Root cause analysis of safety incidents in antineoplastic use in children.

OBJECTIVES: to identify and analyze the factors that contribute to safety incident occurrence in the processes of prescribing, preparing and dispensing antineoplastic medications in pediatric oncology patients. METHODS: a quality improvement study focused on oncopediatric pharmaceutical care processes that identified and analyzed incidents between 2019-2020. A multidisciplinary group performed root cause analysis (RCA), identifying main contributing factors. RESULTS: in 2019, seven incidents were recorded, 57% of which were prescription-related. In 2020, through active search, 34 incidents were identified, 65% relating to prescription, 29% to preparation and 6% to dispensing. The main contributing factors were interruptions, lack of electronic alert, work overload, training and staff shortages. CONCLUSIONS: the results showed that adequate recording and application of RCA to identified incidents can provide improvements in the quality of pediatric oncology care, mapping contributing factors and enabling managers to develop an effective action plan to mitigate risks associated with the process.

Beyond Clinical Trials: Understanding Neurotrophic Tropomyosin Receptor Kinase Inhibitor Challenges and Efficacy in Real-World Pediatric Oncology.

PURPOSE: Our study aimed to explore real-world treatment scenarios for children and adolescents with neurotrophic tropomyosin receptor kinase (NTRK)-fused tumors, emphasizing access, responses, side effects, and outcomes. PATIENTS AND METHODS: Pooled clinical data from 17 pediatric cases (11 soft-tissue sarcomas, five brain tumors, and one neuroblastoma) treated with larotrectinib and radiologic images for 14 patients were centrally reviewed. Testing for gene fusions was prompted by poor response to treatment, tumor progression, or aggressiveness. RESULTS: Six different NTRK fusion subtypes were detected, and various payment sources for testing and medication were reported. Radiologic review revealed objective tumor responses (OR) in 11 of 14 patients: Complete responses: two; partial responses: nine; and stable disease: three cases. Grades 1 or 2 Common Terminology Criteria for Adverse Events adverse effects were reported in five patients. Regarding the entire cohort's clinical information, 15 of 17 patients remain alive (median observation time: 25 months): four with no evidence of disease and 11 alive with disease (10 without progression). One patient developed resistance to the NTRK inhibitor and died from disease progression while another patient died due to an unrelated cause. CONCLUSION: This real-world study confirms favorable agnostic tumor OR rates to larotrectinib in children with NTRK-fused tumors. Better coordination to facilitate access to medication remains a challenge, particularly in middle-income countries like Brazil.

Root cause analysis of safety incidents in antineoplastic use in children / Análisis de causa raíz de incidentes de seguridad en el uso de antineoplásicos en niños / Análise de causa raiz de incidentes de segurança na utilização de antineoplásicos em crianças

ABSTRACT Objectives: to identify and analyze the factors that contribute to safety incident occurrence in the processes of prescribing, preparing and dispensing antineoplastic medications in pediatric oncology patients. Methods: a quality improvement study focused on oncopediatric pharmaceutical care processes that identified and analyzed incidents between 2019-2020. A multidisciplinary group performed root cause analysis (RCA), identifying main contributing factors. Results: in 2019, seven incidents were recorded, 57% of which were prescription-related. In 2020, through active search, 34 incidents were identified, 65% relating to prescription, 29% to preparation and 6% to dispensing. The main contributing factors were interruptions, lack of electronic alert, work overload, training and staff shortages. Conclusions: the results showed that adequate recording and application of RCA to identified incidents can provide improvements in the quality of pediatric oncology care, mapping contributing factors and enabling managers to develop an effective action plan to mitigate risks associated with the process.

RESUMEN Objetivos: identificar y analizar los factores que contribuyen a la ocurrencia de incidentes de seguridad en los procesos de prescripción, preparación y dispensación de medicamentos antineoplásicos en pacientes pediátricos con cáncer. Métodos: estudio de mejora de la calidad centrado en los procesos de atención farmacéutica oncopediátrica que identificó y analizó incidencias entre 2019-2020. Un grupo multidisciplinario realizó un análisis de causa raíz (ACR), identificando los factores contribuyentes clave. Resultados: en 2019 se registraron siete incidentes, el 57% relacionados con la prescripción. En 2020, mediante búsqueda activa se identificaron 34 incidencias, el 65% relacionadas con la prescripción, el 29% con la preparación y el 6% con la dispensación. Los principales factores contribuyentes fueron las interrupciones, la falta de alerta electrónica, la sobrecarga de trabajo, la capacitación y la escasez de personal. Conclusiones: los resultados mostraron que el registro adecuado y la aplicación del ACR a los incidentes identificados pueden proporcionar mejora de la calidad de la atención del cáncer pediátrico mediante el mapeo de los factores contribuyentes y permitiendo a los administradores desarrollar un plan de acción eficaz para mitigar los riesgos asociados con el proceso.

