1
|
Balta B, Gebreyohannis T, Tachbele E. Survival and predictors of mortality among acute leukemia patients on follow-up in Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia: A 5-year retrospective cohort study. Cancer Rep (Hoboken) 2023; 6:e1890. [PMID: 37783566 PMCID: PMC10598244 DOI: 10.1002/cnr2.1890] [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: 02/28/2023] [Revised: 07/04/2023] [Accepted: 07/28/2023] [Indexed: 10/04/2023] Open
Abstract
BACKGROUND Although Ethiopia has more than 78% of leukemia cases and a significant burden of the disease, the survival of leukemia patients in the country is poorly recognized. The purpose of this study was to assess the survival and predictors of acute leukemia patients. METHODS A 5-year retrospective cohort study was conducted including all acute Leukemia patients who visited Tikur Anbessa Specialized Hospital between January 2015 and December 2019. Data were retrieved from patient's medical records between March and April 2020. Using SPSS version 25, the Kaplan-Meier curve and Cox regression models were employed to analyze the data. RESULTS A total of 119 patients with acute leukemia were retrospectively evaluated for 60 months, having 196 person-years of risk. About 46 deaths (38.7%) were recorded over the follow-up period, giving a mortality incidence rate of 23.5 (95% CL:18-52) per 100 person-years. The median survival time was 35 months (95% CI, 28.3-41.7). At 60 months of follow-up, the predicted overall survival rate after diagnosis for acute leukemia was 21%. The adjusted hazard ratio for acute leukemia subtypes (aHR:4.9, 95% CI:2.3-10.4), history of relapse (aHR:3.9, 95% CI:1.0-7.9), participant age (aHR:1.25, 95% CI:1-1.75), hepatomegaly (aHR:2.7, 95% CI:1.36-5.36), and splenomegaly (aHR:2.29, 95% CI:1.2-4.4). CONCLUSION The 5-year overall survival rate was found to be 21%. The finding was remarkably lower than other published reports. Survival among acute leukemia patients was significantly associated with older age, history of relapse, hepatomegaly, splenomegaly, as well as certain subtypes. Therefore, improving early detection and initiation of treatment for all acute leukemia patients is necessary in order to improve patient's survival status.
Collapse
Affiliation(s)
- Bargude Balta
- Department of NursingHawassa University Comprehensive Specialized HospitalHawassaEthiopia
| | | | - Erdaw Tachbele
- College of Health SciencesAddis Ababa UniversityAddis AbabaEthiopia
| |
Collapse
|
2
|
Sharma Poudyal B, Paudel B, Tuladhar S, Neupane S, Bhattarai K, Joshi U. Outcome of ALL With ALL-BFM-95 Protocol in Nepal. JCO Glob Oncol 2023; 9:e2200408. [PMID: 37428991 PMCID: PMC10581644 DOI: 10.1200/go.22.00408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 04/13/2023] [Accepted: 05/24/2023] [Indexed: 07/12/2023] Open
Abstract
PURPOSE Data on survival outcomes in patients with acute lymphoblastic leukemia (ALL) originating from Nepal are limited. We aim to present the real-world data on treatment outcomes of patients with de novo ALL treated with pediatric ALL-Berlin-Frankfurt-Muenster (BFM)-95 protocol in Nepal. PATIENTS AND METHODS We used the medical records of 103 consecutive patients with ALL treated in our center from 2013 to 2016 to evaluate the overall survival (OS) and relapse-free survival (RFS) and analyzed the effects of clinicopathologic factors on survival outcomes in patients with ALL. RESULTS The 3-year OS and RFS in the entire cohort was 89.4% (95% CI, 82.1 to 96.7) and 87.3% (95% CI, 79.8 to 94.7), with a mean OS and RFS of 79.4 months (95% CI, 74.2 to 84.5) and 76.6 months (95% CI, 70.8 to 82.4), respectively. Patients with prednisone good response (PGR) showed better mean OS and RFS, whereas complete marrow response on day 33 was associated with better mean OS alone. Patients with Philadelphia (Ph)-positive ALL showed worse mean RFS compared to those with Ph-negative status. On multivariate analysis, PGR (hazard ratio [HR], 0.11; 95% CI, 0.03 to 0.49; P = .004) and sagittal vein thrombosis (SVT; HR, 5.95; 95% CI, 1.30 to 27.18; P = .02) were the only independent predictors of OS and RFS, respectively. Adverse events on BFM-95 protocol included SVT (4.9%), peripheral neuropathy (7.8%), myopathy (20.4%), hyperglycemia (24.3%), intestinal obstruction (7.8%), avascular necrosis of femur (6.8%), and mucositis (46%). CONCLUSION BFM-95 protocol appears to be a safe and effective strategy in adolescent and young adults and adult Nepalese population with ALL with a low toxicity profile.
Collapse
Affiliation(s)
- Bishesh Sharma Poudyal
- Clinical Hematology and Bone Marrow Transplant Unit, Civil Service Hospital, Kathmandu, Nepal
| | - Bishal Paudel
- Clinical Hematology and Bone Marrow Transplant Unit, Civil Service Hospital, Kathmandu, Nepal
| | | | - Samir Neupane
- Department of Pathology, Civil Service Hospital, Kathmandu, Nepal
| | - Kushal Bhattarai
- Department of Biochemistry, Karnali Academy of Health Sciences, Jumla, Nepal
| | - Utsav Joshi
- Department of Internal Medicine, Rochester General Hospital, New York, NY
| |
Collapse
|
3
|
Falahati V, Ghaffari K, Kouhfar A, Ghasemi A, Gholami M, Arjmand A. A retrospective cytogenetic abnormality in pediatric acute lymphoblastic leukemia: Report of 11 years. Adv Biomed Res 2022; 11:81. [DOI: 10.4103/abr.abr_103_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 05/22/2021] [Accepted: 06/01/2021] [Indexed: 11/04/2022] Open
|
4
|
Outcomes and prognostic factors in adolescents and young adults with ALL treated with a modified BFM-90 protocol. Blood Adv 2021; 5:1178-1193. [PMID: 33635331 DOI: 10.1182/bloodadvances.2020003526] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 12/07/2020] [Indexed: 02/07/2023] Open
Abstract
The use of pediatrics-inspired protocols in adolescent and young adult (AYA) acute lymphoblastic leukemia (ALL) results in superior survival compared with the adult protocols. Pediatrics-inspired protocols carry an increased risk of toxicity and treatment-related mortality in low resource settings, which can offset the potential benefits. We studied the outcomes and prognostic factors in the treatment of AYA ALL with a pediatrics-inspired regimen. We retrieved data regarding demographics, investigations, treatment details, and toxicities from the electronic medical records of patients diagnosed with ALL in the 15- to 25-year-old age group who were initiated on a modified Berlin-Frankfurt-Münster 90 (BFM-90) protocol between January 2013 and December 2016 at the Tata Memorial Centre. A total of 349 patients in the 15- to 25-year-old age group were treated with a modified BFM-90 protocol. The use of this pediatrics-inspired protocol resulted in a 3-year event-free survival (EFS) and overall survival (OS) of 59.4% and 61.8%, respectively. Only 15 patients underwent an allogeneic stem cell transplant. Minimal residual disease (MRD) persistence postinduction emerged as the only factor predictive of poor outcomes. A modified BFM-90 protocol is an effective and safe regimen for AYA ALL with an OS and EFS comparable to the published literature.
Collapse
|
5
|
Jabbour E, Kantarjian H. The Hyper-CVAD Regimen is an Optimal Pediatric-inspired Regimen for Adolescents and Adults With Acute Lymphoblastic Leukemia. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2021; 21:63-65. [PMID: 33191168 DOI: 10.1016/j.clml.2020.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
|
6
|
Chennamaneni R, Gundeti S, Konatam ML, Bala S, Kumar A, Srinivas L. Impact of cytogenetics on outcomes in pediatric acute lymphoblastic leukemia. South Asian J Cancer 2020; 7:263-266. [PMID: 30430098 PMCID: PMC6190389 DOI: 10.4103/sajc.sajc_13_18] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Context: In acute lymphoblastic leukemia (ALL), the most important prognostic factors are age, leukocyte count at presentation, immunophenotype, and cytogenetic abnormalities. The cytogenetic abnormalities are associated with distinct immunologic phenotypes of ALL and characteristic outcomes. Aims: The present study was primarily aimed at analyzing the impact of cytogenetics on postinduction responses and event-free survival (EFS) in pediatric patients with ALL. The secondary objective was to study the overall survival (OS). Subjects and Methods: A total of 240 patients with age <18 years and diagnosed with ALL between January 2011 and June 2016 were retrospectively analyzed. Cytogenetics was evaluated with conventional karyotyping or reverse transcriptase polymerase chain reaction. Based on cytogenetic abnormalities, the patients were grouped into five categories, and the outcomes were analyzed. Results: Of the 240 patients, 125 (52%) patients had evaluable cytogenetics. Of these, 77 (61.6%) patients had normal cytogenetics, 19 (15.2%) had t(9;22) translocation, 10 (8%) had unfavorable cytogenetics which included t(9;11), hypodiploidy, and complex karyotype, 10 (8%) had favorable cytogenetics which included t(12;21), t(1;19), and high hyperdiploidy, 9 (7.2%) had miscellaneous cytogenetics. Seventy-one percent of patients were treated with MCP 841 protocol, while 29% of patients received BFM-ALL 95 protocol. The 3-year EFS and OS of the entire group were 52% and 58%, respectively. On univariate analysis, EFS and OS were significantly lower in t(9;22) compared to normal cytogenetics (P = 0.033 and P = 0.0253, respectively) and were not significant for other subgroups compared to normal cytogenetics. On multivariate analysis, EFS was significantly lower for t(9;22) and unfavorable subgroups. Conclusions: Cytogenetics plays an important role in the molecular characterization of ALL defining the prognostic subgroups. Patients with unfavorable cytogenetics and with t(9;22) have poorer outcomes.
