Cancer Committee Literature Reviews

The Cancer Committee prepares quarterly literature reviews for APSA members which provide an overview of recent cancer research pertinent to all pediatric surgeons. The recommended articles are included on this page.

The selections are compiled by members of the Cancer Committee, but as a group, they are not endorsing the results of these studies as definitive practice.

If you have questions, contact Roshni Dasgupta.


The APSA Cancer Committee

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Recommended Articles

Pancreaticoduodenectomy for malignancies in children.
d'Ambrosio G, del Prete L, Grimaldi C, Bertocchini A, Lo Zupone C, Monti L, de Ville de Goyet J.
J Pediatr Surg. 2014 Apr;49(4):534-8. doi: 10.1016/j.jpedsurg.2013.09.010.
PMID: 24726107 
Summary: This case series examined 5 patients who underwent pancreaticoduodenectomy (PD) for malignant tumors.  Pathologic diagnoses varied with 2 patients with pancreatic acinar cell carcinomas, one with a solid pseudopapillary tumor and two patients with rhabdomyosarcoma of bile ducts.  The patients with RMS of bile ducts also required hepatic resection.  Pyloric preservation was performed when possible.  Reconstruction of the pancreatic stump was done with intussusception into the roux loop.  They noted that 4/5 patients were on full feeds by second week post operatively and did not note any dumping syndrome symptoms.  Pancreatic enzymatic supplementation were required in 3/5 children.  2 patients developed strictures of the pancreaticojejunal anastomosis and required reoperative surgery.   Two patients who underwent surgery for RMS of bile ducts died of disease, the rest are alive and free of disease. 

Pancreaticoduodenectomy outcomes in the pediatric, adolescent, and young adult population.
Mansfield SA, Mahida JB, Dillhoff M, Porter K, Conwell D, Ranalli M, Walker JP, Aldrink JH.
J Surg Res. 2016 Jul;204(1):232-6. doi: 10.1016/j.jss.2016.04.049. Epub 2016 Apr 29.
PMID: 27451891 
Summary: This study examined a single institution outcome of pediatric, adolescent and young adult patients undergoing pancreaticoduodenectomy over a 15 year period. 22 patients were identified with a median age of 25 years of age. 18 patients had mass of the pancreas with a mean tumor size of 4.0 cm. Of the patients with pancreatic malignancy one patient required reoperation due to stricture of the hepaticojejunostomy. The most common post-operative complication was intra-abdominal abscess occurred in 3 patients and one pancreatic leak was noted. No patients died within the first 30 days, and in observational cohort of adults from the same institution was included for qualitative comparison, noting that the pediatric population had a favorable side effect profile.

Pancreaticoduodenectomy for pediatric and adolescent pancreatic malignancy: A single-center retrospective analysis
Lindholm EB, Alkattan AK, Abramson SJ, Price AP, Heaton TE, Balachandran VP, La Quaglia MP.
J Pediatr Surg. 2017 Feb;52(2):299-303. doi: 10.1016/j.jpedsurg.2016.11.025. Epub 2016 Nov 16.
PMID: 27894759 
Summary: A single center review article of all patients <18 years of age over a 22 year span who underwent pancreaticoduodenectomy. 12 patients were identified in this series. 4 patients had previous operations and required PD for recurrent disease. Diagnoses included pancreaticoblastoma (3), Solid pseudopapillary toumor (3) , Neuroblastoma (2), RMS (2), PNET (2). In 8/12 patients a PD was performed as resection of primary disease, 4 patients underwent PD to treat metastatic disease in the head of the pancreas. 9/12 patients had underwent pre-operative chemo or radiation therapy. Pylorus sparing procedures were performed in all patients. Pancreatic reconstruction varied with the distal pancreas invaginated into posterior stomach (3), end of the jejunum (3), sewn to jejunal mucosa (4) . Transfusion was required in half of all patients. Mean length of stay was 10.6 days. Immediate post-operative complications included one intraperitoneal abscess, one patient developed a leak. Long term complications included 10/12 patients requiring pancreatic enzyme supplementation. Delayed gastric emptying was reported in 2 patients. 5 patients with solid pseudopapillary tumor or RMS were long term survivors.

A population-based analysis of a rare oncologic entity, malignant pancreatic tumors in children
Mylonas KS, Nasioudis D, Tsilimigras DI, Doulamis IP, Masiakos PT, Kelleher CM.  
DOI: http://dx.doi.org/10.1016/j.jpedsurg.2017.06.024
Summary: The authors used the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) database to identify 114 patients with pancreatic malignancies.  Pancratoblastomas were most common in children less than 10 years of age, while neuroendocrine tumors were the most frequent cell type overall.  The overall 5-year survival rates for these cell types were 77% and 66% respectively.  Epithelial malignancies were more common in adolescents as were solid pseudopapillary tumors. Controlling for metastatic disease, cancer directed surgery was associated with an improved overall survival.

Solid-pseudopapillary neoplasm of the pancreas in children:  Can we predict malignancy?
Hwang J, Kim DY, Kim SC, Namgoong JM, Hong SM.  
J Ped Surg  2014; 49, 1730-3.  DOI/10.1016/jpedsurg.2014.09.011.
This single institution paper reviews 45 children with solid-pseudopapillary neoplasms of the liver who had undergone resection.  All children had at least one CT scan.  The median age at treatment was 15 years.  Of the cohort,  9 had malignant histologic features and 3 had clinically evident malignant features with peri-pancreatic soft tissue invasion.  Surgical resections included a Whipple variant (27%), distal pancreatectomy (47%) or lesser pancreatic resection (26%).  Of the 45 patients, 4 recurred and were treated aggressively with further surgical resection.  Patients with malignant features were larger (10cm vs 5 cm) and had a higher median solid component  ( 88.5% vs 41.5%).  Median follow up was 34 months.  There were no deaths reported.

