Autologous peripheral blood stem cell mobilization and apheresis in pediatric patients with cancer: A single-center report of 64 procedures

BACKGROUND

The published experience concerning autologous peripheral blood stem cell collection in children is very limited.

METHODS

The data of pediatric patients who underwent autologous stem cell mobilization and apheresis between January 2011 and April 2020 were analyzed retrospectively.

RESULTS

We studied retrospectively 64 mobilization and apheresis procedures in 48 pediatric patients (34 males, 14 females), mean age of 7.31 ± 5.38 (range, 1.5-19.7) years, the underlying disease was mostly neuroblastoma (NBL). The body weight of 21 patients (43.75%) was 15 kg or less. The targeted autologous peripheral stem cell apheresis (APSCA) was successfully achieved in 98% of patients. Neuroblastoma patients were younger than the rest of the patients and underwent apheresis after receiving fewer chemotherapy cycles than others and all of them mobilized within the first session successfully. Plerixafor was added to mobilization in nine heavily pretreated patients (18.7%), median two doses (range, 1-4 doses). 11 patients (22.9%) underwent radiotherapy (RT) before mobilization with doses of median 24 Gy (range, 10.8-54.0 Gy). Patients with RT were older at the time of apheresis and had received more chemotherapy courses than patients without RT. As a result, patients with a history of RT had significantly lower peripheral CD34+ cells and CD34+ yields than those without RT. In 17 patients (35.4%), 22 different complications were noted. The most common complications were catheter-related infections (n:10, 20.8%), followed by catheter-related thrombosis in eight patients (16.7%).

CONCLUSIONS

Patients who had far less therapy before apheresis were more likely to mobilize successfully. Our study provides a detailed practice approach including complications during APSCA aiming to increase the success rates of apheresis in transplantation centers.

Clinical Profile and Outcomes of Primary Immunodeficiency and Malignancy in Childhood at a Tertiary Oncology Center in Developing Country

Primary immune deficiencies are a group of heterogenous genetic disorders characterized by frequent infections, autoimmunity and malignancy. In this study, we aimed to evaluate clinical characteristics, outcomes of children with malignancy developed on background of primary immunodeficiency and compare survival rates of patients between malignant lymphoma with primary immunodeficiency and without immunodeficiency from tertiary oncology center in a developing country. A total 23 patients with primary immunodeficiency and malignancy were evaluated retrospectively. A total of 26 malignancies (first or second) in 23 patients were determined. The median age at the time of the first malignancy was 8 years (ranges 2-18 years) with increased male ratio (M/F:14/9). Non-Hodgkin lymphoma (n = 17; 65%) was the most common malignancy, followed by Hodgkin lymphoma (n = 5), anaplastic ependymoma (n = 1), spinal glioblastoma multiforme (n = 1), retinoblastoma (n = 1) and intracranial hemangiopericytoma (n = 1). The median follow-up time of patients was 25 months (ranges between 1 and 189 months). The 5-year overall survival rate of patients with malignant lymphoma associated with primary immunodeficiency (41%) were lower than immunocompetent patients with malignant lymphoma (80%) (p = 0.000). The 5-year overall survival of patients was diagnosed between 2021 and 2013 years (62%) was higher than previous years (22%) (p = 0.03). In conclusion, non-Hodgkin lymphomas were the most common histopathologic type in patients with malignancy associated with primary immunodeficiency in the present study. The survival of patients with malignant lymphoma associated with primary immunodeficiency has improved in recent years, yet it is still lower than immunocompetent patients with lymphoma and new targeted drugs are required for better survival rates.

Clinical and Demographic Characteristics of Cutaneous Mastocytosis in Childhood: Single-center Experience

INTRODUCTION

Mastocytosis is a rare and heterogenous disease, and in children it is generally limited to the skin and tends to regress spontaneously in adolescence.

AIM

In this study, demographic, clinical, and laboratory characteristics of pediatric patients with mastocytosis, and also coexisting diseases were investigated.

RESULTS

A total of 61 pediatric patients were included in the study. The male-to-female ratio was 2.2, the median age was 2 years (range, 0.25 to 19 y), and the median follow-up period was 2.0 years (range, 0.25 to 19 y). Types of clinical presentation at diagnosis consisted of mainly urticaria pigmentosa (45.9%). Seven patients were further investigated with suspicion of systemic mastocytosis, they were followed up, median of 9 years (range, 2.5 to 16 y), and none of them developed systemic disease. Coexisting allergic diseases were recorded in total 5 patients (8.2%). Three patients had immunoglobulin A deficiency, 1 patient had elevated immunoglobulin E level. A patient developed mature B-cell lymphoma with a heterozygous mutation in c-KIT exon 11.

DISCUSSION

Cutaneous mastocytosis in children may present as a complex disease with different clinical signs and symptoms. Standardized clinical criteria and guidelines for the follow-up of children with mastocytosis are required.

