Incidence of childhood cancer in France: National Children Cancer Registries, 2000–2004

Childhood acute lymphoblastic leukaemia and indicators of early immune stimulation: the Estelle study (SFCE)

Background:

Factors related to early stimulation of the immune system (breastfeeding, proxies for exposure to infectious agents, normal delivery, and exposure to animals in early life) have been suggested to decrease the risk of childhood acute lymphoblastic leukaemia (ALL).

Methods:

The national registry-based case–control study, ESTELLE, was carried out in France in 2010–2011. Population controls were frequency matched with cases on age and gender. The participation rates were 93% for cases and 86% for controls. Data were obtained from structured telephone questionnaires administered to mothers. Odds ratios (OR) were estimated using unconditional regression models adjusted for age, gender, and potential confounders.

Results:

In all, 617 ALL and 1225 controls aged ⩾1 year were included. Inverse associations between ALL and early common infections (OR=0.8, 95% confidence interval (CI): 0.6, 1.0), non-first born (⩾3 vs 1; OR=0.7, 95% CI: 0.5, 1.0), attendance of a day-care centre before age 1 year (OR=0.7, 95% CI: 0.5, 1.0), breastfeeding (OR=0.8, 95% CI: 0.7, 1.0), and regular contact with pets (OR=0.8, 95% CI: 0.7, 1.0) in infancy were observed.

Conclusions:

The results support the hypothesis that conditions promoting the maturation of the immune system in infancy have a protective role with respect to ALL.

Are the studies on cancer risk from CT scans biased by indication? Elements of answer from a large-scale cohort study in France

BACKGROUND

Recent epidemiological results suggested an increase of cancer risk after receiving computed tomography (CT) scans in childhood or adolescence. Their interpretation is questioned due to the lack of information about the reasons for examination. Our objective was to estimate the cancer risk related to childhood CT scans, and examine how cancer-predisposing factors (PFs) affect assessment of the radiation-related risk.

METHODS

The cohort included 67,274 children who had a first scan before the age of 10 years from 2000 to 2010 in 23 French departments. Cumulative X-rays doses were estimated from radiology protocols. Cancer incidence was retrieved through the national registry of childhood cancers; PF from discharge diagnoses.

RESULTS

During a mean follow-up of 4 years, 27 cases of tumours of the central nervous system, 25 of leukaemia and 21 of lymphoma were diagnosed; 32% of them among children with PF. Specific patterns of CT exposures were observed according to PFs. Adjustment for PF reduced the excess risk estimates related to cumulative doses from CT scans. No significant excess risk was observed in relation to CT exposures.

CONCLUSIONS

This study suggests that the indication for examinations, whether suspected cancer or PF management, should be considered to avoid overestimation of the cancer risks associated with CT scans.

The worldwide incidence and prevalence of primary brain tumors: a systematic review and meta-analysis

BACKGROUND

Primary brain tumors are a heterogeneous group of benign and malignant tumors arising from the brain parenchyma and its surrounding structures. The epidemiology of these tumors is poorly understood. The aim of our study is to systematically review the latest literature on the incidence and prevalence of primary brain tumors.

METHODS

The systematic review and meta-analysis were conducted according to a predetermined protocol and established guidelines. Only studies reporting on data from 1985 onward were included. Articles were included if they met the following criteria: (i) original research, (ii) population based, (iii) reported an incidence or prevalence estimate of primary brain tumors.

RESULTS

From the 53 eligible studies overall, 38 were included in the meta-analysis. A random-effects model found the overall incidence rate of all brain tumors to be 10.82 (95% CI: 8.63-13.56) per 100 000 person-years. The incidence proportion estimates were heterogeneous, even among the same tumor subtypes, and ranged from 0.051 per 100 000 (germ cell tumors) to 25.48 per 100 000 (all brain tumors). There were insufficient data to conduct a meta-analysis of the prevalence of primary brain tumors.

CONCLUSIONS

There is a need for more accurate and comparable incidence and prevalence estimates of primary brain tumors across the world. A standardized approach to the study of the epidemiology of these tumors is needed to better understand the burden of brain tumors and the possible geographical variations in their incidence.

Beckwith-Wiedemann syndrome: growth pattern and tumor risk according to molecular mechanism, and guidelines for tumor surveillance

BACKGROUND

Beckwith-Wiedemann syndrome (BWS) is an overgrowth syndrome associated with an increased risk of pediatric tumors. The underlying molecular abnormalities may be genetic (CDKN1C mutations or 11p15 paternal uniparental isodisomy, pUPD) or epigenetic (imprinting center region 1, ICR1, gain of methylation, ICR1 GOM, or ICR2 loss of methylation, ICR2 LOM).