Pancreatic tumours in children: diagnosis, treatment and outcome. 
Nasher O, Hall NJ, Sebire NJ, de Coppi P, Pierro A.
Pediatr Surg Int. 2015 Sep;31(9):831-5. doi: 10.1007/s00383-015-3727-7. Epub 2015 Jul 15.
PMID: 26174862
Summary: This is a single institution retrospective review over a period of 38 years.  There were only 14 patients during this period of whom 12 had complete records.   They also reference 41 cases of pancreatic tumors reported to the UK National Registry of Childhood Tumours from 1971 to 2000.  The histology of cases in the single center were primarily solid pseudopapillary neoplasms and endocrine pancreatic neoplasms.  The diagnoses were very different in the national registry with 11 of 41 (27%) cases being pancreatoblastoma.  Specific description of surgical resections, and long term outcomes were not provided, but it is noteworthy that of 12 with surgical resection 5 had uneventful recovery, there were 2 pseudocysts, 1 peripancreatic fluid collection, 1 hemorrhagic pancreatitis, and 1 death, with 2 unknown outcomes.  The conclusion that laparoscopic resection is optimal therapy is not supported by the data presented.

A Prospective, Holistic, Multicenter Approach to Tracking and Understanding Bloodstream Infections in Pediatric Hematology-Oncology Patients
Gaur AH, Bundy DG, Werner EJ, et al.
Infect Control Hosp Epidemiol. 2017 Apr 12:1-7. doi: 10.1017/ice.2017.57.
PMID: 28399945
Summary: This article reviews and classifies data on 1,110 Blood Stream Infections (BSI) from 39 Pediatric Hematology-Oncology units (Childhood Cancer and Blood Disorders Network) collected over 25 months to define the relative contribution of CLABSI to overall BSIs in this population. All centers followed a standardized central line–maintenance care bundle for at least 2 years prior to the study period.  BSI events and central-line days were tracked monthly. Patients with a positive blood culture and central IV access were assigned to a specific category using National Healthcare Safety Network (NHSN) definitions: CLABSI; secondary BSI; and Single Positive Blood cultures (SPBC). CLABSI infections were further divided into mucosal barrier injury related-lab confirmed BSI [MBI-LCBI] and non-MBI-LCBI. 63.8% of all BSIs were designated as CLABSIs, 15.3% were secondary BSIs, and 20.9% were SPBCs. 51% of CLABSIs were MBI-LCBI.  65% of non-MBI-LCBI, 91% of MBI-LCBI, 82% of secondary BSI and 75% of SPBC were associated with neutropenia (ANC<100cells/mL).  SPBC were associated with Staphylococcus species (54%) and viridans group streptococci (22%). Significantly higher CLABSI rates (88%) and lower secondary BSI rates (12%) were identified over time related to an NHSN update for the definition of BSI.  

These data define the contribution of CLABSI to overall BSIs in the pediatric Hematology-Oncology population in a multi-institutional group utilizing a well-established standardized central-line–maintenance care bundle. Identification of, and removal of, MBI-LCBI from CLABSIs appears to reduce the overall CLABSI rate by approx. 50%. The authors suggest ‘while public reporting of CLABSIs as preventable health-associated infections should continue, the messaging should include the overall context of BSIs and the limits of the definitions used, such that informed interpretations of the reported data can be made.’
 
Preventing CLABSIs among Pediatric Hematology/Oncology Inpatients: National Collaborative Results
Bundy DG, Gaur AH, Billett AL, et al.
Pediatr. 2014 Dec;134(6):e1678-85.
PMID: 25404721
Summary: This study describes implementation a standardized bundle of central venous access care practices and CLABSI surveillance within a 32 Pediatric Hematology/ Oncology collaborative. Pre- and post-implementation rates of CVL infection are documented using Centers for Disease Control and National Healthcare Safety Network (NHSN) surveillance definitions. Baseline CLABSI rate (collected over 4yrs) was 2.85 CLABSIs per 1000 CL-days; by 34 months after adoption the bundle by the collaborative group the mean CLABSI rate was significantly reduced to 2.04 CLABSIs per 1000 CL-days, a reduction of 28% (relative risk: 0.71 [95% confidence interval: 0.55-0.92]). Compliance with CLABSI bundle was initially 38%, but increased to 78% within one year. Compliance remained 81% – 86% throughout the remainder of the reporting period without statistically significant changes in CLABSI rates. The odds of a ‘CLABSI-free’ month for any participating unit after implementation of the care bundle were 2.59x the corresponding odds of CLABSI infection during the pre-implementation period when comparing units of similar CVL days. This study demonstrates the feasibility of implementing a standardized CVL maintenance care bundle program in a large collaborative group of Pediatric Hematology/Oncology units and the efficacy of such a program in reducing CLABSIs in the Pediatric hematology/oncology population.  

Central Venous Catheter Care for the Patient with Cancer: American Society of Clinical Oncology Clinical Practice Guideline
J Clin Oncol. 2013 April 1:31(10);1357-1370.
Schiffer CA, Mangu PB, Wade JC, et al
PMID: 23460705
Summary:  This paper summarizes the guidelines that were created by the American Society of Clinical Oncology to help practitioners in central venous catheter (CVC) management in patients with cancer, including both children and adults.  Recommendations were based upon MEDLINE and Cochrane Collaboration Library literature search covering the years 1980-2012 and discussions amongst an Expert Panel.  The review included 108 RCT, 25 meta-analyses, and several existing guidelines.  The key recommendations include 1) avoidance of femoral vein insertion except for emergencies, 2) CVC’s should be placed by well-trained providers but method of placement (image guided versus landmark) is practitioner dependent, 3) use of a CVC clinical care bundle is recommended to decrease BSI, 4) prophylactic use of systemic antibiotics at the time of insertion is not recommended, 5) if infection is suspected cultures should be obtained prior to starting antibiotics and most BSI’s can be managed with appropriate antimicrobial therapy with catheter removal considered when the infection involves the port or catheter tubing, or if infection with fungi or nontuberculous mycobacteria, or is persistent bacteremia > 48-72 hours after appropriate antimicrobial treatment, 6) routine flushing with saline is recommended, 7) systemic anticoagulation does not appear to decrease CVC related thrombosis and is not recommended, 8) TPA is recommended to restore patency in a non-functioning CVC and removal of a CVC in the face of a radiologically confirmed thrombosis that does not respond to 3-6 months of anticoagulation.