Evaluation of Vitamin D-levels and Bone Mineral Density in Lymphoma and Solid Tumors of Childhood after Treatment

As the survival rate of childhood cancers increases, late effects of the treatment are becoming significantly more critical. The aim of this study is to evaluate serum 25 Hydroxy Vitamin D levels and bone mineral density (BMD) of patients with lymphoma and solid tumors. In this study, we included patients diagnosed with cancer in our pediatric oncology department between 2004 and 2013. These patients were all in remission and completed their treatment. Patient data were collected from corresponding medical files. Vitamin D levels, BMD measurements and other laboratory tests were performed prospectively. The study group consisted of 105 patients who completed treatment at least one year ago. Overall, 59.6 % of the subjects were found to have vitamin D levels less than 20 ng/mL. When the factors affecting vitamin D deficiency were evaluated, there were not any factor related to vitamin D deficiency. However, a positive correlation was observed in the blood sampling time, namely test results taken in summer months (April-September) were higher. In our study, bone mineralization disorder (low BMD) was found in 44.4% of the patients. In addition, we observed that bone health was significantly affected in children who recovered from cancer. 59.6 % of the vitamin D deficiency rate was found to be higher than the similar age group in our country. To our knowledge, this is also the lowest vitamin D levels in children with cancer compared to previously published studies. The rate of low BMD was determined as 44.4%, similar to earlier studies.

Insulin-like growth factor-1 receptor expression in pediatric tumors: a comparative immunohistochemical study

Background/aim: Insulin-like growth factor-1 receptor (IGF-1R) is a pivotal receptor tyrosine kinase involved in the cell cycle and malignant tumor transformation. It is differentially expressed in various types of tumors. We aimed to determine the expression of IGF- 1R in different pediatric tumors and to shed light on possible new indications of anti-IGF-1R treatment approaches. Materials and methods: A total of 147 specimens were analyzed according to their expression of IGF-1R. Specimens included those from rhabdomyosarcomas, Wilms tumors, Ewing sarcoma/primitive neuroectodermal tumors, peripheral neuroblastic tumors, acute lymphoblastic lymphoma, Hodgkin lymphoma, Burkitt lymphoma, retinoblastoma, pleuropulmonary blastoma, Langerhans cell histiocytosis, endodermal sinus tumors (ESTs), and myeloid sarcoma. Analysis was performed on tissue sections by immunohistochemically staining for IGF-1R expression. Results: All six specimens of EST cases showed positivity for IGF-R1. Additionally, about 56% of the Hodgkin lymphoma, 80% of the rhabdomyosarcoma, and 70% of the Wilms tumor specimens showed positivity for IGF-R1 expression. Conclusion: All ESTs examined in our study expressed IGF-1R and to our knowledge this is the first report regarding ESTs and IGF-1R expression. IGF-1R could be included among confirmatory markers for ESTs and, from a therapeutic viewpoint, ESTs should also be examined for IGF-1R expression for beneficial regimens.

NUT Midline Carcinoma of the Lung in a Six-Year-Old Child

BACKGROUND

Nuclear protein of the testis (NUT) midline carcinoma is genetically defined by rearrangement of NUT or by immunohistochemical expression of NUT.

FINDINGS

A 6-year old child had a NUT midline carcinoma of the lung. Despite aggressive therapy, the child died.

CONCLUSION

NUT carcinoma, which can be diagnosed immunohistochemically, remains an aggressive tumor.

Accidental cisplatin overdose in a child: Successful management with repetitive plasmapheresis and use of chemoprotective agents

Cisplatin is one of the effective chemotherapeutic agents widely used for many tumor types in children. The most serious complications of cisplatin overdose are nephrotoxicity and ototoxicity. It may lead to life-threatening complications and even death. We report a 13-year-old female patient with osteosarcoma who received a massive cisplatin overdose mistakenly. She was given cisplatin 120 mg/m2/day for consecutive two days, instead of one day (total 240 mg/m2) due to a prescription error. After 12 hours, her cisplatin level was measured as 8,500 ng/ml (normal: 1,000-5,000 ng/ml). She was treated with repeated plasmapheresis combined with use of two chemoprotectants, (N-acetylcysteine and amifostine). On her follow up, renal functions and audiometric tests remained normal. According to our experience with our case, early urgent combined treatment is very important in the management of cisplatin overdose.

Assessment of tumors in children with tuberous sclerosis: a single centre's experience

AIM

As a result of mutations in TSC1 (9q34) and TSC2 (16p13.3) tumor supressor genes, the mammalian target of the rapamycin (mTor) signaling pathway is overactivated in patients with tuberous sclerosis. Abnormal cell proliferation and differentiation is responsible for the growth several different tumors. The aim of this study was to review tumors in our patients with tuberous sclerosis.

MATERIAL AND METHODS

Thirty-six patients with tuberous sclerosis were reviewed retrospectively in terms of age, sex, family history, clinical findings, presence of tumors, and treatments.

RESULTS

Our study included 36 patients (18/18:M/F) aged between two days and 17 years with a median age of 6 years. There were hypopigmented spots in 30 patients, seizures in 28 patients, and a family history in 11 patients. Tumors related to tuberous sclerosis were renal angiomyolipomas in 21 patients, cardiac rhabdomyomas in 11, subependymal giant cell astrocytomas in seven, and non renal hamartoma in one patient. Everolimus treatment was used in only two patients because of hemodynamic instability.

CONCLUSIONS

Tuberous sclerosis is a multisystemic disease characterized by the presence of various benign tumors and neurologic disorders. Renal angiomyolipomas, cardiac rhabdomyomas, and subependymal giant cell astrocytomas are commonly observed in patients with tuberous sclerosis. mTOR inhibitors such as everolimus and sirolimus have been increasingly used in the treatment of these tumors. However, the duration and optimal dose of mTOR inhibitors is still controversial and should be used in selected cases.

