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Ferreras-Antolín L, Irwin A, Atra A, Chapelle F, Drysdale SB, Emonts M, McMaster P, Paulus S, Patel S, Rompola M, Vergnano S, Whittaker E, Warris A. Pediatric Antifungal Prescribing Patterns Identify Significant Opportunities to Rationalize Antifungal Use in Children. Pediatr Infect Dis J 2022; 41:e69-e74. [PMID: 34784303 PMCID: PMC8826618 DOI: 10.1097/inf.0000000000003402] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/27/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The need for pediatric antifungal stewardship programs has been driven by an increasing consumption of antifungals for prophylactic and empirical use. Drivers and rational of antifungal prescribing need to be identified to optimize prescription behaviors. METHODS A prospective modified weekly Point Prevalence Survey capturing antifungal prescriptions for children (> 90 days to < 18 years of age) in 12 centers in England during 26 consecutive weeks was performed. Demographic, diagnostic and treatment information was collected for each patient. Data were entered into an online REDCap database. RESULTS One thousand two hundred fifty-eight prescriptions were included for 656 pediatric patients, 44.9% were girls, with a median age of 6.4 years (interquartile range, 2.5-11.3). Most common underlying condition was malignancy (55.5%). Four hundred nineteen (63.9%) received antifungals for prophylaxis, and 237 (36.1%) for treatment. Among patients receiving antifungal prophylaxis, 40.2% did not belong to a high-risk group. In those receiving antifungal treatment, 45.9%, 29.4%, 5.1% and 19.6% had a diagnosis of suspected, possible, probable of proven invasive fungal disease (IFD), respectively. Proven IFD was diagnosed in 78 patients, 84.6% (n = 66) suffered from invasive candidiasis and 15.4% (n = 12) from an invasive mold infection. Liposomal amphotericin B was the most commonly prescribed antifungal for both prophylaxis (36.6%) and empiric and preemptive treatment (47.9%). Throughout the duration of the study, 72 (11.0%) patients received combination antifungal therapy. CONCLUSIONS Antifungal use in pediatric patients is dominated by liposomal amphotericin B and often without evidence for the presence of IFD. A significant proportion of prophylactic and empiric antifungal use was seen in pediatric patients not at high-risk for IFD.
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Affiliation(s)
- Laura Ferreras-Antolín
- From the Medical Research Council Centre for Medical Mycology, University of Exeter, United Kingdom
- St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Adam Irwin
- Department of Paediatric Infectious Diseases, Great Ormond Street Hospital for Children, London, United Kingdom
- The University of Queensland Centre for Clinical Research, Brisbane, Australia
| | - Ayad Atra
- Department of Paediatric Oncology, Royal Marsden Hospital, Downs Road, Sutton, London, United Kingdom
| | - Faye Chapelle
- Department of Infectious Diseases and Immunology, Evelina Children Hospital, London, United Kingdom
| | - Simon B. Drysdale
- St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, United Kingdom
| | - Marieke Emonts
- Department of Paediatric Immunology, Infectious Diseases and Allergy, Great North Children’s Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Paddy McMaster
- Department of Paediatric Infectious Diseases, Royal Manchester Childrens´ Hospital, Manchester, United Kingdom
| | - Stephane Paulus
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, United Kingdom
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
| | - Sanjay Patel
- Department of Paediatric Infectious Diseases, University Hospital Southampton NHS Foundation Trust, United Kingdom
| | - Menie Rompola
- Dept. of Paediatric Haematology and Oncology, Leeds General Infirmary, Leeds, United Kingdom
| | - Stefania Vergnano
- Department of Paediatric Infectious Diseases, Bristol Royal Hospital for Children, Bristol, United Kingdom
| | - Elizabeth Whittaker
- Paediatric Infectious Diseases, Imperial College Healthcare NHS Trust and Section of Paediatrics, Department of Infectious Diseases, Imperial College, London, United Kingdom
| | - Adilia Warris
- From the Medical Research Council Centre for Medical Mycology, University of Exeter, United Kingdom
- Department of Paediatric Infectious Diseases, Great Ormond Street Hospital for Children, London, United Kingdom
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Schumacher-Kuckelkorn R, Atra A, Belli ML, den Engelsman G, Fréneaux P, Gauthier A, Heijlaerts-Klever A, Scuderi F, Senent Peris L, Tewari S, Zapletal O, Ernst A, Berthold F. The reliability of bone marrow cytology as response criterion in metastatic neuroblastoma. Pediatr Blood Cancer 2021; 68:e28819. [PMID: 33245195 DOI: 10.1002/pbc.28819] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 10/20/2020] [Accepted: 11/03/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND The quantitative assessment of neuroblastoma cell content in bone marrow aspirates for response evaluation has been introduced recently. Data on the concordance of interobserver reports are lacking so far. METHODS Investigators of seven European countries representing national reference or large oncological centers convened in 2016. They agreed to quantitatively assess routine bone marrow smears of the participating institutions and to discuss the discrepant results in joint meetings. RESULTS From 2017 through 2019, three cytology rounds with 24, 28, and 28 bone marrow samples were run evaluating the representativity of the smears (yes/[restricted]/no) and the presence of tumor cells (yes/no and %). The comparison of the reports using κ (Fleiss) and α (Krippendorff) statistics demonstrated no robust reliabilities. The agreement on the representativity was moderate to poor, on the presence of tumor cells moderate to good, and on the percentage of tumor cells slight to moderate. Though the value of cytology is unquestioned to detect even tiny metastatic cells in bone marrow, the investigators unanimously agreed that a reliable quantification of the tumor cell content in bone marrow smears is unrealistic. For the key issue of representativity, a new practical definition was developed. CONCLUSION For any work with bone marrow aspirates, the representativity of the material is of paramount importance. A practical definition is proposed. A reliable quantitative cytological assessment of tumor cell content in bone marrow aspirates is not feasible in metastatic neuroblastoma. Therefore, its use as response criterion should be reconsidered.
