Pediatric lymphoma: a 10-year experience at a tertiary care hospital in Pakistan

Outcome and prognostic factors of pediatric patients with Hodgkin lymphoma: a single-center experience

BACKGROUND

Hodgkin lymphoma (HL) is a highly curable malignant tumor. Risk-adapted treatment for children with HL aims to maximize survival while minimizing toxicity. The purpose of this study is to evaluate the outcome and prognostic characteristics of Egyptian pediatric HL patients treated at the National Cancer Institute (NCI), Cairo University.

METHODS

All newly diagnosed cases of classic HL treated between January 2016 and December 2018 were included in this study.

RESULTS

The median age at initial presentation was 8 years in 69 eligible individuals, with a male-to-female ratio of 4.7:1. Eighteen percent of patients had an elevated erythrocyte sedimentation rate (ESR) of more than 50, 42% had more than three lymph node (LN) group involvements, 18.8% had bulky disease, 52.2% were at an advanced stage, and 34% had B symptoms. Age  > 15 years, B symptoms,  > 3 LN group involvement, extra-nodal disease, and advanced stages significantly affected the overall survival rate (OS) (P-values = 0.03, 0.033, 0.008, 0.017, and 0.032). There was no statistically significant difference between patients who got combined modality therapy (CMT) and those who received chemotherapy alone (3-year OS and event-free survival (EFS) were 95.5% and 87.6% vs. 89.9% and 83.3%, P-values of 0.70 and 0.90). Patients with an interim-negative positron emission tomography-computed tomography (PET-CT) had a 3-year OS of 94.7%, compared to 74.1% in patients with an interim-positive PET-CT (P = 0.06), suggesting that rapid early response (RER) is a significant prognostic factor. There was no statistically significant survival difference between patients with a negative interim PET-CT who got CMT and those who received chemotherapy alone (3-year OS and EFS: 100% and 88.2% vs. 95% and 90%; P = 0.35 and 0.70, respectively). Three-year OS was 93.3% and 100%, and EFS was 74.3% and 100% (P = 0.495 and 0.196%) for those who got 15 Gy versus those who received 20 Gy or more, respectively. At the end of the study, the OS and EFS at 3 years for the whole group were 91.9% and 83.6%.

CONCLUSION

Treatment with risk- and response-adaptive treatment should be the standard of care for treating pediatric patients with HL.

Infection-Associated Mortality During Induction Chemotherapy in Group B Intermediate-Risk Pediatric Burkitt's Lymphoma

Background Burkitt's lymphoma (BL) in the pediatric population has significant burden in developing countries. Infection-related complications during the induction chemotherapy phase pose a major challenge and contribute to high mortality rates due to a severely immunocompromised state. However, there is scarce data on the etiologies and optimal management strategies for infection-related mortality in pediatric BL patients, especially in developing countries like Pakistan. Methods This is a cross-sectional study that included a total of 116 pediatric patients with intermediate-risk BL. All patients were treated based on the Children's Cancer and Leukaemia Group (CCLG) 2020 guidelines. Data on patient demographics, presenting symptoms, diagnosis, infectious etiologies, and outcomes were collected. Infection-related complications and mortality were monitored during the induction chemotherapy period. The results of relevant culture reports were tabulated and data were analyzed. Results Among the 116 included patients, 61.1% were males with a mean age of 4.83 ± 2.12 years. Abdominal BL was the most common anatomical location. During the induction period, 66 patients (56.9%) had culture-proven infections, resulting in 33 deaths (28.4%). Fever was the predominant presenting symptom in all patients, followed by vomiting (57.6%), loose stools (42.4%), and cough (18.2%). Neutropenic colitis, sepsis, pneumonia, and meningitis were among the diagnosed infections. Hospital-acquired bacterial infections, including multi-drug resistant gram-negative and gram-positive organisms, were the main cause of mortality, with fungal infections and cytomegalovirus viremia also identified in a few patients. Conclusions This study highlights the urgent need for improved management strategies in pediatric BL patients in Pakistan to reduce infection-related complications and mortality rates, emphasizing the importance of context-specific approaches for infection prevention and management.