Collapse
Affiliation(s)
- Rachana Chennamaneni
- Department of Medical Oncology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Sadashivudu Gundeti
- Department of Medical Oncology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Meher Lakshmi Konatam
- Department of Medical Oncology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Stalin Bala
- Department of Medical Oncology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Ashok Kumar
- Department of Medical Oncology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Lakshmi Srinivas
- Department of Medical Oncology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| |
Collapse
|
7
|
Lashkari HP, Faheem M, Sridevi Hanaganahalli B, Bhat KG, Joshi J, Kamath N, Ahlawat S, B P. Resource limited centres can deliver treatment for children with acute lymphoblastic leukaemia with risk-stratified minimal residual disease based UKALL 2003 protocol with no modification and a good outcome. Expert Rev Hematol 2020; 13:1143-1151. [PMID: 32870048 DOI: 10.1080/17474086.2020.1813563] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Acute Lymphoblastic Leukemia (ALL) is the most common malignancy in children. With improved supportive care and a better understanding of the disease biology, it is now a curable cancer in the developed world. However, in low-income countries, the cure rate remains relatively poor. We report our experience on the survival of children with ALL treated on the MRD-based risk-stratified UKALL 2003 protocol, from a center in South India. METHODS All consecutive children diagnosed with ALL between years 2013 and 2019 were included in this retrospective study. All received uniform treatment as per the UKALL 2003 protocol based on NCI risk and post-induction MRD status. All the details including the type of leukemia, NCI risk status, date of diagnosis, treatment start date, the regimen, MRD status, cytogenetics, molecular genetics, and complications were captured. Analysis was done using prism GraphPad version 8.0. RESULTS A total of 107 children were started on treatment during this period. The majority of them were boys (68/107). Fifty-nine of them were NCI standard risk (55%). B-ALL was the most common type (92%).Total of 56/107(52.3%) children received treatment under the government's insurance scheme for low-income bracket. The post-induction MRD was performed in 95/107 children. It was >0.01% in 22% (21/95) of children. Five (4.7%) children relapsed so far with a mean follow up of 27 months from the diagnosis. There were 17 deaths (15.9%). The EFS at 3 years was 85% (95% CI 75% to 92%). CONCLUSION It is feasible to deliver chemotherapy as per the UKALL2003 protocol without any modifications in resource-limited setting. The survival rates have significantly improved over the years in our center from 5 years EFS of 60% in 2010 and now to 3 year EFS of 85%. It is important to note that there was no treatment abandonment in our cohort.
Collapse
Affiliation(s)
- Harsha Prasada Lashkari
- Department of Paediatrics, Kasturba Medical College , Mangalore, India.,Department of Paediatrics, Manipal Academy of Higher Education , Manipal, India
| | - Moideen Faheem
- Department of Paediatrics, Kasturba Medical College , Mangalore, India.,Department of Paediatrics, Manipal Academy of Higher Education , Manipal, India
| | - Basaviah Sridevi Hanaganahalli
- Department of Paediatrics, Kasturba Medical College , Mangalore, India.,Department of Paediatrics, Manipal Academy of Higher Education , Manipal, India
| | - Kamalakshi G Bhat
- Department of Paediatrics, Kasturba Medical College , Mangalore, India.,Department of Paediatrics, Manipal Academy of Higher Education , Manipal, India
| | - Jayatheerth Joshi
- Department of Paediatrics, Kasturba Medical College , Mangalore, India.,Department of Paediatrics, Manipal Academy of Higher Education , Manipal, India
| | - Nutan Kamath
- Department of Paediatrics, Kasturba Medical College , Mangalore, India.,Department of Paediatrics, Manipal Academy of Higher Education , Manipal, India
| | - Shivali Ahlawat
- Department of Paediatrics, Oncquest Laboratories , New Delhi, India
| | - Prashantha B
- Department of Paediatrics, Kasturba Medical College , Mangalore, India.,Department of Paediatrics, Manipal Academy of Higher Education , Manipal, India
| |
Collapse
|
8
|
Cardoso de Carvalho D, Pereira Colares Leitão L, Mello Junior FAR, Vieira Wanderley A, de Souza TP, Borges Andrade de Sá R, Cohen-Paes A, Rodrigues Fernandes M, Santos S, Salim Khayat A, Pimentel de Assumpção P, Pereira Carneiro dos Santos N. Association between the TPMT*3C (rs1142345) Polymorphism and the Risk of Death in the Treatment of Acute Lymphoblastic Leukemia in Children from the Brazilian Amazon Region. Genes (Basel) 2020; 11:genes11101132. [PMID: 32992962 PMCID: PMC7601477 DOI: 10.3390/genes11101132] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 09/11/2020] [Accepted: 09/18/2020] [Indexed: 12/21/2022] Open
Abstract
Acute lymphoblastic leukemia (ALL) is the leading cause of death from pediatric cancer worldwide. However, marked ethnic disparities are found in the treatment of childhood ALL with less effective results and higher mortality rates being obtained in populations with a high level of Native American ancestry. Genetic variations of the patient can affect resistance to ALL chemotherapy and potentially play an important role in this disparity. In the present study, we investigated the association of 16 genetic polymorphisms with the cell and metabolic pathways of the chemotherapeutic agents used in the treatment of ALL with the risk of death in treating childhood ALL in patients with a high contribution of Amerindian ancestry, coming from the Brazilian Amazon. The study included 121 patients with B-cell ALL treated with the BFM-2002 protocol. We are the first to identify the association between the TPMT gene rs1142345 polymorphism and the high risk of death in treating childhood ALL. Patients with the CC genotype had an approximately 25.5 times higher risk of dying during treatment of the disease than patients with other genotypes (p = 0.019). These results may help elucidate how the patient's genetic characteristics contribute to the mortality disparity in populations with a high contribution of Native American ancestry. The rs1142345 variant of the TPMT gene could be used as a potential marker to early stratify patients at high risk of death in treating childhood ALL in the investigated population.
Collapse
Affiliation(s)
- Darlen Cardoso de Carvalho
- Oncology Research Nucleus, Universidade Federal do Pará, Belém 66063-023, Brazil; (D.C.d.C.); (L.P.C.L.); (F.A.R.M.J.); (A.V.W.); (R.B.A.d.S.); (A.C.-P.); (M.R.F.); (S.S.); (A.S.K.); (P.P.d.A.)
| | - Luciana Pereira Colares Leitão
- Oncology Research Nucleus, Universidade Federal do Pará, Belém 66063-023, Brazil; (D.C.d.C.); (L.P.C.L.); (F.A.R.M.J.); (A.V.W.); (R.B.A.d.S.); (A.C.-P.); (M.R.F.); (S.S.); (A.S.K.); (P.P.d.A.)
| | - Fernando Augusto Rodrigues Mello Junior
- Oncology Research Nucleus, Universidade Federal do Pará, Belém 66063-023, Brazil; (D.C.d.C.); (L.P.C.L.); (F.A.R.M.J.); (A.V.W.); (R.B.A.d.S.); (A.C.-P.); (M.R.F.); (S.S.); (A.S.K.); (P.P.d.A.)
| | - Alayde Vieira Wanderley
- Oncology Research Nucleus, Universidade Federal do Pará, Belém 66063-023, Brazil; (D.C.d.C.); (L.P.C.L.); (F.A.R.M.J.); (A.V.W.); (R.B.A.d.S.); (A.C.-P.); (M.R.F.); (S.S.); (A.S.K.); (P.P.d.A.)
- Departamento de Pediatria, Ophir Loyola Hospital, Belém 66063-240, Brazil
| | - Tatiane Piedade de Souza
- Human and Medical Genetics Laboratory, Instituto de Ciências Biológicas, Universidade Federal do Pará, Belém 66075-110, Brazil;
| | - Roberta Borges Andrade de Sá
- Oncology Research Nucleus, Universidade Federal do Pará, Belém 66063-023, Brazil; (D.C.d.C.); (L.P.C.L.); (F.A.R.M.J.); (A.V.W.); (R.B.A.d.S.); (A.C.-P.); (M.R.F.); (S.S.); (A.S.K.); (P.P.d.A.)
| | - Amanda Cohen-Paes
- Oncology Research Nucleus, Universidade Federal do Pará, Belém 66063-023, Brazil; (D.C.d.C.); (L.P.C.L.); (F.A.R.M.J.); (A.V.W.); (R.B.A.d.S.); (A.C.-P.); (M.R.F.); (S.S.); (A.S.K.); (P.P.d.A.)
| | - Marianne Rodrigues Fernandes
- Oncology Research Nucleus, Universidade Federal do Pará, Belém 66063-023, Brazil; (D.C.d.C.); (L.P.C.L.); (F.A.R.M.J.); (A.V.W.); (R.B.A.d.S.); (A.C.-P.); (M.R.F.); (S.S.); (A.S.K.); (P.P.d.A.)
| | - Sidney Santos
- Oncology Research Nucleus, Universidade Federal do Pará, Belém 66063-023, Brazil; (D.C.d.C.); (L.P.C.L.); (F.A.R.M.J.); (A.V.W.); (R.B.A.d.S.); (A.C.-P.); (M.R.F.); (S.S.); (A.S.K.); (P.P.d.A.)
- Human and Medical Genetics Laboratory, Instituto de Ciências Biológicas, Universidade Federal do Pará, Belém 66075-110, Brazil;
| | - André Salim Khayat
- Oncology Research Nucleus, Universidade Federal do Pará, Belém 66063-023, Brazil; (D.C.d.C.); (L.P.C.L.); (F.A.R.M.J.); (A.V.W.); (R.B.A.d.S.); (A.C.-P.); (M.R.F.); (S.S.); (A.S.K.); (P.P.d.A.)
| | - Paulo Pimentel de Assumpção
- Oncology Research Nucleus, Universidade Federal do Pará, Belém 66063-023, Brazil; (D.C.d.C.); (L.P.C.L.); (F.A.R.M.J.); (A.V.W.); (R.B.A.d.S.); (A.C.-P.); (M.R.F.); (S.S.); (A.S.K.); (P.P.d.A.)
- João de Barros Barreto University Hospital, Universidade Federal do Pará, Belém 66063-023, Brazil
| | - Ney Pereira Carneiro dos Santos
- Oncology Research Nucleus, Universidade Federal do Pará, Belém 66063-023, Brazil; (D.C.d.C.); (L.P.C.L.); (F.A.R.M.J.); (A.V.W.); (R.B.A.d.S.); (A.C.-P.); (M.R.F.); (S.S.); (A.S.K.); (P.P.d.A.)
