Staged intraperitoneal brachytherapy and hyperthermic intraperitoneal chemotherapy in an adolescent: novel anesthetic challenges for pediatric anesthetists.

Newer techniques that have found a place in cancer management in adults are offered far less commonly in pediatric patients. We present a case of a patient with recurrent Wilms' tumor managed with a novel combination of cytoreductive surgery, intraperitoneal brachytherapy, and subsequent hyperthermic intraperitoneal chemotherapy. Each stage presents challenges that the pediatric anesthetist is unlikely to have faced before. Such cases require flexibility and thorough planning to manage the combination of major surgery, remote anesthesia with brachytherapy and hyperthermic chemotherapy with its potential for metabolic derangement, significant fluid shifts, analgesic care, and potential exposure of staff to cytotoxic agents. Comprehensive care can be offered in pediatric centers.

Colobronchial fistula: a late complication of childhood radiotherapy.

We present the case of a colobronchial fistula in a 41-year-old man who underwent radiotherapy for nephroblastoma as an infant. He attended for barium enema, which demonstrated a fistula between colon and bronchial tree. Following right hemicolectomy and pathological examination of the resected bowel, no active disease process was identified to explain the development of this rare fistula. Radiotherapy was deemed the most probable aetiology. We are unaware of this having been previously described.

Chylous ascites following surgical treatment for wilms tumor.

PURPOSE: Postoperative chylous ascites is a rare complication of retroperitoneal surgery that has considerable morbidity. We review the pathogenesis and management of chylous ascites following surgical treatment of Wilms tumor. MATERIALS AND METHODS: We identified 9 children with chylous ascites after surgical treatment of Wilms tumor. Of these cases 3 were treated at a single institution during the last 20 years and 6 were identified during retrospective chart reviews of patients enrolled in National Wilms Tumor Studies 3 and 4 to identify surgical complications. Chylous ascites presented as increased abdominal girth and poor feeding. Paracentesis or laparotomy was diagnostic. RESULTS: Patient age at presentation with Wilms tumor ranged from 6 to 95 months (median 15). Left nephrectomy was performed in 5 cases, right nephrectomy in 3, and left nephrectomy and partial right nephrectomy in 1 with bilateral disease. Lymphadenectomy including the hilar and periaortic lymph nodes was performed in 5 patients, 4 of whom also underwent some form of suprahilar lymph node dissection. Three patients underwent lymph node sampling of the hilar, periaortic and some suprahilar lymph nodes. All children received adjuvant chemotherapy and 4 were treated with adjuvant irradiation to the surgical bed before the diagnosis of chylous ascites. The interval between surgery and diagnosis of ascites ranged from 12 to 49 days (median 21). Of the patients 7 were successfully treated with conservative measures, total parenteral nutrition and/or a diet containing primarily medium chain triglycerides, and 2 required invasive procedures, including exploratory laparotomy and ligation of disrupted lymphatic vessels or placement of a peritoneovenous shunt. CONCLUSIONS: Extensive lymph node dissection, particularly above the level of the renal hilum, appears to be associated with the development of postoperative chylous ascites. The National Wilms Tumor Study guidelines do not require formal lymph node dissection for staging and only lymph node sampling is recommended. Elimination of formal lymphadenectomy along with meticulous ligation of lymphatics should decrease the incidence of this complication. Fortunately, conservative treatment with total parenteral nutrition and/or medium chain triglycerides will remedy the problem in the majority of children.

[The value of the proton magnetic resonance spectroscopy (HMRS) of white matter injury in children treated with chemo- and/or radiotherapy. Preliminary report]. / Wartosc spektroskopii protonowej rezonansu magnetycznego (HMRS) w diagnostyce zmian w istocie bialej u dzieci leczonych radio- i/lub chemoterapia. Doniesienie wstepne.

UNLABELLED: THE AIM of this study was to estimate the value of HMRS in the diagnosis of brain lesions observed in children treated with chemo and radiotherapy and to assess the possibility to differentiate these lesions from neoplasm or recurrent disease. MATERIALS AND METHOD: We examined 6 children, aged from 7 to 15 yrs, 3 with brain tumours, 1 with esthesioneuroblastoma treated with chemo and radiotherapy and 2 patients with chemotherapy only, for other neoplasms (leukemia, Wilms tumor). Indications to perform imaging studies were routine for brain tumour patients (no clinical symptoms) and suspicion of disease recurrence in others. MR with 1.5 T scanner and additionally single voxel HMRS in PRESS sequence were performed. RESULTS: In all cases MRI showed extensive hyperintensive changes in brain tissue with significant mass effect. In 3 cases HMRS was within normal limits, in other 3 cases moderately elevated peak of choline and peak of lactate and lipids were found. In follow up examinations all lesions regressed and all patients are in good clinical condition. COMMENTS: It could be difficult to differentiate white matter injury from malignancies on MRI. HMRS in case of doubtful findings on MRI in children treated with chemo and radiotherapy, especially in those without symptoms of their disease, is a helpful method.

Advances in pediatric radiotherapy in the last ten years and future proposals.

Advances made can be divided into five main categories. Firstly, the problem of geographic miss which has been reduced by delivering effective radiation doses with greater precision. This has been accomplished with more sophisticated diagnostic and therapeutic equipment, immobilization techniques and computerized treatment planning. Second is the recognition of the interplay of radiation and chemotherapy on normal tissue tolerance and local tumor control. This interaction has necessitated reduction in both dose and volume of irradiation. Third is the use of wide field irradiation as a systemic treatment. Fourthly, the utilization of cooperative group trials to define the role of irradiation. Finally, with the improvement in survival has come the recognition of late effects of irradiation in the growing child and the means of reducing such effects. The current role of radiation therapy in childhood malignancies is summarized, controversies are identified, and future prospects explored.