Tibial Plasmablastic Lymphoma in a HIV-Negative Child: A Novel Extraoral Localisation

Plasmablastic lymphoma is an aggressive, high-grade non-Hodgkin lymphoma predominantly seen in HIV-infected individuals. Alongside a strong correlation with HIV, PBL can manifest in immunocompromised HIV-negative patients. A rare case of PBL in an immunocompetent and otherwise healthy child presented to Indus Hospital & Health Network (IHHN), Karachi, Pakistan. The patient had complaints of swelling and pain in the right leg and was referred from a city in Interior Sindh. Histopathological analysis revealed sheets and aggregates of neoplasm replacing bone marrow interspersed with sclerotic bony fragments. Large, monomorphic, multinucleated neoplastic cells containing abundant cytoplasm and scattered pleomorphic cells were also noted, leading to the diagnosis of tibial plasmablastic lymphoma. A FAB/LMB96 group C chemotherapy regimen for aggressive and high-risk cancer was administered with a marked improvement in clinical symptoms.

Childhood aggressive B-cell non-Hodgkin lymphoma in low-middle-income countries

In high-income countries (HICs) paediatric aggressive B-cell lymphomas are curable in about 90% of cases. Much worse results, with cure rates ranging from less than 30% to about 70%, are achieved in low- and middle-income countries (LMICs), where 90% of paediatric non-Hodgkin lymphomas occur. Low socio-economic and cultural conditions, the lack of optimal diagnostic procedures, laboratory facilities and adequate supportive care exert a strong negative impact on compliance, treatment delivery, toxicity and, consequently, on the clinical outcome. Published data are scarce, generally originating from single institutions, and are difficult to compare. National and international cooperation projects have been undertaken to reduce the unacceptable gap between HICs and LMICs in the management of children with cancer, by promoting the sharing of knowledge and by implementing adequate local healthcare facilities, with initial promising results. In the present review, we will summarize the results so far obtained in the management of paediatric aggressive B-cell NHL in LMICs.

RS, Janarthinakani M, Prasad K, Patil C, Anoop P, Reddy N, Anumula SK, Roopa SP, Golamari KR, Danthala M, Malipatil B, Rangarajan B, Udupa KS, Nandennavar M, Niraimathi K. Role of Interim PET Scan after 2 Cycles of ABVD in Pediatric Hodgkin Lymphoma: Retrospective Multicenter Study from South India

Introduction Most Indian centers use Adriamycin/Bleomycin/Vinblastine/Dacarba-zine (ABVD) chemotherapy for pediatric Hodgkin lymphoma (pHL). To reduce the late toxicity, robust predictive markers are needed to risk stratify pHL patients, thereby limiting the number of chemotherapy cycles and omitting radiation for low-risk and intensifying treatment for high-risk children.

Objective This study was conducted to analyze the outcome of pHL patients treated with ABVD and various factors predicting the outcome.

Materials and Methods This retrospective study analyzed the outcome of 113 consecutive pHL children treated with ABVD chemotherapy from 11 tertiary care centers in South India from 2009 to 2019.

Results The median duration of follow-up was 2.73 years. The median age was 13 years. B symptoms are seen in 50.5% patients, bulky disease in 23%, and stage IV in 28.3%. Of 113 pHL, 69% had a positron emission tomography (PET) and 31% had computed tomography (CT)-based staging. Stage IV (37.1%) and extranodal involvement (31.2%) were seen more often with PET than with CT staging (8.5 and 2.8%, respectively). Among 64 patients with interim PET scan after two cycles (iPET2), 20.3% did not achieve complete remission (CR) and no factors were significantly associated. The 4-year event-free survival (EFS) rate of the entire cohort was 86%. The 4-year EFS rate was 93% for patients with CR in iPET2 and 52% for patients not achieving CR. The only independent predictor of low EFS was iPET2 response (p < 0.05).

Conclusion Our study confirms the prognostic role of PET scan staging and response assessment. Not achieving CR on the iPET2 scan indicates poor prognosis and warrants clinical trial enrollment for a better outcome.

