Diagnosing childhood tumors: A review of 147 cutting needle biopsies in 110 children.

BACKGROUND/PURPOSE: The aims of this study were to evaluate the diagnostic accuracy and safety of cutting needle biopsy for diagnosis in children with tumors suspected for malignancy. METHODS: Medical records and biopsy slides recorded from 1988 to 1999 were reviewed. One hundred ten patients had undergone a total of 147 cutting needle biopsies. The biopsy was performed under ultrasound guidance, using a 1.2-mm (18 gauge) Biopsy-cut biopsy needle. The diagnoses were benign tumors (n = 8), malignant tumors (n = 84), and nonneoplastic diseases (n = 18), with repeat biopsy performed in 24 patients. RESULTS: The diagnostic accuracy of cutting needle biopsies was 89% (131 of 147). The accuracy for pretreatment diagnosis was 88% (102 of 116), and for confirming or excluding a recurrence or metastasis 93% (26 of 28). The sensitivity of this method was 82% (86 of 105), and the positive predictive value 99% (86 of 87). Nondiagnostic cutting needle biopsy (n = 16) was not related to the age of the patient, experience of the radiologist, number of needle insertions, or site of puncture. No patient exhibited tumor growth along the needle tract. Complications occurred in 10 cases (7%) and pain in 20 (14%). CONCLUSION: Cutting needle biopsy is an accurate and safe procedure with a low learning threshold that is recommended for diagnosing malignancies in childhood.

Etoposide as the basic and interferon-alpha as the maintenance therapy for Langerhans cell histiocytosis: a RTC.

The treatment of patients who suffer from a disseminated form of Langerhans cell histiocytosis (LCH) is still controversial. So far, few larger randomized studies have been performed. The authors present 3 patients with a disseminated form of LCH--4 months, 9 months, and 2 years old, respectively. The lesional Langerhans cells in each patient showed positive immunohistochemical reaction to S-100 protein and the presence of Birbeck granules was confirmed by electron microscopy. All the patients were treated with etoposide (VP-16), 200 mg/m2 for 3 consecutive days, with 15 cycles at intervals of 3 weeks between each cycle, followed by maintenance therapy with IFN-alpha. All 3 patients reached complete stabile remission. The patients were young, at high risk, with multiple-organ involvement of LCH, and two of them had obvious signs of organ dysfunction at presentation, suggesting a poor prognosis. All remain disease-free several years after therapy. The results suggest that INF-alpha may prevent recurrences in high-risk patients.

A randomized trial of treatment for multisystem Langerhans' cell histiocytosis.

OBJECTIVE: To compare 2 active agents, vinblastine and etoposide, in the treatment of multisystem Langerhans' cell histiocytosis (LCH) in an international randomized study. STUDY DESIGN: One hundred forty-three untreated patients were randomly assigned to receive 24 weeks of vinblastine (6 mg/m(2), given intravenously every week) or etoposide (150 mg/m(2)/d, given intravenously for 3 days every 3 weeks), and a single initial dose of corticosteroids. RESULTS: Vinblastine and etoposide were equivalent (P > or = .2) in all respects: response at week 6 (57% and 49%); response at the last evaluation (58% and 69%); toxicity (47% and 58%); and probability of survival (76% and 83%) [corrected], of disease reactivation (61% and 55%), and of developing permanent consequences (39% and 51%) including diabetes insipidus (22% and 23%). LCH reactivations were usually mild, as was toxicity. All children > or = 2 years old without risk organ involvement (liver, lungs, hematopoietic system, or spleen) survived. With such involvement, lack of rapid (within 6 weeks) response was identified as a new prognostic indicator, predicting a high (66%) mortality rate. CONCLUSIONS: Vinblastine and etoposide, with one dose of corticosteroids, are equally effective treatments for multisystem LCH, but patients who do not respond within 6 weeks are at increased risk for treatment failure and may require different therapy.

Sequence variation in the ftsZ gene of Bartonella henselae isolates and clinical samples.

