Papers by Chris R. Staalman
In 30 young children suspected of gastroesophageal reflux (GER), the G-E junction was examined wi... more In 30 young children suspected of gastroesophageal reflux (GER), the G-E junction was examined with ultrasonography directly after a feeding while these children were on overnight extended esophageal pH monitoring (EEpHM) (32 simultaneous ultrasound/EEpHM studies). The two tests showed 81% to 84% agreement in the detection of the presence or absence of GER, depending on whether the whole period of EEpHM or only the part of it covering the ultrasound observation period were used as the standard. The discrepancies between the two tests were explained by the much longer monitoring period of EEpHM compared to ultrasonog-raphy and the inability of EEpHM to show reflux of neutralized gastric contents directly after milk feedings. The two studies probably measure different aspects of clinically significant reflux and must be correlated with the clinical symptoms. Morphological findings associated with significant reflux were (1) a short intra-abdominal part of the esophagus, (2) a rounded gastroesophageal angle, and (3) a " beak " at the gastroesophageal junction. Barium meal findings confirmed these sonographic signs, indicating a sliding hiatal hernia of the distal esophagus, either fixed or intermittent. Ultrasonography can be recommended as a useful and physiological screening test to demonstrate clinically significant GER and a predisposing hi-atal hernia of the esophagus in symptomatic children.
615 The diagnosis of hypertrophic pylonc stenosis (HPS) with ultrasonography (US) is dependent on... more 615 The diagnosis of hypertrophic pylonc stenosis (HPS) with ultrasonography (US) is dependent on measurements of pyloric diameter (PD), pyloric length (FL), and muscle thickness. The authors were unable to confidently diagnose the condition with US in 45% of patients who underwent surgery for HPS because all three criteria were not fulfilled. An overall measurement of the "amount" of pyloric hypertrophy was introduced: pyloric volume (PV), which was equated to 1/4T X PD2 x FL No overlap was found between patients with HPS (n = 22; Pv = 3.13 mL; range, 1.4-5.1 mL) and asympp omatic control subjects (n = 28; PV = 0.65 mL; range, 0.2-1.3 mL) or symptomatic subjects without HPS (n = 25; PV = 0.86 mL; range, 0.4-1.3 mL). A positive correlation was found between age at diagnosis and PV, a finding reflecting that HPS is an acquired condition. In patients less than 4 weeks of age, the criterion of PV greater than or equal to 1.4 mL proved to aid in the identification of early HPS more accurately than any existing criteria.
In 30 young children suspected of gastroesophageal reflux (GER), the G-E junction was examined wi... more In 30 young children suspected of gastroesophageal reflux (GER), the G-E junction was examined with ultrasonography directly after a feeding while these children were on overnight extended esophageal pH monitoring (EEpHM) (32 simultaneous ultrasound/EEpHM studies). The two tests showed 81% to 84% agreement in the detection of the presence or absence of GER, depending on whether the whole period of EEpHM or only the part of it covering the ultrasound observation period were used as the standard. The discrepancies between the two tests were explained by the much longer monitoring period of EEpHM compared to ultrasonog-raphy and the inability of EEpHM to show reflux of neutralized gastric contents directly after milk feedings. The two studies probably measure different aspects of clinically significant reflux and must be correlated with the clinical symptoms. Morphological findings associated with significant reflux were (1) a short intra-abdominal part of the esophagus, (2) a rounded gastroesophageal angle, and (3) a " beak " at the gastroesophageal junction. Barium meal findings confirmed these sonographic signs, indicating a sliding hiatal hernia of the distal esophagus, either fixed or intermittent. Ultrasonography can be recommended as a useful and physiological screening test to demonstrate clinically significant GER and a predisposing hi-atal hernia of the esophagus in symptomatic children.
