 95% CI, 1.1 to 2.0), but remained at increased risk for intestinal obstruction (RR, 9.4; 95% CI, 3.9 to 22.2) and kidney failure (RR, 11.9; 95% CI, 4.2 to 33.6). Magnitudes of risk for grade 3-5 CHCs, including intestinal obstruction, kidney failure, premature ovarian insufficiency, and heart failure, increased by treatment group intensity. CONCLUSION With approximately 40% of patients with newly diagnosed WT currently treated with VA alone, the burden of late mortality/morbidity in future decades is projected to be lower than that for survivors from earlier eras. Nevertheless, the risk of late effects such as intestinal obstruction and kidney failure was elevated across all treatment groups, and there was a dose-dependent increase in risk for all grade 3-5 CHCs by treatment group intensity.
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Affiliation(s)
- Brent R. Weil
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA
| | - Andrew J. Murphy
- Department of Surgery, St Jude Children's Research Hospital, Memphis, TN
| | - Qi Liu
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Rebecca M. Howell
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Susan A. Smith
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Christopher B. Weldon
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Elizabeth A. Mullen
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA
| | - Arin L. Madenci
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
- Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Wendy M. Leisenring
- Clinical Research and Public Health Sciences Divisions, Fred Hutchinson Cancer Center, Seattle, WA
| | - Joseph P. Neglia
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
| | - Lucie M. Turcotte
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
| | | | - Amanda M. Termuhlen
- Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
| | - Sogol Mostoufi-Moab
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Kevin R. Krull
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Yutaka Yasui
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Leslie L. Robison
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Gregory T. Armstrong
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Eric J. Chow
- Clinical Research and Public Health Sciences Divisions, Fred Hutchinson Cancer Center, Seattle, WA
| | - Saro H. Armenian
- Department of Population Sciences, City of Hope, Duarte, CA
- Department of Pediatrics, City of Hope, Duarte, CA
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10
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Wu NL, Chen Y, Dieffenbach BV, Ehrhardt MJ, Hingorani S, Howell RM, Jefferies JL, Mulrooney DA, Oeffinger KC, Robison LL, Weil BR, Yuan Y, Yasui Y, Hudson MM, Leisenring WM, Armstrong GT, Chow EJ. Development and Validation of a Prediction Model for Kidney Failure in Long-Term Survivors of Childhood Cancer. J Clin Oncol 2023; 41:2258-2268. [PMID: 36795981 PMCID: PMC10448933 DOI: 10.1200/jco.22.01926] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 12/05/2022] [Accepted: 12/20/2022] [Indexed: 02/18/2023] Open
Abstract
PURPOSE Kidney failure is a rare but serious late effect following treatment for childhood cancer. We developed a model using demographic and treatment characteristics to predict individual risk of kidney failure among 5-year survivors of childhood cancer. METHODS Five-year survivors from the Childhood Cancer Survivor Study (CCSS) without history of kidney failure (n = 25,483) were assessed for subsequent kidney failure (ie, dialysis, kidney transplantation, or kidney-related death) by age 40 years. Outcomes were identified by self-report and linkage with the Organ Procurement and Transplantation Network and the National Death Index. A sibling cohort (n = 5,045) served as a comparator. Piecewise exponential models accounting for race/ethnicity, age at diagnosis, nephrectomy, chemotherapy, radiotherapy, congenital genitourinary anomalies, and early-onset hypertension estimated the relationships between potential predictors and kidney failure, using area under the curve (AUC) and concordance (C) statistic to evaluate predictive power. Regression coefficient estimates were converted to integer risk scores. The St Jude Lifetime Cohort Study and the National Wilms Tumor Study served as validation cohorts. RESULTS Among CCSS survivors, 204 developed late kidney failure. Prediction models achieved an AUC of 0.65-0.67 and a C-statistic of 0.68-0.69 for kidney failure by age 40 years. Validation cohort AUC and C-statistics were 0.88/0.88 for the St Jude Lifetime Cohort Study (n = 8) and 0.67/0.64 for the National Wilms Tumor Study (n = 91). Risk scores were collapsed to form statistically distinct low- (n = 17,762), moderate- (n = 3,784), and high-risk (n = 716) groups, corresponding to cumulative incidences in CCSS of kidney failure by age 40 years of 0.6% (95% CI, 0.4 to 0.7), 2.1% (95% CI, 1.5 to 2.9), and 7.5% (95% CI, 4.3 to 11.6), respectively, compared with 0.2% (95% CI, 0.1 to 0.5) among siblings. CONCLUSION Prediction models accurately identify childhood cancer survivors at low, moderate, and high risk for late kidney failure and may inform screening and interventional strategies.
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Affiliation(s)
- Natalie L. Wu
- Division of Oncology, Department of Pediatrics, University of California San Francisco Benioff Children's Hospital, Oakland, CA
- Division of Hematology/Oncology, Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Yan Chen
- Department of Public Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | | | - Matthew J. Ehrhardt
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Sangeeta Hingorani
- Division of Hematology/Oncology, Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Rebecca M. Howell
- Division of Radiation Oncology, Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - John L. Jefferies
- Department of Medicine, The University of Tennessee Health Science Center, Memphis, TN
| | - Daniel A. Mulrooney
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | | | - Leslie L. Robison
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Brent R. Weil
- Department of Surgery, Boston Children's Hospital, Boston, MA
| | - Yan Yuan
- Department of Public Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Yutaka Yasui
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Melissa M. Hudson
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | | | - Gregory T. Armstrong
- Department of Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN
| | - Eric J. Chow
- Division of Hematology/Oncology, Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, WA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
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11
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Friedman DN, Goodman PJ, Leisenring WM, Diller LR, Cohn SL, Howell RM, Smith SA, Tonorezos ES, Wolden SL, Neglia JP, Ness KK, Gibson TM, Nathan PC, Weil BR, Robison LL, Oeffinger KC, Armstrong GT, Sklar CA, Henderson TO. Long-Term Morbidity and Mortality Among Survivors of Neuroblastoma Diagnosed During Infancy: A Report From the Childhood Cancer Survivor Study. J Clin Oncol 2023; 41:1565-1576. [PMID: 36525618 PMCID: PMC10043581 DOI: 10.1200/jco.22.01732] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 11/02/2022] [Accepted: 11/11/2022] [Indexed: 12/23/2022] Open
Abstract
PURPOSE To describe the risk of late mortality, subsequent malignant neoplasms (SMNs), and chronic health conditions (CHCs) in survivors of neuroblastoma diagnosed in infancy by treatment era and exposures. METHODS Among 5-year survivors of neuroblastoma in the Childhood Cancer Survivor Study diagnosed age < 1 year between 1970 and 1999, we examined the cumulative incidence of late (> 5 years from diagnosis) mortality, SMN, and CHCs (grades 2-5 and 3-5). Multivariable Cox regression models estimated hazard ratios (HRs) and 95% CIs by decade and treatment (surgery-alone v chemotherapy with or without surgery [C ± S] v radiation with or without chemotherapy ± surgery [R ± C ± S]) among survivors and between survivors and 5,051 siblings. RESULTS Among 1,397 eligible survivors, the 25-year cumulative incidence of late mortality was 2.1% (95% CI, 1.3 to 3.9) with no difference by treatment era. Among 990 participants who completed a baseline survey, fewer survivors received radiation in more recent eras (51.2% 1970s, 20.4% 1980s, and 10.1% 1990s; P < .001). Risk of SMN was elevated only among individuals treated with radiation-containing regimens compared with surgery alone (HR[C ± S], 3.2 [95% CI, 0.9 to 11.6]; HR[R ± C ± S], 5.7 [95% CI, 1.2 to 28.1]). In adjusted models, there was a 50% reduction in risk of grade 3-5 CHCs in the 1990s versus 1970s (HR, 0.5 [95% CI, 0.3 to 0.9]; P = .01); individuals treated with radiation had a 3.6-fold risk for grade 3-5 CHCs (95% CI, 2.1 to 6.2) versus those treated with surgery alone. When compared with siblings, risk of grade 3-5 CHCs for survivors was lowest in the most recent era (HR[1970s], 4.7 [95% CI, 3.4 to 6.5]; HR[1980s], 4.6 [95% CI, 3.3 to 6.4]; HR[1990s], 2.5 [95% CI, 1.7 to 3.9]). CONCLUSION Neuroblastoma survivors treated during infancy have a relatively low absolute burden of late mortality and SMN. Encouragingly, risk of CHCs has declined in more recent eras with reduced exposure to radiation therapy.
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Affiliation(s)
| | | | | | | | | | | | - Susan A. Smith
- The University of Texas, MD Anderson Cancer Center, Houston, TX
| | | | - Suzanne L. Wolden
- Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Cornell Medical College, New York, NY
| | | | | | - Todd M. Gibson
- National Cancer Institute, National Institutes of Health, Rockville, MD
| | | | - Brent R. Weil
- Dana Farber Cancer Institute, Boston, MA
- Boston Children's Hospital, Boston, MA
| | | | | | | | - Charles A. Sklar
- Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Cornell Medical College, New York, NY
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12
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Geiger EJ, Liu W, Srivastava DK, Bernthal NM, Weil BR, Yasui Y, Ness KK, Krull KR, Goldsby RE, Oeffinger KC, Robison LL, Dieffenbach BV, Weldon CB, Gebhardt MC, Howell R, Murphy AJ, Leisenring WM, Armstrong GT, Chow EJ, Wustrack RL. What Are Risk Factors for and Outcomes of Late Amputation After Treatment for Lower Extremity Sarcoma: A Childhood Cancer Survivor Study Report. Clin Orthop Relat Res 2023; 481:526-538. [PMID: 35583517 PMCID: PMC9928620 DOI: 10.1097/corr.0000000000002243] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 04/21/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Although pediatric lower extremity sarcoma once was routinely treated with amputation, multiagent chemotherapy as well as the evolution of tumor resection and reconstruction techniques have enabled the wide adoption of limb salvage surgery (LSS). Even though infection and tumor recurrence are established risk factors for early amputation (< 5 years) after LSS, the frequency of and factors associated with late amputation (≥ 5 years from diagnosis) in children with sarcomas are not known. Additionally, the resulting psychosocial and physical outcomes of these patients compared with those treated with primary amputation or LSS that was not complicated by subsequent amputation are not well studied. Studying these outcomes is critical to enhancing the quality of life of patients with sarcomas. QUESTIONS/PURPOSES (1) How have treatments changed over time in patients with lower extremity sarcoma who are included in the Childhood Cancer Survivor Study (CCSS), and did primary treatment with amputation or LSS affect overall survival at 25 years among patients who had survived at least 5 years from diagnosis? (2) What is the cumulative incidence of amputation after LSS for patients diagnosed with pediatric lower extremity sarcomas 25 years after diagnosis? (3) What are the factors associated with time to late amputation (≥ 5 years after diagnosis) in patients initially treated with LSS for lower extremity sarcomas in the CCSS? (4) What are the comparative social, physical, and emotional health-related quality of life (HRQOL) outcomes among patients with sarcoma treated with primary amputation, LSS without amputation, or LSS complicated by late amputation, as assessed by CCSS follow-up questionnaires, the SF-36, and the Brief Symptom Inventory-18 at 20 years after cancer diagnosis? METHODS The CCSS is a long-term follow-up study that began in 1994 and is coordinated through St. Jude Children's Research Hospital. It is a retrospective study with longitudinal follow-up of more than 38,000 participants treated for childhood cancer when younger than 21 years at one of 31 collaborating institutions between 1970 and 1999 in the United States and Canada. Participants were eligible for enrollment in the CCSS after they had survived 5 years from diagnosis. Within the CCSS cohort, we included participants who had a diagnosis of lower extremity sarcoma treated with primary amputation (547 patients with a mean age at diagnosis of 13 ± 4 years) or primary LSS (510 patients with a mean age 14 ± 4 years). The LSS cohort was subdivided into LSS without amputation, defined as primary LSS without amputation at the time of latest follow-up; LSS with early amputation, defined as LSS complicated by amputation occurring less than 5 years from diagnosis; or LSS with late amputation, defined as primary LSS in study patients who subsequently underwent amputation 5 years or more from cancer diagnosis. The cumulative incidence of late amputation after primary LSS was estimated. Cox proportional hazards regression with time-varying covariates identified factors associated with late amputation. Modified Poisson regression models were used to compare psychosocial, physical, and HRQOL outcomes among patients treated with primary amputation, LSS without amputation, or LSS complicated by late amputation using validated surveys. RESULTS More study participants were treated with LSS than with primary amputation in more recent decades. The overall survival at 25 years in this population who survived 5 years from diagnosis was not different between those treated with primary amputation (87% [95% confidence interval [CI] 82% to 91%]) compared with LSS (88% [95% CI 85% to 91%]; p = 0.31). The cumulative incidence of amputation at 25 years after cancer diagnosis and primary LSS was 18% (95% CI 14% to 21%). With the numbers available, the cumulative incidence of late amputation was not different among study patients treated in the 1970s (27% [95% CI 15% to 38%]) versus the 1980s and 1990s (19% [95% CI 13% to 25%] and 15% [95% CI 10% to 19%], respectively; p = 0.15). After controlling for gender, medical and surgical treatment variables, cancer recurrence, and chronic health conditions, gender (hazard ratio [HR] 2.02 [95% CI 1.07 to 3.82]; p = 0.03) and history of prosthetic joint reconstruction (HR 2.58 [95% CI 1.37 to 4.84]; p = 0.003) were associated with an increased likelihood of late amputation. Study patients treated with a primary amputation (relative risk [RR] 2.04 [95% CI 1.15 to 3.64]) and LSS complicated by late amputation (relative risk [RR] 3.85 [95% CI 1.66 to 8.92]) were more likely to be unemployed or unable to attend school than patients treated with LSS without amputation to date. The CCSS cohort treated with primary amputation and those with LSS complicated by late amputation reported worse physical health scores than those without amputation to date, although mental and emotional health outcomes did not differ between the groups. CONCLUSION There is a substantial risk of late amputation after LSS, and both primary and late amputation status are associated with decreased physical HRQOL outcomes. Children treated for sarcoma who survive into adulthood after primary amputation and those who undergo late amputation after LSS may benefit from interventions focused on improving physical function and reaching educational and employment milestones. Efforts to improve the physical function of people who have undergone amputation either through prosthetic design or integration into the residuum should be supported. Understanding factors associated with late amputation in the setting of more modern surgical approaches and implants will help surgeons more effectively manage patient expectations and adjust practice to mitigate these risks over the life of the patient. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Erik J. Geiger
- Department of Orthopaedic Surgery, University of California-Los Angeles, Los Angeles, CA, USA
| | - Wei Liu
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Deo Kumar Srivastava
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Nicholas M. Bernthal
- Department of Orthopaedic Surgery, University of California-Los Angeles, Los Angeles, CA, USA
| | - Brent R. Weil
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - Yutaka Yasui
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Kirsten K. Ness
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Kevin R. Krull
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
- Department of Psychology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Robert E. Goldsby
- Division of Oncology, Department of Pediatrics, University of California San Francisco, Benioff Children's Hospital, San Francisco, CA, USA
| | - Kevin C. Oeffinger
- Department of Medicine and Duke Cancer Institute, Duke University School of Medicine, Durham, NC, USA
| | - Leslie L. Robison
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Bryan V. Dieffenbach
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - Christopher B. Weldon
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
- Department of Surgery and Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Mark C. Gebhardt
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Rebecca Howell
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrew J. Murphy
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Wendy M. Leisenring
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Gregory T. Armstrong
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Eric J. Chow
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Rosanna L. Wustrack
- Department of Orthopaedic Surgery, University of California-San Francisco, San Francisco, CA, USA
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13
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Ross AB, Rouanet E, Murphy AJ, Weldon CB, Weil BR. Complications associated with totally implantable access ports in children less than 1 year of age. J Pediatr Surg 2022; 57:463-468. [PMID: 34991865 DOI: 10.1016/j.jpedsurg.2021.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 11/24/2021] [Accepted: 12/01/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Long term central venous access is necessary for the treatment of several conditions affecting young children. Totally implantable access ports (ports) offer the advantage of containing no external components, thus simplifying their care and maintenance. However, there is no consensus on the safety of port placement in infants (birth to 1-year of age). The aim of this study was to describe complications associated with port placement in infants, including which specific factors may be associated with risk for developing complications among these patients, and thereby assess the safety of port placement in this young population. METHODS A two-institution, retrospective cohort study identified patients under 1-year old who underwent port placement. Intraoperative, early postoperative (within 30 days), and late postoperative (greater than 30 days) complications were recorded. Multivariate logistic regression models were employed to assess factors associated with port-related complications. RESULTS Among 121 patients who received a port, 36 (30%) experienced a complication with a median time to complication of 299.5 days [IQR 67.5-440.75]. Of those, 26 required unplanned port removal. Only 3 patients (2.5%) experienced an intraoperative complication, and 3 patients (2.5%) experienced a complication within 30 days of port placement. A diagnosis of cancer was found to be protective against early catheter malfunction (OR=0.31, p = 0.03). A non-statistically significant trend associated with increased complications for large caliber devices (>6.0Fr) and weight <7-kg (OR 2.20, p = 0.06 and OR=2.26, p = 0.11 respectively) was observed. CONCLUSIONS Port placement appears to be safe for most infants with low or acceptable rates of intra- or post-operative complications. Smaller patient size (< 7 kg) and larger-sized catheters (> 6.0Fr) may be associated with an increased risk for complications among this population. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Aaron B Ross
- College of Medicine, University of Tennessee Health Science Center, Memphis, TN 38163, United States.
| | - Eva Rouanet
- Department of Surgery, Boston Children's Hospital/Harvard Medical School, Boston, MA 02115, United States; Department of Surgery, Brigham & Women's Hospital/Harvard Medical School, Boston, MA 02115, United States
| | - Andrew J Murphy
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN 38105, United States
| | - Christopher B Weldon
- Department of Surgery, Boston Children's Hospital/Harvard Medical School, Boston, MA 02115, United States; Department of Pediatric Oncology, Dana-Farber Cancer Institute/Harvard Medical School, Boston, MA 02115, United States; Department of Anesthesiology, Critical Care & Pain Medicine, Children's Hospital/Harvard Medical School, Boston, MA 02115, United States
| | - Brent R Weil
- Department of Surgery, Boston Children's Hospital/Harvard Medical School, Boston, MA 02115, United States; Department of Pediatric Oncology, Dana-Farber Cancer Institute/Harvard Medical School, Boston, MA 02115, United States
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14
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Vo KT, DuBois SG, Neuhaus J, Braunstein SE, Weil BR, Naranjo A, Irtan S, Balaguer J, Matthay KK. Pattern and predictors of sites of relapse in neuroblastoma: A report from the International Neuroblastoma Risk Group (INRG) project. Pediatr Blood Cancer 2022; 69:e29616. [PMID: 35188340 PMCID: PMC9329207 DOI: 10.1002/pbc.29616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 01/31/2022] [Accepted: 02/01/2022] [Indexed: 11/09/2022]
Abstract
PURPOSE We sought to analyze biologic, clinical, and prognostic differences according to pattern of failure at the time of first relapse in neuroblastoma. PATIENTS AND METHODS Children <21 years diagnosed with neuroblastoma between 1989 and 2017 with known site of first relapse (isolated local vs. distant only vs. combined local and distant sites) were identified from the International Neuroblastoma Risk Group (INRG) database. Data were compared between sites of relapse according to clinical features, biologic features, initial treatment, time to first relapse, and overall survival (OS) from time of first relapse. RESULTS Pattern of first relapse among 1833 children was 19% isolated local; 65% distant only; and 16% combined sites. All evaluated clinical and biologic variables with exception of tumor diagnosis differed statistically by relapse pattern, with patients with isolated local failure having more favorable prognostic features. Patients with stage 3 disease were more likely to have isolated local failure compared to all other stages (49% vs. 16%; p < .001). OS significantly differed by relapse pattern (5-year OS ± SE): isolated local: 64% ± 3%; distant only: 23% ± 2%; and combined: 26% ± 4% (p < .001). After controlling for age, stage, and MYCN status, patients with isolated local failure (adjusted hazard ratio [HR] = 0.46; 95% confidence interval [CI]: 0.33-0.62; p < .001) and distant-only failure (adjusted HR = 0.57; 95% CI: 0.45-0.71; p < .001) remained at decreased risk for death as compared to patients with combined failure. CONCLUSION Patients with distant-only and combined failures have a higher proportion of unfavorable clinical and biological features, and a lower survival than those with isolated local relapse.
