Pretransplant functional imaging and outcome in pediatric patients with relapsed/refractory Hodgkin lymphoma undergoing autologous transplantation

1 Background

Pretransplant functional imaging (FI), particularly a negative positron emission tomography (PET), is a strong predictor of outcome in adults with relapsed or refractory Hodgkin lymphoma (HL), but data in pediatrics are limited.

2 Methods

The medical records of 49 consecutive pediatric patients, who received autologous transplant at a single institution, were retrospectively analyzed. All patients had either gallium or PET scan before transplant and were conditioned with carmustine, etoposide, cytarabine, and melphalan (BEAM). Deauville scores were retrospectively assigned for patients with PET (score ≥ 4 positive).

3 Results

Of the 49 patients (median age, 16.2 years), 41 (84%) were pretransplant FI negative and eight (16%) were pretransplant FI positive, after first‐ to fourth‐line salvage therapy, and a median of two salvage cycles. Eighteen patients (37%) received posttransplant radiation. At a median follow up of 46 months, 45 patients (92%) were alive and disease free, and there were three nonrelapse deaths and only one relapse death (Deauville score of 5). The 4‐year progression‐free survival (PFS) for the entire cohort was 92% (95% confidence interval [CI]: 78–97), and PFS based on pretransplant disease status was 95% (95% CI: 82–99%) in the negative FI group versus 75% (95% CI: 31–93) if positive FI (P = 0.057).

4 Conclusion

Our analysis revealed outstanding outcomes for children and adolescents with relapsed/refractory HL. There were too few relapses to identify the predictive value of pretransplant metabolic status, but pediatric patients with relapsed/refractory HL and a negative pretransplant FI had excellent survival.     

Utility of FDG-PET/CT in follow-up of children treated for Hodgkin and non-Hodgkin lymphoma

Positron emission tomography using F-flurodeoxyglucose (FDG-PET) is considered an excellent tool for staging and monitoring disease status in adults with lymphoma. We retrospectively reviewed results of PET/CT and diagnostic computed tomography (CT) scans performed during follow-up after completion of therapy in 41 children <18 years of age with Hodgkin lymphoma and non-Hodgkin lymphoma. PET/CT scan with uptake greater than that of the liver was considered positive. Uptake that increased over the background but less than in the liver was equivocal. Clinical outcomes were obtained from medical records. Thirteen (32%) had a positive PET/CT scan and an equal number had equivocal scans in a median follow-up of 2.3 years. Diagnostic CT scans revealed new findings in 13 (32%) and persistent abnormalities in 21 (51%) of the children. Five children developed recurrent disease, and one developed a second cancer. No children with equivocal positivity developed recurrent disease. PET/CT scan was 95% sensitive, with a positive predictive value (PPV) of 53%. Diagnostic CT was 79% sensitive, with a PPV of 52%. We conclude that a negative PET/CT scan during routine follow-up for lymphoma in children strongly suggests absence of recurrence but a positive PET/CT and diagnostic CT scans have low PPV and should be interpreted with caution in this setting.     

Routine use of PET scans after completion of therapy in pediatric Hodgkin disease results in a high false positive rate

PURPOSE: Fluoro-2-deoxy-D-glucose positron emission tomography scans are becoming standard of care in the evaluation of Hodgkin disease (HD). The frequency of false positive (FP) PET scans in pediatric HD after completion of therapy has not been well studied. PATIENTS AND METHODS: All PET scan reports on pediatric HD patients at our institution between February 2000 and February 2005 were retrospectively reviewed. Scans were considered positive if the interpretation was most consistent with malignancy. FP results were determined by pathologic evaluation, resolution on scan, or absence of disease progression over at least 1 year without intervention. RESULTS: We reviewed 255 PET scans on 47 patients, including 156 posttherapy scans on 34 patients. Positive predictive value for scans obtained during routine follow-up was 11%, with an FP rate of 16%. Identifiable etiologies of FP scans included: fibrosis, progressive transformation of germinal centers, abdominal wall hernia, appendicitis, thymus and HIV associated lymphadenopathy. CONCLUSIONS: Routine PET scans after completion of therapy in pediatric HD patients have a low positive predictive value and a high FP rate. Prospective studies are needed to reduce the ambiguity of positive results. In the interim, positive PET scans after treatment should be interpreted cautiously and therapeutic decisions should not be made without histologic confirmation.     

