Outcome of pediatric recurrent and refractory malignant solid tumors following ifosfamide/carboplatin/etoposide (ICE): A phase II study in a pediatric oncology centre in Brazil

The RELIVE consortium for relapsed or refractory pediatric hepatoblastoma and hepatocellular carcinoma: a scoping review of the problem and a proposed solution

Liver tumors account for approximately 2% of all pediatric malignancies. Children with advanced stages of hepatoblastoma (HB) are cured only 50-70% of the time while children with advanced hepatocellular carcinoma (HCC) have a <20% 5-year overall survival. This scoping review was performed to highlight the paucity of rigorous, reliable data guiding the management of relapsed pediatric HB or HCC. When these patients are enrolled on prospective trials, the trials are often histology-agnostic, exclude patients less than a year of age, lack a liquid formulary of the drug under study, exclude recipients of a solid organ transplant, and enroll only 1-2 patients limiting the ability to deduce efficacious regimens for current use or future study. We highlight the creation of a global pediatric consortium intended to source retrospective relapse data from over 100 institutions spanning 4 continents. The data collected from this effort will inform future relapse trials.

Chemotherapy-induced peripheral neuropathy in children and adolescent cancer patients

Brain cancer and leukemia are the most common cancers diagnosed in the pediatric population and are often treated with lifesaving chemotherapy. However, chemotherapy causes severe adverse effects and chemotherapy-induced peripheral neuropathy (CIPN) is a major dose-limiting and debilitating side effect. CIPN can greatly impair quality of life and increases morbidity of pediatric patients with cancer, with the accompanying symptoms frequently remaining underdiagnosed. Little is known about the incidence of CIPN, its impact on the pediatric population, and the underlying pathophysiological mechanisms, as most existing information stems from studies in animal models or adult cancer patients. Herein, we aim to provide an understanding of CIPN in the pediatric population and focus on the 6 main substance groups that frequently cause CIPN, namely the vinca alkaloids (vincristine), platinum-based antineoplastics (cisplatin, carboplatin and oxaliplatin), taxanes (paclitaxel and docetaxel), epothilones (ixabepilone), proteasome inhibitors (bortezomib) and immunomodulatory drugs (thalidomide). We discuss the clinical manifestations, assessments and diagnostic tools, as well as risk factors, pathophysiological processes and current pharmacological and non-pharmacological approaches for the prevention and treatment of CIPN.

Peripheral Nervous System Involvement in Non-Primary Pediatric Cancer: From Neurotoxicity to Possible Etiologies

Peripheral neuropathy is a well described complication in children with cancer. Oncologists are generally well aware of the toxicity of the main agents, but fear the side effects of new drugs. As chemotherapeutic agents have been correlated with the activation of the immune system such as in Chemotherapy Induced Peripheral Neuropathy (CIPN), an abnormal response can lead to Autoimmune Peripheral Neuropathy (APN). Although less frequent but more severe, Radiation Induced Peripheral Neuropathy may be related to irreversible peripheral nervous system (PNS). Pediatric cancer patients also have a higher risk of entering a Pediatric Intensive Care Unit for complications related to therapy and disease. Injury to peripheral nerves is cumulative, and frequently, the additional stress of a malignancy and its therapy can unmask a subclinical neuropathy. Emerging risk factors for CIPN include treatment factors such as dose, duration and concurrent medication along with patient factors, namely age and inherited susceptibilities. The recent identification of individual genetic variations has advanced the understanding of physiopathological mechanisms and may direct future treatment approaches. More research is needed on pharmacological agents for the prevention or treatment of the condition as well as rehabilitation interventions, in order to allow for the simultaneous delivery of optimal cancer therapy and the mitigation of toxicity associated with pain and functional impairment. The aim of this paper is to review literature data regarding PNS complications in non-primary pediatric cancer.

Sustained Remission After Maintenance Irinotecan in Patient With Multiply Relapsed Hepatoblastoma

Children with recurrent hepatoblastoma have a poor prognosis and limited treatment options. The authors describe a child with metastatic hepatoblastoma who had multiple relapses. He was treated with surgical resection and adjuvant chemotherapy at first relapse. At second relapse, he had progressive disease postresection. He was treated with ifosfamide/carboplatin/etoposide chemotherapy followed by maintenance irinotecan and achieved long-term disease-free survival. Irinotecan as maintenance should be explored in recurrent hepatoblastoma.

Risk-based treatment for patients with first relapse or progression of rhabdomyosarcoma: A report from the Children's Oncology Group

BACKGROUND

The purpose of this study was to evaluate risk and response-based multi-agent therapy for patients with rhabdomyosarcoma (RMS) at first relapse.

