annals 1-2.qxd - Centrum Zdrowia Dziecka

This issue includes the proceedings of the 

6th SYMPOSIUM 

Progress in Molecular Diagnosis and Treatment 

of Genetic Based Pediatric Malignancies 

and 

3rd SYMPOSIUM 

of Historical Section PAPS 

9–10 june 2006 

Zegrze, Poland 

The symposium is held under scientific supervision of Polish Union of Oncology 

With medial support of Polish Regional Television TVP3 

and press support of „Konsyliarz” magazine

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Annals of Diagnostic Paediatric Pathology 

Official Journal of the Polish Paediatric Pathology Society 

and Section of Oncological Surgery of Polish Association of Paediatric Surgeons 

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The journal is supported by the State Committee for Research. 

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The Annals of Diagnostic Paediatric Pathology is an international peer−reviewed journal. The focus of the journal is current progress in 

clinical paediatric pathology in both basic and clinical applications. Experimental studies and clinical trials are accepted for publication, 

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© Copyright by Polish Paediatric Pathology Society, 2001 

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Official Journal of the Polish Paediatric Pathology Society 

and Section of Oncological Surgery of Polish Association of Paediatric Surgeons 

Volume 10 Number 1–2 Summer 2006 

CONTENTS 

Review 

paper 

Original 

papers 

Pathogenesis and clinical manifestation of celiac disease: analysis of atypical symptoms . . 7 

Bo¿ena Cukrowska, Barbara Burda-Muszyñska, Maria Zegad³o-Mylik, Jerzy Socha 

Polyoma BK virus nephropathy in children after kidney transplantation . . . . . . . . . . . . . . 13 

Przemys³aw Kluge, Ewa Œmirska, Sylwester Prokurat, Agnieszka Perkowska, Bo¿ena Cukrowska 

Primary malignant liver cell tumours in children – different treatment strategies . . . . . . . 17 

Andrzej Igor Prokurat, Ma³gorzata Chrupek, Roman KaŸmirczuk, Przemys³aw Kluge, Andrzej Koœciesza, 

Pawe³ Rajszys, El¿bieta Dzik, Arthur Zimmermann 

Utilization of internal sphincter in the reconstruction of anorectal malformations 

in girls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 

Andrzej Igor Prokurat, Ma³gorzata Chrupek, Roman KaŸmirczuk, Przemys³aw Kluge 

Comparison of histological changes in liver biopsy specimens in patients 

with biliary atresia of poor and good prognosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 

Joanna Cielecka-Kuszyk, Piotr Czubkowski, Ludmi³a Bacewicz, Joanna Paw³owska, Irena Jankowska, 

Tamara Szymañska-Dêbiñska 

The impact of probiotic Lactobacillus casei and paracasei strains on cytokine profile 

in children with atopic dermatitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 

Ilona Rosiak, Urszula Witos³aw, Aldona Ceregra, El¿bieta Klewicka, Ilona Motyl, Zdzis³awa Libudzisz, 

Bo¿ena Cukrowska 

Case 

report 

Paraganglioma associated with neuroblastoma: rare composite tumor 

in a 16-year-old girl . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 

Przemyslaw Galazka, Malgorzata Chrupek, Roman Kazmirczuk, Jaroslaw Peregud-Pogorzelski, 

Malgorzata Pacholska, Grzegorz Meder, Przemyslaw Kluge, Zdzislaw Skok, Krzysztof Kusza 

and Andrzej Igor Prokurat 

Program Case of the Symposium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 

reports 

Abstracts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

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Annals of Diagnostic Paediatric Pathology 2006, 10(1–2):7–12 

© Copyright by Polish Paediatric Pathology Society Annals of 

Pathogenesis and clinical manifestation of celiac disease: 

analysis of atypical symptoms 

Bo¿ena Cukrowska 1 , Barbara Burda-Muszyñska 2 , Maria Zegad³o-Mylik 1 , Jerzy Socha 2 

Diagnostic 

Paediatric 

Pathology 

1 


2 

Department of Gastrology, Hepatology and Immunology 


Warsaw, Poland 

Abstract 

Celiac disease is defined as enteropathy occurring after ingestion of gluten from cereals in genetically 

predisposed individuals. Recently, after introduction of sensitive and specific screening tests, the increase 

in prevalence of celiac disease has been observed. The celiac disease incidence of 1:100 – 1:300 is similar 

in Europe, United States, Australia and Asia. Still, a lot of celiac patients is undiagnosed. Difficulties in 

diagnosis are caused by the changes of clinical features of the disease into atypical and the occurrence of 

illness in older children and adults. In this review pathogenetic factors playing role in atypical celiac disease 

have been shown, intestinal and non-intestinal symptoms of disease, and risk groups, in which screening 

tests should be done, have been presented as well. 

Key words: celiac disease, gluten, screening tests, atypical symptoms, risk groups 

Introduction 

Celiac disease (CD) is an immune-mediated enteropathy caused 

by a permanent sensitivity to gluten, i.e. a protein present 

in cereals, occurring in genetically susceptible individuals, 

in whom ingestion of gluten induces typical changes in 

small intestine mucosa [16]. The development of reliable serological 

screening tests has dramatically increased our awareness 

of CD as a common condition. The prevalence of CD 

in a healthy population of Europe, United States, Australia 

and Asia varies between 1:100 – 1:300 [17, 24, 36, 37]. In 

Poland CD screening tests in healthy population have not been 

done, yet. Due to the fact that the prevalence of CD in Europe 

is so high, it is expected that even about 380 thousand 

of CD patients live in Polish country. 

CD has extremely changed since the moment Dutch 

physician Willem Dicke had described the clinical aspects of 

the disease [13]. Nowadays, so called classical type of CD 

with chronic diarrhea, abdominal distension, poor weight gain, 

starting under 2 years of age, occurs rather rare. CD appears 

in each age after the introduction of gluten to the diet, and 

in many older patients presents atypical non-gastrointestinal 

symptoms or has a silent form with minimal or no clinical 

symptoms [10]. Gastrointestinal symptoms of CD represent 

the tip of the celiac iceberg presented by Logan [32]. Because 

of atypical manifestations, many patients with CD remain 

undiagnosed or are treated symptomatically. In adults, CD is 

diagnosed on average over 10 years after the first symptoms 

[21]. The lack of proper treatment, i. e. a strict gluten free diet 

(GFD), increases the risk of life-threatening complications that 

are difficult to manage, such as cancers and malignant lymphomas 

[7]. There is also strong evidence that in unrecognized 

CD patients the frequency of other autoimmune diseases 

is higher than in general population [58]. 

Pathogenesis 

CD is a highly genetically determined disease with the major 

genetic factor being the expression of specific HLA class 

II antigens. About 90–95% of CD patients express HLA- 

-DQ2 molecule, the rest of them are HLA-DQ8-positive 

[33]. These HLA-DQ receptors have the capacity to bind the 

Address for correspondence 

Bo¿ena Cukrowska, MD, PhD, DrSc 

Zak³ad Patologii 

Instytut „Pomnik-Centrum Zdrowia Dziecka” 


04-734 Warszawa 

E-mail: ptpd@czd.waw.pl

8 

specific gliadin peptides that have been implicated in CD. 

HLA-DQ molecules present on the surface of antigen presenting 

cells (macrophages, dendritic cells), i.e. cells, which 

catch the gliadin peptides and present them in association 

with specific HLA-DQ receptors to T lymphocytes [43]. 

Gluten contains peptides presenting extremely high 

affinity to DQ2 and DQ8 receptors [51]. These toxic peptides 

are characterized by high glutamine content, i.e. the amino 

acid which is a substrate for the enzyme – tissue transglutaminase 

(tTG). tTG catalyzes deamination of glutamine into 

glutamine acid. This reaction increases about 100-times 

the affinity of toxic peptides, and is essential for significant 

stimulation of gliadin-specific – T lymphocytes (Fig. 1). Activated 

gliadin-specific T lymphocytes produce pro-inflammatory 

cytokines responsible for histological changes in intestinal 

mucosa [10, 11]. 

Fig. 1 Effector mechanisms of celiac disease – the activation of specific T 

lymphocytes 

Toxic peptides are present in wheat, barley and rye 

[9]. Corn, rise and, as recently has been shown, pure oats do 

not contain toxic peptides active in CD [23]. 

The recent reports by Shan et al. shows that digestion 

of recombinant gliadin with gastric and pancreatic enzymes 

in vitro produces the highly stable 33-mer peptide that is rich 

in proline and glutamine, and which contains all known toxic 

peptides [51]. This 33-mer peptide is resistant to brush 

border enzymes, but it can be easily degestive by endopeptidases 

coming from intestinal bacteria [51]. 

Findings showing that gut bacteria could deprive gliadin 

peptides of toxicity open a new therapeutic possibility 

with using probiotics, i.e. non-pathogenic bacteria regulating 

gut microflora ecosystem. It is not excluded that bacterial endopeptidases 

could be also used in preparation of non toxic 

cereals [12]. 

HLA-DQ2 and -DQ8 are common in human population. 

This haplotype is present in 20–30% of health controls, 

suggesting that activation of pathological processes could be 

influenced by other genes. It seems that HLA class I related 

gene – the major histocompatibility complex class I chain-related 

gene A (MICA) is an attractive candidate for better un- 

derstanding of physiopathological mechanisms of CD [31]. 

MICA molecule is mainly expressed on the intestinal epithelium 

and is recognized by T lymphocytes, CD8+ lymphocytes 

and natural killer cells. The binding of MICA to cells induces 

cytotoxic and inflammatory responses in the intestine. 

Lopez-Vazquez et al. found an association of the MICA A5.1 

allele with atypical form of CD. Up to 29% of patients with 

atypical CD expressed A5.1 allele in comparison to 13% of 

patients with typical CD and 7% of healthy population. The 

mechanism by which atypical manifestations are triggered is 

connected with the fact that MICA-A5.1 is responsible for secretion 

of soluble form of MICA molecule. This protein reacts 

with cytotoxic and pro-inflammatory lymphocytes and 

inhibits their activation in intestine by MICA present in gut 

epithelium. 

Clinical symptoms 

The classical clinical picture of childhood celiac disease consists 

of prolonged diarrhea with failure to thrive, abdominal 

distension, vomiting. Severe malnutrition and even cachexia 

can occur when diagnosis is delayed. This type of presentation 

has decreased in many European countries over the past 

few decades. The factors responsible for this change might be 

explained by the exclusion of gluten from the diet of babies 

and promotion of natural feeding [14]. Studies performed in 

United States on children with recognized CD showed that older 

age of CD onset and atypical manifestations were results 

of prolonged breast feeding [14]. On the other hand Swedish 

observed that breast feeding decreased occurrence of CD in 

children before 2 years of age, and high doses of gluten introduced 

to the baby's diet independent on the age without protection 

of breast milk increased the risk of CD [26]. Presented 

results open the discussion on the period of introduction 

of gluten to the infant diet. Experimental data show that oral 

tolerance is developed only in early ontogeny, thus too late 

administration of gluten to the diet could be responsible for 

gluten intolerance. It seems that low amounts of gluten in the 

diet before 6 months of life, but introduced during breast feeding 

could prevent the development of CD [25]. However, 

intake the gluten either before 3 month of life or under 

7 month of life increased the risk of CD [46]. 

In Poland Szaflarska-Szczepanik observed the decreased 

frequency of classical form of CD in children starting 

from 1990 [55]. Children presented atypical symptoms, such 

as low weight, short stature, anemia, abdominal pain. Ludvigsson 

at al. reported similar tendency in children before 

2 years old, in whom in addition, irritability and muscle wasting 

were found [34]. 

Recently, increased frequency of CD reaching 3,4% 

was found in patients with irritable bowel syndrome (IBS) [15, 

53]. These patients tend to experience diarrhea, vomiting, recurrent 

abdominal pain, constipation, nausea. Our studies also 

showed high frequency of CD in children with IBS (1:60) [4]. 

Many symptomatic patients with newly diagnosed 

CD initially present with non-gastrointestinal manifestations 

of CD. Atypical symptoms of CD are presented in Table 1.

9 

Table 1 

Nongastrointestinal symptoms of celiac disease 

Iron and folic acid anaemia 

Short stature 

Pubertal delay 

Unexplained infertility, spontaneous abortions 

Epilepsy with intracranial calcifications 

Cerebellar ataxia 

Depression, irrtability 

Osteopenia /osteoporosis 

Arthritis 

Dental enemal hypoplasia 

Recurrent oral ulcers 

Unexplained hypertransaminaesemia 

Dermatitis herpetiformis 

The most common non-gastrointestinal manifestation 

of CD, especially in adults is iron and folic acid anemia. 

About 11% of adults with anemia resistant to oral iron or folate 

supplementation have CD [3, 41]. When patients represent 

unexplained iron deficiency anemia the frequency is lower 

ranging up to 8%. In children, short stature is the most 

common non-gastrointestinal symptom of CD. The incidence 

of CD in this group is 8–10% [56]. 

Numerous studies confirm that disturbances in bone 

mineral density are often symptoms in celiac patients. Osteoporosis 

is one of the well-known complications of untreated 

CD [28, 44]. A GFD in children reverses bone density abnormalities 

and the beneficial effects of gluten withdrawal are 

persistent [42]. Contrary to pediatric cases, in adults affected 

by osteoporosis, a GFD does not reduce the risk of fractures 

[57]. In children dental enamel hypoplasia of permanent teeth 

could be a single manifestation of CD [1]. 

A number of neurological and psychological manifestations, 

including epilepsy with intracranial calcifications, 

primary ataxia, autism, depression, headaches, have been reported 

in patients with CD, but the evidence for their association 

with CD in children is weak [65]. Our studies on frequency 

of CD at risk group of children did not confirm occurrence 

of CD in children with epilepsy and autism [4]. 

There is some evidence for unexplained hypertransaminaesemia 

in untreated patients with CD. Up to 9% of 

adults with elevated serum transaminases present CD [61]. 

In biopsies of liver obtained from these patients only nonspecific 

inflammatory changes were found, and tle level of enzymes 

appeared to normalize on a GFD [61]. Sjogren et al. 

found a nonspecific increase of anti-gliadin antibodies 

(AGA) in a numbers of liver diseases, such as alcoholic cirrhosis 

(20%), primary biliary cirrhosis (16%), primary sclerosing 

cholangitis (24%), hepatitis HCV (11%) [52]. However, 

the evidence of an increase of CD confirmed by histo- 

logical lesions was found only in patients with autoimmune 

hepatitis [59]. 

Unexplained infertility could be also a syndrome of 

atypical CD [29]. Incidences of menstrual irregularities and 

spontaneous abortions appear more often in women with CD 

than in general populations [29]. In children with CD pubertal 

delay can occur. 

Other atypical syndromes of CD are recurrent oral 

ulcers and arthritis. Up to 3% of children with juvenile arthritis 

present CD [54]. 

Nowadays, dermatitis herpetiformis is considered to 

be a cutaneous manifestation of gluten sensitivity [27]. Dermatitis 

herpetiformis is a severe itchy, blistering skin disease 

with abnormalities occurring on the elbows, knees and buttocks. 

In intestinal biopsy typical for CD histological lesions 

are found. The treatment with a GFD approves skin and intestinal 

abnormalities. 

Associated conditions 

CD is associated with a number of autoimmune and non autoagressive 

genetical diseases (Table 2). Autoimmune disorders 

occur ten times more frequently in adult patients with 

CD than in general populations. Up to 8% of patients with 

type 1 diabetes have the characteristic features of CD in 

small intestinal biopsy [8, 48]. This figure may be an underestimate, 

as serial screening of individuals with type 1 diabetes 

over a period of years has identified additional cases 

who initially had negative serological tests [8]. CD is also 

more often recognize in patients with autoimmune thyroiditis 

[54, 61], Sjogren's syndrome [35], cardiomyopathy [47], 

autoimmune myocarditis [18] and in autoagressive endocrynological 

disorders [45]. 

The incidence of CD in individuals with Down syndrome 

is between 5% and 12% [20]. About one third of patients 

present atypical non-gastrointestinal syndromes. An increased 

prevalence of CD, which ranges from 4,1 to 8,1% 

Table 2 

Diseases associated with celiac disease 

Disease 

Percentage of association 

Diabetes mellitus type 1 1 5–8% 

Autoimmune thyroitidis 4–5% 

Sjogren’s syndrome 5% 

Autoimmune hepatitis 6,4% 

Juvenile arthritidis 6,6% 

Addison’s disease 7,9% 

Cardiomyopathies 2,1–5,76% 

Autoimmune myocarditis 4,4% 

Down syndrome 5–12% 

Turner syndrome 4–8% 

Wiliams syndrome 8,2% 

Selective IgA deficiency 2–8%

10 

has also been reported in Turner syndrome [2, 50] and in 

Wiliams syndrome (8, 2%) [19]. 

Based on retrospective studies the frequency of selective 

immunoglobulin (Ig) A deficiency in CD was between 

1,7% and 7,7% [6]. 

There is strong evidence that first-degree relatives of 

diagnosed CD cases are at increased risk for CD with a prevalence 

of 4% to 5% [22]. The frequency of CD is lower in 

second-degree relatives. 

Diagnosis 

Although serological tests have been improved during last 

years, still biopsy of small intestine is necessary for CD recognition. 

According criteria established by European Society 

of Gastrology, Hepatology and Nutrition in 1990, CD diagnosis 

is based upon histological evidence of typical small 

intestinal mucosal abnormalities and clinical improvement 

after introduction of gluten free diet [62]. CD affects the mucosa 

of the proximal small intestine, with damage gradually 

decreasing in severity towards the distal small intestine. Because 

the histological changes in CD may be patchy, it is recommended 

that multiple biopsy specimens should be obtained 

from the jejunum and examined according modified 

Marsh scale (Fig. 2) [38, 40]. 

There is strong evidence that villous atrophy (Marsh 

grade III) is a characteristic histopathological feature of CD 

[22]. The presence of infiltrative changes with crypt hyperplasia 

(Marsh grade II) is compatible with CD but with less clear 

evidence. Diagnosis in these cases is dependent on positive 

serological tests. When serological tests are negative, other 

conditions for the intestinal changes should be considered. 

The presence of infiltrative intraepithelial lymphocytes alone 

(Marsh grade I) is not specific for CD. Concomitant positive 

serology increases the likehood of CD. In such cases it is recommended 

additional strategies, such as determination of 

the HLA antigens, repeat biopsy or a trial of treatment with 

a GFD and repeated measurement of antibodies [22]. 

Thus, intestinal biopsy together with determination of 

specific antibodies in sera provides definitive CD diagnosis. 

As a GFD improved the intestinal lesions [64], it should be 

stressed that GF diet should not be introduced before planned 

biopsy. 

Serological tests are frequently used to identify individuals 

for whom the biopsy procedure. They are also useful 

for screening the population to determine the prevalence 

of CD and for monitoring of a GFD therapy [64]. 

A comparison between several commercial available 

serological tests demonstrated that determination of anti-endomysial 

antibodies (EMA) by an indirect immunofluorescence 

technique (IIF) and anti-human recombinant tissue 

transglutaminase antibodies (hrtTG-Ab) by immunoenzymatic 

(ELISA) method are superior to anti-gliadin antibodies 

(AGA) and anti-guinea pig tissue transglutaminase antibodies 

(gTG-Ab) [63, 64]. The sensitivity and specificity 

of those tests range about 90%. Our studies showed that also 

anti-reticulin antibodies (ARA) determined by IIF are 

characterized by very high sensitivity (98%) and specificity 

(100%) [64]. 

Thus, the autoantibodies produced against the same 

autoantigen, i.e. tissue transglutaminase [30], should be employed 

for diagnosis and screening of CD. Our observations 

confirm that in some patients EMA/ARA tests are negative, 

but hrtTG-Ab are present, so it seems that determination of 

autoantibodies by two tests performed by different methods 

are needed. 

Fig. 2 Histopathological lesions in celiac patients

11 

Screening tests 

Screening tests should be done at risk groups: 

! in first degree relatives of known CD cases, 

! in patients with diseases associated with CD (Table 1) 

! in patients with atypical syndromes (Table 2). 

Epidemiological studies have shown that screening 

tests at risk groups should be done in 2–3 years old children 

[5]. As the occurrence of CD at risk groups is increasing with 

age, it is recommended to repeat serological tests in the case 

of negative results. 