- Human and Medical Genetics Laboratory, Instituto de Ciências Biológicas, Universidade Federal do Pará, Belém 66075-110, Brazil;
- Correspondence:
| |
Collapse
|
9
|
Basnet J, Alsadoon A, Prasad PWC, Aloussi SA, Alsadoon OH. A Novel Solution of Using Deep Learning for White Blood Cells Classification: Enhanced Loss Function with Regularization and Weighted Loss (ELFRWL). Neural Process Lett 2020. [DOI: 10.1007/s11063-020-10321-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
|
10
|
Garg A, Kashyap R, Lal H, Mishra P. Cerebral Sinus Venous Thrombosis in Indian Pediatric Patients With Acute Lymphoblastic Leukemia: Incidence, Risk Factors, and Outcome. Indian J Med Paediatr Oncol 2020. [DOI: 10.4103/ijmpo.ijmpo_206_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
AbstractCerebral sinus venous Thrombosis (CSVT) is a rare complication of acute lymphoblastic leukemia (ALL) treatment, with an incidence rate ranging from 1.1% to 2.9%. Steroids and L-asparaginase (LASP) are the major risk factors.The aim of this study was to find the incidence rate and risk factors for CSVT in our patients. Ninety-two pediatric ALL diagnosed and treated with ALL-Berlin–Frankfurt–Munster-95 protocol over a period of 5 years (2013–2017) were the subject of the study. Six (6.5%) patients developed CSVT during their therapy and were further analyzed.Six (five males and one female) patients had a CSVT event. The mean age at presentation was 13.5 ± 4.1 years. CSVT event occurred during the induction/re-induction phase of chemotherapy. The superior sagittal sinus was the most frequent site of thrombosis. The timing of CSVT was related to using of LASP and steroids. High-risk disease was associated with an increased risk of thrombosis. Infection and dehydration were other important risk factors. No association was observed between the risk of CSVT and age, sex, immunophenotype, and white blood cell count. All the patients were treated with low-molecular-weight heparin and one patient developed heparin-induced thrombocytopenia. No death occurred due to CSVT.The Incidence of CSVT was 6.5% in our study which is significantly high but comparable with studies from other Asian countries. It is, therefore, important to be vigilant for the detection of CSVT during treatment of ALL and initiate the appropriate treatment to prevent adverse events.
Collapse
Affiliation(s)
- Akanksha Garg
- Department of Hematology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Rajesh Kashyap
- Department of Hematology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Hira Lal
- Department of Radiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Prabhakar Mishra
- Department of Biostatistics and Health Informatics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| |
Collapse
|
11
|
Kodidela S, Dorababu P, Thakkar DN, Dubashi B, Sundaram R, Muralidharan N, Nidanapu RP, Aribandi A, Pradhan SC, Uppugunduri CRS. Association of NUDT15*3 and FPGS 2572C>T Variants with the Risk of Early Hematologic Toxicity During 6-MP and Low-Dose Methotrexate-Based Maintenance Therapy in Indian Patients with Acute Lymphoblastic Leukemia. Genes (Basel) 2020; 11:genes11060594. [PMID: 32481505 PMCID: PMC7349017 DOI: 10.3390/genes11060594] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 05/13/2020] [Accepted: 05/25/2020] [Indexed: 02/07/2023] Open
Abstract
Genetic variants influencing the pharmacokinetics and/or pharmacodynamics of the chemotherapeutic drugs used in Acute Lymphoblastic Leukemia (ALL) therapy often contribute to the occurrence of treatment related toxicity (TRT). In this study, we explored the association of candidate genetic variants with early hematological TRT (grade 3–4) occurring within the first 100 days of low-dose methotrexate and 6-mercaptopurine based maintenance therapy (n = 73). Fourteen variants in the following candidate genes were genotyped using allele discrimination assay by real-time PCR: ABCB1, DHFR, GGH, FPGS, MTHFR, RFC1, SLCO1B1, TPMT, and NUDT15. Methotrexate polyglutamate (MTXPG3-5) levels in red blood cells were measured by LC-MS/MS. Early hematological TRT (grade 3–4) was seen in 54.9% of patients. The NUDT15c.415T allele was associated with early TRT occurrence [HR: 3.04 (95% CI: 1.5–6.1); p = 0.007]. Sensitivity of early TRT prediction improved (from 30.7% to 89.7%) by considering FPGS variant (rs1544105’T’) carrier status along with NUDT15c.415T allele [HR = 2.7 (1.5–4.7, p = 0.008)]. None of the considered genetic variants were associated with MTXPG3-5 levels, which in turn were not associated with early TRT. NUDT15c.415T allele carrier status could be used as a stratifying marker for Indian ALL patients to distinguish patients at high or low risk of developing early hematological TRT.
Collapse
Affiliation(s)
- Sunitha Kodidela
- College of Pharmacy, University of Tennessee Heath Science Center, Memphis, TN 38163, USA
- Correspondence: (S.K.); (C.R.S.U.)
| | - Patchava Dorababu
- Department of Pharmacology, Apollo Institute of Medical Sciences and Research, Hyderabad 500090, India;
| | - Dimpal N. Thakkar
- Department of Pharmacology, Jawaharlal Institute of Postgraduate Medical Education & Research, Pondicherry 605006, India; (D.N.T.); (R.S.); (R.P.N.)
| | - Biswajit Dubashi
- Department of Medical Oncology, Jawaharlal Institute of Postgraduate Medical Education & Research, Pondicherry 605006, India;
| | - Rajan Sundaram
- Department of Pharmacology, Jawaharlal Institute of Postgraduate Medical Education & Research, Pondicherry 605006, India; (D.N.T.); (R.S.); (R.P.N.)
| | - Niveditha Muralidharan
- Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education & Research, Pondicherry 605006, India;
| | - Ravi Prasad Nidanapu
- Department of Pharmacology, Jawaharlal Institute of Postgraduate Medical Education & Research, Pondicherry 605006, India; (D.N.T.); (R.S.); (R.P.N.)
| | - Anil Aribandi
- Division of Haemato-Oncology, Care Hospitals, Hyderabad 500019, India;
- American Oncology Institute, Nallagandla Serilingampalli, Hyderabad 500019, India
| | - Suresh Chandra Pradhan
- Department of Pharmacology, Kalinga Institute of Medical Sciences, Bhubaneswar 751024, India;
| | - Chakradhara Rao Satyanarayana Uppugunduri
- Onco-Hematology Unit, Research Platform of Pediatric Onco-Hematology, Department of Paediatrics, Gynaecology and Obstetrics, University Hospitals of Geneva, University of Geneva, 1205 Geneva, Switzerland
- Correspondence: (S.K.); (C.R.S.U.)
| |
Collapse
|
12
|
Prednisolone Prophase for a Week Versus Upfront Multiagent Chemotherapy in Childhood Acute Lymphoblastic Leukemia: An Analysis With Reference to Induction Mortality in a Developing Country. J Pediatr Hematol Oncol 2020; 42:181-184. [PMID: 31688627 DOI: 10.1097/mph.0000000000001636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In childhood acute lymphoblastic leukemia, high treatment-related mortality, especially in the induction phase of treatment, is a major challenge for developing countries. The reasons are multifactorial, including a late presentation with higher disease burden, malnourishment, and limited support services. These factors may aggravate the toxic effects of upfront multiagent chemotherapy in terms of severe neutropenic sepsis and tumor lysis. Therefore, instead of upfront chemotherapy, we offered prednisolone prophase for 1 week with the objective of balancing the antileukemic versus the toxic effect of treatment. The data of 538 patients who received induction with this approach (cohort B) are compared for induction mortality with previous records of 438 patients (cohort A) treated with upfront chemotherapy. In the presence of similar clinical characteristics including age, sex, risk group, and phenotype in both cohorts, a significant difference was found in overall induction mortality of 9% in cohort B versus 14% in cohort A (P<0.05). This difference was also significant in the high-risk and T-cell phenotype, which strengthens our hypothesis that patients with higher burden of disease may experience more fatal toxic effects with upfront intensive chemotherapy. Therefore, we suggest that the prednisolone prophase approach is beneficial to control the disease with less severe toxic effects in our settings.
Collapse
|
13
|
Abdelmabood S, Fouda AE, Boujettif F, Mansour A. Treatment outcomes of children with acute lymphoblastic leukemia in a middle-income developing country: high mortalities, early relapses, and poor survival. J Pediatr (Rio J) 2020; 96:108-116. [PMID: 30240631 PMCID: PMC9432263 DOI: 10.1016/j.jped.2018.07.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 07/07/2018] [Accepted: 07/24/2018] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE Acute lymphoblastic leukemia is the most common childhood cancer, yet surprisingly, very few studies have reported the treatment outcomes and the relapse rate of patients from low/middle-income countries. METHOD This study was a 5-year retrospective cohort study. It was conducted at Oncology Center of Mansoura University in Egypt and aimed to estimate the treatment outcomes and the relapse rates of newly diagnosed acute lymphoblastic leukemia in children. RESULTS Two hundred children suffering from acute lymphoblastic leukemia were studied; forty-six patients (23%) died during induction and most of those deaths were related to infection. Forty-one patients (27%) relapsed out of the 152 patients who achieved complete remission. The most common site of relapse was the bone marrow, followed by the isolated central nervous system, 53.7% and 31.7%, respectively. Seventy-eight percent of relapses occurred very early/early rather than later. The majority of relapse patients' deaths were related to infection and disease progression. The 5-year overall survival rate for patients was 63.1% (82.1% for non-relapsed compared to 36.6% for relapsed patients). CONCLUSION There was a high incidence of induction deaths related to infection and high percentages of very early/early relapses, with high mortalities and low 5-year overall survival rates. These findings suggest the urgent need for modification of chemotherapy regimens to be suitable for the local conditions, including implementation of supportive care and infection control policies. There is also a requirement for antimicrobial prophylaxis during induction period combined with the necessary increase in government healthcare spending to improve the survival of acute lymphoblastic leukemia in Egyptian children.