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Affiliation(s)
- Kieuhoa T. Vo
- UCSF Benioff Children’s Hospital and Departments of Pediatrics, University of California, San Francisco School of Medicine, San Francisco, CA, USA
| | - Steven G. DuBois
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center and Harvard Medical School, Boston, MA, USA
| | - John Neuhaus
- Epidemiology and Biostatistics, University of California, San Francisco School of Medicine, San Francisco, CA, USA
| | - Steve E. Braunstein
- Radiation Oncology, University of California, San Francisco School of Medicine, San Francisco, CA, USA
| | - Brent R. Weil
- Department of Surgery, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Arlene Naranjo
- Department of Biostatistics, University of Florida, Children’s Oncology Group Statistics and Data Center, Gainesville, FL, USA
| | - Sabine Irtan
- Department of Pediatric Surgery, Hôpital d’enfants Armand-Trousseau, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Paris, France
| | - Julia Balaguer
- Pediatric Oncology Unit, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Katherine K. Matthay
- UCSF Benioff Children’s Hospital and Departments of Pediatrics, University of California, San Francisco School of Medicine, San Francisco, CA, USA
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15
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Bryce YC, Armstrong GT, Leisenring WM, Whitton J, Chow EJ, Weil BR, Dieffenbach B, Howell RM, Oeffinger KC, Nathan PC, Tonorezos ES. Use and correlates of carotid ultrasound in survivors of childhood cancer: A report from the Childhood Cancer Survivor Study. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.e22023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e22023 Background: Survivors of childhood cancer with history of radiation therapy (RT) to the head/neck/chest are at increased risk for stroke. Children’s Oncology Group Guidelines recommend carotid ultrasound (CU) when clinically indicated or 10 years after RT ≥ 40Gy to the neck. Yet, the use of CU has not been previously described. Methods: 8,693 survivors of childhood cancer (median age at diagnosis 8.0 years, range 0-20; median age at evaluation 37.4, range 18-65) diagnosed between 1970-1999 were asked if they had ever had a CU. Cardiovascular disease (CVD) was defined as any of the following: stroke, congestive heart failure, hypertension, myocardial infarction, coronary heart disease, or arrythmia. Prevalence ratios (PR) were calculated; age and sex-adjusted multivariable Poisson regression models evaluated factors associated with CU. Results: 4.9% (427) of survivors had a history of stroke and 28% (2,442) had a history of any CVD. Of these, 40.0% (171) with a history of stroke and 28.6% (748) with any CVD had CU. Comparatively, 14.6% (1,404) without a stroke and 11.1% (798) without any CVD had a CU (both p<0.0001 vs those with condition). Among survivors without CVD, having seen only a primary care physician was not associated with CU (PR 0.84 95% CI 0.58-1.25, p = 0.36), while seeing a cancer specialist (+/- a primary care physician) (PR 1.83 95% CI 1.23-2.79, p = 0.036) was associated with increased likelihood of CU compared to seeing neither. Survivors who had had other surveillance studies, including a colonoscopy (PR 1.76 95% CI 1.44-2.17, p<0.0001), skin cancer exam (PR 1.62 95% CI 1.30-2.03, p=0.0002), or mammogram (PR 2.06 95%CI 1.42-3.07, p<0.0001) were more likely to have a carotid ultrasound, compared to those without that test. Having a history of anthracyclines or RT to the neck were associated with higher prevalence of CU, with RT to the neck exhibiting a dose-response relationship (Table). Conclusions: CU was more common among survivors with a history of stroke or other CVD event. In those without CVD, CU use was associated with anthracyclines and RT dose exposures and with care provided by a cancer specialist. A high proportion (70%) of survivors who received >40Gy RT to the neck have never had a CU, suggesting that greater awareness of guidelines is needed.[Table: see text]
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Paul C. Nathan
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
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16
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Khaja A, Frazier L, Weil BR, Weldon CB, Laufer MR, Shim J. Interdisciplinary Management of Malignant Ovarian Tumors in the Pediatric and Adolescent Age Group. J Pediatr Adolesc Gynecol 2022; 35:260-264. [PMID: 34718078 DOI: 10.1016/j.jpag.2021.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 10/10/2021] [Accepted: 10/18/2021] [Indexed: 10/20/2022]
Abstract
Malignant ovarian neoplasms are uncommon in the pediatric and adolescent population. Imaging and tumor markers help to guide the preoperative risk/benefit analysis for planned surgical management, which is the mainstay of therapy. An interdisciplinary approach should be taken in the management of this vulnerable population from diagnosis through post-treatment surveillance. In this review, the initial evaluation, risk stratification, and management of various types of malignant ovarian masses will be addressed, with a special focus on how to optimize an interdisciplinary approach to ovarian masses.
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Affiliation(s)
- Anam Khaja
- Division of Gynecology, Boston Children's Hospital, Boston, Massachusetts.
| | - Lindsay Frazier
- Dana Farber/Boston Children's Cancer and Blood Disorders Center, Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Brent R Weil
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Christopher B Weldon
- Department of Anesthesiology, Critical Care, and Pain Medicine, Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marc R Laufer
- Division of Gynecology, Boston Children's Hospital, Boston, Massachusetts; Department of Surgery, Boston Children's Hospital, Center for Infertility and Reproductive Surgery, Brigham and Women's Hospital, Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School. Boston, Massachusetts
| | - Jessica Shim
- Division of Gynecology, Boston Children's Hospital, Boston, Massachusetts; Division of Gynecology, Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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17
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Kamihara J, Hamilton KV, Pollard JA, Clinton CM, Madden JA, Lin J, Imamovic A, Wall CB, Wassner AJ, Weil BR, Heeney MM, Vargas SO, Kaelin WG, Janeway KA, Perini RF, Zojwalla NJ, Voss SD, DuBois SG. Belzutifan, a Potent HIF2α Inhibitor, in the Pacak-Zhuang Syndrome. N Engl J Med 2021; 385:2059-2065. [PMID: 34818480 DOI: 10.1056/nejmoa2110051] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The integration of genomic testing into clinical care enables the use of individualized approaches to the management of rare diseases. We describe the use of belzutifan, a potent and selective small-molecule inhibitor of the protein hypoxia-inducible factor 2α (HIF2α), in a patient with polycythemia and multiple paragangliomas (the Pacak-Zhuang syndrome). The syndrome was caused in this patient by somatic mosaicism for an activating mutation in EPAS1. Treatment with belzutifan led to a rapid and sustained tumor response along with resolution of hypertension, headaches, and long-standing polycythemia. This case shows the application of a targeted therapy for the treatment of a patient with a rare tumor-predisposition syndrome. (Funded by the Morin Family Fund for Pediatric Cancer and Alex's Lemonade Stand Foundation.).
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Affiliation(s)
- Junne Kamihara
- From the Departments of Pediatric Oncology (J.K., K.V.H., J.A.P., C.M.C., A.I., C.B.W., K.A.J., S.G.D.) and Medical Oncology (W.G.K.), Dana-Farber Cancer Institute, Harvard Medical School, the Divisions of Hematology and Oncology (J.K., J.A.P., M.M.H., K.A.J., S.G.D.) and Endocrinology (A.J.W.) and the Departments of Surgery (B.R.W.), Pathology (S.O.V.), and Radiology (S.D.V.), Boston Children's Hospital, Harvard Medical School, and the Manton Center for Orphan Disease Research and the Division of Genetics and Genomics, Boston Children's Hospital (J.A.M., J.L.) - all in Boston; Howard Hughes Medical Institute, Chevy Chase, MD (W.G.K.); and Merck, Kenilworth, NJ (R.F.P., N.J.Z.)
| | - Kayla V Hamilton
- From the Departments of Pediatric Oncology (J.K., K.V.H., J.A.P., C.M.C., A.I., C.B.W., K.A.J., S.G.D.) and Medical Oncology (W.G.K.), Dana-Farber Cancer Institute, Harvard Medical School, the Divisions of Hematology and Oncology (J.K., J.A.P., M.M.H., K.A.J., S.G.D.) and Endocrinology (A.J.W.) and the Departments of Surgery (B.R.W.), Pathology (S.O.V.), and Radiology (S.D.V.), Boston Children's Hospital, Harvard Medical School, and the Manton Center for Orphan Disease Research and the Division of Genetics and Genomics, Boston Children's Hospital (J.A.M., J.L.) - all in Boston; Howard Hughes Medical Institute, Chevy Chase, MD (W.G.K.); and Merck, Kenilworth, NJ (R.F.P., N.J.Z.)
| | - Jessica A Pollard
- From the Departments of Pediatric Oncology (J.K., K.V.H., J.A.P., C.M.C., A.I., C.B.W., K.A.J., S.G.D.) and Medical Oncology (W.G.K.), Dana-Farber Cancer Institute, Harvard Medical School, the Divisions of Hematology and Oncology (J.K., J.A.P., M.M.H., K.A.J., S.G.D.) and Endocrinology (A.J.W.) and the Departments of Surgery (B.R.W.), Pathology (S.O.V.), and Radiology (S.D.V.), Boston Children's Hospital, Harvard Medical School, and the Manton Center for Orphan Disease Research and the Division of Genetics and Genomics, Boston Children's Hospital (J.A.M., J.L.) - all in Boston; Howard Hughes Medical Institute, Chevy Chase, MD (W.G.K.); and Merck, Kenilworth, NJ (R.F.P., N.J.Z.)
| | - Catherine M Clinton
- From the Departments of Pediatric Oncology (J.K., K.V.H., J.A.P., C.M.C., A.I., C.B.W., K.A.J., S.G.D.) and Medical Oncology (W.G.K.), Dana-Farber Cancer Institute, Harvard Medical School, the Divisions of Hematology and Oncology (J.K., J.A.P., M.M.H., K.A.J., S.G.D.) and Endocrinology (A.J.W.) and the Departments of Surgery (B.R.W.), Pathology (S.O.V.), and Radiology (S.D.V.), Boston Children's Hospital, Harvard Medical School, and the Manton Center for Orphan Disease Research and the Division of Genetics and Genomics, Boston Children's Hospital (J.A.M., J.L.) - all in Boston; Howard Hughes Medical Institute, Chevy Chase, MD (W.G.K.); and Merck, Kenilworth, NJ (R.F.P., N.J.Z.)
| | - Jill A Madden
- From the Departments of Pediatric Oncology (J.K., K.V.H., J.A.P., C.M.C., A.I., C.B.W., K.A.J., S.G.D.) and Medical Oncology (W.G.K.), Dana-Farber Cancer Institute, Harvard Medical School, the Divisions of Hematology and Oncology (J.K., J.A.P., M.M.H., K.A.J., S.G.D.) and Endocrinology (A.J.W.) and the Departments of Surgery (B.R.W.), Pathology (S.O.V.), and Radiology (S.D.V.), Boston Children's Hospital, Harvard Medical School, and the Manton Center for Orphan Disease Research and the Division of Genetics and Genomics, Boston Children's Hospital (J.A.M., J.L.) - all in Boston; Howard Hughes Medical Institute, Chevy Chase, MD (W.G.K.); and Merck, Kenilworth, NJ (R.F.P., N.J.Z.)
| | - Jasmine Lin
- From the Departments of Pediatric Oncology (J.K., K.V.H., J.A.P., C.M.C., A.I., C.B.W., K.A.J., S.G.D.) and Medical Oncology (W.G.K.), Dana-Farber Cancer Institute, Harvard Medical School, the Divisions of Hematology and Oncology (J.K., J.A.P., M.M.H., K.A.J., S.G.D.) and Endocrinology (A.J.W.) and the Departments of Surgery (B.R.W.), Pathology (S.O.V.), and Radiology (S.D.V.), Boston Children's Hospital, Harvard Medical School, and the Manton Center for Orphan Disease Research and the Division of Genetics and Genomics, Boston Children's Hospital (J.A.M., J.L.) - all in Boston; Howard Hughes Medical Institute, Chevy Chase, MD (W.G.K.); and Merck, Kenilworth, NJ (R.F.P., N.J.Z.)
| | - Alma Imamovic
- From the Departments of Pediatric Oncology (J.K., K.V.H., J.A.P., C.M.C., A.I., C.B.W., K.A.J., S.G.D.) and Medical Oncology (W.G.K.), Dana-Farber Cancer Institute, Harvard Medical School, the Divisions of Hematology and Oncology (J.K., J.A.P., M.M.H., K.A.J., S.G.D.) and Endocrinology (A.J.W.) and the Departments of Surgery (B.R.W.), Pathology (S.O.V.), and Radiology (S.D.V.), Boston Children's Hospital, Harvard Medical School, and the Manton Center for Orphan Disease Research and the Division of Genetics and Genomics, Boston Children's Hospital (J.A.M., J.L.) - all in Boston; Howard Hughes Medical Institute, Chevy Chase, MD (W.G.K.); and Merck, Kenilworth, NJ (R.F.P., N.J.Z.)
| | - Catherine B Wall
- From the Departments of Pediatric Oncology (J.K., K.V.H., J.A.P., C.M.C., A.I., C.B.W., K.A.J., S.G.D.) and Medical Oncology (W.G.K.), Dana-Farber Cancer Institute, Harvard Medical School, the Divisions of Hematology and Oncology (J.K., J.A.P., M.M.H., K.A.J., S.G.D.) and Endocrinology (A.J.W.) and the Departments of Surgery (B.R.W.), Pathology (S.O.V.), and Radiology (S.D.V.), Boston Children's Hospital, Harvard Medical School, and the Manton Center for Orphan Disease Research and the Division of Genetics and Genomics, Boston Children's Hospital (J.A.M., J.L.) - all in Boston; Howard Hughes Medical Institute, Chevy Chase, MD (W.G.K.); and Merck, Kenilworth, NJ (R.F.P., N.J.Z.)
| | - Ari J Wassner
- From the Departments of Pediatric Oncology (J.K., K.V.H., J.A.P., C.M.C., A.I., C.B.W., K.A.J., S.G.D.) and Medical Oncology (W.G.K.), Dana-Farber Cancer Institute, Harvard Medical School, the Divisions of Hematology and Oncology (J.K., J.A.P., M.M.H., K.A.J., S.G.D.) and Endocrinology (A.J.W.) and the Departments of Surgery (B.R.W.), Pathology (S.O.V.), and Radiology (S.D.V.), Boston Children's Hospital, Harvard Medical School, and the Manton Center for Orphan Disease Research and the Division of Genetics and Genomics, Boston Children's Hospital (J.A.M., J.L.) - all in Boston; Howard Hughes Medical Institute, Chevy Chase, MD (W.G.K.); and Merck, Kenilworth, NJ (R.F.P., N.J.Z.)
| | - Brent R Weil
- From the Departments of Pediatric Oncology (J.K., K.V.H., J.A.P., C.M.C., A.I., C.B.W., K.A.J., S.G.D.) and Medical Oncology (W.G.K.), Dana-Farber Cancer Institute, Harvard Medical School, the Divisions of Hematology and Oncology (J.K., J.A.P., M.M.H., K.A.J., S.G.D.) and Endocrinology (A.J.W.) and the Departments of Surgery (B.R.W.), Pathology (S.O.V.), and Radiology (S.D.V.), Boston Children's Hospital, Harvard Medical School, and the Manton Center for Orphan Disease Research and the Division of Genetics and Genomics, Boston Children's Hospital (J.A.M., J.L.) - all in Boston; Howard Hughes Medical Institute, Chevy Chase, MD (W.G.K.); and Merck, Kenilworth, NJ (R.F.P., N.J.Z.)
| | - Matthew M Heeney
- From the Departments of Pediatric Oncology (J.K., K.V.H., J.A.P., C.M.C., A.I., C.B.W., K.A.J., S.G.D.) and Medical Oncology (W.G.K.), Dana-Farber Cancer Institute, Harvard Medical School, the Divisions of Hematology and Oncology (J.K., J.A.P., M.M.H., K.A.J., S.G.D.) and Endocrinology (A.J.W.) and the Departments of Surgery (B.R.W.), Pathology (S.O.V.), and Radiology (S.D.V.), Boston Children's Hospital, Harvard Medical School, and the Manton Center for Orphan Disease Research and the Division of Genetics and Genomics, Boston Children's Hospital (J.A.M., J.L.) - all in Boston; Howard Hughes Medical Institute, Chevy Chase, MD (W.G.K.); and Merck, Kenilworth, NJ (R.F.P., N.J.Z.)