Some authors suggest that due to the high prevalence 

of CD and occurrence of atypical forms of CD, screening tests 

should be done not only at risk groups, but in the whole 

population (mass-screening) [39]. 

Conclusions 

1. Celiac disease is a very common disorder with prevalence 

1:100 – 1:300. 

2. Most people with CD manifest atypical non-gastrointestinal 

syndromes or silent form of the disease. 

3. Screening tests should be done at least at-risk groups of 

patients. 

Acnowledgment 

The study was support by the projekt PBZ/KBN- 

097/P06/2003. 

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Polyoma BK virus nephropathy in children after kidney 

transplantation 

Przemys³aw Kluge 1 , Ewa Œmirska 2 , Sylwester Prokurat 2 , Agnieszka Perkowska 3 , 

Bo¿ena Cukrowska 1 

Diagnostic 

Paediatric 

Pathology 

1 


2 

Department of Nephrology, Kidney Transplantation and Arterial Hypertension 

The Children's Memorial Health Institute 


3 

Institute of Transplantology Medical University 


Abstract 

Polyoma BK virus nephropathy in transplanted kidney may lead to premature graft failure in up to 10% of 

adult patients. In children there are only very few data from the literature on this problem. We examined 

retrospectively the material (kidney biopsies and nephrectomy specimens) collected at the Department of 

Pathology, the Children’s Memorial Health Institute from 1997–2004. Two out of 69 patients developed 

Polyoma BK virus associated nephropathy (2,9%). In one of them virus caused injury resulted in graft lost. 

Key words: children, kidney transplantation, nephropathy, polyoma BK virus 

Introduction 

Polyomavirus hominis type 1, known also as BK virus represents 

a family of DNA viruses. BK virus genome shares a homology 

with other viruses of the family: JC virus and SV40 

virus [3]. This homology has important implications for some 

diagnostic procedures. Primary BK virus infection occurs 

during childhood and about 75% of adults are seropositive. 

The humoral response results in production of antibodies in 

various classes of immunoglobulins. In a host with normal 

immunity the infection has a clinically indolent course, 

which is subclinical or with slight flu-like symptoms [3]. 

After primary infection virus particles persist mainly in epithelial 

cells of urinary tract including kidneys. 

The clinical course is different in immunocompromised 

patients [1, 3]. In both inherited and secondary immune 

dysfunctions previously „silent” virus undergoes reactivation. 

In some patients this results in an injury of infected organs, 

viremia and sometimes generalized disease. In practice 

BK virus caused organ injury is mainly observed in transplanted 

kidneys. In up to 10% of adult patients after kidney 

replacement Polyoma BK virus associated nephropathy 

(PAN) occurs, sometimes leading to graft failure [1, 3]. The 

prevalence of PAN seems to become more and more frequent, 

probably because of using modern, potent immunosuppressive 

drugs. 

According to data from the literature PAN was diagnosed 

6–270 weeks after kidney transplantation (KT) – average 

44 weeks. In retrospective studies PAN was associated 

with graft failure in 10–100% patients after 12–240 weeks of 

follow up [3]. In morphological picture kidney injury consist 

of necroinflammatory damage of tubules with occurrence of 

characteristic nuclear inclusions containing virus particles 

[1–4]. This damage, in some patients, subsequently results in 

irreversible scarring of renal parenchyma and organ lost. 

To classify a morphological pattern of PAN a 3-step 

system is proposed [1, 3]. In stage (or pattern) A there is only 

focal involvement of tubular medullar epithelium. Nuclear 

inclusion and inflammatory cells are not numerous. In this 

stage a false-negative diagnosis is probable because of sam- 


Przemys³aw Kluge, MD Fax: + 48 22 815 19 75 




04-730 Warsaw, Poland

14 

pling error, particularly in kidney core biopsies. In stage B 

a pattern of necroinflammatory injury is evident occurring 

multifocally or diffusely. Nuclear inclusions are numerous, 

they may be observed in tubular as well as Bowman capsule 

epithelial cells. The inflammatory infiltrates include lymphocytes, 

plasma cells and polymorphonuclears. The differential 

diagnosis in such cases may sometimes be difficult. It 

includes acute cellular rejection, other viral infections (particularly 

CMV virus and Adenovirus) as well as tubular cells 

nuclear pleomorphism occurring during regeneration after 

acute tubular necrosis or recovery from acute cellular rejection. 

In difficult cases immunomorphology should be used 

with SV40 antibody. This antibody, originally developed for 

SV40 virus, is useful because of above mentioned homology 

of BK and SV40 viruses. „In situ” hybridization also may 

be used for more precise diagnosis. In stage C diffuse, chronic 

injury is seen with fibrosis and scarring of kidney parenchyma. 

In this stage virus specific changes may be very focal 

and again difficult to observe. 

When PAN is diagnosed antiviral therapy should be 

considered, but there are no specific drugs against BK virus. 

In some cases therapy with cidofovir is helpful [3]. 

Little is known about PAN in children after kidney 

transplantation but probably it occurs comparable to adults 

[5, 6]. The aim of our study is to examine the prevalence of 

PAN after KT in our, pediatric group of patients. 

function injury (creatynine level was 5 mg%) and severe 

pneumonia. As the patient did not improved after therapy 

with antibiotics, the immunosuppression was stopped and nephrectomy 

was decided. Macroscopically the kidney was enlarged 

(12 × 7 × 6 cm) and firmed. Microscopically there were 

changes in kidney cortex and medulla (Fig. 1). Numerous 

nuclear inclusions of characteristic morphology were found 

in tubular cells as well as in epithelium of Bowman capsule 

of numerous glomeruli. The infected cells were also seen in 

tubular lumina. Extensive inflammatory infiltrates were observed. 

They consisted of lymphocytes, plasma cells and polymorphonuclears. 

Interstitial oedema was also found. No 

necrotic foci were observed. There were no morphological 

signs of cellular vascular rejection (no arteritis). The number 

of inflammatory cells (lymphocytes) not exceeded 4 per 10 

tubular epithelium cells (pattern t1 according to Banff classification). 

Reaction with SV40 antibody was strongly positive 

in infected cells (Fig. 2). The pattern found was consistent 

with stage B changes. It was found that in this patient 

core kidney biopsy was performed 3 months earlier. Origi- 

Material and methods 

Patients 

Retrospectively, 102 microscopic slides collected at the Department 

of Pathology, the Children’s Memorial Health Institute. 

Material including core biopsies and nephrectomy 

specimens were obtained from 69 KT pediatric patients. All 

biopsies were performed in 1997–2004 because of transplanted 

organ injury. There were no protocol biopsies. In all patients 

calcineurin inhibitors have been used as basic immunosuppression. 

PAN diagnosis 

PAN was primarily diagnosed with light microscopy from 

HE slides. The diagnosis was confirmed by the immunohistochemical 

method using SV40 T Ag antibody (Calbiochem). 

Anti-mouse IgG labeled with biotin was used as the 

secondary antibody (Vector). The reaction was visualized by 

Vectastatin ABC kit (Vector) and AEC substrate chromogen 

(Dakocytomation). 

Fig. 1 PAN – Stage B pattern in transplanted kidney. Numerous nuclear 

inclusions in tubular epithelium as well as inflammatory infiltrates. HE 200× 

Results 

PAN was microscopically diagnosed in 2 out of 69 patients 

(2,9%). 

Case 1 

In the first patient (6 year old girl) the diagnosis was established 

from the nephrectomy specimen. The operation was 

performed 12 months after KT in the patient with allograft 

Fig. 2 PAN in transplanted kidney. Numerous cells are positive vith SV40 

antibody. 100×

15 

Discussion 

Fig. 3 PAN – Stage A pattern in transplanted kidney. Only single tubuli 

contain virus nuclear inclusions. HE 100× 

nally, only borderline changes (according to Banff classification) 

were diagnosed. In second review of slides PAN in 

stage A was diagnosed. In those slides there were only a few 

foci of infected tubular cells in the medullar part of biopsy 

specimen (Fig 3). Finally, after nephrectomy the patient improved, 

no specific antiviral drugs were used, dialysis program 

has been started. 

Case 2 

In the second patient (8 years old girl) core kidney biopsy 

was performed because of transplanted organ dysfunction 18 

months post KT (creatynine level was 4,6 mg%). Microscopically 

extensive changes consistent with PAN stage B were 

found. Nuclear inclusions were found in tubular epithelium, 

there were also prominent exfoliations of infected cells. 

Inflammatory infiltrates consist of lymphocytes and plasma 

cells focally forming t1-type pattern according to Banff classification. 

No features of cellular vascular rejection were observed. 

After diagnosis of PAN antiviral therapy with cidofovir 

was administered. It resulted in slowly improving renal 

function (finally, creatynine level was 2,4 mg%). 

In the analyzed group of pediatric patients PAN was observed 

in 2/69 (2,9%). This result is in line with studies concerning 

adult patients. The prevalence of PAN is 1–7% 

according to retrospective studies [3]. PAN was diagnosed 

on average 44 weeks post-transplantation including a peak 

around the fist 24 weeks, i.e. similar as in our patients. Persistence 

of PAN was associated with irreversible allograft failure 

in 10–100%. In our both patients clinical course was rather 

severe with evident injury of transplanted kidney function. 

In one patient kidney injury was so severe that, 

particularly in the context of severe pneumonia, the only reasonable 

treatment was nephrectomy after stopping of immunosuppression. 

Morphological findings confirmed very 

extensive damage of the kidney parenchyma. It is possible, 

that in this patient earlier proper diagnosis would be helpful. 

In the first biopsy of the patient the PAN pattern was observed, 

but morphological changes are discrete and difficult to 

observe. 

In the second patient the main problem in microscopical 

diagnosis was to determine the etiology of injury as 

well as excluding of the acute cellular rejection. PAN diagnosis 

was preferable because of identification of infected 

cells. It should be mentioned however that coexistence of 

PAN and „true” acute cellular rejection could exist. The final 

result of treatment (antiviral therapy, no anti-rejection 

therapy) confirmed BK virus etiology as main factor of kidney 

injury. 

In summary we can conclude that transplanted kidney 

biopsy should to be considered as the useful method of PAN 

diagnosis, but it should be stressed that visible organ injury 

during PAN occurs rather late in a course o BK virus caused 

disease. Other methods, for example, serial viral load measurements 

may be very helpful. 

Acknowledgment 

The study was supported by internal grant from the Children’s 

Memorial Health Institute. 

References 

1. Drachenberg CB, Hirsch HH, Ramos E, 

Papadimitriou JC (2005) Polyomavirus 

disease in renal transplantation. Review 

of pathological findings and diagnostic 

methods. Hum Pathol 36:1245–1255 

2. Drachenberg CB, Papadimitriou JC, 

Hirsch HH, et al (2004) Histological 

pattern of Polyomavirus nephropathy: 

correlation with graft outcome and viral 

load. Am J Transplant 4:2082–2092 

3. Hirsch HH, Steiger J (2003) Polyomavirus 

BK. Lancet Infect Dis 3:611–623 

4. Singh HK, Nickleit V (2004) Kidney 

disease caused by viral infections. Curr 

Diag Pathol 10:11–21 

5. Smith JM, McDonald RA, Finn LS, 

Healey PJ, Davis CL, Limaye AP 

(2004) Polyomavirus nephropathy in 

pediatric kidney transplat recipients. 

Am J Transplant 4:2109–2117 

6. Vats A (2004) BK virus-associated 

transplant nephropathy: need for increased 

Awareness in children. Pediatr 

Transplant 8:421–425



Primary malignant liver cell tumours in children – 

different treatment strategies 

Andrzej Igor Prokurat 1,2 ,Ma³gorzata Chrupek 1,2 , Roman KaŸmirczuk 3,4 , Przemys³aw Kluge 5 , 

Andrzej Koœciesza 6 , Pawe³ Rajszys 6 , El¿bieta Dzik 6 , Arthur Zimmermann 7 

Diagnostic 

Paediatric 

Pathology 

1 

Department of Paediatric Surgery 

3 

Department of Anaestesiology and Intensive Care Unit 

L. Rydygier Collegium Medicum 

N. Copernicus University in Toruń, Poland 

2 

Department of Paediatric Surgery and Organ Transplantation 

4 


5 


6 

Department of Radiology 

The Children's Memorial Health Institute in Warsaw, Poland 

7 

Department of Surgical Pathology 

Institute of Pathology of the University in Berne, Switzerland 

Abstract 


Malignant liver cell tumours in children still present a real diagnstic and therapeutic challenge. The histology 

of these tumours is often not clearly defined, and the differentiation between hepatoblastoma (HBL) and 

hepatocellular carcinoma (HCC) is sometimes difficult. Intermediate forms between HBL and HCC called 

„Transitional Liver Cell Tumours” (TLCT) can also be observed. The introduction of complex treatments 

(chemotherapy and operation) has led to an increase in the 3-year survival rate of patients with HBL of over 

70% but not improved the survival rate of children with HCC and TLCT, which is still not higher than 40%. 

The most important factors affecting the final results of treatment in children with malignant liver cell 

tumours still are microscopic radical operations, the presence of extrahepatic spread of disease, and distant 

metastases. The aim of this study is the analysis of the results of treatment in children with malignant liver 

cell tumours using 3 different treatment strategies: typical anatomcal liver resection, atypical borderline non 

anatomical liver resection for giant tumours and liver transplantation. The results of treatment of 59 children 

with primary malignant liver cell tumours treated during last 20 years have been analysed; the patients 

consisted of 29 patients with HBL (children up to 4 years of age), 10 patients with TLCT (children over 

5 years of age) and 20 patients with HCC. Liver resection (typical or atypical) was performed in 39 children 

and liver transplantation (primary or secondary) was performed in 8 children. Type and size of tumour, 

response of tumour to chemotherapy, the possibility of radical resection, type of operation and its microscopic 

radicality and final results of complex treatment against the morphology of the tumour were analysed in all 

patients. Clear differences in the treatment response are indicated, depending on the histology of the tumour. 

Very good results with a complex treatment have been confirmed in the group of small children with HBL, 

except for patients with an unfavourable histology (anaplasia or SCUD-small cell undifferentiated HBL), 

patients with TLCT and HCC demonstrated unsatisfactory results after complex treatment. Detailed 

histological analysis also demonstrated difficulties in achieving microscopic radicality in the operative 

treatment of patients with TLCT and HCC as well as in children with HBL in cases the tumour size exceeded 

10 cm in diameter. In conclusions, it is suggested that it worth verifying the indications for traditional surgical 

treatment and adapting the treatment to the histology of tumour as well as broadening the indications for 

liver transplantation as a primary operation, which may guarantee microscopic surgical radicality. 

Key words: liver tumours in children, liver resections, liver transplantation 

Prof. Andrzej I. Prokurat Phone: +48 52 585 40 15 

Department of Paediatric Surgery L.Rydygier Collegium Medicum Fax: +48 52 585 40 95 

N. Copernicus University in Toruñ, Poland E-mail: aprokurat@cm.umk.pl 

ul. M. Sk³odowskiej-Curie 9 

04-736 Bydgoszcz, Poland

18 

Introduction 

Primary malignant liver cell tumours are the most common 

hepatic tumours in children. They account to 70% of all hepatic 

lesions encountered in paediatric age group [20, 25]. 

These tumours represent a heterogeneous group, whereby hepatoblastoma 

(HBL) tend to occur predominantly in younger 

children and hepatocellular carcinoma (HCC) in older children 

and adolescents. The rare intermediate tumours „Transitional 

Liver Cell Tumours” (TLCT) are on the borderline 

between HBL and HCC: they have intermediate clinical and 

histological features, their biological behaviour is not completely 

known and the treatment strategy has not yet been defined 

[16, 18]. The histological picture of liver cell tumours 

is often unclear, which makes the differentiation between 

HBL, HCC and TLCT sometimes difficult [18]. This results 

in difficulties in selection and standardisation of the best treatment 

strategies, aggravated by the high percentage of giant 

tumours or multifocal lesions [14, 15], the unpredictable response 

to chemotherapy [15, 18] and big differences in biological 

behaviour between HBL, HCC and TLCT [15–18]. 

Advances in liver surgery [3, 4], the determination of risk 

factors, and standardisation of the protocols of chemotherapy 

have significantly improved the results of treatment of 

HBL in children [5, 19]. However this has not affected the 

treatment results for HCC and TLCT, where – despite the application 

of different treatment strategies – results still remain 

poor [7, 15–18]. 

The aim of the study is to analyse the treatment results 

of children with malignant liver cell tumours using three different 

treatment strategies: typical anatomical liver resection, 

atypical borderline non anatomical liver resection for giant 

tumours and liver transplantation. The most reliable surgical 

procedures for different types of tumours are discussed. 

Materials and methods 

Retrospective analysis of the methods and results of surgical 

treatment in 59 patients with malignant liver cell tumours treated 

during last 20 years in the Children’s memorial Health 

Institute in Warsaw was carried out. The patients consisted 

of 29 children with HBL, 10 children with TLCT, and 20 

children with HCC. The age of the children with HBL ranged 

from 1 month to 4 years (mean 1.3 years), of children 

with TLCT from 5 to 17 years (mean 10 years), and of children 

with HCC from 2 to 20 years (mean 12.2 years). The final 

diagnosis was based on surgical biopsies before treatment, 

the resected specimen after surgery or post mortem 

protocols, together with previously described clinical and histological 

criteria [16, 18, 20, 25]. Before initiating therapy 

(chemotherapy, surgery) all patients underwent radiological 

examination with imaging techniques (angio-CT scan, USG). 

Further monitoring of tumour response to chemotherapy was 

carried out with the same scanning procedure. Initial chemotherapy 

was introduced prior to surgery in the majority of patients. 

Before 1989, chemotherapy for HBL and TLCT was 

given on an individual basis (mainly VCA) and after 1990 

was switched to PLADO, while for HCC chemotherapy consisted 

mainly of VCAF or PLADO. Radical surgical treatment, 

either resection of the tumour with part of the liver or 

orthotopic liver transplantation (OLT), was undertaken in 47 

of 59 children according to previously described standards 

[12, 14]. Partial liver resection (typical or atypical) together 

with resection of the tumour was performed in 39 children 

and OLT (primary or secondary) in 8 patients. Typical liver 

resections were undertaken when the localisation of tumour 

allowed resection within the planes of the segmental division 

of the liver as proposed by Couinaud [4, 6]. In cases of atypical 

resection due to the location or size of the tumours, the 

planes of resection differed from the anatomical division of 

the liver. Primary OLT was undertaken when traditional liver 

resection was impossible, whereas secondary OLT was 

done in cases of local tumour recurrence after previous liver 

surgery. Follow-up ranged from 1 to 20 years. Retrospective 

analysis investigated the type and size of the tumour, the 

response of chemotherapy, the possibility of radical tumour 

resection, biliary complications, microscopic radicality of 

surgery, and the final results after complex treatment. 

Results 

Nature and size of malignant liver cell tumours 

„Resectability” of a tumor was determined by analyzing the 

nature and size of the lesion. All hepatic lesions were divided 

into three categories depending on the localization and 

type of the tumor: lesions up to 5 cm, up to 10 cm, and over 

10 cm or multifocal (Table 1). 

Table 1 

Diameter of malignant liver cell tumours before treatment 

Initial diameter of tumour before treatment 

Up to 5 cm Up to 10 cm Over 10 cm 

or multifocal 

HBL n=29 – 8 (27,5%) 21 (72,5%) 

TLCT n=10 – 2 (20%) 8 (80%) 

HCC n=20 6 (30%) 3 (15%) 11 (55%) 

In cases of HBL and TLCT most lesions (about 70- 

80%) were very advanced (with diameter greater than 10 cm 

or multifocal) (Fig. 1). In children with HCC advanced lesions 

were noted in about 50% cases, and lesions of up to 

5 cm in 30% of patients. Despite the high percentage of very 

advanced lesions in patients with HBL and TLCT, after 

initial chemotherapy about 80% of tumours were found to be 

resectable (table 2). In cases of HCC, despite the higher percentage 

of relatively small lesions, only 35% of tumors were 

assessed as traditionally suitable for resection and 65% of 

tumors were assessed as not resectable according to traditional 

criteria.

microscopic radicality of surgery (Table 4). Complete microscopic 

radicality was documented in 70% of children with 

HBL. Detailed histologic examination in cases of TLCT and 

HCC indicated that complete microscopic radicality in these 

tumours is very difficult to achieve. Traditional liver resections 

performed in children with TLCT and HCC showed incomplete 

microscopic radicality in 75% and 71% of patients, 

respectively. Microscopic radicality and incidence of postoperative 

biliary complications depended on the type of performed 

resection (Table 5). 