Collapse
Affiliation(s)
- Suzy Abdelmabood
- Mansoura University, Faculty of Medicine, Pediatric Department, Hematology/Oncology Unit, Al-Mansoura, Egypt
| | - Ashraf Elsayed Fouda
- Mansoura University, Faculty of Medicine, Pediatric Department, Hematology/Oncology Unit, Al-Mansoura, Egypt.
| | | | - Ahmed Mansour
- Mansoura University, Mansoura Faculty of Medicine, Mansoura Oncology Center - Pediatric Oncology Unit, Al-Mansoura, Egypt
| |
Collapse
|
14
|
Abdelmabood S, Fouda AE, Boujettif F, Mansour A. Treatment outcomes of children with acute lymphoblastic leukemia in a middle‐income developing country: high mortalities, early relapses, and poor survival. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2020. [DOI: 10.1016/j.jpedp.2018.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
|
15
|
Pandey A, Ahlawat S, Singh A, Singh S, Murari K, Aryan R. Outcomes and impact of minimal residual disease (MRD) in pediatric, adolescent and young adults (AYA) with acute lymphoblastic leukemia treated with modified MCP 841 protocol. CANCER RESEARCH, STATISTICS, AND TREATMENT 2020. [DOI: 10.4103/crst.crst_85_20] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
16
|
Saikia BJ, Roy PS, Kumar G, Mishra RK, Sarma A. Clinico-epidemiological features and response in childhood acute lymphoblastic leukemia at regional cancer center of Northeast India. South Asian J Cancer 2019; 8:241-243. [PMID: 31807488 PMCID: PMC6852634 DOI: 10.4103/sajc.sajc_249_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Introduction: Acute lymphoblastic leukemia (ALL) comprises 19.3% of all childhood cancers in Northeast India. Methods: We analyzed clinicoepidemiological features and early response to the treatment of all the cases of childhood ALL (age <15 years) diagnosed and treated at Dr. B Borooah Cancer Institute over 1 year. Results: Of 52 eligible cases, 69% were male (male:female ratio of 2.2:1) and the mean age was 7.1 years. Thirty-three children (63%) had baseline white blood cell count ≥20 × 109/L. Precursor B-cell was most the common subtype seen in 61% of children. Seven cases (14%) had high-risk (HR) cytogenetics, with t (9,22) being the most common one. Male sex and HR cytogenetics were significantly associated with poor early responses. Conclusion: ALL is a common childhood malignancy with high cure rates. However, poor socioeconomic status and the presence of higher proportions of disease-related factors lead to poor outcome in this part of the country.
Collapse
Affiliation(s)
- Bhargab Jyoti Saikia
- Department of Medical Oncology, Dr. B Borooah Cancer Institute, Guwahati, Assam, India
| | - Partha Sarathi Roy
- Department of Medical Oncology, Dr. B Borooah Cancer Institute, Guwahati, Assam, India
| | - Gaurav Kumar
- Department of Medical Oncology, Dr. B Borooah Cancer Institute, Guwahati, Assam, India
| | - Rakesh Kumar Mishra
- Department of Medical Oncology, Dr. B Borooah Cancer Institute, Guwahati, Assam, India
| | - Anupam Sarma
- Department of Pathology, Dr. B Borooah Cancer Institute, Guwahati, Assam, India
| |
Collapse
|
17
|
Chidambaram S, Elangovan V, Mahajan V, Ganesan P, Radhakrishnan V. Neurocognitive and Neuroanatomical Changes in Children with Acute Lymphoblastic Leukemia Treated with the Modified BFM-95 Protocol. Indian J Med Paediatr Oncol 2019. [DOI: 10.4103/ijmpo.ijmpo_138_18] [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
Abstract
Background: The use of cranial radiotherapy for central nervous system (CNS) prophylaxis in children with acute lymphoblastic leukemia (ALL) is debated owing to its effect on neurocognitive functioning, as only <30% of the patients present with low risk in India and majority of the patients with high risk have to be treated with cranial radiation therapy (CRT) to prevent relapse. Given the increasing number of ALL survivors in India, the effect of CRT on neurocognitive functioning in children with ALL needs to be studied. Methods: Children (n = 44) with ALL who received CRT, intrathecal methotrexate (IT-MTX), and high-dose methotrexate (HD-MTX) for CNS prophylaxis as part of the modified Berlin-Frankfurt-Munster 95 protocol were included. Neurocognitive assessments and magnetic resonance image were performed to assess neurocognitive functioning and neuroanatomical structures, respectively. Five assessments were performed during the induction, end of re-induction I and II, commencement of maintenance, and end of maintenance phases of the modified BFM-95 protocol. Neurocognitive data of children with ALL were compared with those of healthy children (n = 60) at the baseline and after the final assessment. Results: A significant deterioration was observed in the performance intelligence, visuospatial ability, processing speed, and verbal retention domains after the completion of CNS prophylaxis. Three children had white matter changes on magnetic resonance imaging and showed reduced functioning in performance intelligence quotient, working memory, visual immediate and delayed memory, processing speed, verbal retention, visuospatial ability, processing speed, attention, planning and fine motor skills, and verbal comprehension. Children with ALL had poorer neuropsychological functioning when compared with healthy children. Conclusion: CNS prophylactic therapy as part of the BFM-95 protocol had an adverse effect on the neuropsychological functioning of children with ALL, and the effect was more pronounced when CRT was added to the treatment.
Collapse
Affiliation(s)
| | - Vidhubala Elangovan
- Departments of Psycho-Oncology, Cancer Institute (WIA), Chennai, Tamil Nadu, India
| | - Vandana Mahajan
- Departments of Radiology, Cancer Institute (WIA), Chennai, Tamil Nadu, India
| | - Prasanth Ganesan
- Departments of Medical Oncology, Cancer Institute (WIA), Chennai, Tamil Nadu, India
| | | |
Collapse
|
18
|
Mishra S, Majhi B, Sa PK. Texture feature based classification on microscopic blood smear for acute lymphoblastic leukemia detection. Biomed Signal Process Control 2019. [DOI: 10.1016/j.bspc.2018.08.012] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
19
|
Alam A, Kumar A. Impact of financial support and focussed group counselling on treatment abandonment in children with acute lymphoblastic leukaemia. Experience over 22 years from North India. Psychooncology 2018; 28:372-378. [DOI: 10.1002/pon.4951] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 10/29/2018] [Accepted: 11/23/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Areesha Alam
- Division of Pediatric Hematology‐Oncology, Department of PediatricsKing George's Medical University Lucknow India
| | - Archana Kumar
- Division of Pediatric Hematology‐Oncology, Department of PediatricsKing George's Medical University Lucknow India
| |
Collapse
|
20
|
Alam A, Kumar A. Prevalence, predictors, causes of treatment refusal and abandonment in children with acute lymphoblastic leukaemia over 18 years in North India. Treatment phase affecting factors: A step towards better focussed counselling. Cancer Epidemiol 2018; 57:53-59. [DOI: 10.1016/j.canep.2018.07.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 07/05/2018] [Accepted: 07/18/2018] [Indexed: 11/28/2022]
|
21
|
Varghese B, Joobomary AA, Savida P. Five-Year Survival Rate and the Factors for Risk-Directed Therapy in Acute Lymphoblastic Leukemia. Indian J Med Paediatr Oncol 2018. [DOI: 10.4103/ijmpo.ijmpo_9_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Abstract
Background: Acute lymphoblastic leukemia (ALL) has 5-year survival of more than 90% in many advanced cancer research institutes. However, advanced cancer care is not available to majority of poor in developing countries. The experience of treating such patients in a resource-scarce setting is described herewith. Of the 75 individuals studied, 11% of the children were stunted, >21% were underweight, and 16% of the under-five children had acute malnutrition. Massive hepatosplenomegaly and lymphadenopathy were present in 75% and 77% children, respectively. About 71% patients achieved complete remission (CR). A total of 30 (40%) children lived for >5 years after diagnosis and 21 (28%) of them had event-free 5 years. Weight for height for under-five children (P = 0.029) and total count (P = 0.019) were found to be significantly associated with deaths during induction. Weight for age (P = 0.024), weight for height of under-five children (P = 0.009), and lymphadenopathy (P = 0.049) had a strong association with 5-year event-free survival. Using multivariate model, only weight for height among under five remained significantly associated with induction deaths (P = 0.021) and absence of lymphadenopathy with event-free 5-year survival (P = 0.042). Context: ALL has 5-year survival of >90% in many advanced cancer research institutes. However, advanced care is not available to majority of poor in the periphery of developing countries. Data available on the survival and the factors affecting the outcome among patients treated in poor resource settings are limited. Aims: This study aims to find the 5-year survival rate and the factors for risk-directed therapy in the region. Settings and Design: Cross-sectional analytical study at a tertiary center of public health in central Kerala. Subjects and Methods: Retrospective analysis of case sheets of 75 children who were treated at the institute from March 2006 to March 2011. Statistical Analysis Used: Univariate and Multivariate analysis using IBM SPSS Statistics for Windows, Version 20.0. Results:: Of the 75 individuals studied, 11% of the children were stunted, >21% were underweight, and 16% of the under-five children had acute malnutrition. Massive hepatosplenomegaly and lymphadenopathy were present in 75% and 77% children, respectively. About 71% patients achieved CR. A total of 30 (40%) children lived for >5 years after diagnosis and 21 (28%) of them had event-free 5 years. Weight for height for under-five children (P = 0.029) and total count (P = 0.019) were found to be significantly associated with deaths during induction. Weight for age (P = 0.024), weight for height of under-five children (P = 0.009), and lymphadenopathy (P = 0.049) had a strong association with 5-year event-free survival. Using multivariate model, only weight for height among under five remained significantly associated with induction deaths (P = 0.021) and absence of lymphadenopathy with event-free 5-year survival (P = 0.042). Conclusions: Overall survival was 40% and event-free survival was 28%. Children with acute malnutrition and a higher white blood cell count were more likely to die during induction. Underweight children, malnourished children, and children with lymphadenopathy had significantly poor chances of surviving 5 years' event free.
Collapse
Affiliation(s)
- Bibin Varghese
- Department of Paediatrics, Institute of Child Health, Kottayam, Kerala, India
| | | | - P Savida
- Department of Paediatrics, Institute of Child Health, Kottayam, Kerala, India
| |
Collapse
|
22
|
Trehan A, Bansal D, Varma N, Vora A. Improving outcome of acute lymphoblastic leukemia with a simplified protocol: report from a tertiary care center in north India. Pediatr Blood Cancer 2017; 64. [PMID: 27762058 DOI: 10.1002/pbc.26281] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 09/01/2016] [Accepted: 09/01/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND The outcome of malignancies in low- and middle-income countries (LMICs) is hampered owing to numerous factors. Current protocols are complex, demanding supportive care, often not optimally available. We de-escalated the UKALL 2003 protocol to improve the outcome of acute lymphoblastic leukemia (ALL) at our center. METHODS In 2007-2009, children were treated as per the UKALL 2003 protocol (protocol 1). In 2010 and 2011, a modified version of the UKALL 2003 (protocol 2) was followed. RESULTS Three hundred and seventy-four children aged 5.71+3.1 (1-13) years were treated. Remission was achieved in 335 of the 338 who completed induction. Treatment-related mortality decreased significantly with the modified protocol (P ≤ 0.001). Relapses were similar with both protocols. Protocol used, regimen, counts at diagnosis, weight for age, gender, education of parents and occupation of caregiver were associated with the outcome of death (P < 0.05). On Cox proportional hazard analysis, patients on protocol 1, female gender and weight ≤5th centile had a greater hazard of dying (0.46 [P < 0.0001]; 1.5 [P = 0.04] and 1.64 [P = 0.01]). The 3 years overall survival (OS) with protocols 1 and 2 was 54.8% (95% CI 47.4-61.7%) and 73.9% (95% CI 66-79%) (P < 0.001), respectively. The event-free survival with protocols 1 and 2 was 50.8% (95% CI 43-57%) and 65.7% (95% CI 58-72%) (P < 0.001), respectively. CONCLUSIONS A steady improvement in survival has been observed at our center to a 3-year present OS of 73.9% with reduction in treatment intensity. The way forward for LMICs is to formulate rational treatment protocols at par with resources.
