The implementation of a national paediatric oncology protocol for neuroblastoma in South Africa

Purpose

The aim of the World Health Organization-International Paediatric Oncology Society is to improve childhood cancer survival in low- and middle-income countries to 60% by 2030. This can be achieved using standardised evidence-based national treatment protocols for common childhood cancers. The aim of the study was to describe the development and implementation of the SACCSG NB-2017 neuroblastoma (NB) treatment protocol as part of the treatment harmonisation process of the South African Children’s Cancer Study Group.

Methods

The Consolidated Framework for Implementation Research was used to identify factors that could influence the implementation of the national NB protocol as a health care intervention. The evaluation was done according to five interactive domains for implementation: intervention characteristics, inner setting, outer setting, individual or team characteristics and the implementation process.

Results

The protocol was developed over 26 months by 26 physicians involved in childhood cancer management. The process included an organisational phase, a resource identification phase, a development phase and a research ethics approval phase. Challenges included nationalised inertia, variable research ethical approval procedures with delays and uncoordinated clinical trial implementation.

Conclusion

The implementation of the national NB protocol demonstrated the complexity of the implementation of a national childhood cancer treatment protocol. However, standardised paediatric cancer treatment protocols based on local expertise and resources in limited settings are feasible.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10552-021-01424-2.

Age at diagnosis as a prognostic factor in South African children with neuroblastoma

PURPOSE

Low- and middle-income countries (LMICs) reported a higher median age at diagnosis of neuroblastoma (NB) compared to high-income countries. The aim was to determine if the optimal age at diagnosis, which maximizes the difference in overall survival between younger versus older patients in the South African population was similar to the internationally validated 18 months age cut-point.

METHODS

Four hundred sixty NB patients diagnosed between 2000 and 2016 were included. Receiver operating characteristic (ROC) curves were used to predict potential age cut-point values for overall survival in all risk group classifications. Risk ratios, sensitivity, specificity, and positive and negative predictive values at the specific cut-points were estimated with 95% confidence intervals, and time to mortality by age at the specific cut-points was shown with Kaplan-Meier curves and compared using log-rank tests.

RESULTS

The median age at diagnosis for the total cohort was 31.9 months (range 0.2-204.7). For high-risk (HR), intermediate-risk, low-risk, and very low-risk patients, the median age at diagnosis was, respectively, 36 months (range 0.4-204.7), 16.8 months (range 0.7-145.1), 14.2 months (range 2.0-143.5), and 8.7 months (range 0.2-75.6). The ROC curves for the total NB cohort (area under the curve [AUC] 0.696; P < .001) and HR (AUC 0.682; P < .001) were analyzed further. The optimal cut-point value for the total cohort was at 19.1 months (sensitivity 59%; specificity 78%). The HR cohort had potential cut-point values identified at 18.4 months age at diagnosis (sensitivity 45%; specificity 87%) and 31.1 months (sensitivity 67%; specificity 62%). The 19.1 months cut-point value in the total cohort and the 18.4 months cut-point value in HR were as useful in predicting overall survival as 18 months age at diagnosis.

CONCLUSION

The 18 months cut-point value appears to be the appropriate age for prognostic determination, despite the higher median age at diagnosis in South Africa.

The evaluation of induction chemotherapy regimens for high-risk neuroblastoma in South African children. Pediatr Hematol Oncol 2020;37:300-313. [PMID: 32075464 DOI: 10.1080/08880018.2020.1717698]

Achieving remission after induction therapy in high-risk neuroblastoma (HR-NB) is of significant prognostic importance. This study investigated remission after induction-chemotherapy using three standard neuroblastoma protocols in the South African (SA) setting. Retrospective data of 261 patients with HR-NB diagnosed between January 2000 and December 2016, who completed induction chemotherapy with standard treatment protocols were evaluated. The treatment protocols were either OPEC/OJEC or the St Jude NB84 protocol (NB84) or rapid COJEC (rCOJEC). The postinduction metastatic complete remission (mCR) rate, 2-year overall survival (OS) and 2-year event free survival (EFS) were determined as comparative denominators. The majority (48.3%; n = 126) received OPEC/OJEC, while 70 patients received (26.8%) rCOJEC and 65 (24.9%) NB84. Treatment with NB84 had the best mCR rate (36.9%), followed by OPEC/OJEC (32.5%) and rCOJEC (21.4%). The 2-year OS of treatment with NB84 was 41% compared to OPEC/OJEC (35%) and rCOJEC (24%) (p = 0.010). The 2-year EFS of treatment with NB84 was 37% compared to OPEC/OJEC (35%) and rCOJEC (18%) (p = 0.008). OPEC/OJEC had the least treatment-related deaths (1.6%) compared to rCOJEC (7.1%) and NB84 (7.5%) (p = 0.037). On multivariate analysis LDH (p = 0.023), ferritin (p = 0.002) and INSS stage (p = 0.006) were identified as significant prognostic factors for OS. The induction chemotherapy was not significant for OS (p = 0.18), but significant for EFS (p = 0.08) Treatment with NB84 achieved better mCR, OS and EFS, while OPEC/OJEC had the least treatment-related deaths. In resource-constrained settings, OPEC/OJEC is advised as induction chemotherapy in HR-NB due to less toxicity as reflected in less treatment-related deaths.

The importance of local control management in high-risk neuroblastoma in South Africa

PURPOSE

To investigate the impact of local therapies on high-risk neuroblastoma (HR-NB) outcomes in South Africa.

METHODS

Data from 295 patients with HR-NB from nine pediatric oncology units between 2000 and 2014 were analysed. All patients received chemotherapy. Five-year overall (OS) and event free survival (EFS) were determined for patients who had received local therapy, either surgery or radiotherapy or both.

