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Jain R, Hans R, Totadri S, Trehan A, Sharma RR, Menon P, Kapoor R, Saxena AK, Mittal BR, Bhatia P, Kakkar N, Srinivasan R, Rajwanshi A, Varma N, Samujh R, Marwaha N, Bansal D. Autologous stem cell transplant for high-risk neuroblastoma: Achieving cure with low-cost adaptations. Pediatr Blood Cancer 2020; 67:e28273. [PMID: 32196923 DOI: 10.1002/pbc.28273] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 02/16/2020] [Accepted: 03/02/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND The majority of patients in low- and middle-income countries (LMIC) are unable to receive optimal therapy, including autologous stem cell transplant (ASCT) for high-risk neuroblastoma. Management is intensive and multidisciplinary; survival is often poor. We report a single-center outcome of high-risk neuroblastoma, with adaptations optimized for LMIC. PROCEDURE The study was retrospective. Patients were treated on the backbone of the high-risk neuroblastoma study-1 of SIOP-Europe (HR-NBL1/SIOPEN) protocol with ASCT. Adaptations incorporated to decrease cost, requirement for inpatient admission, infections, and faster engraftment included (a) optional outpatient administration for rapid-COJEC, (b) two sessions of stem-cell apheresis, (c) storing stem cells at 2-6°C without cryopreservation for up to 7 days, (d) no central lines, (e) no antibacterial/antifungal/antiviral prophylaxis, (f) omitting formal assessment of cardiac/renal/pulmonary functions before ASCT, and (g) administration of pegylated granulocyte colony-stimulating factor on Day +4. RESULTS Over 5 years 9 months, 35 patients with high-risk neuroblastoma were treated. Rapid-COJEC was administered over a median duration of 80 days (interquartile range: 77, 83). Conditioning regimen included melphalan (n = 7), oral busulfan-melphalan (Bu/Mel; n = 6), or intravenous Bu/Mel (n = 22). The median viability of stem cells stored for 6 days (n = 28) was 93% (range: 88-99). Two (5.7%) patients had ASCT-related mortality. The 3-year overall and event-free survival was 41% and 39%, respectively. A relapse occurred in 20 (57%) patients. Treatment abandonment was observed in one (3%) patient. CONCLUSIONS Administration of therapy in a disciplined time frame along with low-cost adaptations enables to manage high-risk neuroblastoma with low abandonment and an encouraging survival in LMIC. Stem cells can be stored safely without cryopreservation for up to 7 days.
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Affiliation(s)
- Richa Jain
- Department of Pediatrics, Pediatric Hematology-Oncology Unit, Advanced Pediatrics Center, Chandigarh, India
| | - Rekha Hans
- Department of Transfusion, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sidharth Totadri
- Department of Pediatrics, Pediatric Hematology-Oncology Unit, Advanced Pediatrics Center, Chandigarh, India
| | - Amita Trehan
- Department of Pediatrics, Pediatric Hematology-Oncology Unit, Advanced Pediatrics Center, Chandigarh, India
| | - Ratti Ram Sharma
- Department of Transfusion, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Prema Menon
- Department of Pediatric Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rakesh Kapoor
- Department of Radiotherapy, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Akshay Kumar Saxena
- Departement of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Bhagwant Rai Mittal
- Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Prateek Bhatia
- Department of Pediatrics, Pediatric Hematology-Oncology Unit, Advanced Pediatrics Center, Chandigarh, India
| | - Nandita Kakkar
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Radhika Srinivasan
- Department of Cytopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Arvind Rajwanshi
- Department of Cytopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Neelam Varma
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ram Samujh
- Department of Pediatric Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Neelam Marwaha
- Department of Transfusion, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Deepak Bansal
- Department of Pediatrics, Pediatric Hematology-Oncology Unit, Advanced Pediatrics Center, Chandigarh, India
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Meena JP, Gupta AK. Neuroblastoma in a Developing Country: Miles to Go. Indian J Pediatr 2019; 86:403-405. [PMID: 30915646 DOI: 10.1007/s12098-019-02930-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 03/12/2019] [Indexed: 01/19/2023]
Affiliation(s)
- Jagdish Prasad Meena
- Division of Pediatric Oncology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Aditya Kumar Gupta
- Division of Pediatric Oncology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India.