Collapse
Affiliation(s)
- Amita Trehan
- Pediatric Hematology Oncology Unit, Advanced Pediatric Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Deepak Bansal
- Pediatric Hematology Oncology Unit, Advanced Pediatric Center, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Neelam Varma
- Department of Hematology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajay Vora
- Department of Pediatric Hematology, Sheffield Children's Hospital, Sheffield, United Kingdom
| |
Collapse
|
23
|
Mishra S, Majhi B, Sa PK, Sharma L. Gray level co-occurrence matrix and random forest based acute lymphoblastic leukemia detection. Biomed Signal Process Control 2017. [DOI: 10.1016/j.bspc.2016.11.021] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
|
24
|
The Impact of Socioeconomic Factors on the Outcome of Childhood Acute Lymphoblastic Leukemia (ALL) Treatment in a Low/Middle Income Country (LMIC). J Pediatr Hematol Oncol 2016; 38:587-596. [PMID: 27467375 DOI: 10.1097/mph.0000000000000653] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Survival for childhood acute lymphoblastic leukemia (ALL) has improved significantly, but these benefits may not be available to many children from low and middle income countries, where reasons for treatment failure may be unique to their environment. We retrospectively reviewed data on pediatric (1 to 18 y or younger) patients with newly diagnosed ALL treated over 5 years at a children's cancer hospital in Pakistan. Patients were treated with modified Berlin-Frankfurt-Muenster -based therapy without risk stratification. There were 255 children with a median age of 7 years (mean, 7.65 y) and a male preponderance (M:F=1.6:1). 20% had T-ALL, one-third had white blood cells >50×10/L and 13.7% central nervous system disease. A majority (56.5%) was malnourished. In total, 49 (19.2%) died before the end of induction and 21 died in complete remission. Most deaths were infection-related. A total of 50 patients relapsed and 19 abandoned therapy after complete remission. Five-year overall survival is 52.9% with abandonment censored and 45.8% with abandonment as an event. Overall survival was related to socioeconomic status but not to known risk factors. The outcome of ALL at our center is suboptimal and associated with factors not commonly seen in developed countries. Special attention to early diagnosis, infection control, and parental educational are needed to improve the survival.
Collapse
|
25
|
Determinants of Treatment Abandonment in Childhood Cancer: Results from a Global Survey. PLoS One 2016; 11:e0163090. [PMID: 27736871 PMCID: PMC5063311 DOI: 10.1371/journal.pone.0163090] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2015] [Accepted: 09/03/2016] [Indexed: 11/19/2022] Open
Abstract
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.
Collapse
|
26
|
Abstract
Acute leukemias are the most common diagnostic group of childhood cancer. This review summarizes the published literature on reported current outcomes of childhood acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML) from India. Overall survival in ALL ranged from 45% to 81% (commonly >60%) and event-free survival ranged from 41% to 70% (commonly >50%). Outcome data for AML was patchy with varying duration of follow-up, but it can be inferred that 50-80% of treated patients had experienced an event (toxic death, refractory disease or relapse). It is imperative that going forward focus should be on collaborative efforts, which promote treatment of patients on risk-stratified adapted protocols based on local infrastructure, improvement in supportive care and encourage prospective multi-center clinical trials.
Collapse
Affiliation(s)
| | - Brijesh Arora
- Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| |
Collapse
|
27
|
Roy Moulik N, Kulkarni KP, Kumar A. Tracking children with acute lymphoblastic leukemia who abandoned therapy: Experience, challenges, parental perspectives, and impact of treatment subsidies and intensified counseling. Pediatr Hematol Oncol 2016; 33:327-337. [PMID: 27645371 DOI: 10.1080/08880018.2016.1212956] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Refusal for treatment and therapy abandonment are important reasons for unfavorable outcome of childhood acute lymphoblastic leukemia (ALL) in resource-poor countries. The present study, conducted on children with ALL whose treatment was abandoned, attempted to track all these children to ascertain the causes and outcome of therapy abandonment/refusal. In order to improve outcome of ALL, measures to prevent abandonment were introduced in the form of treatment subsidies and intensified multistage counseling. Of the 77 (of 418) children abandoning therapy, 17 (22%) refused upfront, whereas the rest abandoned during various phases of chemotherapy. Only 39 (50.6%) of these 77 families could be subsequently contacted. Financial problems, too many dependents at home, and wrong perceptions about cancer led to abandonment in majority. Children abandoning treatment before completion of induction had a significantly shorter survival than who abandoned post induction (P < .0001). Intensified preabandonment counseling and subsidized treatment led to significant reduction in abandonment rates (P < .0001).
Collapse
Affiliation(s)
- Nirmalya Roy Moulik
- a Department of Pediatrics , King George's Medical University , Lucknow , India
| | - Ketan Prasad Kulkarni
- b Division of Hematology/Oncology , Department of Pediatrics , IWK Health Centre , Halifax , Canada
| | - Archana Kumar
- c Division of Pediatric Hematology-Oncology , Department of Pediatrics , King George's Medical University , Lucknow , India
| |
Collapse
|
28
|
A 10-Year Follow-up Survey of Treatment Abandonment of Children With Acute Myeloid Leukemia in Suzhou, China. J Pediatr Hematol Oncol 2016; 38:437-42. [PMID: 27322718 DOI: 10.1097/mph.0000000000000601] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A survey of the clinical data on acute myeloid leukemia (AML) over the past 10 years in the treatment center of Children's Hospital was presented. The aim of the study was to identify the factors influencing the treatment abandonment rate (AR) of AML. Of the 474 AML cases examined, 264 were abandoned (55.7%). The most important factor affecting AR appeared to be the AML subtype-that is, the M3 versus non-M3 (42% vs. 60%). Patient age was observed to be closely related to AR-the older the patients, the lower the AR-and infants had the highest prevalence of abandonment (84.2%). The patient's residential location was markedly correlated to AR, which was almost inversely proportional to the size of the township where the patient came from. From large cities, intermediate and small towns to countryside villages, the AR increased linearly. So was the correlation with health insurance coverage, which decreased in the same way. Sex and karyotypes did not affect AR. In conclusion, the patients' financial burden and the perceived incurability of AML were the 2 leading factors dominating the decision for abandonment in parents and caregivers.
Collapse
|
29
|
|
30
|
Das R, Ahluwalia J, Sachdeva MUS. Hematological Practice in India. Hematol Oncol Clin North Am 2016; 30:433-44. [DOI: 10.1016/j.hoc.2015.11.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
|
31
|
Kapoor A, Kalwar A, Kumar N, Singhal MK, Beniwal S, Kumar HS. Analysis of outcomes and prognostic factors of acute lymphoblastic leukemia patients treated by MCP841 protocol: A regional cancer center experience. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2016; 21:15. [PMID: 27904561 PMCID: PMC5121999 DOI: 10.4103/1735-1995.178754] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 07/02/2014] [Accepted: 02/08/2016] [Indexed: 12/01/2022]
Abstract
Background: A dramatic improvement in the survival of acute lymphoblastic leukemia (ALL) patients in the last three decades has been observed. MCP 841 protocol is an old but effective tool with tolerable toxicities. The objective of this study was to estimate the relapse-free survival of ALL patients treated uniformly with MCP 841 protocol on the basis of various prognostic factors. Materials and Methods: The study design was retrospective and it was conducted in a regional cancer center of Northwest India. Three hundred and ten ALL patients who underwent treatment with MCP 841 protocol and regular follow-up for up to 5 years were selected for this study. Relapse-free survival was calculated by Kaplan–Meier analysis and Cox regression analysis was used to calculate the hazards ratio (HR) using Statistical Package for the Social Sciences (SPSS) software for windows version 20.0. Results: Fifty-four percent patients were <15 years of age and 69% were males. 53.2% patients were in remission at the end of 5 years of starting the treatment. Relapse-free survival at 5 years by Kaplan–Meir analysis for B-cell ALL was 62% [HR 0.67 {95% confidence interval (CI) 0.47-0.95}] with patients with unknown lineage taken as reference] while for T cell it was 28% [HR 1.41 (95% CI 1.19-1.63), P 0.001]. Patients with total leukocyte count (TLC) <1 lakh/cmm at presentation, relapse-free survival was 68% and those with TLC >1 lakh/cmm had 41% survival [HR 2.14 (1.76-2.48) with, P < 0.001]. Conclusion: MCP 841 protocol is a useful tool for the treatment of ALL in children when more aggressive protocols can not be used.