Journal of Clinical Oncology, 2005
Preoperative staging (pretreatment extent of disease [PRETEXT]) was developed for the first prosp... more Preoperative staging (pretreatment extent of disease [PRETEXT]) was developed for the first prospective liver tumor study by the International Society of Pediatric Oncology (SIOPEL-1 study; preoperative chemotherapy and delayed surgery). Study aims were to analyze the accuracy and interobserver agreement of PRETEXT and to compare the predictive impact of three currently used staging systems. Hepatoblastoma (HB) patients younger than 16 years who underwent surgical resection (128 of 154 patients) were analyzed. The centrally reviewed preoperative staging was compared with postoperative pathology (accuracy) in 91 patients (81%), and the local center staging was compared with the central review (interobserver agreement) in 97 patients (86%), using the agreement beyond change method (weighted kappa). The predictive values of the three staging systems were compared in 110 patients (97%) using survival curves and Cox proportional hazard ratio estimates. Preoperative PRETEXT staging compared with pathology was correct in 51%, overstaged in 37%, and understaged in 12% of patients (weighted kappa = 0.44; 95% CI, 0.26 to 0.62). The weighted kappa value of the interobserver agreement was 0.76 (95% CI, 0.64 to 0.88). The Children's Cancer Study Group/Pediatric Oncology Group-based staging system showed no predictive value for survival (P = .516), but the tumor-node-metastasis-based system and PRETEXT system showed good predictive values (P = .0021 and P = .0006, respectively). PRETEXT seemed to be superior in the statistical fit. PRETEXT has moderate accuracy with a tendency to overstage patients, shows good interobserver agreement (reproducibility), shows superior predictive value for survival, offers the opportunity to monitor the effect of preoperative therapy, and can also be applied in patients who have not had operations. For comparability reasons, we recommend that all HB patients included in trials also be staged according to PRETEXT.
Paper resulting from an interview conducted by Chris Staalman and Benjamin Vis with Ron Spronk ab... more Paper resulting from an interview conducted by Chris Staalman and Benjamin Vis with Ron Spronk about his approach and the scientific advances in analysing paintings using newly emerging technologies and the state of progress of implementation anno 2006.
Editorial Board JCU, Russell L. Deter MD, General Editor
The Editorial Board of the Journal of Clinical Ultrasound announces the winners of the Joseph H. ... more The Editorial Board of the Journal of Clinical Ultrasound announces the winners of the Joseph H. Holmes Award for 1989. This award, which is sponsored by John Wiley and Sons, Inc. and the General Electric Company, is given for a study of the use of ultrasound in detecting gastroesophageal reflux and hiatal hernia in children. These conditions lead to esophagitis, recurrent pneumonia, reactive airways disease, and esophageal stricture. They can be difficult to diagnose because of their intermittant nature. The ability to detect these conditions using ultrasound will greatly improve clinical management and make possible the detailed follow-up studies needed to evaluate the effectiveness of treatment regimes. As a consequence, the severe complications associated with these conditions should be greatly reduced.
Vis BN, Staalman CR., Jun 2006
Aronson DC, Schnater JM, Staalman CR, Weverling GJ, Plaschkes J, Perilongo G, Brown J, Phillips A, Otte JB, Czauderna P, Mackinlay G, Vos A.
PURPOSE:
Preoperative staging (pretreatment extent of disease [PRETEXT]) was developed for the f... more PURPOSE:
Preoperative staging (pretreatment extent of disease [PRETEXT]) was developed for the first prospective liver tumor study by the International Society of Pediatric Oncology (SIOPEL-1 study; preoperative chemotherapy and delayed surgery). Study aims were to analyze the accuracy and interobserver agreement of PRETEXT and to compare the predictive impact of three currently used staging systems.
PATIENTS AND METHODS:
Hepatoblastoma (HB) patients younger than 16 years who underwent surgical resection (128 of 154 patients) were analyzed. The centrally reviewed preoperative staging was compared with postoperative pathology (accuracy) in 91 patients (81%), and the local center staging was compared with the central review (interobserver agreement) in 97 patients (86%), using the agreement beyond change method (weighted kappa). The predictive values of the three staging systems were compared in 110 patients (97%) using survival curves and Cox proportional hazard ratio estimates.
RESULTS:
Preoperative PRETEXT staging compared with pathology was correct in 51%, overstaged in 37%, and understaged in 12% of patients (weighted kappa = 0.44; 95% CI, 0.26 to 0.62). The weighted kappa value of the interobserver agreement was 0.76 (95% CI, 0.64 to 0.88). The Children's Cancer Study Group/Pediatric Oncology Group-based staging system showed no predictive value for survival (P = .516), but the tumor-node-metastasis-based system and PRETEXT system showed good predictive values (P = .0021 and P = .0006, respectively). PRETEXT seemed to be superior in the statistical fit.
CONCLUSION:
PRETEXT has moderate accuracy with a tendency to overstage patients, shows good interobserver agreement (reproducibility), shows superior predictive value for survival, offers the opportunity to monitor the effect of preoperative therapy, and can also be applied in patients who have not had operations. For comparability reasons, we recommend that all HB patients included in trials also be staged according to PRETEXT.
Comment in
Predictive value of staging systems in hepatoblastoma. [J Clin Oncol. 2007]
Perilongo G, Shafford E, Maibach R, Aronson D, Brugières L, Brock P, Childs M, Czauderna P, MacKinlay G, Otte JB, Pritchard J, Rondelli R, Scopinaro M, Staalman C, Plaschkes J.
