Acute malnutrition is common in Malawian patients with a Wilms tumour: A role for peanut butter

Predictors of Adverse Outcomes Following Nephrectomy for Pediatric Renal Tumors: Analysis of National Surgical Quality Improvement Program-Pediatric Data

INTRODUCTION

This study aimed to characterize the 30-d outcomes of nephrectomies for renal tumors (RTs) in children and identify predictors of operative morbidity.

METHODS

We queried the National Surgical Quality Improvement Program-Pediatric database for children aged <18 y with RTs who underwent nephrectomy from 2012 to 2021. Relevant clinical variables relating to patient demographics, outcomes, and type of nephrectomy were extracted. The primary outcome variable was any major adverse outcome (MAO). The secondary outcome variable was intra- or post-operative transfusion of blood products. Multivariable logistic regression was conducted to identify possible predictors of the primary or secondary outcomes after multiple imputations to account for missing data.

RESULTS

We identified 1759 patients with a median age of 3.6 y (interquartile range: 1.9-5.8 y) and an equal sex distribution (51.4% female). Approximately 4.7% of patients had an MAO and 29.8% had a transfusion event. On multivariate regression, the predictors most strongly associated with MAO were a history of chronic lung disease (adjusted odds ratio [aOR] = 1.329, 95% confidence interval [CI] = 1.206-1.465), preoperative nutritional support (aOR = 1.129, 95% CI = 1.074-1.188), and prior inotropic support (aOR = 1.100, 95% CI = 1.010-1.198). A nephron sparing approach was associated with a slightly higher odds of both MAO (aOR = 1.044, 95% CI = 1.015-1.074) and intra-/post-operative transfusion (aOR = 1.109, 95% CI = 1.045-1.177).

CONCLUSIONS

Patients undergoing nephrectomy for RTs had low rates of surgical mortality and complications. A nephron sparing approach appeared to be associated with a slightly higher odds of operative morbidity-this may be because patients selected for nephron sparing surgery likely had higher stage, bilateral tumors, or a genetic predisposition to developing RTs.

Reflections on 20 years of the Wilms Africa project: Lessons learned and the way forward

Wilms tumour (WT) is one of the common and curable childhood cancer types included in the Global Initiative for Childhood Cancer (GICC) to monitor progress. Local evidence is key to finding effective and sustainable solutions to local challenges to improve care and survival. Local evidence generated by the Wilms Africa project is summarised with recommendations for the future.

Prevalence of Undernutrition Among Children and Adolescents with Cancer Living in Sub-Saharan African Countries: A Systematic Review and Meta-analysis

Objective. To systematically review studies to provide the pooled estimate of undernutrition among children and adolescents with cancer living in sub-Saharan African countries. Methods. The review followed the recommendations outlined in the PRISMA statement. Online searches were performed on electronic databases such as PubMed, Scopus, Embase, and Hinari; gray literature sources: such as Google, Google Scholar, and university repositories were also searched. A random effect model was used to drive the pooled prevalence, and was reported at a 95% Confidence Interval (CI). Heterogeneity was assessed using subgroup analysis and univariable meta-regression. The effect of each study on the overall prevalence was assessed using leave-one-out sensitivity analysis. In all the models, statistical significance was set at P-value <.05. Result. A total of 623 articles were identified, and 21 articles were retrieved for the final analysis. The overall pooled prevalence of undernutrition was 41.34% (95% CI: 31.64%, 51.04%). The highest prevalence of undernutrition was observed from studies that used Arm Muscle Area (AMC) for age to assess undernutrition: 61.66% (95% CI: 47.59%, 75.72%). The protocol for this review has been registered at PROSPERO (CRD42024510052). Conclusion. The prevalence of undernutrition in sub-Saharan African countries was considerably high. Therefore, policy directions and cost-effective approaches that sustainably address undernutrition among pediatric patients with cancers are needed.

Advances in the clinical management of high-risk Wilms tumors

Outcomes are excellent for the majority of patients with Wilms tumors (WT). However, there remain WT subgroups for which the survival rate is approximately 50% or lower. Acknowledging that the composition of this high-risk group has changed over time reflecting improvements in therapy, we introduce the authors' view of the historical and current approach to the classification and treatment of high-risk WT. For this review, we consider high-risk WT to include patients with newly diagnosed metastatic blastemal-type or diffuse anaplastic histology, those who relapse after having been initially treated with three or more different chemotherapeutics, or those who relapse more than once. In certain low- or low middle-income settings, socio-economic factors expand the definition of what constitutes a high-risk WT. As conventional therapies are inadequate to cure the majority of high-risk WT patients, advancement of laboratory and early-phase clinical investigations to identify active agents is urgently needed.

Risk of Surgical Intervention in Children with Diagnoses of Cancer and Preoperative Malnutrition: A National Analysis

BACKGROUND

Perioperative nutrition is a critical component of appropriate healing and recovery after surgery. We sought to identify perioperative risk in children with cancer and low preoperative hypoalbuminemia undergoing surgical intervention.

METHODS

We queried the 2015-2019 NSQIP-Peds datasets for children with a primary diagnosis of renal or hepatic malignancy undergoing surgical resection. Postoperative outcomes were evaluated for comparative risk between patients with low albumin (albumin<3.0 g/dL) and normal albumin within 30 days of their surgical procedure. Univariate analysis and multivariable logistic regression were conducted to identify perioperative risk in patients with hypoalbuminemia.

