Sandeep Agarwala

Whole-body MR imaging with the use of parallel imaging for detection of skeletal metastases in pediatric patients with small-cell neoplasms: comparison with skeletal scintigraphy and FDG PET/CT

BackgroundIn pediatric patients with small-cell tumors, there is an increasing demand for accurate and early detection of skeletal, especially bone marrow, metastases as new treatment protocols are introduced. Whole-body MR imaging (WB-MR) and 18F-fluorodeoxyglucose PET/CT (FDG PET/CT) are new promising imaging methods that can detect metastases before osteoblastic host response occurs, which is the basis for detection of metastases by skeletal scintigraphy (SSC).ObjectiveTo assess the ability of WB-MR to detect marrow metastases in children with small-cell neoplasms and compare its performance with that of FDG PET/CT and SSC.Materials and methodsDuring a 16-month period, 26 children and adolescents with histopathologically proven small-cell neoplasms underwent WB-MR, FDG PET/CT and Tc-phosphonate-based SSC in a random order within a 25-day period. Metastases were localized in relation to eight regions of the body.ResultsWB-MR revealed metastases in 39 out of a total of 208 regions in 26 patients (sensitivity 97.5%, specificity 99.4%, positive predictive value 97.5%, negative predictive value 99.4%), SSC in 12 regions (sensitivity 30%, specificity 99.4%, PPV 92.3%, NPV 85.6%) and FDG PET/CT in 36 regions (sensitivity 90.0%, specificity 100%, PPV 100%, NPV 97.7%). Both WB-MR and FDG PET/CT showed excellent agreement (kappa) with the final diagnosis (96.9% and 93.6% respectively), whereas SSC showed only moderate agreement (39.6%).ConclusionOur results suggest that WB-MR and FDG PET/CT studies are robust imaging modalities for screening for skeletal metastases, and are far more accurate than SSC. The lack of radiation is an additional advantage of WB-MR, especially in the pediatric population.

Gastric teratoma in children.

Abstract Gastric teratoma (GT) comprises less than 1% of all teratomas in children. Though GT in the presence of immature neuroepethelial elements is regarded as malignant, the prognosis is excellent after complete excision of the tumor. Because of its rarity the world literature lacks a large study. Clinical experience with ten cases of GT is presented and discussed. Only one patient was female; the mean age at presentation was 3.2 months. Two cases were immature grade III GT; one of these had infiltrated the left lobe of the liver and the transverse colon while the other had metastasized to the regional lymph nodes and omentum. All the patients underwent complete excision. There were no deaths, and after a mean follow-up period of 4.2 years, all the patients had no recurrence and were healthy. Both the mature and immature types of GT have an excellent prognosis after complete excision of the tumor. Even when the immature type infiltrates surrounding structures, complete excision offers recurrence-free survival without requiring chemo- or radiotherapy.

Effect of cyclosporine on fertility in male rats

Abstract The effect of cyclosporine (CsA) on fertility has assumed greater importance with the increasing numbers of pediatric transplantations being performed all over the world. Conflicting reports on the effects of CsA on sex hormones are available. This experimental animal study was designed to examine the effect of CsA on testicular weight, sperm counts, seminiferous tubular diameter (STD), testicular morphology, DNA flowcytometry, sex hormone levels, and fertility in male rats. Those rats who received CsA (20 mg/kg per day) showed significant reductions in testicular weight (P < 0.05), sperm count (P < 0.01), Johnsen score (P < 0.05), STD (P < 0.01), serum testosterone levels (P < 0.05), haploid cell population (P < 0.001) in the testis, and fertility (P < 0.001) compared to those receiving CsA 10 mg/kg per day and control rats. These findings will have an important bearing for children receiving cyclosporine for long periods to guide the physician in optimally adjusting long-term treatment.

Randomized control trial comparing oral amoxicillin-clavulanate and ofloxacin with intravenous ceftriaxone and amikacin as outpatient therapy in pediatric low-risk febrile neutropenia.

