Infections during induction therapy of protocol CCLG-2008 in childhood acute lymphoblastic leukemia: a single-center experience with 256 cases in China

Simultaneous Presentation of B-Acute Lymphoblastic Leukemia and Streptococcus agalactiae Meningitis in a 3-Year-old Girl

Infection is a major cause of treatment-related morbidity and mortality in pediatric acute lymphoblastic leukemia (ALL). Most children with ALL who develop life-threatening bacterial infections do so during induction therapy. We describe a rare case of ALL presenting simultaneously with Streptococcus agalactiae group B Streptococcus bacteremia and meningitis in a 3-year-old girl. She received appropriate antimicrobial therapy and a 2-drug early induction regimen consisting of vincristine and dexamethasone, leading to slow neurologic recovery and a favorable initial response to anti-neoplastic therapy as evidenced by minimal residual disease of 1.12% on day 15 of induction.

Clinical features and prognosis of pediatric acute lymphocytic leukemia with JAK-STAT pathway genetic abnormalities: a case series

The objective of this study is to explore the clinical features and outcomes of pediatric patients with acute lymphoblastic leukemia (ALL) harboring JAK-STAT signaling pathway genetic abnormalities. This retrospective case series examined the clinical data of pediatric patients diagnosed with ALL harboring JAK-STAT pathway genetic abnormality at the Children's Hospital of the Capital Institute of Pediatrics between January 2016 and January 2022. Bone marrow next-generation sequencing was used to reveal the JAK pathway abnormalities. Descriptive statistics were used. From 432 children with ALL during the study period, eight had JAK-STAT pathway genetic abnormalities. Regarding immunotyping, there were four patients with common-B cell types and one with pre-B cell type. The three patients with T-ALL had early T-cell precursor(ETP) type, pre-T cell type, and T cell type. Gene mutations were more common than fusion genes. There was no central nervous system involvement in eight patients. All patients were considered at least at intermediate risk before treatments. Four patients underwent hematopoietic stem cell transplantation (HSCT). One child had a comprehensive relapse and died. The child had a severe infection and could not tolerate high-intensity chemotherapy. Another child relapsed 2 years after HSCT and died. Disease-free survival was achieved in six children. JAK-STAT pathway genetic abnormalities in pediatric Ph-like ALL are rare. Special attention should be paid to treatment-related complications, such as infection and combination therapy (chemotherapy, small molecule targeted drugs, immunotherapy, etc.) to reduce treatment-related death and improve long-term quality of life.

Risk Factors for Relapse of Childhood B Cell Acute Lymphoblastic Leukemia

Background

B cell acute lymphoblastic leukemia (B-ALL) is the most common type of ALL. This study aimed to explore risk factors for relapse of childhood B-ALL.

Material/Methods

Total of 102 pediatric B-ALL patients were included in this study. B-ALL patients were divided into a relapse group and a non-relapse group. Chemotherapy-induced agranulocytosis time, fusion gene, and minimal residual disease (MRD) were assessed. White blood cell (WBC) count in peripheral blood and risk stratification were evaluated in newly-diagnosed patients. Kaplan-Meier plots were used to evaluate the correlation between risk factors and relapse rates. Multivariate analysis was performed with Cox proportional hazard model to estimate relative risk (RR), 95% confidence interval (95% CI), and hazard ratio (HR). Finally, 99 cases of B-ALL were included in this study.

Results

There were significant differences between the relapse group and the non-relapse group in age (p=0.004), chemotherapy-induced agranulocytopenia (p=0.001), WBC count in peripheral blood of newly diagnosed patients (p=0.016), risk stratification (p=0.000), and MRD at 12^th week (p=0.007). Age over 10 years, high-risk stratification, long period of agranulocytopenia, higher WBC counts, and MRD more than 10⁻⁴ were correlated with higher B-ALL relapse rate (p<0.05). Multivariate analysis showed significantly higher relapse rates for age ≥10 years, high-risk stratification, and MRD at 12^th week >10⁻⁴, with RR (95% CI) of 4.001 (1.005–15.930), 4.964 (1.050–23.456), and 4.646 (1.383–15.614), respectively.

