Complete regression of human neuroblastoma xenografts in athymic mice after local Newcastle disease virus therapy.

BACKGROUND: Neuroblastoma is the most common pediatric extra-cranial solid cancer. Using conventional therapies, children older than 1 year of age with advanced neuroblastoma have a poor prognosis. The development of new approaches for treating such children with neuroblastoma continues to be one of the most important goals today in pediatric oncology. Despite numerous anecdotal reports of human tumor regression during viral infections, the use of viruses to directly lyse neuroblastoma cells has never been reported as a potential therapy. Newcastle disease virus (NDV) has been shown to replicate in and kill cultured human and rat neuroblastoma cells but not normal human fibroblasts. PURPOSE: Our purpose was to determine if this selective killing of human neuroblastoma (IMR-32) cells is maintained during the in vivo treatment of established tumors. METHODS: Two experiments were performed using NDV strain 73-T. Athymic mice with subcutaneous IMR-32 human neuroblastoma xenografts (6-12 mm) were treated intralesionally with live NDV, UV-inactivated NDV, or phosphate-buffered saline (PBS). To study virus replication in situ, mice were given intratumoral or intramuscular injections of NDV. These mice were then killed at various times, and the amount of infectious virus present in tumor or muscle was determined. RESULTS: After one injection of live NDV, 17 of 18 tumors regressed completely, whereas rapid tumor growth occurred in all 18 mice treated with PBS and in all nine mice treated with UV-inactivated NDV (P < .0001). The one tumor that showed only a partial response to a single injection regressed completely after a second NDV treatment. Six months following virus-induced regression, only one tumor had recurred. No significant acute or chronic side effects of live NDV were noted in athymic mice given doses up to 500 times that used in this study. Virus levels increased more than 80-fold between 5 and 24 hours in virus-injected tumors (P < .04), while no infectious virus was produced in NDV-injected muscle tissue. CONCLUSIONS: NDV 73-T appears to replicate selectively in human IMR-32 neuroblastoma xenografts, leading directly to a potent antitumor effect as demonstrated by long-lasting, complete tumor regression occurring after a single local injection of virus. IMPLICATION: These experiments may provide an important step in the development of new therapeutic approaches to challenging cancers such as neuroblastoma.

Complete regression of human fibrosarcoma xenografts after local Newcastle disease virus therapy.

We have recently demonstrated that a single local injection of the avian pathogen Newcastle disease virus (NDV; strain 73-T) causes complete regression of human neuroblastoma xenografts in athymic mice (R. M. Lorence, K. W. Reichard, B. B. Katubig, H. M. Reyes, A. Phuangsab, B. R. Mitchell, C. J. Cascino, R. J. Walter, and M. E. Peeples. J. Natl. Cancer Inst., 86: 1228-1233, 1994). In this report, we tried to determine if this in vivo antineoplastic effect of NDV extends to human sarcomas. Athymic mice with s.c. HT1080 fibrosarcoma xenografts (7-14 mm) were randomly divided into two groups and treated i.t. with a single injection of either 10(7) plaque-forming units of NDV or phosphate-buffered saline. Complete tumor regression occurred in 8 of 10 mice treated with NDV while unabated tumor growth occurred in all 9 mice treated with phosphate-buffered saline (P < 0.001). To determine if complete tumor regression was long lasting, the 8 mice were monitored for 1 year, during which time no tumor recurred. To test the antitumor effects of NDV on tumors derived from a fresh human sarcoma, a similar experiment was performed in athymic mice using TH15145 synovial sarcoma xenografts at their first and second passages. Of 9 mice with TH15145 xenografts, a single i.t. injection of NDV (10(7) plaque-forming units) caused complete regression of 3 tumors and > 80% regression in 3 more tumors. In contrast, tumors in all 5 mice treated with phosphate-buffered saline exhibited unabated growth (P < 0.03 for > 80% tumor regression). Since HT1080 fibrosarcoma cells express the N-ras oncogene, we explored the effects that transfection of this oncogene has on the sensitivity to NDV. Cultured human fibroblasts that were made tumorigenic following N-ras-transfection were found to be 1000-fold more sensitive to NDV than normal fibroblasts in a cytotoxicity assay. Oncogene expression by the HT1080 fibrosarcoma may therefore contribute to the long-lasting complete regression of this sarcoma following a single local injection of NDV.