In a search for methods for subtyping of Bartonella henselae in clinical samples, we amplified and sequenced a 701-bp region in the 3' end of the ftsZ gene in 15 B. henselae isolates derived from cats and humans in the United States and Europe. The ftsZ sequence variants that were discovered were designated variants Bh ftsZ 1, 2, and 3 and were compared with 16S rRNA genotypes I and II of the same isolates. There was no ftsZ gene variation in the strains of 16S rRNA type I, all of which were Bh ftsZ 1. The type II strains constituted two groups, with nucleotide sequence variation in the ftsZ gene resulting in amino acid substitutions at three positions, one of which was shared by the two groups. One 16S rRNA type II isolate had an ftsZ gene sequence identical to those of the type I strains. Variants Bh ftsZ 1 and 2 were detected in tissue specimens from seven Swedish patients with diagnoses such as chronic multifocal osteomyelitis, cardiomyopathy, and lymphadenopathy. Patients with similar clinical entities displayed either Bh ftsZ variant. The etiological role of B. henselae in these patients was supported by positive Bartonella antibody titers and/or amplification and sequencing of a part of the B. henselae gltA gene. B. henselae ftsZ gene sequence variation may be useful in providing knowledge about the epidemiology of various B. henselae strains in clinical samples, especially when isolation attempts have failed. This report also describes manifestations of atypical Bartonella infections in Sweden.

Cyclosporine A therapy for multisystem langerhans cell histiocytosis.

BACKGROUND: Treatment of multisystem Langerhans cell histiocytosis (LCH) remains difficult. Various regimens of single and multiagent chemotherapy have been used, but a significant proportion of patients fail to respond to treatment. PROCEDURE: We have evaluated the use of cyclosporine A (CSA) in a controlled group of patients, who had received a systematic primary therapy (LCH-I). Patients received CSA either as a single agent (10 patients) or in combination with vinblastine, etoposide, prednisolone, and/or antithymocyte globulin (16 patients). RESULTS: Among the total of 26 patients treated, a single patient developed a complete response and three a partial response, whereas 85% (22 patients) had no response to CSA. CONCLUSIONS: CSA is at best of limited value in the treatment of patients with multisystem LCH, particularly those who had progressive disease while receiving chemotherapy.

Pretreatment, ultrasound-guided cutting needle biopsies in childhood renal tumors.

BACKGROUND: The current International Society of Paediatric Oncology (SIOP)-10 protocol does not allow pretreatment histological classification of low-stage renal tumors in children for fear of needle tract recurrences. The aims of this retrospective study were to evaluate the safety, sensitivity, and specificity of ultrasound-guided cutting needle biopsies (UCNB) performed at our institution in pediatric patients with renal tumors. PROCEDURE: Of 28 pediatric patients presenting with a renal tumor between 1988 and 1996, 25 underwent biopsy with the Biopty biopsy instrument (needle diameter 1.2 mm). The preoperative biopsy and nephrectomy slides were reviewed by a SIOP reference pathologist. The patients' hospital records were reviewed and biopsy complications were noted. RESULTS: At review of the nephrectomy slides, the diagnoses were: Wilms tumor (16 patients), with anaplasia in one case, rhabdoid tumor (2 patients), neuroblastoma (2 patients), mesoblastic nephroma (2 patients), clear cell sarcoma (1 patient), malignant teratoma (1 patient), and renal cell carcinoma (1 patient). No needle tract recurrence or other major complication was observed. The only complication was local pain at the biopsy site, which occurred in 24% (6/25) of the cases. The sensitivity of UCNB was 76% (19/25); five biopsies did not yield diagnostic material and one was not concordant. All cases of Wilms tumor were correctly diagnosed by UCNB, but only 33% (3/9) of the other tumors. CONCLUSIONS: In all cases of Wilms tumor a correct diagnosis was made. The overall sensitivity was 76%. UCNB proved to be a safe procedure that was not associated with needle tract recurrence or other serious complications.

Elevated circulating levels of interleukin-1 receptor antagonist but not IL-1 agonists in hemophagocytic lymphohistiocytosis.

The familial form of hemophagocytic lymphohistiocytosis (HLH) is an inherited disease with disturbed immunomodulation and characterized by fever, hepatosplenomegaly, cytopenia, hypertriglyceridemia, and coagulopathy, i.e., findings which are similar to many of the reported biological effects of the inflammatory cytokines. Due to the previously shown hypercytokinemia in active HLH with elevated levels of interleukin (IL)-6, tumor necrosis factor-alpha, and interferon-gamma, it has been suggested that cytokine dysregulation may be of pathophysiological importance. Here we have assayed the serum levels of the members of the IL-1 ligand family, the two agonists IL-1 alpha and IL-1 beta and the antagonist IL-1 receptor antagonist (IL-1ra), in nine children with HLH and cerebrospinal fluid (CSF) specimens from four children. Serum IL-1ra was elevated in all patients with active disease to a degree which correlated well with disease activity. Furthermore, the levels decreased day by day during treatment of a patient who suffered a relapse. Moreover, high levels of IL-1ra were also detected in CSF during active disease. However, IL-1 beta levels were all within normal limits and circulating IL-1 alpha levels were normal in all but two patients.