The utility of FDG PET in diagnosis and follow-up of lymphoma in childhood

Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL) are among the most common malignancies of childhood. ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography (PET) can be employed for accurate staging, treatment planning, and response assessment in pediatric patients with lymphomas, taking advantage of the increased FDG uptake of the malignant cells, secondary to their increased metabolic needs. FDG PET has higher sensitivity than other imaging modalities to detect nodular or diffuse lesions and higher sensitivity than bone marrow biopsy to detect bone marrow infiltration. FDG PET consists of an invaluable imaging modality during evaluation and treatment of pediatric lymphomas.     

Radiographic evaluation for suspected cerebrospinal fluid shunt obstruction

OBJECTIVE: To measure the predictive value of plain radiographs (shunt series) and computed tomography (CT) scans in a group of children undergoing evaluation for suspected shunt obstruction in a tertiary care pediatric emergency department (ED). METHODS: Radiology reports were reviewed for all ED patients who underwent a shunt series over an 18-month period. Two investigators categorized all reports as normal, possibly abnormal (eg, kink in shunt tubing, no prior CT scan for comparison), or abnormal (with definite evidence of shunt dysfunction, such as shunt tubing disconnection and increase in ventricular size since prior CT scan). Studies for which there was disagreement were re-read independently by a pediatric radiologist. Medical records were reviewed to determine outcomes. RESULTS: A total of 233 patients had shunt series and CT scans ordered. Of these, 60 patients subsequently required surgery for shunt obstruction. The shunt series revealed abnormalities in 12 patients (sensitivity, 20%; negative predictive value, 22%), whereas CT scans showed definite or possible abnormalities in 50 patients (sensitivity, 83%; negative predictive value, 93%). Combined, the two tests detected 53 shunt obstructions (sensitivity, 88%; negative predictive value, 95%). Two obstructed patients had abnormalities on shunt series that would not have been suspected after physical examination or CT scan. CONCLUSIONS: Over one quarter of pediatric ED patients evaluated radiographically for suspected shunt obstruction required surgical management. One in eight obstructed patients had normal radiographic studies. Routine performance of shunt series had a low overall yield but on rare occasions detected abnormalities that were missed by CT. Prospective studies are needed to improve the use of radiographic tests for shunt evaluation and determine clinical indications for further workup when studies are normal.     

Blunt bowel and mesenteric injuries in children: Do nonspecific computed tomography findings reliably identify these injuries?