Collapse
Affiliation(s)
- Akhil Kapoor
- Department of Oncology, Acharya Tulsi Regional Cancer Treatment and Research Institute, Sardar Patel Medical College and Associated Group of Hospitals, Bikaner, Rajasthan, India
| | - Ashok Kalwar
- Department of Oncology, Acharya Tulsi Regional Cancer Treatment and Research Institute, Sardar Patel Medical College and Associated Group of Hospitals, Bikaner, Rajasthan, India
| | - Narender Kumar
- Department of Oncology, Delhi State Cancer Research Institute, New Delhi, India
| | - Mukesh Kumar Singhal
- Department of Oncology, Acharya Tulsi Regional Cancer Treatment and Research Institute, Sardar Patel Medical College and Associated Group of Hospitals, Bikaner, Rajasthan, India
| | - Surender Beniwal
- Department of Oncology, Acharya Tulsi Regional Cancer Treatment and Research Institute, Sardar Patel Medical College and Associated Group of Hospitals, Bikaner, Rajasthan, India
| | - Harvindra Singh Kumar
- Department of Oncology, Acharya Tulsi Regional Cancer Treatment and Research Institute, Sardar Patel Medical College and Associated Group of Hospitals, Bikaner, Rajasthan, India
| |
Collapse
|
32
|
Radhakrishnan V, Gupta S, Ganesan P, Rajendranath R, Ganesan TS, Rajalekshmy KR, Sagar TG. Acute lymphoblastic leukemia: A single center experience with Berlin, Frankfurt, and Munster-95 protocol. Indian J Med Paediatr Oncol 2016; 36:261-4. [PMID: 26811597 PMCID: PMC4711226 DOI: 10.4103/0971-5851.171552] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND There is a paucity of data on the outcome following the treatment for acute lymphoblastic leukemia (ALL) from developing countries. MATERIALS AND METHODS Two hundred and thirty-eight consecutive patients with ALL <30 years of age diagnosed between January 2005 and December 2011 were analyzed retrospectively. Patients were treated modified Berlin, Frankfurt, and Munster 95 protocol. Event-free survival (EFS) was calculated using Kaplan-Meier survival analysis and variables were compared using log-rank test. RESULTS The EFS was 63.4% at a median follow-up was 32.7 months. On univariate analysis National Cancer Institute (NCI) risk stratification, sex, white blood cell count, day 8 blast clearance, and income were significantly associated with EFS. However, on multivariate analysis only female sex (P = 0.01) and day 8 blast clearance (P = 0.006) were significantly associated with EFS. Seventy-four of 238 (31%) patients had recurrent leukemia. The common sites of relapse were bone marrow in 55/74 (75%) patients and central nervous system in 11/74 (20%) patients. CONCLUSION Compared to western data, there was an increased proportion of NCI high-risk patients and T-cell immunophenotype in our study. There has been an improvement in outcome of patients with ALL at our center over the last 2 decades. Female sex and clearance of blast in peripheral blood by day 8 of induction was associated with better EFS.
Collapse
Affiliation(s)
| | - Sumant Gupta
- Department of Medical Oncology, Cancer Institute (WIA), Adyar, Chennai, Tamil Nadu, India
| | - Prasanth Ganesan
- Department of Medical Oncology, Cancer Institute (WIA), Adyar, Chennai, Tamil Nadu, India
| | - Rejiv Rajendranath
- Department of Medical Oncology, Cancer Institute (WIA), Adyar, Chennai, Tamil Nadu, India
| | - Trivadi S Ganesan
- Department of Medical Oncology, Cancer Institute (WIA), Adyar, Chennai, Tamil Nadu, India
| | | | - Tenali Gnana Sagar
- Department of Medical Oncology, Cancer Institute (WIA), Adyar, Chennai, Tamil Nadu, India
| |
Collapse
|
33
|
Iqbal Z, Akhtar T, Awan T, Aleem A, Sabir N, Rasool M, Absar M, Akram AM, Shammas MA, Shah IH, Khalid M, Taj AS, Jameel A, Alanazi A, Gill AT, Hashmi JA, Hussain A, Sabar MF, Khalid AM, Qazi MH, Karim S, Siddiqi MH, Mahmood A, Iqbal M, Saeed A, Irfan MI. High frequency and poor prognosis of late childhood BCR-ABL-positive and MLL-AF4-positive ALL define the need for advanced molecular diagnostics and improved therapeutic strategies in pediatric B-ALL in Pakistan. Mol Diagn Ther 2015; 19:277-87. [PMID: 26266519 DOI: 10.1007/s40291-015-0149-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Fusion oncogenes (FOs) resulting from chromosomal abnormalities have an important role in leukemogenesis in pediatric B cell acute lymphoblastic leukemia (ALL). The most common FOs are BCR-ABL, MLL-AF4, ETV6-RUNX1, and TCF3-PBX1, all of which have important prognostic and drug selection implications. Moreover, frequencies of FOs have ethnic variations. We studied Pakistani frequencies of FOs, clinical pattern, and outcome in pediatric B-ALL. METHODS FOs were studied in 188 patients at diagnosis using reverse transcriptase-polymerase chain reaction (RT-PCR) and interphase fluorescent in situ hybridization (FISH). Data were analyzed using SPSS version 17 (SPSS Inc., Chicago, IL, USA). RESULTS FOs were detected in 87.2 % of patients. Mean overall survival was 70.9 weeks, 3-year survival was 31.9 %, and 3-year relapse-free survival was 18.1 %. Four patients died of drug toxicities. ETV6-RUNX1 (19.14 %) had better survival (110.9 weeks; p = 0.03); TCF3-PBX1 (2.1 %) was associated with inferior outcome and higher central nervous system (CNS) relapse risk; MLL-AF4 (18.1 %) was more common in the 8- to 15-year age group (24/34; p = 0.001) and was associated with organomegaly, low platelet count, and poor survival; and BCR-ABL (47.9 %) was associated with older age (7-15 years, 52/90), lower remission rates, shorter survival (43.73 ± 4.24 weeks) and higher white blood cell count. Overall, MLL-AF4 and BCR-ABL were detected in 66 % of B-ALL, presented in later childhood, and were associated with poor prognosis and inferior survival. CONCLUSIONS This study reports the highest ethnic frequency of BCR-ABL FO in pediatric ALL, and is consistent with previous reports from our region. Poor prognosis BCR-ABL and MLL-AF4 was detected in two-thirds of pediatric B-ALL and is likely to be the reason for the already reported poor survival of childhood ALL in South-East Asia. Furthermore, MLL-AF4, usually most common in infants, presented in later childhood in most of the ALL patients, which was one of the unique findings in our study. The results presented here highlight the need for mandatory inclusion of molecular testing for pediatric ALL patients in clinical decision making, together with the incorporation of tyrosine kinase inhibitors, as well as hematopoietic stem cell transplantation facilities, to improve treatment outcome for patients in developing countries.
Collapse
Affiliation(s)
- Zafar Iqbal
- Medical Genetics/Hematology and Oncology, CLS, CAMS, King Saud Bin Abdulaziz University for Health Sciences/KAIMRC, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, 11426, Saudi Arabia. .,Hematology Oncology and Pharmacogenetic Engineering Sciences (HOPES) Group, Health Sciences/Parasitology Laboratories (HSL), Department of Zoology, University of the Punjab (ZPU), Lahore, Pakistan. .,Department of Biotechnology, University of Sargodha, Sargodha, Pakistan. .,Institute of Molecular Biology and Biotechnology (IMBB), Centre for Research in Molecular Medicine (CRiMM), The University of Lahore, Lahore, Pakistan. .,Pakistan Society for Molecular and Clinical Hematology (PSMH) & Hematology Oncology and Pharmacogenetic Engineering Sciences Group (HOPES), Lahore, Pakistan.
| | - Tanveer Akhtar
- Department of Zoology, Faculty of Biological Sciences, University of the Punjab, Lahore, Pakistan.,Pakistan Society for Molecular and Clinical Hematology, Lahore, Pakistan.,Hematology Oncology and Pharmacogenetic Engineering Sciences (HOPES) Group, Health Sciences/Parasitology Laboratories (HSL), Department of Zoology, University of the Punjab (ZPU), Lahore, Pakistan.,Pakistan Society for Molecular and Clinical Hematology (PSMH) & Hematology Oncology and Pharmacogenetic Engineering Sciences Group (HOPES), Lahore, Pakistan
| | - Tashfin Awan
- Hematology Oncology and Pharmacogenetic Engineering Sciences (HOPES) Group, Health Sciences/Parasitology Laboratories (HSL), Department of Zoology, University of the Punjab (ZPU), Lahore, Pakistan.,Pakistan Society for Molecular and Clinical Hematology (PSMH) & Hematology Oncology and Pharmacogenetic Engineering Sciences Group (HOPES), Lahore, Pakistan
| | - Aamer Aleem
- Division of Hematology/Oncology, Department of Medicine, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Noreen Sabir
- Hematology Oncology and Pharmacogenetic Engineering Sciences (HOPES) Group, Health Sciences/Parasitology Laboratories (HSL), Department of Zoology, University of the Punjab (ZPU), Lahore, Pakistan.,Pakistan Society for Molecular and Clinical Hematology (PSMH) & Hematology Oncology and Pharmacogenetic Engineering Sciences Group (HOPES), Lahore, Pakistan
| | - Mahmood Rasool
- Centre of Excellence in Genomic Medicine Research, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Muhammad Absar
- Hematology Oncology and Pharmacogenetic Engineering Sciences (HOPES) Group, Health Sciences/Parasitology Laboratories (HSL), Department of Zoology, University of the Punjab (ZPU), Lahore, Pakistan.,Pakistan Society for Molecular and Clinical Hematology (PSMH) & Hematology Oncology and Pharmacogenetic Engineering Sciences Group (HOPES), Lahore, Pakistan
| | - Afia M Akram
- Hematology Oncology and Pharmacogenetic Engineering Sciences (HOPES) Group, Health Sciences/Parasitology Laboratories (HSL), Department of Zoology, University of the Punjab (ZPU), Lahore, Pakistan.,Pakistan Society for Molecular and Clinical Hematology (PSMH) & Hematology Oncology and Pharmacogenetic Engineering Sciences Group (HOPES), Lahore, Pakistan
| | - Masood A Shammas
- Translational Genomic Instability Program, Harvard (Dana-Farber) Cancer Institute, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Ijaz H Shah
- Department of Oncology, Allied Hospital, Punjab Medical College, Faisalabad, Pakistan
| | - Muhammad Khalid
- Department of Oncology, Allied Hospital, Punjab Medical College, Faisalabad, Pakistan
| | - Abid S Taj
- Institute of Radiotherapy and Nuclear Medicine, Peshawar, Pakistan
| | - Abid Jameel
- Hayatabad Medical Complex, Peshawar, Pakistan.,Department of Oncology, Khyber Teaching Hospital, Peshawar, Pakistan
| | - Abdullah Alanazi
- Medical Genetics/Hematology and Oncology, CLS, CAMS, King Saud Bin Abdulaziz University for Health Sciences/KAIMRC, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, 11426, Saudi Arabia
| | - Ammara T Gill
- Hematology Oncology and Pharmacogenetic Engineering Sciences (HOPES) Group, Health Sciences/Parasitology Laboratories (HSL), Department of Zoology, University of the Punjab (ZPU), Lahore, Pakistan.,Cox Health System, Springfield, MO, USA
| | - Jamil Amjad Hashmi
- Hematology Oncology and Pharmacogenetic Engineering Sciences (HOPES) Group, Health Sciences/Parasitology Laboratories (HSL), Department of Zoology, University of the Punjab (ZPU), Lahore, Pakistan
| | - Akhtar Hussain
- Department of Biotechnology, University of Peshawar, Peshawar, Pakistan.,Pakistan Society for Molecular and Clinical Hematology (PSMH) & Hematology Oncology and Pharmacogenetic Engineering Sciences Group (HOPES), Lahore, Pakistan
| | - Muhammad Farooq Sabar
- Core DNA Facilities, Centre for Advanced Molecular Biology, University of the Punjab, Lahore, Pakistan
| | - Ahmad M Khalid
- Hematology Oncology and Pharmacogenetic Engineering Sciences (HOPES) Group, Health Sciences/Parasitology Laboratories (HSL), Department of Zoology, University of the Punjab (ZPU), Lahore, Pakistan.,Department of Biotechnology, University of Sargodha, Sargodha, Pakistan
| | - Mehmood Hussain Qazi
- Institute of Molecular Biology and Biotechnology (IMBB), Centre for Research in Molecular Medicine (CRiMM), The University of Lahore, Lahore, Pakistan
| | - Sajjad Karim
- Centre of Excellence in Genomic Medicine Research, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Muhammad Hassan Siddiqi
- Hematology Oncology and Pharmacogenetic Engineering Sciences (HOPES) Group, Health Sciences/Parasitology Laboratories (HSL), Department of Zoology, University of the Punjab (ZPU), Lahore, Pakistan.,Pakistan Society for Molecular and Clinical Hematology (PSMH) & Hematology Oncology and Pharmacogenetic Engineering Sciences Group (HOPES), Lahore, Pakistan
| | - Aamir Mahmood
- Stem Cell Research Group, Department of Anatomy, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
| | - Mudassar Iqbal
- Hematology Oncology and Pharmacogenetic Engineering Sciences (HOPES) Group, Health Sciences/Parasitology Laboratories (HSL), Department of Zoology, University of the Punjab (ZPU), Lahore, Pakistan.,Asian Medical Institute and National Surgical Centre, Kant, Kyrgyzstan.,Pakistan Society for Molecular and Clinical Hematology (PSMH) & Hematology Oncology and Pharmacogenetic Engineering Sciences Group (HOPES), Lahore, Pakistan
| | - Anjum Saeed
- Prince Abdullah Bin Khalid Celiac Disease Research Chair, King Saud University, Riyadh, Saudi Arabia
| | | |
Collapse
|
34
|
Acute lymphoblastic leukemia in low and middle-income countries: disease characteristics and treatment results. Curr Opin Oncol 2015; 26:650-5. [PMID: 25202926 DOI: 10.1097/cco.0000000000000125] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Acute lymphoblastic leukemia is the most common pediatric cancer. The cure rate of this disease is over 80% in developed countries utilizing protocols with very tolerable toxicity. Several factors contributed to this success, including the implementation of large collaborative clinical trials and the better understanding of disease biology allowing for risk-stratified treatment. We will review the current state of the treatment of acute lymphoblastic leukemia in low-income and medium-income countries. RECENT FINDINGS The picture differs from country to country, but recent advances have been made in many countries and the cure rates have improved significantly. Tackling problems such as access to care, abandonment of treatment and toxicity of protocols and the development of centers of excellence are critical for continued improvement. Twinning with programs in developed countries and the creation of regional collaborative groups will allow the implementation of risk-directed therapy and better supportive care. SUMMARY The experience in low-income countries shows that a structured approach to the treatment of acute lymphoblastic leukemia results in improved survival.