RESULTS

We identified 360 children with primary diagnosis of hepatic malignancy and 896 children with renal malignancy undergoing surgical resection. Of these, 77 children had hypoalbuminemia. Patients with renal or hepatic malignancy diagnosis and low albumin levels were more likely to experience postoperative dehiscence, need for TPN at discharge, postoperative bleeding or transfusion, unplanned reoperation, and unplanned readmission, based on univariate analysis (all P > 0.05). Postoperative bleeding, need for nutritional support at discharge, and unplanned readmission were each associated with hypoalbuminemia.

CONCLUSION

We demonstrate that low preoperative albumin is associated with significant perioperative risk. More attention should focus on perioperative nutritional status of children with cancer who are undergoing major resections.

Advances in the clinical management of high-risk Wilms tumors

Outcomes are excellent for the majority of patients with Wilms tumors (WT). However, there remain WT subgroups for which the survival rate is approximately 50% or lower. Acknowledging that the composition of this high-risk group has changed over time reflecting improvements in therapy, we introduce the authors' view of the historical and current approach to the classification and treatment of high-risk WT. For this review, we consider high-risk WT to include patients with newly diagnosed metastatic blastemal-type or diffuse anaplastic histology, those who relapse after having been initially treated with three or more different chemotherapeutics, or those who relapse more than once. In certain low- or low middle-income settings, socio-economic factors expand the definition of what constitutes a high-risk WT. As conventional therapies are inadequate to cure the majority of high-risk WT patients, advancement of laboratory and early-phase clinical investigations to identify active agents is urgently needed.

The Burden of Malnutrition in Childhood Cancer in Malawi - Risk Regardless of Age

Malnutrion among children with childhood cancer in low and middle income countries (LMICs) is prevelant. While national nutrition programs focus on children under 5 years, childhood cancer can occur regardless of their age. Through a single-center retrospective cohort in Lilongwe, Malawi, we aim to characterize the burden of age-related malnutrition among children diagnosed with cancer in Lilongwe, Malawi, and evaluate them for any associations with mortality. Four hundred and sixty-three children (63.5% ≥5 years and 58.3% males) were identified.The majority of children (63.3%) were malnourished; 23.1% had moderate acute malnutrition (MAM) and 40.2% had severe acute malnutrition (SAM). Malnutrition was more common in children ≥5 years (70.0%) compared to children <5 years (51.8%); p < 0.0001. Age <5 years (HR 1.6; 95%CI 1.1-2.3, p = 0.016) and presence of sever acute malnutrition (HR 1.6, 95%CI 1.1-2.3, p = 0.012) were both associated with increased mortality risk. Acute malnutrition was highly prevalent among children with cancer above 5 years of age. This age group is not prioritized among malnutrition programs in LMICs, hence there is a direct need to include children with cancer regardless of age in national nutrition guidelines in LMICs to give them acces to adequate nutritional support.

Wilms tumour

Wilms tumour (WT) is a childhood embryonal tumour that is paradigmatic of the intersection between disrupted organogenesis and tumorigenesis. Many WT genes play a critical (non-redundant) role in early nephrogenesis. Improving patient outcomes requires advances in understanding and targeting of the multiple genes and cellular control pathways now identified as active in WT development. Decades of clinical and basic research have helped to gradually optimize clinical care. Curative therapy is achievable in 90% of affected children, even those with disseminated disease, yet survival disparities within and between countries exist and deserve commitment to change. Updated epidemiological studies have also provided novel insights into global incidence variations. Introduction of biology-driven approaches to risk stratification and new drug development has been slower in WT than in other childhood tumours. Current prognostic classification for children with WT is grounded in clinical and pathological findings and in dedicated protocols on molecular alterations. Treatment includes conventional cytotoxic chemotherapy and surgery, and radiation therapy in some cases. Advanced imaging to capture tumour composition, optimizing irradiation techniques to reduce target volumes, and evaluation of newer surgical procedures are key areas for future research.

Efficacy of ready-to-use therapeutic food in malnourished children with cancer: Results of a randomized, open-label phase 3 trial

BACKGROUND

The adverse influence of undernutrition in children with cancer may be remediated by early nutritional intervention. This study assessed the efficacy of ready-to-use therapeutic food (RUTF) in improving nutritional status and reducing treatment-related toxicities (TRTs) in such children.

METHODS

In a randomized controlled phase-3 open-label trial, severely and moderately undernourished children with cancer were randomized 1:1 to receive standard nutritional therapy (SNT) or SNT+RUTF for 6 weeks. The primary outcome (weight gain >10%) and secondary outcomes (improved/maintained nutritional status, improved body composition) were assessed after 6 weeks. TRTs were assessed over 6 months.

RESULTS

Between July 2015 and March 2018, 260 subjects were enrolled, 126 were analyzable in both arms at 6 weeks. More children on RUTF had weight gain (98 [77.8%] vs. 81 [64.2%], p = .025) with a greater increase in fat mass as a percentage of body mass (median 2% [IQR -0.12 to 4.9] vs. 0.5% [IQR -1.45 to 2.27, p = .005]) but a greater loss of lean mass (median -1.86% [IQR -4.4 to 0.50] vs. -0.4% [IQR -2.4 to 1.4, p = .007]) compared to the SNT arm. Fewer subjects on the RUTF arm had episodes of severe infection (10.6% vs. 31%, p < .0001), treatment delays (17.7% vs. 39%, p < .0001), and severe mucositis (11% vs. 23.8%, p = .006) compared to the SNT arm. The odds of developing TRTs on the RUTF arm were lower even after adjusting for improvement in nutritional status.

