Improving outcome of acute lymphoblastic leukemia with a simplified protocol: report from a tertiary care center in north India

The Outcome of Pediatric Philadelphia Chromosome-Positive Acute Lymphoblastic Leukemia: Experience from a Referral Center in South India

Although improved survival in children with Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph-ALL) has been demonstrated in trials, the outcome appears to be inferior in low- and middle-income countries (LMIC). Methods A file review of children aged ≤ 15 years diagnosed with Ph-ALL from 2010 to 2019 was performed. Minimal residual disease (MRD) was assessed by flow-cytometry. Real-time polymerase chain reaction (qRT-PCR) was used to quantify the BCR::ABL1 transcripts during treatment. Results The mean age of the 20 patients in the study was 91 months. Of 19 patients in whom the BCR::ABL1 transcript was confirmed, 10(50%) had P210, 7(35%) had P190, and two showed dual expression. The mean dose of imatinib that was administered was 294 ± 41 mg/m2/day. qRT-PCR for BCR::ABL1 was < 0.01% in all patients who were in remission or had a late relapse and was ≥ 0.01% in patients who had an early relapse. Two patients underwent HSCT. The 3-year event-free survival (EFS) was 35.0 ± 10.7%. Patients with a good prednisolone response (GPR) and a negative end-of-induction MRD demonstrated a superior EFS to those who lacked either or both (80.0 ± 17.9% vs. 16.7 ± 15.2%, P = 0.034). Conclusion The 3-year EFS of 20 children with Ph-ALL treated with chemotherapy and TKI was < 50%. An unusually high proportion of patients with p210 transcript expression; sub-optimal TKI dosing and lesser intensity of chemotherapy, due to the concern of high treatment-related mortality in LMIC are possible reasons for the poor outcome. Conventional treatment response parameters such as GPR and MRD predict outcomes in Ph-ALL. qRT-PCR for BCR::ABL1 may have a role in predicting early relapse.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12288-023-01684-9.

Treatment-related mortality in children with cancer in low-income and middle-income countries: a systematic review and meta-analysis

BACKGROUND

Approximately 90% of children with cancer live in low-income and middle-income countries (LMICs), where 5-year survival is lower than 20%. Treatment-related mortality in high-income countries is approximately 3-5%; however, in LMICs, treatment-related mortality has been reported in up to 45% of children with cancer. This study aimed to systematically explore the burden of treatment-related mortality in children with cancer in LMICs and to explore the association between country income level and treatment-related mortality.

METHODS

For this systematic review and meta-analysis we identified articles published between Jan 1, 2010, and June 22, 2021, describing treatment-related mortality in paediatric patients (aged 0-21 years) with cancer in LMICs. We searched PubMed, Trip, Web of Science, Embase, and the WHO Global Metric Index databases. The search was limited to full-text articles and excluded case reports (<10 patients) and haematopoietic stem-cell transplantation recipients. Two reviewers independently screened studies for eligibility, extracted data from included publications, and evaluated data quality. Random and mixed-effects models were used to estimate treatment-related mortality burden and trends. The Cochran-Q statistic was used to assess heterogeneity between studies. This study is registered on PROSPERO (CRD42021264849).

FINDINGS

Of 13 269 identified abstracts, 501 studies representing 68 351 paediatric patients with cancer were included. The treatment-related mortality estimate was 6·82% (95% CI 5·99-7·64), accounting for 30·9% of overall mortality (4437 of 14 358 deaths). Treatment-related mortality was inversely related to country income. Treatment-related mortality was 14·19% (95% CI 9·65-18·73) in low-income countries, 9·21% (7·93-10·49) in lower-middle-income countries, and 4·47% (3·42-5·53) in upper-middle-income countries (Cochran-Q 42·39, p<0·0001). In upper-middle-income countries, the incidence of treatment-related mortality decreased over time (slope -0·002, p=0·0028); however, outcomes remained unchanged in low-income (p=0·21) and lower-middle-income countries (p=0·16).

INTERPRETATION

Approximately one in 15 children receiving cancer treatment in LMICs die from treatment-related complications. Although treatment-related mortality has decreased in upper-middle-income countries over time, it remains unchanged in LMICs. There is an urgent need for targeted supportive care interventions to reduce global disparities in childhood cancer survival.

FUNDING

American Lebanese Syrian Associated Charities and National Cancer Institute.

