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Kumar S, Arwind DA, Kumar B H, Pandey S, Nayak R, Vithalkar MP, Kumar N, Pai KSR. Inhibition of STAT3: A promising approach to enhancing the efficacy of chemotherapy in medulloblastoma. Transl Oncol 2024; 46:102023. [PMID: 38852276 PMCID: PMC11220551 DOI: 10.1016/j.tranon.2024.102023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Revised: 05/27/2024] [Accepted: 06/01/2024] [Indexed: 06/11/2024] Open
Abstract
Medulloblastoma is a type of brain cancer that primarily affects children. While chemotherapy has been shown to be effective in treating medulloblastoma, the development of chemotherapy resistance remains a challenge. One potential therapeutic approach is to selectively inhibit the inducible transcription factor called STAT3, which is known to play a crucial role in the survival and growth of tumor cells. The activation of STAT3 has been linked to the growth and progression of various cancers, including medulloblastoma. Inhibition of STAT3 has been shown to sensitize medulloblastoma cells to chemotherapy, leading to improved treatment outcomes. Different approaches to STAT3 inhibition have been developed, including small-molecule inhibitors and RNA interference. Preclinical studies have shown the efficacy of STAT3 inhibitors in medulloblastoma, and clinical trials are currently ongoing to evaluate their safety and effectiveness in patients with various solid tumors, including medulloblastoma. In addition, researchers are also exploring ways to optimize the use of STAT3 inhibitors in combination with chemotherapy and identify biomarkers that can predict treatment that will help to develop personalized treatment strategies. This review highlights the potential of selective inhibition of STAT3 as a novel approach for the treatment of medulloblastoma and suggests that further research into the development of STAT3 inhibitors could lead to improved outcomes for patients with aggressive cancer.
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Affiliation(s)
- Sachindra Kumar
- Department of Pharmacology, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education (MAHE), Manipal 576104, India
| | - Dube Aakash Arwind
- Department of Pharmacology and toxicology, National Institute of Pharmaceutical Education and Research, Hajipur, Vaishali-844102, Bihar, India
| | - Harish Kumar B
- Department of Pharmacology, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education (MAHE), Manipal 576104, India
| | - Samyak Pandey
- Department of Pharmacology, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education (MAHE), Manipal 576104, India
| | - Raksha Nayak
- Department of Pharmacology, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education (MAHE), Manipal 576104, India
| | - Megh Pravin Vithalkar
- Department of Pharmacology, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education (MAHE), Manipal 576104, India
| | - Nitesh Kumar
- Department of Pharmacology and toxicology, National Institute of Pharmaceutical Education and Research, Hajipur, Vaishali-844102, Bihar, India
| | - K Sreedhara Ranganath Pai
- Department of Pharmacology, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education (MAHE), Manipal 576104, India.
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Gupta T, Mani S, Chatterjee A, Dasgupta A, Epari S, Chinnaswamy G. Risk-stratification for treatment de-intensification in WNT-pathway medulloblastoma: finding the optimal balance between survival and quality of survivorship. Expert Rev Anticancer Ther 2024; 24:589-598. [PMID: 38761170 DOI: 10.1080/14737140.2024.2357807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 05/16/2024] [Indexed: 05/20/2024]
Abstract
INTRODUCTION Advances in molecular biology have led to consensus classification of medulloblastoma into four broad molecular subgroups - wingless (WNT), sonic hedgehog (SHH), Group 3, and Group 4, respectively. Traditionally, children >3 years of age, with no/minimal residual tumor (<1.5 cm2) and lack of metastasis were classified as average-risk disease with >80% long-term survival. Younger age (<3 years), large residual disease (≥1.5 cm2), and leptomeningeal metastases either alone or in combination were considered high-risk features yielding much worse 5-year survival (30-60%). This clinico-radiological risk-stratification has been refined by incorporating molecular/genetic information. Contemporary multi-modality management for non-infantile medulloblastoma entails maximal safe resection followed by risk-stratified adjuvant radio(chemo)therapy. Aggressive multi-modality management achieves good survival but is associated with substantial dose-dependent treatment-related toxicity prompting conduct of subgroup-specific prospective clinical trials. AREAS COVERED We conducted literature search on PubMed from 1969 till 2023 to identify putative prognostic factors and risk-stratification for medulloblastoma, including molecular subgrouping. Based on previously published data, including our own institutional experience, we discuss molecular risk-stratification focusing on WNT-pathway medulloblastoma to identify candidates suitable for treatment de-intensification to strike the optimal balance between survival and quality of survivorship. EXPERT OPINION Prospective clinical trials and emerging biological information should further refine risk-stratification in WNT-pathway medulloblastoma.
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Affiliation(s)
- Tejpal Gupta
- Department of Radiation Oncology, ACTREC/TMH, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Shakthivel Mani
- Department of Radiation Oncology, ACTREC/TMH, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Abhishek Chatterjee
- Department of Radiation Oncology, ACTREC/TMH, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Archya Dasgupta
- Department of Radiation Oncology, ACTREC/TMH, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Sridhar Epari
- Department of Pathology, ACTREC/TMH, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Girish Chinnaswamy
- Department of Pediatric Oncology, ACTREC/TMH, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, India
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Force LM, Hlatywayo L, Salek M, Bhakta M, Bonilla M, Kaye EC, Rodriguez-Galindo C, Baker JN, Bhakta N, Chitsike I. Understanding treatment recommendations at diagnosis of advanced cancer in pediatric oncology: The need to explore decision-making challenges globally. Pediatr Blood Cancer 2024; 71:e30854. [PMID: 38233986 PMCID: PMC10922856 DOI: 10.1002/pbc.30854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 12/26/2023] [Indexed: 01/19/2024]
Affiliation(s)
- Lisa M. Force
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Loyce Hlatywayo
- Parirenyatwa Hospital and University of Zimbabwe, Harare, Zimbabwe
| | - Marta Salek
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Manoo Bhakta
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Miguel Bonilla
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Erica C. Kaye
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
- Division of Quality of Life and Palliative Care, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Carlos Rodriguez-Galindo
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Justin N. Baker
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
- Division of Quality of Life and Palliative Care, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Nickhill Bhakta
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN, USA
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Inam Chitsike
- Parirenyatwa Hospital and University of Zimbabwe, Harare, Zimbabwe
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Joseph A, Akinsete A, Adeneye S, Balogun O, Awofeso O, Oladipo A, Ajose A, Elhamamsi I, Merrell K, Ngwa W, Puthoff D, Shour AR, Onitilo A. Feasibility and Safety of Implementing Volumetric Arc Therapy (VMAT) for Pediatric Craniospinal Irradiation in a Low-Middle-Income Region: The Nigerian Experience. Adv Radiat Oncol 2024; 9:101325. [PMID: 38405304 PMCID: PMC10885594 DOI: 10.1016/j.adro.2023.101325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 07/19/2023] [Indexed: 02/27/2024] Open
Abstract
Purpose Volumetric modulated arc therapy (VMAT) is a relatively new treatment technique in sub-Saharan Africa. Although craniospinal irradiation (CSI) in the pediatric population has been practiced in Nigeria for many years, the use of VMAT to deliver this treatment is previously undocumented. We reviewed the first set of patients to undergo CSI at a cancer center in Nigeria, detailing the treatment technique, the progress experienced, dose statistics achieved, treatment toxicities, and cancer outcomes to date. Methods and Materials This was a prospective case series of 5 children with histologically diagnosed cancers requiring CSI whose parents consented to the study. They were recruited at evaluation and followed through the process of their therapy. Toxicity was monitored at weekly review appointments using the Common Terminology Criteria for Adverse Events version 5.0. Follow-up of the children will continue in the long-term effects clinic. Results Five patients with a median age of 6 were recruited. Diagnoses were intracranial germ cell tumor (n = 2), medulloblastoma (n = 1), pineoblastoma (n = 1), and ependymoma (n = 1). For all patients, a dose of 36.0 Gy in 1.8 Gy daily fractions was prescribed to the entire neuraxis. A subsequent boost of 18 Gy (n = 4) to 19.8 Gy (n = 1) in 10 daily fractions to the primary tumor bed (n = 2) and posterior fossa (n = 2) was delivered. Four patients had chemotherapy before, during, or after radiation therapy. No patient experienced grade 3 or greater toxicity. Conclusions Our results indicate great progress has been made in the delivery of CSI in Nigeria, demonstrating tolerable acute side effects using VMAT. This series suggests the feasibility of implementing VMAT technology in low- or middle-income countries. Additional follow-up will be needed to determine whether survival rates and chronic toxicity rates are similar to those reported in the literature.
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Affiliation(s)
- Adedayo Joseph
- NSIA-LUTH Cancer Center, Lagos University Teaching Hospital, Lagos, Nigeria
| | - Adeseye Akinsete
- Department of Pediatrics, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Samuel Adeneye
- NSIA-LUTH Cancer Center, Lagos University Teaching Hospital, Lagos, Nigeria
- Department of Radiation Biology, Radiotherapy and Radiodiagnosis, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Onyinye Balogun
- Department of Radiation Oncology, Weill Cornell Medicine, New York, New York
| | - Opeyemi Awofeso
- Psychosocial Oncology & Palliative Care, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Aishat Oladipo
- NSIA-LUTH Cancer Center, Lagos University Teaching Hospital, Lagos, Nigeria
| | - Azeezat Ajose
- NSIA-LUTH Cancer Center, Lagos University Teaching Hospital, Lagos, Nigeria
| | - Ibrahim Elhamamsi
- NSIA-LUTH Cancer Center, Lagos University Teaching Hospital, Lagos, Nigeria
| | - Kenneth Merrell
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Wilfred Ngwa
- Sidney Kimmel Comprehensive Cancer Center, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - David Puthoff
- Office of Research and Sponsored Programs, Marshfield Clinic Research Institute, Marshfield Clinic Health System, Marshfield, Wisconsin
| | - Abdul R. Shour
- Cancer Care and Research Center, Marshfield Clinic Research Institute, Marshfield Clinic Health System, Marshfield, Wisconsin
| | - Adedayo Onitilo
- Cancer Care and Research Center, Marshfield Clinic Research Institute, Marshfield Clinic Health System, Marshfield, Wisconsin
- Department of Oncology, Cancer Care and Research Center, Marshfield Clinic Health System, Marshfield, Wisconsin
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Haizel-Cobbina J, Chotai S, Labuschagne J, Belete A, Ashagere Y, Shabani HK, Copeland W, Sichizya K, Ahmad MH, Nketiah-Boakye F, Dewan MC. Pediatric neurosurgical-oncology scope and management paradigms in Sub-Saharan Africa: a collaboration among 7 referral hospitals on the subcontinent. Front Oncol 2023; 13:1257099. [PMID: 38023182 PMCID: PMC10646489 DOI: 10.3389/fonc.2023.1257099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 10/18/2023] [Indexed: 12/01/2023] Open
Abstract
Background Understanding of the epidemiology and biology of pediatric CNS tumors has advanced dramatically over the last decade; however there remains a discrepancy in the understanding of epidemiologic data and clinical capacity between high- and lower-income countries. Objective We collected and analyzed hospital-level burden and capacity-oriented data from pediatric neurosurgical oncology units at 7 referral hospitals in Sub-Saharan Africa (SSA). Methods A cross sectional epidemiological survey was conducted using REDCap at the 7 SSA sites, capturing 3-month aggregate data for patients managed over a total of 9 months. Descriptive statistical analyses for the aggregate data were performed. Results Across the neurosurgical spectrum, 15% of neurosurgery outpatient and 16% of neurosurgery operative volume was represented by pediatric neuro-oncology across the 7 study sites. Eighty-six percent and 87% of patients who received surgery underwent preoperative CT scan and/or MRI respectively. Among 312 patients evaluated with a CNS tumor, 211 (68%) underwent surgery. Mean surgery wait time was 26.6 ± 36.3 days after initial presentation at the clinic. The most common tumor location was posterior fossa (n=94, 30%), followed by sellar/suprasellar region (n=56, 18%). Histopathologic analysis was performed for 189 patients (89%). The most common pathologic diagnosis was low grade glioma (n=43, 23%), followed by medulloblastoma (n=37, 20%), and craniopharyngioma (n=31, 17%). Among patients for whom adjuvant therapy was indicated, only 26% received chemotherapy and 15% received radiotherapy. Conclusion The histopathologic variety of pediatric brain and spinal tumors managed across 7 SSA referral hospitals was similar to published accounts from other parts of the world. About two-thirds of patients received a tumor-directed surgery with significant inter-institutional variability. Less than a third of patients received adjuvant therapy when indicated. Multi-dimensional capacity building efforts in neuro-oncology are necessary to approach parity in the management of children with brain and spinal tumors in SSA.
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Affiliation(s)
- Joseline Haizel-Cobbina
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, United States
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, United States
- Department of Surgery, Cape Coast Teaching Hospital, Cape Coast, Ghana
| | - Silky Chotai
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Jason Labuschagne
- Department of Paediatric Neurosurgery, Nelson Mandela Children’s Hospital, Johannesburg, South Africa
| | - Addisalem Belete
- Department of Neurosurgery, Zewditu Memorial Hospital, Addis Ababa, Ethiopia
| | - Yordanos Ashagere
- Department of Neurosurgery, Zewditu Memorial Hospital, Addis Ababa, Ethiopia
| | - Hamisi K. Shabani
- Department of Neurosurgery, Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania
| | - William Copeland
- Department of Neurosurgery, Tenwek Mission Hospital, Bomet, Kenya
| | - Kachinga Sichizya
- Department of Neurosurgery, University Teaching Hospital, Lusaka, Zambia
| | | | | | - Michael C. Dewan
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, United States
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, United States
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Kartal İ, Dağdemir A, Dinçer OS, Şimşek HK, Uygun A, Gürsel ŞB. Treatment Outcomes of Childhood Medulloblastoma with the SIOP/UKCCSG PNET-3 Protocol. Indian J Pediatr 2023; 90:1116-1122. [PMID: 37335442 PMCID: PMC10581932 DOI: 10.1007/s12098-023-04675-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 03/17/2023] [Indexed: 06/21/2023]
Abstract
OBJECTIVES To retrospectively compare the overall and event-free survival rates of patients with standard and high risk medulloblastoma who received postoperative radiotherapy (RT) followed by maintenance chemotherapy. METHODS The study included 48 patients with medulloblastoma who were treated and followed-up between 2005 and 2021. Patients were classified according to the Chang classification because no molecular analysis was done. Immediately after surgery all patients received postoperative RT followed by eight cycles of chemotherapy (SIOP/UKCCSG PNET-3 protocol); if thrombocytopenia developed, carboplatin was replaced by cisplatin to avoid treatment delay. The clinical characteristics, risk categories and treatment outcomes of all patients were analyzed. RESULTS The mean age of the 48 patients (26 males, 22 females) at diagnosis was 7.27±4.21 y. The median start time of RT after surgery was 37 (range 19-80) d. The median follow-up was 56 (3-216) mo. The 5-year event-free survival was 61.2±10% in the high-risk group and 82.5±11.5% in the standard-risk group. The 5-year overall survival was 73.2±7.1%; it was 61.2±10% and 92.9±6.9% for high- and standard-risk patients, respectively (p = 0.026). CONCLUSIONS The outcomes of patients who were started on the modified SIOP/UKCCSG PNET-3 chemotherapy protocol, in which RT was begun as soon as possible after surgery, were comparable to those of current treatment protocols. Although a definitive conclusion is difficult, given the limited number of patients in the present study, authors suggest that their treatment protocol is a viable option for centers with limited facilities (such as an inability to perform molecular analysis).