OBJECTIVE: Abdominal computed tomography has proven accurate for the detection of pediatric solid organ injuries following blunt abdominal trauma but is less reliable in detecting blunt bowel and mesenteric injuries (BBMI). The purpose of this study was to determine the significance of nonspecific findings on abdominal computed tomography (CT) scan in children at risk for BBMI. DESIGN: Retrospective chart review. SETTING: Regional pediatric trauma center. PATIENTS: All patients who received an abdominal CT scan as part of their evaluation following blunt abdominal trauma over a 10-yr period (September 1991 to September 2001). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Individual records were reviewed by one of the authors and analyzed for age, gender, mechanism of injury, diagnostic studies and procedures, results of initial CT scan, treatment, surgical procedures, complications, and outcome. Patients were excluded if they suffered penetrating trauma, had an abdominal CT scan performed at another institution, had a surgical procedure before CT scan, or had incomplete records. A total of 2,114 patients met inclusion criteria. Sixty-five percent were male and ages ranged from 3 wks to 18 yrs. There were 178 patients who had at least one nonspecific finding on abdominal CT scan suggestive of BBMI; 151 patients had one finding, 24 patients had two findings, and three had three findings. The risk of BBMI increased with the number of nonspecific findings (positive predictive value = 11% with at least one finding and 44% with two or more findings). This increase in positive predictive value, however, was accompanied by a reduction in sensitivity (62% and 37%, respectively). A total of 32 patients had surgically proven BBMI. Of these, eight had a single nonspecific finding on CT scan, ten had two findings, and two had three findings (12 patients had no CT findings suggestive of BBMI). There were complications in four of the 32 patients with BBMI and one death (due to laceration of the superior mesenteric artery). The complications appeared to occur independent of the time to surgical intervention. CONCLUSIONS: The presence of multiple nonspecific findings on abdominal CT scan does not reliably predict BBMI in children. Children also appear to suffer complications from BBMI less frequently than adults, regardless of the time to surgery. Therefore, nonspecific findings alone do not warrant surgical exploration. The decision to operate should instead be based on clinical data that include serial physical examinations.     

PET for staging in rhabdomyosarcoma: an evaluation of PET as an adjunct to current staging tools

BACKGROUND: Complete staging of rhabdomyosarcoma is critical to deliver appropriate therapy. We evaluated the role of F-fluorodeoxyglucose positron emission tomography (PET) in the staging of patients with rhabdomyosarcoma. METHODS: Twenty-four patients with rhabdomyosarcoma had a PET scan during staging evaluation, before or within 13 days of initiation of therapy. PET was compared with computed tomography (CT), magnetic resonance imaging (MRI), bone scan, and pathology. RESULTS: Ninety-six sites were evaluated. All patients had positive PET scans at the primary site. Thirty-one PET positive sites at primary, regional, or distant sites were biopsied. Pathology in all 31 confirmed disease. Standardized uptake value for the primary site at diagnosis ranged from 2.4 to 12.7 (mean 6.4). At 23 sites, CT or MRI was equivocal for the detection of regional or distant spread. In these cases, a negative PET helped to exclude disease in 21 of 23 patients. PET failed to capture sites of disease visualized by CT, MRI, or bone scan at 10 sites. When comparing PET with the final clinical determination of disease extent, PET was 77% sensitive and 95% specific. CONCLUSIONS: These preliminary data indicate that PET is a useful adjunct in staging rhabdomyosarcoma. A prospective study of PET for staging of rhabdomyosarcoma is warranted.     

Liver involvement in pediatric Hodgkin lymphoma: A systematic review by an international collaboration on Staging Evaluation and Response Criteria Harmonization (SEARCH) for Children,Adolescent, and Young Adult Hodgkin Lymphoma (CAYAHL)

Hepatic involvement in Hodgkin lymphoma (HL) is uncommon (～5% of patients) but always implies stage IV disease. Accurate staging is mandatory for making the appropriate risk assignment and treatment decisions. The Staging Evaluation and Response Criteria Harmonization for Childhood, Adolescent and Young Adult Hodgkin Lymphoma (SEARCH for CAYAHL) international working group conducted a systematic literature review of liver involvement in HL patients with the aim to propose a universally acceptable definition for liver involvement in pediatric HL. Thirty‐three articles describing 6985 pediatric and adult HL patients were reviewed, of which 539 (7.7%) mentioned liver involvement. The literature did not provide a uniform definition of hepatic involvement and we propose consensus criteria derived from the EuroNet and Children's Oncology Group protocols, where liver involvement is defined as any hepatic lesion on computed tomography scan that correlates with ¹⁸F‐FDG uptake greater than background liver. A clear definition of liver lesions is necessary to consistently identify liver involvement and compare its impact on outcomes among protocols worldwide.     