The Correlation Between Pre-treatment Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography Parameters and Clinical Prognostic Factors in Pediatric Hodgkin Lymphoma

Objective:

To compare standardized uptake values (SUV) derived from pre-treatment 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) imaging and clinical prognostic factors in pediatric patients with Hodgkin lymphoma (HL).

Methods:

Pre-treatment FDG PET/CT findings of 28 children with HL were evaluated in this retrospective study. Metabolic tumor volume (MTV), SUV_max normalized by weight (SUVw_eight), lean body mass (SUV_lbm), body surface area (SUV_bsa) and plasma glucose levels of tumors (SUV_glucose) were calculated using pre-treatment FDG PET/CT scan images. These metabolic parameters were correlated with clinical factors [age, sex, number of lymph node groups, presence of splenic involvement, bulky mediastinal disease, Ann Arbor stage, serum white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), serum albumin and hemoglobin levels].

Results:

SUV_bsa, SUV_lbm, SUV_weight, SUV_glucose and MTV were higher in patients with stage III-IV disease, bulky tumor and ≥3 lymph node groups (p<0.05). SUV_bsa and SUV_glucose were higher in patients with splenic involvement (p<0.05). There was no significant correlation between these metabolic parameters and sex, ESR, levels of albumin and WBC (p>0.05). SUV_bsa and SUV_lbm were higher in patients with anemia (p<0.05). Additionally, significant increases were detected in SUV_weight, MTV, and SUV_glucose with increasing age (p=0.005, p=0.027, and p=0.009, respectively). SUV_bsa and SUV_lbm had no significant correlation with age (p>0.05).

Conclusion:

Metabolic parameters derived from pre-treatment FDG PET/CT may have an important role in predicting high-risk disease in patients with HL. Also, SUV_bsa and SUV_lbm may be better markers than SUV_weight in the quantitative evaluation of FDG PET/CT scans in pediatric patients.

Squamous cell carcinoma associated with Xeroderma pigmentosum: an unusual presentation with a tremendously huge mass over the face and paraneoplastic hypercalcemia-hyperleukocytosis

Emir S, Hacısalihoğlu Ş, Özyörük D, Kaçar D, Erdem A, Karakuş E. Squamous cell carcinoma associated with Xeroderma pigmentosum: an unusual presentation with a tremendously huge mass over the face and paraneoplastic hypercalcemia-hyperleukocytosis. Turk J Pediatr 2017; 59: 711-714. Xeroderma pigmentosum (XP) is a rare autosomal recessive disorder that results from genetic defects in DNA repair and manifests with a marked hypersensivity to ultraviolet rays. Children with X-P are at high risk of developing skin cancers. On the other hand, hypercalcemia-hyperleukocytosis is a rare paraneoplastic syndrome in children with cancer compared to adults. Here, we report a five-year-old female with X-P and squamous cell carcinoma (SCC). The patient presented with a necrotic, ulcerating huge mass sized 20x15x10 cm involving the right half of the face. She had a history of increased freckling over the face since the age of two years. Her other cutaneous findings are dryness of skin, photosensitivity, freckling and telengiectasis all over the body. A diagnosis of Xeroderma pigmentosum was made based on clinical features. She also had high fever, anemia, hyperleukocytosis, thrombocytosis and hypercalcemia. After pathological diagnosis of squamous cell carcinoma, she was treated with chemotherapy. All the symptoms and signs resolved dramatically with the initiation of chemotherapy. Our case is an example of early development of massive disfiguring SCC in children with undiagnosed and untreated X-P. Although we could not prove the paraneoplastic nature of hypercalcemia-hyperleukocytosis, dramatic response to the chemotherapy may be an evidence for paraneoplastic origin.

Endometriosis-associated Maternal Pregnancy Complications - Case Report and Literature Review

The incidence of endometriosis is increasing. Particularly during pregnancy and labour, clinicians should be alert to possible endometriosis-associated complications or complications of previous endometriosis treatment, despite a low relative risk. In addition to an increased rate of early miscarriage, complications such as spontaneous bowel perforation, rupture of ovarian cysts, uterine rupture and intraabdominal bleeding from decidualised endometriosis lesions or previous surgery are described in the literature. Unfavourable neonatal outcomes have also been discussed. We report on an irreducible ovarian torsion in the 16th week of pregnancy following extensive endometriosis surgery, and an intraabdominal haemorrhage due to endometriosis of the bowel in the 29th week of pregnancy.

Assessment of Nutritional Status in Children With Cancer and Effectiveness of Oral Nutritional Supplements

Malnutrition is a common consequence of cancer in children, but the most effective methods of nutrition intervention are under debate. We aimed to evaluate the nutritional status of children diagnosed with cancer, and to investigate the effect of oral nutritional supplements on anthropometric measurements, biochemical parameters, and outcome. A randomized clinical study of 45 newly diagnosed cancer patients was performed. Anthropometric and biochemical data and related factors were assessed at 0, 3, and 6 months after diagnosis. On initial anthropometric assessment, prevalence of malnutrition by weight or height was found to be lower as compared with body mass index (BMI), or weight for height (WFH), or arm anthropometry. Twenty-six of the patients (55%) received oral nutritional supplement. During the second 3 months after diagnosis, there was a statistically significant decrease in number of the patients with WFH <90th percentile and BMI <5th percentile (P = .003 and P = .04, respectively). Infectious complications occurred more frequently in malnourished patients during first 3 months, and survival of children who were malnourished at the 6th month was significantly lower than that of well-nourished children (P = .003). On laboratory assessment, serum prealbumin levels of the all subjects were below normal ranges, but no relation was found for serum prealbumin or albumin levels in patients who were malnourished or not at diagnosis. Nutritional intervention is necessary to promote normal development and increase functional status as a child receives intensive treatment. Protein- and energy-dense oral nutritional supplements are effective for preventing weight loss in malnourished children.