RESULTS

Surgery was performed in only 35.9% (n = 106/295) patients. Surgical excision was done for 34.8% (n = 85/244) of abdominal primaries, 50.0% (n = 11/22) of thoracic primaries; 22.2% (n = 2/9) neck primaries and 66.7% (n = 8/12) of the paraspinal primaries. Only 15.9% (n = 47/295) of all patients received radiotherapy. Children, who had surgery, had an improved five-year OS of 32.1% versus 5.9% without surgery (p < 0.001). Completely resected disease had a five-year OS of 30.5%, incomplete resections 31.4% versus no surgery 6.0% (p < 0.001). Radiated patients had a five-year OS of 21.3% versus 14.2% without radiotherapy (p < 0.001). Patients who received radiotherapy without surgical interventions, had a marginally better five-year OS of 12.5% as opposed to 5.4% (p < 0.001). Patients who underwent surgery had a longer mean overall survival of 60.9 months, while patients, who were irradiated, had a longer mean overall survival of 7.9 months (p < 0.001). On multivariate analysis, complete metastatic remission (p < 0.001), surgical status (p = 0.027), and radiotherapy status (p = 0.040) were significant predictive factors in abdominal primaries.

CONCLUSION

Surgery and radiotherapy significantly improve outcomes regardless of the primary tumor site, emphasizing the importance of local control in neuroblastoma.

Overall survival for neuroblastoma in South Africa between 2000 and 2014

BACKGROUND

Outcome data for neuroblastoma in sub-Saharan Africa are minimal, whereas poor outcome is reported in low- and middle-income countries. A multi-institutional retrospective study across South Africa was undertaken to determine outcome.

METHODS

Patients treated between January 2000 and December 2014 in nine South African pediatric oncology units were included. Kaplan-Meier curves and Cox regression models were employed to determine two-year survival rates and to identify prognostic factors.

RESULTS

Data from 390 patients were analyzed. The median age was 39.9 months (range, 0-201 months). The majority presented with stage 4 disease (70%). The main chemotherapy regimens were OPEC/OJEC (44.8%), St Jude NB84 protocol (28.96%), and Rapid COJEC (22.17%). Only 44.4% had surgery across all risk groups, whereas only 16.5% of high-risk patients received radiotherapy. The two-year overall survival (OS) for the whole cohort was 37.6%: 94.1%, 81.6%, and 66.7%, respectively, for the very-low-risk, low-risk, and intermediate-risk groups and 27.6% for the high-risk group (P < 0.001, 95% CI). The median survival time for the whole group was 13 months (mean, 41.9 months; range, 0.1-209 months). MYCN-nonamplified patients had a superior two-year OS of 51.3% in comparison with MYCN-amplified patients at 37.3% (P = 0.002, 95% CI).

CONCLUSIONS

Limited disease had an OS comparable with high-income countries, but advanced disease had a poor OS. South Africa should focus on early diagnosis and implementation of a national protocol with equitable access to treatment.

Paediatric surgery outreach: analysis of referrals to a tertiary paediatric surgery service to plan an outreach programme Kwa-Zulu Natal, South Africa

Paediatric surgical disease is a neglected health problem. Patients travel great distances to tertiary level care for management. This study aimed at analysing referral patterns to design an outreach programme for paediatric surgery in KwaZulu Natal. Data forms of patients referred to the service between January and July 2016 were correlated with the clinical record. Delays in management were compared to morbidity and mortality. Out of 781, 158 referrals were accepted as emergencies. The majority (62%) were children aged < 1 year. Gastro-intestinal problems (38.4%) and congenital anomalies (26.9%) formed the majority. Patients who died had a significantly longer delay in transfer. Longer total delay was associated with statistically significant greater morbidity. In a setting where a large rural population is served by single-centre tertiary care, delays exist and contribute to morbidity. The authors advocate the establishment of an outreach programme to address these issues.

Nutritional status of children with Wilms' tumour on admission to a South African hospital and its influence on outcome

BACKGROUND

In developing countries up to 77% of children with cancer have been shown to be malnourished on admission. High rates of malnutrition occur due to factors such as poverty and advanced disease. Weight can be an inaccurate parameter for nutritional assessment of children with solid tumours as it is influenced by tumour mass. This study aimed to assess the prevalence of malnutrition amongst children with Wilms tumour (WT), the level of nutritional support received on admission and the influence of nutritional status on outcome.

METHODS

Seventy-six children diagnosed with WT and admitted to Inkosi Albert Luthuli Central Hospital between 2004 and 2012 were studied prospectively. Nutritional assessment was conducted using weight, height, mid-upper arm circumference (MUAC) and triceps skinfold thickness (TSFT) prior to initiating treatment. Outcome was determined 2 years after admission. Time until commencement of nutritional resuscitation and nature, thereof, were recorded.

RESULTS

Stunting and wasting was evident in 12% and 15% of patients, respectively. The prevalence of malnutrition was 66% when MUAC, TSFT and albumin were used. Malnutrition was not a predictor of poor outcome and did not predict advanced disease. The majority of patients (84%) received nutritional resuscitation within 2 weeks of admission.

CONCLUSIONS

When classifying nutritional status in children with WT, the utilisation of weight and height in isolation can lead to an underestimation of the prevalence of malnutrition. Nutritional assessment of children with WT should also include MUAC and TSFT. Early aggressive nutritional resuscitation is recommended.

High-risk neuroblastoma in a sub-Saharan African country: telling it like it is

Neuroblastoma is uncommon in Africa, but when seen usually presents as high-risk disease with a poor prognosis. This aggressive biology of the tumour is frequently augmented by delayed presentation. Current treatment depends upon technologies and skills that are scarce in developing countries and the cost involved is generally beyond the means of healthcare providers who are faced with a myriad more pressing healthcare issues. The presentation, treatment and outcome of 45 African children with neuroblastoma are described. Due to a lack of resources precise risk stratification was impossible but visceral or bone metastases were present in 73% of patients at diagnosis. In 91% the primary tumour was intra-abdominal. Three children (7%) were paraplegic on admission. A localised tumour was seen in one child (2%). Fifteen children (33%) underwent a surgical procedure, with intent to cure in five among whom resection was incomplete in three. For all other children, treatment was palliative using chemotherapy with judicious use of radiotherapy. Thirteen children (29%) survived longer than six months. Overall survival at three years was 4%.