Collapse
|
35
|
Ceppi F, Antillon F, Pacheco C, Sullivan CE, Lam CG, Howard SC, Conter V. Supportive medical care for children with acute lymphoblastic leukemia in low- and middle-income countries. Expert Rev Hematol 2015; 8:613-26. [DOI: 10.1586/17474086.2015.1049594] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
|
36
|
Kulkarni KP. In the realms of future: new frontiers of 'techno-oncology' as a platform for global improvement in the outcomes of childhood cancer. Expert Rev Hematol 2014; 8:1-4. [PMID: 25537882 DOI: 10.1586/17474086.2015.995623] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The survival outcome of childhood cancers in developing nations has failed to keep pace with that of developed nations. Technological advances offer a unique and radical opportunity to develop programs and strategies to improve outcomes of childhood cancer globally. The novel field of 'techno-oncology' has a broad scope and the potential to phenomenally impact, revamp and model the care of pediatric cancer patients in the developing world. Many frontiers and opportunities in the area remain to be explored as well as many challenges to be surmounted.
Collapse
Affiliation(s)
- Ketan P Kulkarni
- Department of Pediatrics, Division of Hematology/Oncology, IWK Health Centre, 5850/5980 University Avenue, Halifax, NS B3K 6R8, Canada
| |
Collapse
|
37
|
Oberoi S, Trehan A, Marwaha RK. Medication errors on oral chemotherapy in children with acute lymphoblastic leukemia in a developing country. Pediatr Blood Cancer 2014; 61:2218-22. [PMID: 25175850 DOI: 10.1002/pbc.25203] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2014] [Accepted: 07/07/2014] [Indexed: 11/05/2022]
Abstract
BACKGROUND Medication errors occur universally. Inappropriate administration of chemotherapy drugs can have adverse effects in cancer patients. Our objective was to assess the rate and type of medication errors in children with acute lymphoblastic leukemia (ALL) receiving oral chemotherapy in outpatient setting. PROCEDURE Prescription and administration of oral chemotherapy drugs in children with ALL were evaluated prospectively to determine rate and type of medication errors. Errors were defined as prescription (physician) level or administration (patient) level errors. RESULTS Two hundred eighty-nine drugs were prescribed to 121 patients. Medication errors occurred in 36 (12.5%) prescriptions; 21(7.3%) were administration errors, 13 (4.5%) were prescribing errors, and two errors occurred at both levels. Mercaptopurine (6-MP) was significantly associated with higher rates of errors (Odds ratio [OR] = 2.1, 95% CI [confidence interval] 1-4.1) whereas lapses were less with dexamethasone (OR = 0.25, 95% CI 0.09-0.67). As a result of medication errors 28 (23.1%) patients received inappropriate doses. Twenty five (21%) patients received sub-optimal doses whereas three got higher doses of chemotherapy. On univariate analysis, socioeconomic status, education status of the caregiver, 6-MP and methotrexate were significantly associated with errors (P ≤ 0.05). On multivariate analysis, ≤ primary school education of the caregiver and prescription of methotrexate were independent predictors of errors. CONCLUSIONS Medication errors affected nearly one fourth of the children receiving oral chemotherapy. Future studies are needed to look at effective interventions to avoid chemotherapy associated errors especially amongst the lower strata of society.
Collapse
Affiliation(s)
- Sapna Oberoi
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
| | | | | |
Collapse
|
38
|
Yadav SP, Rastogi N, Kharya G, Misra R, Ramzan M, Katewa S, Dua V, Bhat S, Kellie SJ, Howard SC. Barriers to cure for children with cancer in India and strategies to improve outcomes: a report by the Indian Pediatric Hematology Oncology Group. Pediatr Hematol Oncol 2014; 31:217-24. [PMID: 24673115 DOI: 10.3109/08880018.2014.893596] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
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.
Collapse
Affiliation(s)
- Satya Prakash Yadav
- 1Pediatric Hematology and Bone Marrow Transplant Unit, Fortis Memorial Research Institute, Gurgaon, India
| | | | | | | | | | | | | | | | | | | |
Collapse
|
39
|
Al-Sudairy R, Al-Nasser A, Alsultan A, Al Ahmari A, Abosoudah I, Al-Hayek R, Al-Harbi T, Al-Manjomi F, Al-Harbi M, Al-Ghamdi H, Al-Shahrani M, Belgaumi AF. Clinical characteristics and treatment outcome of childhood acute lymphoblastic leukemia in Saudi Arabia: a multi-institutional retrospective national collaborative study. Pediatr Blood Cancer 2014; 61:74-80. [PMID: 23940019 DOI: 10.1002/pbc.24584] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2013] [Accepted: 04/08/2013] [Indexed: 11/06/2022]
Abstract
BACKGROUND Treatment of childhood acute lymphoblastic leukemia (ALL) has been available in Saudi Arabia (SA) for over 30 years; however, only limited data have been published from there. This study was conducted to establish processes for collaborative data collection and provide clinical characteristics and outcome of children with ALL in SA. PROCEDURE Clinical data for patients diagnosed from 2004 to 2008 were retrospectively collected at eight institutions and entered remotely into a custom-built database. Statistics regarding clinical and genetic characteristics and treatment outcome were calculated. RESULTS The 594 evaluable patients had a median age of 4.37 years and 56.4% were boys. Majority of patients had B-precursor ALL while 10.7% had T-ALL. CNS leukemia was present in 5.2% of patients. The distribution of common genetic abnormalities was similar to that reported from western populations, with 24.6% hyperdiploidy, 21% RUNX1-ETV6 positivity, 4.2% BCR-ABL1 positivity, and 2.5% with MLL gene rearrangement. Patients received risk-adapted therapy according to various protocols, although treatment strategies for the majority were similar. Five-year OS, RFS and EFS were 86.9%, 79.1%, and 73.3%, respectively. The OS for patients with pre-B ALL was significantly higher than for T-ALL (88.0% vs. 71.8%; P = 0.019, Log-Rank test). Patients with pre-B ALL categorized as low-risk by NCI/Rome criteria and those with hyperdiploidy had OS of 93.4% and 95.8%, respectively. CONCLUSIONS The characteristics of childhood ALL in SA are similar to those observed in developed countries. Future prospective studies utilizing unified national protocols are needed to further improve the outcome of our patients.
Collapse
Affiliation(s)
- Reem Al-Sudairy
- Department of Oncology, King Fahad National Guard Hospital/King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Kodidela S, Suresh Chandra P, Dubashi B. Pharmacogenetics of methotrexate in acute lymphoblastic leukaemia: why still at the bench level? Eur J Clin Pharmacol 2013; 70:253-60. [PMID: 24370659 DOI: 10.1007/s00228-013-1623-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2013] [Accepted: 11/27/2013] [Indexed: 12/28/2022]
Abstract
PURPOSE The antifolate drug methotrexate (MTX) was introduced into clinical practice about 60 years ago and remains an important component of different acute lymphoblastic leukemia (ALL) treatment protocols. It acts by inhibiting several enzymes in the folate pathway, thereby resulting in the disruption of folate homeostasis. To date, treatment regimens have not been personalized despite there being experimental evidence that gene polymorphisms of folate metabolizing enzymes affect MTX response. The aim of this review was to evaluate the influence of genetic polymorphisms of the enzymes involved in the MTX pathway on ALL treatment outcomes and identify factors underlining the failure to personalize MTX therapy. METHODS We conducted a literature search in PUBMED and Google Scholar using the following key words: methotrexate, polymorphism, acute lymphoblastic leukemia, pharmacogenetics, pharmacogenomics and personalized medicine. RESULTS The reasons for the failure to personalize MTX therapy may be due to (1) most studies involving single-center, small-sized cohorts, (2) differences in MTX dose across different protocols, (3) failure to consider minimal residual disease as a risk factor for post-induction treatment, (4) differences in outcome criteria between studies and (5) failure to consider the folate levels of a patient before initiation of MTX therapy. Although high-throughput techniques allow the mapping of thousands of genetic polymorphisms in a single run, it remains a major challenge to dissect out folate-metabolizing enzymes which have a high impact on the efficacy and toxicity of MTX and which, therefore, could be the targets for intervention. CONCLUSIONS Prospective pharmacogenetic studies which consider all of the above-mentioned factors should be undertaken to facilitate the design of personalized MTX treatment for ALL patients.