RESUMO Objetivos: identificar e analisar os fatores contribuintes para ocorrência de incidentes de segurança nos processos de prescrição, preparo e dispensação de medicamentos antineoplásicos em pacientes oncopediátricos. Métodos: estudo de melhoria da qualidade focado nos processos de assistência farmacêutica oncopediátrica que identificou e analisou incidentes entre 2019-2020. Um grupo multidisciplinar realizou análise de causa raiz (ACR), identificando principais fatores contribuintes. Resultados: em 2019, registraram-se sete incidentes, sendo 57% relacionados à prescrição. Em 2020, através de busca ativa, identificaram-se 34 incidentes, sendo 65% relativos à prescrição, 29% ao preparo e 6% à dispensação. Os principais fatores contribuintes foram interrupções, ausência de alerta eletrônico, sobrecarga de trabalho, treinamento e déficit de funcionários. Conclusões: os resultados mostraram que registro adequado e aplicação da ACR aos incidentes identificados podem proporcionar melhoria na qualidade do cuidado oncopediátrico mapeando os fatores contribuintes e possibilitando aos gestores desenvolverem plano de ação efetivo para mitigar riscos associados ao processo.

Diverse mutational spectrum in the 13q14 chromosomal region in a Brazilian cohort of retinoblastoma.

Retinoblastoma is a rare childhood tumor caused by the inactivation of both copies of the RB1 gene. Early diagnosis and identification of heritable RB1 mutation carriers can improve the disease outcome and management via genetic counseling. We used the Multiplex Ligation-dependent Probe Amplification (MLPA) method to analyze the RB1 gene and flanking regions in blood samples from 159 retinoblastoma patients previously negative for RB1 point mutations via Sanger sequencing. We detected a wide spectrum of germline chromosomal alterations, ranging from partial loss or duplication of RB1 to large deletions spanning RB1 and adjacent genes. Mutations were validated via karyotyping, fluorescent in situ hybridization (FISH), SNP-arrays (Single Nucleotide Polymorphism-arrays) and/or quantitative relative real-time PCR. Patients with leukocoria as a presenting symptom showed reduced death rate (p = 0.013) and this sign occurred more frequently among carriers of two breakpoints within RB1 (p = 0.05). All unilateral cases presented both breakpoints outside of RB1 (p = 0.0075). Patients with one breakpoint within RB1 were diagnosed at earlier ages (p = 0.017). Our findings characterize the mutational spectrum of a Brazilian cohort of retinoblastoma patients and point to a possible relationship between the mutation breakpoint location and tumor outcome, contributing to a better prospect of the genotype/phenotype correlation and adding to the wide diversity of germline mutations involving RB1 and adjacent regions in retinoblastoma.

Evaluation of risk stratification strategies in pediatric patients with febrile neutropenia

Abstract Objective To evaluate the performance of risk stratification protocols for febrile neutropenia specific to the pediatric population. Methods Retrospective study of a cohort of pediatric patients undergoing cancer treatment with episodes of neutropenia due to chemotherapy and fever, treated at the emergency department of a tertiary cancer hospital from January 2015 to June 2017. Patients who were bone marrow transplant recipients and patients with neutropenia due to causes other than chemotherapy were excluded. Six protocols were applied to all patients: Rackoff, Alexander, Santolaya, Rondinelli, Ammann 2003, and Ammann 2010. The following outcomes were assessed: microbiological infection, death, ICU admission, and need for more than two antibiotics. The performance of each protocol was analyzed for sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and receiver operator characteristic (ROC) curve. Results This study evaluated 199 episodes of febrile neutropenia in 118 patients. Microbiological infection was identified in 70 samples from 45 distinct episodes (22.6%), 30 patients used more than two antibiotics during treatment (15%), eight required ICU admission (4%), and one patient died (0.8%). Three protocols achieved high sensitivity indices and NPV regarding the outcomes of death and ICU admission: Alexander, Rackoff, and Ammann 2010; however, Rackoff showed higher sensitivity (0.82) and NPV (0.9) in relation to the microbiological infection outcome. Conclusion The Rackoff risk rating showed the best performance in relation to microbiological infection, death, and ICU admission, making it eligible for prospective evaluation.

Evaluation of risk stratification strategies in pediatric patients with febrile neutropenia.

