Biomedical subjects

T E Lobe

Publications and source records attributed to T E Lobe.

At least 55 records · Page 3Linked to original sources

PubMed1996

Extremity sarcomas: an analysis of prognostic factors from the Intergroup Rhabdomyosarcoma Study III.

PURPOSE: Prognostic factors for extremity sarcomas have been reported previously, after analysis of Intergroup Rhabdomyosarcomas Studies (IRS) I and II. This report reviews the experience of IRS III (1984-1992), in light of these reported factors, and the pretreatment factors used in the staging system currently being evaluated in IRS IV. The results of treatment of extremity sarcomas in IRS III are reported. METHODS: The charts of all patients entered in IRS III with an extremity-site tumor were reviewed. This group included patients with shoulder girdle and buttock sites. All patients were treated according to IRS III protocols. Survival rates were estimated by the method of Kaplan and Meier, and comparisons among groups of patients were made using a log-rank test. A multivariate analysis was performed to analyze all pretreatment factors that were significant by univariate analysis. RESULTS: Of the 189 patients entered in IRS III with extremity sites, 88 (47%) had the most common alveolar histology. Fifty-nine patients were in group I at the time of presentation (completely resected disease), 48 in group II (microscopic residual disease), 36 in group III (gross residual disease), and 46 in group IV (metastatic disease). By univariate analysis, the significant prognostic factors affecting survival were clinical group, age at time of diagnosis, tumor size, distant metastases, nodal metastases, and local and distant recurrence. By multivariate analysis of pretreatment factors, age at time of diagnosis, nodal metastases, and distant metastases were significant prognostic factors affecting survival; tumor size approached significance. Both the clinical group system and pretreatment staging system (Lawrence/Gehan) predicted significant differences in survival between groups of patients. The lower survival rate among group II and III node-negative patients with a distal tumor (who, with more extensive surgery, could have been in group I) in comparison to group I patients with a distal lesion, approached significance. In patients without distant metastases, survival was significantly different in those patients that had negative nodes from those in whom nodes were not biopsied. CONCLUSION: This review confirms that both clinical grouping and the new pretreatment staging system used in IRS IV can predict the likelihood of survival of children with extremity sarcomas. By multivariate analysis of the elements included in the staging system, nodal metastases, distant metastases, and tumor size were useful in predicting survival. In addition, age was a significant predictor. This study confirms previous suggestions that complete excision with gross and microscopically negative margins is preferable in the treatment of children with extremity rhabdomyosarcomas.

Adolescent↗

PubMed1996

A prospective evaluation of an endoscopic ultrasonic probe to detect intraparenchymal malignancy at pediatric thoracoscopy.

Thoracoscopy has been proposed as the procedure of choice for the evaluation of focal, suspected malignant pulmonary lesions in children. One drawback with this approach, however, is the concern that intraparenchymal lesions may go undetected. We prospectively evaluated the ability of an endoscopic ultrasonic probe to detect intraparenchymal nodules. The handheld probe contains a piezoelectric ultrasound emitter and receiver that operates at 7.5 MHz. The axial resolution of the probe is 1.1 cm. Two different probe tips were used. One is a forward viewing tip and the other is angled at 45 degrees relative to the axis of the probe shaft. Both probes image 90 degrees sectors. Twelve thoracoscopies on nine patients were performed using the ultrasound probe. Of seven patients with confirmed metastatic disease, six had thoracoscopy converted to open thoracotomy to assure that no lesion had been missed. The probe was able to accurately assess surrounding bronchovascular structures and the presence and location of previously placed surgical clips. Although deep structures were readily visualized with the probe, lesions within 1.5 cm of the surface of the lung were poorly visualized. No complications occurred. This ultrasound system allows for the distinction of dense lesions from the surrounding pulmonary parenchyma except for those lying near the surface of the lung, which are usually easy to see directly. Furthermore, the images define the broncho vascular structures adjacent to the lesion. This device may enhance thoracoscopy by facilitating the detection of, and ability to resect, pulmonary intraparenchymal lesions.

Endoscopes↗

PubMed1996

Early impact of new health care legislation on the pediatric surgical experience of surgical residents.

On January 1, 1994, Tennessee implemented TennCare, an insurance program for the state's medically uninsured and those who were previously covered by Medicaid. To determine how this change has affected the pediatric surgical experience of residents in training, we reviewed our institution's operative case logs from the first quarter of 1994 and compared them with logs for the first quarter of the years 1990 through 1993. Cases were classified according to urgency and necessity of surgical procedures. No significant change was noted in the number of patients having operations for the most necessary or urgent conditions, such as solid tumors or appendicitis. In contrast, the number of elective operations, principally for hernias, decreased significantly during the same period. While Tennessee's legislative change apparently has not affected the volume of urgent surgical cases, it has significantly decreased surgical residents' elective pediatric surgical experience.