Early mortality continues to be a barrier to excellent survival in childhood acute promyelocytic leukemia: a retrospective study of 62 patients spanning 17 years

Data on childhood acute promyelocytic leukemia (APL) from low-and middle-income countries is limited. Early mortality is a concern and often not highlighted in clinical trials. The retrospective study was conducted on patients (≤12 years) with APL from 2003 to 2021 at a single center in India. Patients were treated with all-trans-retinoic acid (ATRA) and chemotherapy. Induction and three courses of consolidation were followed by maintenance for 2 years. In 2015, the protocol was updated with following modifications: (a) obtaining diagnostic cerebrospinal fluid at end-of-induction rather than at diagnosis, (b) administering intrathecal cytarabine regardless of risk-category, (c) risk-stratified administration of chemotherapy, and (d) inclusion of ATRA in all the cycles of consolidation. Sixty-two patients were diagnosed over the 17 years. The median age was 8 years (range: 0.9-12). Half had high-risk disease. Differentiation syndrome was observed in 32%, none being fatal. Eighteen (29%) patients died due to hemorrhage (83%) or septicemia (17%). Thirteen (21%) had early mortality (≤15 days), all due to hemorrhage. A platelet count <20 × 10⁹/L predicted early mortality (odds ratio: 4.5; 95% CI: 0.9-22, p = 0.06). Treatment abandonment reduced from 23.5% during 2003-2015 to nil during 2015-2021 (p = 0.006). Three (8%) patients relapsed. The 4-year OS of all patients and the patients who survived >15 days was 70.1% and 89.6%, respectively. The 4-year EFS, including abandonment and early mortality, before and following updated protocol, was 61.4% and 65.5%, respectively (p = 0.77). Early mortality continues to be a barrier to an otherwise excellent survival in childhood APL. A significant reduction in treatment abandonment in recent years is gratifying.

The Nutritional Trajectory of Children with Acute Lymphoblastic Leukemia: A 10-Year Follow up Study from a Referral Center in South India

OBJECTIVE

Survivors of childhood acute lymphoblastic leukemia (ALL) are vulnerable to late adverse events such as obesity and an associated metabolic syndrome.

METHODS

Children treated for ALL from 2002 to 2012 were included. BMI was calculated at diagnosis, end of treatment, and 5, 8, and 10-years from diagnosis. BMI-centiles were used to categorize the patients: underweight (<5th-percentile), normal (5th-85th percentile), overweight (85th-95th percentile), and obese (≥95th centile).

RESULTS

The study included 179 children with ALL (median age: 59-months). The proportions of patients who were underweight, normal, overweight/obese, were 37%, 56% and 7%, respectively, at diagnosis; and 15%, 51% and 34%, respectively, at 5-years from diagnosis. The median (IQR) BMI Z-score at diagnosis was -1.12(-2.40, -0.26). The median (IQR) BMI z-score of the cohort was higher after 5 [0.22(-0.83,1.24), P < 0.001] and 10-years of diagnosis [0.30(-0.69,0.99), P < 0.001], respectively. The proportion of overweight/obese individuals was higher after 5 (34%, P < 0.001) and 10 (26%, P = 0.001) years. There was a significant correlation between the baseline BMI Z-score and that observed after 5-years (ρ = 0.49, P < 0.001), and 10-years (ρ = 0.55, P < 0.001).

CONCLUSION

At 10-years of follow-up, >25% of children with ALL were overweight/obese. The BMI Z-score at the time of diagnosis continued to correlate with the Z-score after 10-years.

Management of B-cell lineage acute lymphoblastic leukemia: expert opinion from an Indian panel via Delphi consensus method

Introduction

Currently, there are no guidelines for the management of B-cell lineage acute lymphoblastic leukemia (B-ALL) from an Indian perspective. The diagnostic workup, monitoring, and treatment of B-ALL vary among different physicians and institutes.

Objective

To develop evidence-based practical consensus recommendations for the management of B-ALL in Indian settings.

Methods

Modified Delphi consensus methodology was considered to arrive at a consensus. An expert scientific committee of 15 experts from India constituted the panel. Clinically relevant questions belonging to three major domains were drafted for presentation and discussion: (i) diagnosis and risk assignment; (ii) frontline treatment; and (iii) choice of therapy (optimal vs. real-world practice) in relapsed/refractory (R/R) settings. The questionnaire was shared with the panel members through an online survey platform. The level of consensus was categorized into high (≥ 80%), moderate (60%-79%), and no consensus (< 60%). The process involved 2 rounds of discussion and 3 rounds of Delphi survey. The questions that received near or no consensus were discussed during virtual meetings (Delphi rounds 1 and 2). The final draft of the consensus was emailed to the panel for final review.

