Etoposide in Langerhans cell histiocytosis in children: a preliminary experience

Treatment of Langerhans cell histiocytosis (LCH) is yet to be established. We treated seven patients with etoposide alone at a dose of 100 mg/m2/day for 3 days given every 3 to 4 weeks for six cycles. Three patients had received prior chemotherapy, two patients were less than 2 years of age, and two had liver dysfunction. A positive response to therapy was seen in five patients. There was no major toxicity. Etoposide therapy is safe and effective in the treatment of LCH.

Intra-abdominal desmoplastic small round cell tumor in children: a clinicopathologic study

Desmoplastic small round cell tumor (RCT) is a relatively newly recognized neoplasm. It has a very distinct morphologic and high-grade polyphenotypic expression with a very poor prognosis. It is commonly seen in adolescent boys. We describe two cases of intra-abdominal desmoplastic small RCT in young girls (5 and 11 years of age). In both cases, the exact origin of tumor in the abdomen could not be established. Histopathologic examination of the biopsy specimens showed distinct desmoplastic stroma and coexpression of various epithelial, neural, and muscle markers. These two patients were treated primarily by debulking surgery followed by adjuvant chemotherapy (RCT II protocol). One of the two had a stable disease while the other had a progressive disease while on treatment. Thus our findings support the diverse histogenesis of this tumor and its poor prognosis.

Survival of childhood acute lymphoblastic leukemia: results of therapy at Tata Memorial Hospital, Bombay, India

The purpose of this study was to analyze the outcome of patients who completed therapy for acute lymphoblastic leukemia (ALL) and to study the role of an aggressive induction regimen in preventing post therapy relapses. Four hundred and twenty-two patients with ALL who completed therapy during the period 1975-1991 were followed. Two hundred and sixty patients received the aggressive MCP 841 protocol and 162 patients received various other less aggressive treatment regimens. Patients were followed with periodic examination and complete blood counts. The incidence of post therapy relapse was 27% in the less aggressive protocols and 15% in the MCP 841 protocol (p = 0.001). An higher percentage of relapses was seen in males (p = 0.05) and 89% relapses occurred within two years of stopping therapy. The relapse rate after 5 years of cessation of therapy was 0.59%. In conclusion, aggressive induction therapy is the most crucial factor in predicting relapses following cessation of therapy in ALL patients. However, relapses are unlikely to occur five years post therapy.

Treatment results of Hodgkin's disease in Indian children

This is a retrospective study of Hodgkin's disease in children less than 15 years of age who were registered at Tata Memorial Hospital in India from January 1985 through December 1990. Clinicopathologic characteristics and response were evaluated in 147 patients and survival was calculated in 187. There were 126 boys and 21 girls (6:1). All patients were treated with combination chemotherapy and involved field radiotherapy. The COPP schedule was given to 108 patients. COPP/ABVD to 33, and ABVD to 6. Ninety-three patients (63%) had stage I or II disease and 54 (37%) had stage III or IV disease. B symptoms were observed in 65 patients (56%) and bulky disease in 40 (27%). Histologically, the most common subtype was mixed cellularity, seen in 95 patients (65%). Complete response was observed in 136 (89%), partial response in 6 (4%), and there were 4 treatment-related deaths. Relapse has been observed in 11%. Seven-year actuarial survival was 73% and event-free survival was 64%. Median survival has not yet been reached, with a median follow-up of 36 months.

Pediatric germ cell tumor. An experience with BEP

PURPOSE

This study is an analysis of our experience with bleomycin, etoposide, and cisplatin (BEP) chemotherapy, in pediatric germ cell tumors (GCTs).

PATIENTS AND METHODS

The study included all children (age < 16 years) who were registered between May 1988 and May 1993 with a histologically confirmed diagnosis of GCT and received BEP chemotherapy. In addition to the clinicopathological features, the response rate, survival rate, and toxicity were analyzed.

RESULTS

There was a total of 56 patients, of whom 22 had an ovarian tumor and 17 each had a testicular or an extragonadal tumor. Histologically, endodermal sinus tumor was the most common type (62%). Tumor markers were increased in 89% (50 of 56). Complete responses were observed in 89.1% (49 of 55) and partial responses in 10.9% (6 of 55) of the evaluable patients. Five-year actuarial survival was 83% and progression free survival was 93%. Median follow-up was 18 months. Median survival is not yet reached. The chemotherapy was well tolerated.

CONCLUSIONS

From the present report, it is apparent that BEP chemotherapy is very effective and well tolerated in children with GCT. The data probably suggests that conservative surgery, when combined with effective chemotherapy, can result in cure of the majority of children with GCTs.

