1577
Neuroectodermal tumours in children born after assisted conception SiR,—The problem of infertility has been increasingly addressed by various methods and programmes.’ Among pregnancies after assisted conception that are notified to a national register in Australia,’ there were 2285 livebirths after conception by in-vitro fertilisation (IVF) between 1979 and 1987. Although various perinatal outcomes and congenital malformations have been recorded, so far there have been no reports of malignant disease in the offspring. We have diagnosed neuroectodermal tumours (2 neuroblastoma, 1 medulloblastoma) in 3 children who were born after IVF between 1985 and 1987 (table). 2 further patients (1neuroblastoma, 1 supratentorial primitive neuroectodermal tumour) were conceived during the same period after ovulation induction with clomiphene and artificial insemination. Our institution is one of two referral centres for paediatric oncology in New South Wales. The reported annual incidence rates for neuroblastoma and medulloblastoma in Australia are 10 and 0-4 per 100 000 children, respectively.7 Up to 1987 there were 604 livebirths in NSW resulting from IVF conceptions. During the same period, there were 10 livebirths in NSW and 56 nationally after frozen embryo transfer. There are no data for the total number of babies born after ovulation induction and artificial insemination.
1. Hull MGR, Glazener CMA, Kelly NJ, et al. Population study of causes, treatment and outcome of infertility. Br Med J 1985, 291: 1693. 2. IVF and GIFT pregnancies, Australia and New Zealand, 1988. Sydney: National Perinatal Statistic Unit, 1990. ISSN 1030 4711. 3. Australian In Vitro Fertilisation Collaborative Group. High incidence of pre-term births and early losses in pregnancy after in vitro fertilisation. Br Med J 1985; 291: 1160-63. 4. Spensley JC, Mushin D, Barreda-Hanson M. The children of IVF pregnancies: a cohort study. Aust Paediatr J 1986; 22: 285-89. 5. Lancaster PAL. Congenital malformations after in-vitro fertilisation. Lancet 1987; ii: 1392. 6. Morin NC, Wirth FH, Johnson DH, et al. Congenital malformations and psychosocial development in children conceived by in vitro fertilisation. J Pediatr 1989; 115: 222-27. 7. Childhood cancer in Australia. A report of the Australian Paediatric Cancer Registry. Brisbane Australian Paediatric Cancer Registry, 1990. ISBN 0 959632174.
Percutaneous parietal pleurectomy for recurrent
spontaneous pneumothorax
SiR,—A third spontaneous pneumothorax or a contralateral episode is usually an indication for preventive treatment. The best way to do this is pleurectomy or pleural abrasion, but the morbidity rate associated with thoractomy has prompted clinicians to look at chemical or mechanical pleurodesis, which does not require thoracotomy. Pleurodesis is less dangerous but it is not as effective at preventing recurrence. Video-endoscopy now permits parietal pleurectomy without thoracotomy. For this percutaneous endoscopic procedure a posterior 2-3 cm incision is made in the non-muscular zone between the spinal edge of the latissimus dorsi and the anterior edge of the trapezius. The intercostal space is then reached at the inferior edge of the rhomboid muscle. The intercostal muscles are detached for 4 cm at the superior edge of the rib. The extrapleural detachment is a bloodless operation done under video-endoscopic surveillance without retraction of the intercostal space. This detachment is pursued within the region bounded by the external edge of the first rib, the internal mammary vessels, the costovertebral cradle, and a horizontal line passing through the median arc or eighth rib. The pleura is resected by electrocoagulation and sectioned within these limits. The lung is explored under ventilation. Video-endoscopic surgery allows ligation of apical bullae. The pleural cavity is drained through two tubes exiting via an axillary incision. Percutaneous parietal pleurectomy has been done on ten patients (eight men and two women of average age 26) between August and October, 1990. In nine cases the patient had had his or her third episode of spontaneous pneumothorax. Two patients had had contralateral pneumothorax. Operative bleeding averaged only 30 ml and no transfusions were needed. Postoperative drainage averaged only 3 days (range 2-7 days) and the patients stayed in hospital for 5 days on average (range 4-7 days). On discharge from
*Hydroxyprogesterone
hexanoate 250
mg/ml