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Affiliation(s)
- İbrahim Kartal
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey.
| | - Ayhan Dağdemir
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey
| | - Oğuz Salih Dinçer
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey
| | - Hülya Kangal Şimşek
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey
| | - Alper Uygun
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey
| | - Şükriye Bilge Gürsel
- Department of Radiation Oncology, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey
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Wang Q, Xin X, Dai Q, Sun M, Chen J, Mostafavi E, Shen Y, Li X. Medulloblastoma targeted therapy: From signaling pathways heterogeneity and current treatment dilemma to the recent advances in development of therapeutic strategies. Pharmacol Ther 2023; 250:108527. [PMID: 37703952 DOI: 10.1016/j.pharmthera.2023.108527] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/27/2023] [Accepted: 09/05/2023] [Indexed: 09/15/2023]
Abstract
Medulloblastoma (MB) is a major pediatric malignant brain tumor that arises in the cerebellum. MB tumors exhibit highly heterogeneous driven by diverse genetic alterations and could be divided into four major subgroups based on their different biological drivers and molecular features (Wnt, Sonic hedgehog (Shh), group 3, and group 4 MB). Even though the therapeutic strategies for each MB subtype integrate their pathogenesis and were developed to focus on their specific target sites, the unexpected drug non-selective cytotoxicity, low drug accumulation in the brain, and complexed MB tumor microenvironment still be huge obstacles to achieving satisfied MB therapeutic efficiency. This review discussed the current advances in modern MB therapeutic strategy development. Through the recent advances in knowledge of the origin, molecular pathogenesis of MB subtypes and their current therapeutic barriers, we particularly reviewed the current development in advanced MB therapeutic strategy committed to overcome MB treatment obstacles, focusing on novel signaling pathway targeted therapeutic agents and their combination discovery, advanced drug delivery systems design, and MB immunotherapy strategy development.
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Affiliation(s)
- Qiyue Wang
- School of Pharmaceutical Science, Nanjing Tech University, Nanjing 211816, China
| | - Xiaofei Xin
- Center for Research Development and Evaluation of Pharmaceutical Excipients and Generic Drugs, Department of Pharmaceutics, China Pharmaceutical University, Nanjing 210009, China
| | - Qihao Dai
- School of Pharmaceutical Science, Nanjing Tech University, Nanjing 211816, China
| | - Mengjuan Sun
- Center for Research Development and Evaluation of Pharmaceutical Excipients and Generic Drugs, Department of Pharmaceutics, China Pharmaceutical University, Nanjing 210009, China
| | - Jinhua Chen
- Center for Research Development and Evaluation of Pharmaceutical Excipients and Generic Drugs, Department of Pharmaceutics, China Pharmaceutical University, Nanjing 210009, China
| | - Ebrahim Mostafavi
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.
| | - Yan Shen
- Center for Research Development and Evaluation of Pharmaceutical Excipients and Generic Drugs, Department of Pharmaceutics, China Pharmaceutical University, Nanjing 210009, China.
| | - Xueming Li
- School of Pharmaceutical Science, Nanjing Tech University, Nanjing 211816, China.
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Hernandez S, Burger H, Nguyen C, Paulino AC, Lucas JT, Faught AM, Duryea J, Netherton T, Rhee DJ, Cardenas C, Howell R, Fuentes D, Pollard-Larkin J, Court L, Parkes J. Validation of an automated contouring and treatment planning tool for pediatric craniospinal radiation therapy. Front Oncol 2023; 13:1221792. [PMID: 37810961 PMCID: PMC10556471 DOI: 10.3389/fonc.2023.1221792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 09/06/2023] [Indexed: 10/10/2023] Open
Abstract
Purpose Treatment planning for craniospinal irradiation (CSI) is complex and time-consuming, especially for resource-constrained centers. To alleviate demanding workflows, we successfully automated the pediatric CSI planning pipeline in previous work. In this work, we validated our CSI autosegmentation and autoplanning tool on a large dataset from St. Jude Children's Research Hospital. Methods Sixty-three CSI patient CT scans were involved in the study. Pre-planning scripts were used to automatically verify anatomical compatibility with the autoplanning tool. The autoplanning pipeline generated 15 contours and a composite CSI treatment plan for each of the compatible test patients (n=51). Plan quality was evaluated quantitatively with target coverage and dose to normal tissue metrics and qualitatively with physician review, using a 5-point Likert scale. Three pediatric radiation oncologists from 3 institutions reviewed and scored 15 contours and a corresponding composite CSI plan for the final 51 test patients. One patient was scored by 3 physicians, resulting in 53 plans scored total. Results The algorithm automatically detected 12 incompatible patients due to insufficient junction spacing or head tilt and removed them from the study. Of the 795 autosegmented contours reviewed, 97% were scored as clinically acceptable, with 92% requiring no edits. Of the 53 plans scored, all 51 brain dose distributions were scored as clinically acceptable. For the spine dose distributions, 92%, 100%, and 68% of single, extended, and multiple-field cases, respectively, were scored as clinically acceptable. In all cases (major or minor edits), the physicians noted that they would rather edit the autoplan than create a new plan. Conclusions We successfully validated an autoplanning pipeline on 51 patients from another institution, indicating that our algorithm is robust in its adjustment to differing patient populations. We automatically generated 15 contours and a comprehensive CSI treatment plan for each patient without physician intervention, indicating the potential for increased treatment planning efficiency and global access to high-quality radiation therapy.
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Affiliation(s)
- Soleil Hernandez
- The University of Texas MD Anderson Cancer Center UTHealth Houston Graduate School of Biomedical Sciences, Houston, TX, United States
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Hester Burger
- Department Medical Physics, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Callistus Nguyen
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Arnold C. Paulino
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - John T. Lucas
- Department of Radiation Oncology, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Austin M. Faught
- Department of Radiation Oncology, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Jack Duryea
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Tucker Netherton
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Dong Joo Rhee
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Carlos Cardenas
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Rebecca Howell
- The University of Texas MD Anderson Cancer Center UTHealth Houston Graduate School of Biomedical Sciences, Houston, TX, United States
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - David Fuentes
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Julianne Pollard-Larkin
- The University of Texas MD Anderson Cancer Center UTHealth Houston Graduate School of Biomedical Sciences, Houston, TX, United States
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Laurence Court
- The University of Texas MD Anderson Cancer Center UTHealth Houston Graduate School of Biomedical Sciences, Houston, TX, United States
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Jeannette Parkes
- Department of Radiation Oncology, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
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Salek M, Silverstein A, Tilly A, Gassant PY, Gunasekera S, Hordofa DF, Hesson D, Duffy C, Malik N, McNeil M, Force LM, Bhakta N, Rodin D, Kaye EC. Factors influencing treatment decision-making for cancer patients in low- and middle-income countries: A scoping review. Cancer Med 2023; 12:18133-18152. [PMID: 37526041 PMCID: PMC10524036 DOI: 10.1002/cam4.6375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 07/01/2023] [Accepted: 07/16/2023] [Indexed: 08/02/2023] Open
Abstract
PURPOSE In this scoping review, we evaluated existing literature related to factors influencing treatment decision-making for patients diagnosed with cancer in low- and middle-income countries, noting factors that influence decisions to pursue treatment with curative versus non-curative intent. We identified an existing framework for adult cancer developed in a high-income country (HIC) context and described similar and novel factors relevant to low-and middle-income country settings. METHODS We used scoping review methodology to identify and synthesize existing literature on factors influencing decision-making for pediatric and adult cancer in these settings. Articles were identified through an advanced Boolean search across six databases, inclusive of all article types from inception through July 2022. RESULTS Seventy-nine articles were identified from 22 countries across six regions, primarily reporting the experiences of lower-middle and upper-middle-income countries. Included articles largely represented original research (54%), adult cancer populations (61%), and studied patients as the targeted population (51%). More than a quarter of articles focused exclusively on breast cancer (28%). Approximately 30% described factors that influenced decisions to choose between therapies with curative versus non-curative intent. Of 56 reported factors, 22 novel factors were identified. Socioeconomic status, reimbursement policies/cost of treatment, and treatment and supportive care were the most commonly described factors. CONCLUSIONS This scoping review expanded upon previously described factors that influence cancer treatment decision-making in HICs, broadening knowledge to include perspectives of low- and middle-income countries. While global commonalities exist, certain variables influence treatment choices differently or uniquely in different settings. Treatment regimens should further be tailored to local environments with consideration of contextual factors and accessible resources that often impact decision-making.
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Affiliation(s)
- Marta Salek
- Department of Global Pediatric MedicineSt Jude Children's Research HospitalMemphisTennesseeUSA
| | - Allison Silverstein
- Department of PediatricsUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Alyssa Tilly
- Division of General Medicine and Clinical EpidemiologyUniversity of North Carolina School of MedicineChapel HillNorth CarolinaUSA
| | | | - Sanjeeva Gunasekera
- Department of Paediatric OncologyNational Cancer InstituteMaharagamaSri Lanka
| | - Diriba Fufa Hordofa
- Department of Pediatrics and Child HealthJimma University Medical CenterJimmaEthiopia
| | - Donna Hesson
- Welch Medical LibraryJohns Hopkins UniversityBaltimoreMarylandUSA
| | - Caitlyn Duffy
- Department of Global Pediatric MedicineSt Jude Children's Research HospitalMemphisTennesseeUSA
| | - Nauman Malik
- Department of Radiation OncologyUniversity of California, San FranciscoSan FranciscoCaliforniaUSA
| | - Michael McNeil
- Department of Global Pediatric MedicineSt Jude Children's Research HospitalMemphisTennesseeUSA
| | - Lisa M. Force
- Department of Health Metrics Sciences and Department of Pediatrics, Division of Pediatric Hematology/OncologyUniversity of WashingtonSeattleWashingtonUSA
| | - Nickhill Bhakta
- Department of Global Pediatric MedicineSt Jude Children's Research HospitalMemphisTennesseeUSA
| | - Danielle Rodin
- Department of Radiation, OncologyUniversity of TorontoTorontoOntarioCanada
- Radiation Medicine ProgramPrincess Margaret Cancer CentreTorontoOntarioCanada
- Canada Global Cancer ProgramPrincess Margaret Cancer CentreTorontoOntarioCanada
| | - Erica C. Kaye
- Department of OncologySt Jude Children's Research HospitalMemphisTennesseeUSA
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10
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Hernandez S, Nguyen C, Gay S, Duryea J, Howell R, Fuentes D, Parkes J, Burger H, Cardenas C, Paulino AC, Pollard-Larkin J, Court L. Resection cavity auto-contouring for patients with pediatric medulloblastoma using only CT information. J Appl Clin Med Phys 2023:e13956. [PMID: 36917640 DOI: 10.1002/acm2.13956] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 02/18/2023] [Accepted: 02/20/2023] [Indexed: 03/15/2023] Open
Abstract
PURPOSE Target delineation for radiation therapy is a time-consuming and complex task. Autocontouring gross tumor volumes (GTVs) has been shown to increase efficiency. However, there is limited literature on post-operative target delineation, particularly for CT-based studies. To this end, we trained a CT-based autocontouring model to contour the post-operative GTV of pediatric patients with medulloblastoma. METHODS One hundred four retrospective pediatric CT scans were used to train a GTV auto-contouring model. Eighty patients were then preselected for contour visibility, continuity, and location to train an additional model. Each GTV was manually annotated with a visibility score based on the number of slices with a visible GTV (1 = < 25%, 2 = 25-50%, 3 = > 50-75%, and 4 = > 75-100%). Contrast and the contrast-to-noise ratio (CNR) were calculated for the GTV contour with respect to a cropped background image. Both models were tested on the original and pre-selected testing sets. The resulting surface and overlap metrics were calculated comparing the clinical and autocontoured GTVs and the corresponding clinical target volumes (CTVs). RESULTS Eighty patients were pre-selected to have a continuous GTV within the posterior fossa. Of these, 7, 41, 21, and 11 were visibly scored as 4, 3, 2, and 1, respectively. The contrast and CNR removed an additional 11 and 20 patients from the dataset, respectively. The Dice similarity coefficients (DSC) were 0.61 ± 0.29 and 0.67 ± 0.22 on the models without pre-selected training data and 0.55 ± 13.01 and 0.83 ± 0.17 on the models with pre-selected data, respectively. The DSC on the CTV expansions were 0.90 ± 0.13. CONCLUSION We successfully automatically contoured continuous GTVs within the posterior fossa on scans that had contrast > ± 10 HU. CT-Based auto-contouring algorithms have potential to positively impact centers with limited MRI access.