AIM

We aimed to describe a cohort of 407 BWS patients with molecular defects of the 11p15 domain followed prospectively after molecular diagnosis.

RESULTS

Birth weight and length were significantly higher in patients with ICR1 GOM than in the other groups. ICR2 LOM and CDKN1C mutations were associated with a higher prevalence of exomphalos. Mean adult height (regardless of molecular subtype, n = 35) was 1.8 ± 1.2 SDS, with 18 patients having a final height above +2 SDS. The prevalence of tumors was 8.6% in the whole population; 28.6 and 17.3% of the patients with ICR1 GOM (all Wilms tumors) and 11p15 pUPD, respectively, developed a tumor during infancy. Conversely, the prevalence of tumors in patients with ICR2 LOM and CDKN1C mutations were 3.1 and 8.8%, respectively, with no Wilms tumors.

CONCLUSION

Based on these results for a large cohort, we formulated guidelines for the follow-up of these patients according to the molecular subtype of BWS.

[Ewing's sarcoma of the mandible in children: reconstruction by induced membrane]

INTRODUCTION

Ewing's sarcoma (ES) is a malignant bone neoplasm that develops during the first two decades of life, and affects male more than female patients (sex ratio 1.6/1). ES head and neck bone localization is extremely uncommon (2 to 4%). We report a rapid induced membrane reconstruction without primary bone autograft.

OBSERVATION

A 7-year-old boy presented with a 50mm mandibular ES centered on the horizontal branch of the right mandible. This patient was treated by a combination of neo-adjuvant chemotherapy, surgery, and adjuvant radio-chemotherapy, according to the Euro-Ewing 99 protocol. The right horizontal mandibular branch was resected, following induction chemotherapy. A macroplate and a cement spacer were used for the reconstruction, while expecting anatomopathological results. Seventeen days later, we removed the spacer because of scar disunion. The radiographic controls revealed a spontaneous osteogenesis along the macroplate despite the early cement spacer removal. This spontaneously bone growth allowed avoiding a free vascularized bone transfer for the reconstruction. The tissue regeneration potential of this young boy and the cement spacer induced membrane could explain this spontaneous osteogenesis phenomenon.

DISCUSSION

Induced membrane can be added to the therapeutic options for pediatric oncologic mandibular bone loss. It avoids using of a free vascularized bone transfer.

[Childhood cancer: progress but prognosis still very unequal. Example of Retinoblastoma and high-risk Neuroblastoma]

Children suffering with cancer have a higher probability of cure than adult. Since the 1950's, high cure rates have been achieved following remarkable progress in the overall care of these children. Not only children are more often "cured" than during the past century but they are probably "better cured" with the hope of experiencing less late effects. Nevertheless, there are still large disparities related to tumor diagnosis and regional area on the globe. If retinoblastoma is now cured in about 100% of the cases in industrialized countries, a different figure is seen unfortunately in economically disadvantaged countries. Not only is access to primary care lower, but also ophthalmologic techniques and available cancer treatments are less effective. Nowadays, such high cure rates observed for children with retinoblastoma are not the rule for all children with cancer. For example, despite considerable progress with new innovative treatments, the cure rate of children with metastatic neuroblastoma does not exceed 40%.

The role of SIOP as a platform for communication in the global response to childhood cancer

Since the year 2000, there has been a 35% annual decrease in mortality among children under the age of five worldwide. The decrease is mainly attributed to the decrease in childhood epidemic infections, for example, due to vaccination programs. In the near future, this decrease will draw attention to paediatric non-communicable diseases (NCDs), and cancer is one of the most common. Access to care for children with cancer and survival rates have improved dramatically in high-income countries. However, it is important that a global perspective addresses problems in developing countries in particular. To meet this challenge, it is critical that emphasis is placed on demands such as access to care and drugs that are known to be effective, and which can be safely administered in resource-limited settings. Additionally, cancer registries and improved health care structures that include care for children with cancer, are paramount for further progress to increase awareness and the survival of children with cancer. The purpose of this paper is to describe current worldwide interventions to improve childhood cancer from the perspective of the International Society of Paediatric Oncology (SIOP). This global perspective will serve as an introduction to a series of papers from six SIOP continental branches, which will highlight the specific and/or common issues related to children with cancer worldwide. To strengthen the communication among and synergistic effects of various paediatric cancer stakeholders, SIOP could serve as a global platform for a proposed Global Paediatric Cancer Network through the interaction of its continental branches and partner collaborations.