Collapse
Affiliation(s)
- Sunitha Kodidela
- Department of Pharmacology, Jawaharlal Institute of Medical Education and Research (JIPMER), Puducherry, India,
| | | | | |
Collapse
|
41
|
Yeoh AEJ, Tan D, Li CK, Hori H, Tse E, Pui CH. Management of adult and paediatric acute lymphoblastic leukaemia in Asia: resource-stratified guidelines from the Asian Oncology Summit 2013. Lancet Oncol 2013; 14:e508-23. [PMID: 24176570 PMCID: PMC4059516 DOI: 10.1016/s1470-2045(13)70452-2] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Survival for adults and children with acute lymphoblastic leukaemia has risen substantially in recent years because use of improved risk-directed treatments and supportive care has widened. In nearly all developed countries, multidisciplinary panels of leukaemia experts have formulated clinical practice guidelines in which standard treatment approaches are recommended on the basis of current evidence. However, those guidelines do not take into account resource limitations in low-income countries, including financial and technical challenges. In Asia, huge disparities in economy and infrastructure exist between countries, and even among different regions in some large countries. At a consensus session held as part of the 2013 Asian Oncology Summit in Bangkok, Thailand, a panel of experts summarised recommendations for management of adult and paediatric acute lymphoblastic leukaemia. Strategies were developed for Asian countries on the basis of available financial, skill, and logistical resources and were stratified in a four-tier system according to the resources available in a particular country or region (basic, limited, enhanced, and maximum).
Collapse
Affiliation(s)
- Allen E J Yeoh
- Department of Paediatrics, National University Hospital, National University of Singapore, Singapore
| | | | | | | | | | | |
Collapse
|
42
|
Acute lymphoblastic leukemia with pancytopenia at presentation: clinical correlates, prognostic impact, and association with survival. J Pediatr Hematol Oncol 2013; 35:573-6. [PMID: 23929316 DOI: 10.1097/mph.0b013e31829d46f3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Acute lymphoblastic leukemia has a wide variety of presentations. There is paucity of any data addressing pancytopenia at presentation in acute lymphoblastic leukemia. In this study we assessed 84 patients with pancytopenia at presentation. They had a significantly lower incidence of bulky disease at presentation. A significantly higher fraction of these patients (n=66, 78.57%) opted for therapy (P=0.005) as compared with the rest. The estimated mean survival in patients presenting with pancytopenia (67.2±17.2 mo) was significantly higher (P=0.031, log-rank test) as compared with that of other patients (47.2±7.4 mo). Pancytopenia was an independent predictor of better survival (P=0.043) in multivariate analysis.
Collapse
|
43
|
Kulkarni KP, Marwaha RK. Outcome of neuroblastoma in India. Indian J Pediatr 2013; 80:832-7. [PMID: 23340984 DOI: 10.1007/s12098-012-0948-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Accepted: 11/30/2012] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To assess the outcome of childhood neuroblastoma in India over the last 2 decades, identify management lacunae and suggest remedial measures. METHODS A comprehensive search to identify literature addressing outcome of childhood neuroblastoma from India was performed. International Society of Paediatric Oncology and American Society of Clinical Oncology Annual-Meeting abstracts were hand searched to identify unpublished data. Clinico-demographic and outcome data was extracted. RESULTS Outcome of approximately 700 patients has been published over the last 2 decades with predominantly small to moderate single center series from 6 cities. Primarily non-myeloablative multiagent chemotherapy protocols alongwith surgery, have been used for treatment. A large majority of patients had stage III/IV neuroblastoma. Limited diagnostic facilities were available at most centers. Survival outcome of 8.7 to 80 % has been reported with high death and relapse rates alongwith high incomplete control/disease progression and treatment abandonment. Few series have identified prognostic parameters. Few patients with high-risk disease have been adequately treated and cured. CONCLUSIONS There is a clear need for replicating neuroblastoma outcomes at centers of excellence in other cancer centers, improving diagnostic and laboratory facilities, administering adequate and appropriate contemporary therapy, assessing disease response and improving supportive care. National data management infrastructure along with better financial and social support initiatives are key factors.
Collapse
Affiliation(s)
- Ketan Prasad Kulkarni
- Division of Pediatric Hematology Oncology, Stollery Children Hospital, University of Alberta, Edmonton, AB, Canada,
| | | |
Collapse
|
44
|
Kulkarni KP, Marwaha RK. Significant male preponderance in childhood acute lymphoblastic leukemia in India and regional variation: tertiary care center experience, systematic review, and evaluation of population-based data. Pediatr Hematol Oncol 2013; 30:557-67. [PMID: 23528149 DOI: 10.3109/08880018.2013.779768] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Although, a slight male preponderance has been reported in childhood acute lymphoblastic leukemia (ALL) from several developed nations, several Indian studies suggest a skewed gender ratio in ALL. To assess the gender ratio at presentation in ALL in India, we used a three-prong approach: (i) center audit, (ii) systematic review of published studies on ALL in India, and (iii) assessment of population based registry data. Data on gender at presentation in ALL were extracted from these multiple sources. In our center audit, we observed a significantly higher of male:female (M:F) ratio of 3.16:1 (P = .046) in ALL as compared to world literature. In the systematic review of all ALL studies from India, 367 articles were identified and reviewed. A total of 4230 and 1843 boys and girls in these studies were assessed and the M:F ratio was 2.503:1; much higher than the world ratio but not significantly different (P = .10). Population-based data obtained from the National Cancer Registry Program also depicted a male preponderance, especially from large cities in India in a consistent manner since 1984. There is also significant (P = .025) interregional variation in the gender ratio in India. Our study clearly demonstrates a consistent male preponderance in childhood ALL in India along with significant interregional variations over the last three decades. There is a clear need of prospective nationwide multicenter assessment of high-resolution data to confirm this important observation and assess its implications, especially on the health care system.
Collapse
Affiliation(s)
- Ketan Prasad Kulkarni
- Division of Pediatric Hematology Oncology, Stollery Children Hospital, University of Alberta, Edmonton, Canada.
| | | |
Collapse
|
45
|
|
46
|
Tantawy AAG, El-Rashidy FH, Ragab IA, Ramadan OA, El-Gaafary MM. Outcome of childhood acute Lymphoblastic leukemia in Egyptian children: a challenge for limited health resource countries. ACTA ACUST UNITED AC 2013; 18:204-10. [PMID: 23394310 DOI: 10.1179/1607845412y.0000000061] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
UNLABELLED In childhood acute lymphoblastic leukemia (ALL) the reported 5-year event-free survival (EFS) rates are as high as 80%. Since 2004, multiple Egyptian centers shifted protocol of therapy of ALL to the CCG 1991 (the single delayed intensification arm) and CCG 1961 protocol for standard risk and high-risk ALL therapy, respectively, being cost effective. We aimed to evaluate the efficacy and safety of the CCG protocol in treatment of childhood ALL in Ain Shams and Menoufeya University hospitals. METHODS Fifty-two ALL patients, aged 1-17 years, treated according to the modified CCG protocol in both centers and registered from November 2004 to December 2005 were included. They were classified into three risk groups, standard risk (SR), high-risk standard arm (HR-SA), and high-risk augmented arm (HR-AA). RESULTS The mean age at diagnosis was 5.9 + 3.3 years, male/female ratio of 1.6:1, and central nervous system leukemia represented 6%. The 5-year overall survival (OS) and EFS were 84.6% and 67%, respectively. The 5-year OS and EFS were 92.6% and 70% in SR, 68.8% and 55% in HR-SA, 88.9% and 80% in HR-AA patients, respectively. Six patients had grade 3-4 adverse events. CONCLUSION The outcome of HR-SA protocol was inferior to the other two groups, necessitating shift to a more intensified arm with double delayed intensification. The use of minimal residual disease for better risk classification of childhood ALL is recommended in our centers.
Collapse
Affiliation(s)
- Azza A G Tantawy
- Pediatric Department-Hematology/Oncology Unit, Ain Shams University, Cairo, Egypt.
| | | | | | | | | |
Collapse
|
47
|
Seasonality in diagnosis of childhood acute lymphoblastic leukemia: impact on disease presentation, survival outcome and resources. J Pediatr Hematol Oncol 2013; 35:81-2. [PMID: 23242329 DOI: 10.1097/mph.0b013e318279eb6f] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
48
|
Kulkarni KP, Marwaha RK. Symptom diagnosis interval in childhood acute lymphoblastic leukemia: Prognostic impact and association with clinico-demographic factors. Indian J Med Paediatr Oncol 2012; 33:188. [PMID: 23248430 PMCID: PMC3523481 DOI: 10.4103/0971-5851.103153] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Ketan P Kulkarni
- Pediatric Hematology Oncology, Stollery Children Hospital, Edmonton, Alberta, Canada. E-mail:
| | | |
Collapse
|
49
|
Kulkarni KP. L-Asparaginase induced thrombosis in acute lymphoblastic leukemia. J Pharmacol Pharmacother 2012; 3:285-6. [PMID: 23129971 PMCID: PMC3487284 DOI: 10.4103/0976-500x.99449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Ketan P Kulkarni
- Division of Pediatric Hematology Oncology, Stollery Children Hospital, University of Alberta, Canada
| |
Collapse
|
50
|
Ekouya Bowassa G, Okouango Ova JD, Ngolet L, Okoko AR, Elira-Dokekias A. [Acute leukemia in children in Brazzaville]. Arch Pediatr 2012; 19:1123-4. [PMID: 22981479 DOI: 10.1016/j.arcped.2012.07.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Revised: 04/24/2012] [Accepted: 07/12/2012] [Indexed: 11/26/2022]
|