The paediatric cancer clinical research landscape in Spain: a 13-year multicentre experience of the new agents group of the Spanish Society of Paediatric Haematology and Oncology (SEHOP)

PURPOSE

Early phase trials are crucial in developing innovative effective agents for childhood malignancies. We report the activity in early phase paediatric oncology trials in Spain from its beginning to the present time and incorporate longitudinal data to evaluate the trends in trial characteristics and recruitment rates.

METHODS

Members of SEHOP were contacted to obtain information about the open trials at their institutions. The study period was split into two equal periods for analysis: 2007-2013 and 2014-2020.

RESULTS

Eighty-one trials and two molecular platforms have been initiated. The number of trials has increased over the time of the study for all tumour types, with a predominance of trials available for solid tumours (66%). The number of trials addressed to tumours harbouring specific molecular alterations has doubled during the second period. The proportion of industry-sponsored compared to academic trials has increased over the same years. A total of 565 children and adolescents were included, with an increasing trend over the study period. For international trials, the median time between the first country study approval and the Spanish competent authority approval was 2 months (IQR 0-6.5). Fourteen out of 81 trials were sponsored by Spanish academic institutions.

CONCLUSIONS

The number of available trials, and the number of participating patients, has increased in Spain from 2007. Studies focused on molecular-specific targets are now being implemented. Barriers to accessing new drugs for all ranges of age and cancer diseases remain. Additionally, opportunities to improve academic research are still required in Spain.

Supramolecular Control of Reactivity toward Hydrolysis of 7-Diethylaminocoumarin Schiff Bases by Cucurbit[7]uril Encapsulation

A series of aromatic Schiff bases, featuring 7-diethylamino-coumarin and with five different substituents at an adjacent phenyl ring, were synthesized and characterized. With the aim of assessing the stability of these dyes in acidic medium, their hydrolysis reactions were kinetically studied in the absence and presence of the macrocycle cucurbit[7]uril (CB[7]). Our results are consistent with a model containing three different forms of substrates (un-, mono-, and diprotonated) and three parallel reaction pathways. The pK a values and the rate constants were estimated and discussed in terms of the presence of a hydroxyl group at the ortho position and electron-releasing groups on the phenyl ring of the dyes. The kinetic study in the presence of CB[7] led to two different behaviors. Promotion of the reaction by CB[7] was observed for the hydrolysis of the Schiff bases containing only one coordination site toward the macrocycle. Conversely, an inhibitor effect was observed for the hydrolysis of a Schiff base with two coordination sites toward CB[7]. The latter effect could be explained with a model as a function of a prototropic tautomeric equilibrium and the formation of a 2:1 host/guest complex, which prevents the attack of water. Therefore, the kinetic results demonstrated a supramolecular control of the macrocycle toward the reactivity and stability of 7-diethylaminocoumarin Schiff bases in acidic medium.

Central nervous system relapse in high-risk stage 4 neuroblastoma: The HR-NBL1/SIOPEN trial experience

BACKGROUND

There is rising concern on the impact of new strategies, such as high-dose chemotherapy (HDC) and immunotherapy, on the pattern of relapse in high-risk neuroblastoma (HR-NBL). Our aim is to evaluate the incidence and identify risk factors for first recurrence in the central nervous system (CNS) in HR-NBL.

PATIENTS AND METHODS

Data from patients with stage 4V HR-NBL included from February 2002 to June 2015 in the prospective HR-NBL trial of the European International Society of Pediatric Oncology Neuroblastoma Group were analysed. Characteristics at diagnosis, treatment and the pattern of first relapse were studied. CNS imaging at relapse was centrally reviewed.

RESULTS

The 1977 included patients had a median age of 3 years (1 day-20 years); 1163 were boys. Among the 1161 first relapses, 53 were in the CNS, with an overall incidence of 2.7%, representing 6.2% of all metastatic relapses. One- and three-year post-relapse overall survival was 25 ± 6% and 8 ± 4%, respectively. Higher risk of CNS recurrence was associated with female sex (hazard ratio [HR] = 2.0 [95% confidence interval {CI}: 1.1-3.5]; P = 0.016), MYCN-amplification (HR = 2.4 [95% CI: 1.2-4.4]; P = 0.008), liver (HR = 2.5 [95% CI: 1.2-5.1]; P = 0.01) or >1 metastatic compartment involvement (HR = 7.1 [95% CI: 1.0-48.4]; P = 0.047) at diagnosis. Neither HDC nor immunotherapy was associated with higher risk of CNS recurrence. Stable incidence of CNS relapse was reported over time.

CONCLUSIONS

The risk of CNS recurrence is linked to both patient and disease characteristics, with neither impact of HDC nor immunotherapy. These findings support the current treatment strategy and do not justify a CNS prophylactic treatment.

Distribution of segmental chromosomal alterations in neuroblastoma

BACKGROUND

Neuroblastoma (NB) is a heterogeneous tumor with extremely diverse prognosis according to clinical and genetic factors such as specific combinations of chromosomal imbalances.

METHODS

Molecular karyotyping data from a national neuroblastic tumor database of 155 NB samples were analyzed and related to clinical data.

RESULTS

Segmental chromosomal alterations (SCA) were detected in 102 NB, whereas 45 only displayed numerical alterations. Incidence of SCA was higher in stage M (92%) and MYCN amplified (MNA) NB (96%). Presence of SCA was associated with older age, especially 1q gain and 3p deletion. 96% of the deaths were observed in the SCA group and 85% of the relapsed NB contained SCA. The alteration most commonly associated with a higher number of other segmental rearrangements was 11q deletion, followed by 4p deletion. Whole-chromosome 19 gain was associated with lower stages, absence of SCA and better outcome.

