Treatment of childhood Wilms' tumor without radiotherapy in Nicaragua

Global health disparities in childhood cancers

PURPOSE OF REVIEW

The high cure rates of children with cancer in high-income countries (HICs) are due to the impact of biomedical innovations on children with highly fatal diseases. We discuss why these innovations have not benefitted most children with cancer globally and propose broad strategies to reduce these disparities.

RECENT FINDINGS

Over 85% of children with cancer in HIC are cured while less than 20% in many low-income countries survive the disease. Hence, childhood cancer survival is poor globally since over 80% of children with cancer live in low-income and middle-income countries (LMICs). Inadequate skilled workforce and health infrastructure across all disciplines of pediatrics in LMIC are the main reasons for these disparities. Although biological differences may contribute to these disparities as well, many are unconfirmed because they are confounded by differences in referral patterns and clinical capacity. HIC partnerships with LMIC that focus on locally based pediatrics training and clinical infrastructure building are beginning to close the gap.

SUMMARY

Pediatric oncology is symbolic of the significant disparities in childhood survival arising from poverty, inadequate pediatric infrastructure, and skilled workforce in LMIC. Partnerships with HIC that build multidisciplinary pediatrics capacity and clinical infrastructure are beginning to make transformative improvements.

Treatment of Wilms Tumor in Sub-Saharan Africa: Results of the Second French African Pediatric Oncology Group Study

PURPOSE

Multidisciplinary management of Wilms tumor has been defined through multicenter prospective studies and an average expected patient cure rate of 90%. In sub-Saharan Africa, such studies are uncommon. After the encouraging results of the first Groupe Franco-Africain d'Oncologie Pédiatrique (GFAOP) study, we report the results of the GFAOP-NEPHRO-02 study using an adaptation of the International Society of Paediatric Oncology 2001 protocol.

PATIENTS AND METHODS

From April 1, 2005, to March 31, 2011, seven African units participated in a nonrandomized prospective study. All patients who were referred with a clinical and radiologic diagnosis of renal tumor were screened. Those older than age 6 months and younger than 18 years with a unilateral tumor previously untreated were pre-included and received preoperative chemotherapy. Patients with unfavorable histology or with a tumor other than Wilms, or with a nonresponding stage IV tumor were excluded secondarily.

RESULTS

Three hundred thirteen patients were initially screened. Two hundred fifty-seven patients were pre-included and 169 with histologic confirmation of intermediate-risk nephroblastoma were registered in the study and administered postoperative treatment. Thirty-one percent of patients were classified as stage I, 38% stage II, 24% stage III, and 7% stage IV. Radiotherapy was not available for any stage III patients. Three-year overall survival rate was 72% for all study patients and 73% for those with localized disease.

CONCLUSION

It was possible to conduct sub-Saharan African multicenter therapeutic studies within the framework of GFAOP. Survival results were satisfactory. Improvements in procedure, data collection, and outcome are expected in a new study. Radiotherapy is needed to reduce the relapse rate in patients with stage III disease.

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.

Implementation Science for Global Oncology: The Imperative to Evaluate the Safety and Efficacy of Cancer Care Delivery

PURPOSE

The development of cancer care treatment facilities in resource-constrained settings represents a challenge for many reasons. Implementation science-the assessment of how services are set up and delivered; contextual factors that affect delivery, treatment safety, toxicity, and efficacy; and where adaptations are needed-is essential if we are to understand the performance of a treatment program, know where the gaps in care exist, and design interventions in care delivery models to improve outcomes for patients.

METHODS

The field of implementation science in relation to cancer care delivery is reviewed, and the experiences of the integrated implementation science program at the Butaro Cancer Center of Excellence in Rwanda are described as a practical application. Implementation science of HIV and tuberculosis care delivery in similar challenging settings offers some relevant lessons.

RESULTS

Integrating effective implementation science into cancer care in resource-constrained settings presents many challenges, which are discussed. However, with carefully designed programs, it is possible to perform this type of research, on regular and ongoing bases, and to use the results to develop interventions to improve quality of care and patient outcomes and provide evidence for effective replication and scale-up.