The association of consumptive hypothyroidism secondary to hepatic hemangioma and severe heart failure in infancy

Although hemangiomas are the most common vascular tumors of the liver in infancy, data regarding hypothyroidism and heart failure related to hepatic hemangiomas are limited. Here, we present a 15- day -old girl who presented with prolonged jaundice at the age of 15 days. Because her TSH level was found to be 74 μIU/mL, she was initially diagnosed with congenital hypothyroidism and L-Thyroxine replacement therapy was initiated. On follow-up examination performed two months later, it was observed that her TSH level was not suppressed and a mass was noticed in the right upper abdomen on physical examination. Abdominal ultrasonography revealed multiple masses with sizes of about 3-3,5 cm covering the whole liver. When evaluated with clinical and radiological appearance, oral methylprednisolone at a dose of 5 mg/kg/day and propranolol at a dose of 2 mg/kg were initiated with a diagnosis of hepatic hemagioma/hemangioendothelioma. Consumptive hypothyroidism due to hepatic hemangioma and congestive heart failure were considered in the patient who had findings of heart failure. The dose of L-Thyroxine was increased 2-fold. The patient received intensive care treatment for severe heart failure. Because his findings resolved, he was started to be followed up with propranolol, steroid and L-Thyroxine treatment.

Pulmonary arterial hypertension in a child with stage-IV neuroblastoma after autologous hematopoietic stem cell transplantation and review of the literature

PH is a rare condition with high mortality rate after pediatric HSCT. As clinical presentation is non-specific and may mimic other conditions, a high degree of suspicion is required for diagnosis. Here, we present a patient with stage-IV neuroblastoma who developed PAH after autologous HSCT. After exclusion of other causes of PH, we regarded that this condition was secondary to HSCT.

Comparison of colorectal neoplastic polyps and adenocarcinoma with regard to NLR and PLR

OBJECTIVE

Cancer-related inflammation affects many aspects of malignancy, including proliferation and survival of malignant cells, angiogenesis, and therapeutic response. Some biomarkers representing the degree of systemic inflammation, such as the Glasgow prognostic score, NLR and PLR, have been shown to have prognostic value in many kinds of cancer patients. Aim of this study to investigate to compare neutrophil/leukocyte (NLR) and platelet/lymphocyte (PLR) ratios of the patients with colorectal neoplastic polyps and colorectal cancer (CRC) and tried to determine whether this could be used as a biomarker in follow up of the patients with neoplastic polyps.

PATIENTS AND METHODS

A total of 100 colorectal polyps, 113 colorectal cancers and 124 healthy controls were included in the study. Exculusion criteria were endocrinologic or metabolic diseases, acute or chronic diseases, hypertension and atherosclerotic heart diseases, renal diseases. Blood count parameters of the patients were measured. The NLR was calculated as a simple ratio between the absolute neutrophil and the absolute lymphocyte counts. The PLR was defined as the platelet counts to lymphocyte ratio.

RESULTS

A statistically significant difference was not detected between Group A and C with regard to NLR and PLR. NLR and PLR were found statistically significantly high in Group B (CRC), Group A (colorectal polyp) and Group C (healthy individuals) (p < 0.001 and p < 0.001). Our study showed that the optimum NLR cut-off point for neoplastic polyps was 2.28 (sensitivity: 68.7%, specificity: 42.3%). When the sensitivity and specificity levels of the PLR were assessed, they were 68.7% and 46.5% for neoplastic polyps, 80% and 68.9% for colorectal cancer.

CONCLUSIONS

NLR and PLR may be used for follow up conversion of colonic and rectal neoplastic polyps to invasive tumor.

Occurrence of Wilms' tumor in a child with hereditary spherocytosis

Hereditary spherocytosis (HS) is the most frequent cause of congenital hemolytic anemia. It is an autosomal dominant genetic disorder characterized by cell membrane abnormalities, specifically in red blood cells. Although the association between benign, borderline and malignant tumors and HS is not clear, various tumors such as splenoma, adrenal myolipoma, pancreatic schwannoma, ganglioneuroma, extramedullary hematopoiesis, myeloproliferative disorders, multiple myeloma, B-cell lymphoma and acute lymphoblastic leukemia have been presented in case reports concerning HS patients. Here we describe a 6-year-old boy with HS who presented with a mass in the left kidney. Tru-cut biopsy revealed Wilms' tumor (WT). To the best of our knowledge, this is the first case of WT associated with HS to be reported in the literature.

Teratoid Wilms' tumor exhibiting extensive squamous differentiation

Teratoid Wilms' tumor is a rare renal tumor. Herein, we report an unusual variant of such tumor which simulated renal teratoma because of abundant keratinized squamous epithelium within the tumor.

Primary ovarian malignant melanoma arising in teratomatous component of mixed- germ cell tumor in a child: case report

Primary ovarian malignant melanoma arising in teratomatous component of germ cell tumors is seen extremely rare with most reports being only of single cases and small series in reproductive aged woman and mostly from cystic teratoma, whereas information on pediatric presentation is sparse. This case is reported for being extremely rare tumor.