| | - Sara O Vargas
- From the Departments of Pediatric Oncology (J.K., K.V.H., J.A.P., C.M.C., A.I., C.B.W., K.A.J., S.G.D.) and Medical Oncology (W.G.K.), Dana-Farber Cancer Institute, Harvard Medical School, the Divisions of Hematology and Oncology (J.K., J.A.P., M.M.H., K.A.J., S.G.D.) and Endocrinology (A.J.W.) and the Departments of Surgery (B.R.W.), Pathology (S.O.V.), and Radiology (S.D.V.), Boston Children's Hospital, Harvard Medical School, and the Manton Center for Orphan Disease Research and the Division of Genetics and Genomics, Boston Children's Hospital (J.A.M., J.L.) - all in Boston; Howard Hughes Medical Institute, Chevy Chase, MD (W.G.K.); and Merck, Kenilworth, NJ (R.F.P., N.J.Z.)
| | - William G Kaelin
- From the Departments of Pediatric Oncology (J.K., K.V.H., J.A.P., C.M.C., A.I., C.B.W., K.A.J., S.G.D.) and Medical Oncology (W.G.K.), Dana-Farber Cancer Institute, Harvard Medical School, the Divisions of Hematology and Oncology (J.K., J.A.P., M.M.H., K.A.J., S.G.D.) and Endocrinology (A.J.W.) and the Departments of Surgery (B.R.W.), Pathology (S.O.V.), and Radiology (S.D.V.), Boston Children's Hospital, Harvard Medical School, and the Manton Center for Orphan Disease Research and the Division of Genetics and Genomics, Boston Children's Hospital (J.A.M., J.L.) - all in Boston; Howard Hughes Medical Institute, Chevy Chase, MD (W.G.K.); and Merck, Kenilworth, NJ (R.F.P., N.J.Z.)
| | - Katherine A Janeway
- From the Departments of Pediatric Oncology (J.K., K.V.H., J.A.P., C.M.C., A.I., C.B.W., K.A.J., S.G.D.) and Medical Oncology (W.G.K.), Dana-Farber Cancer Institute, Harvard Medical School, the Divisions of Hematology and Oncology (J.K., J.A.P., M.M.H., K.A.J., S.G.D.) and Endocrinology (A.J.W.) and the Departments of Surgery (B.R.W.), Pathology (S.O.V.), and Radiology (S.D.V.), Boston Children's Hospital, Harvard Medical School, and the Manton Center for Orphan Disease Research and the Division of Genetics and Genomics, Boston Children's Hospital (J.A.M., J.L.) - all in Boston; Howard Hughes Medical Institute, Chevy Chase, MD (W.G.K.); and Merck, Kenilworth, NJ (R.F.P., N.J.Z.)
| | - Rodolfo F Perini
- From the Departments of Pediatric Oncology (J.K., K.V.H., J.A.P., C.M.C., A.I., C.B.W., K.A.J., S.G.D.) and Medical Oncology (W.G.K.), Dana-Farber Cancer Institute, Harvard Medical School, the Divisions of Hematology and Oncology (J.K., J.A.P., M.M.H., K.A.J., S.G.D.) and Endocrinology (A.J.W.) and the Departments of Surgery (B.R.W.), Pathology (S.O.V.), and Radiology (S.D.V.), Boston Children's Hospital, Harvard Medical School, and the Manton Center for Orphan Disease Research and the Division of Genetics and Genomics, Boston Children's Hospital (J.A.M., J.L.) - all in Boston; Howard Hughes Medical Institute, Chevy Chase, MD (W.G.K.); and Merck, Kenilworth, NJ (R.F.P., N.J.Z.)
| | - Naseem J Zojwalla
- From the Departments of Pediatric Oncology (J.K., K.V.H., J.A.P., C.M.C., A.I., C.B.W., K.A.J., S.G.D.) and Medical Oncology (W.G.K.), Dana-Farber Cancer Institute, Harvard Medical School, the Divisions of Hematology and Oncology (J.K., J.A.P., M.M.H., K.A.J., S.G.D.) and Endocrinology (A.J.W.) and the Departments of Surgery (B.R.W.), Pathology (S.O.V.), and Radiology (S.D.V.), Boston Children's Hospital, Harvard Medical School, and the Manton Center for Orphan Disease Research and the Division of Genetics and Genomics, Boston Children's Hospital (J.A.M., J.L.) - all in Boston; Howard Hughes Medical Institute, Chevy Chase, MD (W.G.K.); and Merck, Kenilworth, NJ (R.F.P., N.J.Z.)
| | - Stephan D Voss
- From the Departments of Pediatric Oncology (J.K., K.V.H., J.A.P., C.M.C., A.I., C.B.W., K.A.J., S.G.D.) and Medical Oncology (W.G.K.), Dana-Farber Cancer Institute, Harvard Medical School, the Divisions of Hematology and Oncology (J.K., J.A.P., M.M.H., K.A.J., S.G.D.) and Endocrinology (A.J.W.) and the Departments of Surgery (B.R.W.), Pathology (S.O.V.), and Radiology (S.D.V.), Boston Children's Hospital, Harvard Medical School, and the Manton Center for Orphan Disease Research and the Division of Genetics and Genomics, Boston Children's Hospital (J.A.M., J.L.) - all in Boston; Howard Hughes Medical Institute, Chevy Chase, MD (W.G.K.); and Merck, Kenilworth, NJ (R.F.P., N.J.Z.)
| | - Steven G DuBois
- From the Departments of Pediatric Oncology (J.K., K.V.H., J.A.P., C.M.C., A.I., C.B.W., K.A.J., S.G.D.) and Medical Oncology (W.G.K.), Dana-Farber Cancer Institute, Harvard Medical School, the Divisions of Hematology and Oncology (J.K., J.A.P., M.M.H., K.A.J., S.G.D.) and Endocrinology (A.J.W.) and the Departments of Surgery (B.R.W.), Pathology (S.O.V.), and Radiology (S.D.V.), Boston Children's Hospital, Harvard Medical School, and the Manton Center for Orphan Disease Research and the Division of Genetics and Genomics, Boston Children's Hospital (J.A.M., J.L.) - all in Boston; Howard Hughes Medical Institute, Chevy Chase, MD (W.G.K.); and Merck, Kenilworth, NJ (R.F.P., N.J.Z.)
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18
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Tracy M, Weil BR, Verhave M. Where Did the Blood Go?: A Meckel's Diverticulum Bleed Without Hematochezia or Melena. JPGN Rep 2021; 2:e119. [PMID: 37206468 PMCID: PMC10191587 DOI: 10.1097/pg9.0000000000000119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 07/16/2021] [Indexed: 05/21/2023]
Abstract
A 2-year-old patient with chronic abdominal pain presented with acutely worsening abdominal pain and acute anemia. The patient had no stigmata of bleeding including no hematemesis, melena or hematochezia, but had falling hemoglobin and hematocrit over the course of 24 hours. Abdominal ultrasound and computerized tomography showed a large cystic, fluid filled mass in the right midabdomen. The patient was taken to the operating room and a blood-filled mass arising from the ileum was identified and resected by the surgical team. Pathology was consistent with Meckel's diverticulum with heterotopic gastric mucosa. This is an atypical presentation of Meckel's diverticulum with bleeding contained within the diverticulum rather than bleeding in the intestinal lumen. Gastroenterologists must consider this unusual presentation when encountering progressive, acute anemia even in the absence of overt gastrointestinal blood loss.
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Affiliation(s)
- Michaela Tracy
- From the Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA
| | - Brent R. Weil
- Division of Pediatric Surgery, Department of Surgery, Boston Children’s Hospital, Boston, MA
| | - Menno Verhave
- From the Division of Gastroenterology, Hepatology and Nutrition, Boston Children’s Hospital, Boston, MA
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19
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Dieffenbach BV, Liu Q, Murphy AJ, Stein DR, Wu N, Madenci AL, Leisenring WM, Kadan-Lottick NS, Christison-Lagay ER, Goldsby RE, Howell RM, Smith SA, Oeffinger KC, Yasui Y, Armstrong GT, Weldon CB, Chow EJ, Weil BR. Late-onset kidney failure in survivors of childhood cancer: a report from the Childhood Cancer Survivor Study. Eur J Cancer 2021; 155:216-226. [PMID: 34391054 PMCID: PMC8429192 DOI: 10.1016/j.ejca.2021.06.050] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 06/16/2021] [Accepted: 06/30/2021] [Indexed: 01/26/2023]
Abstract
BACKGROUND The incidence of and risk factors for late-onset kidney failure among survivors over the very long term remains understudied. MATERIALS AND METHODS A total of 25,530 childhood cancer survivors (median follow-up 22.3 years, interquartile range 17.4-28.8) diagnosed between 1970 and 1999, and 5045 siblings from the Childhood Cancer Survivor Study were assessed for self-reported late-onset kidney failure, defined as dialysis, renal transplantation, or death attributable to kidney disease. Piecewise exponential models evaluated associations between risk factors and the rate of late-onset kidney failure. RESULTS A total of 206 survivors and 10 siblings developed late-onset kidney failure, a 35-year cumulative incidence of 1.7% (95% confidence interval [CI] = 1.4-1.9) and 0.2% (95% confidence interval [CI] = 0.1-0.4), respectively, corresponding to an adjusted rate ratio (RR) of 4.9 (95% CI = 2.6-9.2). High kidney dose from radiotherapy (≥15Gy; RR = 4.0, 95% CI = 2.1-7.4), exposure to high-dose anthracycline (≥250 mg/m2; RR = 1.6, 95% CI = 1.0-2.6) or any ifosfamide chemotherapy (RR = 2.6, 95% CI = 1.2-5.7), and nephrectomy (RR = 1.9, 95% CI = 1.0-3.4) were independently associated with elevated risk for late-onset kidney failure among survivors. Survivors who developed hypertension, particularly in the context of prior nephrectomy (RR = 14.4, 95% CI = 7.1-29.4 hypertension with prior nephrectomy; RR = 5.9, 95% CI = 3.3-10.5 hypertension without prior nephrectomy), or diabetes (RR = 2.2, 95%CI = 1.2-4.2) were also at elevated risk for late-onset kidney failure. CONCLUSIONS Survivors of childhood cancer are at increased risk for late-onset kidney failure. Kidney dose from radiotherapy ≥15 Gy, high-dose anthracycline, any ifosfamide, and nephrectomy were associated with increased risk of late-onset kidney failure among survivors. Successful diagnosis and management of modifiable risk factors such as diabetes and hypertension may mitigate the risk for late-onset kidney failure. The association of late-onset kidney failure with anthracycline chemotherapy represents a novel finding that warrants further study.
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Affiliation(s)
- Bryan V Dieffenbach
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA; Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA.
| | - Qi Liu
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Andrew J Murphy
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Deborah R Stein
- Division of Nephrology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Natalie Wu
- Clinical Research and Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Arin L Madenci
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA; Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - Wendy M Leisenring
- Clinical Research and Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Nina S Kadan-Lottick
- Section of Pediatric Hematology-Oncology, Yale University and Yale Cancer Center, New Haven, CT, USA
| | - Emily R Christison-Lagay
- Division of Pediatric Surgery, Department of General Surgery, Yale School of Medicine, New Haven, USA
| | - Robert E Goldsby
- Division of Oncology, Department of Pediatrics, UCSF Benioff Children's Hospital, San Francisco, CA, USA
| | - Rebecca M Howell
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Susan A Smith
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kevin C Oeffinger
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Yutaka Yasui
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Gregory T Armstrong
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Christopher B Weldon
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA; Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - Eric J Chow
- Clinical Research and Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Brent R Weil
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA; Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
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20
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Wu NL, Chen Y, Dieffenbach BV, Li N, Ehrhardt MJ, Green DM, Hingorani S, Howell RM, Jefferies JL, Mulrooney DA, Oeffinger KC, Robison LL, Weil BR, Yuan Y, Yasui Y, Hudson MM, Leisenring WM, Armstrong GT, Chow EJ. Development and validation of a prediction model for kidney failure in long-term survivors of childhood cancer: A report from the Childhood Cancer Survivor Study (CCSS). J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.10047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
10047 Background: Kidney failure (need for dialysis or kidney transplantation, or death due to kidney disease) is a rare but serious late effect for survivors of childhood cancer. We aimed to develop a model using demographic and treatment characteristics to predict individual risk of kidney failure among five-year survivors of childhood cancer. Methods: CCSS survivors without kidney failure at five years after cancer diagnosis (n = 25,483) were assessed for subsequent kidney failure by age 40. Outcomes were self-reported and corroborated by the Organ Procurement and Transplantation Network and the National Death Index. A sibling cohort (n = 5045) served as a comparator. Piecewise exponential models with backward selection estimated the relationships between potential predictors and kidney failure and were converted to integer risk scores. Additional results from the St. Jude Lifetime Cohort Study (SJLIFE, n = 2490) and the National Wilms Tumor Study (NWTS, n = 6760) validated the models. Results: Among CCSS survivors, 204 developed late kidney failure. We developed a model with sex, race/ethnicity, age at cancer diagnosis, nephrectomy, exposure to specific chemotherapy, any abdominal radiation, presence of genitourinary anomalies, and early-onset hypertension (Table). Risk scores achieved an area under the curve (AUC) and concordance (C) statistic of 0.65 and 0.68 for kidney failure by age 40. Validation cohort AUC and C statistics were 0.83/0.86 for SJLIFE (8 cases) and 0.61/0.63 for NWTS (91 cases). An alternative model with specific chemotherapy doses and kidney-specific radiation dosimetry had similar AUC and C statistic (0.67/0.70). Integer risk scores were collapsed to form statistically distinct low (score <3; 87 cases of 17,326), moderate (score 3-5; 63 cases of 4667), and high (score 6+; 18 cases of 401) risk groups. These groups corresponded to cumulative incidences in CCSS of kidney failure by age 40 of 0.6% (95% CI 0.4-0.7%), 2.3% (95% CI 1.6-3.2%), and 9.4% (95% CI 4.4-16.7%), compared with 0.2% (95% CI 0.1-0.5%) among siblings. Conclusions: Using readily available information, we were able to identify low, moderate, and high risk groups for developing kidney failure following treatment for childhood cancer. These prediction models may help guide screening and interventional strategies for higher risk survivors.[Table: see text]
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Affiliation(s)
| | - Yan Chen
- University of Alberta, Edmonton, AB, Canada
| | | | - Nan Li
- St. Jude Children's Research Hospital, Memphis, TN
| | | | | | | | - Rebecca M. Howell
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | | | | | - Yan Yuan
- University of Alberta, Edmonton, AB, Canada
| | - Yutaka Yasui
- St. Jude Children's Research Hospital, Memphis, TN
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21
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Brodigan K, Kapadia M, Frazier AL, Laufer MR, Yu R, Weil BR, Ginsburg ES, Duncan C, Lehmann L. Safety of Surgical Fertility Preservation Procedures in Children Prior to Hematopoietic Stem Cell Transplant. Transplant Cell Ther 2021; 27:696.e1-696.e4. [PMID: 33864966 DOI: 10.1016/j.jtct.2021.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 03/21/2021] [Accepted: 04/07/2021] [Indexed: 10/21/2022]
Abstract
Long-term survival following hematopoietic stem cell transplant (HSCT) in childhood continues to improve, and patients are thus increasingly faced with the late effects of treatment. Infertility is very common for both males and females following HSCT and is one of the most distressing sequelae. Adoption and surrogate egg or sperm donation are possibilities for some patients, but post-HSCT reversal of gonadal failure is not possible. We have recently initiated an oncofertility program with a dedicated practitioner with specific expertise in this area. Our practice is for her to meet with all families and age-appropriate patients during the pre-HSCT evaluation period. This allows patients and families to be accurately informed about the expected treatment-related infertility risk and the available options for fertility preservation. Sperm banking and egg or embryo cryopreservation are established approaches but are not achievable for many children and adolescents. Recently, the harvesting and cryopreservation of ovarian and testicular tissue represents a novel surgical option that allows for the possibility of fertility preservation to be extended to children of all ages. The purpose of this investigation is to evaluate the safety of these procedures proximal to conditioning therapy and HSCT. This is a retrospective report on a consecutive cohort of all patients aged 0 to 25 years who, after discussion with our oncofertility specialist, chose to undergo surgical fertility preservation (laparoscopic unilateral oophorectomy or testicular biopsy) at our institution between March 2018 and April 2020. These procedures occurred under general anesthesia at the time of central line placement prior to the initiation of HSCT conditioning. We assess the safety of the procedures in terms of postoperative complications and impact on HSCT course. Twenty-two patients underwent fertility preservation surgical procedures. Thirteen patients (59%) were female, median age 13 years (1 to 22 years), and 9 (41%) were male, median age 8 years (5 to 12 years). Fourteen (63%) were prepubertal and 8 (36%) pubertal. HSCT indications were hematologic malignancies/solid tumor (40%) and nonmalignant diseases (60%). Most received an allogenic graft (68%) and 81% had myeloablative conditioning. All patients became neutropenic at a median of 10 days (0 to 51 days) from the surgical procedure; 1 was neutropenic at the time of testicular tissue cryopreservation (TTC). The mean duration for the procedures performed, including ovarian tissue cryopreservation (OTC) or TTC, was 98 minutes (49 to 260 minutes) and 97 minutes (56 to 178 minutes), respectively. Estimated blood loss was minimal and no postoperative site infections occurred. One postprocedure, blood culture-negative fever was reported without an identifiable source; the patient completed 48 hours of antibiotics with resolution of fever. Sixty-two percent of females and 56% of males started conditioning within 24 hours of OTC/TTC (15 hours to 113 days; median, 1 day). The median time to engraftment was 22 days (9 to 33 days) in females and 17 days (11 to 67 days) in males, consistent with our institutional benchmarks. One patient with aplastic anemia had primary graft failure, attributed to low cell dose. This patient engrafted after a second transplant from an alternative donor but ultimately died of multiorgan failure. He was neutropenic for over 60 days and never experienced surgical site infection. There were no procedure-related delays to start of conditioning or to discharge. Children of all ages can now be offered the possibility of fertility preservation following HSCT for benign and malignant conditions. Our review suggests that these procedure for both females and males can be performed close to the start of conditioning, which allows for coupling with central access placement. These procedures appear to be safe and do not add to transplant-related morbidity.