OBJECTIVE: To evaluate the performance of risk stratification protocols for febrile neutropenia specific to the pediatric population. METHODS: Retrospective study of a cohort of pediatric patients undergoing cancer treatment with episodes of neutropenia due to chemotherapy and fever, treated at the emergency department of a tertiary cancer hospital from January 2015 to June 2017. Patients who were bone marrow transplant recipients and patients with neutropenia due to causes other than chemotherapy were excluded. Six protocols were applied to all patients: Rackoff, Alexander, Santolaya, Rondinelli, Ammann 2003, and Ammann 2010. The following outcomes were assessed: microbiological infection, death, ICU admission, and need for more than two antibiotics. The performance of each protocol was analyzed for sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and receiver operator characteristic (ROC) curve. RESULTS: This study evaluated 199 episodes of febrile neutropenia in 118 patients. Microbiological infection was identified in 70 samples from 45 distinct episodes (22.6%), 30 patients used more than two antibiotics during treatment (15%), eight required ICU admission (4%), and one patient died (0.8%). Three protocols achieved high sensitivity indices and NPV regarding the outcomes of death and ICU admission: Alexander, Rackoff, and Ammann 2010; however, Rackoff showed higher sensitivity (0.82) and NPV (0.9) in relation to the microbiological infection outcome. CONCLUSION: The Rackoff risk rating showed the best performance in relation to microbiological infection, death, and ICU admission, making it eligible for prospective evaluation.

Cost-Effectiveness of Proton Versus Photon Therapy in Pediatric Medulloblastoma Treatment: A Patient Volume-Based Analysis.

BACKGROUND: Proton radiation therapy offers advantages over photon therapy, assisting with severe side effect avoidance. Pediatric patients with medulloblastoma have demonstrated benefit from this technology in recently published cohort studies. OBJECTIVES: To compare the costs and benefits between proton and photon therapy in treating pediatric medulloblastoma. METHODS: The model was built with a lifetime horizon from the Brazilian health system perspective using a 3% discount rate. A microsimulation model was developed after a literature search, comparing scenarios of equipment life span and number of patients treated per year (50, 100, and 150 patients with 10, 25, and 20 years of equipment life span). The baseline parameters were 50 patients treated annually and 20 years of equipment life span. RESULTS: The quality-adjusted life-year gain was 2.71, and the average incremental cost-effectiveness ratio was $34 590.54 per quality-adjusted life-year. For the willingness-to-pay threshold of 1 gross domestic product per capita, it was observed that the incorporation of the technology would be cost-effective if more than 150 patients were treated per year. The weight of the equipment life span and other variables was limited when it varied in the sensitivity analysis, without significant changes to the model results. CONCLUSIONS: Proton therapy is not cost-effective for pediatric medulloblastoma treatment from the Brazilian health system perspective. The investment is not worth when considering the number of potential patients and the country dimensions.

Tumor de Wilms Bilateral Sincrônico: Avaliação Cirúrgica e Sobrevida / Synchronous Bilateral Wilms Tumor: Surgical Evaluation and Survival / Tumor de Wilms bilateral Sincrónico: Evaluación quirúrgica y Sobrevida

Introdução: os tumores renais representam cerca de 7% de todas as neoplasias malignas da infância. o tumor de Wilms bilateral sincrônico corresponde a 5-7% de todos os nefroblastomas. o tratamento consiste em quimioterapia pré-operatória, seguida de cirurgia conservadora, quimioterapia pós-operatória e, quando indicada, radioterapia. Objetivo: analisar o tipo de cirurgia e a sobrevida global dos pacientes com tumor de Wilms bilateral sincrônico. Método: este estudo de coorte retrospectivo incluiu 18 pacientes pediátricos do Hospital do câncer i, do instituto nacional de câncer José alencar Gomes da silva, no rio de Janeiro, de janeiro de 2000 a dezembro de 2017. curvas de sobrevida foram calculadas pelo método Kaplan-Meier. Resultados: a idade mediana ao diagnóstico foi de 19 meses, sendo dez casos do sexo feminino. em 62,5% dos rins operados, foi possível realizar cirurgia conservadora e, em 41,2% (7/17) dos pacientes, em ambos os rins. a sobrevida global em cinco anos, segundo o tipo cirurgia, foi de 87,5% para cirurgia conservadora e de 62,8% para nefrectomia total (p=0,0001). a sobrevida global em cinco anos para a coorte inteira foi de 70,8%. Conclusão: a cirurgia preservadora de tecido renal em crianças com o tumor de Wilms bilateral sincrônico é viável e pode ser realizada com segurança em centros de referência.

Introduction: Kidney tumors account for about 7% of all childhood malignancies. synchronous bilateral Wilms tumor corresponds to 5-7% of all nephroblastomas. The treatment consists of preoperative chemotherapy, followed by conservative surgery, postoperative chemotherapy and, when indicated, radiotherapy. Objective: to analyze the type of surgery and the overall survival of patients with synchronous bilateral Wilms tumor. Method: This retrospective cohort study included 18 pediatric patients from the Hospital do cancer i, from the national cancer institute José alencar Gomes da silva, in rio de Janeiro, from January 2000 to december 2017. survival curves were calculated using the Kaplan-Meier method. Results:The median age at diagnosis was 19 months, and 10 patients were female. it was possible to perform conservative surgery in 62.5% of the kidneys, and in 41.2% (7/17) of patients in both kidneys. The 5-year overall survival according to the type of surgery was 87.5% for conservative surgery and 62.8% for radical nephrectomy (p=0.0001). The 5-year overall survival of the entire cohort was 70.8%. Conclusion: conservative surgery in pediatric synchronous bilateral Wilms tumor is feasible and can be performed safely in reference centers.

