Richard D. Glick

Lymphomas of the Anterior Mediastinum

Lymphomas are the most common cause of masses in the pediatric mediastinum. More than 50% of children with lymphoblastic lymphoma present with an anterior mediastinal mass, and more than one third of all patients with non-Hodgkins lymphoma have their primary sites in the mediastinum. Hodgkins disease also frequently involves this anatomic compartment with approximately two thirds of all pediatric cases manifesting mediastinal adenopathy. Although surgical resection generally is not involved in the primary treatment of these diseases, surgeons often play a key role in obtaining adequate tissue for proper diagnostic analysis. Surgical access to the mediastinum often is required in the acquisition of a specimen.

The effects of serum depletion and dexamethasone on growth and differentiation of human neuroblastoma cell lines.

BACKGROUND/PURPOSE Neuroblastoma is the most solid common extracranial malignancy in childhood. Despite multimodality treatment, high-risk disease continues to carry a poor prognosis. Glucocorticoids have been shown previously to induce differentiation in murine neuroblastoma cell lines, but no such effect has been documented in human neuroblastoma cells. Glucocorticoids are known to be active in the differentiation process of the neural crest. These studies describe the effects of dexamethasone on 6 human neuroblastoma cell lines. METHODS Dexamethasone was added to cultured neuroblastoma cell lines (LA1-5S, LA1-15N, BE[2]S, BE[2]N, SH-EP-1, SH-SY5Y) maintained in media supplemented with either normal serum or charcoal-depleted serum. Proliferation assays were performed, and flow cytometry was used to assess alterations in cell cycle. Cells were closely monitored for morphological changes with serial phase-contrast microscopy. Immunohistochemistry (3F8, NF-1, TRK-A) of cultured cells was used to evaluate differentiation. Glucocorticoid receptor levels was assessed using immunoblotting. RESULTS Dexamethasone decreased the rate of cellular proliferation in both standard and charcoal-depleted conditions. Flow cytometry showed a G1 accumulation. Increased expression of the differentiation-associated antigens was found in cells cultured in charcoal-depleted media, and a further augmentation was seen with the addition of dexamethasone. In standard media, dexamethasone had no detectable effect on the expression of these antigens. Glucocorticoid receptor expression was found to be comparable in all cell lines. CONCLUSIONS Human neuroblastoma cells are sensitive to the differentiating effects of dexamethasone in an environment of charcoal-depleted serum. This phenomenon may be caused by the existence of growth and mitogenic factors in serum that are inhibiting differentiation.

Testicular-sparing surgery for benign testicular tumors.

BACKGROUND/PURPOSE Although there has been a precedent of testicular-sparing surgery in some centers, the authors find it is still not general practice among pediatric surgeons. To address this and emphasize the role of testicular-sparing surgery in children, four patients with testicular masses are presented who underwent this procedure. METHODS Four patients who underwent testicular-sparing surgery between the years 1993 and 1998 were reviewed. Demographic data, histopathology, and follow-up data were obtained from office charts. The period of follow-up ranged from 1 to 5 years. RESULTS Four patients whose ages at diagnosis were 1, 2, 4, and 17 years presented with unilateral testicular masses. The alpha-fetoprotein and beta-human chorionic gonadotropin levels were within normal limits. Testicular ultrasonography was carried out on all patients, and groin exploration with spermatic cord isolation was performed in each case. After enucleation, frozen sections to confirm benignity was carried out before repair of the testis. Follow-up of 6 months to 5 years has shown no recurrence, and on examination, testicular volume is normal in all cases. CONCLUSIONS Testicular-sparing surgery preserves testicular volume, which is important for both cosmetic and functional purposes. It is a viable and useful method in the management of benign testicular tumors in children.