Poor treatment outcome of neuroblastoma and other peripheral nerve cell tumors may be related to under usage of radiotherapy and socio-economic disparity: a US SEER data analysis

PURPOSE

This study used receiver operating characteristic curve to analyze Surveillance, Epidemiology and End Results (SEER) neuroblastoma (NB) and other peripheral nerve cell tumors (PNCT) outcome data. This study found under usage of radiotherapy in these patients.

MATERIALS AND METHODS

This study analyzed socio-economic, staging and treatment factors available in the SEER database for NB and other PNCT. For the risk modeling, each factor was fitted by a generalized jinear model to predict the outcome (soft tissue specific death, yes/no). The area under the receiver operating characteristic curve (ROC) was computed. Similar strata were combined to construct the most parsimonious models. A random sampling algorithm was used to estimate the modeling errors. Risk of neuroendocrine (other endocrine including thymus as coded in SEER) death was computed for the predictors.

RESULTS

There were 5261 patients diagnosed from 1973 to 2009 were included in this study. The mean follow up time (S.D.) was 83.8 (97.6) months. The mean (SD) age was 18 (25) years. About 30.45% of patients were un-staged. The SEER staging has high ROC (SD) area of 0.58 (0.01) among the factors tested. We simplified the 4-layered risk levels (local, regional, distant, un-staged/others) to a simpler 3-tiered model with comparable ROC area of 0.59 (0.01). Less than 50% of PNCT patients received radiotherapy (RT) including the ones with localized disease. This avoidance of RT use occurred in adults and children.

CONCLUSION

The high under-staging rate may have prevented patients from selecting definitive radiotherapy (RT) after surgery. Using RT for, especially, adult PNCT patients is a potential way to improve outcome.

Potential impacts of radon, terrestrial gamma and cosmic rays on childhood leukemia in France: a quantitative risk assessment

Previous epidemiological studies and quantitative risk assessments (QRA) have suggested that natural background radiation may be a cause of childhood leukemia. The present work uses a QRA approach to predict the excess risk of childhood leukemia in France related to three components of natural radiation: radon, cosmic rays and terrestrial gamma rays, using excess relative and absolute risk models proposed by the United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR). Both models were developed from the Life Span Study (LSS) of Japanese A-bomb survivors. Previous risk assessments were extended by considering uncertainties in radiation-related leukemia risk model parameters as part of this process, within a Bayesian framework. Estimated red bone marrow doses cumulated during childhood by the average French child due to radon, terrestrial gamma and cosmic rays are 4.4, 7.5 and 4.3 mSv, respectively. The excess fractions of cases (expressed as percentages) associated with these sources of natural radiation are 20 % [95 % credible interval (CI) 0-68 %] and 4 % (95 % CI 0-11 %) under the excess relative and excess absolute risk models, respectively. The large CIs, as well as the different point estimates obtained under these two models, highlight the uncertainties in predictions of radiation-related childhood leukemia risks. These results are only valid provided that models developed from the LSS can be transferred to the population of French children and to chronic natural radiation exposures, and must be considered in view of the currently limited knowledge concerning other potential risk factors for childhood leukemia. Last, they emphasize the need for further epidemiological investigations of the effects of natural radiation on childhood leukemia to reduce uncertainties and help refine radiation protection standards.

Childhood leukaemia close to high-voltage power lines--the Geocap study, 2002-2007

Background:

High-voltage overhead power lines (HVOLs) are a source of extremely low-frequency magnetic fields (ELF-MFs), which are classified as possible risk factors for childhood acute leukaemia (AL). The study was carried out to test the hypothesis of an increased AL incidence in children living close to HVOL of 225–400 kV (VHV-HVOL) and 63–150 kV (HV-HVOL).

Methods:

The nationwide Geocap study included all the 2779 cases of childhood AL diagnosed in France over 2002–2007 and 30 000 contemporaneous population controls. The addresses at the time of inclusion were geocoded and precisely located around the whole HVOL network.

Results:

Increased odds ratios (ORs) were observed for AL occurrence and living within 50 m of a VHV-HVOL (OR=1.7 (0.9–3.6)). In contrast, there was no association with living beyond that distance from a VHV-HVOL or within 50 m of a HV-HVOL.

Conclusion:

The present study, free from any participation bias, supports the previous international findings of an increase in AL incidence close to VHV-HVOL. In order to investigate for a potential role of ELF-MF in the results, ELF-MF at the residences close to HVOL are to be estimated, using models based on the annual current loads and local characteristics of the lines.

Self-reported and record-collected late effects in long-term survivors of childhood cancer: a population-based cohort study of the childhood cancer registry of the Rhône-Alpes region (ARCERRA)

PURPOSE

We compared long-term health effects induced by childhood cancer or its treatments as reported by young adult survivors and as noted in their medical records.