CONCLUSIONS

RUTF is efficacious in improving weight gain and nutritional status in undernourished children with cancer and decreases TRTs. Incorporating RUTF into a healthy, balanced diet should be considered in undernourished children with cancer.

Sex Cord Stromal Tumors in Children and Adolescents: A First Report by The South African Children's Cancer Study Group (1990-2015)

OBJECTIVES

Pediatric sex cord stromal tumors (SCSTs) are extremely rare and there are no reported data from Africa. The authors evaluated the outcomes of children and adolescents with biopsy-proven SCSTs in preparation for the introduction of a national protocol.

MATERIALS AND METHODS

Retrospective data were collated from 9 South African pediatric oncology units from January 1990 to December 2015. Kaplan-Meier analysis was performed to estimate overall survival (OS) and event-free survival.

RESULTS

Twenty-three patients were diagnosed with SCSTs, 3 male and 20 female individuals, during the study period. Histologies included 1 thecoma, 9 Sertoli-Leydig cell tumors, and 13 juvenile granulosa cell tumors. Stage I tumors predominated (n=14; 60.9%), with 2 stage II (8.7%), 5 stage III (21.7%), and 2 stage IV tumors (8.7%). The upfront resection rate was 91.3% with no reported surgical morbidity or mortality and an OS of 82.1%. Chemotherapy approaches were not standardized. Most children (81.8%), except 2, had recognized platinum-based regimens. Chemotherapy-related toxicity was minimal and acceptable. Assessment of glomerular filtration rate and audiology assessments were infrequent and not standardized. Three patients were lost to follow-up.

CONCLUSIONS

Although the numbers in this cohort are small, this study represents the first national cohort in Africa. The 5-year OS of 82.1% was encouraging. Standardized management of rare tumors like SCSTs is critical to improve ensure OS and address potential long-term sequelae.

Wilms Tumor in Sub-Saharan Africa: Molecular and Social Determinants of a Global Pediatric Health Disparity

Wilms tumor (WT) is the most common renal malignancy of childhood. Global disparities in WT have been reported with the highest incidence and lowest overall survival occurring in sub-Saharan African nations. After a detailed search of PubMed, we reviewed available literature on WT in sub-Saharan Africa and summarized findings that explore biologic and social factors contributing to this alarming cancer health disparity. Access to care and treatment abandonment are the most frequently reported factors associated with decreased outcomes. Implementation of multidisciplinary teams, collaborative networks, and financial support has improved overall survival in some nations. However, treatment abandonment remains a challenge. In high-income countries globally, WT therapy now is risk-stratified according to biology and histology. To a significantly lesser extent, biologic features have been studied only recently in sub-Saharan African WT, yet unique molecular and genetic signatures, including congenital anomaly-associated syndromes and biomarkers associated with treatment-resistance and poor prognosis have been identified. Together, challenges with access to and delivery of health care in addition to adverse biologic features likely contribute to increased burden of disease in sub-Saharan African children having WT. Publications on biologic features of WT that inform treatment stratification and personalized therapy in resource-limited regions of sub-Saharan Africa have lagged in comparison to publications that discuss social determinants of health. Further efforts to understand both WT biology and social factors relevant to appropriate treatment delivery should be prioritized in order to reduce health disparities for children residing in resource-limited areas of sub-Saharan Africa battling this lethal childhood cancer.

Investigating Wilms' Tumours Worldwide: A Report of the OxPLORE Collaboration-A Cross-Sectional Observational Study

BACKGROUND

Childhood cancer is neglected within global health. Oxford Pediatrics Linking Oncology Research with Electives describes early outcomes following collaboration between low- and high-income paediatric surgery and oncology centres. The aim of this paper is twofold: to describe the development of a medical student-led research collaboration; and to report on the experience of Wilms' tumour (WT).

METHODS

This cross-sectional observational study is reported as per STROBE guidelines. Collaborating centres included three tertiary hospitals in Tanzania, Rwanda and the UK. Data were submitted by medical students following retrospective patient note review of 2 years using a standardised data collection tool. Primary outcome was survival (point of discharge/death).

RESULTS

There were 104 patients with WT reported across all centres over the study period (Tanzania n = 71, Rwanda n = 26, UK n = 7). Survival was higher in the high-income institution [87% in Tanzania, 92% in Rwanda, 100% in the UK (X² 36.19, p < 0.0001)]. Given the short-term follow-up and retrospective study design, this likely underestimates the true discrepancy. Age at presentation was comparable at the two African sites but lower in the UK (one-way ANOVA, F = 0.2997, p = 0.74). Disease was more advanced in Tanzania at presentation (84% stage III-IV cf. 60% and 57% in Rwanda and UK, respectively, X² 7.57, p = 0.02). All patients had pre-operative chemotherapy, and a majority had nephrectomy. Post-operative morbidity was higher in lower resourced settings (X² 33.72, p < 0.0001). Methodology involving medical students and junior doctors proved time- and cost-effective. This collaboration was a valuable learning experience for students about global research networks.

CONCLUSIONS

This study demonstrates novel research methodology involving medical students collaborating across the global south and global north. The comparison of outcomes advocates, on an institutional level, for development in access to services and multidisciplinary treatment of WT.

Prognostic Factors in Childhood Acute Myeloid Leukemia; Experience from A Developing Country

BACKGROUND

In the developed world, 5-years survival of childhood acute myeloid leukaemia (AML) has improved to 70%. However, the survival rates in the developing world are below 40%. The main contributing factors to these reduced survival rates are a late presentation, malnutrition and high treatment-related mortality.