The impact of ethnicity on wilms tumor: characteristics and outcome of a South african cohort

Background. Nephroblastoma is the commonest renal tumour seen in children. It has a good prognosis in developed countries with survival rates estimated to be between 80% and 90%, while in Africa it remains low. Method. Retrospective study of patients diagnosed with nephroblastoma who are seen at 4 paediatric oncology units, representing 58.5% of all South African children with nephroblastoma and treated following SIOP protocol between January 2000 and December 2010. Results. A total of 416 patients were seen at the 4 units. Over 80% of our patients were African and almost 10% of mixed ethnicity. The most common stage was stage 4. The median survival was 28 months after diagnosis with the mixed ethnicity patients recording the longest duration (39 months) and the white patients had the shortest median survival. The overall 5-year survival rate was estimated to be 66%. Stage 2 patients did significantly better (85%). Conclusions. Our patients are similar with regard to gender ratio, median age, and age distribution as described in the literature, but in South Africa the more advanced stage disease seen than in other developed countries is translated into low overall survival rate.

Intra-abdominal sepsis--epidemiology, aetiology and management

Peritonitis is a progressive disease leading inexorably from local peritoneal irritation to overwhelming sepsis and death unless this trajectory is interrupted by timely and effective therapy. In children peritonitis is usually secondary to intraperitoneal disease, the nature of which varies around the world. In rich countries, appendicitis is the principal cause whilst in poor countries diseases such as typhoid must be considered in the differential diagnosis. Where resources are limited, the clinical diagnosis of peritonitis mandates laparotomy for diagnosis and source control. In regions with unlimited resources, radiological investigation, ultrasound, CT scan or MRI may be used to select patients for non-operative management. For patients with appendicitis, laparoscopic surgery has achieved results comparable to open operation; however, in many centres open operation remains the standard. In complicated peritonitis "damage control surgery" may be appropriate wherein source control is undertaken as an emergency with definitive repair or reconstruction awaiting improvement in the patient's general condition. Awareness of abdominal compartment syndrome is essential. Primary peritonitis in rich countries is seen in high-risk groups, such as steroid-dependent nephrotic syndrome patients, whilst in poor countries the at-risk population is less well defined and the diagnosis is often made at surgery.

Age is not a prognostic factor in children with Wilms tumor beyond stage I in Africa

BACKGROUND

Patients under age 4 with stage I favorable histology (FH) Wilms tumor have a reported survival advantage. Among children above 10 years, a poorer prognosis has been associated with a higher prevalence of diffuse anaplasia.

PURPOSE

To determine if, in our practice, patients with Wilms tumors >8 years of age (stage II-V) have a poorer prognosis than those aged <8 years or <4 years.

PROCEDURE

Case-control study of 19 patients >8 years with Wilms tumor stages II-V who were identified from a cohort of 192 new patients (2002-2012). For each patient two controls were chosen matched for stage and histology, one 0-3 years and one 4-7 years. Neo-adjuvant chemotherapy was offered to all, combined with intensive supportive care. Postoperative treatment was determined by local stage and histology. OS and EFS at 5 years for the different age groups were compared.

RESULTS

Each age group contained 19 patients, of whom 6 had stage II tumors, 3 stage III, 8 stage IV, and 2 stage V. Histology was intermediate risk (IR) in 17 and high risk (HR) in 2. OS at 5 years was 80.8% and EFS was 79.2% for the whole group. No significant difference in outcome could be shown between age groups. Loss to follow up was 6/57 (11%).

CONCLUSIONS

The survival advantage of young age (<4 years) associated with stage I FH could not be demonstrated in higher stages. Age had no significant impact on prognosis although a trend to better outcome was seen in children <4 years.

Paediatric head injuries in the Kwazulu-Natal Province of South Africa: a developing country perspective

Summary

We investigated the causes, management and outcome of head injuries in paediatric patients admitted to the paediatric surgery unit at King Edward VIII Hospital overa 3-year period, from 1999 to 2001. There were 506 patients (331 male; M:F ratio 2:1) and the mean age was 71.99 +36.8 months (2 weeks to 180 months). The injuries were due to: motor vehicle crashes (324); falls (121); assault (30); inadvertent injury (23); and unknown (11). Forty-nine patients (9%) were admitted with a Glasgow Coma Scale ≤8. The most common intracranial pathology on computed tomography was: intracranial haematoma/haemorrhage (44); contusion (16); and brain oedema (10). Nineteen patients (3.4%) underwent neurosurgical intervention and the rest were managed conservatively. Eighteen died in hospital (3.6%). The mean hospital stay was 5 ± 12 days. Twenty-three patients (4.5%) were discharged with neurological sequelae. Few paediatric patients are admitted with severe head injury: the majority from blunt injury caused by motor vehicle crashes. Management mainly requires simple neurological observation in a general ward with a surprisingly good prognosis. Specific protocols for paediatric head injuries have been proposed based on these findings.

The results of treatment of children with metastatic Wilms tumours (WT) in an African setting: do liver metastases have a negative impact on survival?

BACKGROUND

From Africa, where socio-economic circumstances differ from the developed world, there are no data regarding the influence of liver metastases on survival of children with Wilms tumour.

PROCEDURE

One hundred fifty new patients with WT were seen between 2002 and 2010, 45 (30%) had metastases at diagnosis. Seven patients had bilateral disease with additional visceral metastases. Nine patients who developed liver metastases during treatment were excluded. The site of metastases and the results of pretreatment biopsies were retrieved. Neo-adjuvant chemotherapy was combined with nutritional resuscitation, and aggressive supportive care. Post-operative treatment was determined by stage and histology.

RESULTS

Liver metastases were present in 19 (42%) patients but were the sole metastatic site in only 4 (9%). Overall survival at 5 years was 58.5%. Event Free Survival was 54%. Thirty-three (73%) had favourable histology, nine unfavourable and undetermined in three. No influence of histology on outcome was evident. Three patients had resection of persistent liver metastases. The pattern of metastatic disease had no influence on outcome. Despite aggressive supportive care two patients (4%) died within a week of presentation. Two patients died of chemotoxicity and two of complications following biopsy. Eight patients (17%) were lost to follow-up of whom five were on palliative treatment only.

