Recurrent giant juvenile fibroadenoma

Breast masses in children, though rare, present a difficult clinical challenge as they can represent a wide variety of entities from benign fibroadenomas to phyllodes tumors. Rapidly growing or recurrent masses can be particularly concerning to patients, families and physicians alike. Clinical examination and conventional imaging modalities are not efficacious in distinguishing between different tumor types and surgical excision is often recommended for both final diagnosis and for treatment of large or rapidly growing masses. While surgical excision can result in significant long-term deformity of the breast there are some surgical techniques that can be used to limit deformity and/or aid in future reconstruction. Here we present a case of recurrent giant juvenile fibroadenoma with a review of the clinical presentation, diagnostic tools and treatment options

Surgery for Rectal Cancer Performed at Teaching Hospitals Improves Survival and Preserves Continence

We sought to compare the outcomes of teaching and community hospitals on long-term outcomes for patients with rectal cancer. All rectal adenocarcinomas treated in Florida from 1994 to 2000 were examined. Overall, 5,925 operative cases were identified. Teaching hospitals treated 12.5% of patients with a larger proportion of regionally advanced, metastatic disease, as well as high-grade tumors. Five- and 10-year overall survival rates at teaching hospitals were 64.8 and 53.9%, compared to 59.1 and 50.5% at community hospitals (P = 0.002). The greatest impact on survival was observed for the highest stage tumors: patients with metastatic rectal adenocarcinoma experienced 5- and 10-year survival rates of 30.5 and 26.6% at teaching hospitals compared to 19.6 and 17.4% at community hospitals (P = 0.009). Multimodality therapy was most frequently administered in teaching hospitals as was low anterior resection. On multivariate analysis, treatment at a teaching hospital was a significant independent predictor of improved survival (hazard ratio = 0.834, P = 0.005). Rectal cancer patients treated at teaching hospitals have significantly better survival than those treated at community-based hospitals. Patients with high-grade tumors or advanced disease should be provided the opportunity to be treated at a teaching hospital

Bariatric Surgery to Reverse Metabolic Syndrome in Adolescents

Adolescent obesity is a public health crisis with serious immediate and long-term health consequences. Currently, prevention is the best solution, but this may prove difficult in a world with a growing epidemic of childhood obesity. Bariatric surgery is the only proven intervention that provides sustained weight loss as well as improvement and resolution of obesity-related comorbidities. Prior to any surgical intervention, patients must go through a comprehensive evaluation phase. Available procedures are either restrictive or malabsorptive, with the most common being the Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding. With the advent of laparoscopy, hospital stays have become short, but postoperative complications can still occur. The risks and benefits of operating on these obese adolescents with multiple comorbid conditions must be weighed and thoroughly discussed with patients and their families. According to published studies, there is a proven benefit to obese adolescents, even though most patients do not reach their ideal body weight. Almost all experience an improvement or resolution of comorbid conditions such as metabolic syndrome, diabetes, hyperlipidemia, hypertension, and sleep apnea. These results could have significant, long-lasting benefits on the adolescent patient. Given the young age of these patients, there should be an emphasis on a multidisciplinary approach in their treatment in order to improve compliance. Bariatric surgery appears to be the most effective means of achieving sustained weight loss with improvement or resolution of obesity-related comorbidities in the adolescent population

Percutaneous retropleural drainage of a posttraumatic pancreatic mediastinal pseudocyst in a child

Pancreatic mediastinal pseudocyst is a rare complication of pancreatitis in children. These children usually present with abdominal pain, anorexia, vomiting, and dysphagia. Computed tomography not only is essential in defining the extent of the pseudocyst but also can guide percutaneous external drainage. We present the case of a 4-year-old child with a mediastinal pseudocyst secondary to pancreatic trauma, which was successfully treated with computed tomography–guided percutaneous drainage via a posterior, extrapleural approach

Primary gastrointestinal tract lymphoma in the pediatric patient: review of 265 patients from the SEER registry