Modulation of the cytoskeleton and intracellular calcium in leukocytes exhibiting a cancer-associated chemotaxis defect.

Monocyte chemotaxis is severely depressed in patients with advanced tumors, but the cellular basis for this chemotactic defect is not known. Because the actomyosin cytoskeleton is thought to play a primary role in chemotaxis, we have employed flow cytometry to examine several aspects of the contractile machinery including myosin II, myosin light chain kinase (MLCK), actin, and cytoplasmic calcium in unstimulated and in formylpeptide-stimulated neutrophils and monocytes. Serum-pretreated polymorphonuclear leukocytes (PMNs) and monocytes from healthy blood donors or PMNs and monocytes isolated from tumor patients were studied. Leukocytes pretreated with serum from cancer patients exhibited decreased baseline myosin staining and a vastly different response to formylpeptide stimulation compared with leukocytes pretreated with normal human serum. In contrast, similar amounts of MLCK were observed in neutrophils and monocytes preincubated with normal or cancer serum with or without stimulation with formylpeptide. The fluorescent calcium indicator fluo-3 showed that resting and fMLP-stimulated levels of intracellular calcium were not significantly different in control and cancer serum-pretreated human leukocytes or in leukocytes isolated from tumor patients. Similarly, resting and fMLP-stimulated levels of F-actin in cancer patients' leukocytes as assessed by NBD-phallacidin staining did not differ significantly from those of normal leukocytes. Because the actomyosin cytoskeleton is intricately involved in leukocyte chemotaxis, alterations in the cytoskeleton may dramatically affect cell motility. The cytoskeletal alterations and changes in the response of leukocytes pretreated with cancer patients' serum to formylpeptide stimulation as described here may result in decreased chemotaxis by these cells.

One-drug versus two-drug antibiotic therapy in pediatric perforated appendicitis: a prospective randomized study.

A prospective randomized study was undertaken to compare the use of the combination of gentamicin and clindamycin with single agent, cefoxitin, in the treatment of perforated appendicitis in the pediatric patient. In a 3-year period from 1986 to 1989, 56 patients with perforated appendicitis were randomized. Twenty-nine patients received cefoxitin, and 27 patients received gentamicin and clindamycin. Antibiotics were started before operation and continued for a minimum of 6 days after operation. Skin and subcutaneous tissues were left open at surgery and closed secondarily after day 3, if they appeared to be clean. Wounds were considered infected if they developed increased purulence with positive wound cultures. Age range was similar in both groups, with a mean of 9 years (range, 1 to 17 years); 28 were boys and 28 were girls. No changes in antibiotics were required for reasons of susceptibility. No adverse drug reactions occurred in either group. The most common organisms were Escherichia coli in 35 cases (62%) and Bacteroides species in 26 cases (46%). No difference was noted in infection complications in the two groups nor in length of hospital stay. Therefore, no difference is evident in the use of cefoxitin versus gentamicin and clindamycin in the treatment of perforated appendicitis in terms of disease or drug-related complications.

Management of perforated appendicitis in children--revisited.

Of 522 children with acute appendicitis treated from 1978 to 1985, 170 had appendiceal perforation with peritonitis. The protocol for perforation included aggressive fluid resuscitation, preoperative triple antibiotic therapy, copious peritoneal lavage, avoidance of transperitoneal drains except those used for well-localized abscesses, delayed wound closure, and postoperative antibiotic therapy for seven to ten days. The minor complication rate was 22%; this included pleural effusion, wound infection, atelectasis, and prolonged ileus. The major complication rate was 3%; this included intra-abdominal abscess, gastrointestinal bleeding, wound dehiscence, pneumonia, and intestinal obstruction. Only four postoperative intra-abdominal abscesses occurred, in three patients. The mortality rate was zero. A comparison of this series with a similar group of 24 patients who underwent drainage showed the relative rate of abdominal abscess formation to be 1.8% (undrained) vs 12.5% (drained). We achieved our lowest rate of serious complications following surgery for pediatric perforated appendix with the use of aggressive fluid resuscitation, broad-spectrum antibiotic therapy, copious peritoneal irrigation, and delayed wound closure and without drainage.