Results

Experts recommended morphologic assessment of peripheral blood or bone marrow, flow cytometric immunophenotyping, and conventional cytogenetic analysis in the initial diagnostic workup. Berlin-Frankfurt-Münster (BFM)-based protocol is the preferred frontline therapy in pediatric and adolescent and young adult patients with B-ALL. BFM/German Multicenter Study Group for Adult Acute Lymphoblastic Leukemia-based regimen is suggested in adult patients with B-ALL. Immunotherapy (blinatumomab or inotuzumab ozogamicin) followed by allogeneic hematopoietic cell transplantation (allo-HCT) is the optimal choice of therapy that would yield the best outcomes if offered in the first salvage in patients with R/R B-ALL. In patients with financial constraints or prior allo-HCT (real-world practice) at first relapse, standard-intensive chemotherapy followed by allo-HCT may be considered. For subsequent relapses, chimeric antigen receptor T-cell therapy or palliative care was suggested as the optimal choice of therapy.

Conclusion

This expert consensus will offer guidance to oncologists/clinicians on the management of B-ALL in Indian settings.

Clinical and Prognostic Impact of Copy Number Alterations and Associated Risk Profiles in a Cohort of Pediatric B-cell Precursor Acute Lymphoblastic Leukemia Cases Treated Under ICiCLe Protocol

Copy number alteration (CNA) status and CNA risk profiles of IKZF1^plus, UK-ALL CNA risk groups and MRplus scores, were evaluated for clinical and prognostic impact in a cohort of 493 B-cell acute lymphoblastic leukemia cases diagnosed and treated under the Indian Collaborative Childhood Leukemia group (ICiCLe) protocol trial. Overall CNA frequency was 59% with 60% of cases showing 2-loci deletion. CDKN2A/B deletion was most common CNA (36.3%), while IKZF1 deletion and IKZF1^plus profile were noted in 19.5% and 13.4% of cases, respectively. IKZF1 deletions and other CNA risk profiles were significantly associated with poor (PR)/high risk (HR) clinical and genetic profile parameters (P < 0.001). In addition, the 3-year OS, event-free survival (EFS) was significantly poor with high relapse rate (RR) of 38.6%, 46.5%, and 35.2% for IKZF1 deletions, IKZF1^plus profiles, and UK-ALL CNA-intermediate risk (IR)+PR risk groups, respectively (P < 0.001). Integrated evaluation of UK-ALL CNA risk profile with ICiCLe trial risk stratification groups revealed a worse overall survival, EFS, and RR of 63.3%, 43.2%, and 35.2% for CNA-IR+PR profile compared to CNA-good risk profile (81.3%, 65.0%, and 21.0%; P < 0.001). Hence, routine CNA testing in our setting is must to identify standard risk and IR cases likely to benefit from HR treatment.

Comparative treatment costs of risk-stratified therapy for childhood acute lymphoblastic leukemia in India

BACKGROUND

To evaluate the treatment cost and cost effectiveness of a risk-stratified therapy to treat pediatric acute lymphoblastic leukemia (ALL) in India.

METHODS

The cost of total treatment duration was calculated for a retrospective cohort of ALL children treated at a tertiary care facility. Children were risk stratified into standard (SR), intermediate (IR) and high (HR) for B-cell precursor ALL, and T-ALL. Cost of therapy was obtained from the hospital electronic billing systems and details of outpatient (OP) and inpatient (IP) from electronic medical records. Cost effectiveness was calculated in disability-adjusted life years.

RESULTS

One hundred and forty five patients, SR (50), IR (36), HR (39), and T-ALL (20) were analyzed. Median cost of the entire treatment for SR, IR, HR, and T-ALL was found to be $3900, $5500, $7400, and $8700, respectively, with chemotherapy contributing to 25%-35% of total cost. Out-patient costs were significantly lower for SR (p < 0.0001). OP costs were higher than in-patient costs for SR and IR, while in-patient costs were higher in T-ALL. Costs for non-therapy admissions were significantly higher in HR and T-ALL (p < 0.0001), representing over 50% of costs of in-patient therapy. HR and T-ALL also had longer durations of non-therapy admissions. Based on WHO-CHOICE guidelines, the risk-stratified approach was very cost effective for all categories of patients.