19 

Table 4 

Fig. 1 Liver CT of 17-year-old girl. Giant tumour (TLCT) in the right liver 

(seg V, VI, VIII) 

Table 2 

Resectability of malignant liver cell tumours in children 

Resectability of tumour 

resectable not respectable 

HBL n=29 23 (79%) 6 (21%) 

TLCT n=10 8 (80%) 2 (20%) 

HCC n=20 7 (35%) 13 (65%) 

Treatment of malignant liver cell tumours 

Obvious differences depending on the histology of the tumour 

were demonstrated in the response of the tumours to treatment 

(Table 3). A good response after initial chemotherapy 

was noted in 56% of children with HBL, as opposed to 

only 11% of patients in whom no response was noted. In cases 

of TLCT and HCC the majority of patients (80% and 

91% of cases, respectively) showed no response to initial 

chemotherapy. 

Clear differences between the types of malignant liver 

cell tumours have been demonstrated with respect to the 

Table 3 

Response to initial treatment of malignant liver cell tumours 

Reduction of tumour after chemotherapy 

Up to 50% Up to 25% No reduction 

HBL* 15 (56%) 9 (33%) 3 (11%) 

TLCT – 2 (20%) 8 (80%) 

HCC* – 1 (9%) 10 (91%) 

* patients after OLT were excluded 

Microscopic radicality after resection of malignant liver cell 

tumours 

Table 5 

Microscopic radicality 

radical not radical 

HBL* n=23 16 (70%) 7 (30%) 

TLCT n=8 2 (25%) 6 (75%) 

HCC* n=7 2 (29%) 5 (71%) 

* patients after OLT were excluded 

Microscopic radicality and biliary complications and the type 

of resection 

Microscopic 

Biliary 

radicality complications 

radical not radical absent present 

typical 17 (71%) 7 (29%) 23 (96%) 1 (4%) 

resections 

n=24 

atypical 4 (27%) 11 (73%) 10 (67%) 5 (33%) 

resections 

n=15 

In cases of typical liver resections microscopic radicality 

was documented in 71% of patients and postoperative 

biliary complications occurred only in 4% of children. In 

contrast, in atypical liver resections a lack of microscopic radicality 

was noted in 73% of patients with postoperative biliary 

complications observed in 33% of children. 

Final results of treatment of malignant 

liver cell tumours 

Analysis of the treatment results indicated very satisfactory 

final results in children with HBL and unsatisfactory results 

in patients with TLCT and HCC (Table 6). Out of the whole 

group of children with HBL 63% are alive without recurrence 

of disease at follow-up of 1 year and longer, and in the 

group of patients after surgery the survival rate is 74 %.

20 

Table 6 

Microscopic radicality and biliary complications and the type 

of resection 

Whole group Operated group 

n=53 n=39 

died alive died alive 

HBL* 10 (37%) 17 (63%) 6 (26%) 17 (74%) 

TLCT 7 (70%) 3 (30%) 6 (67%) 3 (33%) 

HCC* 13 (81%) 3 (19%) 4 (57%) 3 (43%) 

* patients after primary OLT were excluded /HBL-2, HCC-4/ 

In contrast, in the groups of patients with TLCT and 

HCC 30% and 19% of patients, respectively are alive without 

recurrence of disease at follow-up of 1 year and longer and 

in the groups of patients having undergone surgery the survival 

rates are only 33% and 43% respectively. 

Liver transplantation 

Primary OLT was done in 2 children with HBL and in 4 children 

with HCC, while secondary OLT was performed in 

1 patient with TLCT and in 1 patient with HCC (Table 7). 

Table 7 

Liver transplantations in patients with malignant liver cell tumours 

Type of liver transplantation 

Primary OLT 

HBL n=2 N=2 – 

1pat. – died after 6 mo. (PTLD) 

1pat. – alive (NAD 1y.after OLT) 

TLCT n=1 – N=1 died 1,5 y. (metastases) 

HCC n=5 N=4 N=1 alive (NAD 1y. after OLT) 

2pat. – alive (NAD 2y. after OLT) 

2pat. – died (PNF, infection) 

PTLD – post transplant lymphoproliferative disease, PNF-primary graft non function. 

Three of 6 children after primary OLT are alive without 

recurrence of disease with a follow-up longer than 

1 year and the remaining 3 children died due to reasons not 

connected with malignancy. The only death after OLT due 

to dissemination of malignancy was noted in a patient with 

TLCT and a history of unsuccessful attempts at traditional radical 

surgery. 

Discussion 

Primary malignant liver cell tumours, despite their relatively 

low incidence in children, represent a real diagnostic and therapeutic 

challenge due to their not completely known biology 

and wide spectrum of morphology. Hepatoblastoma and 

hepatocellular carcinoma, located on the opposite sides of the 

spectrum, account together for over 90 % of primary malignant 

hepatic tumours in children [11]. Malignant hepatic tumours 

contribute to about 70% of all primary hepatic tumours, 

and about 0.5–2% of all malignant diseases in children 

[9, 23]. The incidence of malignant liver tumours is higher in 

the first 2–3 years of age and in children over 10 years of age. 

The first age peak is dominated by HBL and the second by 

HCC. Incidence and age peaks on the other hand are unknown 

for TLCT. It seems, however, that the age distribution for 

TLCT is similar to that of HCC in children [16, 18]. Data 

from the presented series seem also to confirm this statement. 

Causes of malignant liver cell tumours are not well 

known. Genetic, environmental, and viral factors have all been 

considered as contributing factors. The best explanation 

for the development of HBL is the theory of interrupted organogenesis, 

an inappropriate continuation of proliferation of 

persistent embryonic tissue which transforms further into 

embryonal tumour [11]. In contrast to HBL, it has been proven 

that transmission and incorporation of the DNA of HBV 

or HCV onto human genetic material as well as the effect of 

metabolic factors generating liver cirrhosis serve as oncogenic 

factors for HCC [9]. The etiology of TLCT is less known. 

According to the hypothesis proposed by Zimmermann [18], 

these tumours arise from the cellular lines developing on the 

transitional ways between blastemic 

tumours and adult-type 

tumours, which would explain 

the atypical biological behaviour 

of these lesions [16]. The different 

etiology of HBL, TLCT, 

Secondary OLT 

and HCC, as well as their different 

clinical picture and biological 

behaviour seems to require 

different treatment strategies. 

The introduction of new radiological 

imaging techniques has 

increased the accuracy with 

which the localisation and 

extension of the tumour within 

the liver can be assessed, allowing 

monitoring of chemotherapy 

and detailed planning of 

the extent of surgery. Modern diagnostic instruments do not 

allow, however, the prediction of biological behaviour. This 

seems to be the most serious difficulty standing in the way 

of prompt therapeutic decision, in addition to the fact that 

apart from HCC these are not well standardised [7, 15–19]. 

Despite the introduction of chemotherapy, the most 

important factor in deciding on the final treatment of malignant 

liver cell tumours is still the „resectability” of the tumour. 

The microscopic radicality of surgery is the critically 

important factor [24]. This is closely related to the nature of 

the tumour and its response to initial chemotherapy, which 

substantially influences the possibility of radical surgery [10, 

14, 16, 19]. Striking differences in initial tumour size, response 

to initial chemotherapy and resectability between

21 

HBL, TLCT, and HCC were noted in the presented series. 

Whereas the vast majority of patient with HBL and TLCT 

presented with over 10 cm or multifocal giant tumours in 

children with HCC these features were noted in only about 

50% of children. At the same time only children with HBL 

demonstrated a satisfactory rate (about 50%) of patients with 

good response to initial chemotherapy. These data explain 

the high number of children, up to 80% of patients with HBL, 

in whom tumours liable for resections with the use of traditional 

hepatic surgery could be found. Similar data have been 

also reported by others [10, 11]. It appears that this effect 

is related to the high sensitivity to chemotherapy of HBL, resulting 

not only in a reduction of tumour mass but also in an 

increase of tumour density, reduction of vascularity and increase 

of the tumour’s „resistance” to surgical manipulation 

[10]. This together with the limited propensity of HBL to 

form micro metastases in healthy liver tissue, permits microscopically 

radical surgery to be carried out in the majority of 

patients during traditional liver surgery [11, 16]. In contrast 

to this HCC, compared to HBL, presented a clearly higher 

percentage of multifocal lesions, a bad response to chemotherapy, 

and more aggressive biological behaviour what results 

in a clearly lower percentage of resectable lesions. In 

the presented series the percentage of resectable lesions in 

patients with HCC did not exceed 39% of children. In the 

presented series a very low (lower than 30% of patients) percentage 

of tumours which demonstrated microscopic radicality 

after traditional hepatic surgery was noted. Similar data 

have been published also by others [7, 10, 15, 17, 19, 23]. 

The potential for resectability seems to be also limited by liver 

cirrhosis associated with HCC in a majority of patients 

and additionally affecting the possibility of traditional liver 

surgery [7, 10, 15, 17, 19, 23, 25]. Fibrolamellar HCC remains 

the only subtype of HCC in which the potential radicality 

of traditional hepatic surgery has been claimed to be higher 

[9, 15, 17]. However, this has been contradicted by 

others [7, 22, 23]. In the presented series the only microscopically 

radical surgery in HCC was achieved in FL-HCC. 

In cases of TLCT, in contrast to HBL and HCC, despite 

tumours of considerable size with a bad response to initial 

chemotherapy, a high percentage of resectable lesions was 

noted. In the presented series however, due to the giant size 

of the tumours, surgery was connected with many technical 

difficulties (atypical resections) and resulted in a high percentage 

of patients in whom microscopic radicality was impossible, 

determining the final outcome of treatment. Unclear 

etiology and biological behaviour of TLCT as well as the 

small group of analysed patients does not, however, permit 

a definitive assessment of the resectability of these tumours. 

Analysis of the microscopic radicality of surgery and 

the incidence of biliary complications indicated their clear 

dependence on the type of surgical resection. In the presented 

series typical resections, despite the type of tumour, 

which were possible with smaller tumours and performed in 

agreement with the planes of liver division [3, 4, 6], had 

a high percentage of microscopic radicality and a low percentage 

of postoperative biliary complications. Atypical resections 

on the other hand, performed in cases of giant marginally 

resectable tumours or in cases with liver cirrhosis, were 

connected with a low percentage of microscopically radical 

operations and a significant incidence (30% of patients) 

of postoperative biliary complications. These data, confirmed 

by others [7, 14, 16-18], cast some doubt on the arguments 

in favour of performing atypical liver resections, especially 

in HCC and TLCT cases with aggressive biological behaviour. 

For these cases alternative therapeutic strategies are 

needed other than traditional hepatic surgery. 

The assessment of the final results of treatment in the 

presented series of children with malignant liver cell tumours 

showed clear differences between HBL and HCC or 

TLCT cases. Very good results in small children with HBL, 

except in cases with an unfavourable histology (anaplasia or 

small cell undifferentiated SCUD) have been confirmed, 

while really unsatisfactory results after the treatment of patients 

with TLCT and HCC were noted. The results of treatment 

in patients with HBL, similar to other published series 

[5, 9, 11, 19, 23, 24], seems to confirm already accepted therapeutic 

strategies for HBL. 

It also appears that the reason for the large discrepancy 

between the results of treatment achieved in HBL and 

HCC or TLCT is a result of the different biological nature of 

these tumours, the lack of sensitivity to chemotherapy of these 

tumours, and the limited possibilities of achieving microscopic 

radicality during traditional hepatic surgery. These 

differences are also the basis to look into new treatment strategies 

which might be used to treat children with malignant 

liver cell tumours, particularly HCC or TLCT and patients 

with HBL presenting with very large tumours. 

In the last decade the interest of paediatric oncologists 

in a more extensive incorporation of orthotopic liver 

transplantation in the treatment of malignant liver cell tumours 

has increased. However, the role of OLT as a routine treatment 

strategy for these tumours in children is still a matter 

of debate, due to limited experience and relatively small series 

of patients [1, 7, 8, 12, 15, 22, 23]. Because of that the 

main indications for OLT in paediatric oncology remain non 

resectable tumours [1, 2, 8, 9, 13, 15, 17, 19, 21–23]. 

In the presented series of patients with malignant liver 

cell tumours OLT was carried out in 8 patients. Particularly 

encouraging results were achieve in the group of patients with 

primary OLT, of whom 3 patients are alive without evidence 

of disease and the deaths of the remaining 3 children were due 

to reasons not connected with malignancy. These results indicate 

potential possibilities to expand the indications for 

OLT as a routine alternative treatment to traditional hepatic 

surgery, for patients with TLCT and HCC as well as for a limited 

group of patients with HBL with marginally resectable 

tumours. The use of OLT in these cases allows the problem 

of doubtful surgical microscopic radicality to be excluded 

which is a weak point of traditional liver surgery. 

The encouraging results of the use of OLT in paediatric 

liver malignancies (mainly not resectable HBL), which 

have already been published [1, 2, 8, 13, 21, 22] and which 

documents at least two years’ survival by 50–70% of patients,

22 

are in agreement with the results achieved in the presented series. 

However the role of secondary OLT in patients with recurrence 

of tumour after primary treatment by traditional hepatic 

resection remains unclear. It seems that the indications 

for OLT after primary unsuccessful traditional liver surgery 

may be limited due to the high incidence of recurrence of malignancy 

after OLT [21, 22]. In the presented series, out of 

two patients who underwent secondary OLT, one patient with 

TLCT died because of disseminated malignancy, and the follow-up 

of another patient with FL-HCC, because of typical 

tumour recurrences even after several years [9, 11, 23], is not 

long enough to allow any prognostic conclusions. 

Results of the presented series together with the results 

of other already published series seem to document the 

need to differentiate between treatment strategies for malignant 

liver cell tumours. This differentiation must consider 

not only the size and location of the lesion but also the tumour’s 

nature and type, which may lead to different biological 

behaviour determining the long-term results. The use of 

traditional liver surgery (hepatectomy procedures) seems to 

be appropriate for the treatment of smaller lesions of all types 

and in the majority of radiologically documented, evidently 

resectable HBL cases, with the predictable possibility 

of microscopically radical surgery. In cases of giant tumours 

and majority of HCC and TLCT cases, the indications for 

liver transplantation as a primary surgical treatment should 

be considered. Such a strategy based on the biological behaviour 

of different malignant liver cell tumour will increase 

the possibility of full surgical microscopic radicality significantly 

determining the final treatment outcome. 

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Utilization of internal sphincter in the reconstruction 

of anorectal malformations in girls 

Andrzej Igor Prokurat 1,2 , Ma³gorzata Chrupek 1,2 , Roman KaŸmirczuk 3,4 , 

Przemys³aw Kluge 5 

Diagnostic 

Paediatric 

Pathology 

1 


3 


L. Rydygier Collegium Medicum 

N. Copernicus University in Toruń, Poland 

2 

Department of Paediatric Surgery and Organ Transplantation 

4 


5 


The Children's Memorial Health Institute in Warsaw, Poland 

Abstract 

Recto-cutaneous or recto-vestibular fistulas are the most common types of anorectal malformations in girls. 

Among the different methods of reconstruction of these defects the most frequently recommended are 

posterior sagittal anorectoplasty (PSARP) as described by Peòa and anterior sagittal anorectoplasty 

(ASARP) as described by Mollard; both of these procedures exist in several modifications. 

The aim of the study is to compare the results after surgical treatment of girls with anorectal malformations 

and external fistula using both approaches. The results in 55 girls with anorectal malformations and external 

fistula (recto-cutaneous, recto-vestibular, recto-vaginal, and recto-cloacal) were analysed. In 28 girls 

posterior sagittal anorectoplasty (PSARP) as described by Peòa with resection of the end of fistula was 

performed. In 27 girls anterior sagittal anorectoplasty (ASRP), a modification of Okada operation with 

preservation of the external fistula, was performed. In both groups of the defects congenital associated 

anomalies were noted. Reconstructive surgery in all girls operated on with ASARP procedure was preceded 

by a daily dilatation of the fistula to obtain an appropriate diameter size as well as manometric studies of 

the fistula to assess the quality of internal sphincter muscle. After reconstruction of ARMs in both groups 

the postoperative results of continence were clinically assessed with the use of 4 clinical methods and 

anorectal manometry. 

In the group having undergone ASARP operation the presence of the internal sphincter was confirmed 

before and after reconstruction of defects. In the group having undergone PSARP operation the presence 

of an internal sphincter was confirmed after operation only in 3 children. The best functional results as 

demonstrated by both clinical and manometric studies occurred in the group of girls operated on with 

ASARP technique in whom the whole external fistula was preserved. 

In conclusion, the results achieved demonstrated the need of internal sphincter saving procedures by 

utilizing the whole fistula during reconstruction of anorectal malformations to improve the results of 

postoperative continence. 

Key words: Anorectal malformations; internal sphincter; manometry 


Prof. Andrzej I. Prokurat Phone: +48 52 585 40 15 

Department of Paediatric Surgery L.Rydygier Collegium Medicum Fax: +48 52 585 40 95 

N. Copernicus University in Toruñ, Poland E-mail: aprokurat@cm.umk.pl 

ul. M. Sk³odowskiej-Curie 9 


24 

Introduction 

Recto-cutaneous or recto-vestibular fistulas are the most 

common types of anorectal malformations in girls. Among 

the different methods of reconstruction of these defects the 

most frequently recommended are posterior sagittal anorectoplasty 

(PSARP) as described by Peňa [20] and anterior sagittal 

anorectoplasty (ASARP) as described by Mollard [16], 

and known in several modifications [12, 27, 28]. The introduction 

of the modern concept of function of the external 

sphincter based on anatomical and physiological studies [2] 

and operative procedures, known as PSARP, for the reconstruction 

of anorectal malformations (ARM) [19] has been 

a breakthrough in the treatment of these anomalies and resulted 

in a significant improvement in postoperative continence 

[20]. This concept however does not include the possibility 

of utilization of the internal anal sphincter (IAS), documented 

in all fistulas in an experimental model of ARM [13]. 

ASARP, understood as an operative procedure analogous to 

PSARP, makes use of the whole fistula as an embryologic 

form of ectopic anus [11] together with the IAS [9]. This 

operative procedure also described as an „internal sphincter 

saving procedure” has been shown to improve postoperative 

continence [1]. However, better functional results after utilization 

of IAS in reconstructive procedures for ARM have been 

denied by some authors due to recto-urogenital / recto-cutaneous 

innervation defects [15]. The aim of the study is to 

assess the possibilities of utilizing the IAS during reconstructive 

procedures for ARM in girls with external fistula operated 

on with PSARP and ASARP procedures. 

Materials and methods 

The records of 55 girls treated in the CMHI in Warsaw for 

anorectal malformations with external fistula (recto-cutaneous, 

recto-vestibular, recto-vaginal, and recto-cloacal) between 

1987 and 1999 were retrospectively analysed. Reconstructive 

procedures for ARM were performed in all patients. 

28 consecutively treated girls (group 1) were treated using 

posterior sagittal anorectoplasty (PSARP) as described by 

Peňa [19] with resection of the end of fistula. In the next 27 

consecutively treated girls (group 2), modified anterior sagittal 

anorectoplasty (ASARP), a further modification of Okada's 

operation [23] with utilization of the whole external fistula, 

was performed. None of the operated girls were excluded 

from the study. In both groups the type o defect (type of 

fistula) and associated congenital anomalies were assessed. 

The group of girls operated on using the ASARP procedure 

underwent several dilatations of the fistula prior to reconstructive 

surgery until a diameter of 10 H was achieved. In 

this group manometric studies of the fistula were performed 

before the operation to assess the quality of the internal 

sphincter muscle. In both groups of patients, after the standard 

course of dilatation and at least 6 months after reconstruction 

of defects or colostomy closure, postoperative continence 

was clinically assessed with the use of 4 clinical scales: 

Kelly [8], Holschneider and Rintala [26], Kiesewetter 

and Chang [10], and Peňa [21]. The assessment of continence 

was finally completed with anorectal manometric studies. 