Clinical profile and outcomes of Non-Hodgkin's lymphoma in children: A report from a tertiary care hospital from India

Background: Non-Hodgkin's lymphoma (NHL) is an aggressive malignancy. Its outcome has improved over the past decades. Although it accounts for 8%–10% of all childhood cancers, very less information about its clinical presentation and outcomes is available from India. Our objective was to study the clinical presentation and outcomes in children (<15 years) with NHL at our center. Methodology: We retrospectively analyzed 26 children diagnosed with NHL at our center from August 2008 to June 2014 and followed them up to May 2017. Results: The median age at the time of diagnosis was 7.7 years (2.5–13 years). Abdominal distension and an abdominal lump were the most common presenting features occurring in 75%, followed by fever (73.8%) and weight loss (46.2%). Most patients had advanced-stage (Stage III/IV, 92.3%) disease at presentation. The primary presentation was extranodal in 57.7%, nodal in 26.9%, and combined in 15.4%. Burkitt's lymphoma (BL) was the most common subtype (46.2%), followed by T-lymphoblastic lymphoma, diffuse large B-cell lymphoma, and anaplastic large-cell lymphoma. Three patients did not take treatment. The median follow-up of patients was 48 months (36–99 months). Nineteen patients achieved remission and four had progressive disease. Significantly better event-free survival (EFS) was found with younger age and lower stage of presentation. The EFS did not significantly differ with sex, group of disease, lactate dehydrogenase levels, and presenting features. Conclusions: Our cohort of patients with NHL showed characteristics similar to those reported from other developing countries. NHL occurred at a younger age, with a higher incidence of BL. The outcome for patients aged >10 years was poor. The outcome of NHL was comparable to that of other centers in the world.

Malnutrition, Sepsis, and Tumor Lysis Syndrome Are Associated with Increased Rate of Acute Mortality in Mature B Cell Non-Hodgkin Lymphoma in a Pediatric Population-Study from Tertiary Care Hospital in Pakistan

Background

Outcomes of pediatric mature B cell non-Hodgkin's lymphoma in resource-challenged countries are negatively affected by an increased rate of early and toxic deaths. Aim of this study is to assess the rate of acute mortality and define significant risk factors present in children with mature B cell non-Hodgkin's lymphoma.

Methods

A retrospective analysis was done of patients with B cell non-Hodgkin's lymphoma from January 2012 till December 2016. Risk factors studied for acute mortality were malnutrition, stage, prior surgery with open laparotomy, lactate dehydrogenase levels, tumor lysis syndrome, sepsis, and fungal infection.

Results

A total of 233 patients were enrolled in the study. Eighty-five (36.4%) were below 15^th percentile weight for age. Treatment was started in 226 patients. Eighty-eight percent of children showed a 20% response after COP pre-phase. Tumor lysis syndrome was developed in 20.6% (n = 48) children and 42.9% (n = 100) patients had sepsis, 71/100 patients had culture-proven sepsis. 19.7% (n = 46) patients developed fungal infection. There was 19.7% (n = 46) acute mortality. The most common cause of death was sepsis (n = 22, 47.8%) followed by acute renal failure secondary to tumor lysis syndrome. On multivariate analysis, three independent variables found significant for early death are malnutrition, sepsis, and tumor lysis syndrome.

Conclusion

Rate of acute mortality in mature B cell NHL is high in our set up and significant risk factors are tumor lysis syndrome, sepsis, and malnourishment at the time of presentation.

Overview and outcome of Hodgkin's Lymphoma: Experience of a single developing country's oncology centre

Hodgkin's Lymphoma (HL) reveals variable epidemiological and clinico-pathological features in different geographical locations. In this retrospective study, we aimed to assess the epidemiological and clinic-pathological features, and outcome of HL patients treated at one hemato-oncology centre in Erbil, northern Iraq. Medical records of 103 HL patients treated over more than six years were reviewed. Treatment outcome was evaluated by measuring the 5-year overall and progression-free survival rates. The median age of patients was 23 years, children up to 17 years constituted 31.1%, and male to female ratio was 1:1.05. The majority (96.1%) of patients presented with lymphadenopathy. Nodular sclerosis subtype was the mostly encountered histologic type (48.5%); about half of the patients (49.5%) had stage II disease. Relapse occurred in 20 patients; the 5-year overall survival for children was better (89%) compared to adult patients (79%). The associated risk features found to have adverse effects on the survival, however, only high LDH level and presence of B-symptoms at presentation showed significant correlation. The epidemiological and clinical characteristics of HL in our locality followed the pattern in the western world. The 5-year overall and progression-free survivals were far below the international rates, a matter which may necessitate a revision to HL treatment strategy at our centre.