CONCLUSION

Implementation science is both critical and feasible in evaluating, improving, and supporting effective expansion of cancer care in resource-limited settings. In ideal circumstances, it should be a prospective program, established early in the lifecycle of a new cancer treatment program and should be an integrated and continual process.

Childhood acute lymphoblastic leukemia in Nicaragua: long-term results in the context of an international cooperative program

BACKGROUND

The aim of this paper is to describe the results of acute lymphoblastic leukemia (ALL) treatment in Nicaragua from 1995 to 2005 in the context of an international cooperation program.

PROCEDURES

Patients <18 years with ALL were treated with two consecutive protocols (1995 and 2000). After a steroid prophase, a three-drug induction was administered in protocol 1995, and a four-drug induction, including asparaginase, was administered in protocol 2000. In protocol 2000, a modified BFM phase IB with cyclophosphamide, 6-mercaptopurine and cytosine arabinoside was administered to patients at high risk (HR), who also received IV methotrexate (500 mg/m(2)) in the consolidation phase. Reinduction consisted of dexamethasone, vincristine, doxorubicin, cytosine arabinoside, and 6-thioguanine administered over 7 (protocol 1995) or 4 (protocol 2000) weeks; reinduction was repeated twice for patients at HR. Maintenance consisted of p.o. 6-mercaptopurine and methotrexate, and vincristine and dexamethasone pulses were added in the 2000 study. The total duration of therapy was 24 months.

RESULTS

In total, 540 patients were treated. Overall, 7% of patients died during induction, and 9% abandoned treatment. At 5 and 10 years from diagnosis, event-free survival (EFS) rates of 38.1% and 36.6%, respectively, and overall survival rates of 48.0% and 39.6%, respectively, were obtained, considering abandonment as an event.

CONCLUSIONS

In our experience, a 10-year EFS of 36.6% was achieved in a country with limited resources. Factors limiting a higher success rate were treatment abandonment and a high relapse rate.

Asociación de Hemato-Oncología Pediátrica de Centro América (AHOPCA): a model for sustainable development in pediatric oncology

Bridging the survival gap for children with cancer, between those (the great majority) in low and middle income countries (LMIC) and their economically advantaged counterparts, is a challenge that has been addressed by twinning institutions in high income countries with centers in LMIC. The long-established partnership between a Central American consortium--Asociación de Hemato-Oncología Pediátrica de Centro América (AHOPCA)--and institutions in Europe and North America provides a striking example of such a twinning program. The demonstrable success of this endeavor offers a model for improving the health outcomes of children with cancer worldwide. As this remarkable enterprise celebrates its 15th anniversary, it is appropriate to reflect on its origin, subsequent growth and development, and the lessons it provides for others embarking on or already engaged in similar journeys. Many challenges have been encountered and not all yet overcome. Commitment to the endeavor, collaboration in its achievements and determination to overcome obstacles collectively are the hallmarks that stamp AHOPCA as a particularly successful partnership in advancing pediatric oncology in the developing world.

Treatment of nephroblastoma in Africa: results of the first French African pediatric oncology group (GFAOP) study

BACKGROUND

The multidisciplinary management of nephroblastoma has been defined through multicentric prospective studies and an average 90% of patients cured expected. In Africa, such studies are uncommon and results are fragmentary or unknown in most of the countries. We report the results of the GFAOPNEPHRO 01 study using SIOP 2001 protocol approach.

PROCEDURE

From April 1, 2001 to March 31, 2004, 8 African Pilot Units were selected to participate in a nonrandomized prospective study. All patients referred with a clinical and radiological diagnosis of nephroblastoma were registered, those aged over 6 months and less than 18 years with a unilateral tumor not previously treated were included in this study and received preoperative chemotherapy. Patients with unfavorable histology or with a tumor other than Wilms tumor, and those with stage IV tumor and persistent disease after surgery were secondarily excluded.