CONCLUSIONS

Risk-stratified approach to treat childhood ALL is very cost-effective for all categories in our setting. The cost for SR and IR patients is significantly reduced through decreased IP admissions for both, chemotherapy and non-chemotherapy reasons.

Protocol for ICiCLe-ALL-14 (InPOG-ALL-15-01): a prospective, risk stratified, randomised, multicentre, open label, controlled therapeutic trial for newly diagnosed childhood acute lymphoblastic leukaemia in India

Background

In the west, survival following treatment of childhood acute lymphoblastic leukaemia (ALL) approaches 90%. Outcomes in India do not exceed 70%. To address this disparity, the Indian Collaborative Childhood Leukaemia group (ICiCLe) developed in 2013 a contemporary treatment protocol for uniform risk-stratified management of first presentation ALL based on cytogenetics and minimal residual disease levels (MRD). A multicentre randomised clinical trial opened in 2016 (ICiCLe-ALL-14) and examines the benefit of randomised interventions to decrease toxicity and improve outcomes.

Methods

Patients 1–18 years with newly diagnosed ALL are categorised into four risk groups based on presentation features, tumour genetics and treatment response. Standard risk includes young (< 10 years) B cell precursor ALL (BCP-ALL) patients with low presentation leucocyte count (< 50 × 109/L) and no high-risk features. Intermediate risk includes BCP-ALL patients with no high-risk features but are older and have high presentation leucocyte counts and/or bulky disease. High risk includes BCP-ALL patients with any high-risk feature, including high-risk genetics, central nervous system leukaemia, poor prednisolone response at treatment day 8 and high MRD (≥ 0·01%) at the end of induction. Patients with T-lineage ALL constitute the fourth risk group. All patients receive four intensive treatment blocks (induction, consolidation, interim maintenance, delayed intensification) followed by 96 weeks of maintenance. Treatment intensity varies by risk group. Clinical data management is based on a web-based remote data capture system. The first randomisation examines the toxicity impact of a shorter induction schedule of prednisolone (3 vs 5 weeks) in young non-high-risk BCP-ALL. The second randomisation examines the survival benefit of substituting doxorubicin with mitoxantrone in delayed intensification for all patients. Primary outcome measures include event-free survival (overall, by risk groups), sepsis rates in induction (first randomisation) and event-free survival rates following second randomisation.

Discussion

ICiCLe-ALL-14 is the first multicentre randomised childhood cancer clinical trial in India. The pre-trial phase allowed standardisation of risk-stratification diagnostics and established the feasibility of collaborative practice, uniform treatment, patient enrolment and data capture. Pre-trial observations confirm the impact of risk-stratified therapy in reducing treatment-related deaths and costs. Uniform practice across centres allows patients to access care locally, potentially decreasing financial hardship and dislocation.

Trial registration

Clinical Trials Registry-India (CTRI) CTRI/2015/12/006434. Registered on 11 December 2015

PHi-RACE: PGIMER in-house rapid & cost effective classifier for the detection of BCR-ABL1-like acute lymphoblastic leukaemia in Indian patients

For the detection of BCR-ABL1-like ALL cases, two methodologies, specifically Gene expression profiling (GEP) or Next-generation targeted sequencing (NGS) and TaqMan based low-density (TLDA) card, are being used. NGS is very costly and TLDA is not widely commercially available. In this study, we quantified the expression of 8 selected overexpressed genes in 536 B-ALL cases. We identified 26.67% (143/536) BCR-ABL1-like ALLs using hierarchical clustering and principal component analysis. BCR-ABL1-like ALL cases were significantly older at presentation (p = 0.036) and had male preponderance (p = 0.047) compared to BCR-ABL1-negative ALL cases. MRD-positivity and induction failure were more commonest in BCR-ABL1-like ALL cases (30.55 vs.19.35% in BCR-ABL1-negative ALL cases). Lastly, we built a PHi-RACE classifier (sensitivity = 95.2%, specificity= 83.7%, AUC= 0.927) using logistic regression to detect BCR-ABL1-like ALL cases promptly at diagnosis. This classifier is beneficial for hematologists in quick decision making at baseline to start tailored treatment regimes.