AIM

To document the factors affecting treatment outcome of childhood AML at a tertiary care facility of Pakistan.

METHODS AND RESULTS

All newly registered cases of AML under 18 years of age from January 1, 2012 onwards who completed their treatment before November 30, 2019 were included. Data of 219 cases of AML containing 140 (63.9%) males and 79 (36.1%) females was analyzed. The mean age was 6.30 ± 3.66 years. Pallor was the commonest presenting features in 180 (82.2%) and M2 was the commonest French American-British (FAB) subtype in 103 (47.0%) cases. In univariate analysis, high white blood cells (WBC) count at presentation (P = .006), poor nutritional status (P = .005), unfavourable cytogenetics (P = .019), certain types of FAB AML subtype (P = .005), and use of etoposide in induction chemotherapy (P = .042) significantly adversely affected overall survival (OS). Neutropenic sepsis and bleeding were the major causes of treatment-related mortality. Response to induction chemotherapy was the most significant prognostic factor in the multivariate analysis (P = <.001). After a median follow-up of 40.96 ± 26.23 months, 5-year OS and DFS of the cohort were 40.6% and 38.3% respectively.

CONCLUSIONS

In this largest cohort of childhood AML from Pakistan, high WBC count at presentation, malnutrition, unfavourable cytogenetics and use of etoposide during induction chemotherapy were associated with decreased OS and DFS rates. Response to the induction chemotherapy was the most significant prognostic factor.

The influence of nutrition on clinical outcomes in children with cancer

Adequate and appropriate nutrition is essential for growth and development in children; all put at risk in those with cancer. Overnutrition and undernutrition at diagnosis raise the risk of increased morbidity and mortality during therapy and beyond. All treatment modalities can jeopardize nutritional status with potentially adverse effects on clinical outcomes. Accurate assessment of nutritional status and nutrient balance is essential, with remedial interventions delivered promptly when required. Children with cancer in low- and middle-income countries (LMICs) are especially disadvantaged with concomitant challenges in the provision of nutritional support. Cost-effective advances in the form of ready-to-use therapeutic foods (RUTF) may offer solutions. Studies in LMICs have defined a critical role for the gut microbiome in the causation of undernutrition in children and have demonstrated a beneficial effect of selected RUTF in redressing the imbalanced microbiota and improving nutritional status. Challenges in high-income countries relate both to concerns about the potential disadvantage of preexisting obesity in those newly diagnosed and to undernutrition identified at diagnosis and during treatment. Much remains to be understood but the prospects are bright for offsetting malnutrition in children with cancer, resulting in enhanced opportunity for healthy survival.

Review of nutritional status, body composition, and effects of antineoplastic drug disposition

The overall survival for children with cancer in high income countries is excellent. However, there are many disparities that may negatively affect survival, which are particularly problematic in low income countries, such as nutritional status at diagnosis and throughout therapy. Nutritional status as well as concomitant foods, supplements, and medications may play a role in overall exposure and response to chemotherapy. Emerging science around the microbiome may also play a role and should be further explored as a contributor to disease progression and therapeutic response. This article highlights some of these issues and proposes additional areas of research relevant to nutritional status and pharmacology that are needed in pediatric oncology.

Perspective: Creating the Evidence Base for Nutritional Support in Childhood Cancer in Low- and Middle-Income Countries: Priorities for Body Composition Research

There is a striking disparity in survival rates for children in low- and middle-income countries (LMICs) compared with high-income countries (HICs). Many of the contributing factors are preventable, including the comorbidity of malnutrition. There are emerging data that malnutrition, as reflected in body composition changes, impacts survival of cancer. However, not enough priority is given to nutrition management of children with cancer, particularly in LMICs. The primary purpose of this article is to review the current knowledge on childhood cancer and body composition in LMICs and identify priorities for future research into the interlinking associations between cancer, body composition, and clinical outcomes for childhood cancer patients. Evidence will ensure feasible and effective nutrition management is prioritized in childhood cancer centers in LMICs and contribute to improving outcomes for children with cancer.

The role of nutrition in pediatric oncology

Introduction: Obesity compromises survival in children with cancer in high-income countries (HICs) and is accompanied often by sarcopenia. In low and middle-income countries (LMICs), where the great majority of children live, the prevalence of under-nutrition is as high as 95% in those with cancer. Nutritional support improves clinical outcomes, including survival.Areas covered: This narrative review describes the evolution of attention to nutrition in children with cancer and the increasing understanding of this relationship. An initial focus on obesity in children with acute leukemias in HICs has been matched more recently by a recognition of the negative effect of under-nutrition on survival in children with cancer in LMICs. These observations have stimulated explorations of underlying mechanisms, including dysbiosis of the gut microbiome, and structured nutritional interventions to redress adverse outcomes.Expert opinion: Studies of the gut microbiome and metabolome have yielded important information on the pathogenesis of malnutrition in children, providing new avenues for interventions. Combinations of plant products that are inexpensive and readily available in LMICs have been shown to 'mature' the microbiome and the corresponding plasma proteome in children with acute malnutrition, offering the prospect of cost-effective remedies that are tested in children with cancer.

Reducing Surgical Site Infections During Otolaryngology Surgical Missions

OBJECTIVES

To determine what measures an otolaryngology-head and neck surgery team might adopt to decrease the incidence of surgical site infection (SSI) on a short-term surgical mission. Despite concerns about safety and efficacy, short-term surgical missions remain the predominant structure for humanitarian surgical care in low- and middle-income countries (LMIC). Hospitals in high-income countries strive to improve surgical outcomes through implementation of World Health Organization (WHO) safe surgery guidelines. Reduction of SSI risk is a key part of this effort.