PATIENTS AND METHODS

We analyzed and compared health problems reported by 192 young adults treated for childhood cancer between 1987 and 1992 who were included in the population-based childhood cancer registry of the Rhône-Alpes region and those effects inventoried by their healthcare providers in medical records.

RESULTS

Of 14 types of late effects studied, each patient reported experience of 0 to 11 (average 2.8 ± 2.1), and their medical records indicated 0 to 8 (average 1.8 ± 1.7) (P < .001). No late effect was reported by 10.4% of the 192 patients and/or noted in the medical records of 21.9% (P = .048). Only eight patients reported and were observed to experience none of the 14. Nine of the 14 were reported significantly more frequently by survivors than their medical records. Only one of eight survivors with cardiomyopathy reported its presence (P = .008), whereas alopecia was reported 13 times by survivors, once by medical records, and three times by both (P = .001).

CONCLUSION

The disparity between reports of late effects by survivors and medical records underscores the need for better communication between survivors and their health care providers. It is important to recognize the potential for bias from both under- and over-reporting in studies based only on survivor self-report. More thorough observation of late effects among survivors of childhood cancer might result from the implementation of a late-effects clinic.

Risk of cancer associated with cardiac catheterization procedures during childhood: a cohort study in France

BACKGROUND

Radiation can be used effectively for diagnosis and medical treatment, but it can also cause cancers later on. Children with congenital heart disease frequently undergo cardiac catheterization procedures for diagnostic or treatment purposes. Despite the clear clinical benefit to the patient, the complexity of these procedures may result in high cumulative radiation exposure. Given children's greater sensitivity to radiation and the longer life span during which radiation health effects can develop, an epidemiological cohort study is being launched in France to evaluate the risks of leukaemia and solid cancers in this specific population.

METHODS/DESIGN

The study population will include all children who have undergone at least one cardiac catheterization procedure since 2000 and were under 10 years old and permanent residents of France at the time of the procedure. Electronically stored patient records from the departments of paediatric cardiology of the French national network for complex congenital heart diseases (M3C) are being searched to identify the children to be included. The minimum dataset will comprise: identification of the subject (file number in the centre or department, full name, sex, date and place of birth), and characteristics of the intervention (date, underlying disease, type of procedure, technical details, such as fluoroscopy time and dose area product, (DAP), which are needed to reconstruct the doses received by each child). The cohort will be followed up through linkage with the two French paediatric cancer registries, which have recorded all cases of childhood leukaemia and solid cancers in France since 1990 and 2000, respectively. Radiation exposure will be estimated retrospectively for each child. 4500 children with catherizations between 2000 and 2011 have been already included in the cohort, and recruitment is ongoing at the national level. The study is expected to finally include a total of 8000 children.

DISCUSSION

This French cohort study is specifically designed to provide further knowledge about the potential cancer risks associated with paediatric cardiac catheterization procedures. It will also provide new information on typical dose levels associated with these procedures in France. Finally, it should help improve awareness of the importance of radiation protection in these procedures.

Solid tumors in Turkish children: a multicenter study

BACKGROUND

This paper presents a detailed incidence study on childhood solid tumors comprising a histopathology-based documentation of benign and malignant lesions.

METHODS

The Ankara Pediatric Pathology Working Group collected databases of pediatric solid tumors from six pediatric reference centers in order to analyze the incidence, distribution and some epidemiologic characteristics of the tumors and to establish a multicenter database for further studies. A five-year retrospective archive search was carried out. Excluding epithelial tumors of the skin, leukemia, lymphoreticular system neoplasias, metastatic tumors, and hamartomas, 1362 solid tumors in 1358 patients were classified according to age, sex, localization, histopathology and clinical behavior.

RESULTS

The male/female ratio was 0.9; 14.8% (201) of the patients belonged to 0-1 year age group, 20.7% (281) to 2-4 years, 25.9% (352) to 5-10 years, 22.2% (301) to 11-14 years, and 16.4% (223) to 15-18 years. Among all tumors, 708 (52.0%) were malignant, 645 (47.4%) benign tumors, 2 (0.1%) borderline tumors, and 2 (0.1%) unknown behavioral tumors. Malignant tumors were found in 50.2% (357) of female patients and in 54.0% (349) of male patients. A balanced distribution between benign and malignant entities among children under 18 years was observed. Comparison between the age groups revealed malignant cases outnumbered benign cases under 4 years of age while benign tumor numbers increased after 10 years of age. The most common entities in the malignant group were of sympathetic nervous system origin, while soft tissue tumors far outnumbered the others in the benign group.