CONCLUSIONS

SCA are not randomly distributed and are concentrated on recurrent chromosomes. The most frequently affected chromosomes identify prognostic factors in specific risk groups. SCA are associated with older age and MNA. We have identified a small subset of patients with better outcome that share whole-chromosome 19 numeric gain, suggesting its use as a prognostic biomarker in NB.

Challenges in early phase clinical trials for childhood cancer during the COVID-19 pandemic: a report from the new agents group of the Spanish Society of Paediatric Haematology and Oncology (SEHOP)

PURPOSE

The COVID-19 pandemic has forced healthcare stakeholders towards challenging decisions. We analyse the impact of the pandemic on the conduct of phase I-II trials for paediatric cancer during the first month of state of alarm in Spain.

METHODS

A questionnaire was sent to all five ITCC-accredited Spanish Paediatric Oncology Early Phase Clinical Trial Units, including questions about impact on staff activities, recruitment, patient care, supply of investigational products, and legal aspects.

RESULTS

All units suffered personnel shortages and difficulties in enrolling patients, treatment continuity, or performing trial assessments. Monitoring activity was frequently postponed (73%), and 49% of on-going trials interrupted recruitment. Only two patients could be recruited during this period (75% reduction in the expected rate).

CONCLUSIONS

The COVID-19 crisis has significantly impacted clinical research practice and access to innovation for children with cancer. Structural and functional changes are under way to better cope with the expected future restrictions.

Li-Fraumeni syndrome heterogeneity

Clinical variability is commonly seen in Li-Fraumeni syndrome. Phenotypic heterogeneity is present among different families affected by the same pathogenic variant in TP53 gene and among members of the same family. However, causes of this huge clinical spectrum have not been studied in depth. TP53 type mutation, polymorphic variants in TP53 gene or in TP53-related genes, copy number variations in particular regions, and/or epigenetic deregulation of TP53 expression might be responsible for clinical heterogeneity. In this review, recent advances in the understanding of genetic and epigenetic aspects influencing Li-Fraumeni phenotype are discussed.

ECLIM-SEHOP, a new platform to set up and develop international academic clinical trials for childhood cancer and blood disorders in Spain

Introduction

Cancer and blood disorders in children are rare. The progressive improvement in survival over the last decades largely relies on the development of international academic clinical trials that gather the sufficient number of patients globally to elaborate solid conclusions and drive changes in clinical practice. The participation of Spain into large international academic trials has traditionally lagged behind of other European countries, mainly due to the burden of administrative tasks to open new studies, lack of financial support and limited research infrastructure in our hospitals.

Methods

The objective of ECLIM-SEHOP platform (Ensayos Clínicos Internacionales Multicéntricos-SEHOP) is to overcome these difficulties and position Spain among the European countries leading the advances in cancer and blood disorders, facilitate the access of our patients to novel diagnostic and therapeutic approaches and, most importantly, continue to improve survival and reducing long-term sequelae. ECLIM-SEHOP provides to the Spanish clinical investigators with the necessary infrastructural support to open and implement academic clinical trials and registries.

Results

In less than 3 years from its inception, the platform has provided support to 20 clinical trials and 8 observational studies, including 8 trials and 4 observational studies where the platform performs all trial-related tasks (integral support: trial setup, monitoring, etc.) with more than 150 patients recruited since 2017 to these studies. In this manuscript, we provide baseline metrics for academic clinical trial performance that permit future comparisons.

Conclusions

ECLIM-SEHOP facilitates Spanish children and adolescents diagnosed with cancer and blood disorders to access state-of-the-art diagnostic and therapeutic strategies.

Spectroscopic, photochromic and kinetic behavior of photo conversion of Aberchrome 540™ in an ionic liquid media

The photo-bleaching reaction of the chemical actinometer, Aberchrome 540™, is reported for the first time in a series of ionic liquids (ILs). This fulgide in its C-form undergoes an opening reaction to yield its E-form, when it is irradiated with UV light at wavelengths >400 nm. The magnitude of bleaching was monitored spectrophotometrically and their kinetics evaluated, obtaining first-order rate constants (k_obs). The results obtained in different ILs suggest that changes in the rate constants (k_obs) of the opening reaction of Aberchrome 540™ are mainly governed by weaker interactions such as coulombic (π* parameter) and Van der Waals interactions (δ_H², parameter). In addition, the photochemical fatigue resistance was also studied in ILs media and compared with conventional solvents (benzene, toluene, etc.). In particular, we found that three different tendencies dependent on the ILs used exist. The first group of ILs where the reversibility of the fulgide is favored (for example, [Bmim][BF₄], [Bmim][PF₆] and [Bmim][OTf]), behaviour similar to conventional solvents. The second group corresponds to ILs where photo reversibility is partial; and finally, other group of ILs that prevented photo reversibility. It is proposed that depending on the ILs used, the stabilization of different forms of the fulgide can be controlled, thus resulting important in terms of choosing the appropriate ILs for a specific photochemical reaction.

Retinoblastoma: towards an earlier diagnosis

OBJECTIVES

The number of enucleations and visual sequels due to retinoblastoma is high. The aim of this study was to evaluate the different diagnostic aspects and propose strategies that might improve the clinical management of this condition.