Low-sulphated oligosaccharides derived from heparan sulphate inhibit normal angiogenesis.

Heparin, with or without the addition of an adrenocorticosteroid, can inhibit normal angiogenesis in the chick embryo chorioallantoic membrane. Low- or non-sulphated heparin fragments also have anti-angiogenic effect. Attempts to define a saccharide structure responsible for the anti-angiogenic effect implicated a -[GlcA beta 1,4-GlcNAc alpha 1,4]n-sequence. This structure represents the product of the initial polymerization reaction in heparin/heparan sulphate biosynthesis. It persists in the non-sulphated regions of heparan sulphate and also occurs in the Escherichia coli K5 capsular polysaccharide. The K5 polysaccharide, fragments thereof down to octasaccharide size and analogous N-acetylated fragments of heparan sulphate, all showed anti-angiogenic activity. Hyaluronan, however, with the isomeric -[GlcA beta 1,3-GlcNAc beta 1,4]n-structure was inactive. The anti-angiogenic activity of -[GlcA beta 1,4-GlcNAc alpha 1,4]n-containing saccharides was potentiated by the presence of L-iduronic acid and one or two O-sulphate groups in the non-reducing-terminal disaccharide unit. The anti-angiogenic effect of these non- or low-sulphated saccharides was unaffected by the addition of hydrocortisone. Endothelial cell surface-bound heparan sulphate proteoglycans may represent a pool of precursors of anti-angiogenic oligosaccharides which may be of primary importance in the regulation of angiogenesis.

Autologous bone marrow transplantation in children with acute lymphoblastic leukemia.

We report 25 children with acute lymphoblastic leukemia (ALL) treated with purged autologous bone marrow transplantation (ABMT) at a single center. Two children with high-risk ALL were transplanted in first remission and 23 with relapsing ALL were transplanted in second (n = 21) or third (n = 2) remission. There was no procedure-related mortality. The median time to engraftment (i.e. to reach a polymorphonuclear cell count of 0.5 x 10(9)/l) was 25 days (range 16-45 days). Seven children relapsed, four within five months after ABMT: 18 of 25 children (72%) are in continuous complete remission after a median follow-up period of 50 months (range 5-71 months). The predicted long-term disease-free survival is 65% in the whole group and 61% in those transplanted after relapse. Relapse-free children returned to normal activities within three months after ABMT. The major side effects were development of cataract and gonadal insufficiency. We consider the results promising, but our data do not allow comparison with results reported from treatment with chemotherapy alone, since some of our patients were referred from other centers and represent a selected patient group. Long-term follow-up of well-defined patient populations is necessary to evaluate the effect of ABMT.

Cerebrospinal fluid exchange after intrathecal methotrexate overdose. A report of two cases.

Two patients aged 11 and four years, were accidentally given a 10-fold overdose of intrathecal methotrexate while being treated for malignant disease. Neither patient developed any signs of neurotoxicity and exchange of lumbar cerebro-spinal fluid was started 3 and 5 h later, respectively. In one of the patients, who received 120 mg of methotrexate intrathecally, 31% of the given dose was recovered during 2 h of cerebrospinal fluid exchange that was started 3 h after the accidental overdosage. No sequelae were observed in any of the patients. Cerebrospinal fluid exchange is safe and can be recommended in all cases of intrathecal methotrexate overdosage. Ventriculo-cisternal perfusion is not necessary in cases of a 10-fold overdose if the patient has no signs of acute neurotoxicity.

Antiangiogenic effect of heparin and other sulphated glycosaminoglycans in the chick embryo chorioallantoic membrane.

The effect of heparin and other sulphated glycosaminoglycans on normal capillary growth was studied in the chick embryo chorioallantoic membrane, with or without hydrocortisone. Contrary to previous reports, heparin was shown to have an antiangiogenic effect in itself, and an additive effect was obtained when it was combined with hydrocortisone. Heparan sulphate also had an antiangiogenic effect in the chorioallantoic membrane, while keratan sulphate, dermatan sulphate or chondroitin sulphate had no such effect. Copper ions, added in small amounts, did not influence the antiangiogenic effect of heparin, and nor did iron, zinc and magnesium ions, and EDTA.

Antiangiogenic effect of sulphated and nonsulphated glycosaminoglycans and polysaccharides in the chick embryo chorioallantoic membrane.