CONCLUSIONS

In Africa liver metastases do not appear to worsen the prognosis of children with Stage IV WT. Despite the poor socio-economic circumstances survival is comparable to other countries.

Pediatric non-Wilms' renal tumors: a third world experience

BACKGROUND

Pediatric non-Wilms' renal tumors (NWRT) are poorly understood owing to their heterogeneity and relative rarity. This study aimed at auditing the outcome of the management of NWRT in a tertiary hospital in the Third World.

METHODS

Records of all patients (n = 68) treated for NWRT over a 32-year period (1978-2010) were reviewed retrospectively.

RESULTS

The major histological groups included clear cell sarcoma of the kidney (CCSK) (33.8%), mesoblastic nephroma (17.6%), cystic partially differentiated nephroblastoma (CPDN) (17.6%), intrarenal neuroblastoma (8.8%), malignant rhabdoid tumor (MRT) (7.4%), and renal cell carcinoma (RCC) (5.9%). Sixteen (69.7%) patients with CCSK and 11 (91.7%) with CPDN were aged 1-4 years. Ten (83.3%) patients with mesoblastic nephroma were aged <1 year and three (60.0%) with RCC were aged 10-14 years. Ten (43.5%) patients with CCSK and four (80.0%) with RCC had metastases at diagnosis. The sensitivity of a pretreatment Tru-Cut biopsy was 100% for MRT. All the patients with CCSK, mesoblastic nephroma, CPDN, and RCC had radical nephrectomy. Only eight (34.8%) patients with CCSK received radiotherapy. The overall 1-10-year survival rates were 52.2%, 91.7%, 75.0%, 40.0% and 0.0% for CCSK, mesoblastic nephroma, CPDN, RCC, and MRT, respectively. The overall 1-10-year survival for the entire cohort was 51.5%.

CONCLUSIONS

The demography and clinical presentation of pediatric NWRT, which comprises 13.6% of pediatric renal tumors in the Third World, were similar to those in the Developed World. The overall 1-10-year survival for pediatric NWRT was low.

Intestinal inflammatory myofibroblastic tumour

BACKGROUND

Inflammatory myofibroblastic tumours (IMFTs) are rare tumours characterised by nosologic, histogenetic and aetiopathogenetic controversy and variable clinicopathological features. We report our experience with intestinal-IMFTs (I-IMFTs) that have been reported mainly as single case reports to date.

METHODS

Five patients with I-IMFTs, identified between 2005 and 2008, formed the study cohort. The clinicopathological features were obtained from departmental and hospital records.

RESULTS

The median patient age was 13 years. While 4 patients presented with symptoms and signs of intestinal obstruction, one IMFT was an incidental finding at laparotomy for trauma. Three I-IMFTs were located in the small bowel and 2 in the colon. Complete resection with end-to-end anastomoses was performed. The gross morphology included 1 polypoid myxoid tumour that served as a lead point for an intussusception, 3 multinodular whorled masses and 1 firm circumferential, infiltrative tumour. Microscopically, all tumours had typical features of IMFT with variable expression of ALK-1, a low proliferation index and tumour-free resection margins. All patients had an uneventful recovery. One patient was lost to further follow-up. Four patients were well, without local recurrence or metastases at 6 months to 3 years.

CONCLUSIONS

Surgery with tumour-free resection margins is the gold standard of care of adult and paediatric I-IMFTs. Heightened recognition of I-IMFT, albeit rare, as a cause of intestinal obstruction, including intussusception, is necessary for pre-operative suspicion of I-IMFT.

Hypertrophic pyloric stenosis in the Third World

The relative rarity of hypertrophic pyloric stenosis (HPS) in the developing world makes its diagnosis a challenge to many physicians. This study audits the management of HPS at a tertiary hospital in South Africa, with a view to defining its regional pattern. This is a retrospective review of records of all patients ( n = 63) managed for HPS over an eight-year period (2002–2010). The mean age at presentation was 6.2 weeks and the male/female ratio was 6:1. The majority of patients presented with non-bilious vomiting. Abdominal ultrasound had a sensitivity of 65% and 81.3% when the criteria of pyloric muscle thickness >4 mm and pyloric channel length >16 mm were used, respectively. The overall complication rate was 14.3% and the mortality rate was 0%. Despite the rarity of HPS in the Third World, the outcome of its management is favourable. However, the sensitivity of abdominal ultrasound for diagnosing HPS is low.

The management of nephroblastoma with cavo-atrial disease at presentation: experience from a developing country

PURPOSE

To describe the management of cavoatrial extension of nephroblastoma in a developing country.

PATIENTS AND METHODS

Of 406 consecutive children with Wilms tumour, 40 (10%) presented with tumour extension into the inferior vena cava (IVC) (30), right atrium or right ventricle and form the inception cohort. Of this group, 17 (43%) had visceral metastases and two had bilateral synchronous tumours.

RESULTS

Neoadjuvant chemotherapy appropriate to the pre-operative stage caused reduction in intravascular tumour in 18 (45%) patients, allowing 3 children who had atrial tumour at presentation to be surgically managed without recourse to cardiopulmonary bypass. Neoadjuvant chemotherapy also provided a window of opportunity to assess and manage co-morbidity especially malnutrition. Of the inception cohort, 31 (78%) underwent surgical resection; 23 had simple cavotomy, one caval resection and seven resection under cardiopulmonary bypass. There was one post-operative death. 77% of resected specimen contained viable malignant cells despite one or more cycles of neoadjuvant chemotherapy. Retrograde extension into caval tributaries threatened the completeness of resection in all patients necessitating the addition of post-operative radiotherapy. Of nine patients who did not undergo resection, five died pre-operatively. Three of these children died of chemotherapy induced neutropaenic sepsis. Four patients refused surgical treatment. Twenty-three patients completed the post-operative treatment protocol (1,203 characters).

Retrospective surveillance of intussusception in South Africa, 1998-2003

BACKGROUND

Intussusception is a common gastrointestinal emergency in children and appears to have a somewhat different clinical spectrum in developing countries. Its etiology is still unclear, but a link to infective agents and viruses has been highlighted. This study aimed to assess the clinical spectrum and prevalence of intussusception in children from the diverse South African population.