Introducción:los tumores renales representan alrededor del 7% de todas las neoplasias malignas de la infancia. el tumor de Wilms bilateral sincrónico corresponde al 5-7% de todos los nefroblastomas. el tratamiento consiste en quimioterapia preoperatoria, seguida de cirugía conservadora, quimioterapia postoperatoria y, cuando indicada, la radioterapia. Objetivo: analizar el tipo de cirugía y la supervivencia global de los pacientes con un tumor de Wilms bilateral sincrónico. Método: este estudio de cohorte retrospectivo incluyó 18 pacientes pediátricos del Hospital del cáncer i, del instituto nacional de cáncer José alencar Gomes da silva, nel río de Janeiro, de enero de 2000 a diciembre de 2017. las curvas de sobrevida fueron calculadas por el método Kaplan-Meier. Resultados: la edad media al diagnóstico fue de 19 meses, siendo diez casos del sexo femenino. en el 62,5% de los riñones operados fue posible realizar cirugía conservadora, siendo en el 41,2% (7/17) de los pacientes en los dos riñones. la supervivencia global en cinco años según el tipo de cirugía fue de 87,5% para cirugía conservadora y de 62,8% nefrectomía total (p=0,0001). la supervivencia global en cinco años para la cohorte entera fue del 70,8%. Conclusión: la cirugía conservadora en niños con el tumor de Wilms bilateral sincrónico es viable y puede ser realizada con seguridad en centros de referencia

Estratégias de Intervenção para Adesão ao Tratamento do Câncer Infantojuvenil: Relato de Caso / Intervention Strategies for Adherence to the Treatment of Childhood Cancer: Case Report / Estrategias de Intervención para la Adhesión al Tratamiento del Cancer Infanto Juvenil: Relato de Caso

Introdução: o câncer infantil é considerado um problema de saúde pública em razão do seu impacto na mortalidade. o abandono de tratamento é apontado como uma das principais causas de insucesso da terapêutica; dessa forma, estratégias para evitar o abandono são fundamentais para a melhora dos resultados de tratamento em países de baixa e média rendas. Relato do caso: Paciente com 4 anos e 11 meses de idade, admitido na instituição com massa abdominal à direita de crescimento rápido. a biópsia da tumoração confirmou se tratar de neoplasia maligna. o plano de tratamento incluiu quimioterapia e radioterapia. o paciente teve acompanhamento irregular com múltiplas faltas às consultas, aos exames agendados e ao tratamento devido ao contexto socioeconômico em que estava inserido. a equipe multiprofissional orientou à família sobre a importância do tratamento, buscando salvaguardar a saúde da criança, assim como garantir a continuidade do tratamento. as estratégias implementadas foram: institucionais, articulação com a rede e suporte social. Conclusão: após diversas intervenções da equipe multiprofissional do inca, foi possível contribuir para aderência da criança ao tratamento proposto.

Introduction: childhood cancer is considered as public health problem because of the impact on mortality. The abandonment of treatment is indicated as one of the main causes of failure in therapy; because of this, strategies to avoid abandonment are fundamental for the improvement of treatment outcomes in low-and middle-income countries. Case report:Patient 4 years 11 months, admitted in the institution with abdominal mass on the right of rapid growth. Biopsy confirmed malignant disease. The treatment included chemotherapy and radiation therapy. The patient had irregular follow-up with multiple faults in appointments, scheduled exams and treatment due to the socioeconomic context in which he was inserted. The multiprofessional team advised the family about the importance of treatment, seeking to safeguard the child's health, as well as ensuring continuity of treatment. The implemented strategies were: institutional, articulation with the network and social support. Conclusion: after several interventions by inca's multiprofessional team, it was possible to contribute to the child's adherence to the proposed treatment

ntroducción: e l cancer infantil es considerado un problema de salud pública, devido a su impacto en la mortalidad. el abandono del tratamiento es apuntado como una de las principales causas del fracaso de la terapeutica; de esta forma, estratégias para evitar el abandono son fundamentales para la mejoría de los resultados del tratamiento en países de baja y média renta. Relato del caso: Paciente con 4 anos y 11 meses de edad, admitido en la institución con masa abdominal a la derecha con crescimento rápido. la biopsia de la tumoración confirmó tratarse de neoplasia maligna. el plano de tratamiento incluye quimioterapia y radioterapia. el paciente tuvo acompañamiento irregular con múltiplas faltas a las consultas, a los exámenes agendados y al tratamento, debido al contexto socioeconómico en el que estaba insertado. el equipo multiprofissional orientó a la familia sobre la importancia del tratamiento, buscando salvaguardar la salud del niño, así como garantizar la continuidad del tratamiento. las estrategias implementadas fueron: institucionales, articulación con la red de la salud y soporte social. Conclusión: después de diversas intervenciones del equipo multiprofisional del inca, fue posible contribuir para la adherencia del niño al tratamiento propuesto.