A systematic review of modeling and simulation approaches in designing targeted treatment technologies for Leukemia Cancer in low and middle income countries

Virtual experimentation is a widely used approach for predicting systems behaviour especially in situations where resources for physical experiments are very limited. For example, targeted treatment inside the human body is particularly challenging, and as such, modeling and simulation is utilised to aid planning before a specific treatment is administered. In such approaches, precise treatment, as it is the case in radiotherapy, is used to administer a maximum dose to the infected regions while minimizing the effect on normal tissue. Complicated cancers such as leukemia present even greater challenges due to their presentation in liquid form and not being localised in one area. As such, science has led to the development of targeted drug delivery, where the infected cells can be specifically targeted anywhere in the body. Despite the great prospects and advances of these modeling and simulation tools in the design and delivery of targeted drugs, their use by Low and Middle Income Countries (LMICs) researchers and clinicians is still very limited. This paper therefore reviews the modeling and simulation approaches for leukemia treatment using nanoparticles as an example for virtual experimentation. A systematic review from various databases was carried out for studies that involved cancer treatment approaches through modeling and simulation with emphasis to data collected from LMICs. Results indicated that whereas there is an increasing trend in the use of modeling and simulation approaches, their uptake in LMICs is still limited. According to the review data collected, there is a clear need to employ these tools as key approaches for the planning of targeted drug treatment approaches.

Treatment of childhood acute lymphoblastic leukemia in Iraq: a 17-year experience from a single center

We performed a retrospective analysis of 1415 acute lymphoblastic leukemia children diagnosed between January 2000 and December 2016 at Children Welfare Teaching Hospital, Baghdad, Iraq. Patients were divided into three cohorts according to treatment period (2000-2005; 2006-2011; 2012-2016). Treatments were based on modified-UKALL protocols; a steroid-pre-phase was introduced from September 2008. The overall complete remission was 86%, increased from 80% to 91% in the last period. Early deaths occurred in 10%, decreasing to 6%, overtime. Relapses were 23%; toxic deaths and abandonment 8% and 13%, respectively. At a median follow-up of 65.3 months, with abandonment considered as an event, the 5-year overall survival (OS) and event-free survival were 62.2% and 46.3%, statistically influenced by treatment period (5-year OS 62.6%, 59.1%, 66.3%; p=.057, respectively). Though pediatric ALL survival in Iraq is still below that observed in high income countries, survival rates progressively improved. Toxic deaths remain an important cause of failure.

Reference centile curves for mid-upper arm circumference for assessment of under- and overnutrition in school-aged Indian children and adolescents

OBJECTIVES

Malnutrition is common in developing countries and is not restricted to young children. It has been suggested that measuring mid-upper arm circumference (MUAC) is an easy, accurate, and low-cost method of identifying malnutrition in the early stages. The aims of this study were to construct age- and sex-specific MUAC reference centiles, and to define and validate cutoffs for assessment of under- and overnutrition in Indian children 5 to 17 y of age.

METHODS

This was a cross-sectional, multicentric, observational study conducted in seven schools in seven states from June 2018 to November 2019. The study included 6680 healthy 5- to17-y-old children. MUAC was measured using non-stretch tapes (UNICEF). Sex-specific MUAC percentiles were computed for age and height. Cutoffs for MUAC z-scores for thinness and overnutrition were defined and validated for healthy school children (n = 726) and children with cancer (n = 500).

RESULTS

Reference centiles for MUAC for age (and height) for boys and girls are presented. Cutoffs defined for thinness and for obesity were -0.7 and +1.5 z-score, respectively (corresponding to 25th and 95th percentiles of the MUAC for age/height). For ease of use, rounded cutoffs for thinness were 16 and 18.5 cm from 5 to 9 and 10 to 14 y of age, respectively, in both sexes, and a cutoff of 22 cm in boys and 20 cm in girl from 15 to 17 y of age. For obesity, 20 and 25.5 cm from 5 to 9 and 10 to 14 y of age, respectively, in both girls and boys and a rounded cutoff of 29 cm in boys and 27 cm in girls from 15 to17 y are proposed.

CONCLUSIONS

We presented MUAC percentiles and cutoffs for screening for thinness and overnutrition in Indian children from 5 to 17 y of age. These data may also be used in children with cancer and other chronic disorders with growth failure.