METHODS

Retrospective data were obtained from 9 participating pediatric referral units on the occurrence of intussusception in South African children (<14 years old) during a 6-year period (1998-2003). Results were correlated with national population statistics. Intussusception was anatomically classified into ileoileal, ileocolic, and colocolic types. The clinical features, management, outcome, and possible causes were examined.

RESULTS

We reviewed the occurrence and clinical spectrum of intussusception in 423 children (age, 0-14 years) presenting with acute intussusception to 9 pediatric surgical centers. The mean duration of symptoms was 1.5 days, but a delayed presentation was common (median delay, 2.3 days). Intussusception occurred throughout the year, with a peak in the summer months. The majority of patients (89%) were <2 years old, and 78% presented at age 3-18 months of age. Crude population estimates indicate an occurrence of 1 case per 3123 population <2 years old. Only 11% of patients presented after 2 years of age, and the age at presentation was significantly lower (P < .05) in black African patients. All ethnic groups were affected. In 84% of patients, intussusception occurred at the ileocolic region junction, in 7% it was ileoileal, and in 9% it was colocolic. Colocolic intussusception appeared more common in black African patients, and associated pathologic conditions (polyps and Burkitt's lymphoma) occurred mainly in older children. Surgical intervention was required in 81% of patients and involved resection of gangrenous bowel in 40%.

CONCLUSION

Intussusception appears to be a relatively frequent occurrence in children in South Africa. Although the clinical spectrum appears to vary, there is an apparent link to intestinal infection, which requires further investigation. A collaborative approach is required to ascertain the relationship of intussusception to preventable infections and to improve its diagnosis and management.

Clear cell sarcoma of the kidney in children: experience in a developing country

INTRODUCTION

Clear cell sarcoma of the kidney (CCSK) is a rare tumour comprising 4% of primary renal tumours in children. It has a unique constellation of chromosomal and molecular features and should no longer be viewed as an unfavourable histological variant of Wilms tumour. Little is known of its clinical presentation and pathological profile in children living in a developing country.

AIM

To describe the clinical and pathological features of CCSK in children in our practice and to identify factors contributing to poor patient outcomes.

METHOD

A retrospective review of patients with a confirmed diagnosis of CCSK who presented for treatment at a single institution between 1990 and 2008.

RESULTS

14 patients fulfilled the inception criteria. They represented 4% of 356 patients presenting with primary renal tumours during the review period. Clinical and radiological features were indistinguishable from Wilms tumour. Tumours were large (Mean mass 1.4 kg; median 0.9 kg) and metastases were common (42%). Lung and lymph node metastases were more common than skeletal disease. Co-morbidity, particularly hypertension (64%) was common. Initial diagnosis by needle biopsy was correct in only two of seven patients (29%) leading to inappropriate neoadjuvant chemotherapy. Overall survival is poor with 57% of patients alive and disease free from 1 to 7 years off treatment.

CONCLUSION

In a developing country, CCSK is rare and clinically and radiologically indistinguishable from Wilms tumour. Associated hypertension is common. Pretreatment diagnosis is difficult and sampling errors using needle biopsies may be unavoidable. Treatment results are poor and, given the propensity for late recurrence in CCSK, may not be sustained.

Gastroschisis: a third world perspective

PURPOSE

The incidence of gastroschisis is rising worldwide. In developed countries advances in neonatal intensive care (NICU) and the availability of total parenteral nutrition have improved survival for such patients, but in the third world mortality rates remain high. The aim of this study was to evaluate the impact of modern intensive care facilities on the mortality of babies with gastroschisis in Africa.

METHODS

A retrospective review of all neonates admitted with a diagnosis of gastroschisis at Inkosi Albert Luthuli Central Hospital in Durban over a 6-year period (2002-2007) was conducted.

RESULTS

A total of 106 babies with gastroschisis presented during the review period. The prevalence of gastroschisis amongst neonatal surgical admissions increased from 6% in 2003 to 15% in 2007. 72% of patients weighed less than 2.5 kg at birth and 64% were premature (<37 weeks gestation). 91% were "outborn" with 71% delivered vaginally. Median maternal age was 22.6 years and 57% of mothers were primiparous. Primary abdominal wall closure was possible in 74% of patients. The overall mortality was 43% with sepsis being the leading cause. Staged closure was associated with a higher mortality than primary closure.

CONCLUSION

The prevalence of gastroschisis amongst neonatal surgical admissions appears to be increasing. Most babies were "outborn" resulting in delays in diagnosis and referral for surgical management. Despite the availability of NICU and total parenteral nutrition the mortality remains high. Reduction in mortality will depend upon improvements in antenatal diagnosis, primary care and transportation, as well as a reduction in postsurgical sepsis.