SIOPEL 2 was a pilot study designed to test the efficacy and toxicity of two chemotherapy (CT) re... more SIOPEL 2 was a pilot study designed to test the efficacy and toxicity of two chemotherapy (CT) regimens, one for patients with hepatoblastoma (HB) confined to the liver and involving no more than three hepatic sectors ('standard-risk (SR) HB'), and one for those with HB extending into all four sectors and/or with lung metastases or intra-abdominal extra hepatic spread 'high-risk (HR) HB'. SR-HB patients were treated with four courses of cisplatin (CDDP), at a dose of 80 mg/m(2) every 14 days, delayed surgery, and then two more similar CDDP courses. HR-HB patients were given CDDP alternating every 14 days with carboplatin (CARBO), 500 mg/m(2), and doxorubicin (DOXO), 60 mg/m(2). Two courses of CARBO/DOXO and one of CDDP were given postoperatively. Between October 1995 and May 1998, 77 SR-HB (10 of whom were actually treated with the HR protocol) and 58 HR-HB patients were registered and all 135 could be evaluated. Response rates for the entire SR-HB and HR-HB groups were 90% (95% CI 80-96%) and 78% (95% CI 65-87%), and resection rates were 97% (95% CI 87-99%) and 67% (95% CI 54-79%) including several children undergoing liver transplantation. For SR-HB patients, 3-year overall and progression-free survivals were 91% (+/-7%) and 89% (+/-7%) and for the HR-HB group 53% (+/-13%) and 48% (+/-13%), respectively. The short-term toxicity of these regimens was acceptable, with no toxic deaths. A treatment strategy based on CDDP monotherapy and surgery thus appears effective in SR-HB but, despite CT intensification, only half of the HR-HB patients are long-term survivors. For SR-HB patients, the efficacy of CDDP monotherapy and the CDDP/DOXO ('PLADO') combination are now being compared in a prospective randomised trial (SIOPEL 3).
Van der Plas RN, Benninga MA, Staalman CR, Akkermans LMA, Redekop WK, Taminiau JA, Büller HA.
BACKGROUND:
Faecal impaction is frequently observed in children with chronic constipation. The t... more BACKGROUND:
Faecal impaction is frequently observed in children with chronic constipation. The term megarectum is often used to describe this finding.
AIM:
To evaluate rectal functioning and rectal measures in constipated children with a filled rectum, in order to define the terms faecal impaction, enlarged rectum, and megarectum.
METHODS:
All children underwent radiological investigation, colonic transit time study, anorectal manometry, and rectal volume and rectal wall compliance measurements. Patients with faecal impaction were compared with controls, who had an empty rectum on digital rectal examination.
RESULTS:
A total of 31 patients and six controls were included in the study. The mean duration of complaints was 4.2 years and all had faecal incontinence. The colonic transit times in the patients showed a distinct delay in the rectosigmoid segment. Anorectal manometry was not significantly different between patients and controls. The rectal width in patients was 0.68 and in controls 0.52 with an upper limit of 0.61. The pressure-volume curve in patients showed significant less relaxation at a distension of 50 ml. The slope of the curve (corresponding with rectal wall compliance) was comparable for patients and controls.
CONCLUSIONS:
We suggest that faecal impaction is a filled rectum found on digital rectal examination; an enlarged rectum is defined by a rectopelvic ratio greater than 0.61; and megarectum is defined in those with significant abnormalities found with anorectal manometry, pressure-volume curves, or rectal compliance investigation. A diminished relaxation of the rectum on rectal distension could be the first sign of megarectum in children with chronic constipation.
Staalman CR.
On the basis of the literature and own experience the role of ultrasound in the management of pat... more On the basis of the literature and own experience the role of ultrasound in the management of patients with a neuroblastoma is analysed. These findings often enable a detailed anatomical description of the extensions of the tumour, which is of paramount importance in diagnosis and management of these children. Knowledge, experience, patience and understanding of the sonographer, and close cooperation with the surgeon are decisive factors for the reliability of the sonographic results, and for the role which ultrasonography has to play in neuroblastoma.
Van den Berg H, Verhulst L, Behrendt H, Staalman CR.
Most patients with Hodgkin's disease are treated with chemotherapy in conjunction with radiothera... more Most patients with Hodgkin's disease are treated with chemotherapy in conjunction with radiotherapy, but at the end of treatment a residual mass is often present. After combined therapy, it has been assumed that no additional treatment is needed. However, for children treated without radiotherapy, no data exist on the relevance of a residual mediastinal mass to risk of relapse. We report on the findings of follow-up thorax radiographs of a group of 27 children with initial mediastinal involvement, who were treated with chemotherapy only. We conclude that the regression rate of the mediastinal mass was not related to a later recurrence. Regression after chemotherapy without radiotherapy is probably slower than after combined therapy. We consider chest radiograph examinations to be appropriate for the follow-up of tumour regression. When the data were compared with a group of children with Hodgkin's disease without mediastinal involvement, we found that survival was not related to initial mediastinal involvement.