Long-term Central Venous Access in a Pediatric Leukemia Population
J Surg Res. 2016 Oct;205:419-425
Aurelia BF, Hodgman EI, Burkhalter LS, et al
PMID: 27664891
Summary:  This article is a retrospective review covering all central venous access devices (CVAD) from a single institution over a 5 year period (2009-2014) that were placed in leukemia patients (ALL/AML) and reviewing both perioperative and long term complications associated with the lines with the primary focus being on reasons for removal.  This included 292 CVAD’s (240 ports and 52 tunneled lines) for a total of 142,607 catheter days.  In the perioperative period 10 catheters were malpositioned and required intervention. No conclusion was reached on how to prevent the malposition but size of the catheter, port versus tunneled line, position of the reservoir on the chest wall, vessel used, or technique were found to be predictors of malposition.  With respect to long term complications, 70% had some form of complication with unexplained catheter malfunction (39.7%), infection (31.8%), fibrin sheath (5.1%), and DVT (2.4%) being the top four.   A total of 75 lines (25.7%) were removed prematurely as a result of these complications.  On multivariate analysis, obesity, preoperative blood transfusion, infection, and unexplained line malfunction were the only factors associated with premature catheter removal.  In terms of modifiable factors for the pediatric surgeon, on univariate analysis, port placement below the nipple line (less risk for unexplained catheter malfunction) and delay in placement of the implanted line (use of a PICC first) were associated with less catheters removed prematurely.  This study highlights the potential struggles with CVAD in a very fragile population of patients.

Hepatocellular Carcinoma in Children: Does Modified Platinum- and Doxorubicin-Based Chemotherapy Increase Tumor Resectability and Change Outcome? Lessons Learned From the SIOPEL 2 and 3 Studies
J Clin Oncol. 2016 Apr 1;34(10):1050-6.
Murawski M, Weeda VB, Maibach R, et al.
Summary:  This article reports the results of the two most recent prospective International Childhood Liver Tumor Strategy Group trials (SIOPEL 2 and 3). Of 85 patients with hepatocellular carcinoma (HCC), 13 underwent upfront resection and 72 were treated with intensified platinum- and doxorubicin- based neoadjuvant chemotherapy (NAC) regimens in order to render the tumors resectable. Twenty-nine (40%) of the 72 patients had an objective response, but only in 2 (3%) patients did initially unresectable tumors become resectable with NAC. Including 7 patients who had liver transplants (LTX), 34 (40%) of 85 patients had complete resection with negative margins. Overall 5-year survival was dismal at 22%, but 18 (63%) of 27 patients survived after margin-negative resection, 1 of 7 patients (14%) survived with microscopic residual disease after resection, and 2 of 7 patients (29%) survived after LTX. Complete resection was associated with survival (P=0.035). The authors concluded that patients with resectable HCC should undergo upfront resection, that intensified NAC did not improve the survival in patients with HCC, and that LTX is a suitable option for patients with unresectable, non-metastatic HCC and should be considered early after diagnosis.

 
Detection of a Recurrent DNAJB1-PRKACA Chimeric Transcript in Fibrolamellar Hepatocellular Carcinoma
Science. 2014 Feb 28:343(6174):1010-4.
Honeyman JN, Simon EP, Robine N, et al.
Summary:  Fibrolamellar HCC (FL-HCC) is a rare histologic variant of HCC affecting adolescents with no underlying liver disease. Despite its distinct histologic appearance, it shares a poor outcome. This paper documents the discovery of a unique, highly conserved chimeric protein found in all 15 FL-HCC tumors tested. Although there was some variation in the break points, the protein is the product of a 400kb pair deletion on chromosome 19, which joins the promoter and first exon of DNAJB1, a member of the heat shock 40 protein family, to exons 2 to 10 of PRKACA, protein kinase A catalytic subunit alpha. Protein kinase A normally exists in tetramers of catalytic and regulatory subunits. The chimera retains the phosphorylation capacity of PKA, but loses the ability to bind to and be regulated by the regulatory subunit. This retained function, its overexpression in tumor cells compared to wild-type PRKACA, and its presence in 100% of the tumors tested leads the authors to conclude that this is a driving mutation in the development of FL-HCC. The authors also conclude that this distinct DNA, RNA, and protein anomaly may offer a diagnostic and therapeutic target for FL-HCC going forward.
 
Hepatic Metastasectomy in Children
Cancer. 2007 May 15;109(10):2089-93.
Su WT, Rutigliano DN, Gholizadeh M, et al.Summary: While hepatic metastasectomy has proven beneficial in several adult tumors, its use in pediatric solid tumors has been reported much less frequently. This paper reviews the surgical and long-term outcome of 15 patients undergoing hepatic metastasectomy for pediatric solid tumors. The average age at hepatic resection was 6.2 years, 6 of 15 patients had concurrent metastases to other organs, and 12 of 15 resections (80%) were anatomic.  There were no intra- or post-operative deaths, and only two minor complications occurred (1 wound infection, 1 biloma). Median survival after hepatic resection was 9 months, only 3 of 15 patients (20%) were long-term survivors, and all deaths were due to disease progression or treatment complications. The authors conclude that, although hepatic metastasectomy in pediatric solid tumors are safe, they must be performed in highly selected patients, preferably with control of the primary site and no evidence of disease outside the liver.

Characteristics and Outcomes in Children with Undifferentiated Embryonal Sarcoma of the Liver:  A Report from the National Cancer Database
Pediatr Blood Cancer. 2017 Apr 64(4), Epub
Shi Y, Rojas Y, Zhang W, et al.
Summary:  This article is the largest retrospective study of children with undifferentiated embryonal sarcoma of the liver through the National Cancer Database. The authors show a cohort of 103 patients < 18 years. The overall survival (OS) of the group of patients was 86% at 5 years.  Children who had combined therapy that included surgical resection and chemotherapy had a 5-year OS of 92%.  Best outcomes were associated with tumors smaller than 15cm and surgical resection (with or without chemotherapy). Only 1 of the 22 patients who underwent lymph node sampling was found to have disease within the node.  Surgical margins did not correlate with outcome. Metastatic disease was present in 10 patients, and these patients had a 5-year OS of 86% compared to 91% among patients without metastasis. Ten patients underwent liver transplantation as primary treatment and are all alive at 5 years. Of these 10 patients, 9 had chemotherapy in addition to transplant. The multivariate analysis revealed that tumors smaller than 15 cm and combined therapy (surgery and chemotherapy) were independent prognostic indicators associated with the best outcomes.