CONCLUSIONS

We conclude that the cancer patterns of children in the Ankara region mostly resemble with those of the western population. This study provides useful information on the diagnosis of solid tumors in children and highlights variations in cancer incidence in different age groups.

A multisource approach to improving epidemiologic estimates: application to global B-cell malignancies

The compilation of comprehensive, worldwide epidemiologic data can inform hypotheses on cancer etiology and guide future drug development. These statistics are reported by a multitude of sources using varying methods; thus, compiling a complete database of these statistics is a challenge. To this end, this paper examined the usefulness of a novel, multisource approach—extracting data from the peer-reviewed literature, online reports, and query systems from cancer registries and health agencies and directly contacting cancer registry personnel—for building a comprehensive, multinational epidemiologic cancer database. The major B-cell malignancies were chosen as the cancer subtype to test this approach largely because their epidemiology has not been well characterized in the peer-reviewed literature. We found that a multisource approach yields a more comprehensive epidemiologic database than what would have been possible with the use of literature searches alone. In addition, our paper revealed that cancer registries vary considerably in their methodology, comprehensiveness, and ability to gather information on specific B-cell malignancy subtypes. Collectively, this paper demonstrates the feasibility and value of a multisource approach to gathering epidemiologic data.

Delays in diagnosis of paediatric cancers: a systematic review and comparison with expert testimony in lawsuits

Delayed diagnosis of paediatric cancers is reported regularly and is a source of remorse for physicians and parents and a leading cause of malpractice claims. We did a systematic review of information about the distribution, determinants, and consequences of time to diagnosis of paediatric malignancies and compared these findings with those of court-appointed expert witnesses in malpractice claims in Canada and France. Time to diagnosis varied widely between tumour types in the 98 relevant studies (medians ranged from 2-260 weeks) without any significant decrease with time. Determinants of a long delay in diagnosis included older age, qualification of the first physician contacted, non-specific symptoms, histological type, and tumour localisation. Delayed diagnosis was associated with poor outcome for retinoblastoma and possibly for leukaemia, nephroblastoma, and rhabdomyosarcoma (data were insufficient for definitive conclusions). It was not associated with an adverse outcome for most CNS tumours, osteosarcoma or Ewing's sarcoma, and, paradoxically, was frequently associated with better outcomes than was short time to diagnosis in these cancers. A third of the court-appointed experts provided testimony concordant with the medical literature. The relations between delay in diagnosis and outcome are complex and probably depend more on tumour biology than on parental or medical factors.

[Megakaryoblastic acute leukemia: bone and joint manifestations in a 7-month-old child]

Acute megakaryoblastic leukemia accounts for approximately 3-10% of acute myeloid leukemia in children. Its diagnosis may be difficult because of associated myelofibrosis. We report the case of a 7-month-old child who presented hepatomegaly with bicytopenia. She also developed bone and joint pain with recurrent aseptic arthritis. We suggested the diagnosis of megakaryoblastic leukemia early but multiple bone marrow investigations had been processed without positive results because of sampling problems and lack of abnormal cells in the morphological, phenotypic, and cytogenetic examinations. We had a variety of indirect evidence for our assumption: the x-ray showing periosteal new bone, lytic lesions and metaphyseal bands, bone marrow aspirate smears with micromegakaryocytes, and bone marrow biopsy suggesting myelofibrosis. This was very suggestive of leukemia but we could not prove it and we finally found megakaryoblasts on bone marrow aspirate smears after more than 2 months of investigation and initiated a course of corticosteroids.

Characteristics and prognosis of B-cell lymphoma in HIV-infected children in the HAART era

Chronic HIV infection leads to increased risk of non-Hodgkin B-cell lymphoma. However, only few recent data are available about their current management and prognosis in HIV-infected children since the advent highly active antiretroviral therapy (HAART). This multicenter retrospective study describes the 12 cases of B-cell non-Hodgkin lymphoma diagnosed in HIV-infected children in France between 1996 and 2009. All children had moderate to severe immunosuppression and high viral load at the time of diagnosis. Nine children had extracerebral primary sites and 3 had a primary central nervous system lymphoma. Eight patients had Burkitt lymphoma; 4 had diffuse large B-cell lymphoma. Concomitantly with HAART, all children with extracerebral lymphoma received intensive chemotherapy according to LMB protocol, those with primary central nervous system lymphoma received high-dose methotrexate. No toxicity-related deaths occurred. Ten patients entered complete remission (CR), 2 died of tumor progression despite a second line of therapy. No relapses occurred after CR (median follow-up, 72 mo). Thus, prognosis of patients unresponsive to first-line lymphoma treatment remains poor, but relapse seems to be rare when CR is achieved. Children without severe comorbidities can tolerate intensive chemotherapy with a mandatory HAART treatment, taking into account drug interactions.