Complications of ornamental Christmas bulb ingestion. Case report and review of the literature.

Unusual complications ensued when a 14-month-old boy ingested an ornamental Christmas bulb. Profuse rectal bleeding, a large ischiorectal abscess, and an acute condition of the abdomen necessiated a sigmoid colostomy with drainage of the ischiorectal abscess. Following this, repeated episodes of hemorrhage via the colostomy and rectum required multiple operative procedures. The last of these was a total colectomy with an ileostomy and rectal mucous fistula. The patient subsequently developed intestinal obstruction that required lysis of adhesions and drainage of a chronic subhepatic abscess, due to perforation of the terminal part of the ileum. The patient required five months of hospitalization and further surgery to reconstruct gastrointestinal continuity. Hemorrhage is an infrequent complication of foreign body ingestion, as reported in the literature. We theorize that the problems in this case were the result of the extreme thinness (0.033 cm) and the brittleness of the glass fragments.

Pseudocyst of the pancreas in childhood. Current advances in diagnosis.

A pseudocyst of the pancreas is an uncommon problem in the pediatric patient. When present, more than half of these cases are caused by blunt trauma to the abdomen. Recent experience in the management of three cases demonstrated the importance of sonography in the diagnosis of lesion. Sonography is most effective and noninvasive, and false-positive results are rare. Sonography also was used to follow the progress of a resolving pseudocyst in one of these three cases. A more aggressive surgical approach is necessary in the management of this lesion.

Computed tomography in the assessment of pediatric abdominal trauma.

A retrospective review was conducted to determine the clinical reliability of computed tomography(ic) (CT) in the initial evaluation of pediatric blunt abdominal trauma. Sixty patients underwent CT with infusion over the two-year study period. Seventeen injuries were identified by CT scans in 12 patients. Injuries included splenic hematoma, hepatic injury, duodenal hematoma, traumatic pancreatitis, retroperitoneal hematoma, renal pelvis laceration, and perinephric hematoma. Three patients required abdominal exploration and CT findings were confirmed in these cases. Other diagnostic studies (nuclear imaging, ultrasonography, upper gastrointestinal tract studies) that were obtained in some patients also confirmed the CT findings. Patients who had normal CT scans had unremarkable hospital courses, and none required reevaluation for missed injury. Only two CT scans were inadequate due to motion artifact.

Vascular trauma and reconstructive approaches.

Vascular trauma is becoming more common in children. Iatrogenic injuries are beginning to yield to accidental and intentional trauma as the leading cause. In addition to technical considerations, difficulties in the management of these injuries include the high incidence of spasm and the effects of diminished blood flow on limb growth. The literature regarding pediatric vascular injuries is reviewed. Evaluation and management of these injuries is then discussed, with emphasis on the special problems encountered in children as well as on some areas of controversy. Prevention is still the best treatment for iatrogenic as well as traumatic vascular injuries in children.

Characterization of a chemotactic defect in patients with Kartagener syndrome.

Kartagener syndrome (KS) is an autosomally inherited recessive condition characterized by situs inversus, bronchiectasis, and chronic sinusitis. Ciliary dynein, the mechanochemical force generator in ciliary movement, is deficient in patients with KS. We examined blood samples from two patients and tissue biopsy specimens from five patients and found: (1) no significant defect in neutrophil or monocyte chemotaxis in response to formylpeptide chemoattractant; (2) no alterations in centriolar structure, but significantly more centriole-associated microtubules in KS neutrophils and monocytes than in control leukocytes; and (3) a marked reduction in KS fibroblast chemotaxis in response to fibronectin compared with control fibroblasts. The significance of these cellular defects in KS is described.