F-18 FDG-PET imaging and correlation with CT in staging and follow-up of pediatric lymphomas

Background We hypothesized that F-18 FDG-PET could be a useful, functional imaging modality for assessing the initial staging, response to therapy and follow-up of children diagnosed with lymphoma.Objective To assess the role of whole-body F-18 FDG-PET imaging in patients with lymphoma as an initial staging modality and to measure its predictive value for monitoring the response to therapy and disease recurrence compared to CT and clinical follow-up studies.Materials and methods As part of their routine clinical care, 24 patients with histologically proven lymphoma (18 Hodgkin disease and 6 non-Hodgkin lymphoma) underwent an F-18 FDG-PET and a CT scan. A total of 28 studies were performed and the entire set of scans retrospectively reviewed. Seven studies were performed for initial staging, 12 for monitoring therapy response and 9 for detecting recurrence. Initial diagnosis was confirmed by histopathology while the gold standard at follow-up was established by clinical follow-up, additional imaging modalities and/or biopsy. F-18 FDG-PET was visually compared to CT on a lesion-by-lesion basis. Fifteen anatomic regions (seven nodal and eight extranodal) were analyzed.Results Of the 414 regions analyzed, PET and CT were concordant in 366 (positive in 16 and negative in 350). Discordance was found in 48 regions. Overall sensitivities, specificities, and positive and negative predictive values were 78%, 98%, 94% and 90% for F-18 FDG-PET and 79%, 88%, 90% and 46% for CT, respectively.Conclusion F-18 FDG-PET imaging is a useful technique for the staging and follow-up of pediatric patients with lymphoma.     

Primary mediastinal B‐cell lymphoma in the pediatric patient: Can a rational approach to therapy be based on adult studies?

The literature on adult and pediatric primary mediastinal B‐cell lymphoma (PMBCL) was reviewed and compared. Biologically, adult PMBCL has more similarities to Hodgkin Lymphoma (HL) than diffuse large B‐cell lymphoma (DLBCL). Pediatric studies suggest that the biology is similar to that in adults. Median age of children is 14.3 years and the overall survival (OS) is reported as 78.6% and event‐free survival (EFS) as 67.4%. Adverse prognostic factors included LDH >500 and mass size over 10 cm, with a trend towards better survival in younger patients. Studies in adults show better survival with intensified chemotherapy and the addition of rituximab. Data on the use of radiation therapy show improved CR rates and survival with addition of involved field radiation therapy (IFRT). Positron emission tomography (PET) with computerized tomography (CT) imaging response‐assessment after two courses and at therapy‐end may allow for the rational use of IFRT in pediatric/adolescent patients who are more susceptible to development of adverse late effects. Pediatr Blood Cancer 2009;52:566–570. © 2008 Wiley‐Liss, Inc.     

Pediatric Hodgkin lymphoma: are we over-scanning our patients?

Despite the favorable outcome of most pediatric patients with Hodgkin lymphoma (HL), there is rising concern about risks of carcinogenesis from both diagnostic and therapeutic radiation exposure for patients treated on study protocols. Although previous studies have investigated radiation exposure during treatment, radiation from post-treatment surveillance imaging may also increase the likelihood of secondary malignancies. All diagnostic imaging examinations involving ionizing radiation exposure performed for surveillance following completion of therapy were recorded for 99 consecutive pediatric patients diagnosed with HL from 2000 to 2010. Cumulative radiation dosage from these examinations and the frequency of relapse detection by these examinations were recorded. In the first 2 years following completion of therapy, patients in remission received a median of 11 examinations (range 0-26). Only 13 of 99 patients relapsed, 11 within 5 months of treatment completion. No relapse was detected by 1- or 2-view chest radiographs (n = 38 and 296, respectively), abdomen/pelvis computed tomography (CT) scans (n = 211), or positron emission tomography (PET) scans alone (n = 11). However, 10/391 (2.6%) of chest CT scans, 4/364 (1.1%) of neck CT scans, and 3/47 (6.4%) of PET/CT scans detected relapsed disease. Thus, only 17 scans (1.3%) detected relapse in a total of 1358 scans. Mean radiation dosages were 31.97 mSv for Stage 1, 37.76 mSv for Stage 2, 48.08 mSv for Stage 3, and 51.35 mSv for Stage 4 HL. Approximately 1% of surveillance imaging examinations identified relapsed disease. Given the very low rate of relapse detection by surveillance imaging stipulated by current protocols for pediatric HL patients, the financial burden of the tests themselves, the high cure rate, and risks of second malignancy from ionizing radiation exposure, modification of the surveillance strategy is recommended.     

