Detection of irreversible changes in susceptibility-weighted images after whole-brain irradiation of children.

INTRODUCTION: Whole-brain irradiation is part of the therapy protocol for patients with medulloblastomas. Side effects and complications of radiation can be detected by follow-up magnetic resonance imaging (MRI). Susceptibility-weighted images (SWI) can detect even very small amounts of residual blood that cannot be shown with conventional MRI. The purpose of this study was to determine when and where SWI lesions appear after whole-brain irradiation. METHODS: MRI follow-up of seven patients with medulloblastoma who were treated with whole-brain irradiation were analyzed retrospectively. SWI were part of the initial and follow-up MRI protocol. De novo SWI lesions, localization, and development over time were documented. RESULTS: At time of irradiation, mean age of the patients was 13 years (±4 years). Earliest SWI lesions were detected 4 months after radiation treatment. In all patients, SWI lesions accumulated over time, although the individual number of SWI lesions varied. No specific dissemination of SWI lesions was observed. CONCLUSION: Whole-brain irradiation can cause relatively early dot-like SWI lesions. The lesions are irreversible and accumulate over time. Histopathological correlation and clinical impact of these SWI lesions should be investigated.

Response of children with stage IV soft tissue sarcoma to topotecan and carboplatin: a phase II window trial of the cooperative soft tissue sarcoma group.

To investigate antitumor activity and toxicity associated with combined topotecan and carboplatin treatment in children and adolescents with metastasized, untreated soft tissue sarcoma (STS).Patients (n=34) less than 21 years old and untreated, stage IV STS. Patients were treated with topotecan (1 mg/m²/d for 4 days) and carboplatin (150 mg/m²/d for 4 days) (TC course) during week 1 and 4 of a chemotherapy window trial, which was followed by chemotherapy and local therapy from week 6 on. We evaluated the side effects, toxicity and tumor response (using RECIST criteria) 6 weeks after starting the 2 TC chemotherapy courses.The objective response rate (ORR) was 38% (n=13 patients with a partial response (PR)), and a stable disease (SD) was reached in 11 cases. No patient showed a complete response (CR) of all metastatic lesions, although 1 patient showed a CR of the target lesion. 2 patients died of progress of disease (PD). Toxicity was mainly hematological (grade III/IV toxicity 79%), and nonhematological toxicities mainly included infection, fever, nausea,and vomiting. Regarding adverse events, 4 probable and 8 possible events related to study medication occurred among the 66 courses of TC.In conclusion, TC was potent against high-risk STS, but results and toxicity data were not superior to former published monotherapeutic topotecan therapies.

Malignant melanoma and Wiedemann-Beckwith syndrome in childhood.

Patients with Wiedemann-Beckwith syndrome (WBS, MIM 130650), a congenital overgrowth syndrome, have a known increased tumor risk especially for embryonic tumors. WBS belongs to the "imprinting" syndromes caused by overexpression of IGF2 and/or loss of CDKN1C on chromosome 11p15.5. A 13-year-old boy with WBS developed a spitzoid malignant melanoma (Clark level V, Breslow index 4.8 mm) on the right cheek. Genetic analyses of the patient's blood showed hypermethylation at the H19 locus on chromosome 11p. The (epi)genetic changes of the WBS locus might have played a role in the pathogenesis of melanoma development.

Re-transplantation from the same unrelated donor in three adolescents with severe aplastic anemia after graft rejection.

Hematopoietic stem cell transplantation (HSCT) from a matched unrelated donor (MUD) has become the accepted salvage treatment for patients with severe aplastic anemia (SAA) lacking a matched sibling donor and failing immunosuppressive treatment. However, non-engraftment and early rejection remain main reasons for treatment related morbidity and mortality. We report on three adolescents who were grafted from MUD, rejected their graft and were re-grafted 47-51 days after first HSCT from the same donor. For conditioning, fludarabine, cyclophosphamide, ATG and/or OKT3 in combination with total lymphoid irradiation was used. Unmanipulated peripheral blood stem cells at a minimum dose of 8 x 10(6)/kg CD34+cells were infused. Acute toxicity was low. Two patients are alive and well for more than 3 years, one patient developed extended chronic graft-versus-host disease from which he died 34 months after second HSCT. Re-transplantation from MUD in the case of non-engraftment or rejection from the same donor is possible following immunoablation combined with intensive serotherapy in young patients with SAA.

Allogeneic stem cell transplantation for pediatric and adolescent patients with CML: results from the prospective trial CML-paed I.