Management of esophageal atresia and tracheoesophageal fistula.

We can draw several conclusions from an analysis of our series: 1. Although prematurity remains to be an important factor in the survival of infants with major surgical or medical disease, the more important risk factor in esophageal atresia and tracheoesophageal fistula concerns: a. Severity of associated anomalies that are uncorrectable and fatal b. Associated complication from the disease or surgery (especially in infants less than 1500 gm). Complications such as tracheal perforation and gastric perforation are not tolerated well and can be fatal (the case in two of our patients). 2. Premature infants weighing even less than 1500 gm tolerate a major thoracotomy well with correction of an esophageal anomaly. In this series, the smallest weighed 1220 gm. This infant had an uneventful recovery with a good outcome. 3. Simultaneous correction of associated anomalies also is well tolerated by these patients. Judgment, however, should be exercised as to the extent and length of operative procedures performed. 4. Staged reconstruction is still an excellent alternative when one is dealing with a premature infant with concomitant surgical procedures, although lengthening operations with primary anastomosis for the most part have replaced the need for staging esophageal reconstruction. 5. Radiographs indicating a high upper pouch lesion also require bronchoscopic identification of the fistula prior to operative intervention to provide a guide to the proper surgical approach to the lesion. 6. Acute anastomotic leaks should be treated aggressively by antibiotics and immediate thoracotomy, with cervical esophagostomy, closure of the distal esophagus, drainage of the mediastinum, and gastrostomy placement. immediate intervention will result in better survival.(ABSTRACT TRUNCATED AT 250 WORDS)

Neonatal intestinal obstruction.

Our experience in the management of 138 infants with various causes of intestinal obstruction has provided us with important principles of diagnosis and treatments that we adhere to in the course of our practice. 1. The overall mortality of neonates suffering from intestinal obstruction should be fewer than 5 per cent. The high survival rate is accounted for by improved care these patients receive in specialized units. 2. Prematurity did not appear to play a significant factor in the outcome of these infants with intestinal obstruction. Our experience shows that premature infants tolerate operative procedures well, even in those instances in which an associated surgically correctable lesion is simultaneously repaired. 3. The major risk factor in any neonate with intestinal obstruction is the delay in diagnosis and operative intervention, especially in infants diagnosed to have midgut volvulus. The additional second risk factor is the association of chromosome abnormality. 4. Traditional diagnostic studies such as plain films of the abdomen supplemented by either an upper GI or lower GI contrast study for specific indications have been very effective in obtaining an accurate diagnosis of intestinal bowel obstruction. 5. Hirschsprung's disease can be diagnosed in the neonatal period if the index of suspicion for this is high. 6. Special surgical techniques as described should be used whenever indicated to minimize morbidity. 7. The traditional Wangensteen-Rice evaluation of a patient with imperforate anus is accurate, and specialized studies should be deferred for the postoperative period. Collaborative care provided by the neonatologist, pediatric anesthesiologist, and pediatric surgeon for these patients is the key to a favorable outcome.

Gastroschisis and omphalocele.

The etiology, presentation, and treatment of the abdominal wall defects of omphalocele and gastroschisis are discussed, based on a ten-year clinical experience in an urban medical center.

Characterization of acellular dermal matrices (ADMs) prepared by two different methods.

The efficacy of acellular dermal matrix (ADM) in the treatment of full-thickness skin injuries as a dermal substitute depends on its low antigenicity, capacity for rapid vascularization, and stability as a dermal template. These properties will be determined largely by the final composition of the ADM. We have treated human skin with either Dispase followed by Triton X-100 detergent or NaCl followed by SDS detergent, cryosectioned the resulting ADMs, and then characterized them immunohistochemically. Staining for cell-associated antigens (HLA-ABC, HLA-DR, vimentin, desmin, talin), extracellular matrix components (chondroitin sulfate, fibronectin, laminin, vitronectin, hyaluronic acid), elastin, and collagen type VII was dramatically reduced or absent from ADMs prepared by both methods. However, significant amounts of elastin, keratan sulfate, laminin, and collagen types III and IV were still observed in both ADMs. Both methods of ADM preparation resulted in extensive extraction of both cellular and extracellular components of the skin but retention of the basic dermal architecture. In general, ADM prepared by the NaCl-SDS method retained larger amounts of each antigen than did that prepared by the Dispase-Triton method. This was most evident for laminin and type VII collagen but larger amounts of type IV collagen, fibronectin, desmin, elastin, and HLA-DR were also evident in the NaCl-SDS ADM.