Widening Spectrum of Liver Angiosarcoma in Children
J Pediatr Gastroenterol Nutr. 2011 Dec 53(6): 615-9
Ackermann O, Fabre M, Franchi S, et al.
Summary:  Angiosarcoma of the liver is a rare but very rapidly progressing malignancy seen in children. Due to the relationship with hemangioma and hemangioendothelioma of the liver, which are more commonly seen, it is important to understand scenarios in which patients may be at higher risk of angiosarcoma. This article discusses 3 cases in which children presented with multinodular hemangiomas of the liver that initially responded to nonoperative management including steroid therapy and/or hepatic artery embolization. However, after a period of time, relapse occurred with rapidly progressing metastatic disease and death. These patients were all diagnosed with type 2 hemangioendothelioma or angiosarcoma. The last 2 cases discussed are children presenting after 1 year of age with vascular tumors within the liver. The first patient underwent hemihepatectomy but disease recurred in the liver and lungs and the patient died. The second patient underwent liver transplantation and is alive.  Both of these patients also had histologically confirmed angiosarcoma. This paper describes the interesting evolution of hepatic vascular tumors and highlights the potential for multinodular hemangiomas to recur as angiosarcoma, as well as the possibility of tumor sampling error in presumed benign hemangioendothelioma that can miss the angiosarcoma component.

Inflammatory Myofibroblastic Tumor of the Liver in Children
J Pediatr Gastroenterol Nutr. 2013 Sept 57(3): 277-80.
Nagarajan S, Jayabose S, McBride W, et al.
Summary:  Inflammatory myofibroblastic tumors (IMT) are characterized histologically as spindle cell proliferation with chronic inflammatory infiltrate of plasma cells, lymphocytes, and histiocytes. The tumor is considered benign but in many cases can be locally aggressive.  The tumor can arise anywhere in the body and some occur in the liver. The authors present a review of IMT in the liver in children between the ages of 3 months to 15 years, based on data from 35 patients reported in the literature from 1971-2008. Forty percent of patients presented with fever and abdominal pain. Three patients in the published reports experienced resolution of the tumor with NSAID, antibiotic, or no therapy (observation). The majority of patients underwent surgical resection with 6 patients undergoing liver transplantation and all patients surviving without recurrence (minimum follow-up time of 6 months). About 50% of IMT patients are believed to have a gene rearrangement of the anaplastic lymphoma kinase gene, and crizotinib has been used for nonoperative management in these cases with varying results.

Rhabdoid Tumors of the Liver: Rare, Aggressive, and Poorly Responsive to Standard Cytotoxic Chemotherapy
Pediatr Blood Cancer. 2011;57:423-8.
Trobaugh-Lotario AD, Finegold MJ, Feusner JH.
Summary: This literature review of all published English-language reports from 1970-2010 identified 34 patients with rhabdoid tumor of the liver. The median age at diagnosis was 8 months, the majority of patients had systemic symptoms (fever/lethargy/anorexia/vomiting), and serum AFP was normal or minimally elevated. All 10 tumors tested harbored INI1 mutations, now considered necessary for rhabdoid diagnosis. Five (17%) of 29 patients presented with evidence of tumor rupture at diagnosis, and 21 (62%) of 34 patients had metastatic disease at diagnosis. Survival was poor with only 4 (12%) of 34 patients reported surviving. Median time to death from diagnosis was 2 months and nearly all deaths occurred within 1 year of diagnosis. The authors conclude that these tumors are aggressive and poorly responsive to chemotherapy and radiation. They recommend aggressive surgical treatment and intensive chemotherapy to have a chance at cure.

The Evolution of Diagnosis and Management of Pediatric Biliary Tract Rhabdomyosarcoma
Curr Pediatr Rev. 2016 Jan 17;12:190-98.
Malkan AD, Fernandez-Pineda I.
Summary: This review summarizes decades of reports of this very rare tumor. Although it comprises only 1% of pediatric rhabdomyosarcoma (RMS), biliary tract RMS (BT-RMS) is the most common neoplastic cause of biliary tract obstruction in children. BT-RMS presents at a median age of 3 years, has a slight male predominance, and patients present with jaundice 60-80% of the time.  Patients frequently have a conjugated hyperbilirubinemia and an elevated alkaline phosphatase. The diagnosis of BT-RMS is frequently missed due to its rarity and its ability to mimic the more common, benign choledochal cyst in presentation and imaging. The use of CT, MRI, and MRCP can aid in this differential, and any of these showing a soft tissue mass in the porta hepatis should rule out choledochal cyst and raise suspicion for a neoplastic process. Appropriate staging is described, and the importance of biopsy without upfront radical surgery is emphasized. Treatment with RMS-directed chemotherapy and selective radiotherapy and surgery for local control on a case-by-case basis is advocated as the best approach to this rare tumor, which has a good overall survival.


Preserving Fertility in Children and Adolescents with Cancer
Levine JM.
Children (Basel). 2014 Aug 26;1(2):166-85. doi: 10.3390/children1020166. Review.
PMID: 27417474
This review paper highlights important concepts regarding approaches to preserving fertility in pediatric oncology patients. The author outlines the importance of fertility preservation programs in the setting of continuously improving survivorship of childhood cancers. Barriers to comprehensive discussion of fertility preservation with pediatric patients and their families by health care professionals are discussed. The author reviews the risks for gonadal toxicity in female patients with oncologic diagnoses, including the concepts of acute ovarian failure and premature menopause. The processes of embryo and oocyte cryopreservation for fertility preservation in post-pubertal females are discussed, as is the approach of ovarian tissue cryopreservation for pre-pubertal females. The importance of monitoring of ovarian function after completion of therapy is outlined. The author reviews the risks for gonadal toxicity in males, as well as the concept of sperm cryopreservation.  Algorithms of fertility preservation options for female and for male pediatric patients are presented. The importance of appropriate institutional infrastructure and collaboration between oncologists and reproductive endocrinology experts is discussed in the context of assuring pediatric oncology patients access to fertility preservation programs. An excellent overall review of fertility preservation in children and adolescents with cancer.        