PURPOSE: Stem cell transplantation (SCT) can definitely cure chronic myeloid leukemia (CML), a rare disease in childhood. We prospectively evaluated the results of early SCT in pediatric CML after standardized pretreatment with hydroxyurea+/-interferon. PATIENTS AND METHODS: Between 1995 and 2004, 200 children (median age: 12.4 years) were enrolled and stratified: given the availability of an HLA-matched related donor (MRD), SCT was scheduled within 6 months and otherwise from an unrelated donor (UD) within 12 months following diagnosis. RESULTS: 176 patients underwent SCT; from MRD within median 4 months and from UD within median 11 months after diagnosis. At SCT, 158 patients were in chronic phase (CP1 or CP2), 9 patients were in accelerated phase and 9 patients were in blast crisis (BC). The conditioning regimen - total body irradiation or busulfan - exerted no different impact on overall survival (OS). Probability of OS at 5 years was 87+/-11% if grafted from a sibling (n=41), 52+/-9% from matched UD (MUD, n=71), and 45+/-16% from mismatched donors (MMD, n=55), respectively. A trend for better OS in CP1 was observed if SCT was performed within 6 months (n=49; 74+/-9%), compared to 7-12 months (n=52; 62+/-15%), and >12 months (n=43; 62+/-17%) after diagnosis, respectively (p=0.157). Probability of relapse at 5 years was 20+/-12%. Transplant-related mortality and graft-versus-host disease mainly contributed to the inferior outcome in UD and HLA-mismatched SCT. CONCLUSION: These data from the first prospective trial on CML restricted to children and adolescents might be considered for decision making when balancing the risks of SCT against the increasing use of imatinib as upfront treatment for CML.

[Ligneous conjunctivitis]. / Conjunctivitis lignosa.

CASE REPORT: We report the case of a 3-year-old female patient with therapy refractive recurrent conjunctivitis and membrane formation of the upper eyelid. After surgical removal the histological examination showed an image compatible with ligneous conjunctivitis. A manifest serum plasminogen deficiency (22 %) supported the diagnosis. TREATMENT: The treatment with corticosteroids, heparin-containing and fresh frozen plasma (FFP) eye drops, renewed surgical ablation with perioperative intravenous FFP administration and local cyclosporine A eye drops achieved a stable condition with low disease activity. CONCLUSION: The combination of these therapy approaches has been performed here for the first time and has not been described in the literature so far.

Detection of Epstein-Barr virus DNA in peripheral blood of paediatric patients with Hodgkin's disease by real-time polymerase chain reaction.

Hodgkin's disease (HD) is commonly associated with latent Epstein-Barr virus (EBV) infection. The aim of our study was a detailed molecular analysis of the EBV status in the peripheral blood of paediatric patients with HD. Blood samples from HD patients were examined before (n=28) and after treatment (n=12). The control group consisted of 20 healthy children and 10 immunosuppressed children with primary EBV infection. EBV load in plasma and peripheral blood mononuclear cells (PBMC) were determined by real time quantitative polymerase chain reaction (RQ-PCR) as recently described. Before treatment, EBV DNA was detected in the plasma of 13/24 EBV-seropositive HD patients, whereas in plasma of healthy controls no EBV DNA was detectable (P<0.001). After treatment, no EBV genomes were found in the plasma of 6 HD patients in stable and complete remission. In contrast, 2/5 HD patients with relapse of disease were positive for EBV DNA in the plasma. In PBMCs, no differences were found in EBV load measured in HD patients before or after treatment and healthy controls. A high EBV load was found in both the plasma and PBMCs of all immunosuppressed patients with primary EBV infection. Thus, EBV DNA detection in the plasma of paediatric HD patients might be of value for non-invasive diagnostic, prognostic and follow-up tests for HD.

Elevated blood drug levels obtained from indwelling silicon catheters during oral cyclosporine A administration.

Cyclosporine A (CsA) may be bound to and released from the inner surface of central venous catheters resulting in spuriously elevated blood drug levels. We observed this phenomenon in a boy transplanted because of aplastic anemia up to 9 weeks after CsA had been switched from intravenous to oral administration. In comparison to phlebotomy, simultaneous blood sampling from the double lumen catheter resulted in a greater than 10-fold, or two-fold increase in drug levels, respectively, depending on whether or not the line used for prior CsA infusion was selected. Thus, prolonged binding of CsA to the inner surface of venous catheters should also be considered during oral administration.