Dantec 5500 was used for the manometric studies, 

with continuous 30 ml/h flow, together with Polyvinyl Zinetics 

Medical PMCA4-A multichannel catheters with a latex 

balloon and 3-cm distance between the orifices [23, 24]. Manometric 

studies were performed in the lithotomy position 

without sedation. During the studies the following parameters 

were evaluated: 

– Length of high pressure zone (HPZ) in mm obtained during 

profilometry 

– Maximal anal resting pressure (MARP) in cm H 2 O obtained 

during profilometry 

– Recto-anal relaxation reflex (RARR), assessed by % of 

decrease of MARP after insufflations of air into a latex 

balloon located in rectum. RARR was described as full 

(F) when at least a 50% decrease of MARP was recorded 

and partial (P) when only 25–50% decrease of MARP 

was achieved 

– Voluntary anal squeeze pressure (VASP), assessed by % 

of increase of MARP during voluntary anal squeezing of 

the external anal sphincter (EAS). VASP was recorded as 

positive when the achieved pressure reached the level of 

at least 2 × MARP 

– Rectal sensation to balloon distension (RSBD) in ml was 

the lowest volume of insufflated air which lead to filling 

of the rectal distension. 

Results of manometric studies in both groups were 

compared to the results of studies obtained in the same way 

in age-matched controls, each consisting of 10 patients without 

ARM which served as a standard for mannometric values. 

Results 

Assessment of the type of fistula and associated 

congenital anomalies 

In both groups, ARM with recto-cutaneous or recto-vestibular 

fistula was found in 86% of patients (Table 1). Vaginal and 

cloacal defects had the lowest incidence in both groups. Embryological 

and anatomical similarities, which mandated a nearly 

identical surgical approach, were the reason that both 

groups of girls with vestibular and vaginal fistulas were analysed 

together in further studies. The most common type of 

ARM in group 1 was recto-vestibular/vaginal fistula and in 

group 2 recto-cutaneous fistula. There was no significant statistical 

difference between both groups with respect to the type 

of ARM. In each group chi 2 test indicated a significantly 

lower incidence (p

25 

Table 1 

Incidence of different types of defects 

Type of ARM – type of fistula (n) % of patients Statistical p-value 

group 1 

test 

group 2 

Recto-cutaneous (9) 33% 

(12) 45% Fisher NS 

Recto-vestibular or vaginal (15) 53% 


Cloacal (4) 14% 


Table 2 

Incidence of associated congenital anomalies 

Associated congenital anomalies (n) % ACA (% tot) Statistical p-value 

group 1 

test 

group 2 

Genito-urinary defects (13) 87% (46%) 

(12) 86% (45%) Fisher NS 

Skeletal defects (12) 80% (43%) 

(8) 57% (30%) Fisher NS 

Alimentary tract defects (4) 27% (14%) 

(4) 29% (15%) Fisher NS 

Cardiovascular defects (3) 20% (11%) 

(5) 36% (19%) Fisher NS 

CUN defects (2) 13% (7%) 

(3) 22% (11%) Fisher NS 

% ACA – % of children in the group with associated congenital anomalies; 

% tot – % of children with congenital anomaly in the whole group. 

test indicated a significantly higher incidence (p

26 

Table 3 

Incidence of different types of defects 

Type of ARM – type of fistula (n) % of pat. with ACA Statistical p-value 

group 1 

test 

group 2 

Total (15) 54% 


Recto-cutaneous (–) – 


Recto-vestibular or vaginal (11) 73% 


Cloacal (4) 100% 


Table 4 

Manometric studies of the fistula before reconstruction of ARM in group 2 and anorectal manometry in control group 

Group 2 before Control group Statistical p-value 

reconstruction 

test 

(fistula) 

(anus) 

n=27 n =10 

Mean age SD (years) 32,29 ± 22,30 25,50 ± 15,50 t-Student NS 

HPZ (mm) mean value SD 19,55 ± 3,93 20,40 ± 3,09 t-Student NS 

MARP (cm H 2 O) mean value SD 63,33 ± 16,87 75,0 ± 12,69 t-Student NS 

Positive RARR (n) %pac (27) 100% (10) 100% t-Student NS 

Type of RARR* (n) % 

F RARR /P RARR (19) 70% / (8) 30% (10) 100% / (0) – Fisher NS 

HPZ, high pressure zone; MARP, maximal anal resting pressure; RARR, recto-anal relaxation reflex; 

*F, number (n) and % of patients with full RARR; P, number (n) and % of patients with partial RARR. 

(p=0.08) and the Kiesewetter/Chang score showed no statistically 

significant difference. 

The manometric studies indicated statistically significant 

better medium results in group 2 after ASARP for all 

studied manometric parameters. The most significant statistical 

difference between both groups (p

27 

Table 5 

Clinical score and results of manometric studies in girls after PSARP and ASARP 

Group 1 Group 2 Statistical p-value 

after PSARP after ASARP test 

n=28 n=27 

Mean age SD (years) 13,96 ± 3,70 7,22 ± 2,43 t-Student < 0,00001 

Kelly score mean value SD 4,10 ± 2,06 5,07 ± 1,10 t-Student < 0,05 

Holschneider/Rintala 10,03 ± 3,27 11,48 ± 2,63 t-Student NS 

score mean value SD 

(p=0,08) 

Medium value SD (1,32 ± 0,72) (1,59 ± 0,57) 

(after transformation of scale) t-Student NS 

Kiesewetter/Chang* score 46% / 39%/ 14% 63% / 33% / 4% 

(p=0,1) 

%G / %P / %B 

Medium value SD (1,25 ± 0,80) (1,63 ± 0,56) 

(after transformation of scale) 

met. Pena** 

t-Student < 0,05 

%F / %P / %IN 46% / 33% / 21% 66% / 30% / 4% 

Constipation (2 and 3 deg.) (9) 32% (10) 37% Fisher NS 

(n) % pat. 

HPZ (mm) mean value SD 23,78 ± 8,07 27,77 ± 4,12 t-Student < 0,05 

MARP (cm H 2 O) mean value SD 48,92 ± 25,72 74,44 ± 26,21 t-Student < 0,001 

RSBD (ml) mean value SD 40,71 ± 27,07 53,70 ± 38,24 t-Student NS 

Positive RARR (n) % pac (3) 11% (26) 96% Fisher < 0,01 

Positive VASP ■ (n) % pac (14) 50% (26) 96% Fisher < 0,01 

*G, good continence; P, medium continence; B, bad continence (after author of scale); **F, full continence; P. partial continence; IN, 

incontinence (after author of scale); HPZ, high pressure zone; MARP, maximal anal resting pressure; RSBD, rectal sensation to balloon 

distension; RARR, recto-anal relaxation reflex; VASP, voluntary anal squeeze pressure; positive VASP ■ – pressure reaching the level of 

at least 2×MARP; (n), number of patients. 

Table 6 

Manometric studies in the age-matched controls 

Control group for PSARP 

Control group for ASARP 

n=10 n=10 

Mean age SD (years) 13.00 ± 1,33 7,50 ± 2,01 

HPZ (mm) mean value SD 31,20 ± 3,79 27,60 ± 4,19 

MARP (cm H 2 O) mean value SD 93,00 ± 10,59 78,0 ± 14,75 

RSBD (ml) mean value SD 20,00 ± 6,66 32,0 ± 7,88 

Positive RARR (n) % pat (10) 100% (10) 100% 

Positive VASP* (n) % pat (10) 100% (10) 100% 

HPZ, high pressure zone; MARP, maximal anal resting pressure; RSBD, rectal sensation to balloon distension; RARR, recto-anal 

relaxation reflex; VASP, voluntary anal squeeze pressure; Positive VASP* – pressure reaching the level of at least 2×MARP; (n), number 

of patients.

28 

value of MARP between manometric studies of the fistula, 

the same studies undertaken in group 2 after reconstruction 

of ARM and healthy controls. 

The results of manometric studies of patients from 

group 2 indicated that the manometric parameters describing 

the proper function of IAS, both before and after reconstruction 

of ARM, did not differ significantly in this group from 

the normal values of healthy controls (table 4–6). The study 

revealed also that in both groups (group 1 and 2) there were 

no significant statistical differences in RSBD or the incidence 

of postoperative constipation (Table 5). 

Discussion 

Significant improvement have been achieved during the last 

two decades in the treatment of anorectal malformations. 

Both the knowledge of the anatomy, physiology, and pathogenesis 

of ARM and the methods of surgical correction and 

assessment of results have radically changed [9, 12, 19–21]. 

The introduction and popularization of a treatment concept 

described by Alberto Peňa [2, 19] and the acceptance of the 

role of the internal anal sphincter (IAS) in the mechanism of 

continence [13] have had an important influence on improving 

the results of surgical corrections of ARM. Scientific 

documentation of improvements in the results of treatment 

still remains a problem due to differences in classifications 

applied in the past and the present ant the subjectivity of clinical 

methods for assessing continence. Not only the preservation 

of the external sphincter (EAS) but also the utilization 

of the internal sphincter (IAS), which are both still 

a matter of debate, seem to be important. 

ARMs with an external fistula in female patients, occurring 

in about 90% of all girls with ARM [20, 21], offer 

a classic opportunity to study the development of IAS and the 

influence of its preservation during surgery on postoperative 

continence. In the presented series ARMs with recto-cutaneous 

or recto-vestibular fistula were recorded in 86% of patients. 

These results are similar to data published by Peňa 

[21], who found these fistulas to be the most common ARM 

occurring in girls. In the presented series, in contrast to older 

studies [4], the most common ARM was recto-vestibular 

fistula, occurring in 40% of patients of both groups. This probably 

resulted from differences in classification and difficulties 

in the detailed clinical assessment of the perineum. Such 

differences in classification and difficulties in assessment 

may be responsible for the differences between data from published 

series on the incidence of associated congenital anomalies. 

In this series associated congenital anomalies were 

noted in more than 50 % of girls with ARM and external fistula. 

A high incidence of associated anomalies points to the 

need of active screening, also in the group of patients with 

„few defects”, in whom the incidence of associated anomalies 

was underestimated in the past [3, 18]. In these studies 

associated congenital anomalies were recorded in 17% of 

girls with recto-cutaneous fistula and in 73% of girls with 

recto-vestibular/vaginal fistula. Heinen [5] also stressed the 

possibility of understanding the occurrence of congenital 

CUN anomalies, which both in his series and in the presented 

series were equal, occurring in 10% of girls with ARM. 

Underestimation of these defects could be connected with the 

problem of a broad application of modern imaging techniques 

(CT, NMR) in diagnostic schedules in patients with ARM 

[7, 14]. 

The use of clinical scales for the assessment of continence 

indicated clear differences in postoperative continence 

between both study groups. In group 1, compared to age- 

-matched controls, the results of postoperative continence, as 

assessed by all four clinical scales, were distinctly worse 

with results achieving statistical difference. The most significant 

statistical difference in the assessment of continence 

was noted when using the Holschneider/Rintala scale, which 

appears to be the most sensitive scale for all methods. In group 

2, clinical assessment of postoperative continence with 

three of the four methods did not reveal significant statistical 

differences compared to healthy controls. The only statistical 

differences were noted when using the Holschneider/Rintala 

scale, which indicated even delicate disturbances 

of continence between both study groups, and could be 

explained by utilization in group 2 of the whole length of the 

fistula containing the IAS, and the use of ASARP (in comparison 

with PSARP) allowing a limitation in the length of 

separation of the fistula during reconstruction of ARM [1]. 

Manometric studies for the assessment of continence also indicated 

better results in postoperative continence in group 

2 after the ASARP procedure. A direct comparison of all manometric 

parameters indicated statistically significant better 

results in group 2. This together with the fact, that no statistical 

differences were noted between the manometric studies 

in group 2 and the manometric results obtained in healthy 

controls, is a strong argument for the use of the ASARP procedure 

as a surgical technique for the reconstruction of ARM 

in girls. 

The presence and function of the internal anal sphincter 

in the fistula in patients with ARM, as well as its utilization 

during reconstruction and its influence on the quality of 

postoperative continence are still a matter of debate. In the 

presented series manometric studies were used for the assessment 

of the quality and function of IAS in girls with ARM 

and external fistula. The lack of differences in the results of 

manometric studies of the fistula in girls with ARM and the 

result in age-matched healthy controls, clearly point to the 

functional presence of IAS in the fistula. These results together 

with the evidence of recto-anal relaxation reflex in the 

fistula in all girls before surgery for ARM and the evidence 

of RARR in 96 % of patients from group 2 after reconstruction 

of defects not only proves the presence of IAS but also 

its full reflexive ability. The evidence of RARR in 3 patients 

after PSARP procedure was probably connected with remnants 

of the IAS remaining after resection of the end of the 

fistula, while evidence of partial RARR in the fistula of girls 

with ARM prior to reconstruction could be explained by partial 

maldevelopment of the IAS and the presence of a common 

vagina and fistula wall resulting in disturbances in relaxation 

of IAS, as has been noted in other studies [23].

29 

The interpretation of the results achieved allows the 

conclusion to be drawn that an embryologically well developed 

and functionally efficient IAS is always present in the 

external fistula in girls with ARM despite the type of defect. 

These results also confirm the results of embryologic experimental 

studies by Kluth and Lambrecht [11, 13] and of studies 

by Nievelstein in human embryos [17], which considered 

the fistula in ARM to be part of the ectopy of the primitive 

anal canal, providing the basis for the utilization of the 

whole fistula during reconstructive ARM procedures. 

The results of histologic studies by Meier-Ruge [15] 

and Holschneider [6] remain in opposition to this suggestion. 

Disturbances in the innervation of the distal part of the fistula, 

similar to typical aganglionosis or Hirschsprung disease, 

hypoganglionosis, dysganglionosis, or intestinal neuronal 

dysplasia [15] are claimed to be responsible for the high incidence 

of constipation connected with preservation of the fistula 

during reconstruction of ARM [6]. These observations, 

however, are not confirmed by others [22, 25] and in the presented 

series the incidence of postoperative constipation after 

reconstruction of ARM was not different in patients, irrespective 

of whether the procedures had utilized or not utilized 

the whole external fistula. Although the controversy respecting 

ARM procedures with potentially hypoplastic, yet 

functionally completely efficient internal sphincters is still 

there and will generate further detailed studies, the better results 

of continence achieved here in the group in whom an 

„internal sphincter saving procedure” was carried out suggests 

that this procedure should be the procedure of choice for 

all girls with anorectal malformations. 

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The impact of probiotic Lactobacillus casei and paracasei 

strains on cytokine profile in children with atopic dermatitis 

Ilona Rosiak 1 , Urszula Witos³aw 2 , Aldona Ceregra 3 , El¿bieta Klewicka 4 , 

Ilona Motyl 4 , Zdzis³awa Libudzisz 4 , Bo¿ena Cukrowska 1 

Diagnostic 

Paediatric 

Pathology 

1 


3 

Department of Paediatrics 

The Children's Memorial Health Institute, Warsaw, Poland 

2 

Warsaw Agricultural University 


4 

Institute of Fermentation Technology and Microbiology 

Technical University of Lodz, Lodz, Poland 

Abstract 

Probiotic bacteria have been shown to improve the severity of allergic disease such as atopic dermatitis. 

We presented novel Lactobacillus casei and paracasei strains which improved the clinical status of children 

with cow milk protein allergy. The aim of this study was to evaluate the impact of those novel Lactobacillus 

strains on the level of interleukin (IL)-5, IL-10, IL-12, tumor necrosis factor (TNF) -alpha, interferon (IFN) 

-gamma and transforming growth factor (TGF)-beta1 in blood cell cultures of infants with atopic dermatitis. 

The study included 30 children with cow milk protein allergy at the mean age 10 months. Blood cells 

were incubated with the mixture of three selected Lactobacillus strains and polyclonal activator 

phytohemagglutinin (PHA). The level of cytokines was measured in culture supernatants by 

immunoenzymatic assays. The levels of TGF-beta, TNF-alpha. IL-12 and IFN-gamma were markedly 

higher after incubation with probiotic bacteria as compared with PHA. Only differences in IFN-gamma 

level did not achieve statistical significance. In contrast, IL-10 and IL-5 were produced in significantly 

lower amounts when cells were activated by the mixture of Lactobacilllus strains than by PHA. Our results 

show that novel probiotic Lactobacillus casei and paracasei strains can affect the immune system by 

induction of both regulatory and proinflammatory cytokine production and by inhibition of pro-allergic 

cytokine profile. 

Key words: allergy, atopic dermatitis, Lactobacillus, probiotics 

Introduction 

Probiotics are defined as viable microorganisms that exhibit 

beneficial health effects when consumed in adequate amount 

[5]. Most current probiotics are lactic acid bacteria, especially 

Lactobacillus and Bifidobacterium species. It is known clinical 

fact that Lactobacillus rhamnosus GG can be successfully 

used for the treatment of atopic dermatitis [6]. Probiotics 

(Lactobacillus rhamnosus strain GG and Escherichia 

coli strain O83) protect also from the development of allergic 

diseases when they are administrated to atopic mothers 

or newborns [7, 8, 10]. 

Recently, we observed that novel probiotic Lactobacillus 

strains genetically identified as L. casei and L. paracasei 

significantly decreased the severity of atopic dermatitis 

in infants with cow milk allergy [4]. Clinical examinations 

showed the significant improvement of atopic dermatitis 

symptoms measured by SCORAD index in children rece- 


Bo¿ena Cukrowska, MD, PhD Fax: +48 22 815 19 75 


E-mail: b.cukrowska@czd.pl 




32 

iving probiotics as compared with the placebo group. Immunological 

examinations showed a decrease in level of IgE in 

children receiving probiotics as compared with placebo group. 

In contrast to clinical and immunological findings Lactobacillus 

application did not significantly change the composition 

of gut microflora. These results suggest that beneficial 

impact on allergy development is dependent on direct 

activation of the immune system by probiotics. 

It is supposed that lactobacilli contribute to the activation 

of regulatory T-helper cell immune response and to 

the maintaince of T-helper-1 (Th1)/Th2 cytokine homeostasis 

[3, 18]. They were shown to enhance production of pro- 

-inflammatory Th1 cytokines and/or to reduce Th2 dominance 

in allergic patients [12, 13]. 

The aim of this study was to evaluate the impact of 

novel probiotic Lactobacillus casei and paracasei strains 

on the level of pro-inflammatoy (IL-12, IFN-gamma, 

TNF-a-lpha), proallergic (IL-5) and regulatory (TGF-β 1 , 

IL-10) cytokines in blood cell cultures obtained from allergic 

infants. 

Material and methods 

Patients’ characteristics 

The study included 30 children aged 3 months – 15 months 

(mean age 10 months) with atopic dermatitis caused by cow 

milk allergy. The severity of changes measured by SCORAD 

index was 32,5. The infants participated in the study with the 

informed consent of their parents and the study was approved 

by the Ethics Committee of the Children’s Memorial Health 

Institute. 

Genetic identification of Lactobacillus strains 

Lactobacillus bacteria were isolated from human (infant) and 

animal (rat) alimentary tract and from fermented milk beverages, 

and than collected at Collection of Industrial Microorganisms 

of the Institute Fermentation Technology and Microbiology 

£OCK 105 of Technical University, Lodz. Finally, 

twenty four Lactobacillus strains were identified by analysis 

of 16S ribosomal RNA (rRNA) sequences according Salama 

et al. [16]. Total DNA was extracted from bacteria as previously 

described by Tailiez et al. [17]. After PCR amplification 

of 16S rRNA gene, sequencing with universal 343 F and 1406 

GR primers was done using BigDye Terminator Cycle Sequencing 

(Applied Biosystem, USA). Sequences were read in 

ABI 377 apparatus (Applied Biosystem, USA) and analysed 

by computer comparison with BLAST software. 

Three Lactobacillus strains (£OCK 0900, 0908, 

0919) presenting the highest antagonism against pathogens, 

the highest adherence to Caco-2 epithelial cell line, and the 

highest viability in low pH and high bile salt concentration 

[1] were chosen for analyses of cytokine activation in blood 

cultures. 

Blood cultures 

The cell cultures were prepared from the whole blood. Heparinized 

blood was diluted (1:5) with RPMI-1640 medium 

(Sigma) without fetal calf serum with antibiotics (Sigma). 