Challenges in the management of localized Ewing sarcoma in a developing country

Survival in pediatric Ewing sarcoma (ES) lags in low- and middle-income countries (LMICs). This study analyzed factors contributing to a lower outcome in an LMIC center. A retrospective case review of children with localized ES treated from January 2011 till December 2017 was performed. Neoadjuvant chemotherapy with alternating cycles of vincristine, doxorubicin, cyclophosphamide; and ifosfamide, etoposide was administered 3-weekly for 48 weeks. Reassessment was planned for week 12, followed by local therapy (surgery/radiotherapy or both) tailed by adjuvant chemotherapy. Forty-eight patients with mean age 8 years (range: 0.7-14) were evaluated. Extremity and central axis tumors were seen in 25 (52%) and 23 (48%) patients. Three patients died of neutropenic sepsis and five abandoned therapy. Local therapy included primary surgery, radiotherapy and a combination of surgery and radiotherapy in 7 (16%), 20 (45%) and 17 (39%) patients. The 3-year event-free survival (EFS) and disease-free survival (DFS) for the cohort were 47.7 ± 11% and 57.6 ± 11.2%. Time to local therapy >16 weeks was associated with inferior DFS vs. local therapy administered within 16 weeks [46.6 ± 12.4 vs. 63.9 ± 19.4, p=.046]. Older age, axial site, large size and incomplete surgical resection did not predict relapse/progression. Patients who received wide local excision, as local therapy, had 100% DFS. Coordinated efforts to ensure timely therapy can improve outcome in pediatric ES. Abandonment and treatment-related mortality (TRM) are additional challenges that need to be tackled in LMICs.

Resource limited centres can deliver treatment for children with acute lymphoblastic leukaemia with risk-stratified minimal residual disease based UKALL 2003 protocol with no modification and a good outcome

OBJECTIVES

Acute Lymphoblastic Leukemia (ALL) is the most common malignancy in children. With improved supportive care and a better understanding of the disease biology, it is now a curable cancer in the developed world. However, in low-income countries, the cure rate remains relatively poor. We report our experience on the survival of children with ALL treated on the MRD-based risk-stratified UKALL 2003 protocol, from a center in South India.

METHODS

All consecutive children diagnosed with ALL between years 2013 and 2019 were included in this retrospective study. All received uniform treatment as per the UKALL 2003 protocol based on NCI risk and post-induction MRD status. All the details including the type of leukemia, NCI risk status, date of diagnosis, treatment start date, the regimen, MRD status, cytogenetics, molecular genetics, and complications were captured. Analysis was done using prism GraphPad version 8.0.

RESULTS

A total of 107 children were started on treatment during this period. The majority of them were boys (68/107). Fifty-nine of them were NCI standard risk (55%). B-ALL was the most common type (92%).Total of 56/107(52.3%) children received treatment under the government's insurance scheme for low-income bracket. The post-induction MRD was performed in 95/107 children. It was >0.01% in 22% (21/95) of children. Five (4.7%) children relapsed so far with a mean follow up of 27 months from the diagnosis. There were 17 deaths (15.9%). The EFS at 3 years was 85% (95% CI 75% to 92%).

CONCLUSION

It is feasible to deliver chemotherapy as per the UKALL2003 protocol without any modifications in resource-limited setting. The survival rates have significantly improved over the years in our center from 5 years EFS of 60% in 2010 and now to 3 year EFS of 85%. It is important to note that there was no treatment abandonment in our cohort.

Complete Peripheral Blast Clearance is Superior to the Conventional Cut-Off of 1000/µL in Predicting Relapse in Pediatric Pre-B Acute Lymphoblastic Leukemia