Reduced-intensity conditioning prior to allogeneic transplantation of hematopoietic stem cells: the need for T cells early after transplantation to induce a graft-versus-lymphoma effect.

In patients with poor-risk relapse of aggressive lymphoma, reduced-intensity conditioning followed by allogeneic PBSCT may have its limitations because of rapid regrowth of the tumor. We tried to address this problem by intermediate-intensity conditioning followed by allogeneic SCT. A total of 21 patients received fludarabine, busulfan and cyclophosphamide prior to allogeneic SCT. In the first 10 patients, GVHD prophylaxis by CD34+ selection of the grafts was employed (group I). The next 11 patients received nonmanipulated grafts and mycophenolat mofetil plus cyclosporinA (group II). In group I, no GVHD was observed. In contrast, patients in group II had a significant risk of acute GVHD (aGVHD) (six patients with grade II-IV acute GVHD). However, in group I, all surviving patients progressed within 9 months. In contrast, eight of nine surviving patients of group II remain in remission after a median observation time of 10.5 months (range 4-22 months). Survival differed significantly between the groups (P=0.004). Multivariate analysis identified intensive GVHD prophylaxis as important risk factor for survival. These results support the existence of a clinically relevant GVL effect in aggressive lymphoma. T-cell depletion (or CD34 selection) of grafts is not recommended in patients with poor-risk aggressive NHL.

Therapy of steroid-refractory acute GVHD with CD52 antibody alemtuzumab is effective.

The efficacy and safety of CD52 antibody alemtuzumab to treat severe acute GVHD in 18 consecutive patients refractory to standard high-dose corticosteroid therapy is reported. Patients (age range 13-68 years) had developed acute GVHD grade III and IV with gut and/or liver involvement after stem cell transplantation from family donors (n= 7) or HLA-matched unrelated donors (n=11), including five donors with one or two HLA mismatches. Initially, in three patients, start doses of alemtuzumab in the range of 70-80 mg were applied and repeated after 3 to 4 weeks. Impressive responses were seen, but virus reactivation and bacterial infections were frequent. In an attempt to reduce this complication, the next nine patients received a reduced starting dose of 20-33 mg, and the last six patients received 3-13 mg repeated every 2-3 weeks. Seventeen of 18 patients responded to alemtuzumab, six patients are alive with a median follow-up of 108 weeks. Chronic GVHD was observed frequently. Although pronounced lymphocyte depletion requiring close monitoring for signs of infections seems inevitable for efficacy, alemtuzumab given in moderate doses has a substantial activity not only in intestinal but also in severe acute GVHD of the liver.

Haematopoietic SCT for children and adolescents with relapsed and refractory Hodgkin's lymphoma.

Despite the generally excellent prognosis of children and adolescents with Hodgkin's lymphoma (HL), approximately 15% of patients relapse. Salvage therapy options include further chemo-radiotherapy and autologous or allogeneic haematopoietic SCT (HSCT). Autologous HSCT following high-dose chemotherapy, the standard treatment for adult patients with relapsed HL, is also effective in paediatric patients, but randomized trials showing its superiority to conventional therapy are lacking. Although patients with late relapse (>12 months after completion of therapy) may be cured with conventional therapy, those with progressive disease or early relapse (3-12 months) are considered candidates for autologous HSCT. According to patient selection criteria, overall and disease-free survival rates after autologous HSCT are 43-95% and 31-70%, respectively. Short time to relapse and refractory disease at the time of autologous HSCT remain the most important risk factors. Data on allogeneic HSCT in children with HL are scarce. Broader use has been hampered for a long time mainly by high non-relapse mortality, offsetting the advantage of a graft-vs-lymphoma effect. Data suggest that young patients with recurring disease following autologous HSCT, as well as some patients with multiple relapses and selected patients with refractory lymphoma, might benefit from allogeneic HSCT, but relapse remains the major challenge.

[Mediastinal tumour in children misdiagnosed as bronchial asthma]. / Fehldiagnose "Asthma bronchiale" bei Mediastinaltumor im Kindesalter.