METHODS

Patients with RMS and measurable disease at first relapse with unfavorable-risk (UR) features were randomized to a 6-week phase 2 window with 1 of 2 treatment schedules of irinotecan with vincristine (VI) (previously reported). Those with at least a partial response to VI continued to receive 44 weeks of multi-agent chemotherapy including the assigned VI regimen. UR patients who did not have measurable disease at study entry, did not have a radiographic response after the VI window, or declined VI window therapy received 31 weeks of multi-agent chemotherapy including tirapazamine (TPZ) at weeks 1, 4, 10, 19, and 28. Favorable-risk (FR) patients received 31 weeks of the same multi-agent chemotherapy without VI and TPZ.

RESULTS

One hundred thirty-six eligible patients were enrolled. For 61 patients not responding to VI, the 3-year failure-free survival (FFS) and overall survival (OS) rates were 17% (95% confidence interval [CI], 8%-29%) and 24% (13%-37%), respectively. For 30 UR patients not treated with VI, the 3-year FFS and OS rates were 21% (8%-37%) and 39% (20%-57%), respectively. FR patients had 3-year FFS and OS rates of 79% (47%-93%) and 84% (50%-96%), respectively. There were no unexpected toxicities.

CONCLUSIONS

Patients with UR RMS at first relapse or disease progression have a poor prognosis when they are treated with this multi-agent therapy, whereas FR patients have a higher chance of being cured with second-line therapy.

Vincristine, irinotecan, and temozolomide treatment for refractory/relapsed pediatric solid tumors: A single center experience

BACKGROUND

Although the survival of pediatric cancer has increased dramatically in the last decades, the survival of refractory, relapsed, and metastatic cases is still dismal. The combination of irinotecan and temozolomide has shown activity against refractory/relapsed pediatric solid tumors.

METHOD

Thirty-four children with refractory/relapsed solid tumors who had previously been heavily pretreated and who were given vincristine, irinotecan, and temozolomide as third- or further line chemotherapy during 2004-2015 were evaluated.

RESULTS

Patients were diagnosed with Ewing sarcoma (n = 15), rhabdomyosarcoma (n = 8), neuroblastoma (n = 8), osteosarcoma (n = 2), and Wilms' tumor (n = 1). Thirty patients presented with disease progression on therapy and the other four presented with relapsing. A total of 141 cycles were administered. Radiotherapy was used in 17 patients and surgery in 4 as local therapy. Among all patients, 6 had complete response, 3 had partial response, 14 had stable disease, and 11 had progressive disease. The objective response was 26.4% (complete response + partial response) and median survival duration was six months. The first and second year overall survival rates were 22.3% and 16.8%. The objective response in Ewing sarcoma patients was 40%. Diarrhea was the most common toxicity and 14 (10%) courses were associated with grade 3-4 diarrhea.

CONCLUSIONS

In heavily pretreated patients with refractory/relapsed solid tumors, the vincristine, irinotecan, and temozolomide regimen seemed promising in Ewing sarcoma patients and was well tolerated.

Pilot study of ifosfamide/carboplatin/etoposide (ICE) for peripheral blood stem cell mobilization in patients with high-risk or relapsed medulloblastoma

OBJECTIVES

The purpose of this study is to evaluate the stem cell mobilization capacity, anti-tumor effect, and feasibility of ifosfamide/carboplatin/etoposide (ICE) for transplant-eligible patients with medulloblastoma.

MATERIALS AND METHODS

Six patients (23 months to 18 years old) with high-risk or relapsed medulloblastoma received one cycle of ICE, which consisted of ifosfamide at 1.8 g/m(2) for 5 days, carboplatin 400 mg/m(2) for 2 days, and etoposide 100 mg/m(2) for 5 days. Stem cells were mobilized with ICE followed by granulocyte colony-stimulating factor at 10 microg kg(-1) day(-1).

RESULTS

After one cycle of ICE, the median number of harvested CD34+ cells per apheresis session was 11.85 x 10(6) cells/kg (range, 0.2 to 71.2 x 10(6) cells/kg). Two patients obtained a complete response and three patients a partial response. All patients experienced severe myelosuppression, and three infectious toxicities were observed.

CONCLUSIONS

These results suggest that ICE is optimal for mobilizing stem cells, effective for high-risk or relapsed medulloblastoma, and tolerable with limited non-hematological toxicity.

Low prevalence of complications in severe neutropenic children with cancer in the unprotected environment of an overnight camp

BACKGROUND

The high risk of infection and other complications in severely neutropenic pediatric oncology patients receiving chemotherapy has led to development of a variety of preventive measures including isolation and diet restrictions. In order to examine the potential impact of these measures, we evaluated the outcomes of such patients attending a recreational summer camp.

