A clinical staging of patients with neuroblastoma is proposed. Such staging is desirable to aid in estimating the prognosis and to be able to evaluate the efficacy of differing therapeutic regimens by analyzing results obtained in comparable groups of patients. That the suggested staging is practical is illustrated by the ease with which 100 children with neuroblastoma, entered in previous studies by Children's Cancer Study Group A, were staged using the criteria described. Short‐term survival data of this small sample demonstrated, in addition, that the proposed staging appears to be of help in estimating the prognosis. Also proposed is a list of investigations which aid in accurate staging.

There appears to be no benefit from the use of steroids to treat children who have ingested a caustic substance. The development of esophageal stricture was related only to the severity of the corrosive injury.

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ObjectiveThe authors assessed the risks of nonoperative management of solid visceral injuries in children (age range, 4 months-14 years) who were consecutively admitted to a level pediatric trauma center during a 6-year period ending in 1991. MethodOne hundred seventy-nine children (5.0%) sustained injury to the liver or spleen. Nineteen children (1 1.2%) died. Of the 160 children who survived, 4 received emergency laparotomies; 156 underwent diagnostic computer tomography and were managed nonoperatively. The percentage of children who were successfully treated nonoperatively was 97.4%. Delayed diagnosis of enteric perforations occurred in two children. Fifty-three children (34.0%) received transfusions (mean volume 16.7 mL/kg); however, transfusion rates during the latter half of the study decreased from 50% to 19% in children with hepatic injuries, despite increasing grade of injury, and decreased from 57% to 23% in the splenic group with similar injury grade (p < 0.005, chi square test and Student's t test). ConclusionPediatric blunt hepatic and splenic trauma is associated with significant mortality. Nonoperative management based on physiologic parameters, rather than on computed tomography grading of organ injury, was highly successful, with few missed injuries and a low transfusion rate.It is common practice to forgo operative management of pediatric blunt hepatic and splenic injuries for more expectant therapy based on the physiologic status of the child rather than the anatomic nature of the injury. Previous reports have confirmed the efficacy of this approach,'16 but concerns remain about the ability of radiologic imaging to provide a diagnosis of all intraabdominal injuries. In addition, because of the growing Address reprint requests to Sheldon J. Bond, M.D., Division of Pediatric Surgery, Department of Surgery, University of Louisville, Louisville, KY 40292. Accepted for publication July 27, 1995. 286concern oftransmitting diseases through the use ofblood products, many question whether nonoperative management results in excessive transfusion rates. In an attempt to answer these questions and to examine the overall efficacy of treating blunt hepatic and splenic injuries in children nonoperatively, a review of our most recent experience was undertaken.

Members of Childrens Cancer Study Group and the Pediatric Division of the Southwest Oncology Group conducted a study of chemotherapy for children with malignant liver tumors. All patients received vincristine, cyclophosphamide, Adriamycin and 5‐fluorouracil in 6 weekly cycles for one year. Surgical resection and irradiation were employed when indicated. Between January 1976 and August 1978, 62 patients were entered on study; one was rejected for a protocol error, and ten had inadequate trials of chemotherapy, dying within one month of entry. The median time on study for all patients was 12 months. Twenty‐four patients had no measurable disease following surgical treatment and chemotherapy was employed as adjuvant treatment; 20/24 (83%) remain relapse‐free from 8–42+ months, (median, 30 months). In 27 patients, residual measurable disease was available to determine the response to chemotherapy. The response rate was 12/27 (44%), lasting 3–45 months (median, 18 months). The median follow‐up of all survivors is 30 months. Hematologic toxicity was significant, particularly during the initial courses of chemotherapy; 28/57 patients developed severe toxicity which was fatal in three. The results from the current study were compared to those from a previous one initiated in 1972, in which actinomycin D, vincristine, and cyclophosphamide were given in sequence, one during each month for one year. Although the population of the two studies was not identical, there was a difference in the response rates (P = 0.02), relapse‐free interval (P = 0.008), and survival (P = 0.003), The most striking improvement was seen in the patients with Group I disease, there were 7/11 relapses in the first study and 1/16 in the current one.

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