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Affiliation(s)
- Roswitha Schumacher-Kuckelkorn
- Department of Pediatric Oncology and Hematology, National Neuroblastoma Reference Cytology Lab, University of Cologne, Cologne, Germany
| | - Ayad Atra
- Department of Paediatric Oncology/Haematology, The Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK
| | - Maria Luisa Belli
- Department of Haematology and Oncology, Cytomorphology Laboratory, IRCCS, G. Gaslini Institute, Genoa, Italy
| | | | - Paul Fréneaux
- Service de Pathologie, Pôle de médicine diagnosique et théranostic, Institut Curie, Paris, France
| | - Arnaud Gauthier
- Service de Pathologie, Pôle de médicine diagnosique et théranostic, Institut Curie, Paris, France
| | | | - Francesca Scuderi
- Department of Haematology and Oncology, Cytomorphology Laboratory, IRCCS, G. Gaslini Institute, Genoa, Italy
| | - Leonor Senent Peris
- Department of Hematology, Cytomorphology Laboratory, Diagnosis Unit, La Fe University and Polytechnic Hospital, Valencia, Spain.,La Fe Health Research Institute, Hematology Research Group, Valencia, Spain.,Centro de Investigación Biomédica en Red de Cáncer, CIBERONC, Instituto de Salud Carlos III, Madrid, Spain
| | - Sanjay Tewari
- Department of Paediatric Oncology/Haematology, The Royal Marsden NHS Foundation Trust, Sutton, Surrey, UK
| | - Ondrej Zapletal
- Department of Paediatric Haematology, University Hospital Brno, Brno, Czech Republic
| | - Angela Ernst
- Faculty of Medicine and University Hospital Cologne, Institute of Medical Statistics and Computational Biology (IMSB), University of Cologne, Cologne, Germany
| | - Frank Berthold
- Department of Pediatric Oncology and Hematology, National Neuroblastoma Reference Cytology Lab, University of Cologne, Cologne, Germany
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Malik R, Mullassery D, Kleine-Brueggeney M, Atra A, Gour A, Sunderland R, Okoye B. Anterior mediastinal masses - A multidisciplinary pathway for safe diagnostic procedures. J Pediatr Surg 2019; 54:251-254. [PMID: 30503023 DOI: 10.1016/j.jpedsurg.2018.10.080] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 10/30/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The objective of this study was to report our multidisciplinary diagnostic approach for patients with anterior mediastinal masses (AMM). METHODS A retrospective review of patients with AMM at a tertiary pediatric surgical oncology centre (January 2011-December 2016) was performed. We analyzed data on clinical presentation, mode of tissue diagnosis, anesthetic techniques, and complications. RESULTS Of the 44 patients admitted with AMM (median age 11 years, 27 males and 17 females), 22 had respiratory symptoms. Imaging revealed tracheobronchial compression in 26 children. Twenty patients had a lymph node biopsy. Ten patients had image-guided core biopsy of the mediastinal mass, and 2 had mediastinoscopic biopsy of a paratracheal lymph node. One patient with likely recurrence of a relapsed metastatic ethmoid carcinoma did not have a biopsy. The diagnosis was made from alternative tissues, such as pleural fluid in 4 and peripheral blood in 7 patients. Twenty-five anesthetics were assessed, as 14 patients required no or only local anesthesia, and 5 had unavailable anesthetic notes. Eighteen of 25 patients were anesthetized maintaining spontaneous breathing, mostly by means of ketamine sedation. There were no major anesthetic complications. CONCLUSION Safe tissue diagnosis of anterior mediastinal masses can be obtained by a personalized multidisciplinary approach. Use of alternative tissues, local anesthesia, and ketamine sedation help minimize the need for general anesthesia, muscle paralysis, and controlled ventilation. LEVEL OF EVIDENCE IV (Case Series with no Comparison Group).
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Affiliation(s)
- Rubina Malik
- Department of Paediatric Oncology, St George's Hospital NHS Trust, London, UK
| | - Dhanya Mullassery
- Department of Paediatric Surgery, Great Ormond Street Hospital, London, UK
| | - Maren Kleine-Brueggeney
- Department of Anaesthesia, Evelina London Children's Hospital, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Ayad Atra
- Department of Paediatric Surgery, Great Ormond Street Hospital, London, UK
| | - Anami Gour
- Department of Paediatric Intensive Care Medicine, St Georges Hospital NHS Trust
| | - Robin Sunderland
- Department of Paediatric Anaesthesia, St Georges Hospital NHS Trust, London, UK
| | - Bruce Okoye
- Department of Paediatric Surgery, St Georges Hospital NHS Trust, London, UK.
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Faizan M, Taj MM, Anwar S, Asghar N, Ahmad A, Lancaster D, Atra A, Ali AS. Comparison of Presentation and Outcome in 100 Pediatric Hodgkin Lymphoma Patients Treated at Children Hospital, Lahore, Pakistan and Royal Marsden Hospital, UK. J Coll Physicians Surg Pak 2016; 26:904-907. [PMID: 27981925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 11/15/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To compare differences in demographics and outcomes in childhood Hodgkin lymphoma (HL) presenting at the Children's Hospital Lahore (CHL), and Royal Marsden Hospital (RMH), UK. STUDY DESIGN An observational comparative study. PLACE AND DURATION OF STUDY From January 2011 to February 2012 at CH, Lahore and from October 2008 to February 2012 at RMH, UK. METHODOLOGY Consecutive HL patients (50 from each hospital) were inducted. Data regarding age, gender, staging, histopathology and outcome were analysed. Clinical and pathological staging done according to Ann-Arbor and World Health Organization classification. Treatment duration was 6-8 months. They were followed for 6 months post-treatment. Frequencies of variables were noted and compared. Chi-square test was used for determining significance. RESULTS Patients from Children's Hospital, Lahore were younger (mean 7.9 years) with male predominance (n=42, 84%). Histopathology showed Mixed Cellularity (MC) in 32 (64%), Nodular Sclerosis (NS) in 5 (10%), Lymphocyte Rich in 4 (8%) and lymphocyte depleted in 1 (2%), nodular lymphocyte predominant (NLP) in 1 (2%) each. Majority presented in stage IV (n=25,50%), or stage III (n=20,40%). Constitutional B symptoms were present in 37 (74%). Bone marrow involvement observed in 23 (46%). Remission was achieved in 42 (84%) patients; 2 (4%) relapsed, 4 (8%) expired and 2 (4%) left against medical advice. In contrast, RMH patients were older (mean 11.8 years.) and 30 (60%) were males. NS (n=40,80%) and NLP (n=6,12%) types were predominant. Two (4%) patients were in stage I, 27 (54%) in stage II, 12 (24%) in stage III and 9 (18%) presented in stage IV. Fourteen (28%) had B-symptoms. None had bone marrow disease. Event free survival was 46 (92%). Four (8%) patients relapsed. Three responded to second line therapy and one relapsed postautologous transplant. CONCLUSION Significant differences were observed in age at presentation, stage, histopathology and extent of bone marrow involvement between the groups. Of interest is the bone marrow involvement in stage IV patients in Pakistan. Delayed diagnosis account for advanced stage but difference in pathological subtype needs further study.
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Affiliation(s)
- Mahwish Faizan
- Department of Paediatric Haematology/Oncology and Bone Marrow Transplant, Birmingham Children Hospital, Steel House Lane, B4 6NH Birmingham, UK
| | - Mary M Taj
- Department of Paediatric Oncology, Royal Marsden Hospital, Downs Road, Sutton, London, UK SM2 5PT
| | - Saadia Anwar
- Department of Haematology/Oncology, The Children Hospital and ICH, Ferozepur Road, Lahore, Pakistan
| | - Nyla Asghar
- Department of Haematology/Oncology, The Children Hospital and ICH, Ferozepur Road, Lahore, Pakistan
| | - Alia Ahmad
- Department of Haematology/Oncology, The Children Hospital and ICH, Ferozepur Road, Lahore, Pakistan
| | - Donna Lancaster
- Department of Paediatric Oncology, Royal Marsden Hospital, Downs Road, Sutton, London, UK SM2 5PT
| | - Ayad Atra
- Department of Paediatric Oncology, Royal Marsden Hospital, Downs Road, Sutton, London, UK SM2 5PT
| | - Agha Shabbir Ali
- Department of Paediatrics, Lahore General Hospital and PGMI, Lahore, Pakistan
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Maratos EC, Bridges LR, MacKinnon AD, Madigan JB, Atra A, Martin AJ. Isolated intracranial Rosai-Dorfman disease in a child, a case report and review of the literature. Childs Nerv Syst 2014; 30:1595-600. [PMID: 24864019 DOI: 10.1007/s00381-014-2437-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2014] [Accepted: 05/06/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND Rosai-Dorfman disease (RDD), otherwise known as sinus histiocytosis with massive lymphadenopathy (SHML), usually affects young adults and commonly presents with massive painless cervical lymphadenopathy. Extranodal disease is present in a third of patients, and it is recognised that this can involve the central nervous system. Intracranial RDD is rare in adults and fewer than 10 paediatric cases have been reported. CASE A 10-year-old boy with isolated intracranial RDD presents with a painless forehead mass. The management is discussed and the literature reviewed. CONCLUSION This case of isolated intracranial RDD highlights the importance of considering RDD in the differential of paediatric intracranial mass lesions and outlines the diagnostic and treatment challenges faced when managing this rare condition.