Ovarian tissue collection for cryopreservation in pediatric age: laparoscopic technical tips
Lima M, Gargano T, Fabbri R, Maffi M, Destro F.
J Pediatr Adolesc Gynecol. 2014 Apr;27(2):95-7. doi: 10.1016/j.jpag.2013.11.002.
PMID: 24602303
This article focuses on surgical technique for collection of ovarian tissue for cryopreservation in the pediatric population.  The importance of consideration of approaches to fertility preservation for girls who may sustain chemotherapy- or radiotherapy-induced gonadal toxicity is highlighted.  The authors describe their 11-year experience with the use of laparoscopic ovarian tissue collection.  They discuss reasoning for their port selection, their rationale for specimen collection from both ovaries, and their technical tips for cutting into the ovaries and achieving hemostasis.  They also discuss options for transposition of the ovaries in order to reduce follicle damage in the ovarian tissue left in situ, in cases in which children require pelvic radiotherapy as part of their oncology treatment regimen.  A very useful paper to familiarize the pediatric surgeon with the surgical technique for ovarian tissue cryopreservation.

Progress and Prospects for Fertility Preservation in Prepubertal Boys with Cancer
Gies I, De Schepper J, Tournaye H
Curr Opin Endocrinol Diabetes Obes. 2015, 22:203-208
PMID: 25871958
This article is a nice review of what is currently available to the prepubertal boy who is to undergo cancer therapy. According to this paper males have a 46% overall reduction in the likelihood of siring a pregnancy after cancer treatment. The article discusses the option of cryopreservation of spematogonial stem cells (SSC’s) and subsequent autotransplantation. This procedure was first described in mice in 1994. The article goes into detail about the potential cryopreservation techniques available. Of interest is that they discussed the possibility of transplantation of tumor cells into the testis when reimplantation occurs which is an issue with ovarian tissue as well, especially in patients who had leukemia. The authors recommend one large volume biopsy of the testis for preservation which they explained has less risk of devasularization than multiple small biopsies. At this time they also recommend using the technique only for patients at high risk of infertility since there is a small but real risk of the testicular biopsy. They also weighed the options for timing of reimplantation: peripubertal vs as an adult and recommended waiting until adulthood when it is clear the patient is devoid of spermatogenesis and also after they are cured from cancer. This paper was an excellent overview of techniques available and ethical considerations for fertility preservation in the prepubertal male patient.

Fertility Preservation and Reproductive Health in the Pediatric, Adolescent and Young Adult Female Cancer Patient
Trudgen K, Ayensu-Coker L.
Curr Opin Endocrinol Obstet Gynecol 2014, 26: 372-380
PMID: 25160517
One in 530 young adults between the ages of 20-39 is a survivor of childhood cancer so this topic should be in the forefront of those treating these patients. The article details the expected risk to infertility based on treatment. The high risk group are those treated with: cyclophosphamide, ifosphamide, procarbazine, chorambucil, busulfan, melphalan, nitrogen mustard and those undergoing bone marrow ablative chemotherapy for hematopoietic stem cell transplantation (HSCT).  The intermediate risk group includes those treated with: cisplatin, carboplatin, doxorubicin. Low risk category are those treated with bleomycin, Actinomicin D, Hodgkin’s protocols with alkylating agents, ABVD, CHOP, CVP and AML/ALL therapies. Very low risk agents are vincristine, vinblastine, methotrexate and 5-FU. The article addressed the fact that not only cancer patients may be at risk for infertility due to these agents since HSCT is being used in other conditions (such as aplastic anemia, Fanconi anemia). These patients are also at risk for infertility and should be counseled accordingly. This article also explained that Anti-Mullerian Hormone (AMH) is a reliable marker to determine ovarian reserve.  Also mentioned are some options on the horizon including pharmacologic stimulation of ovarian function with Gonadotropin releasing hormone agonists, mesenchymal stem cell transplantation and egg freezing techniques for patient who have low but present oocyte counts after chemotherapy. They also mentioned when counseling families, discussion should also mention other options available such as donor oocytes or embryos, gestational surrogates and adoption. Very interesting perspective and review of fertility preservation in the young female patient. 

The International Pleuropulmonary Blastoma Registry (PPB Registry)
The PPB Registry is an affiliate of the Rare Tumor Sub-Committee of the Children's Oncology Group (COG). The Registry collects cases of PPB for COG. It is comprised of physicians, scientists, and data analysts from many institutions who have been working together for 20 years to evaluate cases of PPB. The goal of the registry is to collect information on as many cases of PPB as possible. Through this accumulation of information, we have begun to understand some of the biological and treatment issues of this disease. The website provides comprehensive information for families and physicians on this childhood chest tumor, including current treatment recommendations and practices.

Pleuropulmonary Blastoma: A Report on 350 Central Pathology-Confirmed Pleuropulmonary Blastoma Cases by the International Pleuropulmonary Blastoma Registry
Messinger YH, Stewart DR, Priest JR, et al.
Cancer 2015;121:276-85  
PMID: 25209242
This is the largest series of PPB cases from the International PPB Registry reporting on 350 centrally reviewed, pathology confirmed cases. The types of PPB were: 33% type I, 35% type II, and 32% type III (or type II/III). The 5 year OS for type I, 91%; type II, 73%; type III, 53%. The strongest predictors of outcome were the type of PPB and presence of distant metastasis. Of the patients tested, 66% were positive for a heterozygous germline DICER1 mutation; however, presence of a DICER1 mutation did not correlate with outcome. PPB is usually found in infants and young children; however, type Ir (regressed) PPB is a cystic lesion without malignant cells found in an older child with a DICER1 mutation or a relative of a PPB patient. About 10% of type I PPB can progress to type II or III. Tumor spillage at surgery, tumor size, or anaplasia did not affect DFS or OS. Interestingly, presence of pneumothorax was associated with a significantly worse DFS and OS in type II and type III patients. Additionally, neoadjuvant chemotherapy significantly improved DFS in type III patients but had no bearing on OS. Nine percent (n=20) of patients presented with metastatic disease. Forty-four patients (19%) had relapse of disease and relapse was the cause of death in 53% of the patients that died.