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Affiliation(s)
- Soleil Hernandez
- The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, Texas, USA.,Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Callistus Nguyen
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Skylar Gay
- The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, Texas, USA.,Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jack Duryea
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Rebecca Howell
- The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, Texas, USA.,Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David Fuentes
- The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, Texas, USA.,Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Jeannette Parkes
- Department of Radiation Oncology, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Hester Burger
- Department of Medical Physics, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Carlos Cardenas
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Arnold C Paulino
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Julianne Pollard-Larkin
- The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, Texas, USA.,Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Laurence Court
- The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, Texas, USA.,Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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11
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Hernandez S, Nguyen C, Parkes J, Burger H, Rhee DJ, Netherton T, Mumme R, Vega JGDL, Duryea J, Leone A, Paulino AC, Cardenas C, Howell R, Fuentes D, Pollard-Larkin J, Court L. Automating the treatment planning process for 3D-conformal pediatric craniospinal irradiation therapy. Pediatr Blood Cancer 2023; 70:e30164. [PMID: 36591994 DOI: 10.1002/pbc.30164] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 11/23/2022] [Accepted: 11/28/2022] [Indexed: 01/03/2023]
Abstract
PURPOSE Pediatric patients with medulloblastoma in low- and middle-income countries (LMICs) are most treated with 3D-conformal photon craniospinal irradiation (CSI), a time-consuming, complex treatment to plan, especially in resource-constrained settings. Therefore, we developed and tested a 3D-conformal CSI autoplanning tool for varying patient lengths. METHODS AND MATERIALS Autocontours were generated with a deep learning model trained:tested (80:20 ratio) on 143 pediatric medulloblastoma CT scans (patient ages: 2-19 years, median = 7 years). Using the verified autocontours, the autoplanning tool generated two lateral brain fields matched to a single spine field, an extended single spine field, or two matched spine fields. Additional spine subfields were added to optimize the corresponding dose distribution. Feathering was implemented (yielding nine to 12 fields) to give a composite plan. Each planning approach was tested on six patients (ages 3-10 years). A pediatric radiation oncologist assessed clinical acceptability of each autoplan. RESULTS The autocontoured structures' average Dice similarity coefficient ranged from .65 to .98. The average V95 for the brain/spinal canal for single, extended, and multi-field spine configurations was 99.9% ± 0.06%/99.9% ± 0.10%, 99.9% ± 0.07%/99.4% ± 0.30%, and 99.9% ± 0.06%/99.4% ± 0.40%, respectively. The average maximum dose across all field configurations to the brainstem, eyes (L/R), lenses (L/R), and spinal cord were 23.7 ± 0.08, 24.1 ± 0.28, 13.3 ± 5.27, and 25.5 ± 0.34 Gy, respectively (prescription = 23.4 Gy/13 fractions). Of the 18 plans tested, all were scored as clinically acceptable as-is or clinically acceptable with minor, time-efficient edits preferred or required. No plans were scored as clinically unacceptable. CONCLUSION The autoplanning tool successfully generated pediatric CSI plans for varying patient lengths in 3.50 ± 0.4 minutes on average, indicating potential for an efficient planning aid in a resource-constrained settings.
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Affiliation(s)
- Soleil Hernandez
- The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, Texas, USA.,Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Callistus Nguyen
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jeannette Parkes
- Department of Radiation Oncology, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Hester Burger
- Department Medical Physics, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Dong Joo Rhee
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Tucker Netherton
- The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, Texas, USA.,Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Raymond Mumme
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jean Gumma-De La Vega
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jack Duryea
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Alexandrea Leone
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Arnold C Paulino
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Carlos Cardenas
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Rebecca Howell
- The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, Texas, USA.,Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David Fuentes
- The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, Texas, USA.,Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Julianne Pollard-Larkin
- The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, Texas, USA.,Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Laurence Court
- The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, Houston, Texas, USA.,Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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12
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Cooney T, Lindsay H, Leary S, Wechsler-Reya R. Current studies and future directions for medulloblastoma: A review from the pacific pediatric neuro-oncology consortium (PNOC) disease working group. Neoplasia 2022; 35:100861. [PMID: 36516489 PMCID: PMC9755363 DOI: 10.1016/j.neo.2022.100861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 11/22/2022] [Accepted: 11/28/2022] [Indexed: 12/14/2022] Open
Abstract
Medulloblastoma (MB) is the most common malignant central nervous system tumor of childhood, comprising a heterogenous group of tumors each with distinct biology, clinical behavior, and prognosis. Long-term survival remains unacceptable, and those who do survive face high late mortality risk, new chronic treatment-related medical conditions, neurocognitive impairments, and poor health-related quality of life. Up-front treatment strategies now integrate molecular subgrouping with standard clinico-radiological factors to more actually risk stratify newly-diagnosed patients. To what extent this new stratification will lead to improvements in treatment outcome will be determined in the coming years. In parallel, discovery and appreciation for medulloblastoma's inter- and intra-tumoral heterogeneity continues growing. Clinical trials treating relapsed disease now encompass precision medicine, epigenetic modification, and immune therapy approaches. The Pacific Pediatric Neuro-Oncology (PNOC) Medulloblastoma Working Group is committed to developing clinical trials based on these evolving therapeutic strategies and supports translational efforts by PNOC researchers and the multi-stakeholder medulloblastoma community at large.
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Affiliation(s)
- Tab Cooney
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical School, Boston, MA, USA; Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Holly Lindsay
- Texas Children's Cancer and Hematology Center, Baylor College of Medicine, Houston, TX, USA
| | - Sarah Leary
- Seattle Children's Hospital, Seattle, WA, USA
| | - Robert Wechsler-Reya
- Department of Neurology and Herbert Irving Comprehensive Cancer Center, Columbia University Medical Center, New York, NY, USA
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13
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Nyeko R, Kambugu JB, Angom R, Senyonjo H, Kibudde S, Geriga F, van Heerden J. The clinicopathological profile and value of multidisciplinary management of pediatric brain tumors in a low-income setting. Pediatr Hematol Oncol 2022; 40:267-280. [PMID: 36314611 DOI: 10.1080/08880018.2022.2140861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Abstract
Brain tumors are the most common solid tumors in children and a leading cause of cancer-related mortality in children worldwide. Data on the epidemiology and management of pediatric brain tumors in Uganda are limited. We aimed to assess the clinicopathological profile and management of pediatric brain tumors at the national oncology center in Uganda since the inception of weekly multidisciplinary meetings. Records of children younger than19 years diagnosed with primary brain tumors at Uganda Cancer Institute between 2017 and 2021 were retrospectively reviewed. Patient and tumor characteristics were collected with multidisciplinary team management treatment plans for analysis. There were 35 patients evaluated, most of whom were males (57.1%). Craniopharyngioma (n = 9, 25.7%) was the most common brain tumor, followed by astrocytoma (n = 5, 14.2%) and medulloblastoma (n = 4, 11.4%). Management included surgical resection in 28.5% of patients, chemotherapy (28.6%), radiotherapy (17.1%) and palliative care (20.0%). Over the last five years, there were increasing trends in the number of cases discussed in the multidisciplinary team and the number for whom the multidisciplinary management decisions were implemented. The majority (n = 18, 51.4%) of the children with brain tumors were alive and active in care, 34.2% abandoned treatment/lost to follow-up, and 8.6% died. The relative distribution of pediatric brain tumors types in Uganda Cancer Institute differs slightly from international reports, and there has been a notable increase in the number of cases over the years. Implementing multidisciplinary management decisions benefited patients and decreased abandonment and patient loss to follow-up.
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Affiliation(s)
- Richard Nyeko
- Department of Pediatric Oncology, Uganda Cancer Institute, Kampala, Uganda.,Department of Pediatrics and Child Health, Faculty of Medicine, Lira University, Lira, Uganda
| | | | - Racheal Angom
- Department of Pediatric Oncology, Uganda Cancer Institute, Kampala, Uganda
| | | | - Solomon Kibudde
- Department of Radiation Oncology, Uganda Cancer Institute, Kampala, Uganda
| | - Fadhil Geriga
- Department of Pediatric Oncology, Uganda Cancer Institute, Kampala, Uganda
| | - Jaques van Heerden
- Department of Pediatric Oncology, Uganda Cancer Institute, Kampala, Uganda.,Department of Pediatric Oncology, Antwerp University Hospital, Antwerp, Belgium
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14
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Bailey S, Davidson A, Parkes J, Tabori U, Figaji A, Epari S, Chinnaswamy G, Dias-Coronado R, Casavilca-Zambrano S, Amayiri N, Vassal G, Bouffet E, Clifford SC. How Can Genomic Innovations in Pediatric Brain Tumors Transform Outcomes in Low- and Middle-Income Countries? JCO Glob Oncol 2022; 8:e2200156. [PMID: 36252166 PMCID: PMC9812475 DOI: 10.1200/go.22.00156] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Pragmatic ways to apply molecular innovation to childhood brain cancer diagnosis and therapy in LMICs![]()
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Affiliation(s)
- Simon Bailey
- Great North Children's Hospital and Newcastle University, Newcastle upon Tyne, United Kingdom,Simon Bailey, MBChB, PhD, Sir James Spence Institute of Child Health, Royal Victoria Infirmary, Queen Victoria Rd, Newcastle upon Tyne NE1 4LP, United Kingdom;
| | - Alan Davidson
- Haematology Oncology Service, Red Cross War Memorial Children's Hospital, Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Jeannette Parkes
- Department of Radiation Oncology, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Uri Tabori
- Neuro-oncology Program, Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Anthony Figaji
- Department of Neurosurgery, Red Cross War Memorial Children's Hospital and University of Cape Town, Cape Town, South Africa
| | - Shridar Epari
- Department of Pathology, ACTREC and Tata Memorial Hospital, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Girish Chinnaswamy
- Department of Pediatric Oncology, Tata Memorial Hospital, Parel, Mumbai, India
| | - Rosaldi Dias-Coronado
- Pediatric Oncology Department—Instituto Nacional de Enfermedades Neoplásicas, Surquillo, Peru
| | - Sandro Casavilca-Zambrano
- Instituto Nacional de Enfermedades Neoplásicas, Lima, Perú and Facultad de Ciencias de la Salud de La Universidad de Huánuco, Huánuco, Peru
| | - Nisreen Amayiri
- Department of Hematology and Oncology, King Hussein Cancer Centre, Amman, Jordan
| | - Gilles Vassal
- Department of Pediatric and Adolescent Oncology, Institut Gustave-Roussy, Villejuif, France
| | - Eric Bouffet
- Neuro-oncology Program, Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Steven C. Clifford
- Wolfson Childhood Cancer Research Centre, Newcastle University Centre for Cancer, Newcastle upon Tyne, United Kingdom
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15
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Lafay-Cousin L, Baroni L, Ramaswamy V, Bouffet E. How do we approach the management of medulloblastoma in young children? Pediatr Blood Cancer 2022; 69:e29838. [PMID: 35686728 DOI: 10.1002/pbc.29838] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 05/20/2022] [Accepted: 05/24/2022] [Indexed: 11/07/2022]
Abstract
Therapeutic strategies avoiding craniospinal irradiation were developed for young children with medulloblastoma to improve survival while protecting the neurocognitive outcomes of these vulnerable patients. These strategies most commonly rely on high-dose chemotherapy with stem cell rescue or conventional chemotherapy combined with intraventricular chemotherapy or conventional chemotherapy with adjuvant focal irradiation. Over the past decade, our growing understanding of the molecular landscape of medulloblastoma has transformed how we risk stratify and allocate treatment in this young age group. We present the results of the most recent approaches and clinical trials for medulloblastoma of early childhood, according to the different molecular subgroups. Overall, young children with sonic hedgehog medulloblastoma treated with intensive adjuvant chemotherapy achieve excellent survival and can safely be spared from radiotherapy. For patients with group 3 and 4 medulloblastomas, the interplay between molecular alterations and treatment intensity still needs to be further delineated. While recent clinical trials point toward more encouraging survival figure for a sizeable number of them, patients identified with very high-risk feature desperately needs innovative therapies.
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Affiliation(s)
- Lucie Lafay-Cousin
- Section of Pediatric Oncology and Bone Marrow Transplantation, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Lorena Baroni
- Service of Hematology/Oncology, Hospital JP Garrahan, Buenos Aires, Argentina
| | - Vijay Ramaswamy
- Division of Pediatric Hematology/Oncology and Bone Marrow Transplantation, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Eric Bouffet
- Division of Pediatric Hematology/Oncology and Bone Marrow Transplantation, The Hospital for Sick Children, Toronto, Ontario, Canada
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16
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Haier J, Schaefers J. Economic Perspective of Cancer Care and Its Consequences for Vulnerable Groups. Cancers (Basel) 2022; 14:cancers14133158. [PMID: 35804928 PMCID: PMC9265013 DOI: 10.3390/cancers14133158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 05/04/2022] [Accepted: 06/15/2022] [Indexed: 12/02/2022] Open
Abstract
Simple Summary For cancer patients, many different reasons can cause financial burdens and economic threads. Sociodemographic factors, rural/remote location and income are known determinants for these vulnerable groups. This economic vulnerability is related to the reduced utilization of cancer care and the impact on outcome. Financial burden has been reported in many countries throughout the world and needs to be addressed as part of the sufficient quality of cancer care. Abstract Within healthcare systems in all countries, vulnerable groups of patients can be identified and are characterized by the reduced utilization of available healthcare. Many different reasons can be attributed to this observation, summarized as implementation barriers involving acceptance, accessibility, affordability, acceptability and quality of care. For many patients, cancer care is specifically associated with the occurrence of vulnerability due to the complex disease, very different target groups and delivery situations (from prevention to palliative care) as well as cost-intensive care. Sociodemographic factors, such as educational level, rural/remote location and income, are known determinants for these vulnerable groups. However, different forms of financial burdens likely influence this vulnerability in cancer care delivery in a distinct manner. In a narrative review, these socioeconomic challenges are summarized regarding their occurrence and consequences to current cancer care. Overall, besides direct costs such as for treatment, many facets of indirect costs including survivorship costs for the cancer patients and their social environment need to be considered regarding the impact on vulnerability, treatment compliance and abundance. In addition, individual cancer-related financial burden might also affect the society due to the loss of productivity and workforce availability. Healthcare providers are requested to address this vulnerability during the treatment of cancer patients.
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17
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Oigman G, Osorio DS, Ferman S, Stanek JR, Aversa do Souto A, Christiani MMC, Magalhaes DMA, Finlay JL, Vianna DA. Epidemiological characteristics and survival outcomes of children with medulloblastoma treated at the National Cancer Institute (INCA) in Rio de Janeiro, Brazil. Pediatr Blood Cancer 2022; 69:e29274. [PMID: 34767315 DOI: 10.1002/pbc.29274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 07/16/2021] [Accepted: 07/19/2021] [Indexed: 11/11/2022]
Abstract
BACKGROUND Medulloblastoma (MB),the most common malignant brain tumor of childhood has survival outcomes exceeding 80% for standard-risk and 60% for high-risk patients in high-income countries (HICs). These results have not been replicated in low- and middle-income countries (LMICs), where 80% of children with cancer live. METHODS This is a retrospective review of 114 children aged 3-18 years diagnosed with MB from 1997 to 2016 at National Cancer Institute (INCA). Sociodemographic, clinical, and treatment data were extracted from the medical records and summarized descriptively. Overall survival (OS) and progression-free survival (PFS) were calculated using the Kaplan-Meier method. RESULTS The male-to-female ratio was 1.32 and the median age at diagnosis was 8.2 years. Headache (83%) and nausea/vomiting (78%) were the most common presenting symptoms. Five-year OS was 59.1% and PFS was 58.4%. The OS for standard-risk and high-risk patients was 69% and 53%, respectively. The median time to diagnosis interval was 50.5 days and the median time from surgery to radiation therapy initiation was 50.4 days. Patients who lived >40 km from INCA fared better (OS = 68.2% vs. 51.1%, p = .032). Almost 20% of families lived below the Brazilian minimum wage. Forty-five patients (35%) had metastatic disease at admission. Gross total resection was achieved in 57% of the patitents. CONCLUSIONS Although there are considerable barriers to deliver effective MB treatment in countries like Brazil, the OS seen in the present study demonstrates that good outcomes are not only feasible but can and should be increased with appropriate interventions.