METHOD

A retrospective study was conducted on 38 patients with retinoblastoma studied genetically (29 unilateral, 9 bilateral). The evaluation included: age of onset, clinical signs, and time since onset, number of enucleations, time to diagnosis, and survival at 5 years.

RESULTS

Leukocoria was the main clinical sign (present in 90% of cases). The mean diagnostic delay was 3.2 months. Among the unilateral cases, the eyes were enucleated in 76%, and 55% in the bilateral forms. Only one death was found among the 25 patients followed-up for at least 5 years.

CONCLUSIONS

Retinoblastoma diagnostic and treatment strategies need to be updated. Good coordination between paediatricians and ophthalmologists is essential for this. Its management in reference centres, which have the necessary technology and experience, should contribute to increase the rate of organ preservation.

Survey on paediatric tumour boards in Europe: current situation and results from the ExPo-r-Net project

BACKGROUND

Under the ExPO-r-NeT project (European Expert Paediatric Oncology Reference Network for Diagnostics and Treatment), we aimed to identify paediatric oncology tumour boards in Europe to investigate the kind of technologies and logistics that are in place in different countries and to explore current differences between regions.

METHODS

A 20-question survey regarding several features of tumor boards was designed. Data collected included infrastructure, organization, and clinical decision-making information from the centres. The survey was distributed to the National Paediatric Haematology and Oncology Societies that forwarded the survey to the sites. For comparative analysis, respondents were grouped into four geographical regions.

RESULTS

The questionnaire was distributed amongst 30 countries. Response was obtained from 23 (77%) that altogether have 212 paediatric oncology treating centres. A total of 121 institutions answered (57%). Ninety-one percent of the centres hold multidisciplinary boards; however, international second consultations are performed in 36% and only 15% participate on virtual tumor boards. Videoconferencing facilities and standard operational procedures (SOPs) are available in 49 and 43% of the centres, respectively. There were statistically significant differences between European regions concerning meeting infrastructure and organization/logistics: specific room, projecting equipment, access to medical records, videoconferencing facilities, and existence of SOPs.

CONCLUSION

Paediatric tumor boards are a common feature in Europe. To reduce inequalities and have equal access to healthcare, a virtual network is needed. Important differences on the functioning and access to technology between regions in Europe have been observed and need to be addressed.

Controlled keto–enol tautomerism of coumarin containing β-ketodithioester by its encapsulation in cucurbit[7]uril

CB7 shifts the tautomeric equilibrium of CAM2, from the enol- to keto-form, whereas β-CD maintains the enol form.

Paediatric tumour boards in Spain: a national survey

PURPOSE

Multidisciplinary tumour boards (MDTs) are conducted worldwide for the management of patients with cancer, and they deliver a higher standard of care by simultaneously involving different specialists in diagnosis and treatment planning. However, information of paediatric MDTs functioning is scarce. A pilot study was conducted in Spain in the frame of the European Expert Paediatric Oncology Reference Network for Diagnostics and Treatment (ExPO-r-Net).

METHODS

A specific questionnaire was designed regarding various features of MDT practice. Data collected included information on the centres and the team, infrastructure for meetings, MDT organization/logistics and clinical decision-making. The survey was distributed to all Paediatric Oncology Units that register patients in the Spanish Registry of Childhood Tumours (RETI-SEHOP).

RESULTS

32 out of 43 contacted centres responded the questionnaire (74 % response rate; 88 % response rate for centres with >25 new patients/year). All units with >25 new patients/year have a dedicated Paediatric MDT compared to 76 % of units with ≤25 new patients/year. MDTs should be improved at institutional level by clear protected time in service planning for all specialists involved, incentives for attendance and attendance registration. Clinical decision-making process and follow-up of recommendation adherence should be assessed and potential legal responsibilities for physicians participating in Tumour Board defined. Network collaboration through virtual MDTs, using available videoconferencing tools, is an opportunity to share expertise among centres.

An unusual mulinane diterpenoid from the Chilean plant Azorella trifurcata (Gaertn) Pers

Four new mulinane-type diterpenoids besides the known compounds mulin-11,13-dien-20-oic acid, 13α-hydroxyazorellane, 13β-hydroxyazorellane, mulinolic acid, azorellanol, and mulin-11,13-dien-18-acetoxy-16,20-dioic acid were isolated from the Chilean plant Azorella trifurcata. One of the new metabolites isolated, 7α-acetoxy-9-epi-13β-hydroxymulinane, possesses a new trans-syn-trans arrangement in a tricyclic ring system not previously encountered in nature. Among the mulinane diterpenoids isolated, mulin-11,13-dien-20-oic acid showed the gastroprotective effect on HCl-EtOH-induced gastric lesions in mice (ED50 = 55 mg kg(-1)). Regarding the mode of gastroprotective action for this active compound, its effect was reduced by pre-treatment of the mice with indomethacin and N-ethylmaleimide, suggesting that prostaglandins and sulfhydryl compounds are positively involved in the gastroprotective activity using this model.

