ABSTRACT
A previously healthy 8-month-old female infant presenting with lethargy and bilateral eye redness and cloudiness had bilateral hypopyon uveitis, which persisted despite topical steroids. Cytology of the anterior chamber and cerebrospinal fluid and flow cytometry of cerebrospinal fluid revealed malignant cells consistent with acute monocytic leukemia. Bone marrow aspirates and biopsies showed no evidence of disease. She was treated with systemic and intrathecal chemotherapy, with subsequent remission and resolution of pseudo-hypopyon. Anterior chamber involvement is a rare presentation of acute myeloid leukemia and may indicate concurrent central nervous system involvement. This has important therapeutic implications, because additional treatment modalities such as intrathecal chemotherapy, local chemotherapy, and ocular radiation may be required to overcome the "pharmacologic sanctuary" created by the blood-ocular barrier. [J Pediatr Ophthalmol Strabismus. 2021;58(5):e30-e33.].
Subject(s)
Leukemia, Monocytic, Acute , Leukemia, Myeloid, Acute , Uveitis , Anterior Chamber , Child , Female , Humans , Infant , Leukemia, Monocytic, Acute/diagnosis , Leukemia, Myeloid, Acute/complications , Leukemia, Myeloid, Acute/diagnosis , Leukemia, Myeloid, Acute/drug therapy , SuppurationABSTRACT
PURPOSE: To evaluate the incidence of surgical intervention in pediatric intracranial hypertension (IH), evaluate the visual outcomes of surgically managed patients, and identify potential predictors for surgical intervention. METHODS: The medical records of patients with primary and secondary IH at Nationwide Children's Hospital from 2010 to 2017 were reviewed retrospectively. Presenting characteristics of medically and surgically managed patients were compared, and the clinical courses of surgically managed patients were reviewed. RESULTS: A total of 129 medically and 14 surgically managed patients were included. The surgical incidence was 9.8%. Final visual acuity in 27 of 28 surgically managed eyes was 20/25 or better. In combined primary and secondary IH patients, elevations in body mass index (BMI; OR = 1.06; 95% CI, 1.01-1.11; P = 0.022) and lumbar puncture opening pressures ≥52 cm H2O (OR = 6.17; 95% CI, 1.93-19.67; P = 0.002) were significantly associated with the likelihood of surgical intervention when assessed by univariate logistic regression; grade of papilledema >2 was of marginal significance. After controlling for BMI, a lumbar puncture opening pressure of ≥52 cm H2O was more likely to result in surgery (adjusted OR = 4.69; 95% CI = 1.39-15.98; P = 0.013). CONCLUSIONS: Most pediatric IH can be treated medically. Patients with lumbar puncture opening pressures ≥52 cm H2O at the time of diagnosis are at a higher risk of surgical intervention and should be monitored closely. Elevations in presenting BMI and grade of papilledema may also increase the odds of surgery.
Subject(s)
Intracranial Hypertension/surgery , Adolescent , Antihypertensive Agents , Body Mass Index , Child , Child, Preschool , Female , Humans , Incidence , Infant , Infant, Newborn , Intracranial Hypertension/epidemiology , Intracranial Hypertension/etiology , Male , Papilledema/epidemiology , Papilledema/etiology , Papilledema/physiopathology , Retrospective Studies , Spinal Puncture , Time-to-Treatment , Treatment Outcome , United States/epidemiology , Vision Disorders/epidemiology , Vision Disorders/etiology , Vision Disorders/physiopathology , Visual Acuity/physiology , Visual Fields/physiologyABSTRACT
PURPOSE: To test the hypothesis that increasing radiation therapy (RT) dose to the thoracic vertebral bodies (TVBs) contributes to the development of hematologic toxicities (HTs) in patients with lung cancer. METHODS AND MATERIALS: Cases of non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC) treated with definitive chemoradiation with concurrent platinum-based doublet chemotherapy at our institution from 2007 to 2016 were identified. Mean TVB dose and the volume of TVBs receiving at least 5 to 60 Gy (V5-V60) were retrospectively recorded. Logistic regression was used to test associations between grade ≥3 HT (HT3+) and dosimetric/clinical parameters. Normal tissue complication probability was evaluated using the Lyman-Kutcher-Burman (LKB) model for HT3+, and receiver operating characteristics analysis was used to determine dosimetric cut-points. RESULTS: We identified 201 patients, the majority having NSCLC (n=162, 81%) and stage III to IV disease (n=179, 89%). All patients received either cisplatin/etoposide (n=107, 53%) or carboplatin/paclitaxel (n=94, 47%). Median RT dose was 60 Gy (range, 60-70 Gy). The rate of HT3+ was 49% (n=99). Increasing mean TVB dose (per Gy) was associated with higher odds of developing HT3+ (odds ratio 1.041, 95% confidence interval 1.004-1.080, P=.032), as were increasing TVB V5 to V20. These dosimetric correlates to HT3+ persisted on multivariate analysis. Constrained optimization of the LKB model for HT3+ yielded the parameters: n=1, m=1.79, and TD50=21.4 Gy. Optimal cut-points identified were V5=65%, V10=60%, V20=50%, and mean dose=23.5 Gy. Patients with values above these cut-points had an approximately 2-fold increased risk of HT3+. CONCLUSIONS: We found that mean TVB dose and low-dose parameters (V5-V20) were associated with HT3+ in chemoradiation for lung cancer. Per the LKB model, bone marrow behaves like a parallel organ (n=1), implying that mean TVB dose is a useful predictor for toxicity. These data suggest that efforts to spare dose to the TVBs may reduce rates of severe HT.