Type I Pleuropulmonary Blastoma: A Report from the International Pleuropulmonary Blastoma Registry
Priest JR, Hill A, Williams GM, et al.
J Clin Oncol. 2006 Sep 20;24(27):4492-8.
PMID: 16983119
This retrospective study from the International PPB Registry sought to analyze the outcomes of type I PPB patients. Thirty-eight type I PPB cases were identified from the Registry (n=30) and the literature (n=8). Twenty children had surgery alone; eight (40%) experienced recurrence, of whom four died. Eighteen children had surgery and adjuvant chemotherapy; one experienced recurrence and died. All recurrences were type II or III PPB. Recurrence-free survival was higher in the surgery and chemotherapy group. However, overall survival did not differ. Recommended management includes complete surgical resection and adjuvant chemotherapy. Recommended surveillance included CT chest every 3-6 months, for up to three years after type I diagnosis, to age five given the observed rapid recurrence rate and growth of tumors. 

Can congenital pulmonary airway malformations be distinguished from Type I pleuropulmonary blastoma based on clinical and radiological features?
Feinberg A, Hall NJ, Williams GM, Schultz KA, Miniati D, Hill DA, Dehner LP, Messinger YH, Langer JC.
J Pediatr Surg. 2016 Jan;51(1):33-7.
PMID: 26561249
This is a retrospective study comparing a cohort of 103 cystic congenital pulmonary airway malformation (CPAM) patients from a single institution to 113 type I PPB patients from the International Pleuropulmonary Blastoma Registry. The purpose of the study was to compare clinical and radiographic characteristics of each entity to help guide treatment in these patients. Of the CPAM cohort, none of the patients were found to have PPB. Features most significantly associated with CPAM were prenatal diagnosis, presence of a systemic feeding vessel (PPB cohort did not have any with a feeding vessel), and presence of simple cyst. Features significantly associated with type I PPB were symptomatic lesion, no hyperinflation, absence of a systemic feeding vessel, and complex cyst. This paper suggests that routine DICER1 mutation analysis take place for patients being considered for observation to alleviate concern for PPB. Other data suggests that an asymptomatic lesion, no family history of DICER1 familial syndrome, and lack of multifocality or bilaterality can be safely observed.

Great Vessel/Cardiac Extension and Tumor Embolism in Pleuropulmonary Blastoma: A Report from the International Pleuropulmonary Blastoma Registry
Priest JR, Andic D, Arbuckle S, et al.
Pediatr Blood Cancer. 2011 Apr;56(4):604-9
PMID: 21298746
This study combined 179 type II and III PPB cases from the International Pleuropulmonary Blastoma registry with 200 cases of type II and III PPB in the literature to focus on cases with great vessel or cardiac extension. Eleven (3%) cases were found and examined in this study. Nine cases (81%) involved the left heart circulation, one case the right heart, and one case involved both circulations. A vascular embolic event occurred in 7 (64%) patients where 5 had a post operative cerebrovascular accident (both hemorrhagic or ischemic), 1 patient had acute paraplegia secondary to descending aorta occlusion from clot, and 1 patient with multiple cerebral infarcts and acute femoral artery occlusion.  Six of these events were between 0-17 days post operative. Six (86%) of these 7 children died of vascular related events. Two (18%) out of the 11 patients survived and both of these patients had neoadjuvant chemotherapy with tumor shrinkage of both the primary tumor and vascular component. The one patient that died due to disease progression after neoadjuvant chemotherapy and surgery had primary tumor shrinkage with chemotherapy, however, the vascular component did not respond. Brain metastasis were found in 3 of the 6 patients that experienced a cerebrovascular accident. The authors hypothesize that surgery itself may precipitate embolization of tumor and later cerebral metastasis development since 11% of type II and 54% of type III PPB develop cerebral metastasis. None of the patients that underwent neoadjuvant chemotherapy experienced a vascular related event.  

DICER1 Mutations in Familial Pleuropulmonary Blastoma
Hill DA, Ivanovich J, Priest JR, et al.
Science 2009;325:965
PMID: 19556464
About 20% of children with PPB have a family history of other solid tumors such as cystic nephroma of the kidney or rhabdomyosarcoma. A heterozygous, germline mutation of DICER1 was found in common among 11 families with PPB. Mutation in DICER1 is a loss of function mutation. Developing mice deficient in DICER1 show cystic airways, disruption of bronchial branching, and cellular expansion similar to PPB. DICER1 gene is found on chromosome 14q.

DICER1 syndrome: clarifying the diagnosis, clinical features and management implications of a pleiotropic tumor predisposition syndrome
Slade I, Bachelli C, Davies H,  et al.
J Med Genet. 2011 Apr;48(4):273-8. Epub 2011 Jan 25.
PMID: 21266384
This study was undertaken as part of the FACT (Factors Associated with Childhood Tumours) Study in the United Kingdom. The goals of this study were to 1) understand the contribution of DICER1 mutations to non-familial, sporadic PPB; 2) determine if constitutional DICER1 mutations predispose to tumors other than PPB; and 3) ascertain if somatic DICER1 mutations contribute to cancer. The authors performed sequencing of over 1600 samples, including constitutional DNA from over 800 patients with broad types of tumors, focusing on tumors associated with PPB, and sequencing of DICER1 in 781 cancer cell lines. 20 cases of PPB were identified through the National Childhood Tumor Registry, none of whom had a family history of PPB. 14 cases were included in this study. A DICER1 mutation was identified in 11 of these cases. This reinforced the knowledge that DICER1 mutation is the major cause of non-familial and familial PBB. When analyzing other tumors commonly associated with PPB, DICER1 mutations were seen in 2/3 cases of cystic nephroma and 3/6 ovarian Sertoli-Leydig cell tumors, indicating that these mutations may play a major role in the development of these tumors also. Furthermore, mutational analysis shows that cancer predisposition results from the haplo-insufficiency mechanism. The study also revealed that the majority of patients with DICER1 mutations are well, and that tumor development is variable. This low penetrance and variable phenotype have led the authors to not advocate for the implementation of routine screening of patients with known DICER1 mutations. 