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Affiliation(s)
- E C Maratos
- Department of Neurosurgery, Atkinson Morley Wing, St. George's Hospital, Blackshaw Road, London, SW17 0QT, UK,
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Anoop P, Shaw BE, Riley U, Ethell ME, Taj M, Lancaster DL, Atra A, Saso R, Littlewood S, Mohammed K, Davies F, Treleaven J, Morgan GJ, Potter MN. Clinical profile and outcome of urotheliotropic viral haemorrhagic cystitis following haematopoietic stem cell transplantation: a 7-year tertiary centre analysis. Hematology 2013; 16:213-20. [DOI: 10.1179/102453311x13025568941763] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Affiliation(s)
- Parameswaran Anoop
- Department of Haematology
- Department of Paediatric Haemato-OncologyRoyal Marsden Hospital NHS Foundation Trust, Sutton, Surrey, UK
| | - Bronwen E Shaw
- Department of Haematology
- Anthony Nolan TrustUCL Cancer Centre, London, UK
| | - Unell Riley
- Department of MicrobiologyRoyal Marsden Hospital NHS Foundation Trust, Sutton, Surrey, UK
| | - Mark E Ethell
- Department of Haematology
- Department of Paediatric Haemato-OncologyRoyal Marsden Hospital NHS Foundation Trust, Sutton, Surrey, UK
| | - Mary Taj
- Department of Paediatric Haemato-OncologyRoyal Marsden Hospital NHS Foundation Trust, Sutton, Surrey, UK
| | - Donna L Lancaster
- Department of Paediatric Haemato-OncologyRoyal Marsden Hospital NHS Foundation Trust, Sutton, Surrey, UK
| | - Ayad Atra
- Department of Paediatric Haemato-OncologyRoyal Marsden Hospital NHS Foundation Trust, Sutton, Surrey, UK
| | | | | | | | - Faith Davies
- Department of Haematology
- Institute of Cancer ResearchSutton, Surrey, UK
| | | | - Gareth J Morgan
- Department of Haematology
- Institute of Cancer ResearchSutton, Surrey, UK
| | - Mike N Potter
- Department of Haematology
- Department of Paediatric Haemato-OncologyRoyal Marsden Hospital NHS Foundation Trust, Sutton, Surrey, UK
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Roche E, Pandya N, Munthali L, Atra A. Genital ulceration in a 4 year old--a case of safeguarding? From social services to pathology... BMJ Case Rep 2012; 2012:bcr.01.2012.5489. [PMID: 22729324 DOI: 10.1136/bcr.01.2012.5489] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
This case of genital ulceration and social concerns in a preschool aged child was highly suspicious for child sexual abuse. However, the lesions presumed to be herpes simplex did not respond to antiviral medication. Specialist input from paediatric oncology and endocrinology resulted in a rare diagnosis of langerhans cell histiocytosis. Furthermore, the complication of diabetes insipidus later developed, making this the youngest child described to our knowledge with vulval lesions of langerhans cell histiocytosis and a central nervous system complication.
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Affiliation(s)
- Emma Roche
- Paediatrics Department, Maidstone & Tunbridge Wells NHS Trust, Kent, UK.
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8
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Anoop P, Lancaster DL, Rassam SMB, Atra A. Florid erythroid dysplasia mimicking congenital dyserythropoietic anemia during the preleukemic phase of acute erythroleukemia. Pediatr Hematol Oncol 2012; 29:173-5. [PMID: 22292463 DOI: 10.3109/08880018.2011.628744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Lashkari HP, Lancaster D, Atra A, Champion MP, Taj MM. Symptomatic severe hypertriglyceridaemia with asparaginase therapy in acute lymphoblastic leukaemia (ALL) and lymphoblastic lymphoma: is rechallenging safe? Int J Hematol 2011; 94:571-5. [DOI: 10.1007/s12185-011-0966-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2011] [Revised: 10/17/2011] [Accepted: 10/20/2011] [Indexed: 01/19/2023]
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Anoop P, Saso R, Atra A. Carcinomatous infiltration of cerebrospinal fluid with reactive lymphocytosis and granulocytosis. Am J Hematol 2010; 85:791. [PMID: 20196167 DOI: 10.1002/ajh.21652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Parameswaran Anoop
- Department of Hematology, Royal Marsden Hospital, Sutton, Surrey, United Kingdom.
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Anoop P, Atra A. Abnormal hematopoiesis with lysosomal vesicles and giant granules in Chediak-Higashi syndrome. Am J Hematol 2010; 85:361. [PMID: 19705436 DOI: 10.1002/ajh.21499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Affiliation(s)
- S Patel
- Department of Paediatric Infectious Diseases, St Mary's Hospital, Praed Street, London W2 1NY, UK.
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Affiliation(s)
- Barbara J Bain
- Imperial College Healthcare NHS Trust, St Mary's Hospital, Praed Street, London, W2 1NY, United Kingdom.
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Atra A, Al-Asiri R, Wali S, Al-Husseini H, Al-Bassas A, Zimmermann A. Hepatocellular carcinoma, syncytial giant cell: a novel variant in children: a case report. Ann Diagn Pathol 2007; 11:61-3. [PMID: 17240310 DOI: 10.1016/j.anndiagpath.2005.12.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Hepatocellular carcinoma (HCC) is the second most common primary malignant hepatic tumor in children. It often develops in patients with underlying liver disease. We report the clinicopathologic features of an unusual HCC occurring in an infant who presented with features of Cushing's syndrome due to bilateral adrenal hyperplasia. The tumor is characterized by epithelial syncytial giant cells. Giant cell carcinoma of the liver has been previously reported, but the cells were osteoclast-like (ie, mesenchymal type) and not epithelial type as it is in this patient. We propose to use the term HCC, syncytial giant cell type, to denote this apparently novel lesion.
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Affiliation(s)
- A Atra
- Department of Oncology, King Abdulaziz Medical City-Jeddah, PO Box 9515, Jeddah 21423, Kingdom of Saudi Arabia.
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Khattab TM, Felimban SK, Atra A. The outcome of infant ALL: Experience at King Abdulaziz Medical City, Jeddah, western Region of Kingdom of Saudi Arabia. J Clin Oncol 2006. [DOI: 10.1200/jco.2006.24.18_suppl.9038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
9038 Background: Infants with ALL have a worse prognosis than older children. Several regimens has been used with a 4 years event free survival ranging from 25%-40%. An international collaborative treatment protocol (Interfant 99) based on the understanding of the biology of infant ALL was introduced aiming to improve the outcome and study the role of allogeneic bone marrow transplantation (BMT). To review the clinical features, treatment outcome and causes of treatment failure of all infant ALL treated at our center. Methods: We retrospectively reviewed all case notes of children with ALL diagnosed between 1986–2005 to identify infants <12 months with ALL. The age, WBC and CNS disease at diagnosis were reviewed. Treatment details and survival were studied. Results: Among 351 patients with ALL, 12 were infants (4.2%). Patients charachteristics are shown in table below. Six were boys and 6 were < 6 month at diagnosis. Nine patients (75%) had WBC count >100,000 and 4/12 CNS disease at presentation. Immunophenotyping showing lacking CD10 7/12, biphentyping 3/12, unknown 2/12 and t (4:11) found in 2/12. Treatment consisted of UKALL-based in 7 patients and Interfant 99 protocol in 5. Two patients received BMT, one from unrelated donor and the other with one antigen mismatch from his mother. Six patients (50%) died of toxicity and 3(25%) of recurrent leukemia including one who had unrelated donor BMT. Three patients survive in full remission including one who had BMT from his mother. Conclusions: This small single center study confirms the inferior outcome of infant ALL. Toxic death remains a major cause of treatment failure. Because of the rarity of infant ALL, international collaboration is required to study the role of different chemotherapy regimens and assess the role of allogeneic BMT. [Table: see text] No significant financial relationships to disclose.