Spectral and kinetic properties of radicals derived from oxidation of quinoxalin-2-one and its methyl derivative

The kinetics and spectral characteristics of the transients formed in the reactions of •OH and •N3 with quinoxalin-2(1H)-one (Q), its methyl derivative, 3-methylquinoxalin-2(1H)-one (3-MeQ) and pyrazin-2-one (Pyr) were studied by pulse radiolysis in aqueous solutions at pH 7. The transient absorption spectra recorded in the reactions of •OH with Q and 3-MeQ consisted of an absorption band with λmax = 470 nm assigned to the OH-adducts on the benzene ring, and a second band with λmax = 390 nm (for Q) and 370 nm (for 3-MeQ) assigned, inter alia, to the N-centered radicals on a pyrazin-2-one ring. The rate constants of the reactions of •OH with Q and 3-MeQ were found to be in the interval (5.9-9.7) × 109 M-1·s-1 and were assigned to their addition to benzene and pyrazin-2-one rings and H-abstraction from the pyrazin-2-one nitrogen. In turn, the transient absorption spectrum observed in the reaction of •N3 exhibits an absorption band with λmax = 350 nm. This absorption was assigned to the N-centered radical on the Pyr ring formed after deprotonation of the respective radical cation resulting from one-electron oxidation of 3-MeQ. The rate constant of the reaction of •N3 with 3 MeQ was found to be (6.0 ± 0.5) × 109 M-1·s-1. Oxidation of 3-MeQ by •N3 and Pyr by •OH and •N3 confirms earlier spectral assignments. With the rate constant of the •OH radical with Pyr (k = 9.2 ± 0.2) × 109 M-1·s‒1, a primary distribution of the •OH attack was estimated nearly equal between benzene and pyrazin-2-one rings.

Dexamethasone does not reduce length of hospitalization or recurrent wheezing 1 year after early bronchiolitis

AIM

It has been suggested that a 6-day dexamethasone course combined with adrenaline may significantly reduce the admission rate in outpatients. It has also been suggested that prednisolone may reduce recurrent wheezing. Our aim was to investigate whether treatment with steroids, especially high dose dexamethasone, is associated with the length of hospitalization or with recurrent wheezing.

METHODS

A prospective-retrospective observational study was performed from January 2009 to December 2011 in a secondary care hospital. Eighty previously healthy patients aged 7-180 days who were hospitalized with a first episode of acute bronchiolitis (AB) were studied. AB treatment was at the attending physician's discretion, among those tested for AB with some benefit. Eligible drugs included bronchodilators and steroids. Primary short-term outcome studied was days of hospitalization. Primary long term outcome was "recurrent wheezing".

RESULTS

Median length of hospitalization was 6 days for all groups. Patients treated with dexamethasone (1 mg/kg/day for 1 day, plus 0.6 mg/kg/day for 5 days) had an average length of hospitalization of 6.8 ± 3.1 (range, 4-20) days, those on prednisolone (prednisolone 1-2 mg/kg/day for 5 days) 7.0 ± 2.6 (range, 4-12) days and those with no steroids 6.6 ± 3.3 (3-21) days (no significant differences). The analysis showed no evidence of association of any management schedule with recurrent wheezing. After adjusting long-term outcome variables for potential confounders, comparisons remained no different.

CONCLUSION

High dose dexamethasone or medium-dose prednisolone during AB provided no benefit in a short or long-term period in young, previously healthy hospitalized infants.

Phase II single-arm study of irinotecan in combination with temozolomide in children with recurrent or refractory medulloblastoma

10018

Background: Irinotecan and temozolomide have demonstrated moderate single agent activity in childhood medulloblastoma (MB). Using the recommended dose established from a prior pediatric phase I study, the combination of irinotecan and temozolomide was investigated in relapsed MB. Methods: Patients aged 6 months to 18 years with radiological measurable relapsed/refractory MB were treated with temozolomide 100–125 mg/m2/day on days 1–5 orally and irinotecan 10 mg/m2/day on days 1–5 and days 8–12 intravenously. After cycle 5, patients who did not progress could receive irinotecan 125 mg/m2 once weekly on days 1 and 8 of the 3-week cycle. The primary objective was confirmed tumor response (partial or complete) after 4 cycles of treatment. According to a two-stage Optimum Simon design, at least 6 of the first 15 evaluable subjects were to have a confirmed objective response, to proceed to stage 2; a total of 19 responses in 46 subjects are required for success. A central radiological review determined tumor response in all patients. Results: Preliminary results are reported on 33 patients entered from May 2007 through to November 2008 in 19 treatment centers. The median age was 9 years (range 2 to 17 years); 23 male and 10 female. The number of relapsed patients with M3:M2:M1:M0 (Chang M stage) were 10:15:2:6, and 17 had more than 1 prior therapy. Previous treatment included chemotherapy, 7 with high-dose regimens, and craniospinal (CSI) (n=30) or posterior fossa irradiation (n=2). Central radiological review is ongoing: 16/26 reviewed patients were evaluable for response. Six patients had confirmed PR, 3 had SD, and 7 had PD. To date, 10 patients have been excluded after central review (8, poor imaging; 2, no measurable disease). Toxicity has been manageable with dose reduction required in 11/33 MB patients, all of these had received prior CSI. The study is ongoing in stage 2 and centrally verified results will be reported at the Meeting. Conclusions: This multi-centre international study is the largest phase II trial of the irinotecan and temozolomide combination in pediatric central nervous system tumors. The activity of the combination in heavily pre-treated recurrent MB patients is promising.

[Table: see text]

Photophysics and photochemistry of naphthoxazinone derivatives

The photophysics and photochemistry of a series of naphthoxazinones have been studied using a combination of methods ranging from steady-state and time-resolved spectroscopic techniques to product analysis. The photophysics of naphthoxazinone derivatives is very dependent on the structure: phenanthrene-like compounds exhibit higher fluorescence quantum yield than the less aromatic anthracene-like homologous. The latter, exhibit a substantial degree of charge transfer in the excited singlet state. These compounds are fairly photostable in the absence of additives, yielding a single photoproduct arising from the triplet state. The presence of electron donors such as amines increases the photoconsumption quantum yield and changes the product distribution, the primary photoproduct being a dihydronaphthoxazinone that photoreacts further yielding ultimately an oxazoline derivative.