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Affiliation(s)
- Gabriela Oigman
- Division of Pediatric Oncology, National Cancer Institute, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Diana S Osorio
- Division of Hematology, Oncology, and BMT, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | - Sima Ferman
- Division of Pediatric Oncology, National Cancer Institute, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Joseph R Stanek
- Division of Hematology, Oncology, and BMT, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | | | - Marcio M C Christiani
- Division of Neurosurgery, National Cancer Institute, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Denise M A Magalhaes
- Division of Radiation Oncology, National Cancer Institute, Rio de Janeiro, Rio de Janeiro, Brazil
| | - Jonathan L Finlay
- Division of Hematology, Oncology, and BMT, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | - Denizar A Vianna
- Internal Medicine Department, State University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil
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18
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Liu APY, Zhen Z, Yang Q, Yuan X, Ma X, Chen J, Wang J, Yang L, Guo H, Jiang L, Weng W, Huang L, Liu W, Wang J, Wu S, Zeng J, Jiang M, He K, Ge M, Cheng KKF, Ho WWS, Li C, Yu L, Zhu S, Ng HK, Chan GCF, Sun X. Treatment barriers and clinical outcome of children with medulloblastoma in China: a report from the Chinese Children's Cancer Group (CCCG). Neurooncol Adv 2021; 3:vdab134. [PMID: 34693286 PMCID: PMC8528264 DOI: 10.1093/noajnl/vdab134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Background Medulloblastoma (MB) is the most common malignant central nervous system tumor of childhood. Management requires interdisciplinary care and is associated with unique challenges in developing regions. Here, we report the characteristics, clinical outcome and treatment barriers for Chinese children with MB based on a multi-institutional cohort from the Chinese Children’s Cancer Group (CCCG). Methods Retrospective cohort study among 12 Chinese pediatric oncology units from the CCCG Brain Tumor Workgroup on patients aged <18 years diagnosed with MB from 2016 to 2019. Results 221 patients (male:female = 138:83) were included, 175 (79%) were ≥3 years of age, and 46 (21%) <3 years. 177 patients (80%) were completely staged, among which 50 (28%) had metastasis and 70 (40%) were considered to have high-risk (HR) disease. Gross/near-total resection was achieved in 203 patients (92%). In patients where molecular grouping could be assigned, 19 (16%), 35 (29%), and 65 (54%), respectively had WNT-activated, SHH-activated, and Group 3/4 MB. The median duration between resection and initiation of adjuvant therapy was 36 days. Respective 2-year PFS and OS rates were 76.0 ± 3.0% and 88.0 ± 2.3%. PFS was significantly associated with age, metastatic status and clinical risk grouping. Chemotherapy use during CSI or alkylator choice were not significant predictors for patient outcome. Conclusions We reported the clinical profiles and outcome from the largest cohort of Chinese children with MB after multi-modal therapy. Strengths and limitations on the local provision of neuro-oncology service are identified.
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Affiliation(s)
- Anthony Pak-Yin Liu
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.,Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong SAR, China
| | - Zijun Zhen
- State Key Laboratory of Oncology in South China, Department of Pediatric Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Qunying Yang
- State Key Laboratory of Oncology in South China, Department of Neurosurgery, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Xiaojun Yuan
- Department of Pediatric Hematology and Oncology, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xiaoli Ma
- Medical Oncology Department, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing, China
| | - Jianliang Chen
- Department of Paediatrics and Adolescent Medicine, HKU-Shenzhen Hospital, Shenzhen, China
| | - Jingsheng Wang
- Department of Neurosurgery, Shenzhen Children's Hospital, Shenzhen, China
| | - Lihua Yang
- Pediatric Center of Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Haixia Guo
- Department of Pediatrics, Southern Medical University Nanfang Hospital, Guangzhou, China
| | - Lian Jiang
- Department of Pediatrics, Hebei Medical University the Fourth Hospital, Shijiazhuang, Hebei, China
| | - Wenjun Weng
- Department of Pediatrics, Sun Yat-sen University Memorial Hospital, Guangzhou, China
| | - Libin Huang
- Department of Pediatrics, Sun Yat-sen University the First Affiliated Hospital, Guangzhou, China
| | - Wei Liu
- Department of Hematology and Oncology, Children's Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Jian Wang
- State Key Laboratory of Oncology in South China, Department of Neurosurgery, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Shaoxiong Wu
- State Key Laboratory of Oncology in South China, Department of Radiation Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Jing Zeng
- State Key Laboratory of Oncology in South China, Department of Pathology, Sun Yat-sen University Cancer Center, GuangzhouChina
| | - Mawei Jiang
- Department of Radiation Oncology, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Kejun He
- Department of Pediatric Hematology and Oncology, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ming Ge
- Department of Neurosurgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | | | - Wilson Wai-Shing Ho
- Department of Neurosurgery, HKU-Shenzhen Hospital, Shenzhen, China.,Department of Neurosurgery, Queen Mary Hospital, Hong Kong SAR, China
| | - Chunyu Li
- Department of Paediatrics and Adolescent Medicine, HKU-Shenzhen Hospital, Shenzhen, China
| | - Lihua Yu
- Pediatric Center of Zhujiang Hospital, Southern Medical University, Guangzhou, China
| | - Shuai Zhu
- Medical Oncology Department, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing Key Laboratory of Pediatric Hematology Oncology, Key Laboratory of Major Diseases in Children, Ministry of Education, Beijing, China
| | - Ho-Keung Ng
- Department of Anatomical and Cellular Pathology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Godfrey Chi-Fung Chan
- Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.,Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong SAR, China
| | - Xiaofei Sun
- State Key Laboratory of Oncology in South China, Department of Pediatric Oncology, Sun Yat-sen University Cancer Center, Guangzhou, China
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19
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Amayiri N, Swaidan M, Ibrahimi A, Hirmas N, Musharbash A, Bouffet E, Al-Hussaini M, Ramaswamy V. Molecular Subgroup Is the Strongest Predictor of Medulloblastoma Outcome in a Resource-Limited Country. JCO Glob Oncol 2021; 7:1442-1453. [PMID: 34609903 PMCID: PMC8492378 DOI: 10.1200/go.21.00127] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Medulloblastoma is composed of four clinically and prognostically distinct molecular subgroups (WNT, SHH, group 3, and group 4). However, the clinical implications of these subgroups in the context of the unique challenges of low- to middle-income countries are rarely reported. METHODS We assembled an institutional cohort of children (3-18 years) diagnosed with medulloblastoma and treated in Jordan between 2003 and 2016. Tumors were subgrouped by NanoString and correlated with clinical and radiologic characteristics. RESULTS Eighty-eight patients were identified (63% male); median age was 6.9 years (interquartile range 4.8-9.2) and median symptom duration was 6 weeks (interquartile range 4-11). Radiotherapy was implemented as standard-risk in 41 patients (47%) and high-risk in 47 patients (53%). Subgrouping revealed 17 WNT (19%), 22 SHH (25%), 21 group 3 (24%), and 28 group 4 tumors (32%). Median time between craniotomy and radiotherapy was 45 days (17-155); 44% of them > 49 days. Median duration of radiotherapy was 44 days (36-74). Seventy-two patients (82%) received chemotherapy afterward. With a median follow-up of 4.6 years (0.2-14.9), 5-year progression-free survival (PFS) and overall survival were 73.5% and 69.4%, respectively, with no statistically significant survival difference between standard-risk and high-risk patients. Metastasis was significant for overall survival (P = .011). Patients with SHH and group 4 tumors had very good PFS (83.4% and 87.0%, respectively) and those with group 3 tumors had dismal outcomes (PFS 44.9%), whereas WNT tumors had less-than expected PFS (70.5%). PFS was statistically significant in patients with nonmetastatic tumors receiving radiotherapy ≤ 49 days (P = .011), particularly group 3 tumors. CONCLUSION Patients with SHH and group 4 medulloblastoma had excellent survival comparable with high-income countries. Compliance with treatment protocols and avoiding radiotherapy delays are important in achieving adequate survival in low- to middle-income country settings. Subgroup-driven treatment protocols should be considered in countries with limited resources.
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Affiliation(s)
- Nisreen Amayiri
- Division of Pediatric Hematology/Oncology, King Hussein Cancer Center, Amman, Jordan
| | - Maisa Swaidan
- Division of Radiology, King Hussein Cancer Center, Amman, Jordan
| | - Ahmed Ibrahimi
- Division of Radiation Oncology, King Hussein Cancer Center, Amman, Jordan
| | - Nader Hirmas
- Research and Grants Office, King Hussein Cancer Center, Amman, Jordan
| | - Awni Musharbash
- Division of Surgery, King Hussein Cancer Center, Amman, Jordan
| | - Eric Bouffet
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Canada
| | | | - Vijay Ramaswamy
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Canada.,Department of Medical Biophysics, University of Toronto, Toronto, Canada
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20
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Rosabal-Obando M, Osorio DS, Lassaletta A, La Madrid AM, Bartels U, Finlay JL, Qaddoumi I, Rutkowski S, Mynarek M. Follow-up evaluation of a web-based pediatric brain tumor board in Latin America. Pediatr Blood Cancer 2021; 68:e29073. [PMID: 34003601 DOI: 10.1002/pbc.29073] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/24/2021] [Accepted: 04/06/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Since 2013, pediatric oncologists from Central and South America discuss neuro-oncology cases with experts from North America and Europe in a web-based "Latin American Tumor Board" (LATB). Here, we evaluate the feasibility of recommendations rendered by the Board. METHODS An electronic questionnaire was distributed to physicians who had received recommendations between October 2017 and October 2018. Physicians were asked regarding the feasibility of each recommendation given during the LATB discussion. Baseline case characteristics of all presented cases were obtained from anonymized minutes. RESULTS Of the 142 patients discussed, data on 103 patients from 15 countries were available, corresponding to 283 recommendations. Physicians followed 60% of diagnostic procedural recommendations and 69% of therapeutic recommendations. The most difficult recommendations to follow were genetic and molecular testing, pathology review, chemotherapy, surgery, and molecular targeted therapies. Histological diagnoses changed in eight of 18 cases in which a pathology review was undertaken. Fifty-four percent of the recommendations that could not be implemented were considered not feasible in the specific context of the patient, while 31% were not implemented due to a decision of the medical staff or the parents (15% not specified). However, 96% of respondents considered the recommendations useful. CONCLUSION Recommendations were frequently perceived as useful, and were applicable in the participating institutions. Nevertheless, limitations in availability of diagnostic procedures and treatment modalities affected the feasibility of some recommendations. Tele-oncology tumor boards offer physicians from low- and middle-income countries access to real-time, high-level subspecialist expertise and provide a valuable platform for worldwide information exchange.
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Affiliation(s)
- Mariel Rosabal-Obando
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Diana S Osorio
- Neuro-Oncology Program, Division of Hematology, Oncology and BMT, Nationwide Children's Hospital, Ohio State University, Columbus, Ohio, USA
| | - Alvaro Lassaletta
- Pediatric Oncology, Hematology and Stem Cell Transplant Department, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | | | - Ute Bartels
- Neuro-Oncology, Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jonathan L Finlay
- Neuro-Oncology Program, Division of Hematology, Oncology and BMT, Nationwide Children's Hospital, Ohio State University, Columbus, Ohio, USA
| | - Ibrahim Qaddoumi
- Global Pediatric Medicine Department, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Stefan Rutkowski
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Mynarek
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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21
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Aristizabal P, Burns LP, Kumar NV, Perdomo BP, Rivera-Gomez R, Ornelas MA, Gonda D, Malicki D, Thornburg CD, Roberts W, Levy ML, Crawford JR. Improving Pediatric Neuro-Oncology Survival Disparities in the United States-Mexico Border Region: A Cross-Border Initiative Between San Diego, California, and Tijuana, Mexico. JCO Glob Oncol 2021; 6:1791-1802. [PMID: 33216645 PMCID: PMC7713516 DOI: 10.1200/go.20.00377] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE Treatment of children with CNS tumors (CNSTs) demands a complex, interdisciplinary approach that is rarely available in low- and middle-income countries. We established the Cross-Border Neuro-Oncology Program (CBNP) between Rady Children's Hospital, San Diego (RCHSD), and Hospital General, Tijuana (HGT), Mexico, to provide access to neuro-oncology care, including neurosurgic services, for children with CNSTs diagnosed at HGT. Our purpose was to assess the feasibility of the CBNP across the United States-Mexico border and improve survival for children with CNSTs at HGT by implementing the CBNP. PATIENTS AND METHODS We prospectively assessed clinicopathologic profiles, the extent of resection, progression-free survival, and overall survival (OS) in children with CNSTs at HGT from 2010 to 2017. RESULTS Sixty patients with CNSTs participated in the CBNP during the study period. The most common diagnoses were low-grade glioma (24.5%) and medulloblastoma (22.4%). Of patients who were eligible for surgery, 49 underwent resection at RCHSD and returned to HGT for collaborative management. Gross total resection was achieved in 78% of cases at RCHSD compared with 0% at HGT (P < .001) and was a predictor of 5-year OS (hazard ratio, 0.250; 95% CI, 0.067 to 0.934; P = .024). Five-year OS improved from 0% before 2010 to 52% in 2017. CONCLUSION The CBNP facilitated access to complex neuro-oncology care for underserved children in Mexico through binational exchanges of resources and expertise. Survival for patients in the CBNP dramatically improved. Gross total resection at RCHSD was associated with higher OS, highlighting the critical role of experienced neurosurgeons in the treatment of CNSTs. The CBNP model offers an attractive alternative for children with CNSTs in low- and middle-income countries who require complex neuro-oncology care, particularly those in close proximity to institutions in high-income countries with extensive neuro-oncology expertise.