METHODS

Literature review and practical experience.

RESULTS

WHO recommendations for reducing SSI are based largely on research done in the North America and Europe. LMIC populations are younger; comorbidities are fewer; infectious disease and trauma are prevalent; and delays in access to care are common. SSI are much more frequent in resource-limited settings. Recommendations regarding preoperative assessment, operating room environment, instrument sterilization, surgical antibiotic prophylaxis, surgical site preparation, gloving, draping, and postsurgical care are reviewed in the context of a surgical mission at a typical LMIC government hospital.

CONCLUSION

Many of the WHO guidelines on reduction of SSI are logical and applicable to the short-term surgical missions; others may need to be modified. Careful prospective data collection and clinical trials are needed to learn which interventions are valid and which should be changed.

LEVEL OF EVIDENCE

5 Laryngoscope, 130:1388-1395, 2020.

Improved outcome at end of treatment in the collaborative Wilms tumour Africa project

BACKGROUND

The Collaborative Wilms Tumour (WT) Africa Project has implemented an adapted WT treatment guideline in sub-Saharan Africa as a multi-centre prospective clinical trial. A retrospective, baseline evaluation of end-of-treatment outcome was performed for a 2-year period prior to the introduction of this guideline. The collaborative project aims to reduce both treatment abandonment and death during treatment to less than 10% for improving survival.

PROCEDURE

All participating centres obtained local Institutional Research Board (IRB) approval and implemented the adapted WT treatment guideline. End-of-treatment outcome was documented for 2 years. It was divided into alive without evidence of disease, treatment abandonment, death during treatment and persistent disease. The outcome of children enroled in the first 2 years of the prospective clinical trial has been compared to the outcome before the start of the project.

RESULTS

One hundred twenty-two patients were included in the baseline evaluation (2011-2012) and 133 in the first 2 years of the collaborative clinical trial (2014-2015). The percentage of patients alive without evidence of disease at the end of treatment increased from 52% (63/122) to 68% (90/133; P = 0.01). Treatment abandonment decreased from 23% (28/122) to 13% (17/133; P = 0.03). Death during treatment decreased from 21% (26/122) to 13% (17/133; P = 0.07).

CONCLUSION

This collaboration, using relatively simple and low-cost interventions, led to a significant decrease in treatment abandonment and increase in survival without evidence of disease at the end of treatment.

A framework to develop adapted treatment regimens to manage pediatric cancer in low- and middle-income countries: The Pediatric Oncology in Developing Countries (PODC) Committee of the International Pediatric Oncology Society (SIOP)

Many children with cancer in low- and middle-income countries are treated in hospitals lacking key infrastructure, including diagnostic capabilities, imaging modalities, treatment components, supportive care, and personnel. Childhood cancer treatment regimens adapted to local conditions provide an opportunity to cure as many children as possible with the available resources, while working to improve services and supportive care. This paper from the Adapted Treatment Regimens Working Group of the Pediatric Oncology in Developing Countries committee of the International Society of Pediatric Oncology outlines the design, development, implementation, and evaluation of adapted regimens and specifies levels of services needed to deliver them.

Effects of malnutrition on treatment-related morbidity and survival of children with cancer in Nicaragua

BACKGROUND

Most children with cancer live in resource-limited countries where malnutrition is often prevalent. We identified the relationship between malnutrition and treatment-related morbidity (TRM), abandonment of therapy, and survival of children with cancer in Nicaragua to better inform targeted nutritional interventions.

PROCEDURE

We conducted a retrospective review of patients aged 6 months to 18 years with newly diagnosed acute lymphoblastic leukemia, acute myeloid leukemia (AML), Wilms tumor, Hodgkin lymphoma, or Burkitt lymphoma (BL) who were treated between January 1, 2004, and December 31, 2007 at Children's Hospital Manuel de Jesus Rivera in Managua, Nicaragua. Statistical analysis examined the relations among nutritional status and cancer type, risk category, TRM, and event-free survival (EFS).

RESULTS

Sixty-seven percent of patients (189/282) were malnourished at diagnosis. Malnutrition was highest among patients with Wilms tumor (85.7%), BL (75%), and AML (74.3%). A total of 92.2% of patients (225/244) experienced morbidity during the first 90 days. Malnutrition was associated with severe infection (P = 0.033). Severely malnourished patients had ≥grade 3 TRM on more days (P = 0.023) and were more likely to experience severe TRM on >50% of days (P = 0.032; OR, 3.27 [95% CI, 1.05-10.16]). Malnourished patients had inferior median EFS (2.25 vs. 5.58 years; P = 0.049), and abandoned therapy more frequently (P = 0.015).

CONCLUSIONS

In Nicaragua, pediatric oncology patients with malnutrition at diagnosis experienced increased TRM, abandoned therapy more frequently, and had inferior EFS. Standardized nutritional evaluation of patients with newly diagnosed cancer and targeted provision of nutritional support are essential to decrease TRM and improve outcomes.

Nutritional status of children with Wilms' tumour on admission to a South African hospital and its influence on outcome

BACKGROUND

In developing countries up to 77% of children with cancer have been shown to be malnourished on admission. High rates of malnutrition occur due to factors such as poverty and advanced disease. Weight can be an inaccurate parameter for nutritional assessment of children with solid tumours as it is influenced by tumour mass. This study aimed to assess the prevalence of malnutrition amongst children with Wilms tumour (WT), the level of nutritional support received on admission and the influence of nutritional status on outcome.