HISTORY: Three school children (2 girls and 1 boy, aged 9-15 years) complained about exercise-induced shortness of breath and stridor. The children were treated with inhalation steroids, one of them with systemic steroids, without a significant effect. INVESTIGATIONS: Because of lack of treatment response a chest X-ray was done. In all cases a mediastinal mass was visible. No radiological signs of an obstructive pulmonary disease was demonstrated. In none of the three cases did a pulmonary function tests demonstrate an obstructive pulmonary disease. DIAGNOSIS, TREATMENT, AND COURSE: Bone marrow aspiration in one girl showed an acute lymphoblastic leukemia of T-cell immunophenotype with a large mediastinal lymphoma. Lymph node biopsy in the boy demonstrated a nodular sclerosing subtype of Hodgkin's disease. In the other girl a ganglioneuroma was found. CONCLUSION: In children and adolescents a chest radiograph and pulmonary function tests should be performed if history and clinical signs are suggestive of bronchial asthma, before a specific inhalative or systemic treatment is started.

Neutrophil aggregates in a 13-year-old girl: a rare hematological phenomenon.

Aggregation of neutrophils in peripheral blood smears is a very rare, mostly self-limiting phenomenon and may result in pseudoleukopenia. In the majority of cases, malignancies, infections, or hepatic disorders have been identified as the underlying condition. Although the exact reason for neutrophil aggregation in vitro has not been clarified, its relation to the use of ethylenediaminetetraacetate acid as an anticoagulant has been described in adults. We report here on the occurrence of transient neutrophil aggregation in a 13-year-old girl with Herpes simplex and concomitant Mycoplasma pneumoniae infection.

[Hepatopathy in patients with stage 4S neuroblastoma]. / Hepatopathie bei Patienten mit Neuroblastom Stadium 4S.

The survival probability is 79% for patients with neuroblastoma stage 4S treated according to the German Society for Pediatric Oncology and Hematology (GPOH) treatment studies. Most of these patients (80%) have liver metastases. Patients are grouped according to their condition at diagnosis and tumour resectability to different risk groups (A, B, C). Chemotherapy is provided for patients who are initially diagnosed as critically ill, caused for example by excessive hepatomegaly due to liver metastases. The aim of this study is to clarify whether liver infiltration is associated with liver dysfunction and whether chemotherapy plays a role in this process. Hepatopathy was diagnosed when clinical signs were present and/or liver function tests revealed pathologic results. The charts of 48 patients (22 boys, 26 girls) diagnosed between 1990 and 1994 from the ongoing NB-90 treatment study were evaluated retrospectively. Median age at diagnosis was 52 days (range: 1-328). 41 patients (85%) had liver infiltration, 26 patients (54%) had bone marrow involvement and in nine patients (19%) skin metastases were found. 12 patients were in poor general condition at diagnosis (risk group C). 36 of 48 patients (75%) received chemotherapy, three children were treated with radiotherapy additionally, due to massive liver enlargement. 15 patients (31%) had signs of hepatic dysfunction at diagnosis or during their illness, 14 of these had liver metastases. All these 15 patients were treated with chemotherapy. 12 of 15 patients with hepatopathy were younger than two months at diagnosis. Five patients with liver dysfunction were not critically ill at diagnosis. Hepatomegaly > or = 6 cm was present in 10 of 15 patients with liver dysfunction. Hepatopathy was transient in eight patients, four patients died soon of multiorgan failure during progression of disease. Three children developed liver fibrosis with conversion to cirrhosis. Hepatopathy was correlated with distribution to risk groups (A and B (5/36) vs. C (10/12), p < 0.001). The appearance of hepatic dysfunction in patients with neuroblastoma stage 4S remains a serious problem especially for young children with excessive hepatic infiltration. Liver dysfunction was of short duration and reversible in most patients, however, even with age-adapted dosages of chemotherapy long-standing cases of hepatopathy were observed. A general recommendation for treatment strategy in this heterogeneous patient group is difficult. Attention should be given to for this complication.

Intracerebral hemorrhage as a late complication after CNS treatment of childhood lymphoma.

Since the majority of children with acute leukemia and lymphoma are long-term survivors, more attention is directed towards late sequelae of therapy. Intracerebral hemorrhage after treatment of central nervous system (CNS) neoplasia in childhood is a very rare event. A seven and a half-year-old boy was admitted to our hospital because of acute third nerve palsy. Three years and eight months before the patient had been treated for a mediastinal T-cell non Hodgkin's lymphoma (T-NHL) with CNS involvement by combined chemo-radiotherapy. Recurrent disease was excluded, but intracerebral hemorrhage in the tectal area was demonstrated by repeated magnetic resonance imaging. Symptoms of incomplete oculomotor paresis improved spontaneously with conservative therapy. Intracerebral hemorrhage may occur as a rare complication in children with malignant CNS disease even years after treatment with combined chemo-radiotherapy.