18-FDG-PET-findings in children and adolescents with Hodgkin's disease: retrospective evaluation of the correlation to other imaging procedures in initial staging and to the predictive value of follow up examinations

Today no evidence based medicine analyses exist about the value of positron emission tomography (PET) in children and adolescents with Morbus Hodgkin. The increasing number of registered PET-examinations within the scope of the GPOH-HD 95 trial motivated to analyse the validity of 18-FDG-PET-examination findings in comparison to the conventional diagnostic methods (CT/MRI/ultrasound) and to the patients follow up. 67 PET-primary staging findings and 48 PET-follow up findings of altogether 106 patients from 27 PET-centres were analysed. Concerning the primary staging findings a concordance of 92% of the PET-findings and the findings of the CT/MRI/ultrasound-examinations per localisation was found, but in more than 50% of the patients a discrepancy occurred in at least one of the 9 investigated localisations. The analysis of the PET follow up findings showed a negative predictive value of 94% in regularly examinations (without previous suspicion of relapse), but only a positive predictive value of 25%. In case of relapse suspicion there was a negative predictive value of 83% and a positive predictive value of 76% in PET. A good prognosis is possible to predict from negative PET follow up findings (relapse risk in regularly controls 7%, at relapse suspicion 17%), whereas the probability for a true relapse in positive PET follow up findings is only markedly increased in case of former relapse suspicion (relapse risk in regularly controls 25%, at relapse suspicion 82%). A prospective multicenter PET study should be realized to analyse systematically the value of PET diagnostics in staging and restaging examinations of children and adolescents with Hodgkin's disease, especially to validate the PET diagnostics in exclusion of vital tumor residuals.     

Identification of Coronary Artery Disease in the Pediatric Cardiac Transplant Patient

Little data exist to identify pediatric patients who have developed transplant coronary artery vasculopathy (CAV). Transplant patients do not exhibit the usual signs of coronary disease, making diagnosis more difficult. The aim of this study is to assess the use of myocardial perfusion imaging to identify CAV in transplant patients and to derive an incidence of occurrence. We studied pediatric cardiac transplant recipients who have undergone myocardial perfusion imaging on a routine basis. All patients from September 1999 through November 2004 with nuclear perfusion scans were included. Twenty patients age 7–24 years (mean: 12.7), 11 male and 9 female, were studied by SPECT technetium 99M tetrofosmin imaging. Sixteen of the 20 patients were studied based on a newly instituted protocol for surveillance. Transplant was 1–14 years (mean: 7.9) earlier. Patients were also studied by stress echocardiography. Six of 20 patients (30%) had a positive perfusion scan. Ages ranged from 8 to 18 years (mean: 12). Time from transplant to positive scans ranged from 1 to 9 years (mean: 5.6). One patient showed the same perfusion defect as 2 years earlier. Five patients with positive nuclear perfusion scans showed the abnormality on the initial study; one had a previous negative study 6 months earlier. Four patients who demonstrated ischemia with exercise showed resolution at rest; the other two had no resting study. Five of these six patients with abnormal perfusion scans had negative stress echocardiograms. Only one patient identified with coronary involvement reported symptoms (exertional dyspnea). Hypertension and rejection episodes were similar in all patients and in those with positive nuclear scans. Of the six patients with positive nuclear perfusion scans, two demonstrated coronary disease at cardiac catheterization. Two patients with coronary disease at catheterization had normal nuclear perfusion scans; one of two had a normal stress echo. When three imaging modalities were used, the incidence of CAV was 30%. Symptoms in pediatric patients with CAV are seldom reported. Unfortunately, coronary arteriopathy occurs frequently and might be found as early as 1 year posttransplant. Six of 20 patients had abnormal perfusion; only 1 had any other noninvasive marker. Importantly, not all patients with CAV were identified by perfusion imaging, stress echocardiography, or coronary injection alone. Therefore, transplant patients need continued evaluation by multiple modalities for detection of developing coronary lesions.     