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Affiliation(s)
- T. M. Khattab
- King Khalid National Guard Hospital, Jeddah, Saudi Arabia
| | - S. K. Felimban
- King Khalid National Guard Hospital, Jeddah, Saudi Arabia
| | - A. Atra
- King Khalid National Guard Hospital, Jeddah, Saudi Arabia
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Atra A, Pinkerton CR, Bouffet E, Norton A, Hobson R, Imeson JD, Gerrard M. Acute neurotoxicity in children with advanced stage B-non-Hodgkin's lymphoma and B-acute lymphoblastic leukaemia treated with the United Kingdom children cancer study group 9002/9003 protocols. Eur J Cancer 2004; 40:1346-50. [PMID: 15177494 DOI: 10.1016/j.ejca.2004.02.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2003] [Revised: 02/04/2004] [Accepted: 02/11/2004] [Indexed: 12/20/2022]
Abstract
We reviewed the pattern of acute neurotoxicity in children with B-non-Hodgkin's lymphoma (B-NHL) and B-acute lymphoblastic leukaemia (ALL) treated with the UKCCSG 9002/9003 protocols. Among 175 patients, 21 (12%) developed acute neurotoxicity: 9002 protocol (n=11/112) and 9003 (n=10/63). There were 20 boys and the median age was 10 years. Patients with neurological symptoms due to other causes were excluded. Acute neurological symptoms developed following induction chemotherapy in 7 patients, or after a more intensive course of chemotherapy containing high-dose methotrexate (n=14). Nine patients required their chemotherapy to be altered because of the acute neurotoxicity. One patient died of cerebral haemorrhage but none of the remaining six deaths was attributed to acute neurotoxicity. We conclude that acute neurotoxicity is common in children treated with the 9002/9003 protocols and tends to be transient. Intrathecal and systemic chemotherapy including high-dose methotrexate is probably the most common predisposing factor. Modification of subsequent chemotherapy is not invariably necessary.
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Affiliation(s)
- A Atra
- Department of Oncology, King Abdulaziz Medical City-Jeddah, P.O. Box 9515, Jeddah 21423, Saudi Arabia.
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Kulkarni S, Powles R, Sirohi B, Treleaven J, Saso R, Horton C, Atra A, Ortin M, Rudin C, Goyal S, Sankpal S, Meller S, Pinkerton CR, Mehta J, Singhal S. Thalidomide after allogeneic haematopoietic stem cell transplantation: activity in chronic but not in acute graft-versus-host disease. Bone Marrow Transplant 2003; 32:165-70. [PMID: 12838281 DOI: 10.1038/sj.bmt.1704033] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Thalidomide was used to treat acute (n=21) or chronic (n=59) graft-vs-host disease (GVHD) in 80 haematopoietic stem cell allograft recipients after failure to respond to the combination of cyclosporine and corticosteroids with or without other agents. The median time to onset of acute GVHD was 11 days, and thalidomide was started at a median of 48 days post transplant. In addition to corticosteroids and cyclosporine, 13 patients had also received other agents before thalidomide. None of the patients responded and all died of acute GVHD. For chronic GVHD (limited in 13, extensive in 46), thalidomide was started at a median of 385 days post transplant. In addition to corticosteroids and cyclosporine, 34 patients received azathioprine concomitantly. In all patients, thalidomide was added to the ongoing immunosuppressive regimen. The median duration of therapy with thalidomide was 60 days (range, 11-1210; <2 weeks in 11). In total, 13 patients (22%) had complete response, eight (14%) partial response and 38 (64%) no response. Response rates were comparable for limited (39%) and extensive (33%) chronic GVHD. At a median of 53 months, 19 patients are alive, 13 without evidence of chronic GVHD. Survival was significantly better in patients who responded to thalidomide. The principal causes of death were progressive chronic GVHD (n=29) and relapsed leukaemia (n=7). In conclusion, thalidomide has no activity in acute GVHD, but has some activity in chronic GVHD in combination with other agents.
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Affiliation(s)
- S Kulkarni
- Leukaemia and Myeloma Units, The Royal Marsden Hospital, Downs Road, Sutton, Surrey SM2 5PT, UK
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Atra A, Higgs E, Capra M, Elsworth A, Imeson J, Radford M, Hewitt M. ChlVPP chemotherapy in children with stage IV Hodgkin's disease: results of the UKCCSG HD 8201 and HD 9201 studies. Br J Haematol 2002; 119:647-51. [PMID: 12437639 DOI: 10.1046/j.1365-2141.2002.03927.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We reviewed the results of two consecutive United Kingdom Childrens' Cancer Study Group (UKCCSG) studies of children with stage IV Hodgkin's Disease (HD) treated between January 1982 and December 1999. Among 697 children with HD, 67 were diagnosed to be stage IV. The median age at diagnosis was 12.7 years (range 4.4-16.2). Thirty-five (52%) were boys. Thirty-nine patients (58%) had B symptoms at diagnosis. All were treated with 6-8 cycles of ChlVPP chemotherapy regimen (Chlorambucil, Vinblastine, Procarbazine and prednisolone) and only 12 had radiotherapy. The overall survival (OS) at 5 and 10 years was 80.8% and 77.2%, respectively, whilst the event-free survival (EFS) at the same time intervals was 55.2% and 48.8% respectively. Twenty-eight patients (41.79%) relapsed/progressed, 18 (64%) survived after further chemotherapy with or without high-dose therapy and stem cell rescue. Twelve patients died, seven of HD, three from infections and one from secondary acute myeloblastic leukaemia (AML). Although the EFS in this study was lower than other studies, 64% of relapsed patients were salvaged with second-line therapy. It is also anticipated that survivors treated with this non-anthracycline-containing regimen will have less long-term toxicity.
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Affiliation(s)
- Ayad Atra
- Department of Paediatrics, Riyadh Armed Forces Hospital, Riyadh Kingdom of Saudi Arabia.
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20
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Atra A, Higgs E, Capra M, Elsworth A, Imeson J, Radford M, Pinkerton R, Hewitt M. Isolated parenchymal lung involvement in children with stage IV Hodgkin's disease: results of the UKCCSG HD8201 and HD9201 studies. Br J Haematol 2002; 119:441-4. [PMID: 12406083 DOI: 10.1046/j.1365-2141.2002.03827.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We retrospectively reviewed the case notes of 27 patients who were diagnosed with stage IV Hodgkin's disease (HD) because of isolated parenchymal pulmonary involvement on chest radiograph and computerized tomography scan (excluding subcategory E). Ten were boys and 15 had B symptoms. Median age at diagnosis was 13.6 years (range 6.1-16.2). All received 6-8 cycles of ChlVPP (chlorambucil, vinblastine, procarbazine and prednisolone) and two had additional whole lung irradiation (12 Gy). Ten patients (37%) relapsed or progressed. Seven survive following second-line therapy while three died, two of HD and one of secondary acute myeloid leukaemia 4 years from diagnosis. At the time of analysis, the median follow-up of patients was 56 months (range 9-127). The event-free survival (EFS) was 58.4% (95% CI 38.5-75.8%) at both 5 and 10 years from diagnosis, and the overall survival (OS) was 84.2% (95% CI 61.8-94.6%) at both 5 and 10 years from diagnosis. We conclude that the outcome for HD patients defined as stage IV, because of isolated parenchymal lung involvement, is encouraging and compares favourably with other extra lymphatic organ involvement. Combination chemotherapy is effective in achieving long-term remission and whole lung irradiation is unnecessary.