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Affiliation(s)
- Katelynn Brodigan
- Division of Pediatric Oncology, Dana Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts.
| | - Malika Kapadia
- Division of Pediatric Oncology, Dana Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts; Department of Pediatrics, Harvard University Medical School, Boston, Massachusetts
| | - A Lindsay Frazier
- Division of Pediatric Oncology, Dana Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
| | - Marc R Laufer
- Division of Gynecology, Boston Children's Hospital, Harvard University Medical School, Boston, Massachusetts; Center for Infertility and Reproductive Surgery, Brigham & Women's Hospital, Harvard University Medical School, Boston, Massachusetts
| | - Richard Yu
- Department of Urology, Boston Children's Hospital, Harvard University Medical School, Boston, Massachusetts
| | - Brent R Weil
- Department of Surgery, Boston Children's Hospital, Harvard University Medical School, Boston, Massachusetts
| | - Elizabeth S Ginsburg
- Center for Infertility and Reproductive Surgery, Brigham & Women's Hospital, Harvard University Medical School, Boston, Massachusetts
| | - Christine Duncan
- Division of Pediatric Oncology, Dana Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts; Department of Pediatrics, Harvard University Medical School, Boston, Massachusetts
| | - Leslie Lehmann
- Division of Pediatric Oncology, Dana Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts; Department of Pediatrics, Harvard University Medical School, Boston, Massachusetts
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22
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Shah R, Weil BR, Weldon CB, Amatruda JF, Frazier AL. Neonatal Malignant Disorders: Germ Cell Tumors. Clin Perinatol 2021; 48:147-165. [PMID: 33583501 DOI: 10.1016/j.clp.2020.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Germ cell tumors (GCTs) comprise a wide spectrum of benign and malignant tumors. Neonatal GCTs are predominantly teratomas (mature or immature), which are typically cured with surgery alone. Relapses are infrequent even in the setting of microscopic residual disease; therefore, negative surgical margins at the cost of significant morbidity are not recommended. In neonates with metastatic malignant disease or malignant disease for which upfront surgical resection is not feasible without significant morbidity, an initial biopsy followed by neoadjuvant chemotherapy and delayed surgical resection is recommended. Carboplatin-based regimens should be considered when chemotherapy is indicated.
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Affiliation(s)
- Rachana Shah
- Division of Oncology, Department of Pediatrics, Cancer and Blood Disease Institute, Children's Hospital Los Angeles, University of Southern California, Keck School of Medicine, 4650 Sunset Boulevard, MS#54, Los Angeles, CA 90027, USA.
| | - Brent R Weil
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Department of Pediatric Oncology, Children's Cancer and Blood Disorders Center, Children's Hospital Dana-Farber Cancer Center, Harvard Medical School, 450 Brookline Avenue, Boston, MA 02215, USA
| | - Christopher B Weldon
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Department of Pediatric Oncology, Children's Cancer and Blood Disorders Center, Children's Hospital Dana-Farber Cancer Center, Harvard Medical School, 450 Brookline Avenue, Boston, MA 02215, USA
| | - James F Amatruda
- Division of Oncology, Department of Pediatrics, Cancer and Blood Disease Institute, Children's Hospital Los Angeles, University of Southern California, Keck School of Medicine, 4650 Sunset Boulevard, MS#54, Los Angeles, CA 90027, USA
| | - A Lindsay Frazier
- Department of Pediatric Oncology, Children's Cancer and Blood Disorders Center, Children's Hospital Dana-Farber Cancer Center, Harvard Medical School, 450 Brookline Avenue, Boston, MA 02215, USA
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23
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Weil BR, Billmire DF. Management of Germ Cell Tumors in Pediatric Patients. Surg Oncol Clin N Am 2021; 30:325-338. [PMID: 33706903 DOI: 10.1016/j.soc.2020.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Germ cell tumors arise from primordial germ cells. Most develop in the gonads or along midline structures of the body. Genetic aberrations leading to disruption in the molecular signaling responsible for primordial germ cell migration early in development may provide rationale for why germ cell tumors originate in extragonadal locations. Establishing best practices for treating pediatric germ cell tumors remains an area of active investigation. Recent advances focused on limiting toxicities of therapy, identifying new therapies for relapsed and refractory tumors, defining best practices for surgical staging and resection, and developing novel methods to monitor for disease relapse.
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Affiliation(s)
- Brent R Weil
- Department of Pediatric Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - Deborah F Billmire
- Department of Pediatric Surgery, Riley Hospital for Children at Indiana University Health, 705 Riley Hospital Drive, Indianapolis, IN 46202, USA
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24
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Liu KX, Collins NB, Greenzang KA, Furutani E, Campbell K, Groves A, Mullen EA, Shusterman S, Spidle J, Marcus KJ, Weil BR, Weldon CB, Frazier AL, Janeway KA, O’Neill AF, Mack JW, DuBois SG, Shulman DS. The use of interval-compressed chemotherapy with the addition of vincristine, irinotecan, and temozolomide for pediatric patients with newly diagnosed desmoplastic small round cell tumor. Pediatr Blood Cancer 2020; 67:e28559. [PMID: 32686305 PMCID: PMC7721987 DOI: 10.1002/pbc.28559] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 06/03/2020] [Accepted: 06/19/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Desmoplastic small round cell tumor (DSRCT) is a rare aggressive sarcoma that affects children and young adults, and portends poor outcomes despite intensive multimodal treatment approaches. We report toxicity, response, and outcomes of patients with DSRCT treated with the addition of vincristine, irinotecan, and temozolomide (VIT) to interval-compressed chemotherapy as per Children's Oncology Group ARST08P1. METHODS All newly diagnosed pediatric patients with DSRCT treated at Dana-Farber Cancer Institute and Boston Children's Hospital between 2014 and 2019 as per ARST08P1, Arm P2 with replacement of VAC cycles with VIT, were identified. Medical records were reviewed for clinical and disease characteristics, and treatment response and outcomes. RESULTS Six patients were treated as per the above regimen. Median age at diagnosis was 15.1 years (range 3.2-16.4) and five patients were male. Five patients had abdominal primary tumors, of which one had exclusively intraabdominal and four had extraabdominal metastases. Two initial cycles of VIT were well tolerated with nausea, vomiting, diarrhea, and constipation as the most common adverse events. Overall response rate defined as partial or complete response after two initial cycles of VIT was 50%. For local control, all patients had surgical resection followed by radiotherapy, and two patients received hyperthermic intraperitoneal chemotherapy at the time of surgery. Of the four patients who have completed therapy to date, three remain disease-free with median follow-up time of 46.7 months. CONCLUSIONS The addition of VIT to interval-compressed chemotherapy is tolerable and active in DSRCT, with activity warranting additional investigation.
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Affiliation(s)
- Kevin X. Liu
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Natalie B. Collins
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - Katie A. Greenzang
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - Elissa Furutani
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - Kevin Campbell
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - Andrew Groves
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - Elizabeth A. Mullen
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - Suzanne Shusterman
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - Jennifer Spidle
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - Karen J. Marcus
- Department of Radiation Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Brent R. Weil
- Departments of Surgery, Anesthesiology& Pediatric Oncology, Boston Children's Hospital/Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Christopher B. Weldon
- Departments of Surgery, Anesthesiology& Pediatric Oncology, Boston Children's Hospital/Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - A. Lindsay Frazier
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - Katherine A. Janeway
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - Allison F. O’Neill
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - Jennifer W. Mack
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - Steven G. DuBois
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
| | - David S. Shulman
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, Massachusetts
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25
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van der Plas E, Qiu W, Nieman BJ, Yasui Y, Liu Q, Dixon SB, Kadan-Lottick NS, Weldon CB, Weil BR, Jacola LM, Gibson TM, Leisenring W, Oeffinger K, Hudson MM, Robison LL, Armstrong GT, Krull KR. Sex-Specific Associations Between Chemotherapy, Chronic Conditions, and Neurocognitive Impairment in Acute Lymphoblastic Leukemia Survivors: A Report From the Childhood Cancer Survivor Study. J Natl Cancer Inst 2020; 113:588-596. [PMID: 32882041 PMCID: PMC8096369 DOI: 10.1093/jnci/djaa136] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 08/18/2020] [Accepted: 08/25/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The purpose was to examine associations between treatment and chronic health conditions with neurocognitive impairment survivors of acute lymphoblastic leukemia (ALL) treated with chemotherapy only. METHODS This cross-sectional study included 1207 ALL survivors (54.0% female; mean age 30.6 years) and 2273 siblings (56.9% female; mean age 47.6 years), who completed the Childhood Cancer Survivor Study Neurocognitive Questionnaire. Multivariable logistic regression compared prevalence of neurocognitive impairment between survivors and siblings by sex. Associations between neurocognitive impairment with treatment exposures and chronic conditions (graded according to Common Terminology Criteria for Adverse Events) were also examined. Statistical tests were 2-sided. RESULTS Relative to same-sex siblings, male and female ALL survivors reported increased prevalence of impaired task efficiency (males: 11.7% vs 16.9%; adjusted odds ratio [OR] = 1.89, 95% confidence interval [CI] = 1.31 to 2.74; females: 12.5% vs 17.6%; OR = 1.50, 95% CI = 1.07 to 2.14), as well as impaired memory (males: 11.6% vs 19.9%, OR = 1.89, CI = 1.31 to 2.74; females: 14.78% vs 25.4%, OR = 1.96, 95% CI = 1.43 to 2.70, respectively). Among male survivors, impaired task efficiency was associated with 2-4 neurologic conditions (OR = 4.33, 95% CI = 1.76 to 10.68) and with pulmonary conditions (OR = 4.99, 95% CI = 1.51 to 16.50), and impaired memory was associated with increased cumulative dose of intrathecal methotrexate (OR = 1.68, 95% CI = 1.16 to 2.46) and with exposure to dexamethasone (OR = 2.44, 95% CI = 1.19 to 5.01). In female survivors, grade 2-4 endocrine conditions were associated with higher risk of impaired task efficiency (OR = 2.19, 95% CI = 1.20 to 3.97) and memory (OR = 2.26, 95% CI = 1.31 to 3.92). CONCLUSION Neurocognitive impairment is associated with methotrexate, dexamethasone, and chronic health conditions in a sex-specific manner, highlighting the need to investigate physiological mechanisms and monitor impact through survivorship.
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Affiliation(s)
- Ellen van der Plas
- University of Iowa Hospital & Clinics, Department of Psychiatry, Iowa City, IA, USA
| | - Weiyu Qiu
- University of Alberta, School of Public Health, Edmonton, Alberta, Canada
| | - Brian J Nieman
- The Hospital for Sick Children, Translational Medicine, Toronto, Ontario, Canada
| | - Yutaka Yasui
- St Jude Children's Research Hospital, Epidemiology and Cancer Control Department, Memphis, TN, USA
| | - Qi Liu
- University of Alberta, School of Public Health, Edmonton, Alberta, Canada
| | - Stephanie B Dixon
- St Jude Children's Research Hospital, Oncology Department, Memphis, TN, USA
| | - Nina S Kadan-Lottick
- Yale University School of Medicine, Pediatric Hematology & Oncology, New Haven, CT, USA
| | | | - Brent R Weil
- Boston Children's Hospital, Department of Surgery, Boston, MA, USA
| | - Lisa M Jacola
- St Jude Children's Research Hospital, Psychology Department, Memphis, TN, USA
| | - Todd M Gibson
- National Institutes of Health, Division of Cancer Epidemiology and Genetics, Bethesda, MD, USA
| | - Wendy Leisenring
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA
| | | | - Melissa M Hudson
- St Jude Children's Research Hospital, Oncology Department, Memphis, TN, USA
| | - Leslie L Robison
- St Jude Children's Research Hospital, Epidemiology and Cancer Control Department, Memphis, TN, USA
| | - Gregory T Armstrong
- St Jude Children's Research Hospital, Epidemiology and Cancer Control Department, Memphis, TN, USA
| | - Kevin R Krull
- St Jude Children's Research Hospital, Psychology Department, Memphis, TN, USA
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Weil BR, Green DM, Murphy AJ, Liu Q, Howell RM, Weldon CB, Mullen EA, Madenci AL, Leisenring WM, Neglia JP, Oeffinger KC, Termuhlen AM, Mostoufi-Moab S, Levine J, Krull KR, Yasui Y, Robison LL, Armstrong GT, Chow EJ, Armenian S. Treatment intensity and risk of chronic health conditions and late mortality among long-term survivors of Wilms tumor: A report from the Childhood Cancer Survivor Study. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.10553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
10553 Background: Refinement in risk stratification has led to intensification of therapy for Wilms tumor (WT) patients with adverse prognostic factors. Chronic health conditions (CHCs) including cardiac conditions, subsequent malignant neoplasms (SMNs), and late mortality are known risks for WT survivors, however the impact of specific treatment regimens on these outcomes is largely unknown. Methods: Late mortality (all-cause and non-recurrence death > 5 years from diagnosis), SMNs, and severity-graded CHCs (2 = moderate, 3 = severe, 4 = life-threatening, 5 = fatal) were assessed in 5-year WT survivors in the Childhood Cancer Survivor Study diagnosed from 1970-99. Survivors were categorized according to therapy received (Table). Cumulative incidence of mortality and standard mortality ratios (SMR) were estimated. Piecewise exponential models estimated rate ratios (RR) with 95% confidence intervals (CI). Results: Among 1507 survivors (median age at follow-up 26 yrs; range 6-55), 35-year cumulative incidence of all-cause mortality was 7.9% (SMR 2.9, CI 2.3-3.6) and 5.1% (SMR 1.9, CI 1.4-2.4) for non-recurrence mortality. RRs for developing any grade 2-5 CHC, grade 3-5 SMN, and grade 2-5 cardiac CHCs were higher for survivors compared to sibling controls (2.0, CI 1.8-2.3; 7.4, CI 5.0-10.8; 2.6, CI 2.2-3.1, respectively). Compared with VA and no RT, RR for non-recurrence late mortality and CHCs among survivors were higher for VAD + any RT, and for ≥ 4 drugs + any RT (Table). Conclusions: Administering increased-intensity therapy for WT is associated with increased late health consequences and non-recurrence late mortality, necessitating strategies to monitor and improve long-term health among survivors. [Table: see text]
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Affiliation(s)
| | | | | | - Qi Liu
- University of Alberta, Edmonton, AB, Canada
| | - Rebecca M. Howell
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | | | | | | | | | | | | | | | - Yutaka Yasui
- St. Jude Children's Research Hospital, Memphis, TN
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27
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Dieffenbach BV, Li N, Madenci AL, Murphy AJ, Barnea D, Gibson TM, Tonorezos ES, Leisenring WM, Howell RM, Diller LR, Liu Q, Chow EJ, Armstrong GT, Yasui Y, Oeffinger KC, Weldon CB, Weil BR. Incidence of and risk factors for late cholecystectomy in survivors of childhood cancer: A report from the Childhood Cancer Survivor Study. Eur J Cancer 2020; 133:4-13. [PMID: 32422507 DOI: 10.1016/j.ejca.2020.03.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 02/28/2020] [Accepted: 03/20/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Gallbladder disease and need for cholecystectomy are common and significant contributors to patient morbidity and healthcare costs. Childhood cancer survivors are at elevated risk for developing cholelithiasis. However, their incidence of and risk factors for late (>5 years from diagnosis) cholecystectomy have not been studied. METHODS A total of 25,549 survivors (median age at diagnosis 6.9 years, range 0-21.0; current age 30.7 years, range 5.6-65.9) diagnosed between 1970 and 1999 and 5037 siblings were queried for self-reported cholecystectomy occurring five or more years from primary cancer diagnosis. Piecewise exponential models evaluated associations between cancer treatment exposures and late cholecystectomy. RESULTS Over a median follow-up period of 21.9 and 26.0 years, respectively, 789 survivors and 168 siblings underwent late cholecystectomy (cumulative incidence 7.2%, 95% confidence interval [CI] = 6.5-7.8% and 6.6%, 95% CI = 5.4-7.6%, respectively; rate ratio [RR] = 1.3, 95% CI = 1.1-1.5). Compared with siblings, survivors of acute lymphoblastic leukaemia (RR = 1.4, 95% CI = 1.2-1.8), soft tissue sarcoma (RR = 1.4, 95% CI = 1.0-1.8) and bone cancer (RR = 1.3, 95% CI = 1.0-1.8) were at the greatest risk. In addition to attained age, female sex and increasing body mass index, exposure to high-dose (≥750 mg/m2) platinum chemotherapy (RR = 2.6, 95% CI = 1.5-4.5), vinca alkaloid chemotherapy (RR = 1.4, 95% CI = 1.1-1.8) or total body irradiation (TBI; RR = 2.2, 95% CI = 1.2-4.2) were each associated with late cholecystectomy. CONCLUSIONS Independent of traditional risk factors for gallbladder disease, exposure to high-dose platinum chemotherapy, vinca alkaloid chemotherapy or TBI increased risk for late cholecystectomy. These findings should inform current long-term follow-up guidelines and education regarding risk for late cholecystectomy.