The objective of this study is to determine outcomes of pediatric patients with primary gastrointestinal tract lymphoma (PGTL) and the impact of surgery or radiation on survival. The Surveillance, Epidemiology, and End Result database was queried from 1973 to 2006 for patients younger than 20 years with PGTL. 265 patients with PGTL were identified. Overall 5- and 10-year survivals were 84% and 83%, respectively. Tumors of the stomach (9%) and rectum/anus (2%) had the worst and best 10-year survivals, respectively (59% vs 100%, P = .023). There was no significant difference in 10-year survival for patients younger than 10 years of age who had surgical extirpation (83% vs 85% no surgery, P = .958) or radiotherapy (76% vs 85% no radiotherapy, P = .532). However, there was a significantly decreased 10-year survival in patients 10 years or older who had surgical extirpation (79% vs 100% no surgery, P = .013) or radiotherapy (49% vs 87% no radiotherapy, P = .001). Under multivariate analysis, tumor location was an independent predictor of improved survival (small bowel, HR 0.21, P = .002; large bowel, HR 0.23, P = .004). We found no significant survival advantage for surgical extirpation or radiotherapy in patients younger than 10 years with PGTL, whereas either treatment modality was associated with lower survival in patients 10 years or older

Rhabdomyosarcoma in Children: A SEER Population Based Study

To examine incidence and outcomes for pediatric rhabdomyosarcoma (RMS). The SEER registry was examined for patients with RMS < 20 y old. Overall, 1544 patients were identified for an incidence of 0.4414/100,000 per year. Males outnumbered females 3:2. Tumors were classified as embryonal (67%), alveolar (32%), and pleomorphic (1%). Alveolar and pleomorphic RMS were more common in adolescents, whereas embryonal type was more common in younger children ( P = 0.0001). Pleomorphic (47%) and alveolar (39%) RMS commonly presented with distant disease, in contrast to embryonal (25%). Most patients had surgical resection (81%) and radiotherapy (63%). Overall, 5- and 10-y survival was 60% and 57%, respectively. Univariate analysis identified higher survival for age < 10 y, local stage, favorable site, embryonal type, <5 cm tumor size, and surgical resection. Multivariate analysis identified non-embryonal type (HR 1.451), non-favorable site (HR 1.570), no surgery (HR 1.726), age ≥ 10 y (HR 1.734), 1973–1978 diagnosis year (HR 1.730), and distant disease (HR 3.456) as independent predictors of mortality. Embryonal histology, the most common type of pediatric RMS, presents in young children and has better prognosis than alveolar or pleomorphic types. Patients with embryonal tumors, favorable tumor location, age < 10 y, localized disease, and surgical resection have improved survival

Continent ileocolonic urinary reservoir (Miami pouch): the University of Miami experience over 15 years

A patient with a recurrent central pelvic malignancy after radiation will require urinary diversion as part of the reconstructive phase of the pelvic exenteration. The aim of our study was to assess the result of our 15-year experience with a continent ileocolonic urinary reservoir, which is known as the Miami pouch. Since 1988, all patients who received a continent ileocolonic urinary reservoir in the Division of Gynecologic Oncology, University of Miami School of Medicine, were included in the study. Parameters that were evaluated during the study period include functional outcomes, early and late perioperative complications, and their treatment. A total of 90 patients were identified from February 1988 to December 2002. Seventy-eight patients (87%) had a recurrent central pelvic malignancy, and 82 patients (91%) received radiation before the Miami pouch procedure. The non–reservoir-related morbidities were fever (76%), wound complication (30%), pelvic collection (12%), ileus/small bowel obstruction (12%), and postoperative death (11%). The most common reservoir-related complications were urinary infection (40%), ureteral stricture (20%), and difficulty with self-catheterization (18%). In our study, the overall complication rate that was related directly to the Miami pouch was 53%. Conservative treatment resolved>80% of these cases. The rate of urinary continence that was achieved in our patients was 93% during our 15-year experience with the Miami pouch. The Miami pouch is a good alternative for continent urinary diversion during exenteration or radiation-induced damage. The rate of major complications that require aggressive surgical intervention is acceptable. Most postoperative complications (80%) can be corrected with the use of conservative techniques that are associated with fewer deaths than reoperation and thus should be used first. The technique is simple and effective in women who are at high risk, who have undergone previous radiation therapy, and who have a high rate of functional success and is a profound advantage for a woman's psychosocial well-being