Alterações Citogenético-Moleculares no Gene FOXO1 em uma Criança com Rabdomiossarcoma Alveolar: Relato de Caso / Citogenetic-Molecular Alterations in FOXO1 Gene in a Child with Alveolar Rhabdomyosarcoma: Case Report / Cambios Citogenetico-moleculares en el gene fOxO1 en un Niño con Rabdomiossarcoma Alveolar: Relato de Caso

Introdução: o rabdomiossarcoma (rMs) é o tumor de tecidos moles mais comum da infância. Pode ser classificado em dois subtipos principais: o rabdomiossarcoma alveolar (rMsa) e o embrionário (rMse). no rMsa, o prognóstico é desfavorável quando comparado ao rMse, necessitando de tratamento intensificado; dessa forma, a distinção entre ambos os subtipos é fundamental. citogeneticamente, o rMsa apresenta translocações cromossômicas envolvendo o gene FOXO1 em 80% dos casos. a metodologia de hibridização in situ por fluorescência (FisH) tem sido muito utilizada para caracterizar o rMsa. Relato do caso: Paciente do sexo feminino, com 7 anos de idade, apresentou ao diagnóstico rMsa parameníngeo, sem metástase ao diagnóstico. a análise por meio de FisH mostrou a translocação envolvendo o gene FOXO1 e uma cópia extra desse gene. a paciente foi incluída no protocolo de tratamento do epssG, classificada como grupo de alto risco e recebeu quimioterapia e radioterapia. no final do tratamento, foi observada resposta parcial e iniciada quimioterapia de segunda linha. não houve resposta clinicorradiológica e a paciente evoluiu com progressão de doença local refratária ao tratamento e óbito após um ano do diagnóstico. Conclusão: de acordo com o nosso conhecimento, é a primeira descrição de um caso de rMsa apresentando a translocação do gene FOXO1 e uma cópia extra desse gene em clones separados. são necessários ainda novos estudos, a fim de compreender melhor o significado prognóstico da presença dessas alterações.

Introduction:rhabdomyosarcoma (rMs) is the most common soft tissue tumor of childhood. it can be classified into two main subtypes: alveolar rhabdomyosarcoma (arMs) and embryonal (erMs). in arMs the prognosis is unfavorable when compared to erMs, requiring intensified treatment, thus the distinction between both subtypes is fundamental. cytogenetically, arMs present chromosomal translocations involving the FOXO1 gene in 80% of the cases. The fluorescence in situ hybridization methodology (FisH) has been widely used to characterize arMs subtype. Case Report: a 7-year-old female patient presented with parameningeal arMs, non-metastatic at diagnosis. FisH analysis showed translocation involving the FOXO1 gene and an extra copy of this gene. The patient was enrolled in the epssG treatment protocol, classified as a high-risk group and received chemotherapy and radiotherapy. at the end of treatment a partial response was observed, and second line chemotherapy was started. There was no clinical-radiological response and the patient progressed with local disease, refractory to rescue treatment and died of disease one year after diagnosis. Conclusion:to our knowledge, this is the first case of arMs presenting FOXO1 gene translocation and an extra copy of this gene in separate clones. More studies are necessary to understand the prognostic significance of these alterations

Introducción: el rabdomiosarcoma (rMs) es el tumor de tejidos blandos más común de la infancia. el rMs puede clasificarse en dos subtipos principales, el rabdomiosarcoma alveolar (rMsa) y el embrionario (rMse). el rMsa presenta un pronóstico desfavorable si se compara al rMse, habiendo así necesidad de intensificación del tratamiento. de esta forma, la distinción entre rMsa y rMse es fundamental. citogéticamente, el rMsa presenta en cerca del 80% de los casos de translocación cromosómica que involucra el gen FOXO1. la metodología de Hibridación fluorescente in situ (FisH) ha sido muy utilizada para caracterizar el rMsa. Caso de estudio: Paciente del sexo femenino, de 7 años de edad presentada con un diagnóstico de rMsa parameningeo, sin metástasis. el análisis a través del FisH mostró la translocación envolviendo el gen FOXO1 y una copia extra de este gen. la paciente fue incluida en el protocolo de tratamiento del epssG, clasificado como grupo de alto riesgo y recibió quimioterapia y radioterapia. al final del tratamiento fue observada una respuesta parcial y se inició la quimioterapia de segunda línea. no hubo respuesta clínico-radiológica y la paciente evolucionó con progresión de enfermedad local, refractaria y óbito después de 1 año del diagnóstico. Conclusión: de acuerdo con nuestro conocimiento, este es el primer caso de un niño con rMsa presentando la translocación del gen FOXO1 y una copia extra de este gen en clones separados. se necesitan nuevos estudios para comprender mejor el significado pronóstico de la presencia de estos cambios.