Risk-adapted stratification for optimally intensive treatment assignment of pediatric patients with non-Hodgkin lymphoma is an effective strategy in developing countries

BACKGROUND

Pediatric patients with non-Hodgkin lymphoma (NHL) in developing countries (DCs) present with greater tumor load even at lower stages and with comorbidities that impact therapy delivery. This causes toxic mortality with "standard" intensive protocols or recurrences with "gentler" treatment.

OBJECTIVES

We developed and evaluated a risk stratification schema that guides intensity of therapy.

DESIGN/METHODS

Sixty-nine patients were prospectively assigned to five risk groups (A-E; n = 6, 15, 16, 15, and 17) following staging and treated with protocols of risk-stratified intensity. Risk stratification utilized St. Jude stage, disease bulk, and sites involved.

RESULTS

Between 2006 and 2011, 69 patients with B-cell NHL were enrolled. Among these, 72.5% were boys with mean age of 6.9 years (±3.33 [SD]; range 2.4-14.2 years). Eighty-seven percent had Burkitt lymphoma, 82.6% had advanced stage (25 [36.2%] stage III; 32 [46.4%] stage IV), and 24.6% were central nervous system positive. Mean lactate dehydrogenase increased progressively across the risk strata. Among these, 0/6, 1/15, 3/16, 2/15, and 7/17 patients relapsed/progressed within each risk stratum. Fifteen patients died; three from treatment-related toxicity. At a median follow-up of 6.2 years, the overall and event-free survival (EFS) for all patients was 78.1 and 75.4%, respectively; EFS was related to risk assignment. The frequency of documented infectious and noninfectious toxicities increased with higher risk group assignment causing prolongation of admissions and potential treatment delays.

CONCLUSIONS

Reduction in treatment intensity for an identified subset of patients with NHL is feasible, while high-intensity therapy is required for high-risk groups. This risk stratification system may be a first step toward improving the outcomes in some DCs.

Determinants of Treatment Abandonment in Childhood Cancer: Results from a Global Survey

BACKGROUND

Understanding and addressing treatment abandonment (TxA) is crucial for bridging the pediatric cancer survival gap between high-income (HIC) and low-and middle-income countries (LMC). In childhood cancer, TxA is defined as failure to start or complete curative cancer therapy and known to be a complex phenomenon. With rising interest on causes and consequences of TxA in LMC, this study aimed to establish the lay-of-the-land regarding determinants of TxA globally, perform and promote comparative research, and raise awareness on this subject.

METHODS

Physicians (medical oncologists, surgeons, and radiation therapists), nurses, social workers, and psychologists involved in care of children with cancer were approached through an online survey February-May 2012. Queries addressed social, economic, and treatment-related determinants of TxA. Free-text comments were collected. Descriptive and qualitative analyses were performed. Appraisal of overall frequency, burden, and predictors of TxA has been reported separately.

RESULTS

581 responses from 101 countries were obtained (contact rate = 26%, cooperation rate = 70%). Most respondents were physicians (86%), practicing pediatric hematology/oncology (86%) for >10 years (54%). Providers from LMC considered social/economic factors (families' low socioeconomic status, low education, and long travel time), as most influential in increasing risk of TxA. Treatment-related considerations such as preference for complementary and alternative medicine and concerns about treatment adverse effects and toxicity, were perceived to play an important role in both LMC and HIC. Perceived prognosis seemed to mediate the role of other determinants such as diagnosis and treatment phase on TxA risk. For example, high-risk of TxA was most frequently reported when prognosis clearly worsened (i.e. lack of response to therapy, relapse), or conversely when the patient appeared improved (i.e. induction completed, mass removed), as well as before aggressive/mutilating surgery. Provider responses allowed development of an expanded conceptual model of determinants of TxA; one which illustrates established and emerging individual, family, center, and context specific factors to be considered in order to tackle this problem. Emerging factors included vulnerability, family dynamics, perceptions, center capacity, public awareness, and governmental healthcare financing, among others.