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Radhakrishnan V, Raja A, Dhanushkodi M, Ganesan TS, Selvaluxmy G, Sagar TG. Real World Experience of Treating Neuroblastoma: Experience from a Tertiary Cancer Centre in India. Indian J Pediatr 2019; 86:417-426. [PMID: 30778950 DOI: 10.1007/s12098-018-2834-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 12/03/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Management of neuroblastoma, especially high-risk (HR) disease is difficult in a resource-limited setting. There is a paucity of literature on outcomes of patients treated in India. The present study was conducted to analyse the clinical profile, treatment, and outcomes of patients with neuroblastoma treated at authors' centre. METHODS The study was a retrospective analysis of newly diagnosed patients with neuroblastoma treated at authors' centre between 2000 to 2017. The International Neuroblastoma Staging System and risk grouping were used to classify patients as low-risk (LR), intermediate-risk (IR) and high-risk (HR). Treatment was individualised and risk-adapted. Kaplan-Meier method was used to calculate the event-free survival (EFS) and overall survival (OS). RESULTS The study included 85 patients with a median age of 4 y and 67% were males. Malnutrition was observed in 55% of patients. Adrenal gland was the most common site in 75% patients followed by mediastinum in 12%. LR was observed in 7/85 (8%) patients, IR 20/85 (24%) and HR in 58/85 (68%) patients. The CCG-3891 protocol was used to treat 80% of the patients. Autologous stem cell transplantation (ASCT) was performed in 32% of HR patients. The median follow-up was 16.6 mo. The median EFS and OS for all patients were 19.2 mo and 26.9 mo respectively and the 3 y EFS and OS was 36% and 47% respectively. The 3y EFS for LR, IR and HR patients was 100%, 54%, and 18.9% respectively (P < 0.001) and for OS was 100%, 77%, and 34% respectively (P = 0.002). On multivariate analysis, a hemoglobin less than 10 g% predicted inferior EFS (P = 0.002) and OS (p = 0.005) for all patients. For patients with high-risk disease, on multivariate analysis, hemoglobin (P = 0.002) and 13-Cis Retinoic acid maintenance (P = 0.002) predicted EFS and only radiotherapy to the primary (P = 0.01) predicted OS. Only 4/19 (21%) are alive and in remission post ASCT. CONCLUSIONS Majority of patients with neuroblastoma presented to authors' centre with advanced disease. Survival outcomes of patients with LR disease are excellent. However, patients with HR disease have poor outcomes despite multimodality management. Non-availability of N-MYC testing in few patients could have falsely down-staged them to IR from HR. A low hemoglobin at diagnosis is a poor predictor of outcome.
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Affiliation(s)
| | - Anand Raja
- Department of Surgical Oncology, Cancer Institute (WIA), Adyar, Chennai, Tamilnadu, India
| | - Manikandan Dhanushkodi
- Department of Medical Oncology, Cancer Institute (WIA), Adyar, Chennai, Tamilnadu, India
| | - T S Ganesan
- Department of Medical Oncology, Cancer Institute (WIA), Adyar, Chennai, Tamilnadu, India
| | - G Selvaluxmy
- Department of Radiotherapy, Cancer Institute (WIA), Adyar, Chennai, Tamilnadu, India
| | - T G Sagar
- Department of Medical Oncology, Cancer Institute (WIA), Adyar, Chennai, Tamilnadu, India
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Agarwala S, Mandelia A, Bakhshi S, Srinivas M, Bajpai M, Gupta AK, Gupta DK, Bhatnagar V. Neuroblastoma: outcome over a 14 year period from a tertiary care referral centre in India. J Pediatr Surg 2014; 49:1280-5. [PMID: 25092090 DOI: 10.1016/j.jpedsurg.2014.03.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2013] [Revised: 03/18/2014] [Accepted: 03/20/2014] [Indexed: 11/27/2022]
Abstract
PURPOSE To evaluate the outcome of children with neuroblastoma (NB) from a tertiary care referral centre in India. METHOD All children with NB registered from October 1996 through July 2009 were included in the study. INSS was used for staging. All children included in the study received chemotherapy and radiation therapy appropriate for stage. Tumor resection was done when feasible. The final outcome was overall survival and it was categorized as Complete Response (CR), Partial Response (PR); No Response (NR) and Progressive Disease (PD). Analysis of three-year overall survival was done using Kaplan Meier method and Log Rank test of significance. Multivariate analysis for significance of age, site and stage was performed. RESULTS 144 children in the age range of 1-132months (median 36) were enrolled. Only 38 (26.4%) children were below 12months. 112 (77.8%) of the tumors were abdominal and 32 (22.2%) were extra-abdominal. Stage distribution was 1+2 in 6 (4.2%); 3 in 58 (40.3%); 4 in 68 (47.2%); 4s in 12 (8.3%). 83 (57.6%) underwent gross complete resection. At the time of last follow-up, 100 (69.4%) were alive [60 CR (41.7%); 33 PR; 7 PD/NR] and 44 (30.6%) were dead [1CR; 11PR; 32 PD/NR]. The three-year OS was 60.7% [95 CI 50.4-69.5]. The OS was 69.7% for those<12months of age [95 CI 51.8-82.0] and CR was achieved in 57.9%, while for those >12months the OS was 55.3% [95 CI 42.2-66.6] and CR was achieved in 35.8% (p=0.73). All 6 (100%) patients with Stage 1 and Stage 2 disease were alive and disease free. The OS was 71.5% for Stage 3[95 CI 55.3-82.7] and CR was achieved in 56.9%, while for Stage 4 the OS was 35.7%[95 CI 19.3-52.4] and CR was achieved in 17.6% (p=0.001). The OS was 83.3% for 4s [95 CI 48.2-95.6] and CR was achieved in 75%. CONCLUSION All the six children with Stage 1 & 2 achieved CR and were alive, while 57% of Stage 3 could achieve CR and had an OS of 71.5%. The OS (35.7%) and CR (17.6%) for Stage 4 were significantly less (p=0.001).
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Affiliation(s)
- Sandeep Agarwala
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi-110029, India.
| | - Ankur Mandelia
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi-110029, India
| | - Sameer Bakhshi
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi-110029, India
| | - M Srinivas
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi-110029, India
| | - Minu Bajpai
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi-110029, India
| | - Arun K Gupta
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi-110029, India
| | - Devendra K Gupta
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi-110029, India
| | - Veereshwar Bhatnagar
- Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi-110029, India
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