METHODS

Seventy-six children diagnosed with WT and admitted to Inkosi Albert Luthuli Central Hospital between 2004 and 2012 were studied prospectively. Nutritional assessment was conducted using weight, height, mid-upper arm circumference (MUAC) and triceps skinfold thickness (TSFT) prior to initiating treatment. Outcome was determined 2 years after admission. Time until commencement of nutritional resuscitation and nature, thereof, were recorded.

RESULTS

Stunting and wasting was evident in 12% and 15% of patients, respectively. The prevalence of malnutrition was 66% when MUAC, TSFT and albumin were used. Malnutrition was not a predictor of poor outcome and did not predict advanced disease. The majority of patients (84%) received nutritional resuscitation within 2 weeks of admission.

CONCLUSIONS

When classifying nutritional status in children with WT, the utilisation of weight and height in isolation can lead to an underestimation of the prevalence of malnutrition. Nutritional assessment of children with WT should also include MUAC and TSFT. Early aggressive nutritional resuscitation is recommended.

A Framework for Adapted Nutritional Therapy for Children With Cancer in Low- and Middle-Income Countries: A Report From the SIOP PODC Nutrition Working Group

The utilization of adapted regimens for the treatment of pediatric malignancies has greatly improved clinical outcomes for children receiving treatment in low- and middle-income countries (LMIC). Nutritional depletion has been associated with poorer outcomes, increased abandonment of therapy, and treatment-related toxicities. Surveys have found that nutritional intervention is not incorporated routinely into supportive care regimens. Establishing nutritional programs based upon institutional resources may facilitate the incorporation of nutritional therapy into clinical care in a way that is feasible in all settings. We present a framework for establishing and monitoring of nutritional care based on the infrastructure of institutions in LMIC.

Treating Nephroblastoma in Rwanda: Using International Society of Pediatric Oncology Guidelines in a Novel Oncologic Care Model

Purpose

Success in treating nephroblastoma in high-income countries has been transferred to some resource-constrained settings; multicenter studies report disease-free survival of greater than 70%. However, few reports present care models with rural-based components, care tasks shifted to internists and pediatricians, and data collection structured for monitoring and evaluation. Here, we report clinical outcomes and protocol compliance for patients with nephroblastoma evaluated at Butaro Cancer Center of Excellence in Rwanda.

Patients and Methods

This retrospective study reports the care of 53 patients evaluated between July 1, 2012, and June 30, 2014. Patients receiving less than half of their chemotherapy at Butaro Cancer Center of Excellence were excluded.

Results

Of the 53 patients included, 9.4% had stage I, 13.2% had stage II, 24.5% had stage III, 26.4% had stage IV, and 5.7% had stage V disease; the remaining 20.8% had unknown stage disease from inadequate work-up or unavailable surgical report. The incidence of neutropenia increased with treatment progression, and the greatest proportion of delays occurred during the surgical referral phase. At the end of the study period, 32.1% of patients (n = 17) remained alive after treatment; 24.5% (n = 13) remained alive while continuing treatment, including one patient with recurrent disease; 30.2% (n = 16) died; and 13.2% (n = 7) were lost to follow-up.

Conclusion

Our findings confirm that nephroblastoma can be effectively treated in resource-constrained settings. Using an approach in which chemotherapy is delivered at a rural-based center by nononcologists and data are used for routine evaluation, care can be delivered in safe, novel ways. Protocol modifications to mitigate chemotherapy toxicities and strong communication between the multidisciplinary team members will likely minimize delays and further improve outcomes in similar settings.

Quality changes of stabilizer-free natural peanut butter during storage

The storage stability of preservative-free peanut butter was evaluated for changes in physicochemical quality including moisture content and water activity, microbiological properties, oxidative stability and textural quality in terms of spreadability and firmness. The study was conducted for 16 weeks at storage temperature of 10, 25 and 35 °C on natural and pure peanut butter produced from two varieties of peanuts, the Virginia and Spanish TMV-2 varieties of China and India origin, respectively. The peanuts were ground using a high speed grinder for 2.5 and 3.0 min to produce peanut butter without addition of other ingredient. The natural peanut butter exhibited stability and had acceptable microbial count during storage. Storage at 10 °C gave similar textural quality with commercial product until week 8 and without appreciable loss in oxidative stability until week 12. At higher storage temperatures of 25 and 35 °C, oxidative stability was shortened to 4 weeks of storage. Among the factors of storage temperature and time, grinding time and peanut variety, storage temperature had the most significant effects on quality changes of natural peanut butter.

The Collaborative Wilms Tumour Africa Project; baseline evaluation of Wilms tumour treatment and outcome in eight institutes in sub-Saharan Africa

AIM

Reported survival of Wilms tumour in sub-Saharan Africa is below 50%. A published International Society of Pediatric Oncology (SIOP) Pediatric Oncology in Developing Countries (PODC) consensus adapted treatment guideline is implemented as a multi-centre prospective clinical trial at eight centres in sub-Saharan Africa. A baseline evaluation has been done to help decide on priorities to improve outcome and to assess improvements over time.

METHODS

A retrospective chart review was performed of patients admitted with Wilms tumour in the three years (2011-2013) preceding the collaborative trial. Patient outcome at the end of treatment was documented for all patients diagnosed in 2011 and 2012. Outcome was classified as (1) alive, no evidence of disease; (2) alive with disease; (3) died during treatment and (4) incomplete treatment. Details on treatment facilities, staff and estimated cost of treatment are documented.