Background Outpatient oral therapy is infrequently used in pediatric low-risk febrile neutropenia (LRFN) as there is insufficient data regarding its equivalence as compared with parenteral therapy. Methods This is a single institutional, randomized control trial in pediatric LRFN aged 2 to 15 years, in which 123 episodes in 88 patients were randomized to outpatient oral ofloxacin 7.5 mg/kg 12 hourly and amoxycillin-clavulanate 12.5 mg/kg 8 hourly or outpatient intravenous (IV) ceftriaxone 75 mg/kg and amikacin 15 mg/kg once daily after blood cultures. Results Out of 119 evaluable episodes, one-third were leukemia patients in maintenance and rest were solid tumors. Success was achieved in 55/61 (90.16%) and 54/58 (93.1%) in oral and IV arms, respectively, (P=0.56). There were 3 hospitalizations but no mortality. Median days to resolution of fever, absolute neutrophil count >500/mm3 and antibiotic use were 3, 5, and 6 days in both arms. There were 5 blood culture isolates (3 gram-positive and 2 gram-negative bacteria). Failure of outpatient therapy was associated with perianal infections, bacteremia, febrile neutropenia onset before day 9 of chemotherapy in solid tumors and Vincristine, actinomycin-D, and cyclophosphamide chemotherapy for rhabdomyosarcoma. All gram-positive isolates were successes, whereas both gram-negative isolates were failures. Diarrhea in IV arm and Vincristine, actinomycin-D, and cyclophosphamide chemotherapy in the oral arm predicted failure in subgroup analysis. Conclusions Outpatient therapy is efficacious and safe in pediatric LRFN. There was no difference in outcome in oral versus IV outpatient therapy. Amoxycillin-clavulanate and ofloxacin may be the oral regimen of choice.

Endoscopic treatment of tracheoesophageal fistula using electrocautery and the Nd:YAG laser

BACKGROUND Endoscopy is a well-established means of diagnosis in recurrent and congenital H-type tracheoesophageal fistulas. There is only limited knowledge of its role in the treatment using either electrocautery or laser. Laser application has not yet been reported in the treatment of recurrent tracheoesophageal fistula. METHODS From 1993 to 1997 five patients with tracheoesophageal fistula (two congenital H-type and three recurrent) were treated endoscopically using a rigid ventilating bronchoscope. The final diagnosis was made on bronchoscopic examination. In two of the patients with recurrent fistulas and one with congenital fistula, the mucosal lining was fulgurated with electrocautery via an insulated wire. In one patient each with recurrent and congenital fistula, the mucosal lining was vaporized with the Nd:YAG laser via a 600 microm bare quartz fiber. RESULTS Obliteration of the fistula was achieved in both the patients in whom laser was used, but it was unsuccessful in two of the three children in whom electrocautery was used. The obliquity of the congenital H-type fistula renders it more amenable to obliteration compared with the short and direct recurrent fistula. There was significant respiratory distress in the postoperative period after use of electrocautery. However, it was uneventful with the use of laser. CONCLUSIONS Endoscopic treatment of recurrent and congenital H-type tracheoesophageal fistula is technically easier than open surgical procedures and helps avoid the risks associated with the latter. The Nd:YAG laser is qualitatively better than electrocautery for the obliteration of the fistula.

Genitourinary tuberculosis in pediatric surgical practice

BACKGROUND Genitourinary tuberculosis (GUTB) has been reported to account for 20% to 73% of all cases of extrapulmonary tuberculosis in the general population but is much rarer in children. GUTB is a form of secondary tuberculosis with vague symptoms. Surgical intervention is required in a minority of cases. METHODS Nine cases of genitourinary tuberculosis (GUTB) were diagnosed and treated from 1988 to 1995. The age of the patients ranged from 5 to 12 years. There were five boys and four girls. Presenting features were diverse and included gross hematuria in 44% of cases and epididymoorchitis in 22% of cases. Rarer presenting features included acute renal failure, staghorn calculus, and pyonephrosis. Associated or past history of tuberculosis was present in three patients. Conclusive diagnosis was made on the basis of isolation of mycobacterium tuberculosis, histopathology, or cystoscopy in eight patients, whereas one patient was given a therapeutic trial based on clinical manifestations. RESULTS Response to antitubercular drug therapy was gratifying. Excisional surgery in the form of nephrectomy was needed in one patient, whereas another underwent bilateral ureteric replacement with ileal loops for multiple ureteric strictures. CONCLUSIONS The wide variety of presenting features and pathological lesions that result from GUTB are emphasized. The diagnosis of GUTB must be suspected in patients who present with hematuria (gross or otherwise), epididymoorchitis, and patients with long segment or multiple ureteric strictures. In view of the anticipated resurgence in tuberculosis caused by the prevalence of aquired immunodeficiency syndrome the pediatric urologist must be aware of the pathophysiology and clinical spectrum of this disease.