Risk-stratification has contributed to a dramatic improvement in survival in pediatric acute lymphoblastic leukemia (ALL). This study evaluated the utility of prephase response and day 15 bone marrow when a minimal residual disease (MRD) assessment was available. A file review of children aged ≤ 15 years diagnosed with precursor-B ALL from 2014 to 2019 was performed. The protocol used for risk stratification and treatment was based on a UKALL-2003 backbone. All patients received one week of prephase therapy comprised of intravenous dexamethasone in the first 48 h followed by oral prednisolone. The median age of the 255 patients in the study was 5 years. Following the prephase, the peripheral blood absolute blast count was 0 and ≥ 1000/µL blasts in 141 (56%) and 29 (11%), respectively. Ten of 199 (5%) patients with an evaluable day 15 bone marrow had M3 status. At the end of induction, 30 (12%), 127 (50%) and 98 (38%) patients belonged to the standard-risk, intermediate-risk and high-risk (HR) groups, respectively. An M3 day15 bone marrow was the sole reason for escalation in three (3%) of the patients in the HR group. A lack of complete clearance of peripheral blood blasts post-prephase [HR: 2.45 (1.04-5.75), p = 0.040] and a positive MRD [HR: 3.00 (1.28-7.02), p = 0.011] independently predicted risk of relapse. Complete blast clearance is superior to the traditional cut-off of 1000/µL in predicting relapse. The role of a day 15 bone marrow morphology is diminished when an end of induction MRD is available.

Validation of an algorithmic nutritional approach in children undergoing chemotherapy for cancer

BACKGROUND

Undernutrition impacts clinical outcome adversely in children with cancer. This study aimed to validate a nutritional algorithm with specific application to the low- and middle-income country (LMIC) setting.

PROCEDURE

Fifty children with a new diagnosis of cancer were enrolled in this randomized interventional study. Weight, height/length, and mid-upper-arm circumference (MUAC) were measured at baseline. The study arm was administered nutritional care as per the algorithm and the control arm received the institutional standard of care. Weight was monitored regularly and MUAC was repeated after 3 months. Children were classified based on weight for height if <2 years of age or body mass index if ≥2 years, as normal, wasted, and severely wasted. The algorithmic approach comprised administration of oral supplements, nasogastric feeds, and/or parenteral nutrition based on objective assessment of the nutritional status.

RESULTS

Fifty patients were analyzed (study: 25, control: 25). Four in the study arm (16%) and six in the control arm (24%) had wasting at baseline. MUAC was <5th percentile in 15 (60%) and 13 (52%) patients in the study and control arms, respectively. At the end of 3 months, the median increment in weight was 0.8 kg (interquartile range [IQR]: -0.02; 2.00) and 0.0 kg (IQR: -0.70; 1.25) in the study and control arms, respectively (P = .153). The median increment in MUAC was 1.20 cm (IQR: 0.10; 2.30) and 0.00 cm (IQR: -0.50; 1.10) in the study and control arms, respectively (P = .020).

CONCLUSIONS

The application of an algorithm designed for use in LMICs resulted in significant improvement in nutritional status, as measured by MUAC.

Effect of socio-economic status & proximity of patient residence to hospital on survival in childhood acute lymphoblastic leukaemia

Background & objectives:

Survival in paediatric acute lymphoblastic leukaemia (ALL) in lower/middle income countries continues to lag behind outcomes seen in high-income countries. Socio-economic factors and distance of their residence from the hospital may contribute to this disparity. This study was aimed at identifying the impact of these factors on outcome in childhood ALL.

Methods:

In this retrospective study, file review of children with ALL was performed. Patients were treated with the modified United Kingdom (UK) ALL-2003 protocol. Details of socio-economic/demographic factors were noted from a web-based patients’ database. Modified Kuppuswamy scale was used to classify socio-economic status.

Results:

A total of 308 patients with a median age of five years (range: 1-13 yr) were studied. Patients belonging to upper, middle and lower SE strata numbered 85 (28%), 68 (22%) and 155 (50%). Nearly one-third of the patients were underweight. There was no treatment abandonment among children whose mothers were graduates. Neutropenic deaths during maintenance therapy were lower in mothers who had passed high school. In patients who survived induction therapy, the five year event-free survival (EFS) of upper SE stratum was significantly better 78.7±4.9 vs. 59±7.2 and 58.1±4.6 per cent in middle and lower strata (P=0.026). Five year overall survival was higher in the higher SE group; being 91.2±3.5, 78.3±5.6 and 78.8±3.9 per cent (P=0.055) in the three strata. Survival was unaffected by a distance of residence from treating centre or rural/urban residence. High-risk and undernourished children had a greater hazard of mortality [1.80 (P=0.015); 1.98 (P=0.027)].

Interpretation & conclusions:

Our findings showed that higher socio-economic status contributed to superior EFS in children with ALL who achieved remission. Undernutrition increased the risk of mortality.