Chronic lymphocytic leukemia in a child: a challenging diagnosis in pediatric oncology practice

Chronic lymphocytic leukemia/lymphoma (CLL) is an extremely rare disease during childhood. We report a 16-year-old female who presented with lymphadenopathies and she was diagnosed as T cell lymphoblastic lymphoma. Her chemotherapy response was minimal and clinical findings were unusual. Therefore, her biopsy specimen was re-examined and diagnosis was changed to CLL. Chemotherapy protocol including fludarabine, cyclophosphamide, rituximab was administrated and good response was observed. In our patient deletion at 1q21.2 region that includes aryl hydrocarbon receptor nuclear translocator (ARNT) gene was detected via comparative genomic hybridization method. ARNT gene deletion may be a new mutation in chronic lymphocytic leukemia development.

Investigation of the relationship between serum hormones and pilonidal sinus disease: a cross-sectional study

AIM

The aim of this cross-sectional study was to determine whether pilonidal sinus is influenced by hormones that stimulate body hair growth. Currently, there are insufficient data on the presence of hormonal abnormalities in pilonidal sinus disease.

METHOD

Hormone levels (including those of thyroid-stimulating hormone, follicular-stimulating hormone, luteinizing hormone, prolactin, progesterone, oestradiol, testosterone, cortisol and dehydroepiandrosterone) were measured in 39 patients with pilonodal sinus presenting between February 2013 and March 2013. The results were compared with those of 39 volunteers without this disease.

RESULTS

There was no statistically significant difference between men with pilonidal sinus disease (P > 0.05). The prolactin levels of women with pilonoidal sinus were significantly higher than those of women in the control group (P < 0.05).

CONCLUSION

Raised serum prolactin levels in women may be related to the development of pilonidal sinus disease.

Comparison of granisetron plus dexamethasone versus an antiemetic cocktail containing midazolam and diphenhydramine for chemotherapy induced nausea and vomiting in children

Background:

Chemotherapy induced nausea and vomiting (CINV) is one of the most disturbing side-effects in children receiving highly emetogenic chemotherapy. We aimed to assess whether the addition of an antiemetic cocktail containing midazolam and diphenhydramine to granisetron plus dexamethasone combination could ameliorate CINV in this study.

Patients and Methods:

A total of 23 children aged between 1 and 16 years to receive cisplatin containing chemotherapy in our clinic were included in this study from April 2007 to April 2008. 76 cycles in 23 patients were randomly assigned to receive either antiemetic regimen 1 or antiemetic regimen 2. Antiemetic regimen 1 containing granisetron 0, 04 mg/kg plus dexamethasone 0, 2 mg/kg were given in 45 chemotherapy cycles. In 31 cycles, an antiemetic cocktail containing midazolam 0, 04 mg/kg, diphenhyramine 2, 5 mg/-kg in addition to granisetron plus dexamethasone was given. Number of vomiting, severity of nausea, the use of rescue therapy and adverse events were assessed between day 1 and day 5.

Results:

Complete response for the acute phase was observed 38/45 (84, 4%) cycles in regimen 1 as compared with 28/31 (90, 3%) in regimen 2, antiemetic cocktail regimen (P > 0.05). Complete response for delayed emesis after 24 h of the beginning of chemotherapy was observed in 29/45 (64, 4 %) in regimen 1 and 16/31 (51, 6%) in regimen 2. Antiemetic cocktail was not superior to the granisetron plus dexamethasone combination in controlling emesis in acute and delayed phase. Furthermore, patients receiving antiemetic regimen 2 were noted significantly more side effects.

Conclusion:

Our data showed that antiemetic cocktail containing midazolam and diphenhydramine was not better in controlling acute and delayed emesis. A slightly more toxicity with additional drugs was also observed.

The management of bilateral Wilms tumor

Wilms tumor (WT) is the most common malignant renal tumor in childhood. Approximately 5-7% of WT patients present with bilateral disease, either synchronously or metachronously. Bilateral WT usually occurs in younger children and more often in girls. Management of a child with bilateral WT is very challenging. In contrast to unilateral WT, there has not been uniform agreement about the therapeutic strategy in the management of bilateral WT. As surgery is a critical component in the treatment of WT, the aim is to achieve a high cure rate while maintaining adequate long-term renal function in patients with bilateral WT. In the past, radical surgical procedures which lead to the patients on dialysis have been traditionally recommended in these patients. After several multicentre trials, bilateral biopsies followed by pre-operative chemotherapy and then renal salvage surgery have been recommended. The management of bilateral WT has evolved from primary surgical extirpation to kidney-preserving resection after preoperative chemotherapy. Preoperative chemotherapy often results in significant reduction in tumor size, thereby facilitating subsequent renal salvage. The analysis of children with bilateral WT shows that preservation of renal parenchyma is possible following initial preoperative chemotherapy. Only centers with experience in bilateral WT should treat the cases with bilateral WT to provide optimal treatment.