Tumour banks in pediatric oncology

INTRODUCTION

The information offered by the new genomic and proteomic techniques will play a central role in our knowledge of cancer; but it is limited by the lack of available tissue samples. Cancer in children is a sum of infrequent diseases, so tumor banks are support tools for translational research, providing access to a sufficiently large series of samples, which would minimize the asymmetric effect of the diverse origin.

MATERIAL AND METHODS

From 2003 a Molecular Pathology Network in Pediatric Solid Tumors Netwoks exists in Spain, and we are a part of it. Our aim was to create a pediatric tumor bank program and consensus documents about its use.

RESULTS

Standard Operating Procedures for collection and transport of samples have been created.

CONCLUSIONS

Thinking about the fast progress in Molecular Biology and the low frequency in pediatric tumors, it is vital to consider the importance of a bio bank.

Long-term results of high-dose chemotherapy and autologous stem cell rescue for high-risk neuroblastoma patients: a report of the Spanish working party for BMT in children (Getmon)

The authors retrospectively analyzed the long-term outcome of 67 patients over 1 year of age at diagnosis with high-risk neuroblastoma (stage 4 or stage 3 with N-myc amplification) who were treated with megatherapy and stem cell rescue from 1984 to 1998. Median age at transplant was 4 years (range 1.6-15 years). The source of cells was peripheral stem cells in 29 and bone marrow in 38 patients. In 12 patients, an in vitro purging of bone marrow harvest was performed. Most patients were conditioned with melphalan, BCNU, and VM-26. After transplant 19 patients received complementary treatment with IL-2 (16) or 13-cis-retinoic acid (3). Six patients (8%) died from transplant-related toxicity and 39 from disease progression. Three patients were alive with active disease at the time of analysis. Nineteen patients are alive and disease-free at a median follow-up of 104 months. Five-year event-free survival is 0.30. Survival of patients who received a purged graft was not significantly better than the rest. Post-transplant complementary treatment significantly improved overall and event-free survival (p = .01 and p = .04, respectively).

Allogeneic PBPC transplantation in children

BACKGROUND

While PBPC are being used increasingly as a source of stem cells in allotransplantation, the published experience in pediatric donor-recipient pairs is limited. Our aim was to evaluate the mobilization of PBPC in healthy child donors and the outcome of child recipients undergoing allogeneic PBSC transplant.

METHODS

Eight children with malignancies AML (one), refractory anemia with excess blasts in transformation (RAEBt) (one), ALL (four), NHL (one) and neuroblastoma (one)] were grafted with PBPC from HLA-identical sibling donors (seven patients) or from a 2-antigen mismatched donor (one case). Donors, aged 1-15 years underwent leukapheresis after mobilization with G-CSF (10-15 g/kg/day, 4 days). The extracorporeal line was primed in five cases (four with HSA). Peripheral venous access was used in all except one infant. The harvests were cryopreserved in six cases. GvHD prophylaxis consisted of CsA plus MTX or methylprednisolone.

RESULTS

No adverse effects related to G-CSF administration, nor procedure-related complications were observed. Median number of CD34(+) cells harvested was 5.18 x 10(6)/kg (range, 2.56-6.40), after one (five cases) or two (three cases) leukaphereses. All patients engrafted. The median time to achieve an ANC > 0.5 x 10(9)/L was 11 days (range 9-13) and a platelet count of > 50 x 10(9)/L was 18 days (range 13-45). Six patients did not develop any acute GvHD and three developed chronic GvHD. After a median follow-up of 18 months (14-44 months), six patients are alive and five in complete remission.

DISCUSSION

Allogeneic PBPC transplantation has shown to be a safe and successful procedure for pediatric donor and recipient pairs.

[Bone scintigraphy and somatostatin receptor scintigraphy in pediatric patients with bone involvement in Langerhans cell histiocytosis]

Langerhans cell histiocytosis (LCH) is a granulomatous disease which can involve multiples sites of the body. Diagnostic imaging is of utmost importance in the management of these patients. Up to now radiographic skeletal survey and bone scintigraphy (BS) have been used to assess bone involvement (both with low specificity). Magnetic resonance imaging (MRI) and CT have been used to assess visceral involvement but with the limitation that they cannot give information about the functional status. Recently somatostatin receptor scintigraphy (SSRS) has been proposed to detect active lesions and to monitor response to treatment. The aim of this study is to assess bone and somatostatin receptor scintigraphy in the detection of bone involvement in LCH in children. Twenty scintigraphies (12 SSRS and 8 BS) were performed in seven patients (3 girls and 4 boys) aged at diagnosis: 18 month-12 years (mean age 6 years). The findings obtained in the scintigraphies were compared with clinical evolution and other imaging techniques. Bone scintigraphy detected all the LCH bone lesions, and discovered one unknown lesion. SSRS scintigraphy visualised the active lesions in 3 patients (clinical and other imaging techniques were also positive). SSRS was negative in one patient classified as disease free and another in clinical remission. SSRS detected 2 new unknown bone lesions, but could not detect LCH bone lesions confirmed in other imaging techniques in 2 patients. Somatostatin receptor and Bone scintigraphy can be used to detect active LCH bone lesions in children and can help to monitor response to treatment. Further studies with more patients are needed to confirm the diagnostic usefulness of these techniques.

