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Seven patients with newly diagnosed metastatic osteosarcoma underwent simultaneous resection of the primary tumor and metastases following intravenous (IV) neoadjuvant chemotherapy. Histologic response was assessed in all tumor specimens. Disparate responses were noted between primary tumor and metastases and, in some cases, between two or more metastatic tumor deposits. The diverse histologic response to neoadjuvant chemotherapy suggests tumor cell heterogeneity. Changing postoperative therapy on the basis of the histologic response induced in the primary tumor may not be appropriate.

Pulmonary fibrosis is a well-recognized complication of bleomycin therapy. Detection of bleomycin-induced pulmonary fibrosis by computed axial tomographic scanning (CT) has not been reported. We report on a patient in whom the development of lesions on chest CT scan following cessation of chemotherapy (including bleomycin) was interpreted as representing recurrent metastatic disease. At bilateral thoracotomy, only pulmonary fibrosis was found. In this patient, the CT scan appearance of bleomycin-induced pulmonary fibrosis mimicked recurrent disease.

Three children with nonlymphoblastic, non-Hodgkin's lymphomas, showed morphologic features that suggested nonlymphoblastic T-cell origin. Tissue for immunologic study was available from two of the three patients; both showed immunophenotypes of T-cells. Although nearly all T-cell lymphomas in children are lymphoblastic based on morphology, nonlymphoblastic T-cell lymphomas do occur in pediatric patients.

The development of fever in neutropenic cancer patients is frequently an indication of infection. The response of these patients to antibiotic treatment is often poor, and the recent literature continues to document a substantial mortality rate in spite of the prompt treatment of these patients with multipleagent antibiotic therapy. Because of limited available information regarding fever and neutropenia in pediatric cancer patients, we undertook an analysis of a group of such patients from a pediatric oncology center. The incidence of probable and documented infections was 39.2% in a group of these patients, representing 158 febrile episodes, The most frequent form of infection was bacterial sepsis; pulmonary infections were the next most frequent, followed by infections of skin and soft tissues. In leukemia patients with culture-proven infections, gram-negative organisms were isolated in 61.1% of episodes while gram-positive organisms were isolated in 41.7%. Escherichia coli and Staphylococcus aureus were the organisms most frequently isolated from these patients. In solid-tumor patients with bacterial infections, gram-positive organisms were isolated in 78% of cases. Patients having the highest incidence of documented infections were those with leukemia H ho had active disease (induction or relapse), and severe neutropenia (

A case of Hodgkin's disease occurred with pulmonary involvement as the initial feature. The disease was initially seen clinically and roentgenographically as a diffuse pulmonary infiltrate. To our knowledge, the pattern of diffuse pneumonic involvement without intrathoracic lymphadenopathy at presentation has been reported only in one other case. Differentiation of this diffuse pneumonic pattern of primary pulmonary Hodgkin's disease from the more common pattern of a focal mass or infiltrate is important in considering appropriate therapy.

Alveolar soft-part sarcoma (ASPS) is an unusual tumor of soft tissues; it has invariably ended in death from disseminated disease, and the lung has been the most common site of metastasis. We present a patient with ASPS with bilateral pulmonary metastases who achieved a complete response after bilateral thoracotomies with removal of all gross disease and after combination chemotherapy including vincristine, actinomycin D, cyclophosphamide, and doxorubicin. The patient has now been followed for five years since the appearance of the metastases and has been off therapy for the past 34 months. He shows no evidence of disease. We suggest that multimodality therapy is a reasonable approach in patients with ASPS and pulmonary metastases and that such therapy has the potential for improving survival.

In my opinion, it is clear that improving the initial disease-free survival is the key to improving the cure rates for patients with osteosarcoma. However, until new drugs with marked activity against osteosarcoma are developed, significant improvements in disease-free survival are unlikely. Almost all patients with newly-diagnosed osteosarcoma will receive preoperative chemotherapy which is followed by a definitive surgical (limb-sparing or amputation) procedure and additional postoperative chemotherapy. The impact of limb-sparing surgery on the incidence of pulmonary metastases and long-term disease-free survival must be assessed carefully in continuing and future trials. It is conceivable that limb-sparing surgery may be contraindicated in certain situations. The cure rate after the development of metastatic disease must be assessed, although I fear that it will be quite low. Lastly, and possibly most importantly, the assessment of biological variables such as tumour ploidy, enzyme content, and so on, should be undertaken in an effort to promote a better understanding of osteosarcoma.

Sequential high-dose cytosine arabinoside (ara-C) and asparaginase were given to 41 children age six months to 21 years of age with advanced leukemia. Ten of 22 patients with acute lymphocytic leukemia (ALL) and eight of 19 patients with acute nonlymphocytic leukemia (ANLL) obtained complete remissions. The most significant toxicity seen was infection in 22 patients. In addition, patients given intrathecal chemotherapy within 24 hours of ara-C developed neurologic toxicity. The high response rate seen in these patients with advanced leukemia indicates that a trial of this regimen is warranted in children with less advanced ALL and ANLL.

In vitro radiobiologic survival parameters have been determined for 7 human osteosarcoma, 5 human soft tissue and bone sarcomas, and 4 Ewing's sarcoma cell lines. The mean D 0 values were 99.5 ± 11.6 cGy, 90.5 ± 7.7 cGy and 95.8 ± 7.9 cGy for osteosarcomas, soft tissue and bone sarcomas and Ewing's sarcomas, respectively. These in vitro survival data do not predict the clinical radiation resistance generally attributed to osteosarcomas and soft tissue and bone sarcomas, and do not differ substantially from the results obtained with the clinically radioresponsive Ewing's sarcomas.

• A case of Hodgkin's disease occurred with pulmonary Involvement as the Initial feature. The disease was initially seen clinically and roentgenographically as a diffuse pulmonary infiltrate. To our knowledge, the pattern of diffuse pneumonic involvement without intrathoracic lymphadenopathy at presentation has been reported only In one other case. Differentiation of this diffuse pneumonic pattern of primary pulmonary Hodgkin's disease from the more common pattern of a focal mass or infiltrate Is important in considering appropriate therapy. ( Arch Intern Med 1982;142:1941-1943)