Rapid cytoreduction in childhood leukemic hyperleukocytosis by conservative therapy

Childhood leukemic hyperleukocytosis poses a serious threat to life because of its associated metabolic complications. The present prospective trial utilized conservative management of childhood acute lymphoblastic leukemia with hyperleukocytosis (total white cell count equal or > 100 x 10(9)/L) by intravenous hydration, urinary alkalinization, and allopurinol presenting without severe life-threatening complications. The median reduction in WBC count was 81.51% (range: 66-98.8%) within a median period of 36 hours (range: 12-60 hours) following hospitalization. There were no failures or treatment related complications. Thus we conclude that in childhood acute lymphoblastic leukemia, hyperleukocytosis can be managed safely and effectively with intravenous hydration, urinary alkalinization, and allopurinol before starting any specific anti-leukemic chemotherapy avoiding risk-associated cranial irradiation, leukapheresis, and exchange transfusion.

Evaluating efficiency of bone marrow harvest and its manipulation--role of CD 34 positivity

We evaluated harvested marrow cells for total nucleated cells (27.49 x 10(9)), absolute 'lymphocyte' count (6.29 x 10(9)) and CD 34 positive cells (3.57 x 10(9)). The same parameters were studied after in vitro manipulation to remove RBCs and plasma. Reinfused WBCs contained 12.87 x 10(9) nucleated cells, 4.25 x 10(9) absolute 'lymphocyutes' and 3.34 x 10(9) CD 34 positive cells. The corresponding figures for loss during in vitro manipulation (tubing, RBCs and plasma) are 14.62 (53.18%), 2.04 (32.43%) and 0.23 x 10(9) (6.44%) cells respectively. Therefore CD 34 positivity may be a better indicator of total yield, loss during manipulation and reinfusion of hemopoietic progenitor cells in bone marrow transplantation.

Malignant germ cell tumors in childhood

The outlook for patients with germ cell tumors was poor before the advent of effective chemotherapy. In this study the outcome of multiagent chemotherapy in children treated for germ cell tumor is assessed. Between January 1984 and December 1990, 107 patients were diagnosed to have germ cell tumors. Postsurgical therapy was based on tumor site, stage, and histology. Combination chemotherapy was employed in patients with Stages I and II disease with postoperative raised tumor markers and all patients with Stages III and IV. Between 1984-1988, patients received cisplatin, vinblastin, bleomycin, and methotrexate (PVB-M), and thereafter between 1988-1990, they received bleomycin, etoposide, and cisplatin (BEP). Of 34 patients treated with PVB-M and 27 treated with BEP, the complete remission rate was 40% and 85%, respectively, and the overall survival was 30% at 5 years for PVB-M and 80% at 3 years for BEP. We conclude that etoposide with cisplatin is superior to vinblastin with cisplatin in the treatment of advanced germ cell tumors because of greater efficacy, decreased toxicity, and better compliance in children.

131I-MIBG scintigraphy in neural crest tumours

Radioiodinated meta-iodobenzylguanidine (131I-MIBG) has been widely used for the diagnosis of neuroblastomas, pheochromocytomas, paragangliomas and medullary carcinomas of thyroid. We have developed a procedure for preparation of 131I-MIBG and studied its utility in diagnosis of primary and metastatic neural crest tumours. Studies were carried out in 54 patients. Of them 39 cases were of neuroblastomas, 1 pheochromocytoma; 6 operated medullary carcinomas; 5 paragangliomas; 2 Ewing's sarcoma and 1 Rhabdomyosarcoma; The sensitivity for the detection of primary tumours of neuroblastomas was 94% and for the detection of metastasis was 83%; while in the case of paragangliomas and medullary carcinoma, the sensitivity was 75% and 70% respectively. Our experience in the present study shows that 131I-MIBG scintigraphy is a sensitive and specific diagnostic tool to localise primary and metastatic disease of neural crest tumours.

Infection analysis in acute lymphoblastic leukemia: a report of 499 consecutive episodes in India

The use of empirical antibiotic combinations in the treatment of febrile neutropenic patients has decreased complication-related mortality in cancer patients. We have analyzed retrospectively 499 consecutive episodes of fever in 432 patients with acute lymphoblastic leukemia over a 5-year period. We have compared various antibiotic combinations used empirically in our study. Of the febrile episodes, 92% were neutropenic. The most common site of clinical documentation was the lung. The most common pathogen isolated in our setting was Pseudomonas aeruginosa (27.27%). The overall response rate to first-line empirical antibiotic combination was seen in 61.92%, the best results being with ceftazidime and amikacin combination (65.69%). A uniform antibiotic policy resulted in a decrease in mortality, with the number of deaths decreasing significantly in the 1989 to 1991 era (P = 0.00000003). The other contributing factors were an improvement in the supportive care with a reduction in length of hospital stay during induction. Our fungal isolates demonstrated 11 patients with documented fungal infection with a positive outcome in 8 patients.