Staalman CR, Hoefnagel CA., 2000
Bearing in mind that the evaluation of a child with a presumptive neuroblastoma varies from insti... more Bearing in mind that the evaluation of a child with a presumptive neuroblastoma varies from institution to institution, depending on the local experience and availability of imaging modalities, the following statements can be made, based on literature data and our own experience:
1. Ultrasonography (US) is a valuable tool in the initial evaluation, preoperative assessment, and follow-up of children with abdominal neuroblastoma.
2. Methyl-Iodo-Benzyl-Guanidine (MIBG) scintigraphy, because of its high sensitivity and specificity, is able to detect multiple primaries and distant metastases of neuroblastoma in one single examination.
3. Together with MIBG scintigraphy, US may be the only imaging modality needed in the majority of cases.
4. IVU (intravenous urography) and angiography have no place in the evaluation of children with neuroblastoma.
5. For the assessment of cervical and thoracic neuroblastoma MRI (magnetic resonance imaging) is the method of choice.
6. MRI in general is not indicated in the initial evaluation of children with presumptive abdominal neuroblastoma. MRI is a valuable imaging modality in selected cases, including the preoperative assessment of a dumbbell tumour.
7. MRI should replace metrizamide-CT (computed tomography), metrizamide-CT, and myelography whenever possible.
8. The evaluation of bone marrow involvement by MRI may influence the prognosis.
Staalman CR, de Kraker J.
Bakker HD, Abeling NGGM, Staalman CR, van Gennip AH.
Beekman RP, Hazekamp MG, Sobotka MA, Meijboom EJ, de Roos A, Staalman CR, Beek FJ, Ottenkamp J.
The conventional diagnostic work-up of a patient suspected of having a vascular cause for stridor... more The conventional diagnostic work-up of a patient suspected of having a vascular cause for stridor, or dysphagia, includes esophagography and bronchoscopy to delineate the abnormal structure without imaging the structure itself. Cine-angiography is regarded as the golden standard, but is not routinely performed. Magnetic resonance imaging (MRI) is non-invasive and has the important advantage over cine-angiography of depicting all structures in the field of view. Color Doppler echocardiography depicts the great vessels, but not the esophagus and trachea. In 14 patients with obstructive symptoms and in four patients without obstructive symptoms MRI successfully imaged the abnormal structure, as was the case in two symptomatic patients using computer tomography. In this series, the findings were confirmed at surgery or by cine-angiography. Conclusion: we suggest that in patients suspected of having a vascular cause for stridor or dysphagia, MRI should be performed. If there is need for a screening procedure, color Doppler echocardiography should be used and if that is equivocal or non-conclusive, esophagography and bronchoscopy should be used. If MRI is difficult to interpret, it should be augmented by magnetic resonance angiography before considering cine-angiography.
Moorman-Voestermans CG, Aronson DC, Staalman CR, Delemarre JF, de Kraker J.
PURPOSE:
After nephrectomy for unilateral Wilms' tumor (WT), two potential hazards threaten the ... more PURPOSE:
After nephrectomy for unilateral Wilms' tumor (WT), two potential hazards threaten the remaining kidney. The development of a metachronous WT (2% to 3%), and decrease in renal function after chemotherapy. Our study aims included: (1) to clarify how many WT patients could benefit from partial nephrectomy (PN) without jeopardizing the high cure rate, (2) to establish the function of the kidney remnant, and (3) to test the radiological criteria for preoperative selection of PN candidates.
METHODS:
A retrospective analysis of 90 consecutive cases of histologically verified WT (1982 to 1992) was carried out. Data were studied independently by the surgeon, the radiologist, and the pathologist. The preoperative selection criteria for PN were functioning kidney, tumor confined to upper or lower pole leaving two thirds of the kidney tumor free, and no hilar or vascular structures involved. After PN, renal function was estimated by a calculated creatinine clearance (CC) combined with the assessment of the relative function of each kidney by renal scintigraphy.