Functional outcome after pyeloplasty for unilateral ¶symptomatic hydronephrosis

Abstract. The functional outcome and factors influencing improvement after pyeloplasty for ureteropelvic junction (UPJ) obstruction are still debated. This retrospective study was aimed at evaluating the factors associated with functional improvement in symptomatic unilateral hydronephrosis (HDN). Patients (n=68) who underwent successful pyeloplasty for unilateral symptomatic UPJ obstruction without any other associated urological abnormality were included. Preoperative evaluation included a diuretic renogram (DR) to confirm obstruction and assess the split renal function (SRF). A follow-up DR was obtained 3 months and 1, 2, and 5 years postoperatively. An absolute increase in the differential function of the operated kidney by over 5% was considered significant; such kidneys were classified as improved (group A) and the others as unimproved (group B). The difference between the preoperative and 3-month SRF was highly significant (P < 0.001). Significant (P < 0.01) improvement in SRF continued until 1 year after pyeloplasty. Patients who presented with a mass had significantly greater improvement (P < 0.05) than those who presented with other clinical features. In group A, a significantly higher number of patients presented with a mass. It was also evident that patients aged less than 1 year showed significantly greater (P < 0.01) improvement in SRF than older patients. Thus, in unilateral symptomatic HDN with impaired function, patients who present with a mass or those in whom pyeloplasty was performed before 1 year of age showed significantly greater improvement.

Imaging of paediatric liver tumours with pathological correlation

Paediatric hepatic tumours are relatively rare with malignant lesions being twice as frequent as benign neoplasms and are mostly metastases. Imaging has a significant role in the evaluation of most paediatric liver tumours. Differentiating benign from malignant tumours is important as it significantly affects treatment decisions. We present the characteristic radiological and pathological features of the most common paediatric liver tumours.

The role of DMSA scans in evaluation of the correlation between urinary tract infection, vesicoureteric reflux, and renal scarring.

Abstract The correlation between urinary tract infection (UTI), vesicoureteric reflux (VUR) and renal scarring was studied in 89 patients (177 renal units; 1 solitary kidney) during the period 1997–2000. There were 63 males and 26 females; ages ranged from neonates to 14 years. UTI was diagnosed on the basis of a positive urine culture, VUR was diagnosed and graded by micturating cystourethrogram (MCU), and renal scarring was assessed by technetium 99 m Tc-dimercaptosuccinic acid (DMSA) scan. Ultrasonography (US) was done to evaluate renal tract dilatation and other structural abnormalities. A follow up DMSA scan was performed approximately 6 months after the initial scan. VUR was present in 106 of the 171 renal units in which it was studied and absent in 65 units. The majority of the VUR was grade V. Renal scars were seen in 90 of 177 renal units at presentation and in 72 of the 163 renal units studied at follow-up. Some information was lacking in 31 patients; hence, the correlation between UTI, VUR, and renal scarring was done in 58 patients. The majority of the suspected scars at presentation were not seen at follow-up, but most of the established scars persisted. Only 2 renal units showed scars for the first time on follow-up. On US, approximately 50% of normal kidneys showed either suspicious or established scars on DMSA scan, and patients with bilateral abnormality on US showed renal scars. Renal scars were seen in 15 of 23 children without VUR, 17 of 18 with unilateral VUR, and 16 of 17 with bilateral VUR. Thus, there is a cause-and-effect relationship between UTI and renal scarring that is made worse by VUR. DMSA scans have been shown to be the most reliable method of assessing renal scarring, and an abnormal US scan showing upper-tract dilatation or a structural abnormality may have a predictive value in the detection of renal scarring.

Congenital hepatoportal arteriovenous fistula: Report of a case

Fistulae between the hepatic artery and portal vein, known as hepatoportal arteriovenous fistula (HPAVF), most commonly occur secondary to trauma or malignancy. Congenital HPAVF is an extremely rare anomaly and only 11 pediatric cases have been documented to date HPAVF causes portal hypertension with the reversal of flow in the portal circulation, leading to hyperemia and congestion of the bowel, causing severe ascites, gastrointestinal bleeding, anemia, and malabsorption. The diagnosis is first made by Doppler sonography, then confirmed by angiography. HPAVF is most effectively treated by performing either ligation of the hepatic artery or percutaneous transcatheter embolization. We describe herein the case of an 8-month-old boy diagnosed to have congenital HPAVF by duplex Doppler sonography and confirmed by digital subtraction angiography, who was successfully managed by percutaneous transcatheter embolization of the feeding right hepatic artery. A review of the previously reported 11 cases of infants with this unusual anomaly, examining presentation, management, and outcome, is also presented.