A comparison between ultrasonography and single-phase computed tomography for preoperative assessment of solid abdominal tumors in children

ObjectiveThis study aimed to estimate the performance of single-phase-enhanced computed tomography and ultrasonography examinations in the preoperative evaluation of solid abdominal tumors and their relationship with relevant adjacent structures in children.MethodsThis retrospective study included 50 pediatric patients with malignant solid abdominal tumors treated with surgical resection between 2009-2017. Preoperative computed tomography and ultrasonography were compared to operative findings (gold standard) in the diagnosis of invasion or encasement of adjacent structures. Accuracy, sensitivity, specificity, and positive and negative predictive values were evaluated.ResultsRenal (20.4%) and neuroblastic (19.4%) tumors were the most common. Complete surgical resection with negative margins was achieved in 44 (88%) patients. The comparison between single-phase-enhanced computed tomography and ultrasonography findings showed the following results: sensitivity = 90.3% vs 86.6%, specificity = 86.8% vs 94.6%, negative predictive value = 95.3% vs 94.4%, positive predictive value = 75.3% vs 86.9%, and accuracy = 87.9% vs 92.2%. The correlation (kappa index) between computed tomography and ultrasonography examinations was 0.72 (p < 0.001). In 14% (7/50) of the patients, the invasion of adjacent structures was diagnosed by ultrasonography but not by computed tomography (1 patient had 2 invaded structures).ConclusionUltrasonography can be considered a complementary method to single-phase-enhanced computed tomography in the preoperative evaluation of children with an abdominal tumor. The present study showed that ultrasonography and single-phase-enhanced computed tomography each possess a high accuracy in the preoperative planning of resection of solid abdominal tumors in children. Thus, it seems that the combination of both imaging methods would be enough for the evaluation of most abdominal tumors in the pediatric population.     

The value of 18F‐FDG PET in pediatric patients with post‐transplant lymphoproliferative disorder at initial diagnosis

PTLD is a serious complication of both solid organ and BMT. This study assessed whether ¹⁸F‐FDG PET, when added to CT scan, had additional value in the initial evaluation of PTLD in pediatric patients and whether PET/CT at baseline can reliably guide biopsy. This retrospective study evaluated 34 consecutive pediatric patients (14 female), aged 3.5–17.0 yr (mean age: 9.9 yr, s.d.: 4.9 yr), who had undergone ¹⁸F‐FDG PET/CT from May 2007 to December 2014 at initial diagnosis of PTLD following heart (n = 13), lung (n = 8), kidney (n = 4), liver (n = 3), liver and bowel (n = 3), and bone marrow (n = 3) transplantation. PTLD was diagnosed histopathologically in 33 patients and was based on clinical findings, elevated EBV, and imaging and follow‐up results in one patient. On lesion‐based analysis, ¹⁸F‐FDG PET showed more lesions than conventional CT scan (168 vs. 134), but CT revealed 22 lesions negative on PET. On per patient analysis, PET detected more lesions in 13 patients, CT identified more abnormalities in seven, and both showed the same number of lesions in 14. Adding ¹⁸F‐FDG PET to CT scans upstaged the disease in seven patients (20.5%). A combination of ¹⁸F‐FDG PET and CT was also useful in guiding biopsy, being positive in 36 of 39 samples (92.3%). These findings indicated that ¹⁸F‐FDG PET and CT are complementary at initial staging of pediatric PTLD and that ¹⁸F‐FDG PET/CT scanning can guide biopsies.     