RESULTS:
There were 46 boys and 44 girls with median age at diagnosis of 3 years 6 months (range, 3 months to 16 years 7 months). Stage I disease occurred in 40 patients, stage II in 23, stage III in 16, and stage IV occurred in 11 patients. Nearly all patients received preoperative chemotherapy. Radiological analysis of 85 available data sets (5 missing) suggested that PN was possible in 13 patients, and data were inconclusive in two. All 13 patients selected by the radiologist appeared to be in agreement with the pathological criteria for resectability. Of these cases, complete resection by PN was performed in five, could have been possible in retrospect in two, and appeared impossible in six. In two more patients, PN was performed; in both cases the radiologist had predicted PN to be impossible. Median follow-up after PN was 61 months, range, 45 to 167 months. Two patients died of distant metastasis, and no local recurrence occurred. Five are in remission with a median CC level of 110 mL/min, range, 85 to 124. Relative functions of the kidney remnants were 20% to 50%. Contralateral nephrectomy for progressive obstruction was performed in one, but CC level remained normal (85 mL/min). Comparing the preoperative radiological prediction with the combined surgical and pathological findings in a 2 x 2 frequency table, the sensitivity of the radiological findings could be calculated to be 80%, the specificity 97%, and the accuracy 87%.
CONCLUSIONS:
(1) Partial nephrectomy is safe in approximately 10% of Wilms' tumor patients. (2) The function of the kidney remnant remains well, and even permits contralateral nephrectomy. (3) Preoperative imaging shows an accuracy of 87% to predict the possibility for partial nephrectomy.
Petjak M, Tiel-van Buul MM, Staalman CR, Greve JC, de Kraker J, van Royen EA.
In a retrospective study we evaluated the agreement between the results of meta-iodo benzylguanid... more In a retrospective study we evaluated the agreement between the results of meta-iodo benzylguanidine (MIBG) scintigraphy and abdominal ultrasonography (US) in the diagnosis and follow up of neuroblastoma (NBL) with respect to the abdominal region. Data of 28 consecutive paediatric patients with NBL or suspected NBL were included (16 M/12 F, mean age 2.9 years, range 3 weeks-13.4 years). The results (as judged by the nuclear physician or radiologist, respectively) of 60 MIBG examinations (123I and 131I) including 26 single photon emission computed tomography (SPECT) and US, respectively, performed within a period of 14 days, could be evaluated. Full agreement was reached in 37 comparisons (62%), while partial and no agreement was found in 17 (28%), and 6 (10%) comparisons respectively. In 8 out of 37 comparisons with full agreement, 12 diagnosed lesions were histopathologically proven, while 11 comparisons with negative findings were also negative in other clinical modalities. US diagnosed correctly in 68% of the histopathological proven lesions, while this was 54% for MIBG scintigraphy. In approximately 50% of the MIBG scans in which SPECT was available, SPECT provided significant additional information.
CONCLUSION:
Congruent results of MIBG scintigraphy and ultrasonography in the detection of abdominal lesions in patients with suspected neuroblastoma indicate a high reliability in the diagnosis and localisation. Due to the favourable results of additional SPECT, it is advisable to perform SPECT routinely in this diagnosis.
Burgers JM, Oldenburger F, de Kraker J, van Bunningen BN, van der Eijken JW, Delemarre JF, Staalman CR, Voûte PA.
The pelvic localisations of Ewing's sarcoma have the worst prognosis due to large size at diagnos... more The pelvic localisations of Ewing's sarcoma have the worst prognosis due to large size at diagnosis, frequent distant metastases, radiosensitive organs next to the tumour and difficult surgery. The purpose of the present study was to analyse treatment results over a period of 25 years and to investigate the impact of newer chemotherapy schedules, improved radiotherapy techniques and newer surgical methods on the prognosis. 35 children and young adults were identified from 1967 to 1994 for whom diagnosis, presentation, performed treatment and outcome were available. Tumour size, as measured from CT scans, response to chemotherapy and radiotherapy target volume, could be reviewed in the later years. Actuarial 5-year survival for the whole group was 31% and for the 24 non-metastatic patients 40%, with a disease-free interval of 19%. Tumour size could be measured in 27 patients and ranged from 36 to 1540 cm3. There were 12 local recurrences, 1 in the 4 patients treated with surgery. After 1983, 9 out of 17 irradiated patients developed local failure. 3 patients had adequate fields and one a close field which did not cover completely the prechemotherapy extent and 3 of these recurred. All 4 patients with stable disease after neoadjuvant CT failed locally, not withstanding high-dose radiotherapy. The mean length of neoadjuvant CT tended to be shorter in patients without local relapse. There was no significant difference in survival before and after 1983.
Burgers JM, Staalman CR, de Kraker J, Oldenburger F, Delemarre JF, van der Eijken JW.
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Papers by Chris R. Staalman
Preoperative staging (pretreatment extent of disease [PRETEXT]) was developed for the first prospective liver tumor study by the International Society of Pediatric Oncology (SIOPEL-1 study; preoperative chemotherapy and delayed surgery). Study aims were to analyze the accuracy and interobserver agreement of PRETEXT and to compare the predictive impact of three currently used staging systems.