Low Expression of Leucocyte Associated Immunoglobulin Like Receptor-1 (LAIR-1/CD305) in a Cohort of Pediatric Acute Lymphoblastic Leukemia Cases

Background:

Immunophenotypic markers can play significant role in prognostic assessment for different cancers and leukocyte-associated Ig-like receptor (LAIR-1) is a recently identified inhibitory immuno-receptor.

Methods:

We measured LAIR-1 expression in paediatric ALL patients (n-42) and appropriate controls by flow cytometry. Median fluorescence intensities (MFIs) were calculated and correlated with demographic and clinical variables and early treatment outcome parameters.

Results:

The ALL cohort had an age range of 1 - 11 y and a M:F ratio of 2.5:1. 64% had WBC counts <50 x 10⁹/L and 15 (36%) >50 x 10⁹/L, 52% being standard risk and 48% high risk. There were 6 cases of T-ALL and 36 of B-ALL. AML1-TEL, E2A-PBX, BCR-ABL and MLL-AF4 transcripts were noted in 3, 6, 2 and 1 patient, respectively. Day 8 ABC was <1,000 in 31 and >1,000 in 8 cases, while 30 had low and 7 high MRD (both >0.01) at day 35 of treatment. The median MFI for LAIR-1 expression in control cases was 8.2 (range 7.76-11.69) and in ALL cases 4.02 (range 0.56 to 11.87), with 74% (n-31) of ALL cases showing reduced LAIR-1 expression. However, no significant correlations were found between standard ALL risk factors and LAIR-1 expression. Out of 42 patients, 4 died during induction treatment and one exited therapy, 60% (n-3/5) of these featuring low expression of LAIR-1. Also ALL patients with low LAIR-1 expression had t (12;21), t (1;19) and t (4;11) translocations in 2, 4 and 1 samples, respectively, but none had t (9;22). Of those with high LAIR-1 expression, 2 had t (9;22) (MFIs-14.43 and 11.87).

Conclusions:

This pilot study of LAIR-1expression in ALL suggests low expression of the inhibitory molecule in leukemic cells. However, the findings need to be confirmed with larger cohort, along with studies focusing on pathophysiological roles in leukemic clone survival and escape from the immune system.

Invasive Fungal Disease in Pediatric Acute Leukemia in the Nontransplant Setting: 8 Years' Experience From a Tertiary Care Center in North India

BACKGROUND/AIM

The aim of this article is to study the spectrum, changing prevalence, and predictors for mortality of invasive fungal disease (IFD) in pediatric leukemia in a resource-limited setting.

OBSERVATIONS

Prevalence was 7% (proven, 69%; probable, 16.4%; possible, 14.6%) and did not differ between acute lymphoblastic leukemia and acute myeloid leukemia. Lungs were frequently involved (46%). Aspergillus was the commonest fungus (47%). Visceral abscesses were frequent with candidiasis as compared with invasive molds (P=0.016). IFD resulted in a prolonged admission (mean, 12.6±2 d; P=0.014) and death (44%) (Aspergillus, 50%; Candida, 50%; Mucor, 34%). Diagnosis of acute myeloid leukemia predicted mortality (P=0.03).

CONCLUSIONS

IFD was an important cause of treatment related mortality in pediatric leukemia (odds ratio, 8.39). Protocolled use of computed tomography-chest and galactomannan-assay aided diagnosis (P<0.05).

Deletion of CDKN2A/B is associated with inferior relapse free survival in pediatric B cell acute lymphoblastic leukemia

Considering conflicting data on CDKN2A/B deletion in ALL, this study to assess its prognostic significance as an independent marker in a total of 96 pediatric B and T-ALL cases was planned. The overall frequency of CDKN2A/B deletion was 44% (n = 43) with 36% (30/83) in B-ALL and 100% (13/13) in T-ALL. CDKN2A/B deletion was significantly associated with high WBC count (p = .002) and National Cancer Institute risk (p = .01) in B-ALL. Importantly, CDKN2A/B deletion cases had poor EFS of 42% at 28 months compared to EFS of 90% in rest (p = .0004). Further, relapse free survival was only 56% for cases with CDKN2A/B deletions (n = 25), compared to 100% in control group (p = .001). Moreover, CDKN2A/B deletion was the only risk factor associated with early relapse (p = .01) compared to IKZF1 deletion (p = .73) or occurrence of BCR-ABL1 fusion transcript (p = .26). Thus our study data highlights potential prognostic role of CDKN2A/B deletions in early disease stratification in pediatric B-ALL.