Conclusions

Agranulocytopenia ≤7 days, peripheral blood WBC >100×10⁹/L, and MRD at 33^rd day >10⁻⁴ were associated with B-ALL relapse. Age ≥10 years, high-risk stratification, and MRD at 12^th week >10⁻⁴ were independent risk factors for relapse.

Body Mass Index (BMI) and Infectious/Febrile Episodes in Children with Intermediate Risk Acute Lymphoblastic Leukemia (IR ALL)

The incidence of treatment related mortality in children with acute lymphoblastic leukemia (ALL) is reported to be between 2% and 4% with infections being the leading cause.

AIM

To establish a relationship between body mass index at diagnosis (BMI 0), after protocol I therapy completion (BMI I) and the incidence rate ratio (IRR) of infectious/febrile episodes in children with ALL intermediate risk.

METHODS

Thirty one consecutive patients (2-18 years old, with a male to female ratio of 19/12) with newly diagnosed ALL that were treated uniformly according to ALL IC 2009 protocol were included in this analysis.

RESULTS

A BMI decrease of at least 5% during protocol I therapy and BMI 1 under 15th percentile score corresponds significantly with higher IRR (with P-values 0.04 and 0.006 respectively) during the whole intensive therapy.

CONCLUSION

Some relationships between BMI reduction and higher IRR in ALL patients were found, but their significance is limited by the size of the group analyzed.

Three-dimensional (3D) Printing Technology Assisted by Minimally Invasive Surgery for Pubic Rami Fractures

The feasibility of three-dimensional (3D) printing technology combined with minimally invasive surgery in the treatment of pubic rami fractures was explored. From August 2015 to October 2017, a series of 30 patients who underwent surgical stabilization of their anterior pelvic ring (all utilizing the 3D printing technology) by one surgeon at a single hospital were studied. The minimally invasive incisions were made through anterior inferior cilia spine and pubic nodule. Data collected included the operative duration, the blood loss, the damage of the important tissue, the biographic union and the recovery of the function after the operation. Measurements on inlet and outlet pelvic cardiograph were made immediately post-operation and at all follow-up clinic visits. The scores of reduction and function were measured during follow-up. Results showed that the wounds of 30 patients were healed in the first stage, and there was no injury of important structures such as blood vessels and nerves. According to the Matta criteria, excellent effectiveness was obtained in 22 cases and good in 8 cases. According to the functional evaluation criteria of Majeed, excellent effectiveness was obtained in 21 cases and good in 9 cases. It was suggested that the 3D printing technology assisted by minimally invasive surgery can better evaluate the pelvic fracture before operation, which was helpful in plate modeling, and can shorten surgery duration and reduce intraoperative blood loss and complications. The positioning accuracy was improved, and better surgical result was finally achieved.

[Pathogens of infections in the induction period of childhood acute lymphoblastic leukemia and drug resistance of isolated strains]

OBJECTIVE

To investigate the infections occurring in the induction period of childhood acute lymphoblastic leukemia (ALL), the pathogens of the infections, and drug resistance of isolated strains.

METHODS

A retrospective analysis was performed for the clinical data of 130 children with newly-diagnosed childhood ALL. Infections occurring during the induction chemotherapy, pathogenic strains, and drug-resistance spectrum were analyzed.

RESULTS

The incidence rate of clinical infection and/or microbial infection reached 76.2%. The lungs were the most common infection site (46.2%). The children with severe infection accounted for 52.3%, among whom 60 had pulmonary infection and/or 21 had sepsis. A total of 50 pathogenic strains were detected, which consisted of 29 bacterial strains and 21 fungal strains. Of all the children, 28.5% experienced infections caused by at least one microbe. Among the 29 bacterial strains, there were 19 (65.5%) Gram-negative bacteria and 10 (34.5%) Gram-positive bacteria. The most common Gram-negative bacteria were Klebsiella pneumoniae, Escherichia coli, and Pseudomonas aeruginosa, which were 100% sensitive to imipenem. The most common Gram-positive bacterium was Streptococcus viridans, which was 100% sensitive to vancomycin. The infections caused by fungi accounted for 16.2%, with Candida albicans as the most common fungus. Compared with those with non-severe infections, the children with severe infections had a significantly shorter time to the occurrence of agranulocytosis, a significantly longer duration of agranulocytosis, significantly higher incidence of fever and C-reactive protein (CRP) level, and a significantly longer length of hospital stay (P<0.05).