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Affiliation(s)
- Bryan V Dieffenbach
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA; Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Department of Paediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA.
| | - Nan Li
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Arin L Madenci
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA; Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA; Department of Paediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA; Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Andrew J Murphy
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Dana Barnea
- Survivorship Clinic, Department of Hematology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Todd M Gibson
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Emily S Tonorezos
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Wendy M Leisenring
- Clinical Research and Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Rebecca M Howell
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lisa R Diller
- Department of Paediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - Qi Liu
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Eric J Chow
- Clinical Research and Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Gregory T Armstrong
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Yutaka Yasui
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Kevin C Oeffinger
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Christopher B Weldon
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA; Department of Paediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - Brent R Weil
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA; Department of Paediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
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Madenci AL, Madsen CK, Kwon NK, Wolf LL, Sonderman KA, Zalieckas JM, Rice-Townsend SE, Haider AH, Ricca RL, Weil BR, Weldon CB, Koehlmoos TP. Comparison of Military Health System Data Repository and American College of Surgeons National Surgical Quality Improvement Program-Pediatric. BMC Pediatr 2019; 19:419. [PMID: 31703566 PMCID: PMC6839070 DOI: 10.1186/s12887-019-1795-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 10/21/2019] [Indexed: 11/10/2022] Open
Abstract
Background Given the rarity of pediatric surgical disease, it is important to consider available large-scale data resources as a means to better study and understand relevant disease-processes and their treatments. The Military Health System Data Repository (MDR) includes claims-based information for > 3 million pediatric patients who are dependents of members and retirees of the United States Armed Services, but has not been externally validated. We hypothesized that demographics and selected outcome metrics would be similar between MDR and the previously validated American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-P) for several common pediatric surgical operations. Methods We selected five commonly performed pediatric surgical operations: appendectomy, pyeloplasty, pyloromyotomy, spinal arthrodesis for scoliosis, and facial reconstruction for cleft palate. Among children who underwent these operations, we compared demographics (age, sex, and race) and clinical outcomes (length of hospital stay [LOS] and mortality) in the MDR and NSQIP-P, including all available overlapping years (2012–2014). Results Age, sex, and race were generally similar between the NSQIP-P and MDR. Specifically, these demographics were generally similar between the resources for appendectomy (NSQIP-P, n = 20,602 vs. MDR, n = 4363; median age 11 vs. 12 years; female 40% vs. 41%; white 75% vs. 84%), pyeloplasty (NSQIP-P, n = 786 vs. MDR, n = 112; median age 0.9 vs. 2 years; female 28% vs. 28%; white 71% vs. 80%), pyloromyotomy, (NSQIP-P, n = 3827 vs. MDR, n = 227; median age 34 vs. < 1 year, female 17% vs. 16%; white 76% vs. 89%), scoliosis surgery (NSQIP-P, n = 5743 vs. MDR, n = 95; median age 14.2 vs. 14 years; female 75% vs. 67%; white 72% vs. 75%), and cleft lip/palate repair (NSQIP-P, n = 6202 vs. MDR, n = 749; median age, 1 vs. 1 year; female 42% vs. 45%; white 69% vs. 84%). Length of stay and 30-day mortality were similar between resources. LOS and 30-day mortality were also similar between datasets. Conclusion For the selected common pediatric surgical operations, patients included in the MDR were comparable to those included in the validated NSQIP-P. The MDR may comprise a valuable clinical outcomes research resource, especially for studying infrequent diseases with follow-up beyond the 30-day peri-operative period.
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Affiliation(s)
- Arin L Madenci
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA. .,Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA. .,Center for Surgery and Public Health, Boston, MA, USA.
| | - Cathaleen K Madsen
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
| | | | - Lindsey L Wolf
- Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Center for Surgery and Public Health, Boston, MA, USA
| | - Kristin A Sonderman
- Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Center for Surgery and Public Health, Boston, MA, USA
| | - Jill M Zalieckas
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.,Center for Surgery and Public Health, Boston, MA, USA
| | - Samuel E Rice-Townsend
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.,Center for Surgery and Public Health, Boston, MA, USA
| | - Adil H Haider
- Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Center for Surgery and Public Health, Boston, MA, USA
| | - Robert L Ricca
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Brent R Weil
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.,Center for Surgery and Public Health, Boston, MA, USA
| | - Christopher B Weldon
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.,Center for Surgery and Public Health, Boston, MA, USA
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Corkum KS, Rhee DS, Wafford QE, Demeestere I, Dasgupta R, Baertschiger R, Malek MM, Aldrink JH, Heaton TE, Weil BR, Madonna MB, Lautz TB. Fertility and hormone preservation and restoration for female children and adolescents receiving gonadotoxic cancer treatments: A systematic review. J Pediatr Surg 2019; 54:2200-2209. [PMID: 30773394 DOI: 10.1016/j.jpedsurg.2018.12.021] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Revised: 12/01/2018] [Accepted: 12/07/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND/PURPOSE The purpose of this systematic review by the American Pediatric Surgical Cancer Committee was to summarize evidence from the current medical literature regarding fertility restoration and hormone replacement for female children and adolescents treated with gonadotoxic treatments. METHODS Using PRISMA guidelines, questions were addressed by searching Medline, Cochrane, Embase Central and National clearing house databases using relevant search terms. Eligible studies included those that addressed ovarian tissue cryopreservation (OTC), oocyte harvest, ovarian transposition, and ovarian tissue auto-transplantation for females under the age of 20. Four reviewers independently screened studies for eligibility, extracted data and assessed the risk of bias. Study outcomes were summarized in a narrative synthesis. RESULTS Two thousand two hundred seventy-six studies were identified by database search and manual review and 2185 were eliminated based on defined exclusion criteria. Ninety-one studies served as the basis for the systematic review. There were 1019 patients who underwent OTC with ages ranging from 0.4 to 20.4 years old, with 298 under the age of 13. Twenty patients aged 13-20 years old underwent successful oocyte harvest. Thirty-seven children underwent ovarian transposition as a means of fertility preservation. Eighteen patients underwent auto-transplantation of thawed ovarian cortical tissue that was harvested before the age of 21 years resulting in 10 live births. CONCLUSIONS Clinically accepted and experimental fertility preservation options such as OTC, oocyte cryopreservation, and ovarian transposition are available to females aged 20 years and younger who are at risk for premature ovarian insufficiency and infertility due to gonadotoxic treatments. There is a large cohort of pediatric-aged patients, with a wide variety of diagnoses and treatments, who have undergone fertility preservation. Currently, fertility and hormone restoration experience for patients who were 20- years of age or younger at the time of fertility preservation remains limited. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Kristine S Corkum
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Daniel S Rhee
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Q Eileen Wafford
- Galter Health Sciences Library, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Isabelle Demeestere
- Research Laboratory in Human Reproduction, Université Libre de Bruxelles, (ULB), Brussels, Belgium
| | | | - Reto Baertschiger
- Division of Pediatric Surgery, Department of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Marcus M Malek
- Division of Pediatric General and Thoracic Surgery, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Jennifer H Aldrink
- Division of Pediatric Surgery, Nationwide Children's Hospital, Department of Surgery, The Ohio State University College of Medicine, Columbus, OH
| | - Todd E Heaton
- Division of Pediatric Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Brent R Weil
- Department of Surgery, Boston Children's Hospital, Boston, MA
| | | | - Timothy B Lautz
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
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30
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Madenci AL, Vandewalle RJ, Dieffenbach BV, Laufer MR, Boyd TK, Voss SD, Frazier AL, Billmire DF, Rescorla FJ, Weil BR, Weldon CB. Multicenter pre-operative assessment of pediatric ovarian malignancy. J Pediatr Surg 2019; 54:1921-1925. [PMID: 30867096 DOI: 10.1016/j.jpedsurg.2019.02.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 02/13/2019] [Accepted: 02/17/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE The purpose of this study was to develop a pre-operative risk assessment tool for childhood and adolescent ovarian malignancy, in order to guide operative management of pediatric ovarian masses. METHODS We conducted a retrospective analysis of patients <18 years old who underwent ovarian surgery at two quaternary care pediatric centers over 4 years (1/1/13-12/31/16). Probability of malignancy was estimated based on imaging characteristics (simple cyst, heterogeneous, or solid), maximal diameter, and tumor markers (α-fetoprotein, β-human chorionic gonadotropin). RESULTS Among 188 children with ovarian masses, 11% had malignancies. For simple cysts, there were no malignancies (0/24, 95% CI = 0-17%). Among solid lesions, 44% (15/34, 95% CI = 28-62%) were malignant. Among marker-elevated heterogeneous masses, 40% (2/5, 95% CI = 12-77%) were malignant. Conversely, small (≤10 cm) and large (>10 cm) marker-negative heterogeneous lesions had malignancy proportions of 0% (0/39, 95% CI = 0-11%) and 5% (2/40, 95% CI = 1-18%), respectively. CONCLUSIONS Given the malignancy estimates identified from these multi-institutional data, we recommend an attempt at ovarian-sparing resection for simple cysts or tumor marker-negative heterogeneous lesions ≤10 cm. Oophorectomy is recommended for solid masses or heterogeneous lesions with elevated markers. Finally, large (>10 cm) heterogeneous masses with non-elevated markers warrant a careful discussion of ovarian-sparing techniques. Complete surgical staging is mandatory regardless of operative procedure. TYPE OF STUDY Study of Diagnostic Test. LEVEL OF EVIDENCE Level I.
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Affiliation(s)
- Arin L Madenci
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA; Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer Center and Harvard Medical School, Boston, MA; Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.
| | - Robert J Vandewalle
- Department of Surgery, Riley Hospital for Children at Indiana University Health, Indianapolis, IN
| | - Bryan V Dieffenbach
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA; Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer Center and Harvard Medical School, Boston, MA; Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Marc R Laufer
- Division of Gynecology, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Theonia K Boyd
- Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Stephan D Voss
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - A Lindsay Frazier
- Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer Center and Harvard Medical School, Boston, MA
| | - Deborah F Billmire
- Department of Surgery, Riley Hospital for Children at Indiana University Health, Indianapolis, IN
| | - Frederick J Rescorla
- Department of Surgery, Riley Hospital for Children at Indiana University Health, Indianapolis, IN
| | - Brent R Weil
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA; Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer Center and Harvard Medical School, Boston, MA
| | - Christopher B Weldon
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA; Department of Pediatric Oncology, Dana-Farber/Boston Children's Cancer Center and Harvard Medical School, Boston, MA
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31
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Madenci AL, Dieffenbach BV, Liu Q, Yoneoka D, Knell J, Gibson TM, Yasui Y, Leisenring WM, Howell RM, Diller LR, Krull KR, Armstrong GT, Oeffinger KC, Murphy AJ, Weil BR, Weldon CB. Late-onset anorectal disease and psychosocial impact in survivors of childhood cancer: A report from the Childhood Cancer Survivor Study. Cancer 2019; 125:3873-3881. [PMID: 31322729 DOI: 10.1002/cncr.32395] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 06/08/2019] [Accepted: 06/13/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND The prevalence and associated psychosocial morbidity of late-onset anorectal disease after surgery and radiotherapy for the treatment of childhood cancer are not known. METHODS A total of 25,530 survivors diagnosed between 1970 and 1999 (median age at cancer diagnosis, 6.1 years; age at survey, 30.2 years) and 5036 siblings were evaluated for late-onset anorectal disease, which was defined as a self-reported fistula-in-ano, self-reported anorectal stricture, or pathology- or medical record-confirmed anorectal subsequent malignant neoplasm (SMN) 5 or more years after the primary cancer diagnosis. Piecewise exponential models compared the survivors and siblings and examined associations between cancer treatments and late-onset anorectal disease. Multiple logistic regression with generalized estimating equations was used to evaluate associations between late-onset anorectal disease and emotional distress, as defined by the Brief Symptom Inventory 18 (BSI-18), and health-related quality of life, as defined by the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36). RESULTS By 45 years after the diagnosis, 394 survivors (fistula, n = 291; stricture, n = 116; anorectal SMN, n = 26) and 84 siblings (fistula, n = 73; stricture, n = 23; anorectal neoplasm, n = 1) had developed late-onset anorectal disease (adjusted rate ratio [RR] for survivors vs siblings, 1.2; 95% confidence interval [CI], 1.0-1.5). Among survivors, pelvic radiotherapy with ≥30 Gy within 5 years of the cancer diagnosis was associated with late-onset anorectal disease (adjusted RR for 30-49.9 Gy vs none, 1.6; 95% CI, 1.1-2.3; adjusted RR for ≥50 Gy vs none, 5.4; 95% CI, 3.1-9.2). Late-onset anorectal disease was associated with psychosocial impairment in all BSI-18 and SF-36 domains. CONCLUSIONS Late-onset anorectal disease was more common among childhood cancer survivors who received higher doses of pelvic radiotherapy and was associated with substantial psychosocial morbidity.
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Affiliation(s)
- Arin L Madenci
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts.,Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.,Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts.,Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Bryan V Dieffenbach
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts.,Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.,Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts
| | - Qi Liu
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Daisuke Yoneoka
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Jamie Knell
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts.,Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.,Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts
| | - Todd M Gibson
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Yutaka Yasui
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Wendy M Leisenring
- Clinical Research and Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Rebecca M Howell
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lisa R Diller
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts.,Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts
| | - Kevin R Krull
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Gregory T Armstrong
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Kevin C Oeffinger
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Andrew J Murphy
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Brent R Weil
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts.,Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts.,Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Christopher B Weldon
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts.,Department of Pediatric Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts
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Madenci AL, Armstrong LB, Kwon NK, Jiang W, Wolf LL, Koehlmoos TP, Ricca RL, Weldon CB, Haider AH, Weil BR. Incidence and risk factors for sepsis after childhood splenectomy. J Pediatr Surg 2019; 54:1445-1448. [PMID: 30029846 DOI: 10.1016/j.jpedsurg.2018.06.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 06/13/2018] [Accepted: 06/15/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Children who have undergone splenectomy may develop impaired immunologic function and heightened risk of overwhelming postsplenectomy infection. We sought to define the long-term rate of and risk factors for postsplenectomy sepsis. METHODS We leveraged the Military Health System Data Repository, a nationally representative claims database including >3 million children registered as dependents of members of the United States Armed Services (2005-2014). Inclusion criterion was splenectomy at age 18 years or prior. The primary outcome was hospitalization for sepsis. RESULTS Among 195 children who underwent splenectomy, 7% (n = 13) were hospitalized with sepsis, with an incidence of 1.8 (95% CI = 1.0-3.1) events per 100 person-years. The median time to sepsis was 224 days (IQR = 109-606) and 38% (5/13) of events occurred within the first postsplenectomy year. The postsplenectomy mortality rate was 1% (n = 3). After adjusting for underlying diagnosis, older age at splenectomy (HR = 0.90 per year, 95% CI = 0.81-0.99) was associated with decreased hazard of sepsis. CONCLUSIONS In a contemporary national cohort, the prevalence of postsplenectomy sepsis was 7% (1.8 events per 100 person-years). Although most presented during the first year after splenectomy, many (62%) sepsis events occurred later, suggesting that postsplenectomy immunologic dysfunction persists beyond one year. The immunologic consequences of asplenia must continue to be acknowledged, as postsplenectomy sepsis remains a serious concern. TYPE OF STUDY Prognosis study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Arin L Madenci
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States; Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States; The Center for Surgery and Public Health, Boston, MA, United States.
| | - Lindsey B Armstrong
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | | | - Wei Jiang
- The Center for Surgery and Public Health, Boston, MA, United States
| | - Lindsey L Wolf
- Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States; The Center for Surgery and Public Health, Boston, MA, United States
| | - Tracey P Koehlmoos
- Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Robert L Ricca
- Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Christopher B Weldon
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - Adil H Haider
- Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States; The Center for Surgery and Public Health, Boston, MA, United States
| | - Brent R Weil
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
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Dieffenbach BV, Madenci AL, Murphy AJ, Weldon CB, Weil BR, Lehmann LE. Therapeutic Impact and Complications Associated with Surgical Lung Biopsy after Allogeneic Hematopoietic Stem Cell Transplantation in Children. Biol Blood Marrow Transplant 2019; 25:2181-2185. [PMID: 31255742 DOI: 10.1016/j.bbmt.2019.06.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 06/17/2019] [Accepted: 06/21/2019] [Indexed: 11/26/2022]
Abstract
Hematopoietic stem cell transplantation (HSCT) in the pediatric population is associated with pulmonary complications in 25% of recipients. The role of surgical lung biopsy (SLB) remains unclear because of concerns about both the therapeutic impact and morbidity associated with the procedure. A retrospective review of consecutive allogeneic HSCT recipients at Dana-Farber and Boston Children's Hospital Cancer and Blood Disorders Center between 2006 and 2016 was performed. All recipients who underwent SLB during the study period were identified and charts reviewed for perioperative complications, histopathologic findings, and changes in therapy delivered. Pearson's chi-square test and Student's t-test (or appropriate nonparametric test) were used to evaluate the associations between perioperative complication and categorical and continuous variables, respectively. Five hundred fifty-five HSCTs were included, among which 48 SLBs (8.6%) were identified. Median follow-up time was 24 months (range, 0 to 139). Thirty-day postoperative morbidity was 16.7% and 30-day postoperative mortality 10.4% (n = 5). The overall 30-day postoperative complication rate (including mortality) was 20.8% (n = 10). No mortalities were directly attributable to SLB. Definitive diagnoses were identified in 70.8% of SLBs (n = 34), and therapeutic changes occurred in 79.2% (n = 38). Overall, 83.3% of SLBs (n = 40) either provided a diagnosis or led to a change in therapy. SLB has an acceptable risk of perioperative complications in this medically complicated and often severely ill population. In most HSCT patients, SLB aids in defining the etiology of pulmonary infiltrates and can inform therapeutic decisions in patients where noninvasive diagnostic modalities have failed to provide a definitive diagnosis.
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Affiliation(s)
- Bryan V Dieffenbach
- Boston Children's Hospital, Boston, Massachusetts; Brigham and Women's Hospital, Boston, Massachusetts.
| | - Arin L Madenci
- Boston Children's Hospital, Boston, Massachusetts; Brigham and Women's Hospital, Boston, Massachusetts; Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | | | - Christopher B Weldon
- Boston Children's Hospital, Boston, Massachusetts; Dana-Farber and Boston Children's Hospital Cancer and Blood Disorders Center, Boston, Massachusetts
| | - Brent R Weil
- Boston Children's Hospital, Boston, Massachusetts; Dana-Farber and Boston Children's Hospital Cancer and Blood Disorders Center, Boston, Massachusetts
| | - Leslie E Lehmann
- Boston Children's Hospital, Boston, Massachusetts; Dana-Farber and Boston Children's Hospital Cancer and Blood Disorders Center, Boston, Massachusetts
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Aldrink JH, Heaton TE, Dasgupta R, Lautz TB, Malek MM, Abdessalam SF, Weil BR, Rhee DS, Baertschiger R, Ehrlich PF. Update on Wilms tumor. J Pediatr Surg 2019; 54:390-397. [PMID: 30270120 PMCID: PMC7542630 DOI: 10.1016/j.jpedsurg.2018.09.005] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 08/28/2018] [Accepted: 09/14/2018] [Indexed: 02/07/2023]
Abstract
This article reviews of the current evidence-based treatment standards for children with Wilms tumor. In this article, a summary of recently completed clinical trials by the Children's Oncology Group is provided, the current diagnostic evaluation and surgical standards are discussed, and the surgical impact on current risk stratification for patients with Wilms tumor is highlighted. LEVEL OF EVIDENCE: This is a review article of previously published and referenced LEVEL 1 studies, but also includes expert opinion LEVEL V, represented by the American Pediatric Surgical Association Cancer Committee.