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Affiliation(s)
- Ayad Atra
- Department of Paediatrics, Riyadh Armed Forces Hospital, Riyadh, Kingdom of Saudi Arabia.
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Abstract
Soft tissue sarcomas (STS) are highly malignant tumours that constitute 5-6% of all malignant childhood neoplasms. Of these, rhabdomyosarcoma (RMS) is the most common in children, and has a characteristic two-peak age incidence, 2-5 and 15-19 years. Most children with RMS are cured with conventional chemotherapy and local therapy (surgery with or without radiotherapy). Children with metastatic disease at presentation, particularly those older than 10 years or with bone marrow or bone involvement have a much poorer outcome. In this subgroup, high-dose therapy with stem cell rescue has been studied over the last two decades. Various single or multiagent chemotherapy regimens with or without radiotherapy and autologous stem cell rescue have been used as consolidation treatment with little success. Recent trials using sequential high-dose chemotherapy in the early phase of treatment have proved to be feasible, but the beneficial effect has to be confirmed. The role of purging remains unclear. Collaboration between different international groups is urgently required, in an attempt to improve the poor outcome of children with high risk STS.
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Affiliation(s)
- Ayad Atra
- Department of Paediatric Oncology, The Royal Marsden Hospital NHS Trust/Institute of Cancer Research, Downs Road, Sutton, SM2 5PT, Surrey, UK
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Atra A, Gerrard M, Hobson R, Imeson JD, Hann IM, Pinkerton CR. Outcome of relapsed or refractory childhood B-cell acute lymphoblastic leukaemia and B-cell non-Hodgkin's lymphoma treated with the UKCCSG 9003/9002 protocols. Br J Haematol 2001; 112:965-8. [PMID: 11298592 DOI: 10.1046/j.1365-2141.2001.02647.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Twenty-six children with B-cell acute lymphoblastic leukaemia (B-ALL) or Murphy Stage III or IV B-cell non-Hodgkin's lymphoma (B-NHL) progressed or relapsed after first-line therapy with a short, intensive multiagent chemotherapy regimen [United Kingdom Childhood Cancer Study Group (UKCCSG) 9003] (n = 62) or a slightly less intensive regimen (UKCCSG 9002) (n = 112). Eight patients (4.6%) never achieved complete remission (CR) and 18 (10.3%) relapsed. Second-line therapy resulted in remission for eight patients (30%). All patients initially treated with the 9003 protocol died. Three patients (11.5%) in the 9002 group, including one who never achieved CR in the primary site, are alive after second-line therapy. This study confirms that the prognosis of relapsed or refractory B-ALL/B-NHL is poor and exceptionally so if relapse occurred less than 6 months from diagnosis. High-dose therapy with stem cell rescue was used in only seven patients; its role needs to be studied further.
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Affiliation(s)
- A Atra
- Department of Paediatric Oncology, The Royal Marsden Hospital NHS Trust/Institute of Cancer Research, Downs Road, Sutton, Surrey SM2 5PT, UK.
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Vaidya S, Atra A, Meller S. Response to Maldonado et al. Bone Marrow Transplant 2000. [DOI: 10.1038/sj.bmt.1702687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Atra A, Imeson JD, Hobson R, Gerrard M, Hann IM, Eden OB, Carter RL, Pinkerton CR. Improved outcome in children with advanced stage B-cell non-Hodgkin's lymphoma (B-NHL): results of the United Kingdom Children Cancer Study Group (UKCCSG) 9002 protocol. Br J Cancer 2000; 82:1396-402. [PMID: 10780517 PMCID: PMC2363364 DOI: 10.1054/bjoc.1999.1083] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
From July 1990 to March 1996, 112 children with stage III or IV B-cell non-Hodgkin's lymphoma (B-NHL) with up to 70% FAB L3-type blasts (n = 42) in the bone marrow without central nervous system (CNS) disease were treated on the United Kingdom Children Cancer Study Group (UKCCSG) 9002 protocol (identical to the French LMB 84). The median age was 8.3 years. There were 81 boys and 31 girls. According to the extent of the primary disease, patients were sub-staged into three groups: IIIA with unresectable abdominal tumour (n = 39); IIIB with abdominal multiorgan involvement (n = 57) and IIIX with extra-abdominal primary lymphoma often presenting as pleural effusion (n = 16). Univariate and multivariate analyses were carried out to evaluate the prognostic significance of lactate dehydrogenase (LDH) level at diagnosis, the sub-stage and the time to achieve complete remission (CR). With a median follow up of 48 months (range 12-92), the overall and event free survival (EFS) is 87% (95% confidence interval (CI) 79.2-92.1 %) and 83.7% (95% CI 76.3-89.2%) respectively. Six patients (5.4%) never achieved CR, of whom one is alive following high-dose therapy. Eight patients (7.1%) relapsed after achieving CR, three are alive after second-line therapy. There were three early toxic deaths (2.7%), mainly from infection, and one late death from a second cancer. There was no significant difference in EFS according to LDH level at diagnosis, the sub-stage or the time to CR. This study confirms the overall good prognosis and low rate of toxic deaths in patients with advanced B-NHL treated with this intensive regimen. No significant difference in EFS according to the sub-stage, the time to achieve CR or LDH level at diagnosis making it difficult to identify a group that should not receive intensive therapy.
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Affiliation(s)
- A Atra
- Department of Paediatric Oncology, The Royal Marsden Hospital NHS Trust, Sutton, Surrey, UK
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25
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Vaidya SJ, Atra A, Bahl S, Pinkerton CR, Calvagna V, Horton C, Milan S, Shepherd V, Brain C, Treleaven J, Powles R, Tait D, Meller ST. Autologous bone marrow transplantation for childhood acute lymphoblastic leukaemia in second remission - long-term follow-up. Bone Marrow Transplant 2000; 25:599-603. [PMID: 10734293 DOI: 10.1038/sj.bmt.1702214] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
From 1984 to 1996, 31 consecutive children without sibling donors, aged 5-19 years (median 8) with acute lymphoblastic leukaemia (ALL) in second complete remission (CR), received unpurged autologous bone marrow transplantation (ABMT) after melphalan and single fraction total body irradiation (TBI). ABMT was performed using fresh unmanipulated marrow harvested after standard reinduction and consolidation therapy 2-11 months (median 5) after relapse. With a median survival of 2.9 years the probability of survival for all patients in continuing second CR was 45.1% (95% CI, 24%-62%) after 5 years. Regimen-related and non-leukaemia mortality was 7% (95% CI, 2%-26%). The longest time to second relapse from ABMT was 3.1 years. Pituitary and gonadal dysfunction requiring hormonal replacement therapy occurred in the majority of long-term survivors. Twelve patients developed cataracts. ABMT with melphalan/single fraction TBI has proved an effective anti-leukaemia treatment with low regimen-related mortality but significant long-term morbidity. The current approach of allogeneic BMT from an unrelated donor when no sibling donor is available, following conditioning with cyclophosphamide/ fractionated TBI has resulted in a reduced relapse rate and improved short-term overall survival in the treatment of relapsed childhood ALL. However, long-term results are awaited.