Early interim FDG PET/CT prediction of treatment response and prognosis in pediatric Hodgkin disease—added value of low-dose CT

Background

Interim 18F-FDG PET helps predict outcome and tailor treatment in adults with Hodgkin disease (HD).

Objective

The purpose of this study was to assess predictive values of interim 18F-FDG PET/CT in children with HD and to define the potential added value to interim PET of low-dose CT.

Materials and methods

Children were prospectively enrolled August 2002–April 2007. PET/low-dose CT was performed at staging, after 2 cycles, at the end of treatment and during follow-up (mean 45 months). Treatment was unchanged regardless of interim results. PET and low-dose CT were read independently.

Results

Of 34 enrolled children (ages 3–17 years), 27 achieved complete response, 4 had progressive disease and 3 had relapse. Interim PET alone had positive and negative predictive values of 67% and 89%, respectively. Interim low-dose CT alone had positive and negative predictive values of 35% and 100%, respectively. Interim PET/CT had positive and negative predictive values of 75% and 96%, respectively.

Conclusions

Early interim PET/CT was a good predictor of outcome. Integrated PET and low-dose CT improved the predictive value in children with HD.     

Preliminary Data on the Diagnostic Accuracy of Rubidium-82 Cardiac PET Perfusion Imaging for the Evaluation of Ischemia in a Pediatric Population

Evaluation of myocardial perfusion is sometimes necessary in children with congenital heart disease or acquired coronary artery abnormalities. Limited information is available regarding the clinical utility of myocardial perfusion imaging in children. PET imaging with rubidium-82 may provide a convenient clinical means of assessing regional circulatory compromise in pediatric patients with small hearts, due to its improved spatial resolution. Clinically indicated cardiac PET studies obtained in 22 pediatric patients were reviewed by two blinded observers and assigned myocardial perfusion scores using a standard 17-segment model. PET results were correlated with coronary angiography, available in 15 cases, to determine the accuracy of PET scanning for evaluating compromise of the myocardial circulation. Reversible defects consistent with myocardial ischemia were present in 6 of 15 (40%) PET cases. The sensitivity and specificity of cardiac PET for the detection of significant coronary artery disease were 100% and 82%, respectively. The positive predictive value of cardiac PET was 67%, while the negative predictive value was 100%. Cardiac PET imaging with rubidium-82 appears promising for the noninvasive assessment of myocardial perfusion in the pediatric population. The findings from this small series suggest that prospective study in a larger patient cohort merits consideration.     

Predicting major adverse events after cardiac surgery in children

OBJECTIVES: To develop a reliable predictor of major adverse events after pediatric cardiac surgery, with the aim of reducing mortality of cardiac extracorporeal life support through earlier, more accurate patient selection. DESIGN: Prospective observational study. SETTING: Tertiary level pediatric intensive care unit. PATIENTS: Fifty-two children undergoing open heart surgery considered above-average risk based on preoperative assessment. INTERVENTIONS: None; strictly observational study. MEASUREMENTS AND MAIN RESULTS: A wide range of measurements was made at 3, 6, 9, 12, and 24 hrs after surgery, including: oxygen consumption, central venous pressure and oxygen saturation (Scvo2), cardiac output (Fick), heart rate, arterial pressure, arterial lactate, urine output, core-toe temperature gradient, and derived hemodynamic variables. Six children had major adverse events; three needed extracorporeal life support, two died. There were no correlations between routine postoperative measurements (blood pressure, pulse, temperature gradient, central venous pressure) and any measure of cardiac function, and neither group of variables predicted adverse outcomes. Lactate (>8 mmol/L) and Scvo2 (<40%) had high sensitivity (both 73.7%) and specificity (96.3% and 95.4%, respectively), for predicting major adverse event but positive predictive values for both were low (63.6% and 58.3%, respectively). The ratio of the two had better predictive power than the individual values. When the ratio (Scvo2, %)/(lactate, mmol/L) fell below 5, the positive predictive value for major adverse event was 93.8% (sensitivity 78.9%, specificity 90.5%). The effect was present at all postoperative time points. CONCLUSIONS: Lactate and Scvo2 are the only postoperative measurements with predictive power for major adverse events. Forming a ratio of the two (Scvo2/lactate), seems to improve predictive power, presumably by combining their individual predictive strengths. Both measures have excellent specificities but lower sensitivities. Predictive power of single measures is only fair but can be improved, in high risk patients, by monitoring repeated measures over time.     