Diagnosis of mediastinal masses in pediatric patients using mediastinoscopy and the Chamberlain procedure

BACKGROUND/PURPOSE Mediastinal masses commonly are referred to the pediatric surgeon and can be difficult diagnostic problems. Various techniques have been used to perform biopsy in the mediastinum, but there are few reports of mediastinoscopy or Chamberlain procedure in children in the literature. The authors reviewed their experience with these techniques in a pediatric oncology population. METHODS The medical records of all patients on the pediatric surgical service between 1987 and 1997, inclusive, who underwent mediastinoscopy or Chamberlain procedure were reviewed. Demographic data, diagnostic accuracy, complications, operating time, and blood loss were recorded. RESULTS Sixteen consecutive patients underwent 13 Chamberlain procedures and six mediastinoscopies over the above period. Diagnostic accuracy was found to be 95% overall (100% for Chamberlain procedure, 83% for mediastinoscopy). Five complications occurred in the Chamberlain group and none in the mediastinoscopy group. No complication required thoracotomy or sternotomy. Among patients whose sole reason for admission was diagnosis of a mediastinal mass, the mean hospital stay was 1.7+/-0.8 days (n = 7) for those who underwent Chamberlain procedure and 1.4+/-0.9 days (n = 4) for those who underwent mediastinoscopy. One mediastinoscopy was performed as an ambulatory procedure. CONCLUSION Mediastinoscopy and the Chamberlain procedure are effective and safe techniques for biopsy of mediastinal masses in this age group.

Extended Left Hepatectomy (Left Hepatic Trisegmentectomy) in Childhood

BACKGROUND/PURPOSE Extended left hepatectomy, also referred to as left hepatic trisegmentectomy, in which segments II, III, IV, V, and VIII are excised, is rarely performed in children. Experience with 7 such resections is reported to describe the anatomy, technique, indications, and outcomes of the operation. METHODS The medical records of all pediatric patients treated at our institution over the last 15 years who underwent extended left hepatectomy were reviewed. Demographic information as well as operative, pathological, and follow-up data were analyzed. RESULTS Seven patients underwent extended left hepatectomy over this period. There were 5 boys and 2 girls ranging in age between 4 months and 9 years with a median age of 3.1 years. Follow-up ranged from 8 months to 5 years with a median of 3.5 years. Diagnoses included hepatoblastoma (HB, n = 3), focal nodular hyperplasia (FNH, n = 1), leiomyosarcoma (LMS, n = 1), hepatocellularcarcinoma (HCC, n = 1), and metastatic neuroblastoma (NB, n = 1). All surgical margins were grossly negative. Median operative blood loss was 13 mL/kg (range, 5 to 32 mL/kg), and mean hospital stay was 9 days (range, 7 to 12 days). No major intra- or postoperative complications were encountered, and there was no perioperative mortality. The 3 HB patients, 1 FNH patient, 1 LMS patient, and 1 NB patient are without evidence of disease, whereas the 1 child with HCC died of recurrent and distant disease. The 6 surviving children have normal hepatic function. CONCLUSION Although technically challenging and rarely performed, extended resection of the left hepatic lobe is feasible in children and can yield curative results with minimal morbidity.

Surgical protocol violations in children with renal tumors provides an opportunity to improve pediatric cancer care: a report from the Children's Oncology Group.

The purpose of this study was to evaluate the frequency and characteristics of surgical protocol violations (SPVs) among children undergoing surgery for renal tumors who were enrolled on the Childrens Oncology Group (COG) renal tumor biology and classification study AREN03B2.

A comparison of the cleft lift procedure vs wide excision and packing for the treatment of pilonidal disease in adolescents

BACKGROUND/PURPOSE The cleft lift for pilonidal disease is a flap procedure designed to counteract suspected causes of closed-technique failure. This study compares cleft lift with wide excision and packing in adolescents with respect to complications, healing, and recurrence. METHODS Charts of all patients surgically treated for pilonidal disease at our institution from August 2000 to August 2009 were reviewed retrospectively. Wide excision was routinely performed until May 2007 when the cleft lift as described by Bascom was instituted here. Factors examined were postoperative complications, wound healing, and disease recurrence. RESULTS Seventy patients (49 males, 21 females; mean age, 16 years; mean weight, 170.5 lb) with pilonidal disease underwent a total of 39 cleft lift procedures and 34 wide excision procedures. All but 1 cleft lift patient (97.4%) healed completely, whereas 25 (73.5%) of 34 patients in the excision group healed (P < .001). The remaining 9 excision patients had chronic wounds, 3 of whom have undergone cleft lift with full healing. One cleft lift patient had recurrent disease (2.5%) compared with 7 (20.6%) of 34 excision patients (P < .02). CONCLUSIONS The cleft lift procedure is a superior treatment method of pilonidal disease in adolescents, resulting in primary healing, lower likelihood of recurrent disease, and simplified wound care.