PATIENTS AND METHODS:
Hepatoblastoma (HB) patients younger than 16 years who underwent surgical resection (128 of 154 patients) were analyzed. The centrally reviewed preoperative staging was compared with postoperative pathology (accuracy) in 91 patients (81%), and the local center staging was compared with the central review (interobserver agreement) in 97 patients (86%), using the agreement beyond change method (weighted kappa). The predictive values of the three staging systems were compared in 110 patients (97%) using survival curves and Cox proportional hazard ratio estimates.
RESULTS:
Preoperative PRETEXT staging compared with pathology was correct in 51%, overstaged in 37%, and understaged in 12% of patients (weighted kappa = 0.44; 95% CI, 0.26 to 0.62). The weighted kappa value of the interobserver agreement was 0.76 (95% CI, 0.64 to 0.88). The Children's Cancer Study Group/Pediatric Oncology Group-based staging system showed no predictive value for survival (P = .516), but the tumor-node-metastasis-based system and PRETEXT system showed good predictive values (P = .0021 and P = .0006, respectively). PRETEXT seemed to be superior in the statistical fit.
CONCLUSION:
PRETEXT has moderate accuracy with a tendency to overstage patients, shows good interobserver agreement (reproducibility), shows superior predictive value for survival, offers the opportunity to monitor the effect of preoperative therapy, and can also be applied in patients who have not had operations. For comparability reasons, we recommend that all HB patients included in trials also be staged according to PRETEXT.
Comment in
Predictive value of staging systems in hepatoblastoma. [J Clin Oncol. 2007]
Faecal impaction is frequently observed in children with chronic constipation. The term megarectum is often used to describe this finding.
AIM:
To evaluate rectal functioning and rectal measures in constipated children with a filled rectum, in order to define the terms faecal impaction, enlarged rectum, and megarectum.
METHODS:
All children underwent radiological investigation, colonic transit time study, anorectal manometry, and rectal volume and rectal wall compliance measurements. Patients with faecal impaction were compared with controls, who had an empty rectum on digital rectal examination.
RESULTS:
A total of 31 patients and six controls were included in the study. The mean duration of complaints was 4.2 years and all had faecal incontinence. The colonic transit times in the patients showed a distinct delay in the rectosigmoid segment. Anorectal manometry was not significantly different between patients and controls. The rectal width in patients was 0.68 and in controls 0.52 with an upper limit of 0.61. The pressure-volume curve in patients showed significant less relaxation at a distension of 50 ml. The slope of the curve (corresponding with rectal wall compliance) was comparable for patients and controls.
CONCLUSIONS:
We suggest that faecal impaction is a filled rectum found on digital rectal examination; an enlarged rectum is defined by a rectopelvic ratio greater than 0.61; and megarectum is defined in those with significant abnormalities found with anorectal manometry, pressure-volume curves, or rectal compliance investigation. A diminished relaxation of the rectum on rectal distension could be the first sign of megarectum in children with chronic constipation.
1. Ultrasonography (US) is a valuable tool in the initial evaluation, preoperative assessment, and follow-up of children with abdominal neuroblastoma.
2. Methyl-Iodo-Benzyl-Guanidine (MIBG) scintigraphy, because of its high sensitivity and specificity, is able to detect multiple primaries and distant metastases of neuroblastoma in one single examination.
3. Together with MIBG scintigraphy, US may be the only imaging modality needed in the majority of cases.
4. IVU (intravenous urography) and angiography have no place in the evaluation of children with neuroblastoma.
5. For the assessment of cervical and thoracic neuroblastoma MRI (magnetic resonance imaging) is the method of choice.
6. MRI in general is not indicated in the initial evaluation of children with presumptive abdominal neuroblastoma. MRI is a valuable imaging modality in selected cases, including the preoperative assessment of a dumbbell tumour.
7. MRI should replace metrizamide-CT (computed tomography), metrizamide-CT, and myelography whenever possible.
8. The evaluation of bone marrow involvement by MRI may influence the prognosis.
After nephrectomy for unilateral Wilms' tumor (WT), two potential hazards threaten the remaining kidney. The development of a metachronous WT (2% to 3%), and decrease in renal function after chemotherapy. Our study aims included: (1) to clarify how many WT patients could benefit from partial nephrectomy (PN) without jeopardizing the high cure rate, (2) to establish the function of the kidney remnant, and (3) to test the radiological criteria for preoperative selection of PN candidates.