Cirurgia Citorredutora e Quimioterapia Intraperitoneal Hipertérmica para Tratamento de Tumor Desmoplásico de Pequenas Células Redondas em Paciente Pediátrico: Relato de Caso / Cytoredutive Surgery and Chemohyperthemia for Desmoplasic Small Round Cell Tumor in Pediatric Patient: Case Report / Cirugia de Citoreducción y quimihipertermia el Tratamento de Tumor desmoplásico de Pequeñas Células Redondas en Paciente Pediátrico: Relato de Caso

Introdução: o tumor desmoplásico de pequenas células redondas (tdPcr) é uma neoplasia rara com comportamento clínico agressivo. trata-se do caso de um paciente com 7 anos de idade, sexo masculino, com tdPcr, matriculado no serviço de Pediatria do instituto nacional de câncer José alencar Gomes da silva. Relato do caso: Paciente iniciou o quadro com queixa de dor e aumento do abdome, ascite volumosa, febre e emagrecimento. nos exames de imagem, apresentava lesão hipodensa no segmento iV a do fígado, ascite volumosa, massa justa parietal no hemitórax direito. o laudo histopatológico foi compatível com tdPcr estádio iV. o paciente foi submetido à quimioterapia sistêmica com resposta completa nas lesões torácicas e redução importante da massa abdominal, restando lesões em cavidade pélvica. o paciente foi submetido à cirurgia com citorredução e hipertermoquimioterapia com cisplatina, e recebeu radioterapia abdominal adjuvante e quimioterapia. o paciente manteve-se estável, apresentando nova progressão e óbito 14 meses após a recidiva. Conclusão: a citorredução cirúrgica associada à hipertermoquimioterapia intraperitoneal permitiu a possibilidade de controle temporário da doença com boa qualidade de vida para o paciente.

Introduction: desmoplastic small round cell tumor (dsrct) is rare and highly aggressive mesenchymal tumor. objective: case report of a 7 y-o boy, diagnosticated with a dsrct, treated in the Pediatric service at national cancer institute José alencar Gomes da silva. Case report: He presented with abdominal pain, abdominal mass, ascites, fever and slimming. computer tomography showed a hypodense tumor on iV hepatic segment, volumous ascitis, tumoral mass in right hemithorax. He was submitted to needle biopsy with histopatologic result as dsrct staged as iV. The patient was submitted to sistemic chemotherapy with complete response on thoracic tumor e abdominal tumor reduction, with stable pelvic lesions. an cytoredutive surgery with cisplatin hyperthermic intraperionteal chemotherapy. He received abdominal radiotherapy and chemotherapy. He presented with tumor progression and death after 14 months. Conclusion:cytoredutive surgery and Hyperthermic intraperitoneal chemotherapy permitted a temporary disease control with a good quality of life

Introducción: el tumor desmoplásico de pequeñas células redondas (tdPcr) es una neoplasia rara con comportamento clínico agresivo. objetivo: relatar el caso de un paciente con 7 años de edad, sexo masculino con tdPcr, matriculado en el servicio de Pediatria en el instituto nacional del cancer José alencar Gomes da silva. Relato del caso: el paciente inició el cuadro con dolor y aumento del abdomen, ascite voluminosa, fiebre y adelgazamiento. en los exámenes de imagen presentaba lesión hipodensa en el segmento iV a del hígado, ascite voluminosa, masa justa parietal en hemitórax derecho. el histopatológico fue compatible con el tdPcr estadio iV. el paciente fue sometido a quimioterapia sistémica con respuesta completa en las lesiones toráxicas y reducción importante de la masa abdominal, restando lesiones en la cavidad pélvica. el paciente fue sometido a cirurgía con citorreducción e hipertermoquimioterapia con cisplatina. recibió radioterapia abdominal adjuvante y quimioterapia. el paciente se mantuvo estable, presentando nueva progresión y óbito 14 meses después de la recidiva. Conclusión: la citoreducción cirúrgica asociada a la hipertermoquimioterapia intraperitoneal permitió la posibilidad de control temporario de la enfermedad con buena calidad de vida para el paciente.

Mielinólise Extrapontina em Adolescente com Diabetes Insípidus Secundário a Disgerminoma do Sistema Nervoso Central: Relato de Caso / Extra-Pontine Myelinolysis in a Patient with Diabetes Insipidus Secondary to Disgerminoma of the Central Nervous System: Case Report / mielinólise Extrapontina en Paciente con diabetes Insípida Secundário a disgerminoma del Sistema Nervioso Central: Relato de Caso

