Splenic hemorrhage in a neonate of a mother on anticonvulsant therapy.

A 24-hour-old male infant was referred to the Eastern Maine Medical Center (EMMC) because of pallor, lethargy, and abdominal distention. Diagnostic abdominal paracentesis revealed free blood. At surgery hemisplenectomy removed the damaged part of the spleen followed by complete recovery of the infant. A liver-spleen scan, performed before discharge, revealed normal uptake in the remaining portion of the spleen.

Parenteral nutritional support in children with cancer.

Acute and chronic starvation is often associated with childhood cancer. Total parenteral nutrition (TPN) with 20% glucose and 3.0% amino acids, and minerals and vitamins was instituted to treat or prevent malnutrition in 41 children with cancer, ages three months to 18 years. TPN was required for anorexia, vomiting and diarrhea associated with anti-cancer therapy in 33 patients for intestinal complications or surgery in nine, and for preoperative correction of malnutrition in two. During TPN, general nutrition and appearance improved in all patients. Weight gain was noted in most. Despite gastrointestinal complications which usually require the interruption of chemotherapy and irradiation, in 21 children treatment could be continued at full dose with nutritional support by TPN. TPN was discontinued in six patients when blood cultures became positive. Sepsis was treated successfully by removal of the central venous catheter in all six and administration of antibiotics in three. No metabolic complications were noted. TPN appears to be a safe and effective means of combating the malnutrition which may occur with cancer and its therapy.

Prognosis for children with neuroblastoma presenting with paralysis.

Since 1947, we have treated 19 children with neuroblastoma whose first symptoms were paralysis or weakness of an extremity, and/or incontinence due to tumor in the spinal canal. In 18 patients, the spine tumor was part of a dumbbell tumor which was present in the adjacent paravertebral area and in one, no extraspinal tumor was found. Aggressive treatment was employed for all. In 17 children, the intraspinal tumor was treated by laminectomy and irradiation with and without chemotherapy. Radiation and chemotherapy were used for two. The extraspinal tumor was excised totally in six and partially in six. All 12 children received postoperative radiation and chemotherapy. In 6 children, the extraspinal tumor was treated only with radiation and chemotherapy. Nine of 19 children are alive without evidence of neuroblastoma. Thirteen patients showed either partial (6) or full (7) neurologic recovery. Survival was related to the child's age at diagnosis and the extent of disease. While 8 of 9 children under 1 yr of age survived, only 1 of 10 children over 1 yr survived. None of the 5 children with Stage IV disease at diagnosis could be saved. The degree and frequency of neurologic recovery were greatest in children whose neurologic symptoms had been present the shortest times and were equal among those who survived and those who died. The outlook for children who became paralyzed by neuroblastoma is not hopeless; therapy aimed at saving life or neurologic function is both worthwhile and rewarding.

Experience with clinical and operative staging of Hodgkin's disease in children.

Accurate staging is critical for the proper treatment of Hodgkin's disease. In the past 5 yr, 60 children with Hodgkin's disease were staged by celiotomy which included splenectomy and biopsy of liver, retroperitoneal lymph nodes, and bone. Fifty children underwent staging celiotomy at initial diagnosis (Group I). Ten others were staged surgically because of suspected reactivation of disease diagnosed and treated before current staging methods were employed (Group II). Forty-one of 50 children in Group I had Stage I or II disease, seven Stage III, and two Stage IV. As a result of operation, therapy was altered in seven children. Three had a higher stag e and four a lower stage than that suspected by clinical evaluation, including two with liver involvement. Of the two patients in Group II, celiotomy revealed unsuspected splenic disease in seven, including one with liver involvement. Celiotomy and splenectomy were well tolerated and no long-term complications have been noted (average follow-up 2 yr). Forty-nine of 50 children in Group I and six of ten in Group II are alive without disease. No cases of sepsis attributable to splenectomy have been observed.

Effects of therapeutic irradiation delivered in early childhood upon subsequent lung function.

To determine the long-term effects of therapeutic pulmonary irradiation and treatment with actinomycin D during a period of lung growth, 12 patients treated for Wilms' tumor metastatic to the lung and 8 patients treated for Wilms' tumor with no evidence of pulmonary metastases were studied 7 to 14 years after their initial tumor therapy. All patients had received irradiation to the tumor bed and treatment with actinomycin D. Group 1 had received a single course of bilateral pulmonary irradiation; group 2 had received additional pulmonary irradiation and/or thoracic surgery; group 3 had received no therapeutic irradiation directed primarily to the chest. Total lung capacity (TLC) averaged 71% of predicted value in group 1, 58% in group 2, and 94% in group 3. Diffusing capacity in groups 1 and 2 was reduced to the same extent as lung volume. Quasi-static pressure-volume relationships, studied in three of six patients in group 1, were within the normal range when lung volume was expressed as percentage of observed TLC. Airway resistance, evaluated by spirometry, maximum expiratory flow-volume curves, and resistance of the total respiratory system, was normal or reduced. The data support the hypothesis that therapeutic irradiation during a period of lung growth primarily affects the lung parenchyma and produces a decrease in subsequent size of both the lung and chest wall. No effect of actinomycin D alone upon the lung could be demonstrated.