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Affiliation(s)
- Jennifer H Aldrink
- Department of Surgery, Division of Pediatric Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH.
| | - Todd E Heaton
- Department of Surgery, Division of Pediatric Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Roshni Dasgupta
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH
| | - Timothy B Lautz
- Department of Surgery, Division of Pediatric Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Marcus M Malek
- Department of Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Shahab F Abdessalam
- Department of Surgery, Division of Pediatric Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Brent R Weil
- Department of Surgery, Division of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Daniel S Rhee
- Depatment of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Reto Baertschiger
- Department of Surgery, Children's Hospital at Dartmouth, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Peter F Ehrlich
- Department of Surgery, Division of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI
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Newman EA, Abdessalam S, Aldrink JH, Austin M, Heaton TE, Bruny J, Ehrlich P, Dasgupta R, Baertschiger RM, Lautz TB, Rhee DS, Langham MR, Malek MM, Meyers RL, Nathan JD, Weil BR, Polites S, Madonna MB. Update on neuroblastoma. J Pediatr Surg 2019; 54:383-389. [PMID: 30305231 DOI: 10.1016/j.jpedsurg.2018.09.004] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 09/09/2018] [Accepted: 09/14/2018] [Indexed: 12/15/2022]
Abstract
Neuroblastoma is an embryonic cancer arising from neural crest stem cells. This cancer is the most common malignancy in infants and the most common extracranial solid tumor in children. The clinical course may be highly variable with the possibility of spontaneous regression in the youngest patients and increased risk of aggressive disease in older children. Clinical heterogeneity is a consequence of the diverse biologic characteristics that determine patient risk and survival. This review will focus on current progress in neuroblastoma staging, risk stratification, and treatment strategies based on advancing knowledge in tumor biology and genetic characterization. TYPE OF STUDY: Review article. LEVEL OF EVIDENCE: Level II.
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Affiliation(s)
- Erika A Newman
- C.S Mott Children's Hospital, The University of Michigan Medicine, Ann Arbor, MI.
| | | | | | - Mary Austin
- Memorial Hermann Texas Medical Center, Houston, TX
| | - Todd E Heaton
- Memorial Sloan Kettering Cancer Center, NY, New York
| | | | - Peter Ehrlich
- C.S Mott Children's Hospital, The University of Michigan Medicine, Ann Arbor, MI
| | | | | | - Timothy B Lautz
- Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University, Chicago, IL
| | | | - Max R Langham
- University of Tennessee Health Science Center and St. Jude Children's Research Hospital, Memphis, TN
| | - Marcus M Malek
- Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | - Rebecka L Meyers
- Primary Children's Hospital, University of Utah, Salt Lake City, UT
| | | | - Brent R Weil
- Boston Children's Hospital and Dana-Farber Cancer Institute, Boston, MA
| | | | - Mary Beth Madonna
- Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University, Chicago, IL
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Madenci AL, Weil BR, Liu Q, Murphy AJ, Gibson TM, Yasui Y, Leisenring WM, Howell RM, Tinkle CL, Nekhlyudov L, Diller LR, Armstrong GT, Oeffinger KC, Weldon CB. Long-Term Risk of Venous Thromboembolism in Survivors of Childhood Cancer: A Report From the Childhood Cancer Survivor Study. J Clin Oncol 2018; 36:JCO2018784595. [PMID: 30216123 DOI: 10.1200/jco.2018.78.4595] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Purpose To estimate the incidence of late-occurring venous thromboembolism (VTE) among survivors of childhood cancer and to identify risk factors for VTE to facilitate diagnosis and prevention. Methods The Childhood Cancer Survivor Study is a multi-institutional cohort of 24,355 5-year childhood cancer survivors (diagnosed between 1970 and 1999; median age at last follow-up, 28.7 years [range, 5.6 to 58.9 years]; median follow-up since diagnosis, 21.3 years [range, 5.0 to 39.2 years]) and 5,051 sibling participants. The primary end point was self-reported late (≥ 5 years after cancer diagnosis) VTE. Rate ratios (RRs) were estimated with multivariable piecewise exponential models. Results Late VTE incidence among survivors and siblings was 1.1 and 0.5 events per 1,000 person-years, respectively (RR, 2.2; 95% CI, 1.7 to 2.8), with 2.5 excess events per 100 survivors over 35 years. Among survivors, risk factors for VTE were female sex (RR, 1.3; 95% CI, 1.1 to 1.6), cisplatin (reference none; 1 to 199 mg/m2: RR, 3.0 [95% CI, 1.4 to 6.5]; 200 to 399 mg/m2: RR, 1.9 [95% CI, 1.0 to 3.6]; ≥ 400 mg/m2: RR, 2.0 [95% CI, 1.2 to 3.3]), l-asparaginase (RR, 1.3; 95% CI, 1.0 to 1.7), obesity or underweight (reference body mass index [BMI] 18.5 to 24.9 kg/m2; BMI ≥ 30.0 kg/m2: RR, 1.6 [95% CI, 1.2 to 2.0]; BMI < 18.5 kg/m2: RR, 2.4 [95% CI, 1.7 to 3.4]), and late cancer recurrence or subsequent malignant neoplasm (RR, 4.6; 95% CI, 3.6 to 5.8). Among lower-extremity osteosarcoma survivors, limb salvage (reference amputation; RR, 3.1; 95% CI, 1.2 to 7.5) and cisplatin 200 to 399 or ≥ 400 mg/m2 (reference none; RR, 4.0 [95% CI, 1.1 to 14.6] and 2.9 [95% CI, 1.1 to 8.0], respectively) were independently associated with late VTE. VTE was associated with increased risk for nonexternal cause late mortality (RR, 1.9; 95% CI, 1.6 to 2.3). Conclusion Childhood cancer survivors are at increased risk for VTE across their lifespan and a diagnosis of VTE increases mortality risk. Interventions that target potentially modifiable comorbidities, such as obesity, warrant consideration, with prophylaxis for high-risk survivors, including those treated with cisplatin and limb-sparing approaches.
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Affiliation(s)
- Arin L Madenci
- Arin L. Madenci, Brent R. Weil, and Christopher B. Weldon, Boston Children's Hospital; Arin L. Madenci and Larissa Nekhlyudov, Brigham and Women's Hospital; Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller and Christopher B. Weldon, Harvard Medical School, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Andrew J. Murphy, Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Rebecca M. Howell, The University of Texas MD Anderson Cancer Center, Houston, TX; and Kevin C. Oeffinger, Duke University School of Medicine, Durham, NC
| | - Brent R Weil
- Arin L. Madenci, Brent R. Weil, and Christopher B. Weldon, Boston Children's Hospital; Arin L. Madenci and Larissa Nekhlyudov, Brigham and Women's Hospital; Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller and Christopher B. Weldon, Harvard Medical School, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Andrew J. Murphy, Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Rebecca M. Howell, The University of Texas MD Anderson Cancer Center, Houston, TX; and Kevin C. Oeffinger, Duke University School of Medicine, Durham, NC
| | - Qi Liu
- Arin L. Madenci, Brent R. Weil, and Christopher B. Weldon, Boston Children's Hospital; Arin L. Madenci and Larissa Nekhlyudov, Brigham and Women's Hospital; Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller and Christopher B. Weldon, Harvard Medical School, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Andrew J. Murphy, Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Rebecca M. Howell, The University of Texas MD Anderson Cancer Center, Houston, TX; and Kevin C. Oeffinger, Duke University School of Medicine, Durham, NC
| | - Andrew J Murphy
- Arin L. Madenci, Brent R. Weil, and Christopher B. Weldon, Boston Children's Hospital; Arin L. Madenci and Larissa Nekhlyudov, Brigham and Women's Hospital; Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller and Christopher B. Weldon, Harvard Medical School, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Andrew J. Murphy, Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Rebecca M. Howell, The University of Texas MD Anderson Cancer Center, Houston, TX; and Kevin C. Oeffinger, Duke University School of Medicine, Durham, NC
| | - Todd M Gibson
- Arin L. Madenci, Brent R. Weil, and Christopher B. Weldon, Boston Children's Hospital; Arin L. Madenci and Larissa Nekhlyudov, Brigham and Women's Hospital; Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller and Christopher B. Weldon, Harvard Medical School, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Andrew J. Murphy, Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Rebecca M. Howell, The University of Texas MD Anderson Cancer Center, Houston, TX; and Kevin C. Oeffinger, Duke University School of Medicine, Durham, NC
| | - Yutaka Yasui
- Arin L. Madenci, Brent R. Weil, and Christopher B. Weldon, Boston Children's Hospital; Arin L. Madenci and Larissa Nekhlyudov, Brigham and Women's Hospital; Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller and Christopher B. Weldon, Harvard Medical School, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Andrew J. Murphy, Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Rebecca M. Howell, The University of Texas MD Anderson Cancer Center, Houston, TX; and Kevin C. Oeffinger, Duke University School of Medicine, Durham, NC
| | - Wendy M Leisenring
- Arin L. Madenci, Brent R. Weil, and Christopher B. Weldon, Boston Children's Hospital; Arin L. Madenci and Larissa Nekhlyudov, Brigham and Women's Hospital; Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller and Christopher B. Weldon, Harvard Medical School, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Andrew J. Murphy, Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Rebecca M. Howell, The University of Texas MD Anderson Cancer Center, Houston, TX; and Kevin C. Oeffinger, Duke University School of Medicine, Durham, NC
| | - Rebecca M Howell
- Arin L. Madenci, Brent R. Weil, and Christopher B. Weldon, Boston Children's Hospital; Arin L. Madenci and Larissa Nekhlyudov, Brigham and Women's Hospital; Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller and Christopher B. Weldon, Harvard Medical School, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Andrew J. Murphy, Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Rebecca M. Howell, The University of Texas MD Anderson Cancer Center, Houston, TX; and Kevin C. Oeffinger, Duke University School of Medicine, Durham, NC
| | - Christopher L Tinkle
- Arin L. Madenci, Brent R. Weil, and Christopher B. Weldon, Boston Children's Hospital; Arin L. Madenci and Larissa Nekhlyudov, Brigham and Women's Hospital; Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller and Christopher B. Weldon, Harvard Medical School, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Andrew J. Murphy, Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Rebecca M. Howell, The University of Texas MD Anderson Cancer Center, Houston, TX; and Kevin C. Oeffinger, Duke University School of Medicine, Durham, NC
| | - Larissa Nekhlyudov
- Arin L. Madenci, Brent R. Weil, and Christopher B. Weldon, Boston Children's Hospital; Arin L. Madenci and Larissa Nekhlyudov, Brigham and Women's Hospital; Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller and Christopher B. Weldon, Harvard Medical School, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Andrew J. Murphy, Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Rebecca M. Howell, The University of Texas MD Anderson Cancer Center, Houston, TX; and Kevin C. Oeffinger, Duke University School of Medicine, Durham, NC
| | - Lisa R Diller
- Arin L. Madenci, Brent R. Weil, and Christopher B. Weldon, Boston Children's Hospital; Arin L. Madenci and Larissa Nekhlyudov, Brigham and Women's Hospital; Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller and Christopher B. Weldon, Harvard Medical School, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Andrew J. Murphy, Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Rebecca M. Howell, The University of Texas MD Anderson Cancer Center, Houston, TX; and Kevin C. Oeffinger, Duke University School of Medicine, Durham, NC
| | - Gregory T Armstrong
- Arin L. Madenci, Brent R. Weil, and Christopher B. Weldon, Boston Children's Hospital; Arin L. Madenci and Larissa Nekhlyudov, Brigham and Women's Hospital; Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller and Christopher B. Weldon, Harvard Medical School, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Andrew J. Murphy, Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Rebecca M. Howell, The University of Texas MD Anderson Cancer Center, Houston, TX; and Kevin C. Oeffinger, Duke University School of Medicine, Durham, NC
| | - Kevin C Oeffinger
- Arin L. Madenci, Brent R. Weil, and Christopher B. Weldon, Boston Children's Hospital; Arin L. Madenci and Larissa Nekhlyudov, Brigham and Women's Hospital; Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller and Christopher B. Weldon, Harvard Medical School, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Andrew J. Murphy, Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Rebecca M. Howell, The University of Texas MD Anderson Cancer Center, Houston, TX; and Kevin C. Oeffinger, Duke University School of Medicine, Durham, NC
| | - Christopher B Weldon
- Arin L. Madenci, Brent R. Weil, and Christopher B. Weldon, Boston Children's Hospital; Arin L. Madenci and Larissa Nekhlyudov, Brigham and Women's Hospital; Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brent R. Weil, Larissa Nekhlyudov, Lisa R. Diller and Christopher B. Weldon, Harvard Medical School, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Andrew J. Murphy, Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Rebecca M. Howell, The University of Texas MD Anderson Cancer Center, Houston, TX; and Kevin C. Oeffinger, Duke University School of Medicine, Durham, NC
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Chow EJ, Antal Z, Constine LS, Gardner R, Wallace WH, Weil BR, Yeh JM, Fox E. New Agents, Emerging Late Effects, and the Development of Precision Survivorship. J Clin Oncol 2018; 36:2231-2240. [PMID: 29874142 PMCID: PMC6053298 DOI: 10.1200/jco.2017.76.4647] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Incremental improvements in the treatment of children and adolescents with cancer have led to 5-year survival rates reaching nearly 85%. In the past decade, impressive progress has been made in understanding the biology of many pediatric cancers. With that understanding, multiple new agents have become available that offer the promise of more-effective and less-toxic treatment. These include agents that target various cell surface antigens and engage the adaptive immune system, as well as those that interfere with key signaling pathways involved in tumor development and growth. For local control, surgery and radiation techniques also have evolved, becoming less invasive or featuring new techniques and particles that more precisely target the tumor and limit the dose to normal tissue. Nevertheless, targeted agents, like conventional chemotherapy, radiotherapy, and surgery, may have off-target effects and deserve long-term follow-up of their safety and efficacy. These include injury to the endocrine, cardiovascular, and immunologic systems. New radiation and surgical techniques that theoretically reduce morbidity and improve long-term quality of life must also be validated with actual patient outcomes. Finally, with advances in genomics, information on host susceptibility to late effects is beginning to emerge. Such knowledge, coupled with improved metrics that better describe the spectrum of potential late effects across the entire lifespan, can lead to the development of decision models that project the potential long-term health outcomes associated with various treatment and follow-up strategies. These developments will help extend the current focus on precision medicine to precision survivorship, where clinicians, patients, and families will have a better grasp of the potential risks, benefits, and tradeoffs associated with the growing number of cancer treatment options.
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Affiliation(s)
- Eric J Chow
- Eric J. Chow and Rebecca Gardner, Fred Hutchinson Cancer Research Center, Seattle Children's Hospital, and University of Washington, Seattle, WA; Zoltan Antal, Weill Cornell Medical College, New York Presbyterian Hospital, and Memorial Sloan Kettering Cancer Center, New York; Louis S. Constine, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; W. Hamish Wallace, Royal Hospital for Sick Children, University of Edinburgh, Edinburgh, United Kingdom; Brent R. Weil and Jennifer M. Yeh, Boston Children's Hospital, Harvard Medical School, Boston, MA; and Elizabeth Fox, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Zoltan Antal
- Eric J. Chow and Rebecca Gardner, Fred Hutchinson Cancer Research Center, Seattle Children's Hospital, and University of Washington, Seattle, WA; Zoltan Antal, Weill Cornell Medical College, New York Presbyterian Hospital, and Memorial Sloan Kettering Cancer Center, New York; Louis S. Constine, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; W. Hamish Wallace, Royal Hospital for Sick Children, University of Edinburgh, Edinburgh, United Kingdom; Brent R. Weil and Jennifer M. Yeh, Boston Children's Hospital, Harvard Medical School, Boston, MA; and Elizabeth Fox, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Louis S Constine
- Eric J. Chow and Rebecca Gardner, Fred Hutchinson Cancer Research Center, Seattle Children's Hospital, and University of Washington, Seattle, WA; Zoltan Antal, Weill Cornell Medical College, New York Presbyterian Hospital, and Memorial Sloan Kettering Cancer Center, New York; Louis S. Constine, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; W. Hamish Wallace, Royal Hospital for Sick Children, University of Edinburgh, Edinburgh, United Kingdom; Brent R. Weil and Jennifer M. Yeh, Boston Children's Hospital, Harvard Medical School, Boston, MA; and Elizabeth Fox, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Rebecca Gardner
- Eric J. Chow and Rebecca Gardner, Fred Hutchinson Cancer Research Center, Seattle Children's Hospital, and University of Washington, Seattle, WA; Zoltan Antal, Weill Cornell Medical College, New York Presbyterian Hospital, and Memorial Sloan Kettering Cancer Center, New York; Louis S. Constine, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; W. Hamish Wallace, Royal Hospital for Sick Children, University of Edinburgh, Edinburgh, United Kingdom; Brent R. Weil and Jennifer M. Yeh, Boston Children's Hospital, Harvard Medical School, Boston, MA; and Elizabeth Fox, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - W Hamish Wallace
- Eric J. Chow and Rebecca Gardner, Fred Hutchinson Cancer Research Center, Seattle Children's Hospital, and University of Washington, Seattle, WA; Zoltan Antal, Weill Cornell Medical College, New York Presbyterian Hospital, and Memorial Sloan Kettering Cancer Center, New York; Louis S. Constine, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; W. Hamish Wallace, Royal Hospital for Sick Children, University of Edinburgh, Edinburgh, United Kingdom; Brent R. Weil and Jennifer M. Yeh, Boston Children's Hospital, Harvard Medical School, Boston, MA; and Elizabeth Fox, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Brent R Weil
- Eric J. Chow and Rebecca Gardner, Fred Hutchinson Cancer Research Center, Seattle Children's Hospital, and University of Washington, Seattle, WA; Zoltan Antal, Weill Cornell Medical College, New York Presbyterian Hospital, and Memorial Sloan Kettering Cancer Center, New York; Louis S. Constine, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; W. Hamish Wallace, Royal Hospital for Sick Children, University of Edinburgh, Edinburgh, United Kingdom; Brent R. Weil and Jennifer M. Yeh, Boston Children's Hospital, Harvard Medical School, Boston, MA; and Elizabeth Fox, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Jennifer M Yeh
- Eric J. Chow and Rebecca Gardner, Fred Hutchinson Cancer Research Center, Seattle Children's Hospital, and University of Washington, Seattle, WA; Zoltan Antal, Weill Cornell Medical College, New York Presbyterian Hospital, and Memorial Sloan Kettering Cancer Center, New York; Louis S. Constine, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; W. Hamish Wallace, Royal Hospital for Sick Children, University of Edinburgh, Edinburgh, United Kingdom; Brent R. Weil and Jennifer M. Yeh, Boston Children's Hospital, Harvard Medical School, Boston, MA; and Elizabeth Fox, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Elizabeth Fox
- Eric J. Chow and Rebecca Gardner, Fred Hutchinson Cancer Research Center, Seattle Children's Hospital, and University of Washington, Seattle, WA; Zoltan Antal, Weill Cornell Medical College, New York Presbyterian Hospital, and Memorial Sloan Kettering Cancer Center, New York; Louis S. Constine, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY; W. Hamish Wallace, Royal Hospital for Sick Children, University of Edinburgh, Edinburgh, United Kingdom; Brent R. Weil and Jennifer M. Yeh, Boston Children's Hospital, Harvard Medical School, Boston, MA; and Elizabeth Fox, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
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Sonderman KA, Wolf LL, Armstrong LB, Taylor K, Jiang W, Weil BR, Koehlmoos TP, Ricca RL, Weldon CB, Haider AH, Rice-Townsend SE. Testicular atrophy following inguinal hernia repair in children. Pediatr Surg Int 2018; 34:553-560. [PMID: 29594470 DOI: 10.1007/s00383-018-4255-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/24/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE We sought to determine the incidence and timing of testicular atrophy following inguinal hernia repair in children. METHODS We used the TRICARE database, which tracks care delivered to active and retired members of the US Armed Forces and their dependents, including > 3 million children. We abstracted data on male children < 12 years who underwent inguinal hernia repair (2005-2014). We excluded patients with history of testicular atrophy, malignancy or prior related operation. Our primary outcome was the incidence of the diagnosis of testicular atrophy. Among children with atrophy, we calculated median time to diagnosis, stratified by age/undescended testis. RESULTS 8897 children met inclusion criteria. Median age at hernia repair was 2 years (IQR 1-5). Median follow-up was 3.57 years (IQR 1.69-6.19). Overall incidence of testicular atrophy was 5.1/10,000 person-years, with the highest incidence in those with an undescended testis (13.9/10,000 person-years). All cases occurred in children [Formula: see text] 5 years, with 72% in children < 2 years. Median time to atrophy was 2.4 years (IQR 0.64-3), with 30% occurring within 1 year and 75% within 3 years. CONCLUSION Testicular atrophy is a rare complication following inguinal hernia repair, with children < 2 years and those with an undescended testis at highest risk. While 30% of cases were diagnosed within a year after repair, atrophy may be diagnosed substantially later. LEVEL OF EVIDENCE Prognosis Study, Level II.