RESULTS

Of the 229 patients initially registered, 166 were included and finally 133 retained in the study, after surgery. Tumor rupture occurred in 7.5% of the patients. Thirty-five percent were stage I, 22% stage II, 23% stage III, and 18% stage IV. Two-year disease-free survival and 5-year survival are, respectively: 77.9% and 76.7% for localized tumors, 72.7% and 71.6% for all study patients.

CONCLUSIONS

It is possible to conduct African multicentric therapeutic studies within the framework of GFAOP. Results in terms of event-free survival and survival are satisfactory. Improvements with respect to procedure, data collection, and outcome are expected in a new study.

Treatment of Wilms tumor: a report from the Turkish Pediatric Oncology Group (TPOG)

AIM

To standardize diagnosis and treatment of childhood Wilms tumor (WT) in Turkey.

METHODS AND PATIENTS

Between 1998 and 2006, WT patients were registered from 19 centers. Patients <16 years with unilateral WT whose treatment started in first postoperative 3 weeks were included. Treatments were stage I favorable (FH) and unfavorable histology (UH) patients, VCR + Act-D; stage IIA FH, VCR + Act-D; stage IIB FH, VCR + Act-D + radiotherapy (RT); stage III-IV FH, VCR + Act-D + adriamycin (ADR) + RT; stages II-IV UH tumors, VCR + Act-D + ADR + etoposide + RT.

RESULTS

165/254 registered cases were eligible (bilateral, 5.9%) [median age 3.0 years; M/F: 0.99; 50/165 cases < or =2 years]. 9.7% cases had UH tumors. Disease stages were stage I 23.6%; IIA 36.4%; IIB 5.5%; III 22.4%; IV 12.1%. Cases >2 years had significantly more advanced disease. 1/11 cases with recurrent disease died; 2/165 had progressive disease, 2/165 had secondary cancers, and all 4 died. In all cases 4-year OS and EFS were 92.8 and 86.5%, respectively. Both OS and EFS were significantly worse in stage IV.

CONCLUSIONS

Despite problems in patient management and follow-up, treatment results were encouraging in this first national experience with a multicentric study in pediatric oncology. Revisions and modifications are planned to further improve results and minimize short- and long-term side effects.

Treatment of Wilms tumor according to SIOP 9 protocol in Casablanca, Morocco

BACKGROUND

Childhood Wilms tumor represents one of the challenge for pediatric oncologists in developing countries. We report the characteristics and treatment results of patients with Wilms tumor according to SIOP 9 protocol in Morocco.

PROCEDURE

From January 1989 to December 2000, 86 children with Wilms tumor were admitted. The diagnosis was based on physical exam and abdominal ultrasound. The metastatic work-up was based on abdominal ultrasound and chest X-ray.

RESULTS

The mean age was 36 months (3-120 months). The sex-ratio was 1. Abdominal mass was the main symptom at presentation (84 cases). There were 13 metastatic cases. Treatment applied was according to SIOP 9 Protocol without randomization. Local deases was present in 75 patients with stage I in 38 cases (50%), IIN0 in 4 cases (6%), IIN1 in 9 cases, and III in 24 cases (44%). The distribution of pathologic groups was: favorable in 4 cases, standard in 69 cases, and unfavorable anaplastic type in 2 cases. Sixty-nine patients were evaluable for therapeutic evaluation. Other patients were lost to follow-up. Three patients died of treatment related toxicity and 13 patients relapsed. With a median follow-up of 70 months, the 5-year EFS and 5 years overall survival for evaluable patients are 77.4% and 79%, respectively while the 5-year EFS for all patients was 56%.

CONCLUSION

These results are encouraging for a developing country but special efforts should be done to reduce the rate of abandonment.