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Affiliation(s)
- S J Vaidya
- Paediatric Oncology, The Royal Marsden NHS Trust, Sutton, UK
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26
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Kulkarni S, Powles R, Treleaven J, Singhal S, Horton C, Sirohi B, Bhagawati N, Tait D, Saso R, Killick S, Pinkerton R, Atra A, Meller S, Mehta J. Melphalan/TBI is not more carcinogeneic than cyclophosphamide/TBI for transplant conditioning: follow-up of 725 patients from a single centre over a period of 26 years. Bone Marrow Transplant 2000; 25:365-70. [PMID: 10723578 DOI: 10.1038/sj.bmt.1702148] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
As there is concern regarding the high carcinogenic potential of melphalan (Mel), 725 patients with haematological malignancies who received allogeneic (n = 714) or syngeneic (n = 11) transplants over the last 26 years were followed-up to evaluate if melphalan was more likely to result in secondary malignant neoplasms (SMNs) than cyclophosphamide (Cy). Three hundred and ninety-five were treated with Cy/TBI and 330 with Mel/TBI. Twelve patients developed non-haematological SMN. Median time to develop a SMN was 7 years (range 2-17 years). Age-adjusted rate was significantly higher than in the general population (observed 12 expected 1.2, risk 10; P < 0.0001). The cumulative overall risk of developing a SMN at 2, 5, 10 and 15 years post transplant was 0.4% (95% CI 0.1-2.6%), 1.7% (95% CI 0.6-4.4%), 6.4% (95% CI 2.8-10.8%) and 6.6% (95% CI 3.4-12.4%), respectively. Even though age-adjusted rates were higher than the general population melphalan/TBI was not associated with higher age-adjusted risk than Cy/TBI (increased risk 7.9 vs 11.4; P = NS). The cumulative overall risk of SMNs was not different with CY/TBI or Mel/TBI (8/393 vs 4/363; 10 year risk 4.4%, 95% CI 1.8-10.6 vs 8.4%, 95% CI 2.9-22.9; P = NS). The risk was significantly higher with use of additional cranial or cranio-spinal irradiation (17.5% vs 2.7% at 10 years; P = 0.0241). Transplants for acute lymphatic leukaemia resulted in a higher incidence of SMNs than did transplants for other diseases (ALL: 17.4%, 95% CI 6.3-42.6%; other diseases: 3.4% (95% 1.3-8.5%, P = 0.0469). The risk of SMN for patients with chronic GVHD was 8.4% (95% CI 3.7-18.7%) as compared to 3.5% (95% CI 1-11.1%) for patients without chronic GVHD (P = NS). No factor was associated with independently increased risk in multivariate analysis. Use of melphalan and TBI for transplant conditioning does not appear to be associated with higher risk of second malignant neoplasms than cyclophosphamide and TBI.
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Affiliation(s)
- S Kulkarni
- Leukaemia Unit, Royal Marsden Hospital, Sutton, UK
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Shankar AG, Pinkerton CR, Atra A, Ashley S, Lewis I, Spooner D, Cannon S, Grimer R, Cotterill SJ, Craft AW. Local therapy and other factors influencing site of relapse in patients with localised Ewing's sarcoma. United Kingdom Children's Cancer Study Group (UKCCSG). Eur J Cancer 1999; 35:1698-704. [PMID: 10674016 DOI: 10.1016/s0959-8049(99)00144-6] [Citation(s) in RCA: 84] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Relapse patterns have been documented in 191 children with localised Ewing's sarcoma treated with the United Kingdom Children's Cancer Group (UKCCSG) Ewing's Tumour regimen ET2. All received chemotherapy comprising ifosfamide, vincristine, doxorubicin and actinomycin D. Local treatment modality was excision and or radiotherapy depending on tumour site and response to primary chemotherapy. Although not strictly comparable, due to the clinical indications used for each modality, local relapse rates were very low and were similar, irrespective of the type of local treatment modality: radiotherapy (3/56), surgery (7/114) or a combination (0/20). Combined relapse (local + distant) rates were similarly low irrespective of the type of local therapy: radiotherapy (4/56), surgery (4/114) or a combination (0/20). Overall survival was lower in females (P = < 0.04), older children (P = < 0.002) and those with primaries at sites other than long bones (P = < 0.02). It is concluded that with effective intensive chemotherapy combined with either radiotherapy or surgery, local control in this study was excellent at sites other than the pelvis. Preventing distant relapse, predominantly to lung and bone, remains the major challenge.
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Affiliation(s)
- A G Shankar
- Paediatric Department, Royal Marsden NHS Trust, Sutton, Surrey, U.K
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Killick S, Matutes E, Powles RL, Min T, Treleaven JG, Rege KP, Atra A, Catovsky D. Acute erythroid leukemia (M6): outcome of bone marrow transplantation. Leuk Lymphoma 1999; 35:99-107. [PMID: 10512167 DOI: 10.3109/10428199909145709] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Erythroid leukemia is an uncommon form of acute myeloid leukemia (AML) which has previously been associated with a poor prognosis. We present the outcome of 27 patients with AML-M6 (19 de novo and 8 secondary) treated with intensive regimens including bone marrow transplantation (BMT). In the de novo group, median age was 30 years (2-72); 5 cases were under 15 years. Remission rate after induction chemotherapy was 95%. Consolidation in those achieving remission with BMT was 82%. Transplant related mortality was 36%. Median survival for de novo M6 was 2.9 years which was not significantly different to matched controls with AML (non M6). Overall relapse rate was 35%. In contrast, patients with secondary disease had a poor prognosis with lower remission rates (57%) and higher relapse rates (75% of those achieving remission after induction chemotherapy). In our series, the prognosis of patients with AML-M6 was most closely related to age and disease status at presentation (de novo or secondary). The disease is sensitive to AML induction regimens and long-term survival can be achieved with BMT in first complete remission.
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Affiliation(s)
- S Killick
- Leukaemia Unit, The Royal Marsden NHS Trust and Institute of Cancer Research, London, UK.
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Killick S, Matutes E, Powles RL, Hamblin M, Swansbury J, Treleaven JG, Zomas A, Atra A, Catovsky D. Outcome of biphenotypic acute leukemia. Haematologica 1999; 84:699-706. [PMID: 10457405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/13/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Although biphenotypic leukemia is now a defined entity, outcome of this rare form of acute leukemia has not been well documented. We present the first comprehensive study analyzing induction and consolidation therapy of biphenotypic leukemia and correlate outcome to prognostic factors. DESIGN AND METHODS In this retrospective study, the incidence of biphenotypic leukemia was found to be 3.6% from 693 adult and pediatric acute leukemias referred to our center for treatment over the last 8 years. Of these, 15 were B-lymphoid/myeloid, 8 were T-lymphoid/myeloid, one was T/B lymphoid and one had trilineage differentiation. RESULTS Induction of remission in de novo cases was achieved in 70% of patients and relapse of disease occurred in 15%. The use of combined lymphoid and myeloid drugs for induction resulted in a high incidence of early deaths (25%). The overall probability of survival at 2 years was 39.4%. Patients with secondary disease had a uniformly poor outcome with low remission rates and high relapse rates. INTERPRETATION AND CONCLUSIONS Prognosis was most strongly related to the presence of the Philadelphia chromosome (p=0.03) and age under 15 years (p=0.01). We conclude that patients with biphenotypic leukemia should have risk stratification with treatment tailored to their prognostic factors.
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Affiliation(s)
- S Killick
- Department of Haematology, St George's Hospital Medical School, Cranmer Terrace, London SW17 ORE, UK.