Alpha-fetoprotein-producing hepatoid gastric adenocarcinoma in a child presenting with spontaneous gastric perforation

Gastric adenocarcinoma is a rare entity in the pediatric population. Gastric hepatoid adenocarcinoma with elevated serum alpha-fetoprotein (AFP) is seen extremely rarely in children. A 12-year-old boy was admitted to the hospital with complaint of abdominal pain. X-ray revealed free air density below the diaphragm. Emergent laparotomy showed perforated stomach. Four weeks after the operation, he was readmitted with severe gastrointestinal obstruction symptoms. He underwent an explorative laparotomy, which revealed intestinal edema and diffuse small solid nodules covering the peritoneum. Serum AFP level was mildly elevated. Endoscopic evaluation of the upper gastrointestinal tract was performed, and a gastric mass was detected. All pathological findings were compatible with gastric carcinoma showing hepatoid differentiation. We report an unusual case of AFP-producing hepatoid gastric adenocarcinoma presenting with gastric perforation. This is, to the best of our knowledge, the first reported case of AFP- producing hepatoid gastric adenocarcinoma presenting with gastric perforation in a child.

Wilms tumor with intravascular tumor thrombus

Wilms tumor (WT) is one of the most common solid tumors in children. It is the second most common extracranial solid tumor after neuroblastoma. WT has a strong tendency to invade blood vessels in the form of tumor thrombus, into the renal veins, and inferior vena cava and even into the right atrium. Extension of tumor thrombus along to the renal vein into the inferior vena cava occurs in 4-10% of all patients. Tumor thrombus extending to the right atrium is less reported as 0.7-1%. WT with renal vein thrombus has been reported to be more common in the right kidney because of the shorter right renal vein. Most patients with tumor thrombus are asymptomatic and diagnosis is only made on imaging investigations. Several imaging modalities including computed tomography (CT), magnetic resonance imaging (MRI) and Doppler ultrasonography (USG) can demonstrate intravascular tumor thrombus before surgery. In addition to CT and MRI, Doppler USG is reliable in demonstrating the presence and extent of inferior vena cava tumor thrombus. The management of WT with tumor thrombus is determined by multiple factors such as extent of tumor thrombus, chemotherapy response of the tumor. Now, it is generally recommended to use preoperative chemotherapy to a patient presenting with intravascular tumor thrombus. This approach is helpful to decrease the extent of the vascular thrombus which facilitates surgical excision. Most intracaval and intraatrial thrombi in WT show a response to chemotherapy. Neoadjuvant chemotherapy causes tumor regression in nearly half of the patients. Most of them can be managed without the need for cardiac bypass surgery. The decision of initial surgery or preoperative chemotherapy should be carefully determined on every case. Primary surgery would only be indicated in a patient who is unstable because of thrombus that might dislodge and cause acute symptoms. Presence of tumor thrombus in WT needs for multidisciplinary care including pediatric oncologists, pediatric surgeons, and pediatric cardiac surgeons.

Successful allogeneic hemopoietic stem cell transplantation in a case of Wiskott-Aldrich syndrome and non-Hodgkin lymphoma

WAS is a severe X-linked recessive disorder characterized by microthrombocytopenia, eczema, and immunodeficiency. A six-yr-old boy with WAS diagnosed as B-cell NHL (Stage III) localized in the liver who underwent successful HSCT from HLA-one antigen mismatch sibling donor has been presented here. His conditioning regimen included ATG, busulfan, and fludarabine. He received 2.3 × 10(6) /kg CD 34+ stem cells and 11 × 10(8) /kg nucleated cells at day 0. Neutrophil engraftment was achieved at day +14 and platelet engraftment at day +20. He has been in CR for more than two yr after transplantation. Thus, HSCT is an effective treatment for children with WAS even after development of lymphoma.

Characteristics of children with non-hodgkin lymphoma associated with primary immune deficiency diseases: descriptions of five patients

BACKGROUND

An increased incidence of non-Hodgkin lymphoma (NHL) has been seen in various primary immune deficiency (PID) cases. The present study aimed to evaluate the clinical characteristics and treatment outcomes of five cases with NHL associated with primary immunodeficiency.

METHODS

We retrospectively evaluated five patients with primary immunodeficiency who developed NHL. Two patients had ataxia-telangiectasia (A-T), one patient had common variable immunodeficiency (CVID), one patient had Bloom's Syndrome, and one patient had Wiskott-Aldrich syndrome (WAS).

RESULTS

All patients were male (median age, 8 years). Stage distribution was stage III in three patients and stage IV in two patients. Three patients had B-cell lymphoma and two had T-cell lymphoma. Reduced doses of Berlin-Frankfurt-Münster (BFM) and French Society of Pediatric Oncology (SFOP) regimens were used in four patients according to histopathological subtype. The two patients with ataxia and one patient with Bloom's Syndrome died of progressive/relapsed disease at months 5, 19, and 6, respectively. The patient with CVID associated with T-cell lymphoma has been in remission for 7 years. A full-dosage regimen of rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) was successfully used in the patient with WAS and B-cell lymphoma; he was still in remission after 3 years.

CONCLUSION

Primary immunodeficiency diseases are one of the strongest known risk factors for the development of NHL. Management of these patients remains problematic. There is a great need to develop new therapeutic approaches in this group. The use of rituximab in combination with CHOP may provide a promising treatment option for B-cell lymphomas associated with immunodeficiency.

