Teratomas of the neck and mediastinum in children

International Abstracts of Pediatric Surgery treatment options for Graves disease. The 3 treatment modalities for treating Graves disease are antithyroid drugs, radioactive iodine therapy, and surgery. Interestingly, in the United States, 70% of endocrinologists recommend radioiodine treatment as first-line treatment, whereas in Europe, 77% of endocrinologists would use antithyroid drugs. Only 1% in either would recommend surgery as the primary mode of therapy. Most patients treated with antithyroid drugs become euthyroid within 6 weeks, and almost all patients are euthyroid by 3 months. The remission rate after 1 year of treatment is 50% to 60%, and after 10 years, only 30% to 40%. With radioactive iodine, 70% of patients become euthyroid within 4 to 8 weeks, but it can take up to 6 months to see the full effect of a dose of radioactive iodine. The risk of developing hypothyroidism is 20% in the first year and increases 3% to 5% per year thereafter, such that most patients eventually become hypothyroid. Many endocrinologists are hesitant to treat patients younger than 20 years of age with radioactive iodine because of concerns about carcinogenesis. No studies have as yet shown an increased risk of thyroid cancer or other malignancies with the use of I-131 in children. Surgery tends to be indicated for younger patients, especially children, where medical treatment has a failure rate up to 80%. Men with Graves disease also have a lower remission rate than women after radioactive iodine and therefore are candidates for surgery. Surgery is also the treatment of choice for pregnant women whose hyperthyroidism is not easily controlled with antithyroid drugs. In addition, women have been advised against breast-feeding while taking antithyroid drugs; hence, women who wish to continue breast-feeding should be considered for surgery. If surgery is to be used, it is important to restore a euthyroid state before the operation to avoid the potential of precipitating a thyroid storm during surgery. This can be done with antithyroid drugs, b-blockers, and saturated solution of potassium iodine to decrease the vascularity of the thyroid gland. There is still controversy as to whether to perform a subtotal thyroidectomy or a total thyroidectomy. There is a risk of recurrent hyperthyroidism after a subtotal thyroidectomy, depending upon the amount of gland left behind, whereas this risk is essentially eliminated after a total thyroidectomy. A recent metaanalysis has found that a total thyroidectomy is as safe as a subtotal thyroidectomy with respect to the complications of hypoparathyroidism and recurrent laryngeal nerve injury. The authors favor a total thyroidectomy for treatment of Graves disease because it can be performed with the same morbidity and mortality as a subtotal thyroidectomy, and it avoids the need for subsequent operations or treatments that carry a higher risk of complications.—Richard R. Ricketts doi:10.1016/j.jpedsurg.2007.03.005

Thorax Teratomas of the neck and mediastinum in children Martino F, Avila LF, Encinas JL, et al. Pediatr Surg Int 2006 (August); 22:627 - 634 Teratomas are often located in the sacrococcygeal region and the ovary but rarely in the neck and mediastinum. They may give rise to neonatal respiratory distress. Prenatal diagnosis is the key for relief of perinatal airway obstruction before spontaneous breathing. Over 10 years, 5 teratomas of the neck and 6 of the mediastinum were treated. Three of 5 newborns with cervical teratoma, 3 had prenatal diagnosis, and 4 of 5 were born by cesarean delivery. All had severe respiratory distress at birth and needed intubation (one ex utero intrapartum treatment), but one could not be intubated after emergency cesarean delivery and died. Computed tomography (CT) or magnetic resonance imaging were followed by removal of the tumor at a mean age of 8.7 days through large transverse, right or left cervicotomy, dissecting mediastinal extension retrosternally from above. Anatomic structures were not invaded and could be secured. The origin of the tumor was the thyroid (3) or the thyroid (1), with the tissue being immature (3) and mature only once. One child needed secondary surgery for enlarged nodes along the jugular vein. The a

1307 fetoprotein levels were 6500 to 125,000 ng/mL, all normalized at the end of surgical therapy. Two patients showed hypothyroidism, one partial tongue atrophy and one asymmetry of the jaw. The age of the 6 patients with mediastinal teratoma ranged from newborn to 17 years. Except for one newborn with prenatal ultrasound diagnosis, presenting features were pain, mild respiratory distress, or incidental finding. After CT, removal of neoplasm via median sternotomy, left or right thoracotomy in 5 children and thoracoscopically in 1 was performed. A total of 5 tumors were mature, and 1 immature, which originated from the thymus (5) or pericardium. One patient had postoperative left recurrent nerve palsy. Cervical teratomas cause difficult labor and severe airway problems after birth. Often diagnosed in utero, cesarean delivery is preferred, and ex utero intrapartum treatment should be planned. Magnetic resonance imaging and CT contribute essential preoperative information, and a fetoprotein (relapse or metastasis) and thyroid hormones need postoperative control. Overall, 33% of patients die mostly from respiratory compromise. Mediastinal teratomas are characterized by vague symptoms and are often diagnosed incidentally. Surgical excision is the treatment of choice, and prognosis following complete resection is excellent.—Peter Schmittenbecher doi:10.1016/j.jpedsurg.2007.03.006

Lytic rib lesion in a 1-year-old child: group A beta streptococcal osteomyelitis mimicking tumor Naik-Mathuria B, Ng G, Olutoye OO. Pediatr Surg Int 2006 (October); 22:837 - 839 Acute hematogenous osteomyelitis primarily occurs in the highly vascular metaphyses of long bones with a prevalence of 1:5000 children and 1:1000 newborns. Osteomyelitis is uncommon in smaller bones, and rib osteomyelitis occurs in less than 1% of all cases. In small bones, onset is more insidious, diagnosis may be difficult, and misdiagnosis as malignancy is possible. A 1-year-old male infant presented with complaints of right chest wall without history of trauma. He was afebrile, and leukocyte count was normal. Chest radiograph revealed splaying of the right eighth rib, computed tomography showed an expansive lytic lesion; malignancy was suspected, and biopsy was performed. Beta Streptococcus group A was cultured from the biopsy, and morphological examination was consistent with osteomyelitis. After a 28-day course of intravenous cefazolin, the child recovered well. Ewing sarcoma may present with a very similar clinical profile to osteomyelitis. The incidence of rib Ewing sarcoma is reported as 10%, and lytic lesions predominate in 82%. On the other hand, rib osteomyelitis by streptococcal species is extremely rare and reported in 4 cases only. The case is presented to promote awareness of this difficult differential diagnosis in small children.—Peter Schmittenbecher doi:10.1016/j.jpedsurg.2007.03.007

Extracorporeal membrane oxygenation in infants with congenital diaphragmatic hernia: a systematic review of the evidence Morini F, Goldman A, Pierro A. Eur J Pediatr Surg 2006 (December);16/6: 385 - 391 The aim of this study was to evaluate the evidence supporting the use of extracorporeal membrane oxygenation (ECMO) in infants with congenital diaphragmatic hernia and severe respiratory failure. Several databases were searched using a defined strategy. Case reports and opinion articles were excluded. The authors performed a systematic review of nonrandomized studies comparing mortality when ECMO was not available with a period when ECMO was available. Mortality was classified as bearlyQ (before hospital discharge) and blateQ (after discharge). Patients