Brain tumors following cure of acute lymphoblastic leukemia

The majority of children with acute lymphoblastic leukemia can be cured with effective modern day therapy. However, more and more long term sequelae including carcinogenic potential of the treatment are being recognised. We report two children who developed acute lymphoblastic leukemia at the age of 4 and 5 years respectively and were successfully treated. They developed meningioma and astrocytoma at 9 and 3 years respectively after completion of therapy. Both were treated surgically and the patient with astrocytoma also received radiotherapy. Both are now free of disease 19 months after diagnosis of second neoplasm.

Pilot study of sequential combination chemotherapy in advanced and recurrent retinoblastoma

Eight patients with advanced/recurrent retinoblastomas were treated with sequential combination chemotherapy incorporating cyclophosphamide, cisplatin, adriamycin, and etoposide. All patients achieved complete clinical response (CR) at the end of the first 75 day cycle. Three patients developed recurrence of which 2 patients had recurrence in the central nervous system and 1 patient had local recurrence. Median time to treatment failure was 30 weeks. Two patients succumbed to chemotherapy related neutropenic sepsis. One patient is alive and disease free for 72 weeks from start of treatment. This combination chemotherapy shows promise in patients with advanced/recurrent retinoblastoma and merits further study.

Response with combined modality treatment in childhood rhabdomyosarcoma

Children diagnosed with rhabdomyosarcoma at the Tata Memorial Hospital during the period January 1986-December 1988 were studied. All were treated with combination chemotherapy incorporating vincristine, Adriamycin, and cyclophosphamide given sequentially in repeated cycles over 18 months, along with local radiotherapy. Of 24 patients, 18 patients had advanced-stage disease at onset. All patients have been followed up for 18 months or more. Of the 11 patients with group III disease, six are in complete remission; of the six patients with group IV disease, two patients are in complete remission. These results are clearly better than those achieved in the past, where surgery was employed as the primary modality of therapy with chemoradiotherapy given only for patients with group IV disease.

Myelodysplastic syndrome. A clinical and pathological analysis of 88 patients

Eighty eight patients with myelodysplastic syndromes were studied to determine the clinical and pathological features and the prognosis. All the patients had anemia. Neutropenia was seen in 44% and thrombocytopenia in 78% patients. The subtypes included refractory anemia in six, refractory anemia with ringed sideroblasts in three, refractory anemia with excess blasts in 30, refractory anemia with excess blasts in transformation in 32 and chronic myelomonocytic anemia in 17 patients. Forty four patients who received chemotherapy were evaluable for response. Three of the 15 patients treated with hydroxyurea achieved partial remission. Eighteen patients were treated with low dose cytosine arabinoside and complete remission was achieved in five and partial response in six patients. Aggressive chemotherapy was given to 11 patients at the onset of the illness resulting in complete remission in six and partial response in two patients. Nineteen of the 88 patients transformed to acute myeloid leukemia. The crude survival of all the patients ranged from 15 days to 22.5 months. The mortality was due to hemorrhage in 15% and septicemia in 85%. Our data reveals ineffectiveness of the current therapy and emphasizes on the need to develop newer therapeutic approaches.

Infantile neuroblastoma: 10 year TMH experience

The results of 19 children with neuroblastoma under one year of age treated at the Tata Memorial Hospital between 1981-1990 were analysed. Biologically, neuroblastomas in children under the age of 12 months have an entirely different prognosis as compared to older children. There were four children less than six months of age and 15 children between six and 12 months. All patients with stage II (2/2) disease are alive; 3/4 patients with stage IV-S disease are disease free; 3/5 stage III patients are disease free and 2/8 patients with stage IV disease are disease free. The survival of infants with stage II and IV-S is better than for those with stage III and IV disease.

