Kenneth W. Gow

Thyroid carcinoma presenting in childhood or after treatment of childhood malignancies: an institutional experience and review of the literature

BACKGROUND/PURPOSEnThyroid carcinomas can occur as a primary malignancy (PTM) or secondary after another malignancy (STM). Information about the presentations and outcomes of patients with STM are limited. The authors sought to compare the clinical characteristics, course, and outcomes of patients with primary or secondary thyroid malignancies.nnnMETHODSnThe authors reviewed the medical records of 8 children with PTM and 17 children with STM referred to St Jude Childrens Research Hospital between February 1962 and February 2002 for evaluation and treatment of malignant thyroid carcinoma.nnnRESULTSnThe 8 children who had primary thyroid carcinoma had it diagnosed at a median age of 12.5 years (range, 7.3 to 16.3 years). Seven patients had papillary carcinoma, and 1 patient had follicular carcinoma. Three of the 8 (37.5%) had metastatic disease involving regional lymph nodes; 2 patients (25.0%) had lung metastases. Six patients required radioactive iodine (I 131) ablation for residual or metastatic disease after surgical resection. All 8 patients remain alive a median of 22.6 years after diagnosis (range, 0.7 to 30.5 years); 1 continues to receive radioactive iodine (I 131) ablation for persistent disease. Seventeen patients had thyroid carcinoma as a second malignant neoplasm after treatment for acute lymphoblastic leukemia (n = 6), Hodgkins disease (n = 5), central nervous system tumor (n = 2), Wilms tumor (n = 1), retinoblastoma (n = 1), non-Hodgkins lymphoma (n = 1), or neuroblastoma (n = 1). Patients with secondary thyroid carcinoma presented at a median age of 21.5 years (range, 15.3 to 42.6 years), a median of 16.2 years (range, 0.9 to 29.2 years) after diagnosis of the primary cancer. Twelve of the 17 patients (70.6%) had received radiation to the thyroid gland during therapy for the primary cancer. Four patients (23.5%) had metastatic disease involving regional lymph nodes. Six patients (35.3%) required I(131) ablation for residual or metastatic disease after thyroidectomy. At the time of this report, all 17 patients are alive and in continue to be free of disease.nnnCONCLUSIONSnPediatric thyroid carcinoma is uncommon and responds well to current therapy. Given the limited period of follow-up of our cohort of secondary malignant thyroid tumors that arise after childhood cancer, these lesions appear to have similar presentations and outcomes when compared with primary carcinomas and can therefore be managed in the same manner.

Accuracy of percutaneous lung biopsy for invasive pulmonary aspergillosis

Background. Invasive pulmonary aspergillosis is fulminant and often fatal in immunosuppressed patients. Percutaneous biopsy may select patients who could benefit from surgical resection. Objective. We sought to determine the accuracy of percutaneous biopsy for pediatric invasive pulmonary aspergillosis. Materials and methods. We retrospectively reviewed 28 imaging-guided percutaneous biopsies of the lungs of 24 children with suspected pulmonary aspergillosis. Twenty-two were being treated for malignancy and two for congenital immunodeficiency; 15 had received bone-marrow transplants. The accuracy of the percutaneous lung biopsy was determined by subsequent surgical resection, autopsy, or clinical course. Results. Histopathological studies showed ten biopsy specimens with septate hyphae, indicating a mold, and seven with Aspergillus flavus colonies in culture. The remaining 18 biopsies revealed no fungi. No patient had progressive aspergillosis after negative biopsy. Invasive pulmonary mold was detected by percutaneous biopsy with 100 % (10/10) sensitivity and 100 % (18/18) specificity. Percutaneous biopsy results influenced the surgical decision in 86 % (24 of 28) of the cases. Bleeding complicated the biopsy in 46 % (13/28) and hastened one death. Conclusion. Percutaneous biopsy of the lung is an accurate technique for the diagnosis of invasive pulmonary aspergillosis and correctly determines which immunosuppressed pediatric patients would benefit from therapeutic pulmonary resection.

Natural History of Thyroid Nodules in Survivors of Pediatric Hodgkin Lymphoma

Survivors of Hodgkin lymphoma and other patients who receive neck irradiation are at increased risk of thyroid cancer. Ultrasonography provides an inexpensive and non‐invasive method of thyroid screening, but the clinical significance of thyroid nodules detected by ultrasound screening is uncertain.