METHODS:
A retrospective analysis of 90 consecutive cases of histologically verified WT (1982 to 1992) was carried out. Data were studied independently by the surgeon, the radiologist, and the pathologist. The preoperative selection criteria for PN were functioning kidney, tumor confined to upper or lower pole leaving two thirds of the kidney tumor free, and no hilar or vascular structures involved. After PN, renal function was estimated by a calculated creatinine clearance (CC) combined with the assessment of the relative function of each kidney by renal scintigraphy.
RESULTS:
There were 46 boys and 44 girls with median age at diagnosis of 3 years 6 months (range, 3 months to 16 years 7 months). Stage I disease occurred in 40 patients, stage II in 23, stage III in 16, and stage IV occurred in 11 patients. Nearly all patients received preoperative chemotherapy. Radiological analysis of 85 available data sets (5 missing) suggested that PN was possible in 13 patients, and data were inconclusive in two. All 13 patients selected by the radiologist appeared to be in agreement with the pathological criteria for resectability. Of these cases, complete resection by PN was performed in five, could have been possible in retrospect in two, and appeared impossible in six. In two more patients, PN was performed; in both cases the radiologist had predicted PN to be impossible. Median follow-up after PN was 61 months, range, 45 to 167 months. Two patients died of distant metastasis, and no local recurrence occurred. Five are in remission with a median CC level of 110 mL/min, range, 85 to 124. Relative functions of the kidney remnants were 20% to 50%. Contralateral nephrectomy for progressive obstruction was performed in one, but CC level remained normal (85 mL/min). Comparing the preoperative radiological prediction with the combined surgical and pathological findings in a 2 x 2 frequency table, the sensitivity of the radiological findings could be calculated to be 80%, the specificity 97%, and the accuracy 87%.
CONCLUSIONS:
(1) Partial nephrectomy is safe in approximately 10% of Wilms' tumor patients. (2) The function of the kidney remnant remains well, and even permits contralateral nephrectomy. (3) Preoperative imaging shows an accuracy of 87% to predict the possibility for partial nephrectomy.
CONCLUSION:
Congruent results of MIBG scintigraphy and ultrasonography in the detection of abdominal lesions in patients with suspected neuroblastoma indicate a high reliability in the diagnosis and localisation. Due to the favourable results of additional SPECT, it is advisable to perform SPECT routinely in this diagnosis.
Preoperative staging (pretreatment extent of disease [PRETEXT]) was developed for the first prospective liver tumor study by the International Society of Pediatric Oncology (SIOPEL-1 study; preoperative chemotherapy and delayed surgery). Study aims were to analyze the accuracy and interobserver agreement of PRETEXT and to compare the predictive impact of three currently used staging systems.
PATIENTS AND METHODS:
Hepatoblastoma (HB) patients younger than 16 years who underwent surgical resection (128 of 154 patients) were analyzed. The centrally reviewed preoperative staging was compared with postoperative pathology (accuracy) in 91 patients (81%), and the local center staging was compared with the central review (interobserver agreement) in 97 patients (86%), using the agreement beyond change method (weighted kappa). The predictive values of the three staging systems were compared in 110 patients (97%) using survival curves and Cox proportional hazard ratio estimates.
RESULTS:
Preoperative PRETEXT staging compared with pathology was correct in 51%, overstaged in 37%, and understaged in 12% of patients (weighted kappa = 0.44; 95% CI, 0.26 to 0.62). The weighted kappa value of the interobserver agreement was 0.76 (95% CI, 0.64 to 0.88). The Children's Cancer Study Group/Pediatric Oncology Group-based staging system showed no predictive value for survival (P = .516), but the tumor-node-metastasis-based system and PRETEXT system showed good predictive values (P = .0021 and P = .0006, respectively). PRETEXT seemed to be superior in the statistical fit.
CONCLUSION:
PRETEXT has moderate accuracy with a tendency to overstage patients, shows good interobserver agreement (reproducibility), shows superior predictive value for survival, offers the opportunity to monitor the effect of preoperative therapy, and can also be applied in patients who have not had operations. For comparability reasons, we recommend that all HB patients included in trials also be staged according to PRETEXT.
Comment in
Predictive value of staging systems in hepatoblastoma. [J Clin Oncol. 2007]
Faecal impaction is frequently observed in children with chronic constipation. The term megarectum is often used to describe this finding.
AIM:
To evaluate rectal functioning and rectal measures in constipated children with a filled rectum, in order to define the terms faecal impaction, enlarged rectum, and megarectum.
METHODS:
All children underwent radiological investigation, colonic transit time study, anorectal manometry, and rectal volume and rectal wall compliance measurements. Patients with faecal impaction were compared with controls, who had an empty rectum on digital rectal examination.