The spectrum of anorectal malformations in Africa

Anorectal malformations (ARM) remain a significant birth defect with geographic variation in incidence, individual phenotypes and regional geographic subtypes. Although early studies indicated a low incidence in Black patients, there is a great paucity of knowledge as to the types, frequency and incidence of ARMs encountered in the African continent and their associated anomalies. Current evidence suggests a significant clinical load. This study set out to evaluate ARM in Southern and other parts of Africa to define the clinical load of ARM. We retrospectively collected data on 1,401 ARM patients from six South African Paediatric Surgical units plus representative samples from five other African countries from West, Central and Southern Africa. Data included ethnic group, age, gender as well as the anatomical pathology, classification and presence or absence of associated anomalies. ARM lesions classified by the Wingspread classification plus an analysis of fistula position was carried out in evaluable cases for purposes of comparison. South African centres reported a higher prevalence of cloacae and vestibular fistulae, whereas rectovaginal, recto prostatic and anorectal malformation without fistula were more prevalent in the Northern African group. 76% of 1,401 patients were ethnically Black African [gender ratio = 2 (vs gender ratio 1.38 overall)] and 49.8% were "low" lesions (Wingspread classification). High or intermediate lesions were mostly males (72%). Anal stenosis was most prevalent in black males and non-Black females. Fistulae were identified in 95% with 682 (52%) being low (perineal/covered anus/vestibular) fistulae. Perineal fistulae had a male predilection (n = 260; 20%), whereas vestibular fistulas (n = 416; 32%) was strikingly frequent in black females (55%). Of the remainder, 15 fistulae were rectovesical (1.2%), 544 recto-urethral or prostatic (42%), 16 recto-vaginal (1.2%). In addition, there were 43 cloacal lesions (3.3%). Isolated rare ARM anomalies included "Pouch" colon (2) and H-type fistula (2). Isolated lesions occurred in 81% but 163 associated anomalies were identified in 114 patients. These included chromosomal lesions (10), genito-urinary anomalies (50), genital (16), cardiac (31), skeletal anomalies (33), gastro-intestinal malformations (28). Other anomalies included CNS anomalies (14), anterior abdominal wall defects (2) and facial (8) abnormalities and neuroblastoma (1). The ARM is not uncommon in Black African populations and constitutes a significant clinical load to surgical practice in Africa. Ethnic differences appear to exist and vestibular fistulae predominate in black females. Cloaca (3.3%) did appear to be more prevalent. Isolated lesions are frequent but the types of associated anomalies appear similar to other series except chromosomal syndromes. This study illustrates the need for more objective data from developing countries to assess geographical differences.

Multimodal therapy for the initial management of genital embryonal rhabdomyosarcoma in childhood

Rhabdomyosarcoma is the most common soft tissue sarcoma found in children. A polypoid form of the embryonal type of rhabdomyosarcoma, namely, sarcoma botryoides, is often found in girls younger than 5 years, and typically presents as a polypoid mass protruding from the vagina. Over the years, there has been a shift in the treatment of this condition from radical surgery to a multimodal approach involving conservative surgery with chemotherapy and radiotherapy. This approach has been associated with improved survival and preservation of normal anatomy and function. We discuss the initial management of a 4-year-old girl with pelvic embryonal rhabdomyosarcoma using a multimodal approach.

Gastrointestinal tract perforation in neonates

Gastrointestinal tract perforation in neonates is a serious problem associated with high morbidity and mortality. Co-morbid factors, particularly prematurity and low birth weight, impact negatively on the outcome. This article highlights issues related to diagnosis and treatment with a view to improving the poor prognosis found in this condition.

The morbidity and outcome of surgery in children with large pre-treated Wilms' tumour: size matters

Sixty-seven patients with resected Wilms' tumour>1.0 kg are reported. Surgery in this group is difficult, may result in the sacrifice of adjacent structures, and frequently upstages the patient. Mortality is related to tumour burden. Whilst there is little agreement on the therapeutic implications of failure to respond to neoadjuvant therapy, these surgical and anaesthetic hazards must be recognized, and alternative stratagems considered, prior to attempting a surgical procedure.

Hypertension in a cohort of African children with renal tumours

Hypertension is a frequent problem in children with renal tumour, yet there are few reports from centres in the third world. A retrospective study of blood pressure in a cohort of 46 patients with renal tumours seen over a 3-year period was carried out. Fifty percent of patients presenting with Wilms' tumour were hypertensive. Serum concentrations of active renin correlated poorly with blood pressure. There was no correlation between serum concentrations of active renin and tumour mass or histology. Specific antihypertensive therapy was offered to 11 patients who had either neurological or cardiac complications of hypertension. All other patients with Wilms' tumour had their blood pressure controlled by neoadjuvant chemotherapy. Patients with mesoblastic nephroma were managed by primary surgery. Patients with asymptomatic hypertension may be monitored as hypertension will resolve with neoadjuvant chemotherapy. Those with compelling symptomatology will require additional hypertensive medication.

Expression of E-cadherin, cadherin-11, α-, β- and γ-catenins in nephroblastomas: relationship with clinicopathological parameters, prognostic factors and outcome

AIM

This study was undertaken to determine the expression of cell adhesion molecules E-cadherin, cadherin-11, and alpha-, beta- and gamma-catenins in nephroblastomas and to correlate this expression with pathological features and known prognostic factors.

METHODS

Immunohistochemistry was performed on 140 cases of nephroblastoma following heat-induced epitope retrieval and using the streptavidin-biotin technique.

RESULTS

E-cadherin was expressed in 75 cases (54%), cadherin-11 in 128 cases (91%), alpha-catenin in 93 cases (66%), beta-catenin in 133 cases (95%) and gamma-catenin in 22 cases (16%). Nuclear localisation of beta-catenin was not demonstrated. There was a statistically significant relationship between the administration of preoperative chemotherapy and the expression of E-cadherin, alpha- and gamma-catenin, respectively. These proteins were more frequently expressed in tumours treated with preoperative chemotherapy. Those tumours that expressed all four proteins (E-cadherin, alpha-, beta- and gamma-catenin) showed a statistically significant association with the administration of preoperative chemotherapy, in contrast to tumours that did not express all four proteins.

CONCLUSION

Nephroblastomas show a heterogeneous distribution of staining for E-cadherin, cadherin-11, alpha-, beta- and gamma-catenins. Tumours treated with preoperative chemotherapy are more likely to express these molecules. The expression status of E-cadherin, cadherin-11 and the catenins in this cohort does not appear to be of prognostic value.

Microsatellite analysis of the adenomatous polyposis coli (APC) gene and immunoexpression of beta catenin in nephroblastoma: a study including 83 cases treated with preoperative chemotherapy

AIMS

To determine whether microsatellite mutations of the adenomatous polyposis coli (APC) gene have pathological or prognostic significance in nephroblastomas and to correlate APC alterations with beta catenin immunoexpression.

METHODS

One hundred nephroblastomas were analysed, 83 of which received preoperative chemotherapy. Normal and tumour DNA was isolated using standard proteinase K digestion and phenol/chloroform extraction from paraffin wax embedded tissue. Polymerase chain reaction using four APC microsatellite markers-D5S210, D5S299, D5S82, and D5S346-was performed and the products analysed. Immunohistochemistry was performed using the LSAB kit with diaminobenzidine as chromogen. Results were correlated with clinicopathological data using the chi(2) test.