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Affiliation(s)
- Kristin A Sonderman
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, and Harvard T.H. Chan School of Public Health, 1620 Tremont Street, 4th Floor, Suite 4-020, Boston, MA, 02120, USA. .,Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.
| | - Lindsey L Wolf
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, and Harvard T.H. Chan School of Public Health, 1620 Tremont Street, 4th Floor, Suite 4-020, Boston, MA, 02120, USA.,Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | | | | | - Wei Jiang
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, and Harvard T.H. Chan School of Public Health, 1620 Tremont Street, 4th Floor, Suite 4-020, Boston, MA, 02120, USA
| | - Brent R Weil
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | | | - Robert L Ricca
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | | | - Adil H Haider
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, and Harvard T.H. Chan School of Public Health, 1620 Tremont Street, 4th Floor, Suite 4-020, Boston, MA, 02120, USA.,Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
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Weil BR, Madenci AL, Liu Q, Howell RM, Gibson TM, Yasui Y, Neglia JP, Leisenring WM, Smith SA, Tonorezos ES, Friedman DN, Constine LS, Tinkle CL, Diller LR, Armstrong GT, Oeffinger KC, Weldon CB. Late Infection-Related Mortality in Asplenic Survivors of Childhood Cancer: A Report From the Childhood Cancer Survivor Study. J Clin Oncol 2018; 36:1571-1578. [PMID: 29664715 DOI: 10.1200/jco.2017.76.1643] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Infection-related outcomes associated with asplenia or impaired splenic function in survivors of childhood cancer remains understudied. Methods Late infection-related mortality was evaluated in 20,026 5-year survivors of childhood cancer (diagnosed < 21 years of age from 1970 to 1999; median age at diagnosis, 7.0 years [range, 0 to 20 years]; median follow-up, 26 years [range, 5 to 44 years]) using cumulative incidence and piecewise-exponential regression models to estimate adjusted relative rates (RRs). Splenic radiation was approximated using average dose (direct and/or indirect) to the left upper quadrant of the abdomen (hereafter, referred to as splenic radiation). Results Within 5 years of diagnosis, 1,354 survivors (6.8%) had a splenectomy and 9,442 (46%) had splenic radiation without splenectomy. With 62 deaths, the cumulative incidence of infection-related late mortality was 1.5% (95% CI, 0.7% to 2.2%) at 35 years after splenectomy and 0.6% (95% CI, 0.4% to 0.8%) after splenic radiation. Splenectomy (RR, 7.7; 95% CI, 3.1 to 19.1) was independently associated with late infection-related mortality. Splenic radiation was associated with increasing risk for late infection-related mortality in a dose-response relationship (0.1 to 9.9 Gy: RR, 2.0; 95% CI, 0.9 to 4.5; 10 to 19.9 Gy: RR, 5.5; 95% CI, 1.9 to 15.4; ≥ 20 Gy: RR, 6.0; 95% CI, 1.8 to 20.2). High-dose alkylator chemotherapy exposure was also independently associated with an increased risk of infection-related mortality (RR, 1.9; 95% CI, 1.1 to 3.4). Conclusion Splenectomy and splenic radiation significantly increase risk for late infection-related mortality. Even low- to intermediate-dose radiation exposure confers increased risk, suggesting that the spleen is highly radiosensitive. These findings should inform long-term follow-up guidelines for survivors of childhood cancer and should lead clinicians to avoid or reduce radiation exposure involving the spleen whenever possible.
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Affiliation(s)
- Brent R Weil
- Brent R. Weil, Arin L. Madenci, and Christopher B. Weldon, Boston Children's Hospital; Brent R. Weil, Arin L. Madenci, Lisa R. Diller, and Christopher B. Weldon, Harvard Medical School; Brent R. Weil, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brigham and Women's Hospital, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Rebecca M. Howell and Susan A. Smith, The University of Texas MD Anderson Cancer Center, Houston, TX; Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Joseph P. Neglia, University of Minnesota, Minneapolis, MN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Emily S. Tonorezos and Danielle N. Friedman, Memorial Sloan Kettering Cancer Center, New York; Louis S. Constine, University of Rochester Medical Center, Rochester, NY; and Kevin C. Oeffinger, Duke University, Durham, NC
| | - Arin L Madenci
- Brent R. Weil, Arin L. Madenci, and Christopher B. Weldon, Boston Children's Hospital; Brent R. Weil, Arin L. Madenci, Lisa R. Diller, and Christopher B. Weldon, Harvard Medical School; Brent R. Weil, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brigham and Women's Hospital, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Rebecca M. Howell and Susan A. Smith, The University of Texas MD Anderson Cancer Center, Houston, TX; Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Joseph P. Neglia, University of Minnesota, Minneapolis, MN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Emily S. Tonorezos and Danielle N. Friedman, Memorial Sloan Kettering Cancer Center, New York; Louis S. Constine, University of Rochester Medical Center, Rochester, NY; and Kevin C. Oeffinger, Duke University, Durham, NC
| | - Qi Liu
- Brent R. Weil, Arin L. Madenci, and Christopher B. Weldon, Boston Children's Hospital; Brent R. Weil, Arin L. Madenci, Lisa R. Diller, and Christopher B. Weldon, Harvard Medical School; Brent R. Weil, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brigham and Women's Hospital, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Rebecca M. Howell and Susan A. Smith, The University of Texas MD Anderson Cancer Center, Houston, TX; Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Joseph P. Neglia, University of Minnesota, Minneapolis, MN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Emily S. Tonorezos and Danielle N. Friedman, Memorial Sloan Kettering Cancer Center, New York; Louis S. Constine, University of Rochester Medical Center, Rochester, NY; and Kevin C. Oeffinger, Duke University, Durham, NC
| | - Rebecca M Howell
- Brent R. Weil, Arin L. Madenci, and Christopher B. Weldon, Boston Children's Hospital; Brent R. Weil, Arin L. Madenci, Lisa R. Diller, and Christopher B. Weldon, Harvard Medical School; Brent R. Weil, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brigham and Women's Hospital, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Rebecca M. Howell and Susan A. Smith, The University of Texas MD Anderson Cancer Center, Houston, TX; Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Joseph P. Neglia, University of Minnesota, Minneapolis, MN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Emily S. Tonorezos and Danielle N. Friedman, Memorial Sloan Kettering Cancer Center, New York; Louis S. Constine, University of Rochester Medical Center, Rochester, NY; and Kevin C. Oeffinger, Duke University, Durham, NC
| | - Todd M Gibson
- Brent R. Weil, Arin L. Madenci, and Christopher B. Weldon, Boston Children's Hospital; Brent R. Weil, Arin L. Madenci, Lisa R. Diller, and Christopher B. Weldon, Harvard Medical School; Brent R. Weil, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brigham and Women's Hospital, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Rebecca M. Howell and Susan A. Smith, The University of Texas MD Anderson Cancer Center, Houston, TX; Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Joseph P. Neglia, University of Minnesota, Minneapolis, MN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Emily S. Tonorezos and Danielle N. Friedman, Memorial Sloan Kettering Cancer Center, New York; Louis S. Constine, University of Rochester Medical Center, Rochester, NY; and Kevin C. Oeffinger, Duke University, Durham, NC
| | - Yutaka Yasui
- Brent R. Weil, Arin L. Madenci, and Christopher B. Weldon, Boston Children's Hospital; Brent R. Weil, Arin L. Madenci, Lisa R. Diller, and Christopher B. Weldon, Harvard Medical School; Brent R. Weil, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brigham and Women's Hospital, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Rebecca M. Howell and Susan A. Smith, The University of Texas MD Anderson Cancer Center, Houston, TX; Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Joseph P. Neglia, University of Minnesota, Minneapolis, MN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Emily S. Tonorezos and Danielle N. Friedman, Memorial Sloan Kettering Cancer Center, New York; Louis S. Constine, University of Rochester Medical Center, Rochester, NY; and Kevin C. Oeffinger, Duke University, Durham, NC
| | - Joseph P Neglia
- Brent R. Weil, Arin L. Madenci, and Christopher B. Weldon, Boston Children's Hospital; Brent R. Weil, Arin L. Madenci, Lisa R. Diller, and Christopher B. Weldon, Harvard Medical School; Brent R. Weil, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brigham and Women's Hospital, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Rebecca M. Howell and Susan A. Smith, The University of Texas MD Anderson Cancer Center, Houston, TX; Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Joseph P. Neglia, University of Minnesota, Minneapolis, MN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Emily S. Tonorezos and Danielle N. Friedman, Memorial Sloan Kettering Cancer Center, New York; Louis S. Constine, University of Rochester Medical Center, Rochester, NY; and Kevin C. Oeffinger, Duke University, Durham, NC
| | - Wendy M Leisenring
- Brent R. Weil, Arin L. Madenci, and Christopher B. Weldon, Boston Children's Hospital; Brent R. Weil, Arin L. Madenci, Lisa R. Diller, and Christopher B. Weldon, Harvard Medical School; Brent R. Weil, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brigham and Women's Hospital, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Rebecca M. Howell and Susan A. Smith, The University of Texas MD Anderson Cancer Center, Houston, TX; Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Joseph P. Neglia, University of Minnesota, Minneapolis, MN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Emily S. Tonorezos and Danielle N. Friedman, Memorial Sloan Kettering Cancer Center, New York; Louis S. Constine, University of Rochester Medical Center, Rochester, NY; and Kevin C. Oeffinger, Duke University, Durham, NC
| | - Susan A Smith
- Brent R. Weil, Arin L. Madenci, and Christopher B. Weldon, Boston Children's Hospital; Brent R. Weil, Arin L. Madenci, Lisa R. Diller, and Christopher B. Weldon, Harvard Medical School; Brent R. Weil, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brigham and Women's Hospital, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Rebecca M. Howell and Susan A. Smith, The University of Texas MD Anderson Cancer Center, Houston, TX; Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Joseph P. Neglia, University of Minnesota, Minneapolis, MN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Emily S. Tonorezos and Danielle N. Friedman, Memorial Sloan Kettering Cancer Center, New York; Louis S. Constine, University of Rochester Medical Center, Rochester, NY; and Kevin C. Oeffinger, Duke University, Durham, NC
| | - Emily S Tonorezos
- Brent R. Weil, Arin L. Madenci, and Christopher B. Weldon, Boston Children's Hospital; Brent R. Weil, Arin L. Madenci, Lisa R. Diller, and Christopher B. Weldon, Harvard Medical School; Brent R. Weil, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brigham and Women's Hospital, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Rebecca M. Howell and Susan A. Smith, The University of Texas MD Anderson Cancer Center, Houston, TX; Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Joseph P. Neglia, University of Minnesota, Minneapolis, MN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Emily S. Tonorezos and Danielle N. Friedman, Memorial Sloan Kettering Cancer Center, New York; Louis S. Constine, University of Rochester Medical Center, Rochester, NY; and Kevin C. Oeffinger, Duke University, Durham, NC
| | - Danielle N Friedman
- Brent R. Weil, Arin L. Madenci, and Christopher B. Weldon, Boston Children's Hospital; Brent R. Weil, Arin L. Madenci, Lisa R. Diller, and Christopher B. Weldon, Harvard Medical School; Brent R. Weil, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brigham and Women's Hospital, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Rebecca M. Howell and Susan A. Smith, The University of Texas MD Anderson Cancer Center, Houston, TX; Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Joseph P. Neglia, University of Minnesota, Minneapolis, MN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Emily S. Tonorezos and Danielle N. Friedman, Memorial Sloan Kettering Cancer Center, New York; Louis S. Constine, University of Rochester Medical Center, Rochester, NY; and Kevin C. Oeffinger, Duke University, Durham, NC
| | - Louis S Constine
- Brent R. Weil, Arin L. Madenci, and Christopher B. Weldon, Boston Children's Hospital; Brent R. Weil, Arin L. Madenci, Lisa R. Diller, and Christopher B. Weldon, Harvard Medical School; Brent R. Weil, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brigham and Women's Hospital, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Rebecca M. Howell and Susan A. Smith, The University of Texas MD Anderson Cancer Center, Houston, TX; Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Joseph P. Neglia, University of Minnesota, Minneapolis, MN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Emily S. Tonorezos and Danielle N. Friedman, Memorial Sloan Kettering Cancer Center, New York; Louis S. Constine, University of Rochester Medical Center, Rochester, NY; and Kevin C. Oeffinger, Duke University, Durham, NC
| | - Christopher L Tinkle
- Brent R. Weil, Arin L. Madenci, and Christopher B. Weldon, Boston Children's Hospital; Brent R. Weil, Arin L. Madenci, Lisa R. Diller, and Christopher B. Weldon, Harvard Medical School; Brent R. Weil, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brigham and Women's Hospital, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Rebecca M. Howell and Susan A. Smith, The University of Texas MD Anderson Cancer Center, Houston, TX; Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Joseph P. Neglia, University of Minnesota, Minneapolis, MN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Emily S. Tonorezos and Danielle N. Friedman, Memorial Sloan Kettering Cancer Center, New York; Louis S. Constine, University of Rochester Medical Center, Rochester, NY; and Kevin C. Oeffinger, Duke University, Durham, NC
| | - Lisa R Diller
- Brent R. Weil, Arin L. Madenci, and Christopher B. Weldon, Boston Children's Hospital; Brent R. Weil, Arin L. Madenci, Lisa R. Diller, and Christopher B. Weldon, Harvard Medical School; Brent R. Weil, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brigham and Women's Hospital, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Rebecca M. Howell and Susan A. Smith, The University of Texas MD Anderson Cancer Center, Houston, TX; Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Joseph P. Neglia, University of Minnesota, Minneapolis, MN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Emily S. Tonorezos and Danielle N. Friedman, Memorial Sloan Kettering Cancer Center, New York; Louis S. Constine, University of Rochester Medical Center, Rochester, NY; and Kevin C. Oeffinger, Duke University, Durham, NC
| | - Gregory T Armstrong
- Brent R. Weil, Arin L. Madenci, and Christopher B. Weldon, Boston Children's Hospital; Brent R. Weil, Arin L. Madenci, Lisa R. Diller, and Christopher B. Weldon, Harvard Medical School; Brent R. Weil, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brigham and Women's Hospital, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Rebecca M. Howell and Susan A. Smith, The University of Texas MD Anderson Cancer Center, Houston, TX; Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Joseph P. Neglia, University of Minnesota, Minneapolis, MN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Emily S. Tonorezos and Danielle N. Friedman, Memorial Sloan Kettering Cancer Center, New York; Louis S. Constine, University of Rochester Medical Center, Rochester, NY; and Kevin C. Oeffinger, Duke University, Durham, NC
| | - Kevin C Oeffinger
- Brent R. Weil, Arin L. Madenci, and Christopher B. Weldon, Boston Children's Hospital; Brent R. Weil, Arin L. Madenci, Lisa R. Diller, and Christopher B. Weldon, Harvard Medical School; Brent R. Weil, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brigham and Women's Hospital, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Rebecca M. Howell and Susan A. Smith, The University of Texas MD Anderson Cancer Center, Houston, TX; Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Joseph P. Neglia, University of Minnesota, Minneapolis, MN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Emily S. Tonorezos and Danielle N. Friedman, Memorial Sloan Kettering Cancer Center, New York; Louis S. Constine, University of Rochester Medical Center, Rochester, NY; and Kevin C. Oeffinger, Duke University, Durham, NC
| | - Christopher B Weldon
- Brent R. Weil, Arin L. Madenci, and Christopher B. Weldon, Boston Children's Hospital; Brent R. Weil, Arin L. Madenci, Lisa R. Diller, and Christopher B. Weldon, Harvard Medical School; Brent R. Weil, Lisa R. Diller, and Christopher B. Weldon, Dana-Farber Cancer Institute; Arin L. Madenci, Brigham and Women's Hospital, Boston, MA; Qi Liu, University of Alberta, Edmonton, Alberta, Canada; Rebecca M. Howell and Susan A. Smith, The University of Texas MD Anderson Cancer Center, Houston, TX; Todd M. Gibson, Yutaka Yasui, Christopher L. Tinkle, and Gregory T. Armstrong, St Jude Children's Research Hospital, Memphis, TN; Joseph P. Neglia, University of Minnesota, Minneapolis, MN; Wendy M. Leisenring, Fred Hutchinson Cancer Research Center, Seattle, WA; Emily S. Tonorezos and Danielle N. Friedman, Memorial Sloan Kettering Cancer Center, New York; Louis S. Constine, University of Rochester Medical Center, Rochester, NY; and Kevin C. Oeffinger, Duke University, Durham, NC
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Weil BR, Al-Ibraheemi A, Vargas SO, Rangel SJ. Autoamputation of the Appendix Presenting as a Calcified Abdominal Mass Following Necrotizing Enterocolitis. Pediatr Dev Pathol 2017; 20:335-339. [PMID: 28727974 DOI: 10.1177/1093526616686256] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Autoamputation of the appendix has previously been reported in the literature, but it is likely an unusual event. We report a 2-year-old male child who had previously undergone laparotomy and bowel resection for necrotizing enterocolitis. Two years later a calcified intra-abdominal mass was identified on abdominal radiography and ultrasonography. Eventual laparotomy revealed a densely calcified mass within the transverse mesocolon. The mass was uneventfully resected. Pathologic evaluation showed appendiceal tissue, consistent with prior autoamputation of the vermiform appendix. Autoamputation of the appendix has not to our knowledge previously been associated with a calcified mass nor been associated with a history of necrotizing enterocolitis, and these factors distinguish this case as noteworthy.