Bronchial carcinoid tumor.

Bronchial carcinoid tumor occurring in an 11-yr-old boy is described. Pertinent diagnostic and therapeutic considerations are discussed briefly.

Penoplasty for buried penis secondary to "radical" circumcision.

An unusual complication of neonatal circumcision occurs when skin from the penile shaft is excised along with the prepuce. Upon healing of the wound, the penis gets buried in the scrotum. Repair is complicated by the lack of available skin to cover the shaft of the penis. We describe a surgical technique for correction of this condition.

The role of a modified intussusception jejunocolic valve in short-bowel syndrome.

Short-bowel syndrome results in malabsorption and malnutrition producing profound metabolic disorders. Attempts to correct this problem with various surgical procedures have so far proved unsuccessful. Studies made in our laboratory using experimental animals, showed that a modified jejunocolic intussusception valve appears to be effective in prolonging the small-bowel transit time and the absorptive capacity of the intestines in short-bowel syndrome. Furthermore, construction of the valve is uncomplicated and unaccompanied by any mortality or morbidity.

Anorectal continence following sphincter reconstruction utilizing the gluteus maximus muscle: a case report.

Rectal incontinence following pull-through procedure for high imperforate anus remains a difficult problem. Based on recent knowledge of the segmental neurovascular supply of the gluteus maximus muscle, the inferior half of the muscle on both sides was used for anorectal sphincter reconstruction on a 10-year-old boy who was totally incontinent following a pull-through procedure for a high imperforate anus. The technique of constructing this sphincter is simple and utilizes principles of muscle tendon transfer without jeopardizing the function of gait. Furthermore, the gluteus maximus muscle, being an accessory muscle of anal continence, is an ideal structure for this reconstruction. Colostomy can be prevented with the use of good preoperative bowel preparation and a constipating program for 1 week postoperatively. The results are directly related to the success of the operative procedure, and the maturity and degree of motivation of the child to undergo bowel-control training.

A variant of the split notochord syndrome.

Split notochord syndrome has been described in several previous case reports; however, we recently treated a patient with a previously undescribed variant of this syndrome. A 2.5-g baby girl was admitted to the neonatal intensive care unit with a skin-covered mass on the back, and a portion of intestine, with meconium being passed, attached to it. The legs were equino varus, and the anus was anteriorly displaced. Radiographs were consistent with a lumbar split notochord, and the patient was taken to the operating room for closure. During surgery, the skin-covered mass was opened and found to contain loops of small intestine leading to an intussuscepted cecum and an open ended duplication of the cecum attached to the end of the spinal cord. The small intestinal loops exited the abdomen from a peritoneal-lined opening to the back. The loops were returned to the abdomen after releasing the duplication from the cord. The peritoneal connection was closed with a purse string suture, and the abdomen was opened. The duplication of the cecum was partially amputated and the rest was used to create a chimney-type stoma. The intraabdominal exploration was significant for nonrotation as well as a normal rectum. The postoperative course was uneventful. This case is unique because most cases of split notochord only involve a fistula to the rectum. In this case, a major part of the small bowel had herniated. Moreover, there was an open duplication similar to that found in extrophy. In approaching such a situation, it is also important to have the neurosurgeon available to provide adequate closure of the back similar to a myelomeningocele.

Pulmonary interstitial emphysema--surgical management; report of three cases.

Three patients with pulmonary interstitial emphysema (PIE) were treated by surgical intervention for two complications of the disease, stiff lung with reduced pulmonary compliance, and persistent tension pneumothorax.