Ewing's sarcoma

Between 1984-1987, 50 patients with Ewing's sarcoma of the bone were entered on combined modality protocol at Tata Memorial Hospital. Protocol treatment involved induction therapy consisting of 6-week therapy with vincristine, Adriamycin (doxorubicin), and cyclophosphamide (VDC) followed by local radiotherapy 50 Gy to the involved bone. This was followed for six more cycles of VDC. Five patients had metastatic disease at presentation. Seventy-six percent (38/50) of patients had disease either at axial or proximal site. With a median follow-up of 48 months (range 14-87) 21 patients remained alive with disease-free survival of 38.0% +/- 2.5% at 5 years and overall survival of 36.0% +/- 2.6% at 5 years. Twenty-five patients relapsed with five patients developing local failure and four local and distant metastasis. Using Lee-Desu statistical methods, only response to therapy was a significant factor for survival. We conclude that more aggressive therapy with proper selection of local treatment modality including surgery and/or radiotherapy is required to produce more long-term survival in high-risk Ewing's sarcoma.

Adjuvant chemotherapy for osteogenic sarcoma of the extremity with sequential adriamycin and cisplatin

Twenty-nine patients with high-grade nonmetastatic osteogenic sarcoma of the extremities were treated with adjuvant chemotherapy following definitive surgery. Chemotherapy consisted of systemic intravenous Adriamycin and cisplatin in a sequential fashion given for six courses. Nineteen out of 29 patients are alive and continuously disease free over a follow-up period ranging from 9+ to 30+ months. The relapse-free survival was 72%, and overall survival for the entire group was 69%. Median survival is not reached yet. Six out of 29 patients relapsed, of which 1 patient is alive for 6+ months after relapse. Three patients died of chemotherapy toxicity. The results were superior to historical controls treated with surgery alone. The need for more aggressive treatment approaches is discussed.

Prognostic significance of myeloperoxidase containing blast cells in acute myelogenous leukaemia

Fifty three newly diagnosed patients of de novo acute myelogenous leukaemia (AML) received treatment consisting of remission induction with daunorubicin 60 mg/m2 on day one and continuous infusion of cytosine arabinoside 200 mg/m2/day over 24 h from day one to 7. Thereafter patients in complete remission received consolidation chemotherapy with two identical courses. Complete remission (CR) could be achieved in 40 patients (75.5%). Seven patients (13.2%) died with complications during aplasia phase following remission induction therapy while six patients (11.3%) had resistant disease. Twenty seven patients (67.5%) developed relapse while eight patients (15.1%) continue to remain in complete remission ranging from 51 to 68 months (median 62.5). The projected event free survival and disease free survival at 60 months is 15 per cent (SE + 11.9%) and 21 per cent (+6%) respectively. Evaluation of the prognostic significance of pretherapy characteristics showed that infection at presentation and low number of myeloperoxidase (MPO) containing blasts affected the achievement of complete remission adversely on univariate analysis. Similarly age at diagnosis, of more than 45 yr, total leucocyte count of 50,000/cumm or more and low number of MPO containing blasts affected the remission duration (disease free survival) adversely on univariate analysis. On multivariate analysis, MPO positivity of blast cells, remained the only significant independent characteristic. High MPO positivity affected the remission duration favourably (P < 0.01). Patients with high MPO positivity also achieved CR with one induction cycle in 32 out of 40 instances while only 2 out of 5 patients with low MPO positivity, achieved CR with one chemotherapy cycle (P < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Aniridia--Wilms' tumour association--a case with 11p 13-14.1 deletion and ventricular septal defect

A two year old female child with bilateral wilms tumor (WT) along with multiple congenital anomalies like bilateral aniridia with congenital cataracts and nystagmus, microcephaly, mental retardation and ventricular septal defect has been described. The karyotype analysis revealed 46 xx, del 11p 13-14.1. Association of ventricular septal defect with the classical features of 'Aniridia-Wilms' tumor association' is an unusual feature in this case.

Childhood myelodysplastic syndromes: clinical features, cytogenetics and prognosis

Sixteen children with myelodysplastic syndrome as defined by the French-American-British co-operative group are presented. The mean age was 10.5 (2.5 to 16) years, with a male predominance. All patients belonged to the more aggressive subtypes of myelodysplastic syndromes. Seven patients presented with refractory anaemia with excess blasts, six had refractory anemia with excess blasts in transformation, and three had chronic myelomonocytic leukemia. Cytogenetic analysis done in 7 of the 16 patients, revealed karyotype abnormalities involving chromosomes 7, 8 and 17. One patient with Down's syndrome had karyotype of 47, XY, +21 (major clone) and 46, XY (minor clone). Five of these patients evolved to acute leukemia. The mean duration of survival was 5.5 months. Aggressive chemotherapy as a primary line of treatment induced remission in five out of six patients. Predominance of aggressive types of myelodysplastic syndromes in children and their good but short-lived response to aggressive chemotherapy suggests the need for early bone marrow transplantation following chemotherapy.