Abstract
Introduction 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.
Patients and 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 × 104/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.
Keywords
solid tumor - perioperative management - hematopoietic stem cell transplantation -
high-dose chemotherapy