Minimal Residual Disease in Neuroblastoma: To GAGE or not to GAGE

We assessed the utility of GAGE gene expression as a marker of minimal residual disease (MRD) in neuroblastoma. The GAGE gene family shows a high degree of homology (>90%), clustering into two subgroups. GAGE-1, -2, and -8 form one subset, almost identical among themselves, while GAGE-3 to -7 constitute the other subset. The entire GAGE family (GAGE-1-8) was studied by RT-PCR followed by Southern blotting to increase both the sensitivity and specificity of the technique. Surprisingly, expression of GAGE was detected in 59% of peripheral blood samples from normal controls (20/35) as well as in a similar proportion from neuroblastoma patients with localized disease (stages 1 and 2). The study of GAGE-1, -2, and -8 with specific primers lowered this percentage to 28% (10/35), of which only two (6%) showed a high level of expression (directly visualized after RT-PCR). We conclude that GAGE genes can show a variable, usually low level of illegitimate expression in normal blood cells, and therefore their use as MRD markers should be taken with caution.

Acute pancreatitis in childhood

AIM

to evaluate etiological agents involved in acute pancreatitis in children, as well as clinical, laboratory and radiological findings and the illness clinical course.

PATIENTS AND METHODS

we reviewed the cases of acute pancreatitis diagnosed over the last 15 years. The criteria used for cases to be included were acute abdominal pain, elevated serum amylase levels and/or ultrasound abnormalities in the pancreatic area in conscious patients, and the last two criteria in unconscious patients.

RESULTS

thirty-one children were included (average age 7.9 years, range 2-15; 55% males). Infection and gallstones were the most common causes (19 and 16 %, respectively). In all, 9.7% of cases were drug-related (valproic acid, L-asparaginase, azathioprine combined with high doses of methylprednisolone); 6.5% were traumatic in origin and another 6.5% was due to systemic diseases. In 35.5 % no cause was found (idiopathic). The most frequent symptoms were abdominal pain (90%) and emesis (38%). Amylase serum levels were elevated in all patients. Abdominal ultrasound scans were abnormal in 64%, with an increase in the pancreatic area in 48% and hypoechogenicity in 51%. Seven cases required surgical treatment (22%). Seven children had acute pancreatitis, and three of them died as a result of shock unrelated to pancreatitis. Relapse of disease occurred in 19% of patients.

CONCLUSIONS

acute pancreatitis should always be considered in children with abdominal pain. There are a wide variety of etiological factors and in a high percentage of patients no underlying cause is found. Prognosis is variable owing to the heterogeneity of the clinical course of this illness in children.

The role of surgery in stage IV neuroblastoma

BACKGROUND/PURPOSE

The importance of primary tumor resection in stage IV neuroblastoma is controversial. The authors analyzed prospectively the role of surgery in a multicentric series of stage IV neuroblastoma patients.

METHODS

Patients were studied according to the International Neuroblastoma Staging System (INSS) recommendations. Age, sex, location of the tumor, type of metastases, time of resection (initial or delayed), extension of resection, surgical complications, pathology, N-myc and Shimada classification results, relapses, and outcome were studied. After diagnosis, children received induction chemotherapy followed by delayed surgery and autologous stem cell transplantation or maintenance chemotherapy. Resection was classified as complete (C), greater than 90% (P1), greater than 50% (P2), less than 50% (P3), and biopsy (B).

RESULTS

Ninety-eight stage IV children were admitted in the study from June 1992 to July 1999. Seventy-six were older than one year, and in 78 the primary tumor was abdominal. Bone was the most common metastatic site followed by bone marrow. Initial biopsy was performed in 74 patients, and resection in 6, with one complication in each group. N-myc was amplified in 20 of 80 tumors, and Shimada was unfavorable in 45 of 67. Delayed surgery was performed in 70 cases, achieving gross total resection in 55 (79%); there were minor complications in 10%. Mean survival rate time was 50 months. Event-free survival rate (EFS) at 5 years for the entire series is 0.32, but 0.0 for children having biopsy only, 0.25 for less than 50% resection, 0.31 for 50% to 90% resection, 0.44 for greater than 90% resection, and 0.33 for complete resection. Differences were statistically significant only when compared with the biopsied group. EFS rate for infants was 0.56, but, again, there was no difference in relation to the type of resection. There were 46 relapses, 12 of them local, 7 of 20 N-myc-amplified tumors, and 4 of 60 not amplified (P <.005).

CONCLUSIONS

Biopsies of stage IV neuroblastoma allow safe assessment of N-myc and other biological factors on tumor tissue. Delayed surgery after chemotherapy is performed with a low rate of complications, achieving a good local control of disease. N-myc-amplified tumors have higher local relapse rates than nonamplified and therefore would need more intensive local treatment. The final outcome in these patients is determined more by metastatic relapses than by the degree of resection.

Herpesvirus-6 encephalitis complicated by Wernicke-Korsakoff syndrome in a pediatric recipient of unrelated cord blood transplantation

A 10-year-old girl with M2 acute myeloid leukemia underwent an unrelated cord blood transplantation in refractory first relapse. On day +13, after 48 hours with fever, she showed a measles-like rash, and on day +15, she began experiencing neurologic symptoms (headache, tremors, weakness, nystagmus, mild confusion, speaking, taste, and behavior disturbances, and focal seizures). She also had amnesia for recent events with disability to learn, mimicking Wernicke-Korsakoff syndrome. Computed tomography of the brain and cerebrospinal fluid (CSF) and electroencephalogram were nonspecific. We found human herpesvirus 6 (HHV-6) DNA in CSF and cytomegalovirus in bronchoalveolar lavage using polymerase chain reaction techniques. Treatment with ganciclovir and foscarnet was effective, with total resolution of symptoms.