Benefit of surgical resection of invasive pulmonary aspergillosis in pediatric patients undergoing treatment for malignancies and immunodeficiency syndromes.

PURPOSEnThe aim of this study was to evaluate the outcome of children undergoing treatment for malignancy and immunodeficiency syndromes in whom invasive pulmonary aspergillosis (IPA) developed.nnnMETHODSnThe authors reviewed the medical records of all patients treated at their institution from January 1990 to August 1999 for culture-proven pulmonary aspergillus infection.nnnRESULTSnAmong the 43 patients studied, the median age at the time of diagnosis of IPA was 13.1 years. The most common primary diagnoses were acute myelogenous leukemia (n = 18) and acute lymphoblastic leukemia (n = 14); 27 patients (63%) had received a bone marrow transplant (BMT). Of the 18 patients who underwent surgical intervention for IPA, 14 (78%) had one operation, whereas the remaining 4 patients had 2. The 4 patients alive at the time this report was written had undergone surgical intervention 2, 10, 23, and 44 months previously respectively. Surgical resection of the involved lung parenchyma was significantly prognostic for survival (P <.001). Other factors that influenced outcome were the extent of pulmonary invasion, steroid use, and the timing of bone marrow transplantation (BMT) in regard to the diagnosis of IPA.nnnCONCLUSIONSnThe overall mortality rate of children treated for malignancies and immunodeficiency syndromes in who IPA develops remains high, and antifungal therapy alone may not be curative. Surgical resection may provide a small but possibly the only chance for survival. Therefore, we would advocate for resection of all involved tissue, even if it requires reoperation.

Interventional radiology techniques for the diagnosis of lymphoma or leukemia

AbstractBackground. Fluid aspiration, percutaneous biopsy, and catheter drainage are standard minimally invasive methods of diagnosing lymphoma or leukemia in adults.n Objective. To determine the effectiveness of interventional radiologic techniques in diagnosing specific hematologic malignancies in children.n Methods. During a 4-year period, 22 patients (16 male, 6 female; median age, 13 years) underwent 25 percutaneous biopsies, 6 fluid aspirations, 3 catheter drainages, and 1 needle localization for diagnosing suspected hematologic malignancy.n Results. For Hodgkins disease, the procedures yielded 6 true-positive (TP) results, 2 true-negative (TN) results, and 2 false-negative (FN) results; for non-Hodgkin lymphoma (NHL), 14 TP results, 1 TN result, and 3 FN results; and for leukemia, 4 TP results and 3 FN results. Percutaneous biopsies yielded 16 TP results, 3 TN results, and 6 FN results. Aspirations and drainages yielded 8 TP results and 1 FN result. The one needle localization yielded a FN result. Overall sensitivity was 75%±7.3%; specificity, 100%; and accuracy, 77%±7.1%.n Conclusion. Percutaneous biopsy of lymphoma is usually diagnostic. Drainage or aspiration of a fluid collection associated with NHL or leukemia is often diagnostic and is less invasive than biopsy. These procedures are minimally invasive and effective for diagnosing pediatric hematologic malignancies.

Multiple entero-entero fistulae : An unusual complication of Henoch-Schönlein purpura

Henoch-Schönlein purpura (HSP) is an immunologically mediated systemic vasculitis of small blood vessels that frequently involves the gastrointestinal tract. Surgeons often are asked to assess patients with HSP for abdominal pain. Common complications that lead to surgical intervention include intussusception, perforation, necrosis, and massive gastrointestinal bleeding. However, the development of multiple entero-entero fistulae has not been described previously. Herein the authors describe the case of a 10-year-old girl with HSP who had a typical rash, seizures secondary to central nervous vasculitis, and gastrointestinal involvement. The abdominal pain persisted for several days until marked fever and hypotension developed, which necessitated surgical intervention. During laparotomy, multiple entero-entero fistulae of the ileum were found, which required resection and primary anastomosis. Histological examination of the ileum was consistent with HSP vasculitis. The patient made an unremarkable recovery and has had no recurrence of symptoms.

Evaluation of diagnostic performance of CT for detection of tumor thrombus in children with Wilms tumor: A report from the Children's Oncology Group: Wilms Tumor Thrombus Detection

Pre‐operative assessment of intravascular extension of Wilms tumor is essential to guide management. Our aim is to evaluate the diagnostic performance of multidetector CT in detection of tumor thrombus in Wilms tumor.