Radiographic Screening of Infants and Young Children with Genetic Predisposition for Rare Malignancies: DICER1 Mutations and Pleuropulmonary Blastoma
Sabapathy DG,  Guillerman RP, Orth RC, et al.
AJR Am J Roentgenol. 2015 Apr;204(4):W475-82. 
PMID: 25794098
The purpose of this study was to compare the risks of radiation exposure in screening strategies using CXR and CT or CT alone, to detect PPB in DICER-1 positive infants and young children, against the risks of disease and its progression. Given the rarity of such tumors a prospective cohort study of screening strategies is not feasible, thus the authors created a decision analytical model to predict the clinical outcome and cumulative radiation dose for each screening strategy and schedule. This statistics-based model analysis showed that increases in imaging frequency decreased loss of life expectancy for the combined (CXR and CT) screening strategy but increased that for the CT-only strategy. Loss of life expectancy was calculated as a composite of risks of undetected disease and rate radiation induced cancer. Thus, in the combined screening strategy the analysis was largely dominated by risk of undetected disease vs risk radiation induced cancer in the CT only group. For all screening strategies and schedules, overall loss of life expectancy was predicted to be less than that associated with no screening. The current practice of CXR followed by CT in cases with positive findings on CXR is predicted by this model to be the optimal regimen. The study concluded that radiographic screening of infants and young children with cancer-predisposing mutations may result in improved life expectancy compared to an unscreened population, despite the risk of radiation induced cancers in this population.

Translating genomic discoveries to the clinic in pediatric oncology
Glade Bender J, Verma A, Schiffman JD.
Curr Opin Pediatr. 2015 Feb;27(1):34-43. doi: 10.1097/MOP.0000000000000172. Review.
PMID: 25502895 

Integrative Clinical Sequencing in the management of refractory or relapsed cancer in youth
Mody RJ, Wu YM, Lonigro RJ et al
JAMA. 2015 Sep 1;314(9):913-25. doi: 10.1001/jama.2015.10080.

Strategies for the management of adverse events associated with mTOR inhibitors
Kaplan B, Qazi Y, Wellen JR.
Transplantation Reviews 28(2014) 126-133

Risk Stratification for Low and Intermediate Risk Neuroblastoma
Advances in Risk Classification and Treatment Strategies for Neuroblastoma
J Clin Oncol. 2015 Sep 20;33(27):3008-17.
Pinto NR, Applebaum MA, Volchenboum SL, et al.
PMID: 26304901

Revised risk estimation and treatment stratification of low- and intermediate-risk neuroblastoma patients by integrating clinical and molecular prognostic markers
Clin Cancer Res. 2015 Apr 15;21(8):1904-15.
Oberthuer A, Juraeva D, Hero B, et al.
PMID: 25231397

Expectant Observation in Very Low Risk Neuroblastoma
A prospective study of expectant observation as primary therapy for neuroblastoma in your infants: a Children's Oncology Group study
Ann Surg. 2012 Oct;256(4):573-80.
Nuchtern JG, London WB, Barnewolt CE, et al.
PMID: 22964741

Outcomes After Surgical Resection in Low-risk Neuroblastoma
Outcome after surgery alone or with restricted use of chemotherapy for patients with low-risk neuroblastoma: results of Children's Oncology Group study P9641
J Clin Oncol. 2012 May 20;30(15):1842-8.
Strother DR, London WB, Schmidt ML, et al. PMID: 22529259

Influence of image-defined risk factors on the outcome of patients with localised neuroblastoma.  A report from the LNESG1 study of the European International Society of Paediatric Oncology Neuroblastoma Group
Pediatr Blood Cancer 2015;62:1536-1542
Monclair T, Mosseri V, Cecchetto G, et al.
PMID: 25663103

Importance of Extent of Resection in High-risk Neuroblastoma
Value of surgical resection in children with high-risk neuroblastoma
Pediatr Blood Cancer. 2015 Sep;62(9):1529-35.
Englum BR, Rialon KL, Speicher PJ et al.
PMID: 25810376

Assessment of primary site response in children with high-risk neuroblastoma: an international multicenter study
J Clin Oncol. 2016 Mar 1;34(7):740-6.
Bagatell R, McHugh K, Naranjo A, et al.
PMID: 26755515

Minimal Access Surgery in Low-/Intermediate-risk Neuroblastoma
Laparoscopic resection of adrenal neuroblastoma without image-defined risk factors: a prospective study on 21 consecutive pediatric patients
Pediatr Surg Int. 2014 Apr;30(4):387-94.
Mattioli G, Avanzini S, Pini Prato A, et al.
PMID: 24477777

High grade osteosarcoma of the extremities metastatic to the lung: Long-term results in 323 patients treated combining surgery and chemotherapy, 1985-2005 
Briccoli A, Rocca M, Salone M, Guzzardella GA, Balladelli A, Bacci G.
Surg Oncol 2010 Dec;19(4):193–199   
PMID: 19515554
Review of long-term survival outcomes of 323 patients with high-grade extremity osteosarcoma with resectable lung metastases either at diagnosis or relapsed. The criteria for resectability were: primary tumor cleared, no pleural/pericardial effusions, no additional distant metastatic disease, and adequate residual pulmonary function after all metastatic lesions removed with clear microscopic margins. Patients were monitored with chest CT and extremity radiographs during chemotherapy every 2 months and after completion of chemotherapy every 3 months for 4 years, and every 6 months for 10 years. Lung resections were approached by lateral thoracotomy with manual palpation of the lungs to detect lesions not identified on chest CT scan. Wedge resection was adequate in most cases to achieve gross and microscopic clear margins. Neoadjuvant or adjuvant chemotherapy was administered according to standard first-line regimens and consisted of combinations of Methotrexate, Cisplatin, Doxorubicin, and Ifosfamide. Relapsed patients were treated with salvage chemotherapy with drugs not previously used or in higher doses. The five-year overall survival was 37% with final outcome related to presence or absence of metastasis/stage at presentation, time of first relapse, and presence of local recurrence. Salvage chemotherapy after relapses did not influence outcome. The best prognosis was seen in patients who underwent only one thoracotomy compared to patients undergoing two or more thoracotomies. There were no differences in survival in patients who underwent two or three versus four or five thoracotomies. Compared to patients who relapsed within 12 months, patients who relapsed after 24 months had higher survival. Lung only metastases had better survival compared to relapse with lung metastases and local recurrence. Thoracotomy should be considered despite the number of lung relapses or the number of secondary pulmonary lesions.