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Affiliation(s)
- Brent R Weil
- 1 Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Alyaa Al-Ibraheemi
- 2 Department of Pathology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Sara O Vargas
- 2 Department of Pathology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Shawn J Rangel
- 1 Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
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Devji TF, Madenci AL, Carpino E, Leahy IC, Samnaliev M, Dearden JL, Weil BR, Weldon CB, Cravero J. Safety and cost-effectiveness of port removal outside of the operating room among pediatric patients. J Pediatr Surg 2016; 51:1891-1895. [PMID: 27624563 DOI: 10.1016/j.jpedsurg.2016.07.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 07/24/2016] [Accepted: 07/25/2016] [Indexed: 11/16/2022]
Abstract
PURPOSE The current emphasis on fiscally responsible health spending in the era of the Affordable Care Act and other health care reform necessitates cost-conscious delivery of care. "Value" in health care is defined as the quality of care divided by the cost. As such, health systems optimize value by providing the most cost-effective care possible without sacrificing safety or outcomes. Elective, minimal risk surgical procedures in children may be value-enhanced by moving from an operating room (OR) to a more cost-efficient setting. The purpose of this study was to assess the safety and cost of performing the removal of implantable central venous access devices ("ports") in locations other than the main OR. METHODS We compared port removal at three sites: 1. Main OR, 2. Satellite OR, and 3. Clinic Procedure Room. This was a mixed-methods study including a retrospective review of medical records and prospective observation/interviewing. To calculate cost without the inherent biases of hospital charges, costs, and payments, we utilized the methodology of time-driven activity based costing. Specifically, we recorded time spent by the patient in hospital facilities and with health care personnel. This duration was then weighted with the hourly cost of each health care professional and hospital space. The Mann-Whitney U test compared time and cost across the three sites. Overall cost at each site was divided by overall cost at the referent site (Main OR) to obtain a ratio of cost savings. RESULTS A total of 120 patients (40 per site) were included in the analysis. Demographic and clinical factors were not significantly different between sites. No complication occurred with port removal at any site. Time of the entire care episode was significantly decreased in the Clinic (median 161min, 95% confidence interval [CI] 134-188min), compared to the Main OR (median 235min, 95% confidence interval [CI] 209-251min) or Satellite OR (median 228min, 95% confidence interval [CI] 211-245min). Overall cost was decreased by 25% (95% CI: 13-34%) at the Clinic and by 6% (95% CI: -2-11%) at the Satellite OR, compared to the Main OR (referent, P<0.01). CONCLUSION In our study, port removal in the Clinic Procedure Room was not associated with increased risk of negative outcomes. Shifting port removal from the Main OR to the Clinic may result in substantial cost savings.
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Affiliation(s)
- Tehsina F Devji
- Department of Anesthesiology, Preoperative and Pain Medicine, Boston Children's Hospital, Boston, MA; Harvard School of Dental Medicine, Boston, MA
| | - Arin L Madenci
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Elizabeth Carpino
- Department of Anesthesiology, Preoperative and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Izabela C Leahy
- Department of Anesthesiology, Preoperative and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Mihail Samnaliev
- Department of Anesthesiology, Preoperative and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Jennifer L Dearden
- Department of Anesthesiology, Preoperative and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Brent R Weil
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Christopher B Weldon
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Joseph Cravero
- Department of Anesthesiology, Preoperative and Pain Medicine, Boston Children's Hospital, Boston, MA.
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Diehl KJ, Weil BR, Greiner JJ, Wright KP, Stauffer BL, DeSouza CA. Impaired endogenous fibrinolytic capacity in prehypertensive men. J Hum Hypertens 2015; 29:468-72. [PMID: 25566873 PMCID: PMC4762274 DOI: 10.1038/jhh.2014.120] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Revised: 10/29/2014] [Accepted: 11/04/2014] [Indexed: 12/14/2022]
Abstract
Prehypertension (BP 120–139/80–89 mmHg) is associated with an increased risk for future atherothrombotic events. Although the mechanisms underlying this elevated risk are not completely understood, one possibility is that prehypertension is associated with impaired endothelial fibrinolytic capacity. We tested the hypothesis that vascular endothelial release of t-PA is impaired in prehypertensive men. Net endothelial release of t-PA was determined, in vivo, in response to intrabrachial infusions of bradykinin (12.5, 25, 50 ng/100 mL tissue/min) and sodium nitroprusside at (1.0, 2.0, 4.0 µg/100 mL tissue/min) in 42 middle-age and older men: 16 normotensive (BP range: 100–119/57–79 mmHg); 16 prehypertensive (BP range: 120–139/76–89 mmHg); and 10 hypertensive (BP range: 140–150/74–100 mmHg). Net release of t-PA antigen was ~25% lower (P < 0.05) in the prehypertensive (−0.9 ± 0.8 to 42.4 ± 5.3 ng/100 mL tissue/min) compared with the normotensive (0.5 ± 1.0 to 53.9 ± 6.5 ng/100 mL tissue/min) men. There was no significant difference in t-PA release between the hypertensive (−1.8±1.6 to 40.8±6.6 ng/100 mL tissue/min) and prehypertensive groups. Sodium nitroprusside did not significantly alter t-PA release in any group. These data indicate that endothelial t-PA release is diminished in prehypertensive men. Further, the level of impairment in t-PA release seen with clinical hypertension is already apparent in the prehypertensive state. Impaired endothelial fibrinolytic function may underlie the increased atherothrombotic risk associated with blood pressure in the prehypertensive range.
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Affiliation(s)
- K J Diehl
- Department of Integrative Physiology, Integrative Vascular Biology Laboratory, University of Colorado, Boulder, CO, USA
| | - B R Weil
- Department of Integrative Physiology, Integrative Vascular Biology Laboratory, University of Colorado, Boulder, CO, USA
| | - J J Greiner
- Department of Integrative Physiology, Integrative Vascular Biology Laboratory, University of Colorado, Boulder, CO, USA
| | - K P Wright
- Department of Integrative Physiology, Integrative Vascular Biology Laboratory, University of Colorado, Boulder, CO, USA
| | - B L Stauffer
- 1] Department of Integrative Physiology, Integrative Vascular Biology Laboratory, University of Colorado, Boulder, CO, USA [2] Department of Medicine, University of Colorado, Denver, CO, USA [3] Denver Health Medical Center, Denver, CO, USA
| | - C A DeSouza
- 1] Department of Integrative Physiology, Integrative Vascular Biology Laboratory, University of Colorado, Boulder, CO, USA [2] Department of Medicine, University of Colorado, Denver, CO, USA
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Brewster BD, Weil BR, Ladd AP. Prospective determination of percutaneous endoscopic gastrostomy complication rates in children: Still a safe procedure. Surgery 2012; 152:714-9; discussion 719-21. [DOI: 10.1016/j.surg.2012.07.018] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2012] [Accepted: 07/12/2012] [Indexed: 01/01/2023]
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Herrmann JL, Fiege JW, Abarbanell AM, Weil BR, Wang Y, Poynter JA, Manukyan MC, Brewster BD, Meldrum DR. TGF-α equalizes age disparities in stem cell-mediated cardioprotection. J Surg Res 2012; 176:386-94. [PMID: 22316665 DOI: 10.1016/j.jss.2011.11.1012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2010] [Revised: 11/11/2011] [Accepted: 11/17/2011] [Indexed: 11/15/2022]
Abstract
BACKGROUND Neonatal mesenchymal stem cells exhibit less cardioprotective potential than their adult counterparts. Transforming growth factor-α (TGF-α) has been shown to stimulate adult stem cell VEGF production, however, it remains unknown whether it may augment neonatal stem cell paracrine function. We hypothesized that TGF-α would equalize adult and neonatal stem cell paracrine function and cardioprotection during acute ischemia/reperfusion. MATERIALS AND METHODS Bone marrow mesenchymal stem cells isolated from adult and 2.5 wk-old mice were treated with TGF-α (250 ng/mL) for 24 h. VEGF, HGF, IGF-1, IL-1β, and IL-6 production were measure in vitro, and cells were infused via an intracoronary route using a model of isolated heart perfusion. RESULTS TGF-α equalized adult and neonatal stem cell VEGF production but did not affect production of HGF, IGF-1, IL-1β, or IL-6. ERK, p38 MAPK, and JNK phosphorylation were greater in adult cells in response to TGF-α. Whereas infusion of adult but not neonatal stem cells was associated with improved myocardial functional recovery during reperfusion, infusions of either TGF-α-pretreated cell group were associated with the greatest functional recovery. TGF-α equalizes adult and neonatal mesenchymal stem cell VEGF production and cardioprotection in association with differential regulation of ERK, p38 MAPK, and JNK phosphorylation.
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Affiliation(s)
- Jeremy L Herrmann
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana 46202, USA
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Cameron SJ, Goulopoulou S, Weil BR, Kanaley JA. Regulation of blood flow by aspirin following muscle ischemia. Eur Rev Med Pharmacol Sci 2012; 16:143-150. [PMID: 22428464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND The vascular endothelium secretes a balance of dilator and constrictor substances which regulate vascular tone. During ischemic stress, this balance changes. After a short period of ischemia, a protective mechanism known as reactive hyperemia (RH) contributes to a post-ischemic increase in blood flow. The agents regulating this phenomenon remain controversial. AIM The purpose of this study was to examine whether aspirin regulates vascular endothelial function following ischemia. METHODS Sixteen healthy volunteers presented for two visits, each serving as their own control, and randomized to receive 500 mg aspirin or placebo. Forearm blood flow (FBF) was measured at baseline and during reactive hyperemia (RH) which was induced by five minutes of arterial occlusion. Blood samples were analyzed for vWF and lipids. RESULTS After ischemia, RH was attenuated when subjects were pre-medicated with 500 mg aspirin compared to placebo: AUC[aspirin] = 1450 +/- 201 mL/100 mL tissue/min vs. AUC[pIacebo] = 2207 +/- 294 mL/100 mL tissue/min; (p < 0.05). Separation of the subjects with high HDL or low HDL levels resulted in a similar peak FBF response with placebo, but in the high-HDL group only, aspirin ingestion attenuated peak FBF after ischemia compared to the placebo condition (22.6 +/- 1.7 m/100 mL tissue/min vs. 33.5 +/- 3.2 mL/100 mL tissue/min, respectively) (p < 0.05). CONCLUSIONS Aspirin partially regulates the RH response following ischemia compared to placebo, and this effect appears to be more profound when adjusting for plasma HDL concentration in healthy individuals. This suggests that the post-ischemic RH response may be partially mediated by arachidonic acid-derived mediators such as the prostaglandins.
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Affiliation(s)
- S J Cameron
- Department of Medicine, SUNY Upstate Medical University, Syracuse, USA
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Weil BR, Leys CM, Rescorla FJ. The jury is still out: changes in gastroschisis management over the last decade are associated with both benefits and shortcomings. J Pediatr Surg 2012; 47:119-24. [PMID: 22244403 DOI: 10.1016/j.jpedsurg.2011.10.029] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Accepted: 10/06/2011] [Indexed: 11/17/2022]
Abstract
PURPOSE Management of gastroschisis has shifted from early primary closure to preformed silo placement and delayed closure. We aimed to identify how closure techniques have changed and how outcomes have been affected. METHODS Records of patients undergoing gastroschisis closure at a single institution from 2000 to 2009 were reviewed. Patient characteristics and outcomes were collected and compared among those undergoing primary closure vs preformed silo placement. Outcomes were also compared in an era when primary closure predominated (2000-2002) vs one when primary silo predominated (2003-2009). RESULTS From 2000 to 2009, 203 patients underwent gastroschisis closure. Primary closure was performed in 50% of patients from 2000 to 2002 vs 12.3% from 2003 to 2009. Preformed silos were placed in 34.7% of patients from 2000 to 2002 vs 84.4% from 2003 to 2009. Patients treated from 2000 to 2002 experienced shorter hospital stays and shorter time to achievement of full enteral nutrition. Patients treated from 2003 to 2009 developed fewer ventral hernias and wound infections and required less ventilator days. Patients undergoing early primary closure developed ventral hernias at higher rates compared with those treated with preformed silos. Intensive care unit stay was longer for patients receiving preformed silos. CONCLUSION Change in our management strategy has resulted in prolonged intensive care unit stay and time to full feeds but reduced postoperative hernias and wound infections.
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Affiliation(s)
- Brent R Weil
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
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Hollander LL, Leys CM, Weil BR, Rescorla FJ. Predictive value of response to steroid therapy on response to splenectomy in children with immune thrombocytopenic purpura. Surgery 2011; 150:643-8. [PMID: 22000175 DOI: 10.1016/j.surg.2011.07.063] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2011] [Accepted: 07/18/2011] [Indexed: 11/25/2022]
Abstract
BACKGROUND Many but not all studies suggest that a favorable response to preoperative steroid therapy predicts a successful outcome after splenectomy in children with immune thrombocytopenic purpura (ITP). The purpose of this study is to further examine the relationship between steroid response and outcome after splenectomy in children. METHODS After institutional review board approval, records of children undergoing splenectomy for ITP were reviewed. Patients' responses were determined by platelet counts and grouped by complete response (CR; ≥ 150,000/μL), partial response (PR; 149,999- ≥ 50,000/μL), or no response (NR; <50,000/μL). RESULTS Thirty-seven children were identified. After steroid therapy, 20 patients (54%) had CR, 9 (24%) had PR, and 8 (22%) had NR. After splenectomy, 31 patients (84%) had CR, 6 (16%) had PR, and 0 had NR. Of the 20 patients that had a CR to steroid therapy, 18 (80%) had CR and 2 (20%) had PR to splenectomy. Of the 9 patients that had PR to steroids, 7 (78%) had CR to splenectomy and 2 (22%) had PR. Of the 8 patients that had NR to steroids, 6 (75%) had CR and 2 (25%) had PR to splenectomy. Response to splenectomy was not associated with response to steroids (P = .59). CONCLUSION These data suggest that response to splenectomy in children with ITP is unrelated to previous response to steroids.
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Affiliation(s)
- Lindsay L Hollander
- Section of General Surgery, Indiana University School of Medicine, Indianapolis, IN 46202, USA
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Herrmann JL, Weil BR, Abarbanell AM, Wang Y, Poynter JA, Manukyan MC, Meldrum DR. IL-6 and TGF-α costimulate mesenchymal stem cell vascular endothelial growth factor production by ERK-, JNK-, and PI3K-mediated mechanisms. Shock 2011; 35:512-6. [PMID: 21263382 DOI: 10.1097/shk.0b013e31820b2fb9] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Mesenchymal stem cells (MSCs) protect ischemic tissues in part through paracrine growth factor production. IL-6, which is upregulated in the heart during ischemia, has been shown to enhance stem cell proliferation and migration. The effect of IL-6 on MSC paracrine function, however, remains unknown. In addition, TGF-α increases MSC vascular endothelial growth factor (VEGF) production and may share downstream signaling pathways with IL-6 involving ERK, JNK, and PI3K. We hypothesize that cotreatment with IL-6 and TGF-α will result in greater MSC VEGF production than by either treatment alone via these signaling pathways. Murine MSCs were treated with IL-6 (0.05 ng/mL) with or without TGF-α (250 ng/mL) and in combination with inhibitors of ERKI/II, JNK, and PI3K for 24 h. Vascular endothelial growth factor concentrations in the supernatants were measured using enzyme-linked immunosorbent assay. Phosphorylation of ERK, JNK, and PI3K was measured using Western blot analysis. IL-6 increased MSC VEGF production at a dose of 0.05 ng/mL, and the combination of IL-6 and TGF-α (250 ng/mL) increased VEGF production to a greater extent than IL-6 or TGF-α alone. IL-6 induced phosphorylation of ERK, JNK, and PI3K, and inhibition of each suppressed IL-6-induced VEGF production. TGF-α cotreatment overcame VEGF suppression after ERK2 inhibition but not ERK1, JNK, or PI3K. These data suggest that IL-6 stimulates MSC VEGF production alone and additively with TGF-α via ERK-, JNK-, and PI3K-mediated mechanisms. IL-6 and TGF-α cotreatment may be a useful strategy for enhancing MSC VEGF production and cardioprotection during myocardial ischemia.
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Affiliation(s)
- Jeremy L Herrmann
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Manukyan MC, Keck AC, Poynter JA, Wang Y, Weil BR, Abarbanell AM, Herrmann JL, Crowe BJ, Alvernaz C, Meldrum DR. Transforming growth factor-alpha does not protect myocardium during acute ischemia/reperfusion. Surgery 2011; 150:339-46. [DOI: 10.1016/j.surg.2011.05.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2011] [Accepted: 05/16/2011] [Indexed: 12/28/2022]
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Crowe B, Poynter JA, Manukyan MC, Wang Y, Brewster BD, Herrmann JL, Abarbanell AM, Weil BR, Meldrum DR. Pretreatment with intracoronary mimosine improves postischemic myocardial functional recovery. Surgery 2011; 150:191-6. [DOI: 10.1016/j.surg.2011.05.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2011] [Accepted: 05/13/2011] [Indexed: 10/17/2022]
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