Introdução: a síndrome de desmielinização osmótica é uma condição neurológica rara causada pelo dano à bainha de mielina dos neurônios, com difícil manejo do distúrbio do sódio em paciente com diabetes insípidus. Relato do caso: adolescente do sexo feminino, 14 anos, com diabetes insípidus secundária a disgerminoma do sistema nervoso central, com hiponatremia grave (sódio 103 meq/l). cinco dias após a correção rápida do sódio, apresentou coma (escala de Glasgow:11), disfagia, mutismo e tetraparesia. os achados na ressonância nuclear magnética craniana foram compatíveis com diagnóstico de mielinólise extrapontina. Vinte e cinco dias após a internação no centro de tratamento intensivo, a paciente encontrava-se lúcida, orientada, deambulando sem dificuldade, alimentando-se por via oral, sem engasgos, ainda com discreta diminuição de força nos membros superiores e comunicação verbal pouco lentificada. a ressonância nuclear magnética após três meses mostrou atrofia dos núcleos da base, comprovando lesão celular grave. Conclusão: a desmielinização osmótica pode apresentar-se com formas clínicas leves ou assintomáticas, até sequelas motoras graves e morte. não existe tratamento específico, o que ressalta a importância do diagnóstico precoce e do manejo adequado do distúrbio do sódio, assim como controle rigoroso dos seus níveis séricos.

Introduction: osmotic demyelination syndrome is a rare neurological condition caused by damage to the myelin sheath of neurons, involving difficulty in the management of sodium imbalance in patients with diabetes insipidus. Case report: Patient was a 14-year-old female with diabetes insipidus secondary to dysgerminoma of the central nervous system, with severe hyponatremia (sodium 103 meq/l). Five days after rapid correction of the sodium imbalance, the patient presented coma (Glasgow scale:11), dysphagia, mutism, and quadriparesis. cranial Mri findings were consistent with a diagnosis of extrapontine myelinolysis. twenty-five days after admission to the icu, the patient was alert, oriented, walking without difficulty, eating an oral diet without choking, although with slightly diminished strength in the upper limbs and slightly sluggish verbal communication. Three-month follow-up Mri showed atrophy of the basal nuclei, confirming severe cellular injury. Conclusion: Presentation of osmotic demyelination may range from mild or asymptomatic clinical forms to severe motor sequelae and death. There is no specific treatment, which highlights the importance of early diagnosis and adequate management of the sodium imbalance, as well as rigorous control of serum sodium levels

Introducción: la síndrome de desmielinización osmótica es una condición neurológica rara causada por el daño en lãs vainas de mielina de las neuronas, con difícil manejo del trastorno de los niveles de sódio en los pacientes con diabetes insípida. Relato del caso: adolescente do sexo feminino, 14 anos, com diabetes insípida secundária a disgerminoma del sistema nervioso central, con hiponatriemia grave (sódio103meq/l). cinco días después de la corrección rápida del sódio, presentó coma (escala de Glasgow: 11), disfagia, mutismo y tetraparesia. los hallazgos en la resonancia magnética del cráneo fueron compatibles con diagnosis de mielinólise extra-pontina. Veinticinco días después de la internaciónen el centro de tratamiento intensivo la paciente se encontraba lúcida, orientada, deambulando sin dificultad, alimentándose por vía oral sin atorarse, aúncon discreta disminución de fuerza en los miembros superiores y comunicación verbal poco lentificada. una resonancia nuclear magnética después de tres meses mostró atrofia de los núcleos de la base del cráneo, comprobando lesión celular grave. Conclusión: una síndrome de desmielinización osmótica puede presentarse con formas clínicas ligeras o asintomáticas, hasta secuelas motoras graves y muerte. no existe tratamiento específico, lo que resaltala importancia del diagnóstico precoz y del manejo adecuado del disturbio del sodio, así como control riguroso de sus niveles séricos

Contribution of multiparameter flow cytometry immunophenotyping to the diagnostic screening and classification of pediatric cancer.

Pediatric cancer is a relatively rare and heterogeneous group of hematological and non-hematological malignancies which require multiple procedures for its diagnostic screening and classification. Until now, flow cytometry (FC) has not been systematically applied to the diagnostic work-up of such malignancies, particularly for solid tumors. Here we evaluated a FC panel of markers for the diagnostic screening of pediatric cancer and further classification of pediatric solid tumors. The proposed strategy aims at the differential diagnosis between tumoral vs. reactive samples, and hematological vs. non-hematological malignancies, and the subclassification of solid tumors. In total, 52 samples from 40 patients suspicious of containing tumor cells were analyzed by FC in parallel to conventional diagnostic procedures. The overall concordance rate between both approaches was of 96% (50/52 diagnostic samples), with 100% agreement for all reactive/inflammatory and non-infiltrated samples as well as for those corresponding to solid tumors (n = 35), with only two false negative cases diagnosed with Hodgkin lymphoma and anaplastic lymphoma, respectively. Moreover, clear discrimination between samples infiltrated by hematopoietic vs. non-hematopoietic tumor cells was systematically achieved. Distinct subtypes of solid tumors showed different protein expression profiles, allowing for the differential diagnosis of neuroblastoma (CD56(hi)/GD2(+)/CD81(hi)), primitive neuroectodermal tumors (CD271(hi)/CD99(+)), Wilms tumors (>1 cell population), rhabdomyosarcoma (nuMYOD1(+)/numyogenin(+)), carcinomas (CD45(-)/EpCAM(+)), germ cell tumors (CD56(+)/CD45(-)/NG2(+)/CD10(+)) and eventually also hemangiopericytomas (CD45(-)/CD34(+)). In summary, our results show that multiparameter FC provides fast and useful complementary data to routine histopathology for the diagnostic screening and classification of pediatric cancer.