CONCLUSION

TxA is a complex and multifactorial phenomenon. With increased recognition of the role of TxA on global pediatric cancer outcomes, factors beyond social/economic status and beliefs have emerged. Our results provide insights regarding the role of established determinants of TxA in different geographical and economic contexts, allow probing of key determinants by deliberating their mechanisms, and allow building an expanded conceptual model of established and emerging determinants TxA.

ABVD-Based Therapy for Hodgkin Lymphoma in Children and Adolescents: Lessons Learnt in a Tertiary Care Oncology Center in a Developing Country

BACKGROUND

As Hodgkin lymphoma (HL) is a highly curable malignancy, most current pediatric trials focus on strategies aimed at reducing late effects of therapy. We report our results with doxorubicin, bleomycin, vinblastine, dacarbazine (ABVD) therapy.

PROCEDURE

We retrospectively analyzed 17 years (1996-2013) data of patients ≤18 years of age with HL. All patients received ABVD chemotherapy and involved field radiotherapy (IFRT) was reserved for those with bulky disease or partial response. The analysis was carried out to assess overall survival (OS) and freedom from treatment failure (FFTF) and factors predicting the events.

RESULTS

Of 167 eligible patients, 72 (43.1%) had B symptoms, 28 (16.7%) had bulky disease, 31 (18.6%) had >4 lymph node regions, and 53 (31.8%) had advanced disease (stages III and IV). In all, 87% patients received six cycles of ABVD and IFRT was administered to 51 (30.5%) patients. The 5-year OS and FFTF were 95.9% and 79%, respectively, and were similar in patients treated with or without IFRT. On multivariable analysis, advanced disease (stages III and IV), involvement of >4 lymph node regions, and serum lactate dehydrogenase (LDH) ≥500 IU/l at diagnosis were statistically significant factors for FFTF (P = 0.03, 0.003, 0.048, respectively).

CONCLUSIONS

The excellent survival of HL patients in the setting of a developing country reported in this retrospective analysis warrants treatment reduction, especially for early-stage patients. The use of risk- and response-based stratification incorporating disease stage, involved lymph node regions, and serum LDH, along with fluorodeoxyglucose-positron emission tomography-based response, may guide development of effective and less toxic protocols.

Burkitt lymphoma: epidemiological features and survival in a South African centre

BACKGROUND

The epidemiology of Burkitt Lymphoma (BL) shows that the endemic type is mainly confined to equatorial Africa and has a very close association with the Epstein-Barr virus (EBV), while the sporadic variant shows only a 20% association with EBV and is seen mainly in Europe and North America. An immunodeficent form of BL has been described more recently. This study aimed to describe the epidemiological characteristics and survival of children presenting with BL to Tygerberg Hospital, Cape Town, in South Africa.

METHODS

A retrospective, descriptive study reviewed all pediatric cases of Burkitt lymphoma at Tygerberg Hospital Oncology Unit between 1 January 1995 and 31 December 2010. The following data were analysed: age at diagnosis, gender, anatomic site, race, socio-economic demographic (rural vs. urban), treatment protocol, side effects, viral characteristics and survival. All cases were confirmed by histology and reviewed by a tumour board.

RESULTS

A total of 51 patients with Burkitt lymphoma were analysed from 1995 to 2010. Their age ranged from 2 to 14 years (mean of 6.8 years).The male to female ratio was 3.6/1. Most of the patients lived in an urban setting (52.9%). The initial presenting tumour site was abdominal in most cases (76.4%). The majority of patients (90%) were treated with the LMB protocol. Neutropenic sepsis, mucositis and gastroenteritis were the top 3 side effects while receiving therapy (58.8%, 50.9% and 31.3% respectively). The overall survival rate was 64.7%. A documented positive HIV1 test was found in 11% of the total number of patients. The stage of the disease at the time of presentation strongly influenced the outcome with only 41.6% of stage 4 patients surviving (p = 0.03).