RESULTS

Every year 114-130 patients are diagnosed. The mean survival at end of treatment is 39% (69/176) ranging from 11% to 61%. Incomplete treatment is the most common cause of treatment failure with 31% (54/176), ranging from 14% to 48% between centres. Twenty-six percent (46/176) of patients died during treatment, ranging from 13% to 37%. Estimated cost of treatment for parents ranged from 100 US$ to 1100 US$ and was considered an important cause of failure to complete treatment.

CONCLUSION

Overall two year survival is estimated at 25%. Prevention of incomplete treatment is possible and will positively affect outcome. Sharing similar local challenges in this regional collaborative project helps to identify and implement feasible, sustainable and successful strategies.

Childhood cancer in Africa

The majority of children with cancer live in low- and middle-income countries (LMICs) with little or no access to cancer treatment. The purpose of the paper is to describe the current status of childhood cancer treatment in Africa, as documented in publications, dedicated websites and information collected through surveys. Successful twinning programmes, like those in Malawi and Cameroon, as well as the collaborative clinical trial approach of the Franco-African Childhood Cancer Group (GFAOP), provide good models for childhood cancer treatment. The overview will hopefully influence health-care policies to facilitate access to cancer care for all children in Africa.

Clinical trials to improve childhood cancer care and survival in sub-Saharan Africa

Over 80% of children with cancer live in low and middle-income countries where survival rates are much lower than high-income countries. Challenges to successful treatment of paediatric cancers in these countries include late presentation, malnutrition, failure to complete treatment and less-intense supportive care leading to increased treatment-related mortality and the need to reduce the intensity of treatment. Clinical trials can contribute to improved care and survival by providing objective information on the number of patients treated, accuracy of diagnosis, causes of treatment failure and the efficacy of specific interventions. Clinical trials can also help to build capacity (salary support and training), improve facilities (equipment) and fund treatment or essential associated costs (social support, nutritional support and follow-up care). In this article, we discuss our experience with clinical trials in Malawi and sub-Saharan Africa with emphasis on the treatment of children with Wilms tumour.

SIOP PODC: recommendations for supportive care of children with cancer in a low-income setting

These supportive care recommendations were prepared to guide doctors who practice in areas with significantly limited resources but who have sufficient infrastructure and training to treat children with cancer with curative intent. The success of any cancer treatment regimen depends largely on the availability and quality of supportive care and this also determines the intensity of treatment that can be delivered. We present practical recommendations on how to prevent infections, general nursing care, management of febrile neutropenia, nutritional assessment and support, treatment of co-infections and the social support to help prevent failure to complete treatment in resource poor settings.

Practical recommendations for the management of children with endemic Burkitt lymphoma (BL) in a resource limited setting

Treatment recommendations for endemic Burkitt lymphoma (BL) in settings with only minimum requirements for curative treatment (PODC setting 1) are described. The reported cure rate for endemic BL is usually <50%. Facilities within setting 1 differ. Three treatment schedules are proposed based on: (1) when accurate staging is not possible, (2) when staging is possible and for (3) relapses and poor responders to primary therapy. A literature review and personal experience were used to formulate the recommendations. Recorded 1-year event free survival was 48% for treatment 1, 61% for treatment 2, and 35% for the rescue treatment.

Global challenges in pediatric oncology

PURPOSE OF REVIEW

Reduction of child mortality is one of the Millennium Development Goals; as low-income and middle-income countries (LMICs) advance toward the achievement of this goal, initiatives aimed at reducing the burden of noncommunicable diseases, including childhood cancer, need to be developed.

RECENT FINDINGS

Approximately 200 000 children and adolescents are diagnosed with cancer every year worldwide; of those, 80% live in LMICs, which account for 90% of the deaths. Lack of quality population-based cancer registries in LMICs limits our knowledge of the epidemiology of pediatric cancer; however, available information showing variations in incidence may indicate unique interactions between environmental and genetic factors that could provide clues to cause. Outcome of children with cancer in LMICs is dictated by late presentation and underdiagnosis, high abandonment rates, high prevalence of malnutrition and other comorbidities, suboptimal supportive and palliative care, and limited access to curative therapies. Initiatives integrating program building with education of healthcare providers and research have proven to be successful in the development of regional capacity. Intensity-graduated treatments adjusted to the local capacity have been developed.

SUMMARY

Childhood cancer burden is shifted toward LMICs; global initiatives directed at pediatric cancer care and control are urgently needed. International partnerships facilitating stepwise processes that build capacity while incorporating epidemiology and health services research and implementing intensity-graduated treatments have been shown to be effective.

SIOP PODC: clinical guidelines for the management of children with Wilms tumour in a low income setting

Wilms tumour is a relatively common and curable paediatric tumour. Known challenges to cure in low income countries are late presentation with advanced disease, malnutrition, failure to complete treatment and limited facilities. In this article, management recommendations are given for a low income setting where only the minimal requirements for treatment with curative intent are available (setting 1). These include general management, supportive care, social support and registration of patients. Recommendations specific for Wilms tumour care include diagnostic procedures with emphasis on the role of ultrasonography, preoperative chemotherapy with a reduced dosage for malnourished children and postoperative chemotherapy based on surgical staging.