RESULTS

Allelic imbalance/loss of heterozygosity was more frequent than microsatellite instability, with 30% of cases showing allelic imbalance/ loss of heterozygosity and 16% showing microsatellite instability. Although there was a significant correlation between the results for individual markers and the clinicopathological data, the overall results do not support a prognostic role for APC in nephroblastoma. Expression of beta catenin was seen in 93% of cases. Staining was predominantly membranous, with epithelium, blastema, and stroma being immunoreactive. Cytoplasmic redistribution was seen in 58% of cases, but no nuclear staining was detected. No significant associations between beta catenin expression and the clinicopathological parameters were found. Kaplan-Meier survival plots showed that patients with loss of membranous staining and pronounced cytoplasmic staining (score, 3) had a significantly shorter survival (p = 0.04; median survival, 5.87 months).

CONCLUSION

Microsatellite analysis of APC and immunoexpression of beta catenin did not provide significant pathological or prognostic information in this cohort of nephroblastomas.

Hepatocellular carcinoma and liver tumors in South African children: a case for increased prevalence

BACKGROUND

The high regional incidence of hepatocellular carcinoma (HCC) in South Africa also may be present in children of the region, although the link to hepatitis B (HBV) appears less clear. The objective of this study was to assess the incidence and probable causes of HCC in South African children.

METHODS

Data were obtained from seven participating pediatric oncology units and from the tumor registry to review hepatic tumors in children in South Africa.

RESULTS

One hundred ninety-four children (ages 0-14 years) presented with malignant primary hepatic tumors (1988-2003). One hundred twelve tumors (57%) were hepatoblastoma (HB), 68 tumors (35%) were hepatocellular carcinoma (HCC) (including 9 patients with the fibrolamellar variant, 6 of which occurred in black children), 10 tumors (5%) were sarcoma of the liver, and 4 tumors were lymphoma. The ratio of HB to HCC (1.67) was markedly lower compared with other reports, suggesting a greater prevalence of HCC. Correlation with population statistics indicated an incidence of 1.066 malignant liver tumors per year per 10(6) children age < 14 years (HB, 0.61 per 10(6) children; HCC, 0.39 per 10(6)). Two-thirds of patients with HCC were positive for HBV surface antigen (HBsAg), and HCC occurred mostly in black African patients (93%). The mean age of onset was 1.47 years for HB and 10.48 years for HCC. A preponderance of males (3.5:1.0) was noted in the HBsAg-positive group that was not reflected elsewhere. Serum alpha-fetoprotein (AFP) levels were raised both in patients with HB (100%; most AFP levels were very high) and in patients with HCC (69%), although 15% of patients with HCC had low or normal AFP levels.

CONCLUSIONS

It appeared from the current results that HCC is more prevalent among children in South Africa compared with the children in more developed countries, although their rates were lower that the rates noted in adults. A collaborative approach will be required to improve their diagnosis and management.

Neonatal gastric perforation

BACKGROUND

Gastric perforation in neonates is a catastrophe associated with high morbidity. Most are due to underlying primary pathology.

OBJECTIVES

To review the management of gastric perforation in neonates in Kwa Zulu-Natal, South Africa.

DESIGN

Retrospective study of consecutive complete data sets of neonates presenting with gastric perforation.

SETTING

Department of Paediatric Surgery, Nelson R. Mandela School of Medicine, University of Natal, Durban, South Africa.

SUBJECTS

Eight neonates treated for gastric perforation between January 1998 and April 2003.

MAIN OUTCOME MEASURES

Morbidity and mortality.

RESULTS

There was an equal number of males and females. Median birth weight was 2.0 kg with a range of 1.4 to 3.2 kg. Five of the eight neonates were premature. Primary pathologies were associated with perforation in seven of the eight neonates. Prematurity, low birth weight and pneumonia were contributing factors to the poor outcome. Sepsis was a complication in seven of the eight neonates leading to their death (88% mortality).

CONCLUSION

Active perinatal management, early treatment of primary pathologies, and protection of the stomach against distension in neonates at risk are essential in the management of neonatal gastric perforation.

Primary tumours of the liver in children: an African perspective

Primary tumours of the liver present diagnostic and management difficulties. In Africa, outcomes reflect limitations imposed by comorbidity and lack of resources, both human and material, for major liver resection. Whilst hepatoblastoma and hepatocellular carcinoma can be readily distinguished on clinical and biochemical grounds, there is a high incidence of sarcomatous tumours that mandate biopsy. In our experience, hepatocellular carcinoma in childhood is a lethal condition, usually bilateral and associated with hepatitis B infection. Sarcomatous tumours are often resectable but have a high rate of local recurrence. Hepatoblastoma is a surgically curable tumour in many patients. Resection for benign liver tumours can be safely accomplished and augments institutional experience with major liver surgery.

Minimizing surgery in complicated intussusceptions in the Third World

When presentation is delayed, intussusceptions may be difficult to reduce using standard enema regimens. Our endeavour to minimize the need for surgery in an environment where failed reductions are common has led to the development of an aggressive, non-operative method of reducing intussusceptions. One hundred and six patients with intussusception were reviewed with the aim of evaluating a new method of reducing intussusceptions suited to our Third World environment. In our cohort, delayed presentation was common, with 32% of patients presenting more than 48 h after the onset of the intussusception. On clinical grounds alone, 41% of patients required a primary laparotomy. Standard barium and air reductions for intussusception were rarely successful under these conditions i.e. 13% and 22%, respectively. By using an air enema under general anaesthesia in the operating theatre, the reduction rate has improved to 53%. This approach is suggested as a last attempt at reducing an intussusception prior to laparotomy following failed standard enema reduction, and as the first line of management in the attempted reduction in the patient with delayed presentation without symptoms of peritonitis.

Gastro-intestinal tract perforation in neonates

BACKGROUND

Gastro-intestinal tract (GIT) perforation in neonates is a serious problem associated with high mortality due to resulting sepsis. Co-morbid factors, eg. prematurity, respiratory problems, low birth weight, and nutritional factors, negatively affect the outcome.