What predicts the risk of recurrent lung metastases?
Murrell Z, Dasgupta R.
J Pediatr Surg 2013 May;48(5):1020–1024 
PMID: 23701776
The authors conducted a review of patients who underwent resection of lung metastases to determine what factors predict recurrent lung metastatic disease in pediatric cancers. The study found that the majority of pediatric patients with recurrent pulmonary metastases are patients with a primary oncologic diagnosis of osteosarcoma (57%). All nodules were identified on chest CT scans. Smaller lesions (8.7mm) had a higher false negative PET scan rate compared to larger nodules (18.2mm). Of all the variables studied (age, gender, race, tumor type, size, lung lobe involved, location of lung nodule, original tumor margin of resection, solitary vs multiple nodules, procedure performed, PET scan positivity, insurance status), the only significant factors influencing recurrence risk were patients with osteosarcoma and an original PET positive study. Recurrent lung nodules in patients with osteosarcoma and those with PET positive nodules are likely to be malignant necessitating surgical intervention.

Sarcomas
HaDuong JH, Martin AA, Skapek SX, Mascarenhas L. Pediatr Clin N Am 2015 Feb;62(1):179-200.  
PMID: 25435119
This article provides a review of the multidisciplinary approach to the multimodal management of sarcomas in children. The pathology and biology of osteosarcoma are described, including several genes implicated in its pathogenesis.  The authors review the clinical and imaging features that differentiate osteosarcoma from other childhood sarcomas, and describe the Enneking staging system.  Prognostic factors for osteosarcoma are reviewed, the most important of which is the presence or absence of metastatic disease.  The authors discuss chemotherapeutic regimens and surgical management of osteosarcoma, including approaches to achieve limb-salvage over amputation. An excellent review of management of sarcomas in children, including osteosarcoma, Ewing sarcoma, rhabdomyosarcoma, and non-rhabdomyosarcoma soft-tissue sarcoma.


Billmire D1, Vinocur C, Rescorla F, Colombani P, Cushing B, Hawkins E, Davis M, London WB, Lauer S, Giller R; Children's Oncology Group.  Malignant retroperitoneal and abdominal germ cell tumors: an intergroup study.  J Pediatr Surg. 2003 Mar;38(3):315-8.
This randomized study examined survival (S) and event-free survival (EFS) rates using high-or standard-dose cisplatin-based combination chemotherapy and surgical resection for this subset of germ cell tumors. Twenty-five identified for inclusion had abdomen or retroperitoneum as the primary site. Patients had biopsy or resection at diagnosis and randomization to chemotherapy including etoposide, bleomycin, and either standard-dose (PEB) or high-dose cisplatin (HDPEB). 6-year survival rate was 90.0% +/- 11.6% for PEB and 85.7 +/- 14.5% for HDPEB. Study concluded that malignant germ cell tumors arising in the abdomen and retroperitoneum have an excellent prognosis despite advanced stage in most children. Aggressive resection need not be undertaken at diagnosis, but a concerted attempt at complete surgical removal after chemotherapy is important to distinguish viable tumor from necrotic tumor or benign elements that will not benefit from further chemotherapy.
 
Billmire D1, Vinocur C, Rescorla F, Colombani P, Cushing B, Hawkins E, London WB, Giller R, Lauer S. Malignant mediastinal germ cell tumors: an intergroup study.  J Pediatr Surg. 2001 Jan;36(1):18-24.
This secondary analysis of the randomized study Pediatric Oncology Group (POG) 9049/Children's Cancer Study Group (CCG) 8882, evaluating clinical and operative findings in patients with primary site in the mediastinum. 36 patients were identified for inclusion in the analysis. Overall, 26 of 36 patients survived, with a 4-year patient survival rate of 71%+/-10%, and a 4-year event-free survival rate of 69%+/-10%. Study concluded that tumor resection may be undertaken at diagnosis or after attempted shrinkage with chemotherapy. Aggressive attempt at complete tumor resection should be offered to all patients even if bulky tumor persists after induction chemotherapy with expectation of a significant salvage rate.

Allan B, Parikh P, Diaz S, et al. Predictors of survival and incidence of hepatoblastoma in the paediatric population. HPB 2013;15:741-746. 
606 patients in the SEER registry were examined in this study.  The authors report that HB has increased 2.2% annually from 1973-2009.  Multivariate analysis found that surgical resection, Hispanic ethnicity, local disease at presentation and age <5 to be independent factors associated with improved survival.   

Spector L, Birch J. The epidemiology of hepatoblastoma. Pediatr Blood Cancer 2012;59:776-779. 
This review article reports the markedly increased rate of HB in patients with Familial Adenomatous Polyposis and Beckwith-Wiedemann Syndromes. These inherited syndromes are rare and only comprise a small amount of HB patients overall.  Birth weight is strongly associated with sporadic HB.  With a 20-fold increase in HB among children born with very low birth weight (<1500 g) and 2-fold increase in those born with moderate low birth weight (1500-2500 g). 

Saettini F, Conter V, Provenzi M et al. Is multifocality a prognostic factor in childhood hepatoblastoma? Pediatr Blood Cancer 2014 Apr 23. Doi:10.1002/pbc.25077 (Epub ahead of print).  
This single center report found that children with multifocal tumors had a lower event free survival (.40 vs. .95), and overall survival (.42 vs .95) when compared with unifocal lesions.  The multivariate analysis suggested a hazard ration of 10, p=0.007 for children with multifocal disease. Multifocality is currently being examined by COG in the AHEP 0731 trial and by SIOPEL and is likely to emerge as a major risk factor which will be important in stratifying future trials.