Wilms' tumor: past, present and (possibly) future

Wilms' tumor is one of the successes of pediatric oncology, with an overall cure rate of over 85%, using relatively simple therapies. This excellent outcome has been the result of collaborative efforts among surgeons, pediatricians, pathologists and radiation oncologists. The results that have been achieved in children with Wilms' tumors support the strong value of the multidisciplinary team approach to cancer. The two largest cooperative groups that have studied the optimum treatment for Wilms' tumor are the National Wilms' Tumor Study group in North America and the International Society of Pediatric Oncology, involving European and other countries. The National Wilms' Tumor Study group recommends primary surgery before any adjuvant treatment, whereas the International Society of Pediatric Oncology trials are based on the use of preoperative chemotherapy. The debate on primary chemotherapy versus primary nephrectomy appears to have been overcome, in the sense that the advantages and disadvantages of these two diverse methods have emerged from large and well-performed clinical trials, and comparably low doses of anthracyclines and radiotherapy are now used. Challenges remain in identifying novel molecular, histological and clinical risk factors for stratification of treatment intensity. This could allow a safe reduction in therapy for patients known to have an excellent chance of cure with the current therapy, while identifying, at diagnosis, the minority of children at risk of relapse, who will necessitate more aggressive treatments. Another positive factor is the substantial progress that has been made in the cure for recurrent patients, with long-term survivals shifting from 30 to almost 60% in more recently treated patients with intensive-dose chemotherapy regimens. The combination of lower relapses and higher salvage rates translated into significantly improved overall survival for Wilms' tumor patients as a whole. This review covers current concepts on treatment strategies for Wilms' tumor, with an overview of the results and achievements of the important clinical trials.

Prognostic significance of metastatic site at diagnosis in Wilms' tumor: results from a single center

The purpose of this study was to identify the prognostic significance of pulmonary and liver involvements present at diagnosis in children with Wilms' tumor. From 1971 to 2002, 57 patients with stage IV Wilms' tumor were diagnosed, treated, and followed in the authors' institution. Metastases were detected by chest radiography, abdominal ultrasonography, and/or thoracoabdominal computed tomography. Nephrectomy with tumor resection was performed and appropriate chemotherapy was given to all the patients. The Kaplan-Meier survival method was used to calculate survival. The log-rank test was used to compare the groups with respect to survival. The age range was 1.25 to 15 years (median 4 years). Thirty-seven patients had only lung metastases, 12 had only liver metastases, 6 had both lung and liver metastases, 1 had adrenal gland metastases, and 1 had other site metastases. The overall survival rate in the whole group was 37.1%. The overall survival rates for lung and liver metastases were 50.2% and 16.6%, respectively. The overall survival rates were significantly different between the two groups (P = 0.005). Only one patient survived in the group with liver involvement. Liver involvement at diagnosis indicates a worse prognosis than lung involvement. Wilms' tumor patients with liver metastases should be treated with more intensive regimens than those with lung metastases.

Inhibitory mechanism on proliferation of hepatocellular carcinoma cell line by tetrandrine

AIM

To study the mechanism of tetrandrine (TTD) on proliferation and apoptosis of hepatic cell carcinoma (HCC) cell line.

METHODS

MTT colorimetry was used to evaluate the influence of TTD on proliferation of cells. Flow cytometry was used to test reactive oxygen species (ROS) levels in cells. Electrophoresis in 1.5% agarose gels was used to assess the DNA laddering.

RESULTS

Proliferation rate of HCC cell line stimulated by 10 and 20 μmol/L TTD at 24 h, 48 h, and 72 h was 90.1±1.0%, 77.5±2.0%, 70.2±2.9% and 56.6±1.6%, 61.6±2.0% and 47.2±1.9%, respectively (F = 40.025, P<0.001). O₂^- and H₂O₂. generated by HCC cell lines incubated with 0, 10 and 20 μmol/L TTD for 2 hours were 35 and 24.5%, 36.6 and 40.5%, 63.2 and 84.6%, respectively. Typical DNA ladder was observed after the cell line was incubated in 20 μmol/L TTD for 48 hours.

CONCLUSION

TTD can induce the apoptosis of ROS of hepatic cell carcinoma cell line by generation of ROS in a dose dependent manner.