Blood sample (150 µl) and equal quantity of the mixture of 

heat inactivated probiotic Lactobacillus casei and paracasei 

in final concentration 2,5 × 10 6 /mL was added to a microtitter 

well. As a positive and negative control polyclonal activator 

phytohemagglutinin (PHA) (Difco Laboratories, Detroit, 

USA) in final concentration 10 µg/mL and alone cultivated 

medium were used respectively. The cultures were 

incubated at 37 o C in humid air containing 5% CO 2 for 72 

hours. After this time supernatants were collected and frozen 

at –70 o C until analysis. 

Cytokine determination 

The cytokine level was determined in supernatants using 

R&D System Kits according to the instructions of the manufacturer. 

Briefly, 50 µl of supernatants was added to 

a microtitter well coated with the specific monoclonal antibody 

and left for 24 hour in 4 o C. After incubation the 

wells were washed and 100 µl of detection antibody was 

added to each well and the plates were incubated for 2 hours 

in room temperature. Then the wells were washed again 

and 100 µl of streptavidin was added for 20 minutes. Finally, 

the plates were washed and 50 µl of solution containing 

o–phenylenediamine dihydrochloride (Sigma) was 

added. The reaction was stopped with acid sulphuric and 

the plates were read on micro-ELISA reader at 450. The 

amounts of cytokines were calculated from the standard curve. 

The results were expressed in pg/mL as arithmetical 

means. 

Statistical analysis 

The results were statistically analyzed using nonparametric 

Mann-Whitney test. P

33 

Fig. 2 The level of pro-allergic IL-5 in blood cultures of allergic infants 

Fig. 1 The level of pro-inflammatory Th 1 cytokines in blood cultures of 

allergic infants 

Fig. 3 The level of regulatory cytokines in blood cultures of allergic infants 

Discussion 

Allergy was recently described as being the result of a deficit 

of bacterial stimulation during childhood [21]. The administration 

of probiotic bacteria, mainly Lactobacillus rhamnosus 

GG into breast-feeding mothers and to newborn babies 

led to a high inhibition (50%) of the risk of atopic dermatitis 

in children [7, 8]. Different Lactobacillus and Bifidobacterium 

strains have been shown to be useful in the treatment 

of atopic dermatitis in children [6, 15, 19, 20]. 

Our group presented novel probiotic L. casei and L. 

paracasei strains, which in infants significantly reduced the 

severity of atopic dermatitis [4]. The results of the present 

study show that novel selected probiotic strains are potent in-

34 

ducers of pro-inflammatory cytokines and TGF-beta1 in allergic 

children. In contrast, they do not trigger pro-allergic 

cytokines produced by type 2 helper cells. 

It is believed that probiotics exert the beneficial effects 

in allergic patients by regulation of Th1/Th2 cytokine 

profile. Allergic diseases are characterized by expression of 

a type 2 cytokine profile. Indeed, IL-4, IL-5, IL-13 and IL-9 

are involved in the initiation and maintenance of the allergic 

reactions [11]. Thus, probiotic bacteria resulting in reduction 

of Th2 cytokines release and enhance of Th1 cytokine production 

can exert beneficial effects in allergic patients. 

The presented probiotic strains activated IL-12, TNFalpha 

and IFN-gamma production in higher amounts than 

known polyclonal activator PHA. Simultaneously IL-5 secretion 

was not detected. Our results correlate with studies 

performed with known probiotic strains. Pochard et al. [12] 

showed that Lactobacillus bacteria including L. rhamnosus 

GG inhibited production of IL-4 and IL-5 in blood mononuclear 

cells isolated from allergic patients, and this effect was 

dependent on enhanced production of IL-12 and IFN-gamma. 

Among the soluble factors that influence the Th1/Th2 

balance, IL-12 is a key cytokine responsible for initiating and 

maintaining IFN-gamma-producing Th1 cells. A wide diversity 

of microbial components trigger this cytokine by reactions 

with pattern recognition receptors, such as Toll-like receptors 

(TLR), which in human are widely expressed in gut 

epithelium, intestinal dendritic cells, lymphocytes [14]. 

On the other hand, it is necessary to stress that continuous 

activation of immune response with the production of 

inflammatory cytokine could be devastating to the host. Therefore, 

probiotic strains should control and prevent an inappropriate 

and dangerous activation of inflammatory cascades 

and should augment development of tolerance towards allergens. 

We demonstrated that our selected probiotic strains induced 

production of TGF-beta1 and in lower amounts IL-10, 

i.e. the regulatory cytokine playing role in maintaining the balance 

between Th1/Th2 responses and in induction of oral tolerance 

[9]. TGF-beta blocks the differentiation of Th1 and 

Th2 cells via inhibition of the transcriptional factors required 

for expression of INF-gamma and IL-4. IL-10 can also inhibit 

both IL-12 synthesis and Th1 differentiation, but in some 

mouse model IL-10 produced by lung dendritic cells appeared 

to be critical for Th2 responses to inhaled antigens [2]. 

Concluding our study showed that novel probiotic 

Lactobacillus casei and paracasei strains can affect the immune 

system by induction of both regulatory and proinflammatory 

cytokine production and by inhibition of pro-allergic 

cytokine profile. 


This study is supported by the State Committee for Research 

(project 2P05E 067 26) and Institute Danone. 

References 

1. Ceregra A, Kozakova H, Czarnowska 

E, at al (2005) Effect of gastrointestinal 

application of probiotic Lactobacillus 

casei/paracasei strains on bacteria translocation 

and cytokine production. Folia 

Histochem Cytobiol 43(Supl 1):28 

2. Constant SL, Brogdon JL, Piggott 

DADA, Herrick CA, Visintin I, Ruddle 

NH, Bottomly K (2002) resident lung 

antigen-presenting cells have the capacity 

to promote Th2 cell differentiation 

in situ. J Clin Invest 110:1441–1448 

3. Cukrowska B (2002) The role of the intestinal 

microflora in the development 

of allergies: the modulation of the immune 

system by probiotics. Ann Diag 

Paediatr Pathol 6:89–96 

4. Cukrowska B, Piontek E, Najberg E, et 

al (2005) The effect of new probiotic 

Lactobacillus casei and casei/paracasei 

strains on gut ecosystem and clinical 

symptoms of children with atopic dermatitis. 

Allegy Clin Immunol Intern 

(Supl 1):1645 

5. Isolauri E (2001) Probiotics in human disease. 

Am J Clin Nutr 73:1142S–1146S 

6. Isolauri E, Matikainen S, Vuopio-Varkila 

J, et al (2000) Probiotics in the management 

of atopic eczema. Clin Exp 

Allergy, 2000, 30, 1604–1610 

7. Kalliomaki M, Salminen S, Arvilommi 

H, Koro P, Koskinen P, Isolauri E 

(2001) Probiotics in primary prevention 

of atopic disease: a randomized placebo- 

-controlled trial. Lancet 357:1076–1079 

8. Kalliomaki M, Salminen S, Poussa T, 

Arvilommi H, Isolauri R (2003) Probiotics 

and prevention of atopic disease: 

4-year follow-up of a randomized placebo-controlled 

trial. Lancet 361: 

1869–1871 

9. Levings MK, Bacchetta R, Schultz U, 

Roncarolo MG (2002) The role of Il-10 

and TGF-beta in the differentiation and 

effecto function of T egulatory cells. Int 

Arch Allergy Immunol 129:263–276 

10. Lodinova-Zadnikova R, Cukrowska B, 

Tlaskalova-Hogenova H (2003) Oral 

administration of probiotic Escherichia 

coli after birth reduces frequency of 

allergies and repeated infections later in 

life (after 10 and 20 years). In Arch 

Allergy Immunol 131: 209-211 

11. Novak N, Bieber T, Leung DYM 

(2003) Immune mechanisms leading to 

atopic dermatitis. J Allergy Clin Immunol 

112:S128–139 

12. Pochard P, Gosset P, Grangette C, et al 

(2002) Lactic acid bacteria inhibit TH2 

cytokine production by mononuclear 

cells from allergic patients. J Allergy 

Clin Immunol 32:563–570 

13. Pohjavuori E, Viljanen M, Korpela R 

(2004) Lactobacillus GG effect in increasing 

IFN-gamma production in infants 

with cow’s milk allergy. J Allergy 

Clin Immunol 114:131–136 

14. Rakoff-Nahoum S, Paglino J, Eslami- 

-Varzaneh F, Edberg S, Medzhitov R 

(2004) Recognition of commensal microflora 

by toll-like receptors is required 

for intestinal homeostasis. Cell 

118:229–241 

15. Rosenfeld V, Benfeldt E, Nielsen SD, 

et al (2003) Effects of probiotic Lactobacillus 

strains in children with atopic 

dermatitis. J Allergy Clin Immunol 

111:389–395

16. Salama M, Sandine W, Giovannoni S 

(1991) Development and application of 

oligonucleotide probes for identification 

of Lactococcus lactis subsp. cremoris. 

Appl Environ Microbiol 57(5): 

1313–1318 

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Chopin A (1998) Molecular diversity 

and relationship with in Lactococcus 

lactis, as revealed by randomly amplified 

polymorphic DNA (RAPD). System 

Appl Microbiol 21:530–538 

18. Tlaskalova-Hogenova H, Stepankova 

R, Hudcovic T, et al (2004) Commensal 

bacteria (normal mikroflora), mucosal 

immunity and chronic inflammatory 

and autoimmune diseases. Immunol 

Lett 93:97–10 

19. Viljanen M, Savilahti E, Haahtela T, et 

al (2005) Probiotics in the treatment of 

atopic eczema/dermatitis syndrome in 

infants: a double-blind placebo-controlled 

trial. Allergy 60:494–500 

35 

20. Westen S, Halbert A, Richmond P, Prescott 

SL (2005) Effects of probiotics on 

atopic dermatitis: a randomized controlled 

trial. Arch Dis Child 90:892–897 

21. Wold AE (1998) The hygiene hypothesis 

revised: is the rising frequency of allergy 

due to changes in intestinal flora 

Allergy 53(Supl):20–25



Comparison of histological changes in liver biopsy specimens 

in patients with biliary atresia of poor and good prognosis 

Joanna Cielecka-Kuszyk 1 , Piotr Czubkowski 2 , Ludmi³a Bacewicz 3 , 

Joanna Paw³owska 2 , Irena Jankowska 2 , Tamara Szymañska-Dêbiñska 1 

Diagnostic 

Paediatric 

Pathology 

1 


2 

Department of Gastroenterology, Hepatology and Immunology 

3 

Department of Pediatric Surgery and Organ Transplantation 

The Children’s Memorial Health Institute, Warsaw, Poland 


Abstract 

In order to compare intrahepatic histological changes in patients with biliary atresia of poor and good 

prognosis, we have examined retrospectively 29 liver biopsy specimens taken during hepatoportoenterostomy 

modo Kasai. We divided the material into two groups: 12 biopsy specimens were qualified to 

the first – unfavorable group with poor prognosis, because patients died or needed liver transplantation 

within 2 years after Kasai procedure and 17 biopsy specimens were qualified to the second – favorable 

group with good prognosis, because children have survived over 5 years with native liver. Presence of 

prominent giant cell transformation, lobular inflammation and features of ductal plate malformation differed 

in these two groups. Lobular cholestasis in zone 2 and 3 was of statistical significance in patients with poor 

prognosis. 

Key words: biliary atresia, hepatoportoenterostomy, ductal plate malformation, giant cells transformation, 

lobular inflammation, cholestasis 

Introduction 

Biliary atresia (BA) is the commonest cause of infantile cholestasis 

and leading indication for liver transplantation in children. 

[1]. Progressive fibro-inflammatory changes lead to irreversible 

cholangiopathy with complete obliteration of extra 

and intrahepatic bile ducts, though basic pathomechnisms of 

disease remain unclear. BA could also result from a developmental 

aberration occurring between 11 and 13 weeks gestation 

[13]. Destructive character of BA leads to death in the 

first 2 years of life if untreated [4]. The only chance to limit 

disease progression is to establish bile flow by Kasai hepatoportoenterostomy 

with best results if procedure is performed 

before 8 weeks of age. [11]. Introducing liver transplantation 

(LTx) in children opened new era in outcome of BA treatment, 

reaching overall 5 year survival in almost 80% of patients. 

LTx timing is an important factor influencing outcome 

so it is crucial to distinguish early prognostic factors. Characteristic 

histopathological changes in liver include cholestasis, 

inflammation, fibrosis and ductular proliferation. Prognostic 

value of liver histopathology is believed to be crucial but so 

far no firm criteria were established [4]. 

The present study is based on a histological analysis 

of the intrahepatic histopathological changes in patients with 

poor and good prognosis of the disease. The aim of the study 

was to compare the stage of liver fibrosis, inflammation, 

ductular proliferation, giant cell transformation and cholestasis 

in surgical specimens taken during hepatoportoenterostomy 

modo Kasai from patients who had good and poor prognosis. 


Jaonna Cielecka-Kuszyk Phone: +48 22 815 19 60 


E-mail: j.kuszyk@czd.pl 


Al. Dzieci Polskich 20 


38 

Patients, material and methods 

The Children's Memorial Health Institute is the referral hospital 

for children with biliary atresia. From children hospitalized 

between May 1991 and April 2001 who underwent 

Kasai hepatoportoenterostomy at age between 30 and 70 

days (average 55 days) we distinguished two groups according 

to clinical outcome after operation: 12 liver biopsy 

specimens were qualified to the first – unfavorable group 

with poor prognosis, because patients, 16% male and 74% 

female, died or needed liver transplantation within 2 years 

after Kasai procedure (Table 1A) and 17 other liver biopsy 

specimens were qualified to the second – favorable group 

with good prognosis, because patients, 23% male and 77% 

female, survived over 5 years with no complications (Table 

1B). The liver wedge biopsies were collected during 

Kasai procedure. The research was carried out in accordance 

with the recommendations of the Bioethic Commission 

in the hospital. 

Histological examination 

All liver biopsy specimens were fixed in 10% neutral buffered 

formalin and embedded in paraffin. Sections displaying 

at least 10 portal tracts were routinely stained by Hematoxylin-Eosin, 

Periodic Acid-Schiff method, with and without 

diastase, Gomori silver stain, Azan method. In the course of 

evaluation histological activity of the disease, each sample 

was described using Ludwig classification for fibrosis and inflammation 

[2]. Liver fibrosis was assessed as follows: grade 

1 mild fibrosis: expansion of fibrous tissue in the portal 

tract; grade 2 moderate fibrosis with portal to portal bridging; 

grade 3 severe fibrosis with portal to portal bridging; grade 

4 cirrhosis with a reconstruction of hepatic lobules. Inflammatory 

changes were classified as grade 1 minimal inflammation; 

grade 2 mild inflammation; grade 3 moderate inflammation; 

grade 4 severe inflammation. The following categories 

of lesions were investigated: piecemeal necrosis, 

lobular inflammation, microabscesses, focal necrosis, portal 

and lobular inflammation, giant cell transformation, cholestasis, 

cholangitis, bile duct dilatation, cholangiolitis. These 

histological criteria were assessed as follows [7] – grade 

0 absent; 1 minimally present; 2 moderately present; 3 severe 

present. 

Immunohistochemical study 

The ductal and ductular phenotype was examined on paraffin 

embedded tissue using monoclonal antibodies directed 

against Cytokeratin 7 (OV-TL 1:50 Dako) and 19 (RCK 108 

1:100 Dako) and SMA by means of EnVision system 

DAKO. This method allowed to determine changes specific 

for ductal plate malformation by the positive staining on bile 

ductules epithelia and abnormal ductal structures. Immunologic 

staining for SMA was performed by an immunoperoxidase 

method allowed to demonstrate the lobular and portal 

architecture of the liver. One negative control was used 

from the liver tissue obtained from a child with autoimmune 

hepatitis. 

Table 1 

Characteristics of patients 

A. Group I: The first unfavorable group, patients died 

or needed liver transplantation within 2 years after Kasai 

procedure 

No patients Age at Kasai Survival/LTx 

procedure (days) (ages) 

1 F 50 0,4 

2 M 64 0,6 

3 M 60 0,6 

4 F 68 0,7 

5 F 49 0,7 

6 F 60 0,7 

7 F 46 0,9 

8 F 68 1,1 

9 F 55 1,2 

10 F 39 1,8 

11 F 47 2,7 

12 F 31 4,0 

B. Group II: The second favorable group, patients survived 

over 5 years with native liver after Kasai procedure 

No patients Age at Kasai Survival/LTx 

procedure (days) (ages) 

1 M 52 5,7 

2 M 60 6,1 

3 F 61 6,1 

4 F 48 6,2 

5 F 68 6,3 

6 F 38 8,1 

7 F 42 8,4 

8 F 63 8,8 

9 F 63 10,0 

10 F 55 10,0 

11 F 65 10,3 

12 M 63 11,0 

13 F 39 11,6 

14 F 48 12,0 

15 F 55 12,7 

16 F 69 16,9 

17 M 58 17,9 

Statistical analysis 

Chi-square Independence test and Kolmogorov-Smirnov test 

(significance level 0,05) was applied for the purpose of comparison 

the various histopathological intrahepatic changes 

with the age at Kasai procedure and length of survival period 

or time to the liver transplantation after operation.

39 

Results 

Morphological changes and cytokeratin expression 

in the liver 

The frequency of histological changes is demonstrated in Table 

2. We have found fibrosis, inflammatory changes in the 

portal tracts and lobules, cholestasis in zone 3, bile ductular 

proliferation with abnormal structures (concentric, tubular, 

reduplicated), cholangiolitis in all cases, but the intensity of 

these changes was different (Table 3). 

Table 2 

Histological changes in the first group of patients with poor 

prognosis and in the second group of patients with good 

prognosis 

No of cases (%) No of cases (%) 

Group I Group II 

Cholestasis 

Zone 1 100% 100% 

Zone 2 83% 41% 

Zone 3 83% 35% 

Ductules 66% 29% 

Ducts 83% 88% 

Dilatation of bile ducts 0% 0% 

Cholangitis 33% 41% 

Cholangiolitis 66% 41% 

Bile ductular proliferation 100% 100% 

Piecemeal necrosis 66% 64% 

Giant cell transformation 66% 29% 

Foci of hematopoesis 66% 41% 

Abnormal structures 

(concentric, tubular, 

reduplicated) 100% 100% 

Ductal plate malformation 66% 35% 

Fibrosis 

Grade 1 0% 0% 

Grade 2 33% 35% 

Grade 3 66% 64% 

Grade 4 0% 0% 

Table 3 

Comparison of significant histological parameters in the first 

group with poor prognosis and the second group with good 

prognosis 

Z3 cholestasis in zone 3, Ch cholangiolitis, GCT giant cell transformation, 

DPM ductal plate malformation 

The degree of fibrosis was similar in both groups at 

the time of Kasai procedure: we found moderate fibrosis of 

portal tracts and fibrous portal to portal septa in 4 infants 

from the first unfavorable group, in 6 infants from the second 

favorable group and severe fibrosis with septal bridging in 

8 infants from the first unfavorable group, in 11 infants from 

the second favorable group (Fig. 1C). Cirrhosis was absent 

at the time of Kasai procedure. 

Mild inflammatory changes with the presence of diffuse 

polymorphous infiltration consisted of granulocytes 

and lymphocytes in the portal tracts and fibrous septa were 

observed in all cases, but piecemeal necrosis was not a constant 

feature. In contrast, lobular inflammation was more 

prominent in the first unfavorable group. Prominent inflammation 

with massive infiltration of granulocytes and lymphocytes 

was seen only in two cases from the first unfavorable 

group, aged 49 days and 60 days at the time of Kasai 

procedure. They had also features of destructive cholangitis. 

We observed active necro-inflammatory lesions of the 

bile ducts and concentric fibrosis around their lumina. One 

of these patients died 7 months after Kasai procedure and 

the second one needed liver transplantation 8 months after 

Kasai procedure. 

In summary, cholangitis was seen in 4 and cholangiolitis 

in 8 patients from the first group as slight inflammation 

and infiltration of epithelial bile duct cells with few 

lymphocytes (periductal and intraepithelial infiltration). We 

found similar changes in 7 patients from the second favorable 

group. We didn`t observe any paucity of intrahepatic 

ducts. 

Bile ductular proliferation, seen in all cases in both 

groups was present at the limiting plate, in periportal zones 

and in the center of portal tracts, often as curved, tubular, 

concentric structures, and was not always associated with the 

inflammation. The degree varied between cases of the same 

group but was not dependent on other factors. 

