Prophylactic cranial irradiation is indicated following complete response to induction therapy in small cell lung cancer: results of a multicentre randomised trial. United Kingdom Coordinating Committee for Cancer Research (UKCCCR) and the European Organization for Research and Treatment of Cancer (EORTC)

Prophylactic cranial irradiation (PCI) reduces the risk of cranial metastasis in small cell lung cancer (SCLC), but the magnitude and value of this reduction, the risks of radiation morbidity and whether PCI influences survival are unclear. We conducted a randomised trial in patients with limited-stage SCLC who had had a complete response to induction therapy. Initially, patients were randomised equally to (1) PCI 36 Gy in 18 daily fractions, (2) PCI 24 Gy in 12 fractions and (3) no PCI; subsequently, to increase the rate of accrual, randomisation was to clinicians' choice of PCI regimen versus no PCI (at a 3:2 ratio). The endpoints were appearance of brain metastases, survival, cognitive function, and quality of life (QoL). Three hundred and fourteen patients (194 PCI, 120 No PCI) were randomised. In the revised design, the most commonly used PCI regimens were 30 Gy in 10 fractions and 8 Gy in a single dose. With PCI, there was a large and highly significant reduction in brain metastases (HR = 0.44, 95% CI 0.29-0.67), a significant advantage in brain-metastasis-free survival (HR = 0.75, 95% CI 0.58-0.96) and a non-significant overall survival advantage (HR = 0.86, 95% CI 0.66-1.12). In both groups, there was impairment of cognitive function and QoL before PCI and additional impairment at 6 months and 1 year, but no consistent difference between the two groups and thus no evidence over 1 year of major impairment attributable to PCI. PCI can safely reduce the risk of brain metastases. Further research is needed to define optimal dose and fractionation and to clarify the effect on survival. Patients with SCLC achieving a complete response to induction therapy should be offered PCI.

Ultrasonography: an aid in the diagnosis of masses in pediatric patients.

Ultrasound was used to evaluate 100 pediatric patients suspected of having a mass. This technique was found to be useful in several ways: (1) differentiation of cystic, solid, and complex masses, which is not usually possible with routine roentgenographic evaluation; (2) delineation of free fluid collections from those that are loculated or contained within masses; (3) measurement of the size of both normal and abnormal structures; and (4) confirmation of the abnormal position or absence of organs. Ultrasound was used as a supplement to routine clinical and radiologic studies.

Lower respiratory infections: how infants differ from adults.

Largely for anatomic reasons, the peripheral airways of infants are more susceptible to inflammatory narrowing than are those of adults. When infection occurs in the lower respiratory tract of an infant, the primary effect is likely to be on the smaller airways, not the alveoli. The results are airtrapping and atelectasis. This airway obstruction often causes severe respiratory embarrassment. It is recognized on chest films by generalized hyperinflation and irregularity of aeration. Small airway obstruction is a common and important manifestation of lower respiratory infection in infancy. True consolidative pneumonia is much less frequent.

Elevated nephrogenous cyclic adenosine monophosphate to monitor early renal osteodystrophy.

Radiographs, serum chemistries, parathyroid hormone (PTH), and nephrogenous cyclic adenosine monophosphate (cAMP) were evaluated in thirty-two children with normal serum creatinine, chronic renal insufficiency, chronic hemodialysis, and transplantation. Nephrogenous cAMP increases linearly with creatinine, and there is a good correlation (r = 0.89) between immunoreactive PTH (iPTH) and nephrogenous cAMP except for patients with severe renal insufficiency or requiring chronic hemodialysis. Elevated nephrogenous cAMP is evidence for metabolic bone disease earlier than usually recognized. Early measurements of iPTH and nephrogenous cAMP could ensure early therapeutic intervention which might alleviate renal osteodystrophy in chronic renal insufficiency and transplant patients.

Appendiceal perforation, pneumoperitoneum, and Hirschsprung's disease.

In this report, we describe an infant with appendiceal perforation due to total colonic Hirschsprung's disease, to emphasize this rare but important presentation of Hirschsprung's disease. Based on our own experience and a survey of similar cases, we suggest that an underlying etiology, namely long-segment Hirschsprung's disease, should be suspected in infants with a perforated appendix, especially when a radiographic pneumoperitoneum is present. Prompt diagnosis and appropriate therapy is essential in this situation to prevent morbidity and mortality.

Imaging procedures in pediatrics.

To demonstrate the use of these multiple techniques, one might consider algorithms that are available for various disorders. It is worth pointing out that for imaging of specific abnormalities, they must be evaluated in light of the skill and interest of available personnel and on the equipment that is available. For example, in acute upper abdominal trauma in children the following is one diagnostic route: With no substantial suspicion of brain injury and after evaluation by an attending surgeon; With upper abdominal injury limited reasonably clearly to the kidneys, renal vessels, and ureters: Intravenous sonography; With upper abdominal injury limited reasonably clearly to the liver, spleen, or both: Liver/spleen scintigraphy; With substantial suspicion that the injury is not limited to the kidneys or the liver and spleen: Enhanced CT of upper abdomen; With a suspicion of brain injury sufficient to require CT of the head: CT scan, and if there is abdominal injury as well, contrast enhanced CT of the upper abdomen; Again it is to be emphasized that this diagnostic route (as well as the ones in Figures 1 and 2) represents an approach and is used in the context of this chapter to illustrate the role of the various imaging techniques that are available to the diagnosis of one pediatric problem.

Bowel perforation in Hirschsprung's disease.

A review of the medical records of 45 infants less than 1 year old with Hirschsprung's disease identified two (4.4%) who presented with bowel perforation. A literature survey was done to evaluate the relationship between bowel perforation of the bowel early in the course of Hirschsprung's disease indicates that: the infant under 4 months old is at the greatest risk; the majority of cases (62%) were associated with long-segment or total colonic Hirschsprung's disease; the most common sites of perforation were the proximal colon (68%) and appendix (17%); in cases with a short or intermediate length of aganglionic bowel, the perforation was proximal to or at the site of transition, but in 84% of infants with total colonic aganglionosis the perforation was situated in aganglionic bowel. Hirschsprung's disease should be a prime differential consideration in a young infant with penumoperitoneum caused by distal bowel perforation.