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Affiliation(s)
- Paula Aristizabal
- Peckham Center for Cancer and Blood Disorders, Rady Children's Hospital San Diego, San Diego, CA.,Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of California, San Diego, La Jolla, CA.,Population Sciences, Disparities and Community Engagement, Moores Cancer Center, University of California, San Diego, La Jolla, CA
| | - Luke P Burns
- School of Medicine, University of California, San Diego, La Jolla, CA
| | - Nikhil V Kumar
- School of Medicine, University of California, San Diego, La Jolla, CA
| | - Bianca P Perdomo
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of California, San Diego, La Jolla, CA
| | - Rebeca Rivera-Gomez
- Hospital General de Tijuana/Universidad Autónoma de Baja California Tijuana, Baja California, Mexico
| | - Mario A Ornelas
- Hospital General de Tijuana/Universidad Autónoma de Baja California Tijuana, Baja California, Mexico
| | - David Gonda
- Department of Neurosciences, University of California, San Diego, La Jolla, CA.,Division of Pediatric Neurosurgery, Department of Neurosurgery, University of California, San Diego, La Jolla, CA
| | - Denise Malicki
- Department of Pathology, University of California, San Diego, La Jolla, CA
| | - Courtney D Thornburg
- Peckham Center for Cancer and Blood Disorders, Rady Children's Hospital San Diego, San Diego, CA.,Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of California, San Diego, La Jolla, CA
| | - William Roberts
- Peckham Center for Cancer and Blood Disorders, Rady Children's Hospital San Diego, San Diego, CA.,Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of California, San Diego, La Jolla, CA
| | - Michael L Levy
- Department of Neurosciences, University of California, San Diego, La Jolla, CA.,Division of Pediatric Neurosurgery, Department of Neurosurgery, University of California, San Diego, La Jolla, CA
| | - John R Crawford
- Peckham Center for Cancer and Blood Disorders, Rady Children's Hospital San Diego, San Diego, CA.,Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of California, San Diego, La Jolla, CA.,Department of Neurosciences, University of California, San Diego, La Jolla, CA.,Division of Pediatric Neurology, Department of Pediatrics, University of California San Diego, La Jolla, CA
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22
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Riedemann J, Figaji A, Davidson A, Stannard C, Pillay K, Kilborn T, Parkes J. Sequential improvement in paediatric medulloblastoma outcomes in a low-and-middle-income country setting over three decades. SOUTH AFRICAN JOURNAL OF ONCOLOGY 2021. [DOI: 10.4102/sajo.v5i0.174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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23
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Gupta T, Sinha S, Chinnaswamy G, Vora T, Prasad M, Bhat V, Goda JS, Krishnatry R, Chatterjee A, Epari S, Sahay A, Moiyadi A, Shetty P, Patil V, Khatua S, Jalali R, Kurkure P. Safety and efficacy of concurrent carboplatin during full-dose craniospinal irradiation for high-risk/metastatic medulloblastoma in a resource-limited setting. Pediatr Blood Cancer 2021; 68:e28925. [PMID: 33533557 DOI: 10.1002/pbc.28925] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 01/08/2021] [Accepted: 01/10/2021] [Indexed: 11/10/2022]
Abstract
PURPOSE To assess the safety and efficacy of concurrent carboplatin during craniospinal irradiation (CSI) in high-risk/metastatic medulloblastoma defined as either residual tumor >1.5 cm2 or leptomeningeal metastases. METHODS This single-arm combined prospective (2005-2011) and retrospective (2011-2019) study was undertaken at a tertiary care cancer center in India. Following surgery, patients with newly diagnosed high-risk/metastatic medulloblastoma received concurrent carboplatin (35 mg/m2 ) for 15 days (day 1 to day 15) during CSI plus posterior fossa/tumor bed boost, followed by six cycles of standard adjuvant chemotherapy. RESULTS All 97 patients completed their planned course of radiotherapy without interruptions, except for two (2.1%) patients who had brief gaps due to treatment-related toxicity. Grade 3-4 anemia, neutropenia, thrombocytopenia, and febrile neutropenia were seen in four (4.1%), 41 (42.2%) 21 (21.6%), and 18 (18.6%) patients, necessitating packed cell transfusion, granulocyte colony-stimulating factor, and platelet support in five (5.1%), 41 (42.2%), and five (5.1%) patients, respectively, during the concurrent phase. Following myelorecovery, 92 (94.9%) patients completed the planned six cycles of standard adjuvant systemic chemotherapy. There were no treatment-related deaths during the concurrent chemo-radiotherapy phase, while three (3.1%) toxic deaths were ascribed to adjuvant chemotherapy-related complications. At a median follow-up of 82 months, the 5-year Kaplan-Meier estimates of progression-free survival and overall survival were 60.2% and 62.1%, respectively. On univariate analysis, leptomeningeal metastases (M0/M1 vs. M2/M3) and histological subtype (large cell/anaplastic vs. others) emerged as significant prognostic factors for survival. CONCLUSION Addition of concurrent carboplatin to RT as radiosensitizing chemotherapy is a simple and effective way of treatment intensification in high-risk/metastatic medulloblastoma.
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Affiliation(s)
- Tejpal Gupta
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India
| | - Shwetabh Sinha
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India
| | - Girish Chinnaswamy
- Department of Pediatric Oncology, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India
| | - Tushar Vora
- Department of Pediatric Oncology, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India
| | - Maya Prasad
- Department of Pediatric Oncology, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India
| | - Vasudev Bhat
- Department of Pediatric Oncology, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India
| | - Jayant Sastri Goda
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India
| | - Rahul Krishnatry
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India
| | - Abhishek Chatterjee
- Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India
| | - Sridhar Epari
- Department of Pathology, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India
| | - Ayushi Sahay
- Department of Pathology, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India
| | - Aliasgar Moiyadi
- Department of Neurosurgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India
| | - Prakash Shetty
- Department of Neurosurgical Oncology, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India
| | - Vijay Patil
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India
| | | | | | - Purna Kurkure
- Department of Pediatric Oncology, Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Mumbai, Maharashtra, India
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24
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Hussain S, Hafeez A, Nazim H, Gohar R, Mallick MJ. Field-in-Field Technique With Intrafractionally Modulated Junction Shifts for Craniospinal Irradiation Planning With Three-Dimensional Conformal Radiation Therapy. Cureus 2021; 13:e14744. [PMID: 34084672 PMCID: PMC8164000 DOI: 10.7759/cureus.14744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Planning craniospinal irradiation (CSI) with ''field-in-field'' (FIF) homogenization technique in combination with daily, intrafractional modulation of the field junctions is needed to avoid spinal cord overdose. Photon-based techniques for CSI may result in dose inhomogeneity within the treatment volume and usually require a weekly manual shift of the field junctions to minimize the possibility of spinal cord overdose. Nowadays, FIF technique is used to feather out the dose inhomogeneity caused by multiple fields. We have started using this technique after acquiring advanced technology machines in recent years. METHODS AND MATERIALS Sixteen patients treated with three-dimensional conformal radiation therapy (3D-CRT) for CSI were retrospectively chosen for analysis. These patients were treated during 2019-2020. Contouring of planning target volume (PTV) and organs at risk (OAR) was done, and planning was done on Varian EclipseTM Treatment Planning System (TPS) (Varian Medical Systems, Palo Alto, CA). These patients were planned with lateral craniocervical fields and posterior spinal fields using a forward-planned FIF technique. Field junctions were automatically modulated and custom-weighted for maximal homogeneity within each treatment fraction. Dose-volume histogram (DVH) was used for analysis of results. A corresponding plan without FIF technique was planned; then maximum dose at the junction was noted for each patient with both plans, and the readings were evaluated. Paired sample t-test was used to compute the p-values for the inferential statistics. RESULTS Without FIF technique, the volume receiving 110% of the prescribed dose ranged from 39% to 74% (mean: 62.12%) and volume receiving 120% dose ranged from 8% to 28% (mean: 17.68%), whereas with FIF technique, the thecal sac volume receiving 110% of dose ranged from 2% to 18% (mean: 11%) and volume receiving 120% ranged from 0% to 2%. Volume receiving 100% of the dose was also calculated in both techniques; mean values of this dose range was almost similar in both groups. Later p-value was calculated, and in both dose ranges of thecal sac volume receiving 110% and 120%, the difference in values was statistically significant. Therefore, it proved that plan inhomogeneity improved with FIF technique. This technique provided consistent dose delivery during each fraction of treatment across the junctions. The maximum doses calculated at the junction were higher in the CSI plans without FIF compared to those with FIF technique. CONCLUSION This study concludes that better dose homogeneity is achieved with FIF technique as compared to non-FIF technique, and the difference in values was statistically significant.
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Affiliation(s)
| | | | - Hira Nazim
- Oncology, Ziauddin University, Karachi, PAK
| | - Rahim Gohar
- Oncology, Aga Khan University Hospital, Nairobi, KEN
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25
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Hughes TM, Empringham B, Wagner AK, Ward ZJ, Yeh J, Gupta S, Frazier AL, Denburg AE. Forecasting essential childhood cancer drug need: An innovative model-based approach. Cancer 2021; 127:2990-3001. [PMID: 33844270 DOI: 10.1002/cncr.33568] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 02/21/2021] [Accepted: 03/04/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Childhood cancer outcomes in low-income and middle-income countries have not kept pace with advances in care and survival in high-income countries. A contributing factor to this survival gap is unreliable access to essential drugs. METHODS The authors created a tool (FORx ECAST) capable of predicting drug quantity and cost for 18 pediatric cancers. FORx ECAST enables users to estimate the quantity and cost of each drug based on local incidence, stage breakdown, treatment regimen, and price. Two country-specific examples are used to illustrate the capabilities of FORx ECAST to predict drug quantities. RESULTS On the basis of domestic public-sector price data, the projected annual cost of drugs to treat childhood cancer cases is 0.8 million US dollars in Kenya and 3.0 million US dollars in China, with average median price ratios of 0.9 and 0.1, respectively, compared with costs sourced from the Management Sciences for Health (MSH) International Medical Products Price Guide. According to the cumulative chemotherapy cost, the most expensive disease to treat is acute lymphoblastic lymphoma in Kenya, but a higher relative unit cost of methotrexate makes osteosarcoma the most expensive diagnosis to treat in China. CONCLUSIONS FORx ECAST enables needs-based estimates of childhood cancer drug volumes to inform health system planning in a wide range of contexts. It is broadly adaptable, allowing decision makers to generate results specific to their needs. The resultant estimates of drug need can help equip policymakers and health governance institutions with evidence-informed data to advance innovative procurement strategies that drive global improvements in childhood cancer drug access.
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Affiliation(s)
- Terence M Hughes
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts.,Icahn School of Medicine at Mount Sinai, New York, New York
| | - Brianna Empringham
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Anita K Wagner
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Zachary J Ward
- Center for Health Decision Science, Harvard TH Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Jennifer Yeh
- Division of General Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Sumit Gupta
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - A Lindsay Frazier
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
| | - Avram E Denburg
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
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26
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Moreira DC, Gajjar A, Patay Z, Boop FA, Chiang J, Merchant TE, Santiago T, Schaeffer E, Sonnenfelt J, Andujar A, Shuler A, Caniza MA, Rodriguez-Galindo C, Qaddoumi I. Creation of a successful multidisciplinary course in pediatric neuro-oncology with a systematic approach to curriculum development. Cancer 2020; 127:1126-1133. [PMID: 33259071 DOI: 10.1002/cncr.33350] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 11/02/2020] [Accepted: 11/03/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND The St Jude Global Academy Neuro-Oncology Training Seminar (NOTS) is a hybrid course in pediatric neuro-oncology specifically designed for physicians from low-income and middle-income countries. METHODS The curriculum for the course was created by conducting a targeted needs assessment that evaluated 11 domains of care for children with central nervous system (CNS) tumors. The targeted needs assessment was completed by 24 institutions across the world, and the data were used to define 5 core elements included in the 2 components of the NOTS: a 9-week online course and a 7-day in-person workshop. Participant acquisition of knowledge and changes in clinical behavior were evaluated as measures of success. RESULTS Teams from 8 institutions located in 8 countries enrolled in the online course, and it was successfully completed by 36 participants representing 6 specialties. On the basis of their performance in the online course, 20 participants from 7 institutions took part in the on-site workshop. The participants exhibited improved knowledge in core elements of treating children with CNS tumors, including barriers of care, possible solutions, and steps for project implementation (P < .0001). All participants expressed a belief that they acquired new concepts and knowledge, leading to changes in their clinical practice. Those present at the workshop created an international multidisciplinary group focused on treating CNS tumors in low-income and middle-income countries. CONCLUSIONS By using a hybrid online and in-person approach, the authors successfully created a multidisciplinary course focused on pediatric CNS tumors for resource-limited settings. Their experience supports this strategy as a feasible mechanism for driving further global collaborations.
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Affiliation(s)
- Daniel C Moreira
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee.,Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Amar Gajjar
- Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Zoltan Patay
- Department of Diagnostic Imaging, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Frederick A Boop
- Department of Surgery, St Jude Children's Research Hospital, Memphis, Tennessee.,Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Jason Chiang
- Department of Pathology, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Thomas E Merchant
- Department of Radiation Oncology, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Teresa Santiago
- Department of Pathology, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Elizabeth Schaeffer
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Jason Sonnenfelt
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Allyson Andujar
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Ana Shuler
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Miguela A Caniza
- Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee.,Department of Infectious Diseases, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Carlos Rodriguez-Galindo
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee.,Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Ibrahim Qaddoumi
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, Tennessee.,Department of Oncology, St Jude Children's Research Hospital, Memphis, Tennessee
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27
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Drug Repurposing in Medulloblastoma: Challenges and Recommendations. Curr Treat Options Oncol 2020; 22:6. [PMID: 33245404 DOI: 10.1007/s11864-020-00805-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2020] [Indexed: 02/06/2023]
Abstract
OPINION STATEMENT Medulloblastoma is the most frequently diagnosed primary malignant brain tumor among children. Currently available therapeutic strategies are based on surgical resection, chemotherapy, and/or radiotherapy. However, majority of patients quickly develop therapeutic resistance and are often left with long-term therapy-related side effects and sequelae. Therefore, there remains a dire need to develop more effective therapeutics to overcome the acquired resistance to currently available therapies. Unfortunately, the process of developing novel anti-neoplastic drugs from bench to bedside is highly time-consuming and very expensive. A wide range of drugs that are already in clinical use for treating non-cancerous diseases might commonly target tumor-associated signaling pathways as well and hence be of interest in treating different cancers. This is referred to as drug repurposing or repositioning. In medulloblastoma, drug repurposing has recently gained a remarkable interest as an alternative therapy to overcome therapy resistance, wherein existing non-tumor drugs are being tested for their potential anti-neoplastic effects outside the scope of their original use.
