Melanoma in children and the use of sentinel lymph node biopsy.

BACKGROUND: The rarity of pediatric melanoma prompted our review of sentinel lymph node biopsy (SLNB) and associated prognosis. METHODS: A chart review from 1989 to 2004 revealed 12 cases of cutaneous melanoma. Variables analyzed included demographics, site, histology, tumor characteristics, nodal status, and distant metastasis (TMN status), SLNB and/or therapeutic lymph node dissection (TLND), adjuvant treatment, disease-free survival, and overall survival. RESULTS: Mean age at diagnosis was 8.5 years with 7 of 12 patients younger than 10 years (range, 0.3-17.9 years). Site distribution was the extremity (7), trunk (4), and head and neck (1). All patients had wide local excision and primary closure or skin graft. Breslow's thickness averaged 3.5 mm (range, 0.8-6 mm). Only patients diagnosed after 2000 with melanomas thicker than 1 mm were offered SLNB (extremity = 2, trunk = 1, head and neck = 1). Two patients had positive sentinel lymph node: one received TLND and interferon and one is followed closely (unclear pathology). Disease-free survival and overall survival by stage were stage I (n = 2, 3.9 years, 100%), stage II (n = 6, 7.7 years, 83%), stage III (n = 4, 2.6 years, 75%), and stage IV (n = 0). A stage II patient with negative SLNB, adjuvant chemotherapy, and interferon died 26 months after diagnosis, and a stage III patient with clinically and pathologically positive nodes after TLND died 15 months after diagnosis. CONCLUSION: Although a negative SLNB does not guarantee a favorable prognosis, its increasing use will further define its role in pediatric melanoma.

Unilobar congenital pulmonary lymphangiectasis mimicking congenital lobar emphysema: an underestimated presentation?

BACKGROUND: Congenital lobar emphysema (CLE) is characterized by unilobar alveolar distension secondary to bronchomalacia or absent cartilage. In contrast, congenital pulmonary lymphangiectasis (CPL) is defined as distended lymphatics in the bronchovascular bundle, in the interlobular septa, and in the subpleural space. Little information is available regarding the radiologic presentation of CLE as it correlates with histological diagnosis. METHODS: In a retrospective chart review from 1995 to 2002, 8 patients (5 boys and 3 girls) with clinical and radiologic diagnosis of CLE were reviewed. RESULTS: The mean age at diagnosis was 26 months (range, 11 days to 10 years). All but one had classic respiratory symptoms of CLE. Six of 7 chest computed tomography (CT), scans were suggestive of CLE. Of 8 patients, 3 were treated without pulmonary resection with resolution of symptoms. Five patients underwent lobectomies, and histology results showed CPL in 3. CT failed to identify CPL in all cases. CONCLUSIONS: Diagnosis of CLE is not as straightforward as the literature suggests. Even retrospectively, radiologic distinction between CLE and CPL could not be achieved by an experienced pediatric radiologist. CPL, thus, mimics CLE clinically and radiologically and, therefore, should be considered in the differential radiologic diagnosis of CLE.

Spontaneous pneumomediastinum: are we overinvestigating?

BACKGROUND: Spontaneous pneumomediastinum (SPM) is uncommon in pediatrics. Because of the growing concern about the risks of radiation in children, the authors analyzed whether an extensive radiologic workup influences management and outcome. METHODS: In a retrospective study from 1991 to 2003, 53 patients were diagnosed with SPM. Charts were reviewed for demographics, predisposing factors, presentation, investigation, and evolution. Pneumomediastinum occurring in the neonatal period or related to either pneumothorax, barotrauma, or trauma were excluded. RESULTS: Of 53 cases, 26 (49%) were bronchospasm related, 11 (21%) had respiratory tract infections, and 8 (15%) were idiopathic. Four (7.5%) were caused by inhaled foreign bodies while other causes accounted for the remaining 7.5%. No esophageal perforations were identified. Presentations included dyspnea (64%), subcutaneous emphysema (60%), cough (45%), cervical or chest pain (42%), and Hamman's sign (19%). Postero-anterior chest x-rays (CXR) were diagnostic in all cases except one. Mean number of CXR per hospitalization was 3. Only 3 patients subsequently had pneumothorax, and none required pleural drainage. Of the 8 patients with idiopathic SPM, 5 underwent a barium swallow, and 2 had a chest CT scan; results of all were normal. CONCLUSIONS: More than 70% of SPMs were related to bronchospasm or respiratory tract infections. Idiopathic SPMs deserve more attention because of the concern about esophageal perforation, although most investigations will be negative. SPM usually is a self-limited condition, and prognosis is related to the underlying disorder. Consequently, with clinical improvement, aggressive investigation and follow-up x-ray rarely is warranted.

Asynchronous bilateral ovarian torsion.

BACKGROUND: Pediatric ovarian torsion (OT) is a serious condition, especially in cases of asynchronous bilateral ovarian torsion (ABOT). The authors sought to evaluate the predisposing factors for ABOT and to evaluate the most appropriate treatment for ovarian torsion. METHODS: The authors retrospectively reviewed the charts of patients with ovarian torsion between 1980 and 2002. Data collected included age at presentation, type and duration of symptoms, ultrasound scan findings, interval to surgery, procedures, pathology report, and follow-up. RESULTS: Seventy-six patients had adnexal torsion confirmed at surgery, 4 of whom had ABOT. The mean age was 10 years. The mean duration of complaints before hospitalisation and interval to surgery were 56 and 33 hours, respectively. Thirty-five patients had simple tubo-ovarian torsion (46%), including all the patients with ABOT (11.4%), and 41 had an ovarian pathology (54%). All patients with ABOT underwent salpingo-oophorectomy at the first episode. They presented earlier for the second episode and had a shorter interval to surgery where detorsion with oophoropexy was performed. Follow-up ultrasound scan showed perfusion and follicles in the remaining ovary. CONCLUSIONS: The diagnosis of ovarian torsion often is delayed, especially when a solid tumor is suspected. Conservative management should be strongly considered when there is no underlying ovarian pathology. Furthermore, oophoropexy of the ipsilateral and contralateral ovary should be considered to prevent a potentially devastating recurrence.