title: Perioperative management after high-dose chemotherapy with autologous or allogeneic hematopoietic stem cell transplantation for pediatric solid tumors.
abstract: BACKGROUND
  An increasing number of children with advanced malignancies have recently received high-dose chemotherapy (HDC) with hematopoietic stem cell transplantation (HSCT), followed by surgery. In this study, we reviewed our experience with surgery after HDC and autologous (auto) or allogeneic (allo) HSCT to elucidate the problems associated with this treatment and establish the optimum surgical management strategy.
  
  
  METHODS
  We retrospectively reviewed the cases of 24 children with advanced malignancy treated with HDC and HSCT before tumor resection at our institution. The tumors included 18 neuroblastomas, 5 soft tissue sarcomas, 2 hepatoblastomas, and 1 Wilms tumor. The source of hematopoietic stem cells was auto-HSCT in 19 patients and allo-HSCT in 5 patients. To be able to undergo surgery, it was necessary that the patient's general condition, including hemostasis, should be fairly good and that the results of hematological examinations should include a white blood cell (WBC) count of>1,000/µL, hemoglobin level of>10 g/dL and platelet count of>5 × 10(4)/µL.
  
  
  RESULTS
  The mean duration before WBC recovery after HSCT was 14.5 ± 1.4 days after auto-HSCT and 23.8 ± 1.2 days after allo-HSCT, respectively (p<0.01). The mean duration before platelet recovery after HSCT was 46.5 ± 5.2 days for auto-HSCT and 48.6 ± 5.5 days for allo-HSCT (not significant [n.s.]). The mean interval between allo-HSCT and surgery was significantly longer (92.8 ± 6.2 days) than that between auto-HSCT and surgery (57.0 ± 3.9 days) (p<0.01), likely because of the use of steroids and immunosuppressants after HSCT. The tumors were completely resected in all cases without severe complications. All the patients treated with allo-HSCT had an acute graft versus host (aGVH) reaction at 2 to 3 weeks after HSCT, and specifically required the administration of steroids and immunosuppressants to prevent aGVH. The postoperative complications included paralytic ileus in two cases and a tacrolimus-associated encephalopathy in one case involving allo-HSCT. In half of the patients, the WBC count was not elevated after surgery, whereas the postoperative serum C-reactive protein (CRP) level was elevated in all cases.
  
  
  CONCLUSIONS
  Our data indicate that surgical treatment can be safely performed even after HDC with HSCT if attention is paid to myelosuppression and the adverse effects of both chemotherapeutic agents and immunosuppressants.
authors.affiliation: Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.
authors.forename: Shuichiro
authors.initials: S
authors.lastname: Uehara
authors.affiliation: Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.
authors.forename: Takaharu
authors.initials: T
authors.lastname: Oue
authors.affiliation: Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.
authors.forename: Kengo
authors.initials: K
authors.lastname: Nakahata
authors.affiliation: Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.
authors.forename: Keigo
authors.initials: K
authors.lastname: Nara
authors.affiliation: Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.
authors.forename: Takehisa
authors.initials: T
authors.lastname: Ueno
authors.affiliation: Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.
authors.forename: Mitsugu
authors.initials: M
authors.lastname: Owari
authors.affiliation: Department of Pediatric Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.
authors.forename: Noriaki
authors.initials: N
authors.lastname: Usui
authors.affiliation: Department of Pediatrics, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.
authors.forename: Takako
authors.initials: T
authors.lastname: Miyamura
authors.affiliation: Department of Pediatrics, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.
authors.forename: Yoshiko
authors.initials: Y
authors.lastname: Hashii
mesh_terms: D000293:Adolescent; D000970:Antineoplastic Agents / Q000008:administration & dosage; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use*; D017024:Chemotherapy, Adjuvant; D002648:Child; D002675:Child, Preschool; D004334:Drug Administration Schedule; D005260:Female; D018380:Hematopoietic Stem Cell Transplantation / Q000379:methods; D018197:Hepatoblastoma / Q000628:therapy; D006801:Humans; D007223:Infant; D007680:Kidney Neoplasms / Q000628:therapy; D008113:Liver Neoplasms / Q000628:therapy; D008297:Male; D008558:Melphalan / Q000008:administration & dosage; D020360:Neoadjuvant Therapy; D018193:Neoplasms, Complex and Mixed / Q000628:therapy*; D009447:Neuroblastoma / Q000628:therapy*; D019990:Perioperative Care / Q000379:methods*; D012189:Retrospective Studies; D012509:Sarcoma / Q000628:therapy*; D013852:Thiotepa / Q000008:administration & dosage; D014182:Transplantation, Autologous; D014184:Transplantation, Homologous; D016896:Treatment Outcome; D009396:Wilms Tumor / Q000628:therapy
chemical_list: D000970:Antineoplastic Agents; D013852:Thiotepa; D008558:Melphalan