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Pollul G, Bostel T, Grossmann S, Akbaba S, Karle H, Stockinger M, Schmidberger H. Pediatric craniospinal irradiation with a short partial-arc VMAT technique for medulloblastoma tumors in dosimetric comparison. Radiat Oncol 2020; 15:256. [PMID: 33153495 PMCID: PMC7643335 DOI: 10.1186/s13014-020-01690-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 10/20/2020] [Indexed: 12/26/2022] Open
Abstract
Background This study aimed to contrast four different irradiation methods for pediatric medulloblastoma tumors in a dosimetric comparison regarding planning target volume (PTV) coverage and sparing of organs at risk (OARs). Methods In sum 24 treatment plans for 6 pediatric patients were realized. Besides the clinical standard of a 3D-conformal radiotherapy (3D-CRT) treatment plan taken as a reference, volumetric modulated arc therapy (VMAT) treatment plans (“VMAT_AVD” vs. “noAVD” vs. “FullArc”) were optimized and calculated for each patient. For the thoracic and abdominal region, the short partial-arc VMAT_AVD technique uses an arc setup with reduced arc-length by 100°, using posterior and lateral beam entries. The noAVD uses a half 180° (posterior to lateral directions) and the FullArc uses a full 360° arc setup arrangement. The prescription dose was set to 35.2 Gy. Results We identified a more conformal dose coverage for PTVs and a better sparing of OARs with used VMAT methods. For VMAT_AVD mean dose reductions in organs at risk can be realized, from 16 to 6.6 Gy, from 27.1 to 8.7 Gy and from 8.0 to 1.9 Gy for the heart, the thyroid and the gonads respectively, compared to the 3D-CRT treatment method. In addition we have found out a superiority of VMAT_AVD compared to the noAVD and FullArc trials with lower exposure to low-dose radiation to the lungs and breasts. Conclusions With the short partial-arc VMAT_AVD technique, dose exposures to radiosensitive OARS like the heart, the thyroid or the gonads can be reduced and therefore, maybe the occurrence of late sequelae is less likely. Furthermore the PTV conformity is increased. The advantages of the VMAT_AVD have to be weighed against the potentially risks induced by an increased low dose exposure compared to the 3D-CRT method.
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Affiliation(s)
- Gerhard Pollul
- Department of Radiation Oncology, University Medical Center Mainz, Langenbeckstraße 1, 55131, Mainz, Germany.
| | - Tilman Bostel
- Department of Radiation Oncology, University Medical Center Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Sascha Grossmann
- Department of Radiation Oncology, University Medical Center Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Sati Akbaba
- Department of Radiation Oncology, University Medical Center Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Heiko Karle
- Department of Radiation Oncology, University Medical Center Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Marcus Stockinger
- Department of Radiation Oncology, University Medical Center Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Heinz Schmidberger
- Department of Radiation Oncology, University Medical Center Mainz, Langenbeckstraße 1, 55131, Mainz, Germany
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Pak‐Yin Liu A, Moreira DC, Sun C, Krull L, Gao Y, Yang B, Zhang C, He K, Yuan X, Chi‐Fung Chan G, Sun X, Ma X, Qaddoumi IA. Challenges and opportunities for managing pediatric central nervous system tumors in China. Pediatr Investig 2020; 4:211-217. [PMID: 33150316 PMCID: PMC7520110 DOI: 10.1002/ped4.12212] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 08/30/2020] [Indexed: 12/21/2022] Open
Abstract
Central nervous system (CNS) tumors represent the most deadly cancer in pediatric age group. In China, thousands of children are diagnosed with CNS tumors every year. Despite the improving socioeconomic status and availability of medical expertise within the country, unique challenges remain for the delivery of pediatric neuro-oncology service. In this review, we discuss the existing hurdles for improving the outcome of children with CNS tumors in China. Need for precise disease burden estimation, lack of intra- and inter-hospital collaborative networks, high probability of treatment abandonment, along with financial toxicities from treatment represent the key challenges that Chinese healthcare providers encounter. The tremendous opportunities for advancing the status of pediatric neuro-oncology care in and beyond the country are explored.
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Affiliation(s)
- Anthony Pak‐Yin Liu
- Department of OncologySt. Jude Children’s Research HospitalMemphisTNUSA
- Department of Paediatrics and Adolescent MedicineLi Ka Shing Faculty of MedicineThe University of Hong KongHong KongChina
| | - Daniel C. Moreira
- Department of OncologySt. Jude Children’s Research HospitalMemphisTNUSA
- Department of Global Pediatric MedicineSt. Jude Children’s Research HospitalMemphisTNUSA
| | - Chenchen Sun
- Department of Global Pediatric MedicineSt. Jude Children’s Research HospitalMemphisTNUSA
| | - Lisa Krull
- Department of Global Pediatric MedicineSt. Jude Children’s Research HospitalMemphisTNUSA
| | - Yijin Gao
- Department of Hematology/OncologyShanghai Children’s Medical CenterSchool of MedicineShanghai Jiao Tong UniversityShanghaiChina
| | - Bo Yang
- Department of NeurosurgeryShanghai Children’s Medical CenterSchool of MedicineShanghai Jiao Tong UniversityShanghaiChina
| | - Chenran Zhang
- Pediatric Neurological Disease CentreXinhua HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Kejun He
- Department of Pediatric Hematology/OncologyXinhua HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Xiaojun Yuan
- Department of Pediatric Hematology/OncologyXinhua HospitalShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Godfrey Chi‐Fung Chan
- Department of Paediatrics and Adolescent MedicineLi Ka Shing Faculty of MedicineThe University of Hong KongHong KongChina
- Department of Paediatrics and Adolescent MedicineHong Kong Children’s HospitalHong KongChina
| | - Xiaofei Sun
- Department of Pediatric OncologyState Key Laboratory of Oncology in South ChinaCollaborative Innovation Center for Cancer MedicineSun Yat‐Sen University Cancer CenterGuangzhouChina
| | - Xiaoli Ma
- Hematology Oncology CenterBeijing Children’s HospitalCapital Medical UniversityBeijingChina
| | - Ibrahim A. Qaddoumi
- Department of OncologySt. Jude Children’s Research HospitalMemphisTNUSA
- Department of Global Pediatric MedicineSt. Jude Children’s Research HospitalMemphisTNUSA
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30
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Mahajan A. How I Treat Medulloblastoma in Children. Indian J Med Paediatr Oncol 2020. [DOI: 10.4103/ijmpo.ijmpo_136_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
AbstractMedulloblastoma (MB) is the most common malignant tumor of the central nervous system in children with up to a third of these tumors presenting in children under 3 years of age. Its exquisite radio and chemosensitivity renders high cure rates in children in whom optimal resection has been achieved. Optimal surgery followed by radiation alone can cure about half of these children. The addition of chemotherapy has improved the outcomes dramatically and over 70% of children over 3 years of age with optimal resection and no metastasis can expect to be cured. Increasingly, the focus is on limiting the long-term sequelae of treatment. Precise molecular characterization can enable us to identify patients who can achieve optimal outcomes even in the absence of radiation. Insights into disease biology and molecular characterization have led to dramatic changes in our understanding, risk stratification, prognostication, and treatment approach in these children. In India, there is limited access to molecular profiling, making it challenging to apply biology driven approach to treatment in each child with MB. The Indian Society of Neuro-Oncology guidelines and the SIOP PODC adapted treatment recommendations for standard-risk MB based on the current evidence and logistic realities of low-middle income countries are a useful adjunct to guide clinical practice on a day-to-day basis in our setting.
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Affiliation(s)
- Amita Mahajan
- Department of Pediatric Hematology and Oncology, Indraprastha Apollo Hospital, New Delhi, India
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31
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Neuroprotection of Radiosensitive Juvenile Mice by Ultra-High Dose Rate FLASH Irradiation. Cancers (Basel) 2020; 12:cancers12061671. [PMID: 32599789 PMCID: PMC7352849 DOI: 10.3390/cancers12061671] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 06/02/2020] [Accepted: 06/18/2020] [Indexed: 02/07/2023] Open
Abstract
Major advances in high precision treatment delivery and imaging have greatly improved the tolerance of radiotherapy (RT); however, the selective sparing of normal tissue and the reduction of neurocognitive side effects from radiation-induced toxicities remain significant problems for pediatric patients with brain tumors. While the overall survival of pediatric patients afflicted with medulloblastoma (MB), the most common type primary brain cancer in children, remains high (≥80%), lifelong neurotoxic side-effects are commonplace and adversely impact patients’ quality of life. To circumvent these clinical complications, we have investigated the capability of ultra-high dose rate FLASH-radiotherapy (FLASH-RT) to protect the radiosensitive juvenile mouse brain from normal tissue toxicities. Compared to conventional dose rate (CONV) irradiation, FLASH-RT was found to ameliorate radiation-induced cognitive dysfunction in multiple independent behavioral paradigms, preserve developing and mature neurons, minimize microgliosis and limit the reduction of the plasmatic level of growth hormone. The protective “FLASH effect” was pronounced, especially since a similar whole brain dose of 8 Gy delivered with CONV-RT caused marked reductions in multiple indices of behavioral performance (objects in updated location, novel object recognition, fear extinction, light-dark box, social interaction), reductions in the number of immature (doublecortin+) and mature (NeuN+) neurons and increased neuroinflammation, adverse effects that were not found with FLASH-RT. Our data point to a potentially innovative treatment modality that is able to spare, if not prevent, many of the side effects associated with long-term treatment that disrupt the long-term cognitive and emotional well-being of medulloblastoma survivors.
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32
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Kian W, Roisman LC, Goldstein IM, Abo-Quider A, Samueli B, Wallach N, Alguayn F, Shalata W, Levitas D, Belochitski O, Levin D, Fenig E, Lavrenkov K, Tokar M, Peled N, Yakobson A. Vismodegib as First-Line Treatment of Mutated Sonic Hedgehog Pathway in Adult Medulloblastoma. JCO Precis Oncol 2020; 4:1900264. [PMID: 32923880 DOI: 10.1200/po.19.00264] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2020] [Indexed: 11/20/2022] Open
Affiliation(s)
- Waleed Kian
- The Legacy Heritage Oncology Center & Dr. Larry Norton Institute, Soroka Medical Center & Ben-Gurion University, Beer-Sheva, Israel
| | - Laila C Roisman
- The Legacy Heritage Oncology Center & Dr. Larry Norton Institute, Soroka Medical Center & Ben-Gurion University, Beer-Sheva, Israel
| | - Iris M Goldstein
- The Legacy Heritage Oncology Center & Dr. Larry Norton Institute, Soroka Medical Center & Ben-Gurion University, Beer-Sheva, Israel
| | - Abed Abo-Quider
- Division of Pediatrics, Ben-Gurion University, Beer-Sheva, Israel
| | - Benzion Samueli
- Department of Pathology, Soroka University Medical Center, Soroka Medical Center & Ben-Gurion University, Beer-Sheva, Israel
| | - Nadav Wallach
- Medical School for International Health, Ben-Gurion University, Beer-Sheva, Israel
| | - Farouq Alguayn
- Department of Neurosurgery, Soroka Medical Center & Ben-Gurion University, Beer-Sheva, Israel
| | - Walid Shalata
- The Legacy Heritage Oncology Center & Dr. Larry Norton Institute, Soroka Medical Center & Ben-Gurion University, Beer-Sheva, Israel
| | - Dina Levitas
- The Legacy Heritage Oncology Center & Dr. Larry Norton Institute, Soroka Medical Center & Ben-Gurion University, Beer-Sheva, Israel
| | - Olga Belochitski
- The Legacy Heritage Oncology Center & Dr. Larry Norton Institute, Soroka Medical Center & Ben-Gurion University, Beer-Sheva, Israel
| | - Daniel Levin
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Eyal Fenig
- Department of Radiotherapy, Davidoff Center, Rabin Medical Center, Petah Tikva, Israel
| | - Konstantin Lavrenkov
- The Legacy Heritage Oncology Center & Dr. Larry Norton Institute, Soroka Medical Center & Ben-Gurion University, Beer-Sheva, Israel
| | - Margarita Tokar
- The Legacy Heritage Oncology Center & Dr. Larry Norton Institute, Soroka Medical Center & Ben-Gurion University, Beer-Sheva, Israel
| | - Nir Peled
- The Legacy Heritage Oncology Center & Dr. Larry Norton Institute, Soroka Medical Center & Ben-Gurion University, Beer-Sheva, Israel
| | - Alexander Yakobson
- The Legacy Heritage Oncology Center & Dr. Larry Norton Institute, Soroka Medical Center & Ben-Gurion University, Beer-Sheva, Israel
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33
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Zulkarnaien B, Suharlim E, Susanto E, Gondhowiardjo SA. Multifocal recurrence of medulloblastoma: a long follow-up case study. MEDICAL JOURNAL OF INDONESIA 2020. [DOI: 10.13181/mji.cr.193480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Medulloblastoma is the most common malignant brain tumor in pediatric patients. Leptomeningeal dissemination often occurs in the spinal canal and rarely into the supratentorial as an extra-axial lesion. This study followed an 8-year progression of multifocal medulloblastoma recurrence as supratentorial metastasis that mimics an intra-axial mass of the temporal lobe. Pathologic examination of the temporal mass showed densely packed small round blue cells that are distributed in a ribboning pattern with areas of necrosis, rosette formation, and mitosis. Ki-67 immunohistochemical staining of the tumor showed a high proliferation index of 40% and revealed positive results for synaptophysin and negative results for glial fibrillary acidic protein and β-catenin. A long follow-up is essential to diagnose the recurrence and elucidate the progression of medulloblastoma.
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34
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de Medeiros CB, Moxon-Emre I, Scantlebury N, Malkin D, Ramaswamy V, Decker A, Law N, Kumabe T, Leonard J, Rubin J, Jung S, Kim SK, Gupta N, Weiss W, Faria CC, Vibhakar R, Lafay-Cousin L, Chan J, Kros JM, Janzen L, Taylor MD, Bouffet E, Mabbott DJ. Medulloblastoma has a global impact on health related quality of life: Findings from an international cohort. Cancer Med 2019; 9:447-459. [PMID: 31755223 PMCID: PMC6970040 DOI: 10.1002/cam4.2701] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 10/25/2019] [Accepted: 10/28/2019] [Indexed: 12/24/2022] Open
Abstract
Background Understanding the global impact of medulloblastoma on health related quality of life (HRQL) is critical to characterizing the broad impact of this disease and realizing the benefits of modern treatments. We evaluated HRQL in an international cohort of pediatric medulloblastoma patients. Methods Seventy‐six patients were selected from 10 sites across North America, Europe, and Asia, who participated in the Medulloblastoma Advanced Genomics International Consortium (MAGIC). The Health Utilities Index (HUI) was administered to patients and/or parents at each site. Responses were used to determine overall HRQL and attributes (ie specific subdomains). The impact of various demographic and medical variables on HRQL was considered—including molecular subgroup. Results The majority of patients reported having moderate or severe overall burden of morbidity for both the HUI2 and HUI3 (HUI2 = 60%; HUI3 = 72.1%) when proxy‐assessed. Self‐care in the HUI2 was rated as higher (ie better outcome) for patients from Western versus Eastern sites, P = .02. Patients with nonmetastatic status had higher values (ie better outcomes) for the HUI3 hearing, HUI3 pain, and HUI2 pain, all P < .05. Patients treated with a gross total resection also had better outcomes for the HUI3 hearing (P = .04). However, those who underwent a gross total resection reported having worse outcomes on the HUI3 vision (P = .02). No differences in HRQL were evident as a function of subgroup. Conclusions By examining an international sample of survivors, we characterized the worldwide impact of medulloblastoma. This is a critical first step in developing global standards for evaluating long‐term outcomes.