Appendicitis↗

PubMed1996

In minimal access surgery.

The pediatrician must be cognizant of the extensive applications of endoscopic surgery in the pediatric patient. The ability to provide either outpatient surgery or short-stay surgery appears to be cost-effective and appropriate state-of-the-art medical care. As the array of surgical instruments continues to evolve, new and innovative endoscopic procedures will become increasingly available.

Age Factors↗

PubMed1995

Malignant peripheral nerve sheath tumors: the St. Jude Children's Research Hospital experience.

BACKGROUND: Malignant peripheral nerve sheath tumors (MPNSTs) are uncommon in young patients. To contribute to the understanding of these tumors, we reviewed the records of all patients treated for PNSTs at one institution over a 30-year period. METHODS: We reviewed the records of eight patients treated for benign PNSTs and 28 patients treated for 29 MPNSTs. We focused on the latter group, statistically testing several clinical factors for their significance in affecting survival. RESULTS: Five-year survival in patients with MPNSTs was 39%. The most significant prognostic factor was gross tumor resectability (p = 0.0004). Five-year survival for patients with resectable tumors was 65%, whereas no patient with unresectable disease survived > 25 months. Tumor grade, site, and patient race were also significant factors by univariate analysis but were not significant when adjusted for resectability. CONCLUSION: Gross tumor resection is crucial in treating malignant PNSTs. Supplemental radiation therapy is recommended for positive microscopic margins. More effective treatment is still being sought for unresectable disease.

Adolescent↗

PubMed1995

Infants with metastatic neuroblastoma have improved survival with resection of the primary tumor.

Although infants (age less than 1 year) with neuroblastoma have a favorable overall prognosis, metastatic disease is associated with poorer treatment outcome. To assess the role of surgery in these patients, the authors reviewed survival data for 151 infants treated for neuroblastoma, focusing on patient and tumor characteristics, biological markers, and surgical management among the 99 patients with metastatic disease. Patients were divided into early (1961 to 1978) and contemporary (1979 to 1993) treatment eras. Potential prognostic factors were statistically tested to determine their significance in affecting survival. Five-year survival by Pediatric Oncology Group stage was: A, 100% (+/- 0%); B, 94% (+/- 6%); DS, 77% (+/- 9%); C, 73% (+/- 9%); and D, 61% (+/- 8%). Survival for infants with metastatic disease (stages C, D, and DS) was affected significantly by treatment era (P = .0001). Analyses restricted to patients treated during the contemporary era showed prognostic significance for DNA index (P = .02), N-myc copy number (P = .007), serum lactate dehydrogenase level (P = .001), and extent of resection (P = .01). A > or = 95% resection of the primary tumor was found to be associated with improved survival. Significantly more surgical complications were associated with resections performed at the time of diagnosis (P = .007), and delaying surgery until after several courses of chemotherapy did not decrease survival. In conclusion, multiple factors affect the outcome of treatment for infants with metastatic neuroblastoma, and whenever feasible, a > or = 95% resection of the primary tumor should be performed in this patient subgroup.

Biomarkers↗

PubMed1995

Conservative management of uterine pediatric rhabdomyosarcoma: a report from the Intergroup Rhabdomyosarcoma Study III and IV pilot.

Previous studies have suggested that women with uterine rhabdomyosarcomas (RMS) represent a distinct group of patients who present at an older age, are less responsive to treatment, and have a poorer prognosis than patients with vaginal RMS. During the Intergroup Rhabdomyosarcoma Study (IRS) III and the IRS IV pilot study, 14 patients were registered with uterine primary RMS. Three patients presented with cervical tumors that were completely removed (group 1). Eight patients had initial biopsies with gross residual disease (group 3), and 3 had metastatic disease at presentation (group 4). Of the 5 patients treated with primary chemotherapy or chemotherapy and radiation, 2 had delayed hysterectomy and vaginectomy, 1 had no further surgery, and 2 had exploratory laparotomy with no evidence of disease. There were no relapses or deaths in this group. One patient underwent initial resection of a broad ligament mass, experienced an early (3-week) recurrence of the mass while on chemotherapy, and progressed to developing distant metastases and death. Four patients died of chemotherapy toxicity or sepsis, one after achieving a complete response from chemotherapy and hysterectomy. This primary chemotherapy or chemotherapy and radiotherapy regimen resulted in 8 of 9 (89%) patients (not including those who died of chemotoxicity) surviving between 1.5 and 6 years without evidence of disease. Of the surviving patients, 2 had hysterectomy and vaginectomy, but pathological specimens showed only localized microscopic residual tumor. This report suggests that less vigorous operative resection may be possible in combination with primary chemotherapy when treating uterine rhabdomyosarcomas.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMed1995

Conservative surgical management of vaginal and vulvar pediatric rhabdomyosarcoma: a report from the Intergroup Rhabdomyosarcoma Study III.