Ductal plate malformation, persistence of fetal biliary 

structures, seen in 8 cases (66%) from the first unfavorable 

group and 6 cases (41%) from the second favorable group 

was characterized by an increased number of bile ducts at 

the limiting plate, without connective tissue between the lobule, 

irregular contours of the ductal lumina, lack of the centrally 

located bile duct and lack of a portal venule. These 

structures were curved, concentric, sometimes around a fibrous 

core in the portal tract (Fig. 1D). Their distribution was 

irregular, they were not present in all portal tracts. The 

expression of CK7 and CK19 was useful to identify features 

of ductal plate malformation, especially when inflammatory 

infiltrates were abundant (Fig. 1D). 

Hepatocytic giant cells were observed in 8 infants 

from the first unfavorable group (66%) and in 5 infants from 

the second favorable group (29%) of examined material. The 

number of nuclei ranged from 8 till 15 nuclei, usually they 

had bile pigment accumulation in the center forming often intralobular 

rosettes. Many well-defined rosettes were partially 

lined by giant cells (Fig. 1B).

40 

A 

D 

B 

C 

Fig. 1 Demonstration of histological changes in biliary atresia 

A. Cholestasis in zone 3, focus of hematopoesis (H&E) 

B. Giant cell transformation (H&E) 

C. Severe fibrosis (H&E) 

D. Features of ductal plate malformation CK7 and CK 19 (EnVision) 

Discussion 

The distribution of cholestasis was significantly different 

in both groups (Fig. 1A). Cholestasis in zone 1 was seen 

in all cases, but regular in zone 2 and 3 in the first group 

and was statistically different from the second group. Chi- 

-square Independence test and Kolmogorov-Smirnov test 

performed on liver specimens from patients with the first 

unfavorable group and the second favorable group (significance 

level 0.05) showed dependency between cholestasis in 

zone 2 and 3. 

There are two clinical forms of biliary atresia: embryonic and 

perinatal. The embryonic type occurs in 35% of patients, is 

characterised by early onset of neonatal cholestasis without 

jaundice free period and ductal plate remnants are often present 

in the liver. The perinatal type occurs in 65% of patients, 

has a later onset of cholestasis and jaundice free period may 

be present after physiological jaundice. The proposed prognostic 

factors after Kasai procedure include age at operation, 

ductal size at porta hepatic, grade of liver fibrosis, ductal plate 

malformation and ductular proliferation [7, 9, 16]. Our 

work based on the retrospective selection of patients at the same 

age during Kasai procedure, but different survival with native 

liver. The grade of fibrosis was similar in both groups and 

we didn`t observe any cirrhotic changes, and age of the patients 

ranged from 31 to 69 days. Some authors believe that 

hepatic fibrosis, rather than age, is an important prognostic 

factor [14]. In our material, two infants who underwent Kasai 

hepatoportoenterostomy at the age of 31 and 39 days, pro-

41 

gressed quickly to liver failure and liver transplantation after 

4 and 1,8 years respectively. In the initial biopsy they presented 

similar changes like other patients from the first, unfavorable 

group, but lobular inflammation, giant cell transformation, 

ductal plate malformation and cholestasis in zone 3 were 

exceptionally severe. It doesn`t mean, as pointed in the 

literature, that outcome of early hepatic portoenterostomy for 

biliary atresia is worse, but it may reflect a difference in the 

pathogenesis of the disease – fetal and perinatal type, phenotype 

for different disease processes [15]. 

Ductal plate malformation may indicate an early onset 

of disease and can be seen in cases, when injury of bile 

ducts occurs early in fetal life with destruction and without 

selection of immature bile ducts. Ductal plate is formed around 

9 weeks of gestation and from 12 weeks of gestation begins 

the remodeling with incorporation into the connective 

tissue surrounding portal vein branches. The process of remodeling 

leads until term and by 4 weeks of life bile structures 

are similar to those of adult bile ducts. That is why the 

presence of ductal plate malformation in neonates is of pathological 

significance. The differential diagnosis of the persistence 

of fetal structures includes marginal ductular proliferation 

in neonatal cholestasis. In the literature it is pointed, 

that, when diagnosis is made on the basis of surgical and radiological 

findings, retrospective examination of the liver 

showed presence of ductal plate malformation in 21% – 85%. 

Other conditions of BA represent injury in a later stage with 

destruction of fully formed extraheaptic and intrahepatic bile 

ducts [3, 5, 12]. It is connected with abnormality of mesenchymal 

tissue around primitive bile ducts and disturbance 

in the epithelial-mesenchymal interactions [13]. In our 

material, ductal plate malformation was seen in 8 infants 

(66%) in the first unfavorable group and in 6 infants (35%) 

in the second favorable group. It was not consistent with degree 

of fibrosis. Presence of ductal plate malformation may 

play role as an indicator of prognosis. 

Ductular proliferation, reported by some authors as 

predictor of poor prognosis [16] was observed in our material 

in all patients in both two groups and was rather associated 

with cholestasis. Ductal proliferation was more intensive 

when ductal plate malformation was present. Epithelial cells 

forming bile ducts expressed CK7 and CK19 in addition to 

CK8 and CK 18 which was also positive in hepatocytes. Former 

immunohistochemical assessments showed that the 

number of CK7 positive cells in initial biopsy is significantly 

higher in a poor bile drainage group [8]. We didn`t demonstrate 

differences of the expression of CK7 and CK19 

because of lack of morphometric study. 

Predominance of giant cells in the biopsy specimens 

of patients with poor prognosis was well documented in our 

material. These giant cells are not regenerative/proliferative 

cells, they can be considered as a fusion of rosette forming 

hepatocytes and they are not associated with viral infection 

[10]. In the present study we have demonstrated that bile duct 

proliferation, cholestasis, cholangiolitis are almost invariably 

present at the time of surgical biopsy during Kasai procedure, 

indicating that neonatal reaction to cholestasis is similar 

to adult liver. 

In summary, presence of prominent giant cell transformation, 

lobular inflammation and features of ductal plate 

malformation differed in these two groups. Lobular cholestasis 

in zone 2 and 3 was of statistical significance in patients 

with poor prognosis. 


Research was supported by Grant Nr PB 695/PO5/2001/21 

and PB 0722/P05/2004/27. 

References 

1. Balistreri WF, Grand R, Hoofnagle JH, 

et al (1996) Biliary atresia: Current concepts 

and research directions. Summary 

of a symposium. Hepatology 23: 

1682–1689 

2. Batts K, Ludwig J (1995) Chronic hepatitis. 

An update on terminology and 

reporting. Am J Surg Pathol 19: 

1409–1417 

3. Chardot C, Carton M, Spire-Bendelac 

N, et al (2001) Is the Kasai operation 

still indicated in children older then 

3 months diagnosed with biliary atresia 

J Pediatr 138:224–229 

4. Chardot C, Carton M, Spire-Bendelac 

N, et al (1999) Prognosis of biliary atresia 

in the era of liver transplantation: 

French national study from 1986 to 

1996. Hepatology 30(3):606–611 

5. Cielecka-Kuszyk J, Paw³owska J, Dura 

WT, Jankowska I, Socha P, Czarnowska 

E, Szymczak M (1999) Immunopathology 

of biliary atresia: clinical and 

pathological study of 7 infants with biliary 

cirrhosis. Ped Develop Pathol 2: 

293–298 

6. Consolato S, Sven A, Kahl P, Herwart 

F (2000) The remodeling of the primitive 

human biliary system. Early Hum 

Dev 58:167–178 

7. Kenneth S, Azarow S, James Philips M, 

Sandler A, Hagerstrand I, Superina R 

(1997) Biliary atresia: should all patients 

undergo a portoentrostomy J Pediatr 

Surg 32(2):168–174 

8. Kinugasa Y, Nakashima Y, Matsuo S, 

Shono K, Suita S, Sucishi K (1999) Bile 

duct proliferation as a prognostic factor 

in biliary atresia: an immunohistochemical 

assessment. J Pediatr Surg 34 

(11):1715–1720 

9. Knisely A (2002) Paediatic biliary tract 

disease. Curr Diagn Pathol 8:152–159 

10. Koukoulis G, Mieli-Vergani G, Portmann 

B (1999) Infantile liver giant 

cells: immunohistochemical study of 

their proliferative stage and possible 

mechanisms of formation. Ped Develop 

Pathol 2:353–359 

11. Paw³owska J (2000) Dziecko z niedro¿- 

noœci¹ dróg ¿ó³ciowych u progu XXI 

wieku. Pediatria Polska LXXV (2): 

99–110 (in Polish)

42 

12. Raweily E, Gibson A, Burt A (1990) 

Abnormalities of intrahepatic bile ducts 

in intrahepatic biliary atresia. Histopathol 

17:521–527 

13. Tan C, Driver M, Howard R, Moscoso 

G (1994) Extrahepatic biliary atresia: 

a first trimester event Clues from light 

microscopy and immunohistochemistry. 

J Ped Surg 29:808–814 

14. Weerasoriya V, White F, Shepherd R 

(2004) Hepatic fibrosis and survival in 

biliary atresia. J Pediatr 144:123–125 

15. Volpert D, White F, Finegold M, Molleston 

J, De Baum M, Perlmutter D 

(2001) Outcome of early hepatic portoenterostomy 

for biliary atresia. J Pediatr 

Gastroenterol Nutr 32(3):265–268 

16. Yee Low, Vijaylaxmy Vijayan, Carolyn 

Tan (2001) The prognostic value of 

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An immunohistochemical study. J Pediatr 

139:320–322



Paraganglioma associated with neuroblastoma: 

rare composite tumor in a 16-year-old girl 

Przemyslaw Galazka 1 , Malgorzata Chrupek 1 , Roman Kazmirczuk 2 , 

Jaroslaw Peregud-Pogorzelski 3 , Malgorzata Pacholska 1 , Grzegorz Meder 4 , 

Przemyslaw Kluge 5 , Zdzislaw Skok 6 , Krzysztof Kusza 2 and Andrzej Igor Prokurat 1 

Diagnostic 

Paediatric 

Pathology 

1 


2 

Department of Anaesthesiology and Intensive Care 

4 

Department of Radiology 

6 Department of Pathology 

Nicolaus Copernicus University, 

Collegium Medicum in Bydgoszcz, Poland 

3 

Department of Oncology 

I Clinic of Pediatric Disorders, 

Pomeranian Medical University in Szczecin, Poland 

5 


Children’s Memorial Health Institute in Warsaw, Poland 

Abstract 

Composite pheochromocytomas are very rare and account for only 3% of both adrenal and extraadrenal 

pheochromocytomas. We report herein a case of 16-year-old girl with tumor of the retroperitoneal space. 

In her history she had episode of circulatory-respiratory collapse with pulmonary oedema during induction 

to general anaesthesia. Diagnosis from microscopic examination was unclear: paraganglioma in specimens 

obtained by core needle biopsy; neuroblastoma in material from open tumor biopsy. Preoperative imaging 

and scintigraphic studies as well as laboratory tests did not allowed to distinguish between paraganglioma 

and neuroblastoma. Preoperative studies have not shown any metastasis; the tumor size did not decrease 

after 4 courses of chemotherapy for neuroblastoma. After preoperative preparation with phenoxybenzamine 

patient underwent surgical removal of the tumor. Histopathologic study revealed paraganglioma with 

extensive areas of fibrosis. Patient remains disease free in 2 years follow up. In case of composite 

pheochromocytomas/paragangliomas an adequate preoperative diagnosis is not always possible using 

clinical, laboratory and imaging studies. In particular cases, even histopathologic examination of the biopsy 

specimen did not allow to establish firm diagnosis. 

Key words: composite paraganglioma, pheochromocytoma-neuroblastoma 

Introduction 

Composite pheochromocytomas are very rare and account 

for only 3% of both adrenal and extraadrenal pheochromocytomas 

[1]. These tumors contain a ganglioneuroma or less 

frequently a ganglioneuroblastoma component. Children 

with composite pheochromocytomas according to the literature 

tended to be older than patients with classical pheochromocytoma, 

and the tumors were mainly functional (catecholamine 

secreting) [5]. Some of these cases were associated 

with neurofibromatosis and multiple endocrine neoplasia 

[1, 8]. Extraadrenal paraganglioma is rare in the pediatric po- 


Przemyslaw Galazka Phone: +48 052 585 40 15 

Department of Pediatric Surgery Fax. +48 052 585 40 95 

Ul. Sklodowskiej-Curie 9 

E-mail: kikchirdz@cm.umk.pl 


44 

pulation and occur mostly in older children and adolescents 

[12]. We report herein a rare case of 16-year-old girl with 

a composite tumor (paraganglioma with neuroblastoma 

component) located in the retroperitoneal space. 

Case report 

A 16-year-old girl was referred to the Department of Oncology 

in Szczecin, Poland for the treatment of the retroperitoneal 

tumor. She had 2-year history of periodic, recurrent abdominal 

pain managed with spasmolythic agents. She did not 

have any additional complaints. On physical examination she 

was in good general condition, antropometrically presenting 

short height, and slightly disturbed body proportions (long 

body corpse and short extremities) similar to her mother. Her 

blood pressure and glycemia was normal, she did not have 

any episodes of vomiting, hypertension, or tachycardia. On 

physical examination there was an ill- defined, slightly tender, 

non-movable mass over the left side of her abdomen. 

Abdominal ultrasonography revealed left paraspinal mass, 

with intensive vascularity and mixed echogenicity. Fine needle 

aspiration biopsy detected atypical cells. Contrast enhanced 

computed tomography of the abdomen revealed a left 

retroperitoneal tumor (65 mm × 46 mm × 90 mm) below the 

pancreatic tail, attached to aorta and reaching aortic bifurcation. 

The mass was well defined, good vascularized, a pressure 

effect on the left illiopsoas muscle and lower pole of the 

left kidney was seen. The tumor displaced left renal, splenic 

and lower mesenteric vessels. There was no extension in the 

vertebral foramina (Fig. 1A, Fig. 1B). 

During induction to general anaesthesia, she had an 

episode of circulatory-respiratory collapse with pulmonary 

oedema. Using epidural analgesia, core needle biopsy of the 

tumor was performed, and the specimen was delivered for 

hematoxylin/eosin staining as well as for immunohistochemical 

studies. These studies were performed with commercially 

available antibodies (S-100 protein, chromogranin, sy- 

naptophysin, MIB-1, NSE and vimentin) and according to 

standard protocols. Pathological studies of the tumor revealed 

paraganglioma. 

In further diagnostic evaluation Metaiodobenzyl guanidine 

I 131 scintigraphy (MIBG) revealed uptake only 

within the tumor in left mid-abdomen with no metastasis. 

Laboratory data included urine catecholamine metabolites 

revealed increased level of vanilmandelic acid (VMA) 

(15,2 – 16,1 mg/24 h, N: 0,41 – 3,74). Based on these findings, 

pheochromocytoma or neuroblastoma was suspected. 

Open tumor biopsy was performed and histological evaluation 

revealed neuroblastoma (Fig. 2A, Fig. 2B). N-myc was 

not amplified in the molecular study of the tumor sample. 

Treatment with combination chemotherapy was executed 

(PACE protocol for III stage neuroblastoma: 4 preoperative 

cycles of vincristine, doxorubicin, cyclophosphamide and 

cisplatin). Tumor response for oncological treatment was 

judged as negative. Tumor size remained unchanged; whereas 

significant decrease of previously elevated level of 

VMA in 24-hour urine collection was noted (8,6 mg/24 h vs 

15,2 mg/24 h). 

Patient was referred to the Department of Pediatric 

Surgery, Collegium Medicum in Bydgoszcz, for the surgical 

treatment. After 3-week preoperative preparation with phenoxybenzamine 

patient underwent surgery. Transperitoneal 

approach was used for the complete removal of the tumor. 

Macroscopically tumor displayed hemorrhagic areas. Histopathologic 

study revealed paraganglioma with extensive areas 

of fibrosis (Fig. 3A, Fig. 3B). There was no perioperative 

and postoperative complications. In 2 years follow up patient 

remains free of disease. 

Discussion 

Composite pheochromocytomas – ganglioneuro (blasto) 

mas are rare composite tumors of both adrenal and extraadrenal 

pheochromocytomas [6]. Other non-pheochromo- 

A 

B 

Fig. 1 

A. Abdominal computed tomography revealed left retroperitoneal tumor. Preoperative study, after 4 courses of chemotherapy for neuroblastoma. 

B. 3-D reconstruction of a contrast enhanced abdominal CT scans provided good orientation in tumor vascularity and preoperative anatomical circumstances.

45 

A 

B 

Fig. 2 

A. Neuroblastoma. Specimen obtained by open tumor biopsy. Nests of small, primitive cells distributed between connective tissue are seen (hematoxylin and 

eosin, original magnification × 125). 

B. Histopathological examination of the specimen obtained by open tumor biopsy showed neuroblastoma: neuroblasts with hyperchromatic nuclei in smallfiber 

stroma consisted of unmyelinized neurons are seen (hematoxylin and eosin, original magnification × 225). 

A 

B 

Fig. 3 

A. Pheochromocytoma. Histopathological study of the resected tumor 

revealed extensive areas of fibrosis without features of necrosis (hematoxylin 

and eosin, original magnification × 125). 

B. Histopathological examination of the resected tumor showed 

pheochromocytoma where chief cells are large with a dark granular cytoplasm 

and vesicular nuclei (hematoxylin and eosin, original magnification × 225). 

cytoma components have been also reported [2,3,7,10]. 

Such type of pheochromocytoma is designated „composite” 

or „mixed”, depending whether the pheochromocytoma 

and non-pheochromocytoma components show the same 

embryonic origin [4]. Pediatric composite pheochromocytomas 

associated with neuroblastomatous elements are very 

rare [8]. According to the fact that these tumors exhibit 

areas of divergent differentiation, the diagnosis of can be 

complicated. Yoshimi et al described pathological features 

of composite pheochromocytoma-ganglioneuroma. Histologically, 

the two components of this tumor were minimally 

admixed with abrupt transition [13]. In other reported case, 

Pytel et al have described intimately admixed areas of 

ganglioneuroma and paraganglioma and this histomorphological 

finding allowed to proper diagnose composite paraganglioma 

[9]. One can conclude that histology of composite 

tumors may vary in each case. According to literature 

pheochromocytoma component in composite tumors is usually 

predominant [5]. To avoid the misdiagnosis of concomitant 

histological pattern in composite tumor, it is essential 

to adequately sample the tumor specimen. In case of 

composite tumors, the most challenging situation for pathologist, 

is when multiple histological patterns are present in 

the same tumor, and when there is limited amount of tissue 

available for evaluation (such as core needle biopsy). For 

these reasons authors reevaluated microscopic specimens 

obtained from the tumor by open biopsy (Fig. 2A, Fig. 2B). 

Surprisingly, one of three independent pathologists (all 

from reference centers) recognized in examined specimens 

only paraganglioma, but not with neuroblastoma components 

as was done by the others. This could illustrate problems 

in equivocal judgement of histomorphological studies 

in case of rare tumors when multiple histological patterns 

are present in the same tumor. 

Further problems which are arising is that because of 

the rarity, adjuvant therapy standards and final outcomes for

46 

composite pheochromocytomas / paragangliomas with neuroblastoma 

component yet has not been well established. Nakagawara 

et al suggested that the metastatic pattern is defined 

by the major component of tumor; one can ask the question 

if the tumor would not metastasize to the other organs, 

even if the foci of neuroblastoma are small [8]. In our case, 

although preoperative evaluation did not reveal any signs of 

metastatic disease, the suspicion of neuroblastoma really existed 

and chemotherapy protocol for neuroblastoma component 

was administered. After complete surgical resection of 

the tumor our patient did not demonstrate any signs of disease 

recurrence in 2 year follow up. 

Conclusions 

We can conclude, that in case of composite pheochromocytomas 

/ paragangliomas an adequate preoperative diagnosis 

is not always possible using clinical, laboratory and imaging 

studies. In particular cases, even histopathologic examination 

of the biopsy specimen did not allow to establish firm diagnosis. 

Composite or mixed tumors in children are rare and 

difficult to diagnose and treat. In these cases good communication 

between specialists involved in diagnostics and the 

treatment of the patient (surgeon, oncologist, radiologist and 

pathologist) is required. 

