A Pediatrician's View
It doesn't seem like very much when it is stated that acute leukemia occurs in 40 out of every 1,000,000 children, Wilms' tumor in approximately 8 per 1,000,000, osteosarcoma in 5 cases per 1,000,000, or rhabdomyosarcoma in 4-4 cases per 1,000,000. But such cases occur from time to time in every pediatric practice and each is a difficult and often traumatic experience for the pediatrician. In my personal practice ot over 50 years, I remember vividly each of my patients who suffered from cancer. I can never forget these children with whom I had developed a warm and close relationship, and 1 can never forget the frantic and terrified parents who leaned on me for hope and support.
The subject is of great importance for all pediatricians, especially in these days when so many children are saved by combination of surgery, radiotherapy, and chemotherapy. It is imperative that the child's physician be capable of recognizing the condition in its early stages, and that he or she have a fair knowledge of modern treatment.
This, the second issue of Pediatric Annals devoted to the subject of cancer, covering Wilms' tumor, rhabdomyosarcoma, osteosarcoma, and neuroblastoma, is under the Guest Editorship of Dr. Carl Pochedly.
It is to be noted that the material presented in this symposium is up-to-date as of December 1987 and comes from leading centers of pediatric oncology in the United States and Canada. Today, such well organized centers of oncology offer superb care to patients affected with cancer as evidenced by the great increase in survivors. The child's pediatrician almost always directs his or her patients to such institutions. However, unfortunately, when a child suffering from a malignancy is referred to and placed under the care of the oncologist, the pediatrician often loses the close contact with the family. And, once the pediatrician is missing, the frantic and bewildered parents miss his or her support and understanding desperately. This support and knowlege of the child's treatment is needed by the child's physician more than ever before. For today, the large majority of cancer patients return home in remission and once again are under the care and supervision of their pediatricians.
The first paper in this second issue discusses "Wilms Tumor" and is presented by Dr. Nathan L. Kobrinsky, Division of Hematology/Oncology, Associate Professor of Pediatrics of the University of Manitoba, Canada and o the Manitoba Cancer Treatment and Research Foundation. Co-authors are Michael Talgoy, MSc, Dr. Bruce Shuckett, and Dr. Hilda Gritter, all of the same institution.
This paper brought back vividly my early days in practice when the diagnosis of Wilms' Tumor was equivalent to a death warrant. Today, as the authors point out, the cure rate is over 80%. The article describes very well the modern treatment responsible for the amazing decline in mortality. This is an excellent article, well written and well illustrated.
The second article deals with the subject of "Rhabdomyosarcoma of Childhood" and has been written by Dr. Jorge A. Ortega, Professor of Pediatrics at the University of Southern California, and Section Head of Clinical Oncology of the Children's Hospital of Los Angeles, and Dr. Marcio H. Malogolowkin, Senior Fellow in Pediatric Oncology at the same institutions.
This malignancy may appear in almost any area in the body, and at times may be difficult to diagnose. Doctors Ortega and Malogolowsky describe the clinical features of this sarcoma and its diagnostic evaluation. They report a marked increase in the survival rate and quote a study from the Children's Cancer Group. In this study of 28 cases, 24 (85%) were relapse free two years after treatment. This is a complete and careful study of a difficult malignancy which to date has no biological markers. The value of early diagnosis is emphasized, followed by excision of the tumor, radiotherapy, and chemotherapy. Problems that remain and future challenges are also presented.
The third contribution in this segment of the symposium deals with "Neuroblastoma." It is written by Dr. Nai-Kong V. Cheung, Associate Attending Pediatrician, and Associate Member of the Memorial Sloan-Kettering Cancer Center in New York City, and Dr. Brian H. Kushner, Clinical Assistant Pediatrician at the same institution.
This is an excellent and careful review of a most interesting and strange tumor that at times may change from a highly malignant state to a benign condition, at times spontaneously, at other times during the course of therapy. The authors take us step-by-step through our present knowledge of this entity presenting the latest information in all important areas. The information is as fascinating as it is valuable. An important section of the article deals with the prognostic factors - and there are many factors besides the age of a child which are of definite prognostic value. A clinical staging system is presented for classifying patients on the basis of physical and surgical findings, imaging studies, and bone marrow status. This is a valuable article and should prove of the greatest value to all pediatricians.
The next article discusses "Osteosarcoma" and comes from the Roswell Park Memorial Institute for Cancer Diagnosis, Treatment and Research in Buffalo, NY. It is written by Dr. Cameron K. Tebbi, Director of the Adolescent Unit of the Department of Pediatrics, and by Dr. John Gaeta of the Department of Pathology.
This highly malignant sarcoma, affecting adolescents primarily, still presents many mysteries. The authors describe 5 major types of osteosarcoma and note that recognition of each type is important since each type has a different prognosis. Early recognition and treatment are urgent to prevent metastases. Therapy is not uniform and, whereas amputation has for years been the primary treatment, a new method of total resection of the tumor is being favored by many as a limb-sparing procedure. Adding to the problems of treatment is the fact that osteosarcoma is a radio-resistant tumor. Chemotherapy is the primary adjunct to surgery. The article ends with a most important section on managing the psychosocial effects which so often follow the drastic treatment of this disease.
The present section of the symposium concludes with remarks by the Guest Editor, Dr. Carl Pochedly, on "Ethical Dilemmas: The Dark Side of Medical Progress. " Dr. Pochedly, who for many years has been closely involved in the field of hematology/ oncology, is Professor of Clinical Pediatrics in the Pritzker School oí Medicine of the University oí Chicago. He is also a member of the Division of Pediatric Hematology/Oncology at the Wyler Children's Hospital and the Kunstadter Children's Hospital at Chicago. He is the Editor of the American Journal of Pediatrics/Hematology/ Oncology. Dr. Pochedly's commentary presents troublesome dilemmas faced by the pediatric oncologist. They should be understood by the child's pediatrician, for only too often he or she must aid the parents in making important decisions suggested by the oncologist. This, once again, emphasizes the need for close cooperation between the child's physician and the specialist caring for the child with cancer.