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Shankar AG, Ashley S, Atra A, Kingston JE, Mott M, Pinkerton CR. A limited role for VEEP (vincristine, etoposide, epirubicin, prednisolone) chemotherapy in childhood Hodgkin's disease. Eur J Cancer 1998; 34:2058-63. [PMID: 10070311 DOI: 10.1016/s0959-8049(98)00314-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The VEEP regimen (vincristine, etoposide, epirubicin, prednisolone), with or without involved field radiotherapy, has been shown to be an effective treatment in adult Hodgkin's disease. In an attempt to avoid the late sequelae of both alkylating agents and radiotherapy this regimen has been studied in a series of 54 children and young adults. Early analysis suggested that the relapse rate was higher with VEEP than with standard alkylating agent-based regimens. Sufficient follow-up has now been achieved to evaluate the likelihood of sustained remission following second-line treatment and therefore the overall long term survival with this treatment approach. The 5-year Overall Survival (OS) and 5-year Progression Free Survival (PFS) for patients with stage I-III disease was 93% and 82% respectively. However, the 5-year OS and PFS for stage IV patients was only 44% and 50%, respectively. Of 13 patients who were initial treatment failures on VEEP, 7 of whom had advanced disease, only 6 were salvaged with second-line therapy. 8 of 33 who attained a complete response (CR) relapsed and there were 2 relapses in those achieving a partial response (PR) (n = 8). All those relapsing from CR/PR were salvaged by second-line alkylating agent chemotherapy +/- radiotherapy, +/- high dose chemotherapy. In conclusion, patients with stage I-IIIA, non-bulky disease, the moderately high relapse rate did not adversely affect the overall high cure rate, although VEEP failures were subjected to a high total treatment burden. VEEP alone is inadequate in patients with stage IV disease, bulky mediastinal disease in/or those with B symptoms in whom there is a high primary failure rate and relatively poor results with second line therapy.
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Affiliation(s)
- A G Shankar
- Paediatric Department, Royal Marsden NHS Trust Institute of Cancer Research, Sutton, Surrey, U.K
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Abstract
Among 447 children with non-Hodgkin's lymphoma (NHL) on the childhood U.K. registry, seven children with follicular (NHL) were identified. Four were male and their age ranged from 4.25 to 13.5 years (median 7.5); all had localized disease, Murphy's stage I (n = 4) and II (n = 3). Sites involved at presentation were cervical lymph nodes and tonsils (n = 5), ileum (n = 1) and parotid gland (n = 1). Three had complete surgical excision only and four had complete (n = 1) or incomplete excision (n= 3) followed by a short multi-agent chemotherapy regimen (UKCCSG 9001 protocol). With a median follow-up of 1.5 years (range 0.25-5 years) from diagnosis, six are alive in complete remission (CR) including three who had no chemotherapy. These results confirm previous reports that follicular lymphomas in children are rare (1.5%) and tend to be localized at presentation. Their rarity makes it difficult to produce guidelines about treatment, but in localized cases a period of non-intervention may be justified.
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Affiliation(s)
- A Atra
- Department of Paediatric Oncology, The Royal Marsden Hospital NHS Trust, Sutton, Surrey
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32
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Atra A, Gerrard M, Hobson R, Imeson JD, Ashley S, Pinkerton CR. Improved cure rate in children with B-cell acute lymphoblastic leukaemia (B-ALL) and stage IV B-cell non-Hodgkin's lymphoma (B-NHL)--results of the UKCCSG 9003 protocol. Br J Cancer 1998; 77:2281-5. [PMID: 9649146 PMCID: PMC2150418 DOI: 10.1038/bjc.1998.379] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
From June 1990 to February 1996, 35 patients with B-cell acute lymphoblastic leukaemia (B-ALL) 13 of whom had CNS disease and 28 patients with stage IV B-cell non-Hodgkin's lymphoma (B-NHL) 22 of whom had CNS involvement were treated with a short, intensive multiagent chemotherapy regimen (UKCCSG 9003 protocol) based on the French LMB 86 regimen. Fifty-five were boys. The age range was 11 months to 16.5 years (median 8.4 years). Chemotherapy included cyclophosphamide, vincristine, daunorubicin, high-dose methotrexate (COPADM) and etoposide/high-dose cytarabine (CYVE) with frequent intrathecal (i.t.) triple therapy (methotrexate, cytarabine and hydrocortisone). Cranial irradiation (24 Gy in 15 fractions) was recommended in patients with overt CNS disease. One patient with Wiskott-Aldrich syndrome was withdrawn after entry and has been excluded from the analysis. Ten patients (16%) have relapsed (CNS, four; BM, two; combined CNS and BM, three; and jaw, one) 4-11 months after diagnosis and two patients never achieved complete remission (CR). All have died. In seven of the patients who relapsed, treatment had been modified or delayed because of poor clinical condition. Seven patients (11%) died of toxicity 11 days to 4 months after diagnosis. The cause of death was sepsis (n = 5) or sepsis with renal failure (n = 2). With a median follow-up of 3.1 years from diagnosis (range 9 months to 6.3 years), 43 patients (69%) survive in CR. This study confirms the effectiveness of this regimen with regard to the relapse rate (16%), although the rate of toxic death is of concern.
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Affiliation(s)
- A Atra
- Department of Paediatric Oncology, The Royal Marsden Hospital NHS Trust/Institute of Cancer Research, Sutton, Surrey, UK
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Abstract
Aspergillus species can cause life-threatening infection in immunocompromised children. Pulmonary infections are the most common, and are usually acquired through inhalations of aspergillus spores in unfiltered air. Some patients acquire invasive aspergillus infection from endogenous spread of colonized para-nasal sinuses.
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Affiliation(s)
- A Atra
- Department of Paediatric Oncology, The Royal Marsden NHS Trust, Sutton, Surrey, UK
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Abstract
There are several reports of osteosarcoma metastases to the heart. A rare case of a metastatic osteosarcoma to the endocardium of the left atrium in a 17 year old patient is described. The radiological features are discussed in detail.
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Affiliation(s)
- A Atra
- Department of Paediatric Oncology, Royal Marsden Hospital, Sutton, Surrey, UK
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35
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Atra A, Whelan JS, Calvagna V, Shankar AG, Ashley S, Shepherd V, Souhami RL, Pinkerton CR. High-dose busulphan/melphalan with autologous stem cell rescue in Ewing's sarcoma. Bone Marrow Transplant 1997; 20:843-6. [PMID: 9404924 DOI: 10.1038/sj.bmt.1700992] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Eighteen patients with poor risk Ewing's sarcoma (including 11 patients with metastatic disease at presentation) received consolidation therapy of busulphan and melphalan with autologous stem cell rescue. There were nine females. The median age at diagnosis was 14.2 years (range 2.75-30 years). There was one early death due to cytomegalovirus pneumonitis. One patient developed a single generalised convulsion during busulphan therapy. Severe renal toxicity was not encountered. One patient developed veno-occlusive disease of the liver (VOD) which eventually resolved. With a median follow up of 2 years, 13 patients survive including six with initial metastatic disease. We conclude that high-dose busulphan/melphalan is well-tolerated and should be evaluated for efficacy in a larger series of patients with high risk Ewing's sarcoma.
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Affiliation(s)
- A Atra
- Department of Paediatric Oncology, The Royal Marsden NHS Trust, Sutton, Surrey, UK
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36
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Abstract
Acute lymphoblastic leukaemia (ALL) presenting as a transient pancytopenia is known to occur in children and less commonly in adults. The period of pancytopenia usually resolves after about 5-38 weeks, to be followed by overt ALL. The pathogenesis is not known and there are no specific cytogenetic abnormalities. Diagnosis is often difficult during the period of bone marrow hypoplasia. Quantitative flow cytometry can help to establish early diagnosis, and can be used on more patients presenting in a similar way.