Cardiac rhabdomyomas associated with tuberous sclerosis complex in 11 children: presentation to outcome

Cardiac rhabdomyomas (CRs) are the most common heart tumors in children and closely associated with tuberous sclerosis complex (TSC). This study was performed to assess the presentation type, clinical course, treatment modalities, and outcome of the patients with rhabdomyoma, associated with TSC. We reviewed our patients with cardiac rhabdomyomas (CRs), who had received a diagnosis of TSC previously or during the follow-up period between June 1996 and January 2012, retrospectively. Thirty-two patients with TSC were evaluated and among them 11 patients (34%) were associated with CRs. Five patients (45%) had multiple tumors and consequently a total of 29 CRs were analyzed in our study. The median follow-up period was 2 years (range: 1 week-15 years). Clinical presentation was cardiac murmur in three patients, cyanosis in two patients and arrhythmia in one patient. Five patients were asymptomatic at the diagnosis and CRs were detected during routine cardiac evaluation for TSC. Cardiac tumors were diagnosed prenatally in two patients. Spontaneous regression rate was 31% and we experienced a complete regression of a tumor with an echogenic bordered tissue defect and septal thinning in a patient. Three patients had hemodynamically significant tumor obstruction; two of them underwent surgery. The other patient, who had multiple CRs, was treated medically with everolimus because of high-risk potential of surgery. Although surgical resection is the preferred treatment in most of the patients with hemodynamic instability, we need novel alternative medical therapies in some critically ill patients who cannot be operated due to various reasons.

Spinal Tuberculosis (Pott's disease) Mimicking Paravertebral Malignant Tumor in a Child Presenting with Spinal Cord Compression

Paravertebral tumors may interfere with the radiological and clinical features of spinal tuberculosis. We report a case of a 3-year-old boy with spinal tuberculosis who was initially misdiagnosed as having a paraspinal tumor. The diagnosis of tuberculosis was made on the basis of intraoperative findings and confirmed by histopathology. This case highlights the importance of awareness of the different radiographic features of spinal tuberculosis, which can mimic a spinal malignancy. In order to avoid delayed diagnosis, pediatricians and radiologists must be aware of spinal tuberculosis, which may interfere with other clinical conditions.

Everolimus: a challenging drug in the treatment of multifocal inoperable cardiac rhabdomyoma

Primary cardiac tumors are rare in childhood. The most common of these are rhabdomyomas. Considering that rhabdomyomas often show spontaneous regression, close follow-up may be sufficient in hemodynamically stable cases. However, hemodynamically significant cardiac rhabdomyomas confer a risk of morbidity and mortality. Herein, we report a newborn infant with multifocal cardiac rhabdomyomas treated with everolimus. The optimal dose of the drug was 0.25 mg 2 times per day, 2 days per week. Patients with inoperable cardiac rhabdomyomas and with symptoms may be candidates for everolimus treatment.

Small bowel obstruction due to anomalous congenital peritoneal bands - case series in adults

BACKGROUND

Congenital bands cause 3 % of all intestinal obstruction and almost always lead to small bowel obstruction. In adults, obstruction due to bands is even rarer.

MATERIALS AND METHODS

A multicenter study in Turkey. From January 2000 to December 2010 inclusive - a period of 10 years - all adult patients admitted to the emergency departments with a clinical diagnosis of acute intestinal obstruction due to congenital peritoneal band were included in the study. Surgery was defined as emergency. Recorded operative findings included the site of obstruction, and the operative procedure to relieve it. In the present study, the findings in adult patients with congenital band reported in the literature together with findings in ten cases operated at four center were retrospectively assessed with respect to their demographic, preoperative, peroperative, and postoperative characteristics.

RESULTS

There were 8 males and 2 females aged between 18 and 72 year. There were no history of abdominal or inguinal surgery. Plain abdominal X-rays radiography revealed air- fluid levels in all patients. All the bands were ligated and divided. On histopathological examination, the bands were composed of loose connective tissue containing blood vessels. There were no calcification in the bands.

CONCLUSION

an anomalous congenital band could be included in the differential diagnosis of intestinal obstruction. This clinical situation requires early surgical intervention that will be diagnostic and therapeutic (Tab. 1, Fig. 4, Ref. 21).

Multiple axillary-infraclavicular lymph node metastasis from malignant rhabdoid tumor of unknown primary site

Malignant rhabdoid tumors (MRT) mostly originate from the kidney and central nervous system. However, they may also originate from retroperitoneal and paravertebral regions, mediastinum, liver, chest wall, extremity, and neck, as well as from the soft tissues. The most important method in the differential diagnosis is the analysis of cytogenetic alterations in the INI1 gene. A six-month-old girl presented with multiple conglomerated lymphadenopathies located in the anterior axillary line. MRT diagnosis was confirmed by loss of INI1 expression in the tumor tissue. This is the first case in the literature with unknown primary focus diagnosed from lymph node metastasis.

Ganglioneuroma in a child with hereditary spherocytosis

Hereditary spherocytosis (HS) is the most frequent cause of congenital hemolytic anemia. Extramedullary hematopoiesis (EMH) mimicking a mass may develop in the lymph nodes, kidneys, pleura, mediastinum, adrenal gland, and in particular the spleen and liver. Other than EMH, B-cell lymphoma, acute lymphoblastic leukemia, and pancreatic schwannoma cases were reported in patients with HS. We present a 13-year-old female patient with HS and ganglioneuroma in the adrenal gland. This association is probably coincidental; however, with increasing cancer cases in HS and the genetic studies being made, this association will be clarified.

The results of surgical treatment for hepatic hydatid disease

BACKGROUND

Hydatid disease is an important health problem worldwide and surgery remains the gold standard in terms of treatment for patients with echinococcosis of the liver. In this study we aimed to present our recent surgical experience in treating patients with hepatic hydatidosis.