CONCLUSIONS

Pulmonary infections are common in the induction period of childhood ALL. Gram-negative bacteria are the most common pathogenic bacteria. Severe infections can be controlled by carbapenems combined with vancomycin and antifungal agents.

[Pathogens of infections in the induction period of childhood acute lymphoblastic leukemia and drug resistance of isolated strains]

OBJECTIVE

To investigate the infections occurring in the induction period of childhood acute lymphoblastic leukemia (ALL), the pathogens of the infections, and drug resistance of isolated strains.

METHODS

A retrospective analysis was performed for the clinical data of 130 children with newly-diagnosed childhood ALL. Infections occurring during the induction chemotherapy, pathogenic strains, and drug-resistance spectrum were analyzed.

RESULTS

The incidence rate of clinical infection and/or microbial infection reached 76.2%. The lungs were the most common infection site (46.2%). The children with severe infection accounted for 52.3%, among whom 60 had pulmonary infection and/or 21 had sepsis. A total of 50 pathogenic strains were detected, which consisted of 29 bacterial strains and 21 fungal strains. Of all the children, 28.5% experienced infections caused by at least one microbe. Among the 29 bacterial strains, there were 19 (65.5%) Gram-negative bacteria and 10 (34.5%) Gram-positive bacteria. The most common Gram-negative bacteria were Klebsiella pneumoniae, Escherichia coli, and Pseudomonas aeruginosa, which were 100% sensitive to imipenem. The most common Gram-positive bacterium was Streptococcus viridans, which was 100% sensitive to vancomycin. The infections caused by fungi accounted for 16.2%, with Candida albicans as the most common fungus. Compared with those with non-severe infections, the children with severe infections had a significantly shorter time to the occurrence of agranulocytosis, a significantly longer duration of agranulocytosis, significantly higher incidence of fever and C-reactive protein (CRP) level, and a significantly longer length of hospital stay (P<0.05).

CONCLUSIONS

Pulmonary infections are common in the induction period of childhood ALL. Gram-negative bacteria are the most common pathogenic bacteria. Severe infections can be controlled by carbapenems combined with vancomycin and antifungal agents.

3D Printed replica of articular fractures for surgical planning and patient consent: a two years multi-centric experience

Background

CT scanning with 3D reconstructed images are currently used to study articular fractures in orthopedic and trauma surgery. A 3D-Printer creates solid objects, starting from a 3D Computer representation.

Case Description

We report from two year of multicenter experience in 3D printing of articular fractures.

Discussion and Evaluation

During the study period, 102 patients (distal radius fractures, radial head, tibial plateau, astragalus, calcaneus, ankle, humeral head and glenoid) underwent 3D printing. The medical models were used by surgeons to appreciate the dislocation of fragments and the yielding of the articular surface. In addition, models were showed to patient as part of the acquisition of the informed consent before surgery.

Conclusions

3D printing of articular fractures are innovative procedures that achieve a preoperative tangible, highly useful evaluation of the fractures to plan intervention and educate patients.

Progress in Treatment of Viral Infections in Children with Acute Lymphoblastic Leukemia

In children, the most commonly encountered type of leukemia is acute lymphoblastic leukemia (ALL). An important source of morbidity and mortality in ALL are viral infections. Even though allogeneic transplantations, which are often applied also in ALL, carry a recognized risk for viral infections, there are multiple factors that make ALL patients susceptible to viral infections. The presence of those factors has an influence in the type and severity of infections. Currently available treatment options do not guarantee a positive outcome for every case of viral infection in ALL, without significant side effects. Side effects can have very serious consequences for the ALL patients, which include nephrotoxicity. For this reason a number of strategies for personalized intervention have been already clinically tested, and experimental approaches are being developed. Adoptive immunotherapy, which entails administration of ex vivo grown immune cells to a patient, is a promising approach in general, and for transplant recipients in particular. The ex vivo grown cells are aimed to strengthen the immune response to the virus that has been identified in the patients' blood and tissue samples. Even though many patients with weakened immune system can benefit from progress in novel approaches, a viral infection still poses a very significant risk for many patients. Therefore, preventive measures and supportive care are very important for ALL patients.