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Affiliation(s)
| | - Iska Moxon-Emre
- Department of Psychology, The Hospital for Sick Children, Toronto, ON, Canada.,Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Psychology, The University of Toronto, Toronto, ON, Canada.,Pediatric Oncology Group of Ontario, Toronto, ON, Canada
| | - Nadia Scantlebury
- Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON, Canada
| | - David Malkin
- Department of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Vijay Ramaswamy
- Department of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Alexandra Decker
- Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Psychology, The University of Toronto, Toronto, ON, Canada
| | - Nicole Law
- Department of Psychology, The Hospital for Sick Children, Toronto, ON, Canada.,Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Psychology, The University of Toronto, Toronto, ON, Canada
| | | | | | - Josh Rubin
- St. Louis Children's Hospital, St. Louis, MO, USA
| | - Shin Jung
- Chonnam National University, Hwasun-gun, Korea
| | - Seung-Ki Kim
- Seoul National University Hospital, Seoul, Korea
| | - Nalin Gupta
- University of California San Francisco, San Francisco, CA, USA
| | - William Weiss
- University of California San Francisco, San Francisco, CA, USA
| | - Claudia C Faria
- Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | | | - Lucie Lafay-Cousin
- Alberta Children's Hospital, Calgary, AB, Canada.,University of Calgary, Calgary, AB, Canada
| | - Jennifer Chan
- Alberta Children's Hospital, Calgary, AB, Canada.,University of Calgary, Calgary, AB, Canada
| | - Johan M Kros
- Erasmus Medical Center, Rotterdam, The Netherlands
| | - Laura Janzen
- Department of Psychology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Michael D Taylor
- Developmental and Stem Cell Biology Program, The Hospital for Sick Children, Toronto, ON, Canada.,The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada.,Division of Neurosurgery, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Surgery, Department of Laboratory Medicine and Pathobiology and Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | - Eric Bouffet
- Department of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada.,The Arthur and Sonia Labatt Brain Tumour Research Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - Donald J Mabbott
- Department of Psychology, The Hospital for Sick Children, Toronto, ON, Canada.,Neurosciences and Mental Health, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Psychology, The University of Toronto, Toronto, ON, Canada
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35
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Gupta T, Achari R, Chatterjee A, Chen ZP, Mehta M, Bouffet E, Jalali R. Comparison of Epidemiology and Outcomes in Neuro-Oncology Between the East and the West: Challenges and Opportunities. Clin Oncol (R Coll Radiol) 2019; 31:539-548. [PMID: 31182288 DOI: 10.1016/j.clon.2019.05.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 05/10/2019] [Accepted: 05/15/2019] [Indexed: 12/24/2022]
Abstract
Although neoplasms of the brain and central nervous system (CNS) are relatively uncommon, comprising only 1-2% of the overall cancer burden, they represent a substantial source of morbidity and mortality worldwide. The age-adjusted annual incidence of CNS tumours is reportedly low; however, there is substantial global variability in its incidence, with nearly a five-fold difference between regions with the highest rates in developed countries in the West and those with the lowest rates in developing countries in South-East Asia, including India, possibly attributable to key differences in environmental factors, genetic susceptibilities and cultural practices, as well as resource constraints in low-middle income countries precluding precise ascertainment and accurate diagnosis. The burden of CNS tumours is further compounded by the fact that they require highly specialised and skilled multidisciplinary care, including access to modern neuroimaging, neurosurgery, neuropathology and molecular biology, radiotherapy, chemotherapy and rehabilitation services, which may not be widely available in an integrated manner in large parts of the world with a large variation in clinical pathways, non-uniformity of care and resultant heterogeneity in clinical outcomes. CNS tumours encompass a heterogeneous spectrum of histopathological entities with differences in presentation, distinct molecular/genetic alterations, diverse biological behaviour and varying clinical outcomes. Survival is highly dependent on histology, grade and molecular biology, but varies widely across continents, even for the same tumour type and grade. In general, survival is higher in children with primary brain tumours than in adults, largely due to the differences in histological distribution across age groups. However, there is widespread variability, with 5-year survival for paediatric brain tumours being <40% in some low-middle income countries compared with 70-80% in the developed world. This review compares the descriptive epidemiology and clinical outcomes of primary brain tumours between the East and the West that pose unique challenges but also provide new opportunities in contemporary neuro-oncological practice.
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Affiliation(s)
- T Gupta
- Department of Radiation Oncology, Tata Memorial Centre, Mumbai, India.
| | - R Achari
- Department of Radiation Oncology, Tata Medical Centre, Kolkata, India
| | - A Chatterjee
- Department of Radiation Oncology, Tata Memorial Centre, Mumbai, India
| | - Z-P Chen
- Department of Neurosurgery, SunYat-sen University Cancer Centre, Guangzhou, China
| | - M Mehta
- Department of Radiation Oncology, Miami Cancer Institute, Miami, Florida, USA
| | - E Bouffet
- Neuro-Oncology Section, Division of Hematology/Oncology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - R Jalali
- Department of Radiation Oncology, Apollo Proton Cancer Centre, Chennai, India
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36
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Elhassan MMA, Mohamedani AA, Osman HHM, Yousif NO, Elhaj NM, Qaddoumi I. Patterns, treatments, and outcomes of pediatric central nervous system tumors in Sudan: a single institution experience. Childs Nerv Syst 2019; 35:437-444. [PMID: 30610484 DOI: 10.1007/s00381-018-04032-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 12/17/2018] [Indexed: 01/09/2023]
Abstract
PURPOSE Studies of epidemiology, treatment modalities, and outcomes of childhood central nervous system (CNS) tumors in Sudan are scarce. To address this shortcoming, we evaluated baseline information about the epidemiology, treatment types, and outcomes of childhood CNS tumors at the National Cancer Institute, University of Gezira (NCI-UG) in Wad Madani, Sudan. METHODS We performed a retrospective health facility-based study of children with CNS tumors who were treated at the NCI-UG from January 2000 to December 2015. RESULTS A total of 62 (5.4% of all childhood cancers) pediatric patients with CNS tumors were identified over the study period. Tumors were more common among male children and involved the infratentorial compartment in 58% of cases. The median age at diagnosis was 9 years (range, 2-14 years). Approximately 60% (n = 37) of the study population had histology-determined diagnoses. Astrocytomas and medulloblastomas were the most common tumors in these cases. The mean time to diagnosis was 6 months (SD, 9). During the study period, the number of children with CNS tumors who were referred for treatment at the NCI-UG increased every year. Of the 37 patients who received surgical interventions, 8 received gross total resections, 20 received partial resections, and 24 received postoperative radiotherapy. The treatment abandonment rate was 11%. The 2-year and 5-year survival rates were 33% and 13%, respectively. CONCLUSION Our findings reveal a high incidence of poor outcomes for patients with CNS tumors in Sudan, which is most likely due to many distinct factors.
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Affiliation(s)
- M Mohammed Ali Elhassan
- Department of Oncology, National Cancer Institute, University of Gezira, PO Box 20, Wad Madani, Sudan.
| | - A Abdalla Mohamedani
- Department of Pathology, Faculty of Medicine, University of Gezira, Wad Madani, Sudan
| | | | - N Osman Yousif
- Department of Oncology, National Cancer Institute, University of Gezira, PO Box 20, Wad Madani, Sudan
| | - N Mohamed Elhaj
- Department of Oncology, National Cancer Institute, University of Gezira, PO Box 20, Wad Madani, Sudan
| | - I Qaddoumi
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
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Elshahoubi A, Khattab E, Halalsheh H, Khaleifeh K, Bouffet E, Amayiri N. Feasibility of high-dose chemotherapy protocols to treat infants with malignant central nervous system tumors: Experience from a middle-income country. Pediatr Blood Cancer 2019; 66:e27464. [PMID: 30251335 DOI: 10.1002/pbc.27464] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Revised: 08/18/2018] [Accepted: 08/26/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND Results of high-dose chemotherapy (HDCT) protocols for the management of malignant central nervous system (CNS) tumors in infants are mostly reported in high-income countries. We evaluated the feasibility and results of such protocols in a middle-income country (Jordan). METHODS A retrospective study of infants' charts with CNS tumors between 2006 and 2015 who were treated according to HeadStart (HS) protocols. Data included patients' demographics, chemotherapy complications, and cost. RESULTS We identified 18 patients with median age 29 months (range, 9-62 months) at diagnosis (12 HS-I and six HS-II). Distribution according to pathology was: atypical teratoid rhabdoid tumors (ATRT) (nine), primitive neuoroectodermal tumors (PNET)/pineoblastoma (five), and medulloblastoma (four). Six patients (33%) had metastatic disease, and 14 (78%) had an incomplete resection. Eleven patients achieved partial or complete remission, two stabilized, and five progressed. Ten patients did not proceed to HDCT due to progression (five), financial reasons (two), failure to collect stem cells (one), and undocumented reasons (two). Seventy-eight chemotherapy cycles were administered (median interval 26 days). Main complications during induction and consolidation were febrile neutropenia (73% and 100%), documented infections (8% and 13%), and mucositis (12% and 88%), respectively. Three patients developed moderate hearing loss. No protocol-related mortality was reported. At the last follow-up, five patients were alive: three with medulloblastoma (19, 29, and 89 months) and two with ATRT (18 and 42 months). Three survivors received focal/craniospinal radiation. The median cost of a complete HS protocol, excluding surgery/radiotherapy, was $103 500 per patient; 39% of the median cost was related to pharmacy expenses. CONCLUSIONS These protocols were manageable in our context of limited health care resources. However, considering the significant costs and the modest survival rate, better selection criteria need to be used to identify patients likely to benefit from this approach.
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Affiliation(s)
- Alya Elshahoubi
- Division of Pediatric Hematology/Oncology, King Hussein Cancer Center, Amman, Jordan
| | - Eman Khattab
- Pediatric Stem Cell Transplantation Unit, King Hussein Cancer Center, Amman, Jordan
| | - Hadeel Halalsheh
- Division of Pediatric Hematology/Oncology, King Hussein Cancer Center, Amman, Jordan
| | - Kawther Khaleifeh
- Division of Pediatric Hematology/Oncology, King Hussein Cancer Center, Amman, Jordan
| | - Eric Bouffet
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Canada
| | - Nisreen Amayiri
- Division of Pediatric Hematology/Oncology, King Hussein Cancer Center, Amman, Jordan
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38
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Is there an increased risk of spinal relapse in standard-risk medulloblastoma/primitive neuroectodermal tumor patients who receive only a reduced dose of craniospinal radiotherapy? Childs Nerv Syst 2018; 34:1657-1662. [PMID: 29868932 DOI: 10.1007/s00381-018-3842-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 05/15/2018] [Indexed: 10/14/2022]
Abstract
PURPOSE Medulloblastoma (MBL) is the most common pediatric brain malignancy. Postoperative radiotherapy to the entire craniospinal axis is the standard-of-care but has linked to long-term morbidity. In this study, we analyzed the implication of reduced dose craniospinal radiotherapy (RT) for survival and pattern of relapse in MBL patients. MATERIAL AND METHODS The clinical characteristics of 32 consecutively diagnosed medulloblastoma/primitive neuroectodermal tumor patients were analyzed. After surgical resection, a dose of 23.4 Gy of spinal RT with a posterior fossa boost of 30.6 Gy was prescribed to standard-risk patients, whereas high-risk patients received 36 Gy spinal RT with additional boosts to the posterior fossa up to 54 Gy. Then, both groups received the same chemotherapy protocol. RESULTS Five-year OS for standard and high-risk patients was 94 and 50%, respectively. When analyzing prognostic factors, postoperative tumor size is the most important one which affects the OS. Ten patients relapsed during follow-up, and there was no isolated spinal relapse in either group. CONCLUSION The risk of isolated spinal relapse does not increase with reduced-dose craniospinal RT, since there is no isolated relapse in either the standard or high-risk groups of patients.
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Mehrvar A, Tashvighi M, Hedayati Asl AA, Niktoreh-Mofrad N, Mehrvar N, Afsar N, Naderi A, Allebouyeh M, Qaddoumi I, Faranoush M. Management and outcomes of treating pediatric medulloblastoma: an eight years' experience in an Iranian pediatric center. Childs Nerv Syst 2018; 34:639-647. [PMID: 29214340 DOI: 10.1007/s00381-017-3672-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 11/27/2017] [Indexed: 12/30/2022]
Abstract
PURPOSE The clinical management of pediatric medulloblastoma requires a multidisciplinary approach, which can be challenging, especially in low- and middle-income countries. The aim of this study was to identify current challenges and describe the treatment and outcomes of Iranian pediatric patients with medulloblastoma who were referred to our center in Tehran, Iran. METHODS Our retrospective review included 126 patient records from April 2007 to May 2015. The records were analyzed for epidemiologic features, treatment modalities, overall survival, and progression-free survival. Data were analyzed using SPSS 22.0 software. RESULTS Median age at diagnosis was 6 years (male:female ratio, 2.3:1). At the time of diagnosis, 7 patients were 2 years or younger, and 76 (60.3%) were categorized as having high-risk disease. Overall, 100 patients had gross or near-total surgical resection. Cerebral spinal fluid involvement was detected in 22.2% of the patients tested, and spinal involvement was detected in 25% of the patients who underwent spinal MRI. Metastasis stages at the time of diagnosis were as follows: M0: 48.4% patients, M1: 16.7%, M2: 5.5%, and M3: 21.4%. Median times of follow-up and progression-free survival were 16 and 12 months, respectively. Probability of 7-year overall survival and progression-free survival were 59 and 53.8%, respectively. CONCLUSIONS Results of the current retrospective study emphasize the need for implementing measures to improve outcome for our patients with medulloblastoma. Such measures include a multidisciplinary approach, unified national treatment guidelines, better disease and metastasis staging, twinning initiatives, and seeking a second opinion when needed.