Management of children with a Wilms tumor in Malawi, sub-Saharan Africa

Wilms tumor has a survival rate of 85% to 90% in well-resourced countries. Malawi is a country in Sub-Saharan Africa with very limited resources. We evaluated the outcome of a treatment guideline including preoperative chemotherapy, supportive care, and strategies to enable parents to complete treatment. Between 2006 and 2011, 95 patients were initially diagnosed with a Wilms tumor; 11 were later excluded due to misdiagnosis. In 31% of patients, metastases were detected at presentation. Treatment outcomes in 8 patients with bilateral tumors and 3 patients who were referred after nephrectomy are analyzed separately. Treatment failed in 51% of 73 remaining patients. Reasons for failure were: 1) incomplete treatment (7%); 2) treatment-related deaths (15%); and 3) disease-related deaths (28%) with 11% unresectable tumors or metastases after preoperative chemotherapy and 17% relapse of disease. Projected survival is 46%. Challenges remain to improve survival for children with Wilms tumor in Malawi. Earlier diagnosis would reduce disease-related deaths as numbers of unresectable disease and relapse are high. Effective strategies, including social support, to enable parents to complete treatment need to be continued. Improved supportive care and nutritional support and possibly less intense preoperative chemotherapy are needed to reduce treatment-related deaths.

The efficacy and toxicity of SIOP preoperative chemotherapy in Malawian children with a Wilms tumour

BACKGROUND

In Malawi, preoperative chemotherapy for Wilms tumour is a logical strategy, but detailed information on toxicity and efficacy in such a resource limited setting has been unavailable.

PROCEDURE

Patients diagnosed with a unilateral Wilms tumour received preoperative chemotherapy-a two-drug 4-week regimen for localized disease and 6 weeks of a three-drug regimen for metastatic disease. Estimated maximum tumour diameter, decrease in tumour size, resectability, stage distribution and haematological toxicity during therapy were documented.

RESULTS

At diagnosis, 28% of 72 patients had an estimated maximum tumour diameter of more than 25 cm; 29% of patients had metastases. Eight children (11%) died during preoperative chemotherapy. More than half (59%) of the patients developed moderate neutropenia (neutrophils <1.0 × 10(9) /L; CTC grade 3) and 27% severe neutropenia (CTC grade 4 neutrophils <0.5 × 10.9/L). Grade 4 neutropenia occurred significantly more frequently in children receiving the three-drug regimen compared to the two-drug regimen; 50% (10/20) versus 15% (6/40) (P = 0.004). Fifty-seven percent of all patients had CTC grade 4 anaemia (Hb < 6.5 g/dL) during treatment. Most tumours (92%, 56/61) showed a response to chemotherapy but 14% (8/58) remained unresectable.

CONCLUSION

Preoperative chemotherapy for Wilms tumour causes considerable haematological toxicity and treatment-related mortality in malnourished Malawian children. A significant number of children have unresectable disease despite preoperative chemotherapy. To reduce treatment related mortality, consideration should be given to starting treatment with reduced doses in acutely malnourished patients.

The management of nephroblastoma with cavo-atrial disease at presentation: experience from a developing country

PURPOSE

To describe the management of cavoatrial extension of nephroblastoma in a developing country.

PATIENTS AND METHODS

Of 406 consecutive children with Wilms tumour, 40 (10%) presented with tumour extension into the inferior vena cava (IVC) (30), right atrium or right ventricle and form the inception cohort. Of this group, 17 (43%) had visceral metastases and two had bilateral synchronous tumours.

RESULTS

Neoadjuvant chemotherapy appropriate to the pre-operative stage caused reduction in intravascular tumour in 18 (45%) patients, allowing 3 children who had atrial tumour at presentation to be surgically managed without recourse to cardiopulmonary bypass. Neoadjuvant chemotherapy also provided a window of opportunity to assess and manage co-morbidity especially malnutrition. Of the inception cohort, 31 (78%) underwent surgical resection; 23 had simple cavotomy, one caval resection and seven resection under cardiopulmonary bypass. There was one post-operative death. 77% of resected specimen contained viable malignant cells despite one or more cycles of neoadjuvant chemotherapy. Retrograde extension into caval tributaries threatened the completeness of resection in all patients necessitating the addition of post-operative radiotherapy. Of nine patients who did not undergo resection, five died pre-operatively. Three of these children died of chemotherapy induced neutropaenic sepsis. Four patients refused surgical treatment. Twenty-three patients completed the post-operative treatment protocol (1,203 characters).

Strategies to improve care for children with cancer in Sub-Saharan Africa

Great progress has been made in the care of children with cancer in recent decades. Worldwide, more than 80% of children with cancer live in resource-limited countries where access to care is poor. Sub-Saharan Africa is the world's poorest region. Child mortality is high, caused by largely preventable and treatable conditions. Paediatric cancer accounts for only a small fraction of deaths and understandably receives little attention from local policy makers or global health agencies. The survival of children with cancer is very poor. Challenges to improving survival include advanced-stage disease at presentation, failure to start or complete treatment (abandonment), inadequate hospital infrastructure and medications, lack of trained health care providers, lack of cancer registration and follow-up and lack of treatment guidelines adapted to local medical facilities. We propose a stepwise approach that integrates paediatric cancer treatment with existing general paediatric care. Priority is given to interventions (improvement of supportive care, diagnostic facilities) that also improve general paediatric care. Minimal requirements for diagnostic procedures include complete blood counts, HIV and malaria tests, blood cultures, histopathology and simple imaging (X-ray and ultrasonography). Feasible interventions include adequate palliative care, curative treatment for Burkitt lymphoma and Wilms tumour and symptomatic treatment for Kaposi sarcoma.