CONCLUSIONS

The patients seen at Tygerberg Hospital, South Africa presented typically with the sporadic variant of Burkitt Lymphoma. The patients presented with large abdominal masses and in an advanced stage of the disease.

Hodgkin lymphoma in children: experience in a tertiary care centre in India

BACKGROUND

In developing countries Hodgkin lymphoma (HL) has been seen to have a high male to female ratio, younger age at presentation, a high proportion of patients in advanced stage of disease, constitutional symptoms, and predominance of mixed cellularity histologic type. The results of treatment appear to be comparable to the results attained in developed nations.

METHODS

Children with HL who were diagnosed and treated at our center between 1990 and 2006 were retrospectively analyzed.

RESULTS

A total of 206 children with a mean age of 7.9±2.6 (range, 3 to 16) years were treated for HL. Among them, 52% presented with advanced-stage (stages III and IV) disease, 54% had B symptoms, and 69.6% had mixed cellularity type of HL. Multiagent chemotherapy was the mainstay of treatment. The 5-year overall survival and event-free survival rates were 92.7% and 77.75%, respectively. Children with early-stage disease and absence of B symptoms had a better overall survival of 97.7% each, as compared with 87.2% and 88.2% in those with late-stage disease and B symptoms, respectively.

CONCLUSIONS

Even though developing countries have a different epidemiological profile, the outcome is good. Chemotherapy alone has shown excellent results in children with HL.

Paediatric lymphoma in China: a clinicopathological study of 213 cases

AIM

This retrospective study was conducted to evaluate information on paediatric lymphoma in China.

METHODS

We reviewed the pathological files of patients less than 12 years of age with lymphoma in Shanghai Xinhua Hospital from January 1982 to June 2009. SPSS version 11.0 was used to analyse the results.

RESULTS

Of the 213 subjects, 176 (82.6%) had non-Hodgkin's lymphoma (NHL) and 37 (17.4%) had Hodgkin's lymphoma (HL). All NHL cases had diffuse and high grade tumours, and 33.5% of these tumours primarily involved extra-nodal sites. Of the NHL cases, 56.6%, 43.3%, and 1.7% were derived from T, B, and null cells, respectively. Lymphoblastic lymphoma (LL, 50.6%), Burkitt's lymphoma (BL, 28.4%), and anaplastic large cell lymphoma (ALCL, 12.5%) comprised the majority of the NHL cases. A significant difference was found in the frequency of stage I/II cases between LL and ALCL. Paediatric HL resembled the disease in adults.

CONCLUSIONS

Paediatric lymphoma in China is different from that in Western countries with respect to the incidence rate of HL and BL. The distribution pattern of NHL histological subtypes is more similar to that in Japan than that in Pakistan. These features suggest ethnic or geographic variations.

Pediatric non-Hodgkin lymphoma: a retrospective 14-year experience with Berlin-Frankfurt-Münster (BFM) protocols from a tertiary care hospital in Serbia

Use of current intensive chemotherapy protocols in pediatric non-Hodgkin lymphoma (NHL) in high-income countries resulted in event-free survival (EFS) rates ranging from 80 to 90%. The results are inferior in less privileged countries with limited resources for medical care. There are no reports about comprehensive data analysis in pediatric NHL in Serbia. A retrospective study was carried out at University Children's Hospital, Belgrade, in children aged less than 18 years diagnosed with non-Hodgkin lymphoma from 1997 to 2011. Fifty-seven children were eligible for analysis. Fourteen were diagnosed with lymphoblastic lymphoma, 38 with mature B-cell NHL (B-NHL), and 5 with anaplastic large-cell lymphoma. Mean age at diagnosis was 9.2 years, with male to female ratio 2.35:1. Children were treated according to Berlin-Frankfurt-Münster (BFM) protocols. With median follow-up of 59.3 months, 5-year probability of EFS was 84.1% for all patients, whereas overall survival was 93%. These results with BFM protocol administration, although inferior to leading international groups, reflect good treatment outcome in our patients. To the best of the authors' knowledge, this article presents the first results regarding treatment and survival of childhood NHL in Serbia.