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Affiliation(s)
- Azim Mehrvar
- MAHAK Pediatric Cancer Treatment and Research Center, Tehran, Iran
- AJA University of Medical Sciences, Tehran, Iran
| | - Maryam Tashvighi
- MAHAK Pediatric Cancer Treatment and Research Center, Tehran, Iran
- Islamic Azad University of Medical Sciences, Qom, Iran
| | | | - Naghmeh Niktoreh-Mofrad
- MAHAK Pediatric Cancer Treatment and Research Center, Tehran, Iran.
- Department of Pediatric Hematology and Oncology, University Children's Hospital Essen, Hufelandstr. 55, 45147, Essen, Germany.
| | - Narjes Mehrvar
- Cancer Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Negar Afsar
- MAHAK Pediatric Cancer Treatment and Research Center, Tehran, Iran
| | - Ali Naderi
- MAHAK Pediatric Cancer Treatment and Research Center, Tehran, Iran
| | | | - Ibrahim Qaddoumi
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Mohammad Faranoush
- MAHAK Pediatric Cancer Treatment and Research Center, Tehran, Iran
- Pediatric Growth and Development Research Center, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Iran
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Parkes J, Hess C, Burger H, Anacak Y, Ahern V, Howard SC, Elhassan M, Ahmed S, Ghalibafian M, Abbasi AN, Qureshi BM, Zaghloul M, Zubizarreta E, Bey P, Davidson A, Bouffet E, Esiashvili N. Recommendations for the treatment of children with radiotherapy in low- and middle-income countries (LMIC): A position paper from the Pediatric Radiation Oncology Society (PROS-LMIC) and Pediatric Oncology in Developing Countries (PODC) working groups of the International Society of Pediatric Oncology (SIOP). Pediatr Blood Cancer 2017; 64 Suppl 5. [PMID: 29297617 DOI: 10.1002/pbc.26903] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 10/31/2017] [Accepted: 11/02/2017] [Indexed: 02/06/2023]
Abstract
Pediatric radiotherapy is a critical part of pediatric oncology protocols and the quality of the radiotherapy may determine the future quality of life for long-term survivors. Multidisciplinary team decision making provides the basis for high-quality care. However, delivery of high-quality radiotherapy is dependent on resources. This article provides guidelines for delivery of good quality radiation therapy in resource-limited countries based on rational procurement and maintenance planning, protocol development, three-dimensional planning, quality assurance, and adequate staff numbers and training.
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Affiliation(s)
- Jeannette Parkes
- Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Clayton Hess
- Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA
| | - Hester Burger
- Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Yavuz Anacak
- Ege University School of Medicine, Izmir, Turkey
| | - Verity Ahern
- Crown Princess Cancer Center, Westmead Hospital, University of Sydney, Sydney, Australia
| | - Scott C Howard
- University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Moawia Elhassan
- National Cancer Institute, University of Gezira, Wad Medani, Sudan
| | - Soha Ahmed
- Children's Cancer Hospital Egypt (CCHE), National Cancer Institute, Cairo University, Cairo, Egypt
| | - Mithra Ghalibafian
- MAHAK Pediatric Cancer Treatment and Research Center (MPCTRC), Tehran, Iran
| | | | | | - Mohamed Zaghloul
- Children's Cancer Hospital Egypt (CCHE), National Cancer Institute, Cairo University, Cairo, Egypt
| | | | | | - Alan Davidson
- Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | | | - Natia Esiashvili
- Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
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Elhassan MMA, Osman HHM, Parkes J. Posterior cranial fossa tumours in children at National Cancer Institute, Sudan: a single institution experience. Childs Nerv Syst 2017; 33:1303-1308. [PMID: 28432426 DOI: 10.1007/s00381-017-3414-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 04/12/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Posterior cranial fossa tumours (PCF) comprise 54-70% of childhood brain tumours. The clinical profile and outcomes of these tumours differ in area of the world. The aim of this study is to describe clinical characteristics, treatment and outcome of posterior cranial fossa tumours in Sudan. MATERIAL AND METHODS A retrospective study of children diagnosed with posterior cranial fossa tumours and treated between January 1998 and December 2015 at National Cancer Institute, Sudan. RESULTS A total of 31 paediatric patients with a posterior cranial fossa brain tumour were identified over the study period. The mean age was 7.9 years (standard deviation (SD) = 3.37). Females were slightly more affected (51%) than males (49%), and the majority of patients were from rural areas (71%). Brainstem tumours were the most frequent tumour type (48%) followed by medulloblastoma (36%). The mean pre-diagnostic symptomatic interval was 3.6 months (SD = 3.95). Overall survival rate of our total study population at 1, 2 and 5 years was 23, 19 and 13%, respectively. CONCLUSION Overall, this study draws attention to the situation of paediatric brain tumours in Sudan. Late presentation, misdiagnosis and limited diagnostic and treatment resources are challenges that may contribute to poor outcome in these patients.
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Affiliation(s)
| | | | - Jeannette Parkes
- Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
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Arora RS, Challinor JM, Howard SC, Israels T. Improving Care for Children With Cancer in Low- and Middle-Income Countries--a SIOP PODC Initiative. Pediatr Blood Cancer 2016; 63:387-91. [PMID: 26797891 DOI: 10.1002/pbc.25810] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 09/23/2015] [Accepted: 09/25/2015] [Indexed: 12/15/2022]
Abstract
The Paediatric Oncology in Developing Countries (PODC) committee of International Society of Paediatric Oncology (SIOP) has 10 working groups that provide a forum for individuals to engage, network, and implement improvements in the care of children with cancer in low- and middle-income countries. The development of adapted guidelines (medulloblastoma, retinoblastoma, Wilms tumor, neuroblastoma, retinoblastoma, Burkitt lymphoma, supportive care), advocacy and awareness (on hospital detention and essential drugs), education and training, and global mapping (nutritional practice, abandonment rates, and twinning collaborations) have been the initial areas of focus, and the impact of some of these activities is evident, for example, in the SIOP Africa PODC Collaborative Wilms tumor project.
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Affiliation(s)
| | - Julia M Challinor
- School of Nursing, University of California San Francisco, San Francisco, California
| | - Scott C Howard
- University of Memphis, School of Health Studies, Memphis, Tennessee
| | - Trijn Israels
- Department of Pediatric Oncology - Outreach Program, VU University Medical Center, Amsterdam, The Netherlands
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Wang C, Yuan XJ, Jiang MW, Wang LF. Clinical characteristics and abandonment and outcome of treatment in 67 Chinese children with medulloblastoma. J Neurosurg Pediatr 2016; 17:49-56. [PMID: 26451721 DOI: 10.3171/2015.5.peds1573] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECT The purpose of this study was to explore the clinical features and outcome of medulloblastoma in Chinese children. The authors analyze the reasons that treatment is abandoned and attempt to provide evidence-based recommendations for improving the prognosis of medulloblastoma in this population. METHODS A total of 67 pediatric cases of newly diagnosed medulloblastoma were included in this study. All of the children were treated at Xinhua Hospital between January 2007 and June 2013. The authors retrospectively analyzed the clinical data, treatment modalities, and outcome. The male-to-female ratio was 2:1, and the patients' median age at diagnosis was 51.96 months (range 3.96-168.24 months). The median duration of follow-up was 32 months (range 3-70 months). RESULTS At the most recent follow-up date, 31 patients (46%) were alive, 30 (45%) had died, and 6 (9%) had been lost to follow-up. The estimated 3-year overall survival and progression-free survival, based on Kaplan-Meier analysis, were 55.1% ± 6.4% and 45.6% ± 6.7%, respectively. Univariate analysis showed that standard-risk group (p = 0.009), postoperative radiotherapy (RT) combined with chemotherapy (p < 0.001), older age (≥ 3 years) at diagnosis (p = 0.010), gross-total resection (p = 0.012), annual family income higher than $3000 (p = 0.033), and living in urban areas (p = 0.008) were favorable prognostic factors. Multivariate analysis revealed that postoperative RT combined with chemotherapy was an independent prognostic factor (p < 0.001). The treatment abandonment rate in this cohort was 31% (21 of 67 cases). CONCLUSIONS There was a large gap between the outcome of medulloblastoma in Chinese children and the outcome in Western children. Based on our data, treatment abandonment was the major cause of therapeutic failure. Parents' misunderstanding of medulloblastoma played a major role in abandonment, followed by financial and transportation difficulties. Establishment of multidisciplinary treatment teams could improve the prognosis of medulloblastoma in Chinese children.
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Affiliation(s)
- Chen Wang
- Departments of 1 Pediatric Hematology/Oncology
| | | | | | - Li-Feng Wang
- Pathology, Xin Hua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
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Ceppi F, Ortiz R, Antillón F, Vasquez R, Gomez W, Gamboa J, Garrido C, Chantada G, Peña A, Gupta S. Anaplastic Large Cell Lymphoma in Central America: A Report From the Central American Association of Pediatric Hematology Oncology (AHOPCA). Pediatr Blood Cancer 2016; 63:78-82. [PMID: 26257093 DOI: 10.1002/pbc.25698] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 07/14/2015] [Indexed: 01/26/2023]
Abstract
BACKGROUND Although anaplastic large cell lymphoma (ALCL) is curable in high-income countries (HIC), data from low- and middle-income countries (LMIC) are lacking. We therefore conducted a retrospective study of the Central American Association of Pediatric Hematology Oncology (AHOPCA) experience in treating ALCL. PROCEDURE We included all patients age <18 years newly diagnosed with ALCL treated between 2000 and 2013 in seven AHOPCA institutions. Retrospective data were extracted from the Pediatric Oncology Network Database. RESULTS Thirty-one patients met inclusion criteria. Twenty-five (81%) had advanced disease (stages III and IV), six (19%) were treated on the APO (doxorubicin, prednisone, vincristine) regimen, 15 (49%) on multi-agent chemotherapy designed for T-cell lineage malignancies (GuatALCL protocol), and 10 (32%) on BFM-based treatment regimens. Five-year overall event-free survival and overall survival were, respectively, 67.1 ± 8.6% and 66.7 ± 8.7%. All 10 events occurred in patients treated on BFM-based treatment regimens or the GuatALCL protocol, none on APO treatment: two patients experienced relapse, six treatment related mortality (TRM), and two abandonment. CONCLUSIONS Treatment of ALCL in countries with limited resources is feasible with similar outcomes as in HIC, though the causes of treatment failure differ. Less intensive regimens may be preferable in order to decrease TRM and improve outcomes. Prospective clinical trials determining the ideal treatment for LMIC children with ALCL are necessary.
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Affiliation(s)
- Francesco Ceppi
- Division of Haematology/Oncology, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Roberta Ortiz
- Department of Pediatric Oncology, Manuel de Jesus Rivera Hospital, Managua, Nicaragua
| | - Federico Antillón
- National Pediatric Oncology Unit, Francisco Marroquín Medical School, Guatemala City, Guatemala
| | - Roberto Vasquez
- Department of Onco-Hematology, Hospital Benjamin Bloom, San Salvador, El Salvador
| | - Wendy Gomez
- Department of Hematology-Oncology, Dr. Robert Reid Cabral Children's Hospital, Santo Domingo, Dominican Republic
| | - Jessica Gamboa
- Department of Hematology-Oncology, Hospital Nacional de Niños "Dr. Carlos Sáenz Herrera", San José, Costa Rica
| | - Claudia Garrido
- National Pediatric Oncology Unit, Francisco Marroquín Medical School, Guatemala City, Guatemala
| | - Guillermo Chantada
- Department of Hemato-oncology, Hospital JP Garrahan, Buenos Aires, Argentina.,International Outreach Program, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Armando Peña
- Department of Pediatric Hemato-Oncology, Hospital Escuela-Universitario, Tegucigalpa, Honduras
| | - Sumit Gupta
- Division of Haematology/Oncology, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
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Israels T, Challinor J, Howard S, Arora RH. Treating Children With Cancer Worldwide--Challenges and Interventions. Pediatrics 2015; 136:607-10. [PMID: 26371201 DOI: 10.1542/peds.2015-0300] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/21/2015] [Indexed: 11/24/2022] Open
Affiliation(s)
- Trijn Israels
- Pediatric Oncology and Hematology Outreach Program, VU University Medical Center, Amsterdam, Netherlands;
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Chan MH, Boop F, Qaddoumi I. Challenges and opportunities to advance pediatric neuro-oncology care in the developing world. Childs Nerv Syst 2015; 31:1227-37. [PMID: 26040936 DOI: 10.1007/s00381-015-2771-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 05/25/2015] [Indexed: 01/13/2023]
Abstract
PURPOSE As the morbidity and mortality associated with communicable diseases continue to decrease in the developing world, the medical burden of childhood cancer continues to expand. Although international aid and relief groups such as the World Health Organization recognize the importance of childhood cancer, their main emphasis is on the more easily treated malignancies, such as leukemias and lymphomas, and not pediatric brain tumors, which are the second most common malignancy in children and the leading cause of cancer-related deaths in the pediatric population. Addressing the needs of these children is a growing concern of several professional neuro-oncology-related societies. Thus, the goal of this review is to describe the current state of pediatric neuro-oncology care in the developing world, address the current and future needs of the field, and help guide professional societies' efforts to contribute in a more holistic and multidisciplinary manner. METHODS We reviewed the literature to compare the availability of neuro-oncology care in various regions of the developing world with that in higher income nations, to describe examples of successful initiatives, and to present opportunities to improve care. RESULTS The current challenges, previous successes, and future opportunities to improve neuro-oncology care are presented. The multidisciplinary nature of neuro-oncology depends on large teams of highly specialized individuals, including neuro-oncologists, neurosurgeons, neurologists, radiologists, radiation oncologists, pathologists, palliative care specialists, oncology nurses, physical therapists, occupational therapists, speech therapists, pediatric intensivists, and social workers, among others. CONCLUSION Pediatric neuro-oncology is one of the most complex types of medical care to deliver, as it relies on numerous specialists, subspecialists, support staff, and physical resources and infrastructure. However, with increasing collaboration and advancing technologies, developed nations can help substantially improve neuro-oncology care for children in developing nations.
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Affiliation(s)
- Michael H Chan
- University of Colorado School of Medicine, 13001 E 17th Place, Aurora, CO, 80045, USA
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Gajjar A, Finlay JL. The management of children and adolescents with medulloblastoma in low and middle income countries. Pediatr Blood Cancer 2015; 62:549-50. [PMID: 25545387 DOI: 10.1002/pbc.25371] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 10/29/2014] [Indexed: 11/09/2022]
Affiliation(s)
- Amar Gajjar
- Department of Oncology, Division of Neuro-oncology, St. Jude Children's Research Hospital, Memphis, Tennessee
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