The inhibiting effect of sulphated and nonsulphated glycosaminoglycans and polysaccharides on the normal outgrowth of capillaries was tested in the chick embryo chorioallantoic membrane (CAM) with and without the presence of hydrocortisone. An antiangiogenic response to 50 micrograms of heparin and heparan sulphate (without hydrocortisone present) was observed in 38.8% and 23.1% of the CAMs, respectively, while the antiangiogenic response rate for dermatan sulphate, chondroitin sulphate A or C, hyaluronic acid and keratan sulphate was 15.9-0%. All sulphated homopolysaccharides tested were more effective than the naturally occurring glycosaminoglycans. Nonsulphated dextran and (methyl) cellulose had no antiangiogenic effect, while largely desulphated heparin retained such an effect. Hydrocortisone generally improved the antiangiogenic effect, a 100% response was obtained when it was combined with cellulose sulphate or fucoidan (polyfucose sulphate derived from marine algae), but the antiangiogenic effect of the largely desulphated heparin was unaffected by the presence of hydrocortisone. The results show that different polysulphated polysaccharides also have an antiangiogenic effect, without the addition of corticosteroids. The effect was apparently independent of their degree of sulphation, but the glycosidic structure may be of critical importance.

Bilirubin accumulation by the rabbit choroid plexus in vitro.

The postnatal development of bilirubin accumulation by the choroid plexus was studied in vitro. Choroid plexus of the fourth and lateral cerebral ventricles from adult or 1-, 7-, 15- or 21-day-old rabbits were incubated in a potassium-rich medium with 70 nmol/l of 3H-bilirubin for 5 min. The tissue/medium (T/M) ratio for 3H-bilirubin was considerable even 1 day post partum and increased during the next 2-3 weeks of life. In adults the 3H-bilirubin T/M ratio returned to the level of 1-day-old rabbits. The biliary excreted contrast agent iodipamide, added as a transport inhibitor, reduced the 3H-bilirubin T/M ratio in the choroid plexus, but to a relatively lesser extent in the 1-day-old rabbits than in the older ones.

Enhancement of FGF-like polypeptides in the retinae of newborn mice exposed to hyperoxia.

Retinae from neonatal mice exposed to prolonged hyperoxia (100% oxygen), show marked vasoproliferation. Extracts of such retinae were chromatographed on a heparin-Sepharose column and the absorbed material subjected to HPLC fractionation. Two components, approx. 10 and 18 kDa, respectively, were found to have angiogenic activity, which was higher than in corresponding extracts from animals exposed to air. Both fractions and an additional 5 kDa component reacted with an antibody to basic fibroblast growth factor (bFGF) and showed higher levels in hyperoxia. The data suggest that hyperoxia activates angiogenic factors belonging to the heparin binding family.

A simple method for shell-less cultivation of chick embryos.

The chorio-allantoic membrane of explanted chick embryos can be used for the study of vascular development and of the vascular response to drugs and to tissue implants or tissue extracts. Three different types of vials for shell-less cultivation of chick embryos were compared in terms of short-term survival. Plastic cups with rounded bottoms were superior to Petri dishes and polyethylene film bags, in that they combined a high survival rate of the embryos with a possibility of using a large number of embryos in each experiment. With the use of plastic cups this method is simple, reliable and inexpensive.

Transport of p-aminohippuric acid (3H-PAH), inulin and dextran out of the cranial cavity: a methodological study using intraventricular injection and sample combustion.

Material injected into the cerebral ventricles can leave the cerebrospinal fluid (CSF) but remain in the cranial cavity. To analyze the disappearance of 3H- and of 14C-labelled material from the cranial cavity, such material was injected into the lateral ventricles together with a bulk flow marker, labelled with the other radionuclide. In the present pilot study 3H-PAH and 14C-inulin were used. Five microliter of a mixture was injected into each lateral cerebral ventricles in rats, which were killed at various intervals. The whole skull was analyzed without opening the CSF space after homogenization in the deep-frozen state. The samples were combusted and analyzed by liquid scintillation counting. Probenecid, injected intraperitoneally, inhibited the removal of 3H-PAH from the skull cavity, as anticipated. Immediately after the intraventricular injection, however, 3H-PAH was transiently retained, probably by uptake into actively transporting tissue. After injection of probenecid, this delay in removal was reduced. The difference in disappearance rate between 3H-PAH and 14C-inulin was estimated by comparing the 3H/14C ratio in the skulls with that in the injected solution, which appeared to be a better method than comparing the recovery of each compound.