OBJECTIVES

To review the management outcome of gastro-intestinal tract perforation in neonates in KwaZulu-Natal and identify factors that require attention for better survival of neonates with GIT perforation.

DESIGN

Retrospective study of consecutive complete data sets of patients presenting with a diagnosis of GIT perforation.

SETTING

Department of Paediatric Surgery, Nelson R. Mandela School of Medicine, University of Natal, Durban, South Africa.

SUBJECTS

Fifty four neonates treated for gastro-intestinal tract perforation between January 1998 and January 2003.

MAIN OUTCOME MEASURES

Morbidity as determined by complications and mortality.

RESULTS

More males (69%) were affected than females (31%). The median birth weight was 2.3 kg and median age at presentation was four days. Eighty nine percent were referred from peripheral hospitals. Abdominal distension was the leading symptom and sign (74%). Co-morbid factors were present in 89%, with prematurity as the leading factor (52%). Necrotising enterocolitis (NEC) was the main cause of perforation (33%) and the terminal ileum was the most common site. Most (56%) were treated by excision and primary repair of perforations. Sepsis was the leading complication (44%) and major cause of death (72%). Mortality was highest (56%) in perforations due to other primary pathology followed by NEC (53%). Overall mortality was 46%.

CONCLUSION

It is essential to prevent secondary perforations by early recognition and management of primary pathology. Management of pneumoperitoneum in neonates with respiratory difficulties should be included in resuscitation before transfer. Rectal temperature monitoring and herbal enemas should be strongly discouraged.

Microsatellite analysis of the DCC gene in nephroblastomas: pathologic correlations and prognostic implications

Microsatellite instability has been reported in a wide variety of cancer types. Inactivation or loss of tumour suppressor genes has been shown to result in cell cycle deregulation and neoplastic growth. We conducted a microsatellite study using fluorescent-based DNA technology to determine whether mutations in the microsatellite sequences of the deleted in colorectal cancer (DCC) gene, a tumour suppressor at 18q21.1, have any pathologic correlation or prognostic significance in nephroblastomas. Normal and tumour DNA was isolated from 106 cases of nephroblastoma using the standard proteinase K digestion and phenol-chloroform extraction method from paraffin wax-embedded tissue. Polymerase chain reaction using three microsatellite markers; D18S21, D18S34 and D18S58, for the DCC gene were performed. The polymerase chain reaction products were analysed on the ALF Express Automated DNA sequencer. The results were correlated with age at diagnosis, preoperative chemotherapy, clinicopathological stage, histological classification and patient outcome using chi(2) test. Allelic imbalance/loss of heterozygosity appeared to be a more frequent genetic aberration than microsatellite instability with 20% of cases showing allelic imbalance/loss of heterozygosity and only 9% of cases showing microsatellite instability. Genetic aberrations were more frequent in unfavourable histology tumours compared to favourable histology tumours (P=0.012). All patients with genetic aberrations for more than one DCC marker died independent of histological classification and stage (P=0.016). There was no statistically significant difference when DCC aberrations were compared with age at diagnosis, preoperative chemotherapy and clinicopathological stage. In conclusion, this study has found that multiple aberrations involving the DCC locus may play a role in the progression of nephroblastomas, and hence confer a poorer prognosis.

Malignant solid tumours in neonates: an African perspective

Malignant tumours in the neonate are distinct pathologically, clinically, and therapeutically from those in older children or adults. Behaviour cannot be directly implied from the histological appearance, and risk stratification is therefore difficult and complex. We review 42 patients seen over a 20-year period. Neuroblastoma (NB) was the commonest tumour seen (11), but the soft-tissue sarcomas were the dominant group (14). The initial management was surgical when possible. Chemotherapy, despite appropriate dose reduction, had significant morbidity and mortality. Whilst the outcome for congenital fibrosarcoma was good (6/7, 86%), there were no survivors amongst 5 patients with rhabdomyosarcoma. In the absence of cytogenetic and biochemical markers, risk stratification amongst babies with NB was based upon INSS staging. Stage I disease was associated with a good prognosis, whilst stage IV disease was uniformly fatal. Stage IVs disease had only 50% early survival. Patients with renal tumours, whether nephroblastoma or mesoblastic nephroma, did well. Only patients with morphologically immature teratomas were included, amongst whom there are 2 of 7 (29%) known survivors, but 43% have been lost to follow-up and their status is unknown. These figures are consistent with other reports from Africa.

Rectal gastric heterotopia in infancy

Heterotopic gastric mucosa is rare in children with most cases presenting in association with Meckel's diverticulum. The authors present a 2-year-old boy with gastric heterotopia of the anorectum, who presented with painless, intermittent rectal bleeding.

Internal drainage of pancreatic pseudocysts in children using an endoscopically-placed stent

Persistent pseudocysts, which are rare in children, have traditionally been managed by open surgery. We describe two children who presented with large, established pseudocysts of the pancreas. They were successfully treated in the short term by minimally-invasive stent placement to create an internal cyst-gastric communication. This approach merits comparison with open surgical techniques.

Improving neonatal transport in the Third World--technology or teaching?

Neonatal transport in the Third World remains hazardous because of a shortage of human and material resources. An audit of the transportation of 126 surgically ill neonates was undertaken to identify areas where improvement is possible. Failure to maintain simple interventions such as intravenous fluid replacement and nasogastric drainage were found to be more important than inadequate technology in defining the status of the patient on arrival. Investment in education is likely to pay greater dividends than further technological advances.

Primary lumbosacral Wilms tumour associated with occult spinal dysraphism

A 4-year-old child presenting with sudden-onset paraplegia and a sacral tumour in association with spina bifida occulta is reported. There were no stigmata of spinal dysraphism at birth. Imaging studies confirmed a sacral tumour with extradural extension up to T10 and spinal dysraphism. The histological features of the extradural and sacral components of the tumour were consistent with a Wilms tumour. The differential diagnosis included a primary sacral teratoma containing Wilms tumour elements or a primary extrarenal Wilms tumour arising in association with a spinal dysraphism. There was no clinical response to chemotherapy or radiotherapy.