The current management of pediatric vaginal and vulvar rhabdomyosarcoma (RMS) uses cytoreductive chemotherapy before surgical intervention. During the Intergroup Rhabdomyosarcoma Study (IRS)-III (1984 to 1988), 27 evaluable patients were entered on a preoperative chemotherapy protocol. Among 24 patients with vaginal primaries, 20 had an initial biopsy with gross residual (group III), 3 had resection with positive margins (group IIA) and 1 had metastatic disease (group IV). At subsequent surgery, 7 patients underwent partial or complete vaginectomy and 6 of them had no viable tumor identified in the specimen. Only 1 of these 7 patients underwent a cystectomy, whereas 5 underwent hysterectomy. Seventeen patients in this group have no evidence of disease 66 to 108 months after diagnosis; 2 died of chemotoxicity and 1 of unknown causes after achieving a complete response. Ten of these 17 patients were treated with biopsy and chemotherapy only. Four of these 10 had radiotherapy as well. All group IIA patients have no evidence of disease. The 1 group IV patient had rapidly progressive disease with early death. This primary chemotherapy protocol resulted in less need for operative intervention or irradiation compared with previous experience. There was no local recurrence, and 20 of 24 patients remain continuously relapse-free with no evidence of disease. All 3 patients with vulvar primaries were treated by wide local excision and chemotherapy and have no evidence of disease. Conservative surgical intervention for vaginal RMS with primary chemotherapy and adjunctive radiation when necessary appears to result in excellent disease-free survival.

Adolescent↗

PubMed1995

Indications for hemiscrotectomy in the management of genitourinary tumors in children.

In the last 30 years at St Jude Children's Research Hospital, 10 boys have undergone hemiscrotectomy for primary testicular tumors or paratesticular rhabdomyosarcoma. Indications for this procedure were scrotal contamination and positive or uncertain surgical margins. Residual tumor was found in only one specimen. There were four complications in the study group. Two patients had complications directly attributable to the hemiscrotectomy, and in one patient this caused a delay in treatment. Preoperative imaging was performed in three patients. This has not been helpful in evaluating residual masses and is not indicated. Based on the authors' experience and a review of the literature, there are a number of indications for hemiscrotectomy in the management of genitourinary tumors in children. Controversies regarding some of these indications should be discussed with the families of these patients during preoperative counseling.

Adolescent↗

PubMed1995

The use of minimal access surgery in pediatric trauma: a preliminary report.

Minimal access surgery (MAS) is becoming an accepted modality in the management of adult trauma, but its use in children is rarely reported. Recently, we began using minimal access surgery to evaluate injured children. The purpose of this report is to review our preliminary experience with the use of laparoscopy and thoracoscopy in blunt and penetrating pediatric trauma. Eight children aged 2-14 years old were evaluated using MAS. Two children with blunt injuries had persistent abdominal pain despite normal radiologic studies. Laparoscopy documented a disrupted gallbladder and a small bowel perforation. Laparoscopy was also used to evaluate five hemodynamically stable children with penetrating wounds to the abdominal wall with potential peritoneal penetration. Only one child was converted to a laparotomy. Four were found to have either tangential penetrating wounds or nonbleeding solid organ injuries and were spared an open exploration. Two children with penetrating trauma with potential mediastinal injury were assessed with thoracoscopy. MAS was also used as a therapeutic modality in two children who had diaphragmatic lacerations repaired with an endoscopic "hernia" stapler. MAS accurately identified all injuries. All children were subsequently discharged without complications. We conclude that MAS is a safe and effective way to evaluate and manage hemodynamically stable children with both penetrating and blunt traumatic injuries.

Adolescent↗

PubMed1995

Children with vesical rhabdomyosarcoma (RMS) treated by partial cystectomy with neoadjuvant or adjuvant chemotherapy, with or without radiotherapy. A report from the Intergroup Rhabdomyosarcoma Study (IRS) Committee.