Influence of MDM2 and MDM4 on development and survival in hereditary retinoblastoma.

BACKGROUND: Retinoblastoma (RB) accounts for 3% of all childhood malignancies, with different incidences around the world. This malignancy results from loss-of-function of both RB1 alleles although other genes, like MDM2 and MDM4, have been proposed to be involved in tumor development. PROCEDURE: We genotyped rs2279744T>G and rs937283A>G in MDM2, and rs4252668T>C and rs116197192G>A in MDM4, in 104 unrelated RB patients and 104 controls. Sixty-month survival Kaplan-Meier curves and χ(2)-tests were performed for estimating the putative effect of MDM2 and MDM4 alleles on disease progression and survival of RB patients. RESULTS: MDM2 rs2279744G was significantly more frequent in controls, indicating an apparently protective effect on RB development. However, survival of patients who carried a constitutional RB1 mutation was significantly lower with rs2279744TG or GG than with rs2279744TT. Presence of rs2279744G and a constitutional RB1 mutation was sixfold more frequent in the 0-12 month age group than other age groups at onset of symptoms (P = 0.0401). MDM4 rs4252668C was present at a significantly higher frequency in controls while the frequency of MDM4 rs116197192G was significantly higher in RB patients, suggesting that this allele might increase the risk of developing RB. CONCLUSION: Our results indicate that MDM2 and MDM4 polymorphisms may influence development and/or survival in RB.

O diagnóstico tardio de rabdomiossarcoma / Late diagnosis of pediatric rhabdomyosarcoma

Objetivo: avaliar o período de tempo decorrido desde o início da sintomatologia até o diagnóstico de rabdomiossarcoma em crianças e a possível implicação na evolução e prognóstico...

Objective: to evaluate the period lenght since the beginning of symptoms until the rhabidomyosarcoma in a reference study was conducted with 163 patients aged under 16-years-old admited for treatment...

Análise de sobrevida de pacientes pediátricos portadores de rabdomiossarcoma: 18 anos de experiência do Instituto Nacional de Câncer - RJ / Survival analysis in pediatric patients with rhabdomyosarcoma: 18-year experience at the National Cancer Institute - RJ

Foram analisados 163 pacientes portadores de rabdomiossarcoma tratados no período de 1986 a 2004 quanto ao perfil demográfico, socioeconômico, clínico, biológico e patológico. A mediana de idade foi 4,9 anos (3 m a 16 a). O sítio primário mais freqüente foi cabeça e pescoço n=73 (44,7por cento). A distribuição de grupos clínicos foi: I + II (10,4por cento), III (49,1por cento) and IV (39,3por cento). A probabilidade acumulada de sobrevida global e de SLE foi 48,6por cento e 42,2por cento em 60 meses, respectivamente. A SLE foi 73,3 por cento (GC I + II), 57,5 por cento (GC III) e 14,9 por cento (GC IV), p <0,001. Os fatores prognósticos independentes foram faixa etária dos menores de 1 ano (HRaj=3,4; p=0,022) e maior de 10 anos (HRaj= 1,7; p=0,069), ter 1 ou 2 e mais sítios de metástase (respectivamente, HRaj=3,3; p<0,001 e HRaj=6,8; p<0,001) e ter percentil de índice de massa corporal < 10 (HRaj= 2,0; p=0,027) / One hundred and sixty three patients with rhabdomyosarcoma were retrospectively analyzed from 1986 to 2004 for demographic, socioeconomic, clinical, biological and pathological variables. Median age at diagnosis was 4.9 years (range: 3 months to 16 years). The most frequent primary site was head and neck in 73 (44.7per cent) patients. Clinical groups (CG) distribution was I + II (10.4 per cent), III (49.1 per cent) and IV (39.3 per cent). Overall survival and EFS in 60 months were 48.6 per cent and 42.2 per cent, respectively. The EFS was 73.3 per cent in CG I + II, 57.5 per cent in GC III and 14.9 per cent in GC IV (p<0.001). The independent prognostic factors were age < 1 year (HRaj=3.4; p=0.022) and > 10 years (HRadj= 1.7; p=0.069), 1 or 2 and more metastatic sites (respectively HRadj=3.3; p<0,001 e HRadj=6.8; p<0.001) and body mass index below the 10th percentile (HRaj= 2.0; p=0.027)...