[Role of French hospital claims databases from care units in epidemiological studies: the example of the "Cohorte Enfant Scanner" study]

BACKGROUND

The "Cohorte Enfant Scanner", a study designed to investigate the risk of radiation-induced cancer after childhood exposure to CT (computed tomography) examinations, used clinical information contained in the "programme de médicalisation des systèmes d'information" (PMSI) database, the French hospital activities national program based upon diagnosis related groups (DRG). However, the quality and adequacy of the data for the specific needs of the study should be verified. The aim of our work was to estimate the percentage of the cohort's children identified in the PMSI database and to develop an algorithm to individualize the children with a cancer or a disease at risk of cancer from medical diagnoses provided by the DRGs database.

METHODS

Of the 1519 children from the "Cohorte Enfant Scanner", who had had a CT scan in the radiology department of a university hospital in 2002, a cross linkage was performed with the DRGs database. All hospitalizations over the period 2002-2009 were taken into account. An algorithm was constructed for the items "cancer" and "disease at risk for cancer" on a sample of 150 children. The algorithm was then tested on the entire population.

RESULTS

Overall, 74% of our population was identified in the DRGs database. The algorithm individualized cancer diagnoses with 91% sensitivity (95% confidence interval [95%CI]: 86%; 97%) and 98% specificity (95%CI: 97%; 99%) and 86% positive predictive value (95%CI: 80%; 93%). For the diagnosis of disease at risk for cancer, the sensitivity, specificity and positive predictive value were respectively 91% (95%CI: 84%; 98%), 94% (95%CI: 92%; 95%) and 52% (95%CI: 43%; 61%).

CONCLUSION

The DRG database identified with excellent sensitivity and specificity children with diagnoses of cancer or disease at risk for cancer. Hence, potential confounding factors related to the disease of the child can be taken into account for analyses performed with the cohort.

[Melanoma in children: diagnosis and treatment specificities]

Skin melanoma is an extremely rare disease at pediatric age and its incidence increases with age. Links with predisposition syndrome exists (giant congenital naevus, xeroderma pigmentosum). Diagnosis is often difficult and distinction between benign or malignant lesion is sometime impossible (Spitzoid naevus, melanocytic neoplasms) leading to the diagnosis of "melanocytic tumor of uncertain malignant potential" (MELTUMP). Atypical features (amelanotic or raised lesions, atypical histotype) are frequent leading to delay in treatment. Diagnosis and treatment require expertise for pathologists and dermatologists pediatricians. Invasive melanomas are of poor prognosis despite recent progress in adult treatment. Early and rigorous treatment of suspect skin lesions is necessary.

Folic acid supplementation, MTHFR and MTRR polymorphisms, and the risk of childhood leukemia: the ESCALE study (SFCE)

PURPOSE

Fetal folate deficiency may increase the risk of subsequent childhood acute leukemia (AL), since folates are required for DNA methylation, synthesis, and repair, but the literature remains scarce. This study tested the hypothesis that maternal folic acid supplementation before or during pregnancy reduces AL risk, accounting for the SNPs rs1801133 (C677T) and rs1801131 (A1298C) in MTHFR and rs1801394 (A66G) and rs1532268 (C524T) in MTRR, assumed to modify folate metabolism.

METHODS

The nationwide registry-based case-control study, ESCALE, carried out in 2003-2004, included 764 AL cases and 1,681 controls frequency matched with the cases on age and gender. Information on folic acid supplementation was obtained by standardized telephone interview. The genotypes were obtained using high-throughput platforms and imputation for untyped polymorphisms. Odds ratios (OR) were estimated using unconditional regression models adjusted for potential confounders.

RESULTS

AL was significantly inversely associated with maternal folic acid supplementation before and during pregnancy (OR = 0.4; 95 % confidence interval: [0.3-0.6]). MTHFR and MTRR genetic polymorphisms were not associated with AL. However, AL was positively associated with homozygosity for any of the MTHFR polymorphisms and carriership of both MTRR variant alleles (OR = 1.6 [0.9-3.1]). No interaction was observed between MTHFR, MTRR, and maternal folate supplementation.

CONCLUSION

The study findings support the hypothesis that maternal folic acid supplementation may reduce the risk of childhood AL. The findings also suggest that the genotype homozygous for any of the MTHFR variants and carrying both MTRR variants could be a risk factor for AL.

