Using Microbiology Culture in Pediatric Appendicitis to Risk Stratify Patients: A Cohort Study.

Background: We sought to investigate the value of intra-operative microbiology samples in pediatric appendicitis. Proposed benefits include tailoring post-operative antimicrobial management, risk-stratifying patients, and reducing post-operative intra-abdominal abscess formation. Patients and Methods: All cases of appendicitis managed with appendicectomy in a single center were collected from January 2015 to August 2020. Intra-operative microbiology samples were taken routinely. Post-operative outcomes were analyzed with reference to culture and sensitivity results. Histologic findings were further categorized as normal, simple, or complex. Results: Six hundred seventy-eight children had appendicectomies, and 608 had both microbiology and histology samples taken. Intra-abdominal fluid collection and subsequent intervention rates were 22% and 9%, respectively. There were more collections in those with a culture positive result (p < 0.001), and those growing each of three recognized organisms, Escherichia coli (p < 0.001), Pseudomonas aeruginosa (p = 0.01), and Streptococcus anginosus group (p < 0.001). Intervention rate was higher in the culture-positive result group (p = 0.002) and the Streptococcus anginosus group (p < 0.001). Conclusions: This study shows an increased risk of developing a collection with the isolation of one of three key organisms (Escherichia coli, Pseudomonas aeruginosa, Streptococcus anginosus group). Sersoal swabs are an effective and practical method of gathering information on organisms. Microbiologic yield was correlated to the severity of appendicitis. Isolation of Streptococcus anginosus increases the incidence of collections to 50%. This is useful to empower surgeons to prognosticate patients' potential outcomes based on both intra-operative, and microbiologic findings, and is useful in counseling patients and managing expectations. A prolonged course of antibiotic agents or higher dose may mitigate this risk.

Standardizing the surgical management of benign ovarian tumors in children and adolescents: A best practice Delphi consensus statement.

AIM: No widely agreed consensus protocols exist for the management of benign ovarian tumors (BOT) in children. This presents a substantial risk for suboptimal management. We aimed to generate multispecialty consensus guidance to standardize surgical management and provide a clear follow-up protocol for children with BOTs. METHODS: Prospective two-round confidential e-Delphi consensus survey distributed among multispecialty expert panel; concluded by two semistructured videoconferences. MAIN RESULTS: Consensus was generated on these core outcome sets: preoperative/intraoperative management; follow-up; adolescent gynecology referral. (1) Children with BOTs should receive the same management as other patients with potentially neoplastic lesions: Preoperative discussion at a pediatric oncology multidisciplinary meeting to risk stratify tumors, and management by health professionals with expertise in ovarian-sparing surgery and laparoscopy. (2) Ovarian-sparing surgery for BOTs should be performed wherever possible to maximize fertility preservation. (3) Ovarian masses detected during emergency laparoscopy/laparotomy should be left in situ wherever feasible and investigated appropriately (imaging/tumor markers) before resection. (4) Follow-up should be undertaken for all patients after BOT resection. Patients should be offered referral to adolescent gynecology to discuss fertility implications. CONCLUSION: This best practice Delphi consensus statement emphasizes the importance of managing children with BOTs through a well-defined oncological MDT strategy, in order to optimize risk stratification and allow fertility preservation by ovarian-sparing surgery wherever possible.

Is carboplatin-based chemotherapy as effective as cisplatin-based chemotherapy in the treatment of advanced-stage dysgerminoma in children, adolescents and young adults?

OBJECTIVE: Dysgerminoma is the most common malignant ovarian germ cell tumor (GCT) with peak incidence during adolescence and young adulthood. Current standard of care for patients with disease that has spread outside of the ovary (advanced-stage) utilizes platin-based chemotherapy regimens. The study objective was to compare clinical outcomes between platin-based (carboplatin versus cisplatin) strategies across all age groups (children < 11 years (y), adolescents = 11-25 y and young adult women > 25 y) for advanced-stage dysgerminoma. METHODS: The Malignant Germ Cell Tumor International Consortium (MaGIC) pooled data from six GCT trials (3 = pediatric, 3 = adult) conducted internationally by pediatric and gynecologic oncology clinical trial organizations (CTOs) between 1983 and 2009. Newly diagnosed patients, with advanced-stage (FIGO IC-IV) dysgerminoma, who received either carboplatin- or cisplatin-based chemotherapy were eligible for analysis. RESULTS: 126 eligible patients were identified; 56 patients (38 = pediatric, 18 = adult) received carboplatin-based and 70 patients (50 = pediatric, 20 = adult) received cisplatin-based chemotherapy. Mean age was 20 y (range = 6-46 y). The median follow-up was 10.3 y (range = 0.17-21.7 y). The five-year event-free survival (EFS5) and overall survival (OS5) was 0.94 (95%CI, 0.88-0.97) and 0.96 (95%CI, 0.91-0.99) respectively. Survival outcomes were comparable between carboplatin-(EFS5 = 0.96 (95%CI, 0.85-0.99), OS5 = 0.96 (95%CI, 0.85-0.99)) and cisplatin-(EFS5 = 0.93 (95%CI, 0.83-0.97), OS5 = 0.96 (95%CI, 0.87-0.99)) based regimens. Across three age groups, comparison of the EFS5 (<11 y = 0.1, 11-25 y = 0.91 (95%CI, 0.82-0.96), >25 y = 0.97 (95%CI, 0.81-0.99)) and OS5 (<11 y = 0.1, 11-25 y = 0.95 (95%CI, 0.87-0.99), >25 y = 0.97 (95%CI, 0.81-0.99)) did not demonstrate any statistically significant differences in outcomes. CONCLUSIONS: Patients diagnosed with dysgerminoma have an excellent OS, across all ages, even in the context of metastatic disease. Data from three large CTOs supports the investigation of carboplatin-based regimens in the frontline treatment of all patients with advanced-stage dysgerminoma to minimize treatment-related toxicities.

