Sepsis is a major barrier to improving survival in childhood acute lymphoblastic leukemia in the developing world

Clinical Profile of Pediatric Oncology Patients Treated by External Beam Radiotherapy: An Institutional Experience

Introduction:

Pediatric tumors are a heterogeneous group of malignant conditions requiring multimodal treatment, and management of such cases is at time challenging. We present the clinical profile of pediatric cancer patients who received radiation, either alone or as adjuvant to surgery and chemotherapy; in prophylactic, radical or palliative clinical setting.

Aim:

This study was envisaged to review our experience of pediatric oncology cases, their clinical and morphological profile, dosage schedule of radiotherapy, and the therapy induced complications.

Settings and Design:

This was a retrospective, observational study carried out in an apex tertiary care cancer institute of government set-up in a developing country.

Materials and Methods:

The treatment charts and clinical summary of patients who had received radiation over the last 5 years period were retrieved and perused. Various clinical and pathological parameters were studied and inferences drawn.

Results:

A total of 50 patients got radiation over 5 year study-period, including 37 male and 13 female patients. The commonest age group of presentation was 8-12 years followed by 13-16 years. The mean age of presentation was 9.3 years. The most common diagnosis was hematological malignancies followed by CNS tumors with 21 and 13 patients respectively. Overall the most common indication of RT was in adjuvant setting after surgery as the definitive management, where 24 patients were irradiated; and the next common indication was prophylactic cranial irradiation in 14 patients of childhood leukemias. 10 patients tolerated treatment with Grade 1 site-specific or systemic toxicities while 7 patients developed Grade 2 and more systemic toxicities. 9 patients received craniospinal irradiation, common indications being medulloblastoma and Atypical teratoma rhabdoid tumor (ATRT). 3 patients received concurrent chemotherapy with weekly Inj Vincristine. 17 patients required sedation or short general anaesthesia for radiation planning and execution.

Conclusion:

External beam Radiotherapy constitutes an important component of management of pediatric cancers. One should be judicious in Radiotherapy planning, execution and monitoring acute and delayed toxicities.

Sevelamer is an Effective Drug in Treating Hyperphosphatemia Due to Tumor Lysis Syndrome in Children: A Developing World Experience

We report here a study on efficacy of sevelamer hydrochloride in treating hyperphosphatemia due to tumor lysis syndrome (TLS) in a developing world setting. Twenty one children with hyperphosphatemia due to TLS were included. All received hyper-hydration, allopurinol and sevelamer. Efficacy was assessed by decrease in serum phosphate level, calcium-phosphate product and TLS score as per Cairo Bishop definition. Four children who underwent dialysis were excluded from analysis. Among the remaining 17 patients with hyperphosphatemia, laboratory TLS was recorded in 15 patients and clinical TLS in five. Sevelamer was given according to weight, most often 400 mg twice to thrice daily. Mean phosphatemia decreased from 8.3 ± 3.0 to 6.7 ± 2.1 mg/dl within 24 h of starting sevelamer (p = 0.02), 6.0 ± 2.1 mg/dl at 48 h, 4.9 ± 1.5 mg/dl at 72 h and 4.39 ± 1.7 mg/dl at 96 h. TLS was corrected in 72 h in 14 patients, 96 h in 1 and 120 h in another patient. Mean calcium-phosphate product decreased from 63.0 ± 14.0 to 49.2 ± 9.7 mg/dl (p = 0.002) at 24 h, 46.1 ± 17.0 mg/dl at 48 h and 39.7 ± 13.5 mg/dl at 72 h. There was no mortality due to hyperphosphatemia. Sevelamer is efficacious in children with malignancy-associated hyperphosphatemia in the developing world.

Barriers to cure for children with cancer in India and strategies to improve outcomes: a report by the Indian Pediatric Hematology Oncology Group

The survival of children with cancer in India is inferior to that of children in high-income countries. The Indian Pediatric Hematology Oncology Group (IPHOG) held a series of online meetings via www.Cure4kids.org to identify barriers to cure and develop strategies to improve outcomes. Five major hurdles were identified: delayed diagnosis, abandonment, sepsis, lack of co-operative groups, and relapse. Development of regional networks like IPHOG has allowed rapid identification of local causes of treatment failure for children with cancer in India and identification of strategies likely to improve care and outcomes in the participating centers. Next steps will include interventions to raise community awareness of childhood cancer, promote early diagnosis and referral, and reduce abandonment and toxic death at each center. Starting of fellowship programs in pediatric hemato-oncology, short training programs for pediatricians, publishing outcome data, formation of parent and patient support groups, choosing the right and effective treatment protocol, and setting up of bone marrow transplant services are some of the effective steps taken in the last decade, which needs to be supported further.

Outcome of pediatric acquired aplastic anemia: a developing world experience

INTRODUCTION

Outcome data of children with acquired aplastic anemia (AA) are lacking from the developing world. Here, we describe the same from a centre in North India.

METHODS

Retrospective data regarding medical history, physical examination, complete blood count, bone marrow aspirate, and biopsy were retrieved for all children <18 years, with acquired AA admitted between January 2005 and June 2012. In addition, the outcome data after immunosuppressive therapy (IST) or bone marrow transplant (BMT) was obtained.

RESULTS

A total of 61 children were diagnosed with AA (Inherited-18 and acquired-43). Among 43 children with acquired AA, 3 had nonsevere and 40 had severe. One patient with nonsevere AA died of sepsis and 2 recovered spontaneously. Of the 40 remaining children with severe AA, 10 refused therapy and 3 died due to severe sepsis prior to any therapy. Five underwent upfront matched sibling donor BMT and one post-IST failure. Four year overall survival (OS) and event free survival (EFS) for children undergoing BMT was 100% and 80 ± 17.9, respectively. Out of 22 treated with IST, 20 were evaluable for response. Seventeen received one course and 3 received two course of IST. The overall response to IST was seen in 14/20 (70%). Only two achieved complete response while remaining 12 had partial response. The 4-year estimated OS and EFS for children treated with IST was 74.4 ± 12.1% and 65.6 ± 12.2.

CONCLUSION

Outcomes for children with AA are encouraging in the developing world although barriers like sepsis and treatment abandonment remain. BMT offers faster and complete recovery.

Antioxidant levels at diagnosis in childhood acute lymphoblastic leukemia

OBJECTIVE

To measure serum zinc, selenium, retinol and tocoferol levels at diagnosis of pediatric acute lymphoblastic leukemia (ALL) and to compare it to that of a control population. Correlation was made with episodes of febrile neutropenia during the first 8 wk of therapy.

METHODS

Fasting levels of serum zinc, selenium, retinol and tocoferol were measured in 45 children diagnosed with acute lymphoblastic leukemia and in 20 healthy controls.

RESULTS

Lower levels of baseline selenium and tocoferol were noted in patients who developed febrile neutropenia compared to the patients who did not (p = 0.022 and 0.026 respectively). Serum retinol was also lower in patients who developed sepsis when compared to those who did not.

CONCLUSIONS

Supplementation of antioxidants may be considered in clinical trials aiming at reducing infection related morbidity and mortality.