血浆β-葡聚糖检测儿童侵袭性真菌感染早期诊断价值探讨

目的:随着免疫受损个体生存期的延长,侵袭性真菌感染（invasive fungal infection, IFI）发病率持续上升。本研究目的在于了解儿童真菌感染高危人群并发IFI的发病情况,评价血液1,3-β-D葡聚糖(1,3-β-D-glucan, BG)（G试验）诊断价值。方法:选择2007年11月至2008年6月在我院儿童ICU、血液肿瘤科住院治疗的持续发热4~7 d以上高危感染患儿进行G试验;每周检测1～2次,直至症状好转,或排除真菌感染,或死亡。G试验采用GKT-5M Set动态真菌检测试剂盒检测,阳性定义为血浆BG水平≥10 pg/mL。结果:① 共计130例入选研究。确诊IFI（proven）2例,均为念珠菌血症。临床诊断（probable）20例,拟诊（possible）7例,排除101例;② IFI组住院天数较非IFI组延长（P＜0.05）,不良预后率明显增加（P＜0.05）;③ IFI组血浆BG水平高于非IFI组(P＜0.01）。G试验诊断敏感度81.8%,特异度82.4%,阳性预测值48.6%,阴性预测值95.7%;④72.2% 病例G试验阳性结果较培养或影像学阳性结果提前或同时发生。结论:儿童高危患者IFI不少见。血液G试验无衡量标准有助于高危患者的筛查,具有早期辅助诊断、指导合理治疗干预的价值。［中国当代儿科杂志,2009,11（11）：905-908］     

Long‐term outcomes of pediatric kidney transplant recipients with a pretransplant malignancy

A childhood malignancy can rarely progress to ESRD requiring a KT. To date, few reports describe long‐term outcomes of pediatric KT recipients with a pretransplant malignancy. Between 1963 and 2015, 884 pediatric (age: 0‐17 years old) recipients received 1055 KTs at our institution. KT outcomes were analyzed in children with a pretransplant malignancy. We identified 14 patients who had a pretransplant malignancy prior to KT; the majority were <10 years old at the time of KT. Ten (71%) patients received their grafts from living donors, the majority of which were related to the recipient. Wilms' tumor was the dominant type of pretransplant malignancy, seen in 50% of patients. The other pretransplant malignancy types were EBV‐positive lymphoproliferative disorders, non‐EBV‐positive lymphoma, leukemia, neuroblastoma, soft‐tissue sarcoma, and ovarian cancer. Ten of the 14 patients received chemotherapy as part of their pretransplant malignancy treatment. Graft survival at 1, 3, and 5 years was 93%, 83%, and 72%, respectively. Patient survival at 1, 5, and 10 years was 100%, 91%, and 83%, respectively. Six (40%) patients suffered AR following KT; half of them had their first episode of AR within 1 month of KT. Our single‐center experience demonstrates that pediatric KT recipients with a previously treated pretransplant malignancy did not exhibit worse outcomes than other pediatric KT patients.