A surgical approach to Wilms' tumour with retrohepatic vena caval extension.

PURPOSE: Wilms' tumours (WT) with retrohepatic vascular extension traditionally requires cardiac bypass for complete excision. We share our experience of these complex cases. METHODS: A retrospective review was performed of children with WT with retrohepatic vascular extension presenting to two UK children's hospitals. Tumour stage, chemotherapy, level of vascular extension, operative details and complication data were analysed. RESULTS: Ten children were identified. Mean age 6.6 years (range 3.3-8.2 years); tumour side 6 right, 2 left, 2 bilateral. Level of tumour extension was to the right atrium in two, diaphragm in two, hepatic vein (HV) level in four and retrohepatic inferior vena cava (IVC) in one patient. Following chemotherapy it reduced to hepatic veins (5) or below (4). Surgery involved radical nephrectomy and complete mobilisation of the liver off the IVC, which was then clamped, opened and the thrombus excised. There were no intraoperative complications. Mean hospital stay was 9.77 days (7-20 days). Histology showed viable tumour thrombus in six patients. One patient died after 1 year from metastatic disease. CONCLUSION: Retrohepatic extension of WT can be managed without bypass using pre-operative chemotherapy and by complete liver mobilisation. The tumour was always adherent to IVC and required sharp dissection.

Efficacy of video-assisted thoracoscopic surgery in managing childhood empyema: a large single-centre study.

BACKGROUND/PURPOSE: A randomised controlled trial evaluating the role of video-assisted thoracoscopic surgery (VATS) in childhood empyema reported a failure rate of 16.6%. Our aim is to determine the outcome of VATS in a large series of children managed by 3 paediatric surgeons experienced in endoscopic surgery. METHOD: A retrospective study of all children with empyema admitted under the care of the 3 surgeons between February 2004 and February 2008 was undertaken. Recorded details included demographic data, mode of presentation, preoperative investigations, operative details, antibiotic usage, microbiological data, postoperative course, follow-up data and complications. RESULTS: 114 children (69 boys, 45 girls) had VATS for empyema. Their median age was 5 (0.2-15) years. The pleural cavity was drained for a median of 4 (2-13) days. Median postoperative hospital stay was 7 (4-36) days. Median follow-up was 8 (1-24) months. There were 8 (7%) treatment failures: 5 conversions to thoracotomy and 3 recurrent empyemas. There were 7 complications (6%): air leak (n = 6) and lung injury (n = 1). 104 (91%) children had full resolution of symptoms. There were no deaths. CONCLUSION: Video-assisted thoracoscopic surgery has a better outcome in childhood empyema than reported in a recent randomised trial and it has an important role in the management of this condition.

Peripheral primitive neuroectodermal tumor with postchemotherapy neuroblastoma-like differentiation.

We report the case of an 11-year-old girl with a retroperitoneal tumor in the left upper quadrant. The girl was admitted to hospital with weight loss and a painless abdominal mass that on biopsy was diagnosed as a peripheral primitive neuroectodermal tumor/Ewing sarcoma (pPNET/EWS) of the soft tissue. The patient underwent chemotherapy followed by surgical resection of the tumor 5 months after diagnosis. The posttreatment residual viable tumor showed a morphologic appearance resembling a neuroblastoma. Interphase and metaphase fluorescent in situ hybridization (FISH) studies performed on the pretreatment and posttreatment samples showed the presence of a t(11;22) rearrangement resulting in EWSR1/FLI1 gene fusion consistent with pPNET/EWS in both specimens. This case is unusual in the sense of showing the typical gene fusion for pPNET/EWS both in the pretherapy sample with the typical morphological appearance of this tumor and in the posttherapy specimen showing neural differentiation suggestive of a neuroblastoma.