Outcome of high-risk neuroblastoma using a dose intensity approach: improvement in initial but not in long-term results

BACKGROUND

Stage 4 and MYCN amplified (MNA) neuroblastoma in children have a poor prognosis. Our aim was to increase initial and long-term response in this population.

PROCEDURE

High-risk children were studied according to the International Neuroblastoma Staging System, then treated with high-dose cyclophosphamide and high-dose carboplatin, followed by surgery and autologous stem cell transplant or maintenance chemotherapy.

RESULTS

From June 1992 to December 1998, 83 children were admitted in the study (72 stage 4> 1 year, 5 stage 4 MNA infants, and 6 MNA stage 3 children); tumor tissue was obtained from 73, MYCN was performed in 65, being amplified in 21 (32%). Induction chemotherapy was administered in the expected time in 35% of patients. Its toxicity was mainly hematologic followed by infections, and there were 3 chemotherapy-related deaths. Delayed surgery was performed on 60 patients with complete or >90% resection in 80% of cases. Chemotherapy plus surgery produced some response in 90% of patients, 53% were in CR/VGPR; 49 children received autologous SCT, and 16 received maintenance chemotherapy for 9 months. Follow-up ranges are 1-87 months, mean 30 months. S and EFS at 4 years are 0.33 (SD 0.02).

CONCLUSIONS

High-dose cyclophosphamide and high-dose carboplatin are effective in the initial treatment of neuroblastoma; combined with surgery they produce some response in most patients. Nevertheless, the CR/VGPR rate reaches only 53%. Survival time has also been prolonged but most patients relapse with metastases.

[Value of 123I-MIBG scanning, neuron-specific enolase and serum ferritin in the diagnosis and follow-up of patients with neuroblastoma]

INTRODUCTION

The neuroblastoma (NB) is one of the most common pediatric malignant neoplasms. The most commonly used tumor markers in the diagnosis and follow-up of this tumor are the serum neuron-specific enolase (NSE), ferritin and lactic dehydrogenase and urinary vanillymandelic and homovanillic acid. The common imaging modalities are CT, MRI and 123I or 131I-meta-iodobenzylguanidine scintigraphy.

AIM

The aim of this study is to assess the value of 123I-meta-iodobenzylguanidine (MIBG) scintigraphy and serum determinations of NSE and ferritin in the diagnosis and evolution of NB patients.

MATERIAL AND METHODS

20 patients (8 female, 12 male) whose ages ranged from 2 months to 9 years with a mean age of 2.64 years diagnosed of NB. 47 123I-MIBG scans, 47 NSE determinations and 47 ferritin ones were selected.

RESULTS

At the time of diagnosis, 100% of the 123I-MIBG scans were positive. 65% of NSE determinations presented clearly pathological levels and 15% were very near to the cut-off point. Only 45% of the ferritin levels were increased. The differences between the lesions visible by 123I-MIBG scanning before and 3 months after treatment as well as NSE and ferritin levels were studied. When the Student's T test was applied, we found statistically significant pre and post-treatment differences in 123I-MIBG scanning and NSE. In the case of ferritin, there was no statistical significance in spite of the decrease in the values. The direct correlation and Spearman correlation between laboratory data and 123I-MIBG scanning as well as correlation between NSE and ferritin were also studied. There was a good correlation between 123I-MIBG and NSE and between NSE and ferritin. We have also studied the data in 7 relapses.

CONCLUSIONS

123I-MIBG scintigraphy and serum determination of NSE are two successful diagnostic tools for the diagnosis and evolution of NB patients.

Results of the cooperative protocol (N-III-95) for metastatic relapses and refractory neuroblastoma

BACKGROUND

Prognosis of relapsed and refractory neuroblastoma is uniformly fatal; new therapeutic approaches are needed.

PROCEDURE

Relapsed and refractory neuroblastoma patients were treated with continuous infusion chemotherapy combined with MIBG.

RESULTS

Over 4 years, 35 heavily pretreated patients were registered, 29 with bone or/and bone marrow metastases. Grade 3 or 4 hematologic toxicity was frequent, without toxic deaths. Sixteen patients responded. The probability of 5-year overall survival was 0.19.

CONCLUSIONS

This approach is feasible and toxicity manageable; it rescued some patients and prolonged their survival. It merits assay in newly diagnosed high-risk neuroblastoma patients.

Angiogenesis in neuroblastoma: relationship to survival and other prognostic factors in a cohort of neuroblastoma patients

PURPOSE

To study angiogenesis in neuroblastoma, using morphometric and computerized image analysis, and correlate the results with survival and other prognostic factors.

PATIENTS AND METHODS

Sixty-nine patients from the Spanish Cooperative Study for Neuroblastoma were studied. Tumoral angiogenesis was studied using an avidin-biotin immunoperoxidase technique with an anti-CD34 antibody. Vascular parameters (VPs) were analyzed by a computerized system. Statistical analysis was also performed.

RESULTS

Sixty-six samples had adequate tumoral tissue, and their tumoral vessels were counted. Endothelial cells were more prominent in pure neuroblastomas than in maturing and more mature tumors. VPs showed no statistical difference between the groups of patients as defined by the levels of the other prognostic factors in neuroblastoma: age, stage, histopathology, TRK-A, P-glycoprotein expression, or MYCN copy number. In patients who relapsed, tumors did not show statistically significant difference in VPs when compared with tumors from patients who did not relapse. There was also no difference in VPs in tumors from living patients when compared with tumors from deceased patients. Overall survival was 75%, and event-free survival was 55% at 50 months.