PATIENTS AND METHODS

Fourty-eight patients with Liver Echinococcosis (LE) who were operated in our department between 2007 and 2008 were reviewed retrospectively. It was observed that cystectomy or hepatectomy had been preferred in certain patients with cysts of small size or subcapsular location.

RESULTS

There was no significant difference in the type of surgical procedures and early post-operative complications. Recurrence rates and mean duration of hospitalization were significantly lower in patients treated by radical procedures than the patients in drainage and obliteration group.

CONCLUSION

Radical operations for hydatid cyst disease are safe methods and may be preffered in selected cases.

Successful treatment of cyclophosphamide-induced haemorrhagic cystitis with intravesical prostaglandin E1 in a child with non-Hodgkin's lymphoma

Abstract A 5-year-old male patient with non-Hodgkin's lymphoma developed haemorrhagic cystitisgrade IV due to cyclophosphamide. Intravesical prostaglandin E(1)was administered safely and successfully. This case demonstrates that intravesical prostaglandin E(1) is a safe, easyand effective treatment method in resistant grade IV haemorrhagic cystitis.

Clinical significance of serum vascular endothelial growth factor, endostatin, and leptin levels in children with lymphoma

BACKGROUND

A number of clinical studies conducted in adults have demonstrated the prognostic significance of angiogenic factors in malignancies, however, only a limited number of studies have been conducted in children. The aim of this study was to determine serum vascular endothelial growth factor (VEGF), endostatin, and leptin levels in children with lymphoma and to investigate whether these factors provide prognostic information.

PROCEDURE

Serum samples from 36 children with lymphoma (non-Hodgkin lymphoma (NHL) N = 21, Hodgkin lymphoma (HL) N = 15) were collected at diagnosis and during remission. Serum samples were also collected from 18 healthy children as the control group. Serum VEGF and endostatin levels were quantified by using enzyme-linked immunosorbent assay (ELISA) and serum leptin by immunoradiometric assay.

RESULTS

The serum VEGF levels were found elevated in patients compared to controls (P = 0.033), while endostatin and leptin levels were lower in patients than in controls (endostatin, 43.9 ± 5.8 ng/ml vs. 123.6 ± 13.5 ng/ml, P < 0.001; leptin, 5 ± 1.5 ng/ml vs. 6.7 ± 1.2 ng/ml, P = 0.013). VEGF levels declined (pre, 151.6 ± 55.9 pg/ml vs. post, 16.2 ± 7.9 pg/ml, P = 0.041), while endostatin and leptin levels increased in patients who achieved remission (33 of 36 patients) when compared to pre-treatment levels (endostatin pre, 43.1 ± 5.9 ng/ml vs. post, 65.9 ± 6.8 ng/ml, P = 0.047; leptin, pre, 5.3 ± 1.6 ng/ml vs. post, 9.8 ± 2.7 ng/ml, P = 0.012). Serum VEGF, endostatin, and leptin levels were not predictive of survival.

CONCLUSION

Serial measurement of serum VEGF, endostatin, and leptin levels could potentially be used to predict response to treatment or progressive disease in children with lymphoma.

Primary hydatid cyst of the rib mimicking chest wall tumor: a case report

Hydatidosis, caused by Echinococcus granulosus, is still an endemic parasitic disease in the Mediterranean area, South America, North Africa, and Australia. The most common anatomic location of hydatid disease is the liver, followed by the lung. Hydatidosis is located in the bones in 0.5% to 2% of all cases. A hydatid cyst can be seen in any part of the body. However, primary hydatid cyst of the rib in childhood is exceedingly rare. We report the first case of a pediatric hydatid cyst of the rib mimicking chest wall tumor.

Are postoperative drains necessary with the Karydakis flap for treatment of pilonidal sinus? (Can fibrin glue be replaced to drains?) A prospective randomized trial

PURPOSE

Different surgical techniques for pilonidal disease have been described in the literature. In this study, our aim was to evaluate the influence of routine cavity drainage in the Karydakis flap technique.

METHODS

As much as 50 male patients with pilonidal sinus who underwent the Karydakis flap operation were evaluated prospectively.The patients were assigned randomly into two groups (Group 1 with suction drain; Group 2 fibrin glue).

RESULTS

Fluid collection was encountered in 8 out of 50 patients (6.25%): 6 in Group 2 (24%) of which 4 experienced superficial, healed with simple dressing, the other 2 with substantial dehiscence healed with wound dressing; 2 in Group 1 (8%) were treated with wound punctures.There has been no recurrence in any of the patients during the follow-up period.The Karydakis flap operations can be performed with a near zero recurrence rate with the use of drains.

CONCLUSION

We recommend the use of fibrin sealant with Karydakis flap procedure, but further studies are needed to confirm this conclusion.

The abdominal cocoon: a rare cause of intestinal obstruction

The abdominal cocoon is a very rare entity leading to bowel obstruction. A 30-year-old man was admitted to the emergency department with symptoms and signs of mechanical intestinal obstruction. In addition to these, the recurrent episodes of obstruction in the patient's history and palpable abdominal mass found during the physical examination, appeared as important clinical characteristics of the pathology. A CT scan of the abdomen showed a conglomerate of bowel loops encased in a membrane. A Cocoon-like mass consisting of encapsulated bowel loops was the main finding of surgical exploration. Dissection and excision of the encapsulating membrane and release of encased loops provided definitive treatment of this rare entity.