METHODS

We collected data on all children who attended an overnight summer camp for children with cancer during the years 1999-2004, and who were either severely neutropenic or at a high-intensity phase of chemotherapy. Outcome measures included fever, bleeding, hospitalization, and clinical or laboratory evidence of infection. The observation period included both, the 2-week camp experience and 30 days post-camp.

RESULTS

The study group was comprised of 34 patients. Although nine (24%) were hospitalized for management of fever and neutropenia, only one patient had clinical or culture-positive evidence of an invasive infectious agent. No bleeding episode was recorded and most patients attended all camp activities.

CONCLUSIONS

Our results support the safety and feasibility of severely neutropenic patients with cancer to attend the non-isolated, non-sterile environment of a summer camp. These findings may be applicable to school and other social settings.

Current therapy for Wilms' tumor

Wilms' tumor was the first solid malignancy in which the value of adjuvant chemotherapy was established. Multimodality treatment has resulted in a significant improvement in outcome from approximately 30% in the 1930s to more than 85% in the modern era. Although the National Wilms' Tumor Study Group and the International Society of Pediatric Oncology differ philosophically regarding the merits of preoperative chemotherapy, outcomes of patients treated with either up-front nephrectomy or preoperative chemotherapy have been excellent. The goal of current clinical trials is to reduce therapy for children with low-risk tumors, thereby avoiding acute and long-term toxicities. At the same time, current clinical trials seek to augment therapy for patients with high-risk Wilms' tumor, including those with bilateral, anaplastic, and recurrent favorable histology tumors.

Medulloblastoma in the second decade of life: a specific group with respect to toxicity and management: a Canadian Pediatric Brain Tumor Consortium Study

BACKGROUND

Most reported data of chemoradiotherapy protocols for the treatment of medulloblastoma describe children who were treated in the first decade of life. To consider the feasibility of this approach in adolescents, the authors studied their clinical course with specific emphasis on toxicity, tolerability, and prognosis.

METHODS

In this retrospective study, the authors examined the toxicity profiles and outcomes of children age 10-20 years with medulloblastoma who were treated at centers throughout Canada between 1986 and 2003. Detailed toxicity data from 2 chemotherapy protocols were collected for teenagers and were compared with data from a group of control patients age 5-10 years.

RESULTS

In total, 72 teenagers were analyzed. Grade >/= 2 ototoxicity and neurotoxicity occurred in 45% and 71% of chemotherapy-treated patients, respectively. Grade 3-4 hematotoxicty occurred in 95% of patients. Toxicity resulted in delay of treatment for 73% of patients and dose modification in 75% of patients, including protocol discontinuation in 25% of patients. Weight loss > 10% was encountered in 73% of patients and required intervention in 45% of patients. Teenagers had significantly more hematotoxicity and neurotoxicity compared with controls on both chemotherapeutic protocols. Ototoxicity was similar in both age groups. Toxicity resulted in significantly more treatment delays and dose modifications in teenager patients compared with controls. The 5-year overall and event-free survival rates (+/- standard deviation) were 78% +/- 6% and 70% +/- 6%, respectively. The mean time (+/- standard deviation) to disease recurrence was 3.2 +/- 2.2 years.

CONCLUSIONS

The increased toxicity rate and high incidence of treatment modifications in this study suggested that current pediatric protocols may require modifications for teenagers with medulloblastoma. The results highlighted several issues that should be addressed in future prospective trials.

Spinal cord compression and lung metastasis of Wilms' tumor in a pregnant adolescent

Wilms' tumor in adults is rare, and no treatment guidelines have been established. Spinal cord compression has also been rarely reported in all age groups. In this case report, we present a 19-year-old adolescent with recurrent Wilms' tumor, a paraspinal dumbbell mass, metastatic involvement of the vertebral bodies, lung metastasis, and pregnancy. To our knowledge, this is the first report of a pregnant patient with Wilms' tumor who had to undergo immediate chemotherapy with vincristine and actinomycin-D owing to spinal cord compression at 25 weeks of pregnancy. After delivery, complete remission was maintained with a regimen of ifosfamide, carboplatin, and etoposide and vincristine, actinomycin-D, and cyclophosphamide. No teratogenic or other toxic effects of vincristine or actinomycin-D were observed in the fetus.

Infective endocarditis (IE) in children receiving treatment for cancer

Infective endocarditis (IE) is rare in children but is associated with substantial morbidity/mortality. Medical records of 161 new patients admitted to the Pediatric Oncology Unit in a 2 years period were reviewed to identify patients with a diagnosis of IE following the Duke criteria. Nine patients developed IE; their ages ranged from 2.4 to 11.3 years. The patients received treatment according to the results of blood cultures. TIPs are associated with a high rate of IE. The diagnosis of IE should be considered in children with cancer who have major/minor criteria as defined by the Duke criteria.