Although these may be chance findings, we report our preliminary observations to encourage further study. The possibility of an association between IVF and childhood malignant diseases in general, or specific subsets of tumours, is difficult to ascertain from the available information. The use of ovulation induction with clomiphene in all 5 of the reported patients is especially noteworthy. We are not aware of any previous or planned follow-up studies with sufficient numbers of children born after assisted conception that would enable the risk of uncommon outcomes such as childhood malignant disease to be determined. A survey has been initiated in which paediatric oncologists in Australia will be asked to review their records and prospectively report new cases. We also encourage all doctors to include information about the method of fertilisation from the families of children with malignant disease. Paediatric Haematology-Oncology, Prince of Wales Children’s Hospital, Randwick, 2031 NSW, Australia
LES WHITE NEELAM GIRI MARCUS R. VOWELS
National Perinatal Statistics Unit, University of Sydney
PAUL A. L. LANCASTER
hospital no patient required analgesic drugs. Chemical (tetracycline) or mechanical (talc, laser) pleurodesis carries a low morbidity rate but is often associated with postoperative pain and/or fever, and the risk of relapse lies between 8% and 25%.’ Pleural abrasion, for which thoracotomy is needed, carries a 2-10% risk of relapse. 5,6 Since parietal pleurectomy offers a relapse rate of less than 0-5%, it is usually seen as the best way to prevent spontaneous pneumothorax. Percutaneous parietal pleurectomy has the double advantage of almost guaranteeing prevention of further recurrences of pneumothorax without the 8-12%’-9 complication rate of thoracotomy-haemothorax, sputum retention, parietal muscle section, and wound infection, for example. Postoperative pain is much reduced, the procedure leaves only a small scar, and time in hospital is reduced. Because it permits percutaneous parietal pleurectomy without thoracotomy, thoracic video-surgery should become the preferred method of treatment for spontaneous pneumothorax relapse. J.-F. LEVI Thoracic Surgery Unit,
Hôpital Laennec, 75007 Paris, France
P. KLEINMANN M. RIQUET B. DEBESSE
Champel F, Biron E, Kalb JC. Talcage pleural par thoracoscopie dans le traitement du pneumothorax. Rev Mal Resp 1985; 2: 25-29. 2. Stephenson L. Treatment of pneumothorax with intrapleural tetracydine. Chest 1989; 6: 803-84. 1 Guerin JC,
Neuroectodermal tumours in children born after assisted conception SiR,—The problem of infertility has been increasingly addressed by various methods and programmes.’ Among pregnancies after assisted conception that are notified to a national register in Australia,’ there were 2285 livebirths after conception by in-vitro fertilisation (IVF) between 1979 and 1987. Although various perinatal outcomes and congenital malformations have been recorded, so far there have been no reports of malignant disease in the offspring. We have diagnosed neuroectodermal tumours (2 neuroblastoma, 1 medulloblastoma) in 3 children who were born after IVF between 1985 and 1987 (table). 2 further patients (1neuroblastoma, 1 supratentorial primitive neuroectodermal tumour) were conceived during the same period after ovulation induction with clomiphene and artificial insemination. Our institution is one of two referral centres for paediatric oncology in New South Wales. The reported annual incidence rates for neuroblastoma and medulloblastoma in Australia are 10 and 0-4 per 100 000 children, respectively.7 Up to 1987 there were 604 livebirths in NSW resulting from IVF conceptions. During the same period, there were 10 livebirths in NSW and 56 nationally after frozen embryo transfer. There are no data for the total number of babies born after ovulation induction and artificial insemination.
1. Hull MGR, Glazener CMA, Kelly NJ, et al. Population study of causes, treatment and outcome of infertility. Br Med J 1985, 291: 1693. 2. IVF and GIFT pregnancies, Australia and New Zealand, 1988. Sydney: National Perinatal Statistic Unit, 1990. ISSN 1030 4711. 3. Australian In Vitro Fertilisation Collaborative Group. High incidence of pre-term births and early losses in pregnancy after in vitro fertilisation. Br Med J 1985; 291: 1160-63. 4. Spensley JC, Mushin D, Barreda-Hanson M. The children of IVF pregnancies: a cohort study. Aust Paediatr J 1986; 22: 285-89. 5. Lancaster PAL. Congenital malformations after in-vitro fertilisation. Lancet 1987; ii: 1392. 6. Morin NC, Wirth FH, Johnson DH, et al. Congenital malformations and psychosocial development in children conceived by in vitro fertilisation. J Pediatr 1989; 115: 222-27. 7. Childhood cancer in Australia. A report of the Australian Paediatric Cancer Registry. Brisbane Australian Paediatric Cancer Registry, 1990. ISBN 0 959632174.