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Affiliation(s)
- A Atra
- The Royal Marsden Hospital, Sutton, Surrey, U.K
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37
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Atra A, Millar B, Shepherd V, Shankar A, Wilson K, Treleaven J, Pritchard-Jones K, Meller ST, Pinkerton CR. Donor lymphocyte infusion for childhood acute lymphoblastic leukaemia relapsing after bone marrow transplantation. Br J Haematol 1997; 97:165-8. [PMID: 9136960 DOI: 10.1046/j.1365-2141.1997.62650.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Four children with acute lymphoblastic leukaemia (ALL) who relapsed after allogeneic bone marrow transplantation (BMT) were treated with donor lymphocyte infusion (DLI) without prior conditioning. Three patients had previously received a non-T-cell-depleted matched sibling BMT and the fourth had a T-cell-depleted matched unrelated BMT. Two patients developed grade III-IV acute graft-versus-host-disease (GVHD) of the skin, which required intervention. Both are alive in complete haematological remission 7 and 10 months from DLI with chronic GVHD of the skin requiring immunosuppressive therapy. A third patient went into haematological remission 6 weeks after DLI, but with no clinical evidence of GVHD. His bone marrow remained in remission 11 months post-DLI despite the disease (ALL) relapsing in extramedullary sites. The fourth patient showed no clinical or haematological response to three consecutive doses of DLI given at 4-weekly intervals and died from progressive disease 11 months after relapse. These preliminary observations indicate that in constrast to experience in adult ALL, DLI may be effective in inducing sustained remission in children with ALL relapsing after BMT, and a response may occur even in the absence of clinical evidence of GVHD.
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Affiliation(s)
- A Atra
- Department of Paediatric Oncology, The Royal Marsden Hospital NHS Trust/The Institute of Cancer Research, Sutton, Surrey
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Duncan N, Hewetson M, Atra A, Dick G, Pinkerton R. An economic evaluation of the use of granulocyte colony-stimulating factor after bone marrow transplantation in children. Pharmacoeconomics 1997; 11:169-74. [PMID: 10165826 DOI: 10.2165/00019053-199711020-00006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Studies that have assessed the use of granulocyte colony-stimulating factor (G-CSF) following bone marrow transplantation have shown a significantly reduced time to neutrophil recovery with the use of this agent, which may translate into a reduced duration of antimicrobial therapy and hospitalisation. We performed a pharmacoeconomic study evaluating the elective use of G-CSF after bone marrow transplantation in children. 22 consecutive children who underwent bone marrow transplantation and received G-CSF 5 micrograms/kg/day were compared with 18 such children (control group) who did not receive G-CSF. Despite a significant reduction in time to recovery of the absolute neutrophil count (ANC) to > 0.5 x 10(9)/L in G-CSF recipients compared with the control group (14 days vs 20.9 days; p < 0.0001), there was only a trend towards a reduction in the duration of intravenous antimicrobial therapy (14.5 days vs 18.6 days; p = 0.15), and there was no significant difference in the duration of hospitalisation (25.3 days vs 29.8 days). Reasons for prolonged hospitalisation beyond ANC recovery included continued use of total parenteral nutrition, treatment of graft-versus-host disease and treatment of ongoing infection. Overall, the mean total cost for patients receiving G-CSF was Pounds 15001, compared with Pounds 15482 for the control group (1995 values). In conclusion, while there appears to be no benefit in financial terms, the release of a child from strict isolation as a result of early ANC recovery must be taken into consideration.
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Affiliation(s)
- N Duncan
- Pharmacy Department, Royal Marsden NHS Trust, Sutton, Surrey, England
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Abstract
High-dose chemoradiotherapy (HDCRT) followed by autologous stem cell (ASC) rescue is now widely used in a number of childhood malignancies. The most common to date is neuroblastoma, where it now has an established role as consolidation of initial complete remission in children over the age of 1 year with stage 4 disease. High-dose melphalan alone prolongs progression-free survival, with a small increase in long-term survival. The value of a total body irradiation (TBI)-based regimen is currently under randomized evaluation. In soft-tissue sarcoma, such as rhabdomyosarcoma or Ewing's sarcoma of bone or soft tissue, high-dose therapy has been used to consolidate initial complete or partial remission. The benefit has not been demonstrated in randomized studies but chemotherapy-alone regimens based on combined alkylating agents appear to be of potential value. Other tumours have been treated in this way but the place of high-dose therapy remains entirely unclear. It is possible that inherently chemosensitive tumours, such as Wilm's tumour, may be candidates where standard treatment has failed. The replacement of bone marrow reinfusion with cytokine-primed peripheral blood stem cell (PBSC) rescue has reduced the morbidity of these procedures. The issue of the potential risk of reinfusing tumour cells has been addressed in neuroblastoma where purging using immunodepletion or in vitro chemotherapy has been carried out.
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Affiliation(s)
- A Atra
- Paediatric Department, Royal Marsden NHS Trust, Sutton, Surrey, UK
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Atra A, Ward HC, Aitken K, Boyle M, Dicks-Mireaux C, Duffy PG, Mitchell CD, Plowman PN, Ransley PG, Pritchard J. Conservative surgery in multimodal therapy for pelvic rhabdomyosarcoma in children. Br J Cancer 1994; 70:1004-8. [PMID: 7947076 PMCID: PMC2033530 DOI: 10.1038/bjc.1994.438] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Twenty-six previously untreated children, median age 3.4 years, with pelvic rhabdomyosarcoma (RMS) were seen between 1983 and 1988. Fourteen were girls. The planned strategy was to conserve pelvic organs, especially the bladder, by using primary chemotherapy, conservative surgery and, in most cases, radiotherapy. With a median follow-up of 71 months (range 34-103 months) overall survival was 73%, with no treatment-related death. The bladder salvage rate of 88% in survivors with bladder base/prostate primaries was much higher than that reported by the United States Intergroup Rhabdomyosarcoma Studies (IRS), though many of the preserved bladders did not function normally. We identified problems with both radiological and histological off-treatment monitoring. The overall accuracy of computerised tomographic (CT) scanning for prediction of tumour recurrence was only 81%, and endoscopic biopsies proved misleading in four of the ten bladder base/prostate patients monitored by serial cystoscopy. We conclude that a higher cure rate can be achieved by using intensive chemotherapy/radiotherapy and conservative surgery to treat children with pelvic RMS. Factors that might contribute to our favourable bladder salvage results, compared with those of the IRS, include (a) the fact that one of two specialist surgeons monitored and operated on all these patients and (b) our increasing awareness, during the study, that post-chemotherapy/radiotherapy histopathology and pelvic CT scan appearances may be misleading. Referral to paediatric centres with special experience of pelvic RMS may help raise the rate of bladder salvage in these children.
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Affiliation(s)
- A Atra
- Department of Haematology and Oncology, Hospitals for Sick Children, London, UK
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Abstract
The pattern of remission deaths was examined in 842 children with acute lymphoblastic leukaemia (ALL) treated at a single centre over 18 years. The mortality rate from leukaemia fell significantly during three consecutive time periods during which treatment became progressively more intensive and that during remission induction fell from 3.5% to under 1%, but the rate of death in remission stayed constant at 5-6%. The factors associated with an increased risk of remission death were: young age, a higher leucocyte count, bone marrow transplantation, and Down's syndrome. The pattern of remission deaths changed over the years; measles and herpes viruses decreased while deaths associated with periods of intensification and gut toxicity increased. Four children developed second neoplasms. Treatment of ALL is still associated with a significant risk of death in remission but the pattern of infective deaths has changed. Many should be avoidable by provision of adequate supportive care, close supervision after periods of intensive treatment, and appropriate antibiotic, antifungal, and cytokine therapy.
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Affiliation(s)
- A Atra
- Department of Haematology and Oncology, Hospitals for Sick Children, London
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42
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Pritchard T, Atra A. Chemotherapy for lymphoid malignancy in immunosuppressed patients. J Pediatr 1992; 120:835-6. [PMID: 1315856 DOI: 10.1016/s0022-3476(05)80270-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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