PURPOSE: Children with bladder rhabdomyosarcoma (RMS) are currently treated with primary chemotherapy and usually with local irradiation. More than 30% of this group ultimately require total cystectomy. The purpose of this study was to review the results of the use of partial as opposed to total cystectomy in 40 patients with bladder RMS during Intergroup Rhabdomyosarcoma Study (IRS)-I, -II, and -III (1972-1989). PATIENTS AND METHODS: A total of 171 children with primary RMS of the bladder were enrolled in the IRS during this interval. Partial cystectomy was performed in 40, in 33 before any other therapy and in seven after 10-57 weeks of chemotherapy (primarily vincristine, actinomycin-D, and cyclophosphamide, i.e., VAC) +/- radiotherapy. Surviving patients have been observed for 4-22 years. RESULTS: Thirty-one of 40 patients (78.5%) have been disease free for 2-16 years. Survival among all other IRS cases with bladder RMS during the same interval was 79.5%. Of the 31 surviving patients, one required secondary total cystectomy and two required bladder augmentation procedures for benign bladder contracture. Three quarters of the total group of living patients who have undergone partial cystectomy are without bladder-related symptoms or demonstrable lower urinary tract disease. The remaining patients have a history of functional bladder problems related to contracture or incontinence. CONCLUSIONS: Partial cystectomy is an alternative to total cystectomy for bladder RMS when the tumor site makes it anatomically feasible. In such patients, it should be considered before total cystectomy and in patients with persistent areas of questionable residual tumor after otherwise apparently successful regimens of primary chemotherapy +/- radiotherapy.

Adolescent↗

PubMed1994

Laparoscopic splenectomy in childhood.

The authors describe their technique for laparoscopic splenectomy in childhood. Five ports, including one 12-mm port for an endoscopic stapler, are placed. With the patient in the supine position, the short gastric vessels are divided between clips. The patient is then placed in the lateral decubitus position for mobilization of the splenic flexure of the colon, division of the posterolateral ligamentous attachments, and en masse transection of the splenic hilum using the EndoGIA stapler. The freed spleen is placed in a nylon reinforced Lap Sac, which is exteriorized at the neck. The spleen is morcellated and the sac removed. Concomitant cholecystectomy is performed in patients with hereditary spherocytosis who have cholelithiasis or sludge. The procedure has been performed without complication in six patients who had hematologic disorders. For another patient, the procedure was converted to an open splenectomy to achieve better hemostasis.

Adolescent↗

PubMed1994

Neonatal rhabdomyosarcoma: the IRS experience.

Neonatal rhabdomyosarcoma is rare, and the characteristics and optimal therapy for patients with this condition have not been well described. Of 3,217 eligible patients entered in the Intergroup Rhabdomyosarcoma Study (IRS), 14 were less than 30 days old at the time of diagnosis. Among these patients, male gender, Caucasian race, caudal tumors, and embryonal/botryoid and undifferentiated histology predominate. Although half the neonates survived, neither histology, tumor size, nor type of surgery were predictive of outcome. The presence of necrosis and small round cell configuration coincides with a poor prognosis, regardless of histological diagnosis. Neonatal rhabdomyosarcoma of caudal origin has a favorable prognosis.

Age Factors↗

PubMed1994

Retroperitoneal node biopsy in paratesticular rhabdomyosarcoma.

UNLABELLED: Retroperitoneal lymph node dissection (RPLND) was used in 121 Intergroup Rhabdomyosarcoma Study (IRS) III patients with nonmetastatic paratesticular (PT) rhabdomyosarcoma (RMS) to assess retroperitoneal lymph node (RPLN) involvement so as to determine the need for x-ray therapy (XRT). Clinical node evaluation (CNE) was accomplished by a computed tomography (CT) scan in 105 and a sonogram in six. Pathological node evaluation (PNE) was performed in 113: lymphadenectomy (9 bilateral, 85 unilateral) and biopsy in 19. Vincristine and actinomycin D were used for 1 year postoperatively in 89%; all patients who had positive PNE received RPLN XRT. This study compares CNE with PNE and evaluates predictors of relapse and survival. FINDINGS: There were clinically negative nodes (cN0) in 81% of the 121 patients. Among cN0 patients, 14% had positive nodes (pN1). Of the clinically positive (cN1) patients, 94% had pN1. RPLN relapse occurred in only two of the 121 patients. Initially both had cN0 and one had PNE that was negative. For all 121 patients, the 5-year survival was 91%. For cN0 patients, the 5-year survival was 96% compared with 69% for cN1 patients (P < .001). Among the children in whom treatment failed, nodes were cN1 in 5 of 11 (45%) compared with 15 of 107 (14%) in those whose treatment did not fail (P < .008). CONCLUSIONS: (1) Results of RPLN imaging studies were negative in 81% of patients with PT RMS (specificity 99%, sensitivity 57%). (2) RPLN recurrence is uncommon (even when RPLN are initially involved) if regional XRT and appropriate chemotherapy are used.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMed1994

The suitability of automatic tissue morcellation for the endoscopic removal of large specimens in pediatric surgery.