References 

1. Brady S, Lechan RM, Schaitzberg SD, 

Dayal Y, Ziar J, Tischler AS (1997) 

Composite pheochromocytoma/ganglioneuroma 

of the adrenal gland associated 

with multiple endocrine neoplasia 

2A. Am J Surg Pathol 21:102–108 

2. Harach HR, Laidler P (1993) Combined 

spindle cell cell sarcoma / phaeochromocytoma 

of the adrenal. Histopathology 

23:567–569 

3. Juarez D, Brown R, Ostrowski M, Reardon 

MJ, Lechago J, Truong LD 

(1999) Pheochromocytoma associated 

with neuroendocrine carcinoma: a new 

type of composite pheochromocytoma. 

Arch Pathol Lab Med. 123:1274–1279 

4. Lack EE (1994) Pathology of adrenal 

and extra-adrenal paraganglia. Major 

Probl Pathol 29:256–260 

5. Lam KY, Lo CY (1999) Composite 

pheochromocytoma-ganglioneuroma of 

the adrenal gland: an uncommon entity 

with distinctive clinicopathologic features. 

Endocr Pathol 10:343–352 

6. Linnoila RI, Keiser HR, Steinberg SM, 

Lack EE (1990) Histopathology of benign 

versus malignant sympathoadrenal 

paragangliomas: clinicopathologic study 

of 120 cases including unusual histologic 

features. Hum Pathol 21: 

1168–1180 

7. Min KW, Clemens A, Bell J, Dick H 

(1988) Malignant peripheral nerve sheath 

tumor and pheochromocytoma: 

a composite tumor of the adrenal. Arch 

Pathol Lab Med 112:266–270 

8. Nakagawara A, Ikeda K, Tsuneyoshi 

M, Daimaru Y, Enjoji M (1985) Malignant 

pheochromocytoma with ganglioneuromatous 

elements in a patient 

with von Recklinghausen’s disease. 

Cancer 55:2794–2798 

9. Pytel P, Krausz T, Wollmann R, Utset 

MF (2005) Ganglioneuromatous paraganglioma 

of the cauda equina – a pathological 

case study. Hum Pathol 36: 

444–446 

10. Sparagana M, Feldman JM, Molnar Z 

(1987) An unusual pheochromocytoma 

associated with androgen secreting adrenocortical 

adenoma: evaluation of its 

polypeptide hormone, catecholamine 

and enzyme characteristics. Cancer 60: 

223–231 

11. Tatekawa Y, Muraji T, Nishijima E, 

Yoshida M, Tsugawa C (2006) Composite 

pheochromocytoma associated with 

adrenal neuroblastoma in an infant: 

a case report. J Ped Sur 41:443–445 

12. Tekautz TM, Pratt CB, Jenkins JJ, 

Spunt SL (2003) Pediatric extradrenal 

paraganglioma. J Pediatr Surg 38: 

1217–1221 

13. Yoshimi N, Tanaka T, Hara A, Bunai Y, 

Kato K, Mori H (1992) Extra-adrenal 

pheochromocytoma-ganglioneuroma. 

A case report. Pathol Res Pract 188(8): 

1098–100; discussion 1101–1103

Katedra i Klinika Chirurgii Dzieciêcej Collegium Medicum UMK w Bydgoszczy 

we wspó³pracy z: 

Klinik¹ Chirurgii i Urologii Dzieci i M³odzie¿y AM w Gdañsku 

oraz 

SEKCJ¥ HISTORYCZN¥ PTCHD 

SEKCJ¥ CHIRURGII ONKOLOGICZNEJ PTCHD 

Polsk¹ Akcj¹ Onkologii Dzieciêcej 

Polsk¹ Fundacj¹ Europejskiej Szko³y Onkologii 

Maj¹ przyjemnoœæ zaprosiæ do udzia³u w VI Sympozjum 

Postêpy w diagnostyce molekularnej i leczeniu nowotworów o pod³o¿u genetycznym u dzieci 

oraz III Sympozjum Sekcji Historycznej PTChD 

9–10 czerwiec 2006 r. 

Hotel 500 nad Zalewem Zegrzyñskim k. Warszawy 

Zegrze Po³udniowe ul. Warszawska 31 a 

Sympozjum pod patronatem naukowym Polskiej Unii Onkologii 

oraz patronatem medialnym TVP 3 i miesiêcznika KONSYLIARZ 

Komitet Naukowy 

Przewodnicz¹cy: prof. A. I. Prokurat, prof. Cz. Stoba, dr hab. P. Czauderna 

prof. Z. Machaliñski, prof. B. Jarz¹b, prof. I. Koz³owicz-Gudziñska, prof. J. Lubiñski, prof. S. Sporny, 

prof. K. Sawicz-Birkowska, prof. B. WoŸniewicz, prof. A. Januszewicz, 

dr hab. M. Liwin, dr hab. J. Peregud-Pogorzelski, dr A. Cedro 

Komitet Organizacyjny 

Przewodnicz¹cy: dr P. Kluge, dr M. Bukowski 

dr W. Ró¿ycki-Gerlach, dr M. Chrupek, dr I. Daniluk -Matraœ, dr R. KaŸmirczuk, dr hab. J. Peregud-Pogorzelski, 

dr I. Leciejewska, dr K. Nierzwicka, dr W. Grajkowska, dr hab. B. Cukrowska, dr M. Chrzanowska, 

dr M. Pacholska, dr P. Ga³¹zka, dr M. Dobruchowska, p. M. Krauza

Szanowni Pañstwo, 

Mamy zaszczyt zaprosiæ Pañstwa do udzia³u w VI Sympozjum poœwiêconym postêpom genetyki 

molekularnej w chorobach nowotworowych wieku dzieciêcego oraz w III Sympozjum Sekcji 

Historycznej PTChD. Tym razem organizatorami s¹: Katedra i Klinika Chirurgii Dzieciêcej Collegium 

Medicum UMK w Bydgoszczy, Klinika Chirurgii i Urologii Dzieci i M³odzie¿y AM w Gdañsku oraz 

Sekcje: Historyczna PTChD i Chirurgii Onkologicznej PTChD. Tradycyjnie wspó³organizatorami s¹ 

tak¿e Stowarzyszenie Polska Akcja Onkologii Dzieciêcej oraz Polska Fundacja Europejskiej Szko³y 

Onkologii. Sympozjum odbywa siê pod patronatem naukowym Polskiej Unii Onkologii. 

Program Sympozjum obejmuje tematykê pod³o¿a genetycznego wybranych nowotworów: raków 

tarczycy i guzów chromoch³onnych. Staramy siê pokazaæ, w jaki sposób postêp biologii molekularnej 

mo¿e przyczyniæ siê do poprawy wyników leczenia tych chorób. Zdaj¹c sobie sprawê z wagi profilaktyki 

w rodzinnie wystêpuj¹cych rozrostach nowotworowych zaplanowano tak¿e wyst¹pienia poœwiêcone 

nowotworom dziedzicznym u dzieci i poradnictwu genetycznemu. Podejmujemy tak¿e tematykê historii 

chirurgii dzieciêcej id¹c tropami zapomnianych sprzêtów, ewolucji technik operacyjnych i anegdoty 

w chirurgii dzieciêcej. 

W ramach ka¿dej z sesji zaproszeni znawcy zagadnienia przedstawi¹ problemy nowoczesnej 

diagnostyki molekularnej, ale tak¿e bardziej tradycyjnego rozpoznawania nowotworów (obrazowanie, 

badania mikroskopowe). Pokazane zostan¹ tak¿e sposoby leczenia zachowawczego i zabiegowego, 

w³¹cznie z profilaktycznym stosowaniem leczenia chirurgicznego. Mamy nadziejê, jak co roku, goœciæ 

liczne grono uczestników, przedstawicieli ró¿nych dyscyplin medycznych. Chcielibyœmy, aby nasze 

Sympozjum by³o tak¿e okazj¹ do pog³êbienia wzajemnej wspó³pracy zarówno w dziedzinie badañ 

naukowych jak i praktyki klinicznej. Liczymy tak¿e na uwagi i propozycje Pañstwa mog¹ce pomóc 

w zaplanowaniu formy i tematyki naszych spotkañ w przysz³ych latach. 

Przewodnicz¹cy 

Komitetu Naukowego 

Przewodnicz¹cy Komitetu 

Organizacyjnego 

Polska Fundacja 

Europejskiej Szko³y Onkologii 

prof. A. I. Prokurat 

prof. Cz. Stoba 

dr P.Kluge 

dr n. med. W. Ró¿ycki-Gerlach 

PATRONAT NAUKOWY 

Prezes Polskiej Unii Onkologii 

dr n. med. J. Meder

PROGRAM – ZEGRZE 2006 

49 

9 CZERWCA (piątek) 

VI SYMPOZJUM „POSTÊPY W DIAGNOSTYCE MOLEKULARNEJ 

I LECZENIU NOWOTWORÓW O POD£O¯U GENETYCZNYM U DZIECI” 

10.00 – 10. 15 OTWARCIE SYMPOZJUM 

• Przewodniczący Komitetu Organizacyjnego – dr P. Kluge 

• Prezes Polskiej Fundacji Europejskiej Szkoły Onkologii – dr W. Różycki-Gerlach 

• Prezes Polskiej Unii Onkologii – dr J. Meder 

• Prezes Polskiego Towarzystwa Chirurgów Dziecięcych – prof. A. Chilarski 

• Prezes Sekcji Historycznej PTChD – prof. Cz. Stoba 

• Prezes Sekcji Chirurgii Onkologicznej PTChD i Prezes Polskiej Akcji Onkologii Dziecięcej – prof. A. I. Prokurat 

10.15 – 11.00 WYK£AD SPECJALNY 

“Endocrine surgery in children” – Prof. Henning Dralle – Martin Luther University, Halle-Wittenberg, 

Department of Surgery 

11.00 – 11.15 PRZERWA NA KAWÊ 

11.15 – 13.30 SESJA 1 – Guzy chromoch³onne u dzieci 

Przew.: M. Litwin, J. Lubiñski, A. I. Prokurat 

1. Guzy chromoch³onne u dzieci – punkt widzenia hipertensjologa. – M. Litwin (30 min.) 

2. Genetyka kliniczna w pheochromocytoma. – J. Lubiñski (30 min.) 

3. Leczenie operacyjne guzów chromoch³onnych u dzieci. – A. I. Prokurat (30 min.) 

4. Leczenie z³oœliwych postaci pheochromocytoma. – J. Krajewska (30 min.) 

5. Ogólnopolski Rejestr Guzów Chromoch³onnych. – M. Pêczkowska (15 min.) 

13.30 – 14.15 WYK£AD SPECJALNY 

“Radioiodine therapy in radiation induced thyroid childhood cancer” – Prof. Christoph Reiners, University Hospital 

Wuerzburg, Clinic and Policlinic of Nuclear Medicine 

14.00 – 15.00 OBIAD 

15.00 – 17.15 SESJA 2 – Zró¿nicowane raki tarczycy u dzieci 

Przew.: I. Koz³owicz-Gudziñska, S. Sporny, P. Kluge 

1. Rak tarczycy u dzieci – ró¿nice w zachowaniu biologicznym i leczeniu – D. Handkiewicz-Junak (30 min.) 

2. Rola BAC w diagnostyce zmian patologicznych tarczycy – S. Sporny (30 min.) 

3. Leczenie chirurgiczne raka tarczycy u dzieci – J. Harasymczuk (30 min.) 

4. Rola medycyny nuklearnej w leczeniu zró¿nicowanych raków tarczycy u dzieci – I. Koz³owicz-Gudziñska (30 min.) 

5. Rejestr raków tarczycy u dzieci w PPGGL – M. Pacholska (15 min.) 


17.30 – 19.00 ZEBRANIE ZARZ¥DU G£ÓWNEGO PTCHD 

19.00 – 19.30 WALNE ZGROMADZENIE CZ£ONKÓW SEKCJI CHIRURGII 

ONKOLOGICZNEJ PTCHD 

20.00 KOLACJA PRZY GRILLU

50 

10 CZERWCA (sobota) 

7.30 – 8.30 ŒNIADANIE 

III SYMPOZJUM SEKCJI HISTORYCZNEJ PTCHD 

EWOLUCJA TECHNIK OPERACYJNYCH. 

TROPEM ZAPOMNIANYCH SPRZÊTÓW. 

CHIRURGIA DZIECIÊCA W ANEGDOCIE. 

09.00 – 09.10 POWITANIE PROF. CZES£AW STOBA 

09.10 – 10.15 WALNE ZGROMADZENIE CZ£ONKÓW SEKCJI HISTORYCZNEJ PTCHD 


10.30 – 11.30 SESJA I 

1. Tropem moich podrêczników chirurgii dzieciêcej. – Cz. Stoba 

2. Wk³ad kobiet – chirurgów dzieciêcych w rozwój tej specjalnoœci w Polsce, w œwietle danych statystycznych – 

I. Mazurkiewicz-Latawiec 

3. Stuletni szpital dzieciêcy w £odzi. – A. Chilarski 

4. Obrazy z ¿ycia Oddzia³u Chirurgii Dzieciêcej w Kielcach. – P. Wolak, A. Porêbska 


11.45 – 13.00 SESJA II 

1. Przepuklina przeponowa w dziejach medycyny œwiatowej i polskiej. – J. Skalski, D. Pyp³acz 

2. Szczeciñska historia pewnej fotografii. – I. Mazurkiewicz-Latawiec 

3. Choroba Hirschsprunga czyli historia pewnego nieporozumienia. – M. Bukowski, A. ¯akowiecka 

4. Zaburzenia lateralizacji prze³o¿enia pni têtniczych i wady u³o¿enia narz¹dów w dawnym polskim piœmiennictwie 

medycznym. – J. Skalski, D. Pyp³acz, M. G³adki 

5. Jan Kossakowski odbr¹zowiony. – A. Cedro 

13.00 ZAKOÑCZENIE SYMPOZJUM 

13.00 – 14.00 OBIAD

51 

Guzy chromochłonne u dzieci – punkt widzenia hipertensjologa 

Mieczys³aw Litwin 

Klinika Nefrologii, Nadciœnienia Têtniczego Transplantacji Nerek, 

Instytut „Pomnik Centrum Zdrowia Dziecka”, Warszawa 

Guz chromoch³onny/przyzwojak stanowi rzadk¹ przyczynê nadciœnienia têtniczego w wieku rozwojowym. Jednak nietypowy przebieg 

kliniczny, trudnoœci w leczeniu farmakologicznym, mo¿liwoœæ rozwoju powa¿nych powik³añ narz¹dowych i nierozpoznanie 

guza z³oœliwego powoduj¹, ¿e w ka¿dym przypadku nadciœnienia w stopniu 2 u dzieci starszych i u ka¿dego dziecka m³odszego 

z nadciœnieniem, nale¿y przeprowadziæ wstêpn¹ diagnostykê w kierunku guza chromoch³onnego/przyzwojaka. W odró¿nieniu od 

doros³ych, w wieku dzieciêcym guz chromoch³onny/przyzwojak czêœciej wystêpuje pozanadnerczowo, rodzinnie i ma charakter 

z³oœliwy, a nadciœnienie têtnicze ma charakter utrwalony. Diagnostyka wstêpna opiera siê na ocenie wydalania katecholamin i ich 

metabolitów z moczem oraz ultrasonograficznym badaniu jamy brzusznej. Podejrzenie guza chromoch³onnego/przyzwojaka na podstawie 

diagnostyki wstêpnej jest wskazaniem do wykonania scyntygraficznych badañ obrazuj¹cych tkankê chromoch³onn¹. Leczenie 

farmakologiczne nadciœnienia w okresie przedoperacyjnym opiera siê na antagonistach receptora alfa-adrenergicznego, a u chorych 

z objawami pobudzenia beta-adrenergicznego dodatkowo podaje siê beta adrenolityki. W ka¿dym przypadku potwierdzonego 

rozpoznania guza chromoch³onnego/przyzwojaka nale¿y zabezpieczyæ materia³ do badañ molekularnych. 

Phaeochromocytoma/paraganglioma in children – hypertesniologist view. Phaeochromocytoma/paraganglioma is a rare cause of 

arterial hypertension in childhood. However, variable clinical course, problems with pharmacologic therapy, risk of severe target 

organ damage and malignancy cause that in every case of older child with arterial hypertension in stage 2 and every young child 

with hypertension screening towards pheochromocytoma/paraganglioma is obligatory. Opposite to adults, pheochromocytoma/paraganglioma 

in children is often extraadrenal, familial and malignant. Screening tests are based on evaluation of catecholamine 

excretion in urine and sonographic examination of abdominal cavity. Positive results of screening tests are an indication to scyntigraphic 

evaluation for presence of chromophilic tissue. Hypotensive therapy is based on alpha-adrenergic blockers and in cases 

with beta-adrenergic stimulation beta-blockers are added. In any case of phaechromocytoma/paraganglioma molecular diagnosis is 

obligatory. 

Genetyka kliniczna pheochromocytoma 

J. Lubiñski, C. Cybulski 

Miêdzynarodowe Centrum Nowotworów Dziedzicznych, PAM Szczecin 

„Pheochromocytoma” jest rzadkim guzem neuroendokrynnym z bardzo zró¿nicowan¹ prezentacj¹ kliniczn¹. Najczêstsze objawy 

kliniczne to bóle g³owy, nadmierna potliwoœæ, dodatkowe skurcze serca i nadciœnienie. 

Biochemiczne badania w kierunku „pheochromocytoma” wskazane s¹ nie tylko u osób z wy¿ej wymienionymi objawami, ale i u pacjentów 

z przypadkowo wykrytymi guzami nadnercza lub ze zidentyfikowan¹ predyspozycj¹ genetyczn¹ (MEN2, VHL, NF1, mutacje 

SDHB i SDHD). TK lub MRI oraz 123I-MIBG s¹ wykorzystywane do lokalizowania guzów aktywnych biochemicznie. 

Preferowan¹ procedur¹ chirurgiczn¹ jest laparoskopowe usuwanie guzów. Usuniêcie „pheochromocytoma”, odpowiednio wczesne, 

gwarantuje bardzo wysoki odsetek wyleczeñ.

52 

Leczenie operacyjne guzów chromochłonnych u dzieci 

A.I. Prokurat 

Katedra i Klinika Chirurgii Dzieciêcej CM UMK, Szpital Uniwersytecki im. dr A. Jurasza 

w Bydgoszczy 

Pheochromocytoma jest guzem wywodz¹cym siê z komórek chromafinowych rdzenia nadnerczy lub zwojów wspó³czulnych. Wystêpuje 

w lokalizacji nadnerczowej lub pozanadnerczowej. W lokalizacji nadnerczowej lokalizuje siê wzd³u¿ osi krêgos³upa pocz¹wszy 

od jamy czaszki poprzez szyjê, klatkê piersiow¹ po dolne obszary jamy brzusznej. Ok. 10–20% przypadków pheochromocytoma 

wykazywane jest u dzieci. Nie wykazano korelacji miêdzy wielkoœci¹ guza a intensywnoœci¹ objawów klinicznych. Histologicznie 

³agodne jak i z³oœliwe postaci pheochromocytoma u dzieci mog¹ prezentowaæ zarówno cechy guza ³agodnego /brak 

atypii komórkowej, brak mitoz/ jak i histologiczne cechy niepokoju onkologicznego /mitozy, martwica, polimorfizm j¹der, naciekanie 

naczyñ lub torebki guza/. Do rozpoznania formy z³oœliwej guza upowa¿nia wykazanie odleg³ych niewydzielaj¹cych przerzutów 

tkankowych. U dzieci mo¿liwe s¹ tak¿e postaci mieszane guza /composit pheo/ zawieraj¹ce komponent neuroblastoma lub ganglioneuroblastoma 

i wymagaj¹ce modyfikacji sposobu postêpowania. 