Percutaneous parietal pleurectomy for recurrent
spontaneous pneumothorax
SiR,—A third spontaneous pneumothorax or a contralateral episode is usually an indication for preventive treatment. The best way to do this is pleurectomy or pleural abrasion, but the morbidity rate associated with thoractomy has prompted clinicians to look at chemical or mechanical pleurodesis, which does not require thoracotomy. Pleurodesis is less dangerous but it is not as effective at preventing recurrence. Video-endoscopy now permits parietal pleurectomy without thoracotomy. For this percutaneous endoscopic procedure a posterior 2-3 cm incision is made in the non-muscular zone between the spinal edge of the latissimus dorsi and the anterior edge of the trapezius. The intercostal space is then reached at the inferior edge of the rhomboid muscle. The intercostal muscles are detached for 4 cm at the superior edge of the rib. The extrapleural detachment is a bloodless operation done under video-endoscopic surveillance without retraction of the intercostal space. This detachment is pursued within the region bounded by the external edge of the first rib, the internal mammary vessels, the costovertebral cradle, and a horizontal line passing through the median arc or eighth rib. The pleura is resected by electrocoagulation and sectioned within these limits. The lung is explored under ventilation. Video-endoscopic surgery allows ligation of apical bullae. The pleural cavity is drained through two tubes exiting via an axillary incision. Percutaneous parietal pleurectomy has been done on ten patients (eight men and two women of average age 26) between August and October, 1990. In nine cases the patient had had his or her third episode of spontaneous pneumothorax. Two patients had had contralateral pneumothorax. Operative bleeding averaged only 30 ml and no transfusions were needed. Postoperative drainage averaged only 3 days (range 2-7 days) and the patients stayed in hospital for 5 days on average (range 4-7 days). On discharge from
*Hydroxyprogesterone
hexanoate 250
mg/ml
Although these may be chance findings, we report our preliminary observations to encourage further study. The possibility of an association between IVF and childhood malignant diseases in general, or specific subsets of tumours, is difficult to ascertain from the available information. The use of ovulation induction with clomiphene in all 5 of the reported patients is especially noteworthy. We are not aware of any previous or planned follow-up studies with sufficient numbers of children born after assisted conception that would enable the risk of uncommon outcomes such as childhood malignant disease to be determined. A survey has been initiated in which paediatric oncologists in Australia will be asked to review their records and prospectively report new cases. We also encourage all doctors to include information about the method of fertilisation from the families of children with malignant disease. Paediatric Haematology-Oncology, Prince of Wales Children’s Hospital, Randwick, 2031 NSW, Australia
LES WHITE NEELAM GIRI MARCUS R. VOWELS
National Perinatal Statistics Unit, University of Sydney
PAUL A. L. LANCASTER
hospital no patient required analgesic drugs. Chemical (tetracycline) or mechanical (talc, laser) pleurodesis carries a low morbidity rate but is often associated with postoperative pain and/or fever, and the risk of relapse lies between 8% and 25%.’ Pleural abrasion, for which thoracotomy is needed, carries a 2-10% risk of relapse. 5,6 Since parietal pleurectomy offers a relapse rate of less than 0-5%, it is usually seen as the best way to prevent spontaneous pneumothorax. Percutaneous parietal pleurectomy has the double advantage of almost guaranteeing prevention of further recurrences of pneumothorax without the 8-12%’-9 complication rate of thoracotomy-haemothorax, sputum retention, parietal muscle section, and wound infection, for example. Postoperative pain is much reduced, the procedure leaves only a small scar, and time in hospital is reduced. Because it permits percutaneous parietal pleurectomy without thoracotomy, thoracic video-surgery should become the preferred method of treatment for spontaneous pneumothorax relapse. J.-F. LEVI Thoracic Surgery Unit,
Hôpital Laennec, 75007 Paris, France
P. KLEINMANN M. RIQUET B. DEBESSE
Champel F, Biron E, Kalb JC. Talcage pleural par thoracoscopie dans le traitement du pneumothorax. Rev Mal Resp 1985; 2: 25-29. 2. Stephenson L. Treatment of pneumothorax with intrapleural tetracydine. Chest 1989; 6: 803-84. 1 Guerin JC,