UNLABELLED: Now that endoscopic removal of tumors and other solid structures from the abdomen and chest is possible, it is important to know the suitability of this technique for the removal of solid pediatric malignancies where accurate histological assessment becomes important for prognosis and staging. The authors tested an automatic tissue morcellator on a variety of pediatric tissues to assess the interpretability of the material obtained. The morcellator consists of a rotary blade within a 1-cm sleeve. When suction is applied to the morcellator and the device is activated, the solid material is shaved or morcellated into bits of tissue that are aspirated and collected for analysis. To test the interpretability of morcellated tissue, the device was used on six Wilms' tumors, three hepatoblastomas, a lung resection, a splenectomy, and a bowel resection. The average size of the pieces of tissue was 1.33 x 0.58 x 0.43 cm. In every instance, the histology was as good as the evaluation of sections from the gross tumor. It was difficult to distinguish the edge of tissue procured by the morcellator from an edge cut by the pathologist's knife. CONCLUSIONS: (1) Morcellated pediatric tissues are available by experienced pediatric pathologists. (2) The adoption of this technique should not interfere with proper histological evaluation of solid pediatric tumors.

Biopsy↗

PubMed1994

Primary malignancy of the salivary gland in children.

Seventeen pediatric patients with a major salivary gland malignancy (16 parotid, 1 submaxillary) were reviewed. Eight patients presented with carcinoma. The usual presentation was a mass over the affected gland. Six patients had localized disease, which was treated by excision. This was accomplished by either a total or subtotal parotidectomy or resection of the submaxillary gland. Two patients received adjuvant radiation therapy. All six patients with localized carcinoma are alive, without evidence of disease. Two patients presented with metastatic disease and died of the disease despite treatment with multiagent chemotherapy, and in one case, radiation therapy. Nine patients had rhabdomyosarcoma (RMS). The usual presentation was a mass at the angle of the mandible. Five patients had involvement of one or more cranial nerves, and two had concomitant cervical adenopathy. Eight patients had a biopsy and then were treated according to an existing prospective institutional protocol. The ninth patient initially underwent a superficial parotidectomy. Seven patients received radiation therapy. In one patient, rapid progression of the disease precluded this treatment. Seven patients died of progressive local and distant disease 2 months to 2 years (median, 6 months) from the time of diagnosis. Two patients are alive, without evidence of disease, 3 and 7 years after presentation. We conclude that carcinoma should be managed with complete excision. For RMS of the salivary gland, a biopsy should be performed, and treatment should consist of chemotherapy and radiation therapy.

Adolescent↗

PubMed1994

Breast malignancy in children.

In 25 years, 18 patients with breast cancer were treated at St Jude Children's Research Hospital, 16 were female and 2 were male. The patients presented with primary malignancy (2), metastatic disease (13), or secondary malignancy (3). One of the females with primary breast malignancy had alveolar rhabdomyosarcoma. She was treated with wide excision and is currently receiving chemotherapy. The other patient presented with non-Hodgkin's lymphoma of the right breast. After biopsy, she was treated with chemotherapy. Of 13 patients with metastatic disease, the primary lesion was rhabdomyosarcoma in nine. One patient each had non-Hodgkin's lymphoma, Hodgkin's lymphoma, neuroblastoma, and signet-cell adenocarcinoma. All patients with metastatic disease to the breast died of the disease. Three females presented with invasive ductal carcinoma of the breast after treatment for Hodgkin's disease. Two underwent mastectomy and are alive without evidence of disease. One patient refused therapy and died of the second malignancy. We conclude that (1) breast malignancies had three distinctly different presentations in our patients, (2) the breasts of pediatric oncology patients should be carefully and routinely examined for metastatic disease, and (3) metastatic disease in the breast of a child is a manifestation of disseminated disease and is associated with an extremely poor prognosis.

Adolescent↗

PubMed1994

Laparoscopic Duhamel pullthrough procedure for Hirschsprung's disease in childhood.

Advances in instrumentation and technique now make laparoscopic correction of some congenital anomalies possible. We report on a 2-year-old boy with biopsy-proven Hirschsprung's disease successfully treated by a laparoscopic Duhamel pullthrough procedure. The technique and its potential role in the treatment of Hirschsprung's disease are described.

Child, Preschool↗