Strategia leczenia pheochromocytoma u dzieci wymaga przedoperacyjnego rozpoznania guza. Najwa¿niejszym elementem leczenia 

pheochromocytoma u dzieci jest leczenie operacyjne, prowadz¹ce w wiêkszoœci przypadków do ca³kowitego wyleczenia. Jednostronna 

adrenalektomia lub ca³kowite usuniêcie guza w lokalizacji pozanadnerczowej jest leczeniem z wyboru u dzieci w przypadkach 

pheochromocytoma o charakterze sporadycznym. W przypadkach guzów obustronnych skojarzonych z zespo³ami MEN 2 i VHL nale¿y 

wykonaæ adrenalektomiê obustronn¹. W przypadkach guzów obustronnych wystêpuj¹cych sporadycznie nale¿y wykonaæ usuniêcie 

wiêkszego guza wraz z ca³ym nadnerczem oraz czêœciow¹ adrenalektomiê wraz z guzem po stronie przeciwnej. W przypadkach 

podejrzanych o postaæ z³oœliw¹ pheochromocytoma radykaln¹ operacjê guza nale¿y po³¹czyæ z usuniêciem wszystkich przerzutów 

wêz³owych. Rozpoznawanie i leczenie z³oœliwych postaci pheochromocytoma jest zwykle trudne. W przypadkach 

pheochromocytoma po³¹czonych ze z³oœliwym komponentem neuroblastycznym /composit pheo/ leczenie operacyjne poprzedzone 

powinno byæ wstêpn¹ chemioterapi¹. Przypadki te stanowi¹ jednak ogromny problem diagnostyczny. W przypadkach z³oœliwego 

pheochromocytoma radykalny zabieg operacyjny uzupe³niaæ powinna chemioterapia, radioterapia lub terapeutyczne podanie MIBG. 

Leczenie złośliwych postaci pheochromocytoma 

Jolanta Krajewska 

Zak³ad Medycyny Nuklearnej i Endokrynologii Onkologicznej, 

Centrum Onkologii-Instytut im. M Sk³odowskiej-Curie, Oddzia³ w Gliwicach 

Guzy chromoch³onne nale¿¹ do nowotworów rzadko spotykanych u dzieci. Czêœciej jednak ni¿ u chorych doros³ych maj¹ charakter 

z³oœliwy, wystêpuj¹ wieloogniskowo, s¹ zlokalizowane pozanadnerczowo. Czêœciej równie¿ stanowi¹ jeden z elementów zespo³ów 

uwarunkowanych dziedzicznie. Z tego powodu rozpoznanie guza chromoch³onnego zawsze wymaga u nich szczególnie 

uwa¿nej diagnostyki, zdecydowanego leczenia a po jego przeprowadzeniu – czêstych badañ kontrolnych. 

Jedynym pewnym kryterium z³oœliwoœci guza jest obecnoœæ przerzutów odleg³ych w tkankach nie zawieraj¹cych skupisk komórek 

chromoch³onnych – zwykle w p³ucach, w¹trobie, koœciach lub wêz³ach ch³onnych, gdy¿ na podstawie badania histopatologicznego 

nie jest mo¿liwe jednoznaczne odró¿nienie postaci ³agodnych od z³oœliwych. Kryteria miejscowej z³oœliwoœci histopatologicznej 

(martwica w guzie, inwazja naczyñ lub torebki, naciekanie otoczenia, atypia j¹der, wysoki indeks mitotyczny, diplopia DNA) 

oraz kryteria kliniczne (m³ody wiek w chwili ujawnienia choroby, du¿e wymiary guza, jego pozanadnerczowa lokalizacja, brak 

wychwytu MIBG przez guz, przetrwa³e pooperacyjne nadciœnienie têtnicze) zwiêkszaj¹ ryzyko z³oœliwoœci, ale nie stanowi¹ wystarczaj¹cej 

przes³anki. 

Postêpowaniem z wyboru jest radykalny zabieg operacyjny poprzedzony przygotowaniem farmakologicznym (blokada receptorów 

– adrenergicznych). U pacjentów z chorob¹ uogólnion¹ konieczne jest dalsze leczenie. Leczeniem 1-szego rzutu jest zastosowanie 

131 I MIBG. OdpowiedŸ, pod postaci¹ >50% redukcji masy guza i poziomu hormonów uzyskuje siê u 30–60 % chorych a u 50–75% 

znacz¹c¹ poprawê samopoczucia i jakoœci ¿ycia. Pewne nadzieje wi¹¿e siê z wprowadzeniem do terapii analogów somatostatyny 

znakowanych Y-90, które mog¹ stanowiæ alternatywê zw³aszcza dla chorych, u których zastosowanie 131 I MIBG jest niemo¿liwe 

(brak gromadzenia radioznacznika w guzie) lub nieskuteczne. Niemniej, gêstoœæ receptorów somatostatynowych na guzach chromoch³onnych 

jest czêsto mniejsza ni¿ na guzach neuroendokrynnych przewodu pokarmowego. Obecnie czynione s¹ próby stosowania 

tak¿e zimnych analogów somatostatyny, ale wstêpne wyniki nie s¹ zachêcaj¹ce. 

Chemioterapiê, opart¹ o cyklofosfamid, winkrystynê i dakarbazynê stosuje siê u chorych z nawrotow¹ chorob¹ lub szybk¹ progresj¹ 

oraz w tych przypadkach, w których inne metody nie przynios³y korzyœci. U wiêkszoœci pacjentów odpowiedŸ jest jednak krótkotrwa³a. 

Klasyczna teleradioterapia stosowana jest rzadko ze wzglêdu na ma³¹ promienioczu³oœæ guzów chromoch³onnych.

53 

Ogólnopolski Rejestr Pheochromocytoma 

Mariola Pêczkowska 

Instytut Kardiologii Klinika Nadciœnienia Têtniczego, Warszawa, ul Alpejska 42 

Czêstoœæ wystêpowania genetycznych postaci guza chromoch³onnego wœród chorych z tzw. sporadycznym pheochromocytoma ocenia 

siê na ok. 25%. Do trzech znanych ju¿ wczeœniej zespo³ów nowotworowych – zespo³u gruczolakowatoœci wewn¹trzwydzielniczej 

typu 2 (MEN 2), zespo³u von Hippla – Lindaua i nerwiakow³ókniakowatoœci typu I (NF1) trzeba obecnie dodaæ nowo wyodrêbniony 

zespó³ paraganglioma/pheochromocytoma (PPS/PGL). Zwa¿ywszy, ¿e wszystkie te zespo³y s¹ zespo³ami wielonowotworowymi, 

wczesna diagnostyka i leczenie a nastêpnie wnikliwe, okresowe badania kontrolne maj¹ olbrzymie znaczenie. 

Ogólnopolski Rejestr Pheochromocytoma powsta³ w 2003 roku. Za cel Rejestru uznaliœmy koniecznoœæ poprawy diagnostyki chorych 

z pheochromocytoma oraz ustalenie odpowiednich i nowoczesnych standardów leczenia. W ramach dzia³alnoœci Rejestru wszyscy 

zg³oszeni chorzy maj¹ wykonywane badania genetyczne w kierunku dziedzicznych postaci pheochromocytoma (badania genów 

SDHB, SDHC, SDHD, VHL, protoonkogenu RET). Rozpoznanie nerwiakow³ókniakowatoœci typu I ustalane jest na podstawie 

klinicznych kryteriów NHI. W przypadku wykazania dziedzicznych postaci pheochromocytoma, osoby te s¹ hospitalizowane 

w Klinice Nadciœnienia Têtniczego Instytutu Kardiologii w Warszawie, gdzie przeprowadzane s¹ badania w kierunku odpowiednich 

zespo³ów chorobowych. Badaniami genetycznymi objêci s¹ równie¿ cz³onkowie rodzin, co stwarza mo¿liwoœci wykrycia nosicielstwa 

mutacji i objêcia wczesn¹ opiek¹ profilaktyczn¹ osób z grupy ryzyka. 

Aktualnie w Rejestrze znajduje siê 271 osób – w tym 192 – index cases: 172 z guzem chromoch³onnym, 18 z paraganglioma g³owy 

i szyi oraz 2 osoby z guzem chromoch³onnym i paraganglioma oraz 79 cz³onków rodzin nosicieli. Nosicielstwo mutacji (SDHD, 

SDHC, SDHB, RET, VHL) stwierdzono u 24,8% chorych. Chorych do 18 roku ¿ycia by³o 15 (8,7%) – wyniki badañ genetycznych 

dostêpne s¹ dla 10 osób: u 9 (90%) stwierdzono dziedziczne postaci pheochromocytoma – VHL u 6, MEN 2B u 1, mutacjê 

genu SDHB – u 1, SDHD – u 1. Tylko u 3 osób wywiad rodzinny w kierunku pheochromocytoma by³ pozytywny. 

Radioiodine therapy in radiation induced thyroid childhood cancer 

Chr. Reiners 1 , J. Biko 1 , Y.E. Demidchik 2 , V. Drozd 3 

1 

Clinic and Policlinic of Nuclear Medicine, University of Würzburg, Germany 

2 Republican Center for Thyroid Tumors, Minsk, Belarus 

3 Belarussian-German Fonds "Arnica" for Follow-Up of Childhood Thyroid Tumors, Minsk, Belarus 

After the Chernobyl reactor accident on April 26 th 1986, the incidence of thyroid cancer in children and adolescents living in contaminated 

areas of the Ukraine and Belarus increased significantly. Totally, between 1986 and 2002 4600 cases of thyroid cancer 

have been observed among those aged 0–18 years at the time of the reactor accident. It is estimated, that approximately 40% of 

those cases are associated with radiation exposure and 60% are spontaneous cases. 

Starting with 01/04/1993, a joint project on the combined treatment with surgery and radioiodine has been launched. Thyroid surgery 

was performed in the Center for Thyroid Tumors in Minsk, Belarus, and radioiodine therapy followed in Germany at the Universities 

of Essen (until the end of 1994) and afterwards the University of Würzburg. 

Until the end of 2005, 242 children and adolescents had received totally in 987 1-week courses of radioiodine therapy. The number 

of girls was 144 and the number of boys 98. The age at the time of radioiodine therapy ranged from 7 to 19 years with a mean age 

of 12.7 2.5 years. Histologically, 236 of the cancers had been classified as papillary and only 2 as follicular cancers. 152 out of 

those 242 patients suffered from locally advanced tumor stage pT4 (33%). In nearly all of the children (235 out of 242 = 97%) 

lymph node metastases in the neck were detected during surgery or follow-up. 104 out of 242 children (= 43%) reveled distant 

metastases (nearly all of them to the lungs). Up to now, 234 patients received more than one course of radioiodine therapy, so that 

the effectivity of the preceeding treatment course could be checked by a consecutive radioiodine wholebody scan. Totally, 131 

children (56%) are in complete remission, 70 children (30%) in stable partial remission and 33 children (40%) in partial remission. 

With respect to the subgroup of children with distant metastases, the rate of complete remissions is 35%, stable partial remissions 

34% and partial remissions 31%. All of the children and adolescents treated with radioiodine are alive.

54 

Paediatric differentiated thyroid cancer – differences in biology and treatment 

Daria Handkiewicz-Junak 

Zak³ad Medycyny Nuklearnej i Endokrynologii Onkologicznej, 

Centrum Onkologii-Instytut im. M Sk³odowskiej-Curie, Oddzia³ w Gliwicach 

Zró¿nicowany rak tarczycy (ZRT) jest najczêstszym nowotworem endokrynnym zarówno u dzieci jak i doros³ych. Poniewa¿ w wielu 

pracach wykazano, ¿e ZRT rozpoznawany poni¿ej 40 roku ¿ycia charakteryzuje siê dobrym rokowaniem, mo¿e sie równie¿ wydawaæ, 

¿e dotyczy to tak¿e dzieci. Niemniej w porównaniu do osób doros³ych ZRT u dzieci charakteryzuje siê co najmniej kilkoma 

istotnymi ró¿nicami: 1) wiêkszym zaawansowaniem miejscowym; 2) typem przerzutowania: a) czêstsze przerzuty do regionalnych 

wez³ów ch³onnych oraz narz¹dów mi¹¿szowych; b) p³uca stanowi¹ prawie jedyn¹ lokalizacjê przerzutów odleg³ych; c) 

przerzuty do p³uc s¹ z regu³y funkcjonalne; 3) wysokim odsetkiem nawrotów, przy bardzo niskiej umieralnoœci z powodu choroby 

nowotworowej. 

Bior¹c pod uwagê czêste nawroty lokoregionalne, celem leczenia ZRT u dzieci powinno byæ nie tylko zapewnienie d³ugiego okresu 

prze¿ycia ca³kowitego, ale przede wszystkim prze¿ycia wolnego od nawrotu choroby nowotworowej. Ten ostatny czynnik odgrywa 

u dzieci tak istotn¹ rolê, gdy¿ wp³ywa na poprawê jakoœæ ¿ycia, zmniejsza niepokój oraz zaburzenia psychologiczne w okresie 

dorastania, redukuje koniecznoœæ skomplikowanych i kosztownych us³ug medycznych oraz mo¿e przek³adaæ siê na wyd³u¿enie 

ca³kowitego czasu prze¿ycia. 

Du¿e zaawansowanie choroby podczas rozpoznania, czêste wznowy oraz dobre wyniki leczenia skojarzonego sk³aniaj¹ ku agresywnemu 

postêpowaniu terapeutycznemu. Optymalny schemat leczenia dzieci z ZRT powinien rozpoczynaæ siê ca³kowit¹/prawie 

ca³kowit¹ tyroidektomi¹ z centraln¹ limfadenektomi¹, poszerzon¹ o zmodyfikowan¹ limfadenektomiê boczn¹ w przypadku przerzutów 

do wêz³ów ch³onnych tej okolicy. Terapia radiojodem, stanowi¹ca uzupe³nienie leczenia chirurgicznego stosowana jest w celu 

zniszczenia pozostawionych kikutów tarczycy i/lub ognisk nowotworowych. 

Chocia¿ dane literaturowe wskazuj¹ na bardzo dobre wyniki leczenia ZRT u dzieci nale¿y poszukiwaæ nowych schematów leczenia, 

których skutecznoœæ najlepiej mierzyæ wyd³u¿eniem czasu wolnego od nawrotu choroby nowotworowej. Powinno siê równie¿ 

poszukiwaæ czynników molekularnych wp³ywaj¹cych na ryzyko nawrotu, przerzutów odleg³ych czy zgonu z powodu choroby nowotworowej. 

Rola BAC w diagnostyce zmian patologicznych tarczycy 

Stanis³aw Sporny 

Zak³ad Patomorfologii Stomatologicznej, Uniwersytet Medyczny w £odzi 

Biopsja aspiracyjna cienkoig³owa (BAC) sta³a siê najszybsz¹ i najbardziej czu³¹ metod¹ rozpoznawania zmian guzowatych gruczo³u 

tarczowego. G³ównymi jej zaletami s¹: mo¿liwoœæ wyodrêbnienia chorych, u których wskazane jest leczenie chirurgiczne, 

ma³a inwazyjnoœæ zabiegu i stosunkowo niewielki koszt procedury. BAC s³u¿y nie tylko do rozpoznawania pojedynczych, twardych 

i szybko rosn¹cych guzów tarczycy, ale równie¿ mnogich zmian patologicznych, zapaleñ oraz wszelkich nieprawid³owoœci 

struktury mi¹¿szu wykrytych ultrasonograficznie ewentualnie podczas badania scyntygraficznego. BAC tarczycy jest szczególnie 

przydatn¹ metod¹ diagnostyczn¹ na obszarze endemii wola, gdzie powiêkszony gruczo³ tarczowy odnotowuje siê u wielu osób. 

Rutynowe stosowanie BAC oznacza zmniejszenie liczby niepotrzebnych operacji tarczycy i prowadzi do zwiêkszenia odsetka raków 

wykrytych w pooperacyjnym badaniu patomorfologicznym. 

BAC tarczycy nie jest trudnym do wykonania zabiegiem i nie grozi powa¿niejszymi powik³aniami. Stwarza mo¿liwoœæ ujawnienia 

z³oœliwych nowotworów we wczesnym stadium rozrostu, co zwiêksza szansê pe³nego wyleczenia. Jednak, jak wiele innych metod 

diagnostycznych, jest obarczona pewnym ryzykiem b³êdu. Nieprecyzyjne lub fa³szywe rozpoznania mog¹ byæ skutkiem z³ej jakoœci 

aspiratów, nieumiejêtnego pobierania materia³u, b³êdnej interpretacji ujawnionych zaburzeñ struktury komórek oraz zbli¿onych 

obrazów cytologicznych w ³agodnych i z³oœliwych zmianach rozrostowych nab³onka pêcherzyków tarczycy.

55 

Rola medycyny nuklearnej w leczeniu zróżnicowanych raków tarczycy u dzieci 

Izabella Koz³owicz-Gudziñska 

Zak³ad Medycyny Nuklearnej i Endokrynologii Klinicznej, Instytut Onkologii, Warszawa 

Raki tarczycy zajmuj¹ szczególne miejsce wœród nowotworów z³oœliwych wystêpuj¹cych u dzieci. Ich biologiRak tarczycy u dzieci 

jest schorzeniem wystêpuj¹cym w 1,5–3% przypadków wszystkich nowotworów. Wystêpuje najczêœciej pomiêdzy 16 a 21 rokiem 

¿ycia. U dzieci poni¿ej 15 roku ¿ycia wystêpuje rzadko z czêstotliwoœci¹ 0,5–1 przypadków na milion mieszkañców. Najczêœciej 

jest rakiem zró¿nicowanym przewa¿nie brodawkowatym a rzadko pêcherzykowatym. 

Jest chorob¹ o dobrym rokowaniu u dzieci i lepszym jak u doros³ych. Jednak czêœciej u dzieci jak u doros³ych towarzysz¹ mu 

przerzuty do wêz³ów ch³onnych szyi. Równie¿ z nawrotami raka trzeba liczyæ siê stosunkowo czêsto i to nawet po 30–40 latach 

bezobjawowego prze¿ycia. 

Jak w przypadku ka¿dego schorzenia a szczególnie nowotworu najwa¿niejsze jest wczesne rozpoznanie. 

Podstawowe znaczenie w leczeniu ZRT u dzieci tak jak i u doros³ych ma radykalne leczenie operacyjnej z nastêpowym leczeniem 

radiojodem oraz dok³adne monitorowanie przebiegu choroby. 

Rejestr raków tarczycy u dzieci w PPGGL 

M. Pacholska 

Katedra i Klinika Chirurgii Dzieciêcej CM UMK, Szpital Uniwersytecki im. dr A. Jurasza 

w Bydgoszczy 

Raki tarczycy zajmuj¹ szczególne miejsce wœród nowotworów z³oœliwych wystêpuj¹cych u dzieci. Ich biologiczna agresywnoœæ 

w odró¿nieniu od innych nowotworów wieku dzieciêcego jest mniejsza a przerzuty odleg³e obserwuje siê dopiero w zaawansowanej 

fazie choroby. Raki tarczycy obejmuj¹ ok. 10% wszystkich guzów z³oœliwych i ok. 35% wszystkich raków wystêpuj¹cych 

u dzieci. Zró¿nicowane raki tarczycy /ZRT/ stanowi¹ 90–95% dzieciêcych raków tarczycy. Wystêpuj¹ niezwykle rzadko poni¿ej 

5 r. ¿. a ok. 70% przypadków wykrywanych jest w wieku 11–17 lat. W odró¿nieniu od doros³ych ZRT u dzieci prezentuj¹ odmienne 

zachowanie zwi¹zane z wiêksz¹ agresj¹ biologiczn¹, tendencj¹ do szybszego rozprzestrzeniania siê w uk³adzie ch³onnym, oraz 

tendencj¹ do wznów wêz³owych. Jednoczeœnie w przeciwieñstwie do doros³ych charakteryzuj¹ siê bardzo dobrym rokowaniem odleg³ym. 

Ma³a liczba przypadków ZRT w poszczególnych oœrodkach oraz wzglêdnie ³agodny ich przebieg utrudnia ocenê wystêpowania 

i leczenia ZRT u dzieci w Polsce, uzale¿niaj¹c j¹ od wysi³ków w³o¿onych w uzyskanie danych epidemiologicznych i klinicznych. 

Autorzy przedstawiaj¹ wyniki analizy wielooœrodkowej prowadzonej w ramach Polskiej Pediatrycznej Grupy Guzów Litych, 

dotycz¹ce diagnostyki i leczenia ZRT u dzieci. Do analizy obejmuj¹cej lata 2000–2005 zg³oszono 107 pacjentów z 14 

oœrodków akademickich w Polsce. Analizie poddano wiek i p³eæ dzieci z ZRT, lokalizacjê zmian w tarczycy, sposoby rozpoznawania 

ZRT, rodzaje i zakres wykonywanych zabiegów operacyjnych, histologiczne typy ZRT oraz leczenie uzupe³niaj¹ce izotopem 

J131.

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