RESULTS:
A total of 31 patients and six controls were included in the study. The mean duration of complaints was 4.2 years and all had faecal incontinence. The colonic transit times in the patients showed a distinct delay in the rectosigmoid segment. Anorectal manometry was not significantly different between patients and controls. The rectal width in patients was 0.68 and in controls 0.52 with an upper limit of 0.61. The pressure-volume curve in patients showed significant less relaxation at a distension of 50 ml. The slope of the curve (corresponding with rectal wall compliance) was comparable for patients and controls.
CONCLUSIONS:
We suggest that faecal impaction is a filled rectum found on digital rectal examination; an enlarged rectum is defined by a rectopelvic ratio greater than 0.61; and megarectum is defined in those with significant abnormalities found with anorectal manometry, pressure-volume curves, or rectal compliance investigation. A diminished relaxation of the rectum on rectal distension could be the first sign of megarectum in children with chronic constipation.
1. Ultrasonography (US) is a valuable tool in the initial evaluation, preoperative assessment, and follow-up of children with abdominal neuroblastoma.
2. Methyl-Iodo-Benzyl-Guanidine (MIBG) scintigraphy, because of its high sensitivity and specificity, is able to detect multiple primaries and distant metastases of neuroblastoma in one single examination.
3. Together with MIBG scintigraphy, US may be the only imaging modality needed in the majority of cases.
4. IVU (intravenous urography) and angiography have no place in the evaluation of children with neuroblastoma.
5. For the assessment of cervical and thoracic neuroblastoma MRI (magnetic resonance imaging) is the method of choice.
6. MRI in general is not indicated in the initial evaluation of children with presumptive abdominal neuroblastoma. MRI is a valuable imaging modality in selected cases, including the preoperative assessment of a dumbbell tumour.
7. MRI should replace metrizamide-CT (computed tomography), metrizamide-CT, and myelography whenever possible.
8. The evaluation of bone marrow involvement by MRI may influence the prognosis.
After nephrectomy for unilateral Wilms' tumor (WT), two potential hazards threaten the remaining kidney. The development of a metachronous WT (2% to 3%), and decrease in renal function after chemotherapy. Our study aims included: (1) to clarify how many WT patients could benefit from partial nephrectomy (PN) without jeopardizing the high cure rate, (2) to establish the function of the kidney remnant, and (3) to test the radiological criteria for preoperative selection of PN candidates.
METHODS:
A retrospective analysis of 90 consecutive cases of histologically verified WT (1982 to 1992) was carried out. Data were studied independently by the surgeon, the radiologist, and the pathologist. The preoperative selection criteria for PN were functioning kidney, tumor confined to upper or lower pole leaving two thirds of the kidney tumor free, and no hilar or vascular structures involved. After PN, renal function was estimated by a calculated creatinine clearance (CC) combined with the assessment of the relative function of each kidney by renal scintigraphy.
RESULTS:
There were 46 boys and 44 girls with median age at diagnosis of 3 years 6 months (range, 3 months to 16 years 7 months). Stage I disease occurred in 40 patients, stage II in 23, stage III in 16, and stage IV occurred in 11 patients. Nearly all patients received preoperative chemotherapy. Radiological analysis of 85 available data sets (5 missing) suggested that PN was possible in 13 patients, and data were inconclusive in two. All 13 patients selected by the radiologist appeared to be in agreement with the pathological criteria for resectability. Of these cases, complete resection by PN was performed in five, could have been possible in retrospect in two, and appeared impossible in six. In two more patients, PN was performed; in both cases the radiologist had predicted PN to be impossible. Median follow-up after PN was 61 months, range, 45 to 167 months. Two patients died of distant metastasis, and no local recurrence occurred. Five are in remission with a median CC level of 110 mL/min, range, 85 to 124. Relative functions of the kidney remnants were 20% to 50%. Contralateral nephrectomy for progressive obstruction was performed in one, but CC level remained normal (85 mL/min). Comparing the preoperative radiological prediction with the combined surgical and pathological findings in a 2 x 2 frequency table, the sensitivity of the radiological findings could be calculated to be 80%, the specificity 97%, and the accuracy 87%.
CONCLUSIONS:
(1) Partial nephrectomy is safe in approximately 10% of Wilms' tumor patients. (2) The function of the kidney remnant remains well, and even permits contralateral nephrectomy. (3) Preoperative imaging shows an accuracy of 87% to predict the possibility for partial nephrectomy.
CONCLUSION:
Congruent results of MIBG scintigraphy and ultrasonography in the detection of abdominal lesions in patients with suspected neuroblastoma indicate a high reliability in the diagnosis and localisation. Due to the favourable results of additional SPECT, it is advisable to perform SPECT routinely in this diagnosis.