Long time to diagnosis of medulloblastoma in children is not associated with decreased survival or with worse neurological outcome

BACKGROUND

The long time to diagnosis of medulloblastoma, one of the most frequent brain tumors in children, is the source of painful remorse and sometimes lawsuits. We analyzed its consequences for tumor stage, survival, and sequelae.

PATIENTS AND METHODS

This retrospective population-based cohort study included all cases of pediatric medulloblastoma from a region of France between 1990 and 2005. We collected the demographic, clinical, and tumor data and analyzed the relations between the interval from symptom onset until diagnosis, initial disease stage, survival, and neuropsychological and neurological outcome.

RESULTS

The median interval from symptom onset until diagnosis for the 166 cases was 65 days (interquartile range 31-121, range 3-457). A long interval (defined as longer than the median) was associated with a lower frequency of metastasis in the univariate and multivariate analyses and with a larger tumor volume, desmoplastic histology, and longer survival in the univariate analysis, but not after adjustment for confounding factors. The time to diagnosis was significantly associated with IQ score among survivors. No significant relation was found between the time to diagnosis and neurological disability. In the 62 patients with metastases, a long prediagnosis interval was associated with a higher T stage, infiltration of the fourth ventricle floor, and incomplete surgical resection; it nonetheless did not influence survival significantly in this subgroup.

CONCLUSIONS

We found complex and often inverse relations between time to diagnosis of medulloblastoma in children and initial severity factors, survival, and neuropsychological and neurological outcome. This interval appears due more to the nature of the tumor and its progression than to parental or medical factors. These conclusions should be taken into account in the information provided to parents and in expert assessments produced for malpractice claims.

Interval between onset of symptoms and diagnosis of medulloblastoma in children: distribution and determinants in a population-based study

Hospital-based studies have reported long delays in the diagnosis of paediatric brain tumours. Our objective was to describe the duration between onset of symptoms and diagnosis of medulloblastoma in children and study their clinical determinants in a population-based study. This retrospective cohort study included all paediatric medulloblastoma from a region of France from 1990 to 2005. The median interval from symptom onset until diagnosis for these 166 patients was 65 days and did not decrease during the study period. The most frequent manifestations were: vomiting (88%), headaches (79%), psychomotor regression (60% of children under 3 years), psychological symptoms (27%), strabismus (26%), and asthenia (25%). For one third of the children under 3 years, the diagnosis was made only after life-threatening signs of intracranial hypertension appeared. The prediagnosis interval was significantly longer (median 91 vs. 60 days, p = 0.001) in children with psychological symptoms (27%). Causes for intervals that exceeded the median (65 days) included inconsistent (25%) or late (36%) combination of headaches and vomiting, a period of spontaneous symptom remission (14%-20%), no (24%) or late (57%) neurological signs, psychological symptoms (35%), and a normal neurological examination (27%). Time to medulloblastoma diagnosis in children remains fairly long, despite advances in imaging. Primary-care physicians must be suspicious not only of suggestive neurological signs, but also of non-specific symptoms that persist or are multiple. A meticulous neurological examination and cerebral imaging for such patients might facilitate earlier diagnosis.

[Cancer before age 40 in France]

Cancer is a rare pathology before the age of 40: a total of 14,000 new cases have been diagnosed in patients under age 40 in 2005, 1,700 under age 15 and 12,500 in the age-group of 15 to 39, this represents 4% of the cancers diagnosed in 2005. The number of deaths is small: in 2008, 2,235 patients died before age 40 in France, 246 under age 15 and 1,989 between age 15 and 39; this corresponds to 1% of the cancer deaths in 2008. The incidence increased between 1980 and 2005, both in the population aged 0 to 14 and in the population aged 15 to 39. Overall, cancer mortality has been decreasing for more than 25 years. The only increase in mortality is observed for brain tumours in children. The overall incidence increase is mostly due to the extension of screening coverage and to improvements in diagnostic procedures. The decrease observed for cervix cancer and lung cancer in men demonstrates the efficacy of screening and of tobacco smoking prevention. The mortality decrease is explained both by improved treatments and by the decreased incidence of some types of cancer. The increasing brain tumours mortality in children is worrying.