CONCLUSION

VPs could be adequately determined by a computerized system in neuroblastoma; however, VPs were not predictive of survival for our patients. In our patients, neither disseminated nor local relapses were influenced by the angiogenic characteristics of the tumors.

Prospective evaluation of the International Neuroblastoma Staging System (INSS) and the International Neuroblastoma Response Criteria (INRC) in a multicentre setting

The aim of this study was to classify prospectively a series of neuroblastoma tumours according to the International Neuroblastoma Staging System (INSS) and the International Neuroblastoma Response Criteria (INRC) and to evaluate the difficulties and pitfalls involved in a multicentre setting. Each hospital provided their data for central review. The surgical procedures and their complications were reported. Kaplan-Meier estimates of survival and event-free survival were calculated according to stage and response to therapy. From June 1992 to December 1996, 194 patients were included in the study, with a mean age of 2 years. Initial studies were performed according to INSS recommendations without major problems. INSS stage was correctly applied to all patients except for 9 (95%). Post-operative complications were observed in 15 patients (8.3%). Response to therapy (INRC) was studied in 63 stage 4 patients, 11 of whom were not classified correctly (17%). Differences in survival according to stage (INSS) and group of response to therapy (INRC) were statistically significant (P < 0.001). In conclusion the INSS was easy to use and separated different prognostic groups. Surgical complications and mortality did not increase in this series because of using the INSS. The feasibility of INRC was evaluated in a small series of stage 4 patients and the designation of response was problematic in a relatively high proportion of cases. The prognostic value of the different responses was highly significant, but less informative than had been hoped for.

Surgical treatment for neuroblastoma: complications during 15 years' experience

BACKGROUND/PURPOSE

Surgery plays an important role in neuroblastoma treatment. Although influence of resectability in survival has been studied deeply, reports about surgical complications are scant. The authors analyze retrospectively their experience in neuroblastomas (NB) diagnosed from 1980 to 1995.

METHODS

Clinical variables such as age, stage, location, presurgical chemotherapy, type, and extent of surgery were studied. Complications were classified according to the following criteria: time, type of surgery, and extent of resection.

RESULTS

Seventy-eight NB patients had surgery performed in our hospital. Mean age at diagnosis was 2.4 years (range, 0 to 11 years); 33 patients were under 1 year of age. Sixty-eight percent of the patients had advanced disease. Abdominal tumors were predominant. Sixty-three percent of the patients had chemotherapy before surgery, with shrinkage of the tumor in most of the cases (88%). Eighty-six surgical procedures were performed, 29 initially and 57 delayed. Complete resection was reached in 52 patients, partial in 19 patients, and seven patients underwent biopsy only. There were 42 surgical complications. Three of them were considered extremely serious (one death caused by cardiac arrest, one tumoral rupture, and one great vessel injury). Nephrectomies (n = 12) were the most frequent intraoperatory complications. Bernard-Horner syndrome (n = 5) and pleural effusions (n = 5) predominated in the postoperative period.

CONCLUSIONS

(1) Surgery in NB can be performed safely. (2) Nephrectomies can be necessary to achieve complete resection in some abdominal tumors. (3) Nephrectomies, Bernard-Horner syndrome, and pleural effusions were the most frequent complications in our patients. (4) Presurgical chemotherapy can lead to a wider and safer removal of locally advanced tumors.

A novel TP53 germ-line mutation identified in a girl with a primitive neuroectodermal tumor and her father

A search of TP53 mutations was undertaken in a series of 51 pediatric brain tumors. The only germ-line mutation was detected in a 9-year-old girl with a PNET. Her family history was unremarkable for neoplastic disease, except for the paternal grandfather, who died of a gallbladder carcinoma at an advanced age. The mutation was a thymine deletion at the first base of codon 241, leading to termination codon at position 246 that has not previously been reported. This mutation was found to be inherited from the proband's father, who was healthy at age 40. In the tumoral sample, loss of heterozygosity in several 17p markers was found, the only TP53 allele preserved in the tumor was the mutated one. The presence of two short tandem repeats and two different palindromic sequences spanning the deletion lead us to propose the predisposition of this region to forming a complex secondary structure during replication. Consequently, it could have facilitated the present deletion. Furthermore, six other short deletions affecting--partially or totally--the region implicated in the folding model that we propose have been described in the literature. These findings confirm that this sequence represents a hotspot of deletion in the TP53 gene.

[Solid ovarian tumors in childhood]

We evaluate our experience in solid ovarian tumors at the Children's Hospital La Fe. The main aims of the study were finding out relevant clinical data for a correct clinical approach, and the optimal surgical attitude in order to obtain tumor relieving with preservation of fertility when possible. A review of 28 girls under 14 years with solid ovarian tumors was carried out. Previous history, initial symptoms and signs, analytical and radiological explorations, treatment and evolution were analysed. 17 benign and 11 malignant tumors were found. Main clinical data were acute abdominal pain and palpation of a mass. Surgery was performed in all of them: salpyngo-oophorectomy in 23 and oophorectomy in 5, with tumoral resection. All patients survive, with periodic follow-up. We remark the frequency of acute abdominal pain as initial symptom of an ovarian tumor, and the importance of a surgical attitude that, intending to be curative, would preserve fertility.