Childhood Hodgkin's lymphoma, non-Hodgkin's lymphoma and factors related to the immune system: the Escale Study (SFCE)

The study investigated the role of factors considered related to the early stimulation of the immune system in the aetiology of childhood lymphoma. The national registry-based case-control study, Escale, was carried out in France over the period 2003-2004. Population controls were frequency matched with the cases on age and gender. Data were obtained from structured telephone questionnaires administered to mothers. Odds ratios (ORs) were estimated using unconditional regression models adjusted for potential confounders. Data from 128 cases of Hodgkin's lymphoma (HL) aged 5-14 years, 164 cases of non-Hodgkin's lymphoma (NHL) aged 2-14 years and 1,312 controls were analyzed. Negative associations were observed between HL and day care attendance [OR = 0.5 (0.2-1.2)] and between HL and repeated early common infections among non-breastfed children [OR = 0.3 (.2-0.7), p = 0.003] [OR for breastfed children: 1.0 (.5-2.1)], but not for the other factors investigated. Negative associations were observed between NHL and birth order 3 or more [OR = 0.7 (0.4-1.1)], prolonged breastfeeding [OR = 0.5 (0.3-1.0)], regular contact with farm animals [OR = 0.5 (0.3-1.0)], frequent farm visits in early life [OR = 0.6 (0.4-1.1)] and history of asthma [OR = 0.6 (0.3-1.1)]. In conclusion, the results partly support the hypothesis that an abnormal maturation of the immune system may play a role in childhood HL or NHL, and call for further investigations.

Road traffic and childhood leukemia: the ESCALE study (SFCE)

BACKGROUND

Traffic is a source of environmental exposures, including benzene, which may be related to childhood leukemia.

OBJECTIVES

A national registry-based case-control study [ESCALE (Etude Sur les Cancers et les Leucémies de l'Enfant, Study on Environmental and Genetic Risk Factors of Childhood Cancers and Leukemia)] carried out in France was used to assess the effect of exposure to road traffic exhaust fumes on the risk of childhood leukemia.

METHODS

Over the study period, 2003-2004, 763 cases and 1,681 controls < 15 years old were included, and the controls were frequency matched with the cases on age and sex. The ESCALE data were collected by a standardized telephone interview of the mothers. Various indicators of exposure to traffic and pollution were determined using the geocoded addresses at the time of diagnosis for the cases and of interview for the controls. Indicators of the distance from, and density of, main roads and traffic nitrogen dioxide (NO(2)) concentrations derived from traffic emission data were used. Odds ratios (ORs) were estimated using unconditional regression models adjusted for potential confounders.

RESULTS

Acute leukemia (AL) was significantly associated with estimates of traffic NO(2) concentration at the place of residence > 27.7 µg/m(3) compared with NO(2) concentration < 21.9 µg/m(3) [OR=1.2; confidence interval (CI), 1.0-1.5] and with the presence of a heavy-traffic road within 500 m compared with the absence of a heavy-traffic road in the same area (OR=2.0; 95% CI, 1.0-3.6). There was a significant association between AL and a high density of heavy-traffic roads within 500 m compared with the reference category with no heavy-traffic road within 500 m (OR=2.2; 95% CI, 1.1-4.2), with a significant positive linear trend of the association of AL with the total length of heavy-traffic road within 500 m.

CONCLUSION

This study supports the hypothesis that living close to heavy-traffic roads may increase the risk of childhood leukemia.

Complementary and alternative medicine use among pediatric patients with leukemia: the case of Lebanon

BACKGROUND

International evidence indicates that caretakers of pediatric leukemia patients are increasingly using complementary and alternative medicine (CAM) therapies. Such a trend has never been substantiated in the Arab world.

OBJECTIVE

Examine the frequency, types, modes, and reasons of CAM use among pediatric leukemia patients in Lebanon.

METHODS

A cross-sectional design was utilized to survey (by phone) the caregivers of all pediatric leukemia patients on the rosters of the 2 largest cancer treatment facilities in Lebanon for years 2005-2009. A total of 125 parents out of 175 (71.4%) completed the questionnaire, which included 3 sections: socio-demographic characteristics, clinical information and CAM use details. Data analysis employed univariate descriptive statistics, t-test, and χ(2)

RESULTS

Overall, 15.2% of respondents reported using one or more CAM therapies for their child (95% confidence interval: 8.9% to 22.0%). The main CAM therapies used included dietary supplements, prayer/spiritual healing, and unconventional cultural practices (ingesting bone ashes). CAM therapies were used for strengthening immunity (42.1%) and improving the chance of cure (21%). Pediatric users of CAM were 2 years older than nonusers and had been diagnosed with leukemia for a longer period of time (4.76 ± 3.24 vs 3.49 ± 2.38, P<.05). The percentage of males among CAM users was higher than that among nonusers (89.5% vs 56.6%, P<.05).

CONCLUSION

Increasing awareness of both caretakers and physicians of pediatric leukemia patients on the effects and risks of CAM therapies is essential should rational, safe, and evidence-based utilization of CAM therapies be achieved.