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Robinson BW, Kairalla JA, Devidas M, Carroll AJ, Harvey RC, Heerema NA, Willman CL, Ball AR, Woods EC, Ballantyne NC, Urtishak KA, Behm FG, Reaman GH, Hilden JM, Camitta BM, Winick NJ, Pullen J, Carroll WL, Hunger SP, Dreyer ZE, Felix CA. KMT2A partner genes in infant acute lymphoblastic leukemia have prognostic significance and correlate with age, white blood cell count, sex, and central nervous system involvement: a Children's Oncology Group P9407 trial study. Haematologica 2023; 108:2865-2871. [PMID: 36861410 PMCID: PMC10543184 DOI: 10.3324/haematol.2022.281552] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 02/23/2023] [Indexed: 03/03/2023] Open
Affiliation(s)
- Blaine W Robinson
- Division of Oncology and the Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, PA
| | - John A Kairalla
- Department of Biostatistics, University of Florida College of Public Health and Health Professions and College of Medicine, Gainesville, FL
| | - Meenakshi Devidas
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - Andrew J Carroll
- Department of Genetics, University of Alabama at Birmingham, Birmingham, AL
| | - Richard C Harvey
- University of New Mexico Cancer Center and Department of Pathology, Albuquerque, NM
| | - Nyla A Heerema
- Department of Pathology, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | | | - Amanda R Ball
- Division of Oncology and the Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Elliot C Woods
- Division of Oncology and the Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Nancy C Ballantyne
- Division of Oncology and the Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Karen A Urtishak
- Division of Oncology and the Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Frederick G Behm
- Department of Pathology, University of Illinois at Chicago, Chicago, IL
| | | | - Joanne M Hilden
- Center for Cancer and Blood Disorders, Children's Hospital Colorado, Aurora, CO
| | | | - Naomi J Winick
- Division of Pediatric Hematology/Oncology, University of Texas Southwestern School of Medicine, Dallas, TX
| | - Jeanette Pullen
- Pediatric Hematology/Oncology, University of Mississippi Medical Center, Jackson, MS
| | - William L Carroll
- Department of Pediatrics and Perlmutter Cancer Center, NYU Langone Health, New York, NY
| | - Stephen P Hunger
- Division of Oncology and the Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | | | - Carolyn A Felix
- Division of Oncology and the Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
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Guest EM, Kairalla JA, Hilden JM, Dreyer ZE, Carroll AJ, Heerema NA, Wang CY, Devidas M, Gore L, Salzer WL, Winick NJ, Carroll WL, Raetz EA, Borowitz M, Loh ML, Hunger SP, Brown PA. Outstanding outcomes in infants with KMT2A-germline acute lymphoblastic leukemia treated with chemotherapy alone: results of the Children's Oncology Group AALL0631 trial. Haematologica 2022; 107:1205-1208. [PMID: 35172563 PMCID: PMC9052896 DOI: 10.3324/haematol.2021.280146] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Indexed: 11/28/2022] Open
Affiliation(s)
- Erin M Guest
- Division of Hematology/Oncology/Blood and Marrow Transplantation, Children's Mercy Kansas City, Kansas City, MO.
| | - John A Kairalla
- Department of Biostatistics, Colleges of Medicine, Public Health and Health Professions, University of Florida, Gainesville, FL
| | - Joanne M Hilden
- Center for Cancer and Blood Disorders, Children's Hospital Colorado, Aurora, CO
| | | | - Andrew J Carroll
- Department of Genetics, University of Alabama at Birmingham, Birmingham, AL
| | - Nyla A Heerema
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Cindy Y Wang
- Department of Biostatistics, Colleges of Medicine, Public Health and Health Professions, University of Florida, Gainesville, FL
| | - Meenakshi Devidas
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN
| | - Lia Gore
- Center for Cancer and Blood Disorders, Children's Hospital Colorado, Aurora, CO
| | - Wanda L Salzer
- U.S. Army Medical Research and Materiel Command, Fort Detrick, MD
| | - Naomi J Winick
- Division of Pediatric Hematology/Oncology, University of Texas Southwestern School of Medicine, Dallas, TX
| | - William L Carroll
- Department of Pediatrics and Perlmutter Cancer Center, NYU Langone Health, New York, NY
| | - Elizabeth A Raetz
- Department of Pediatrics and Perlmutter Cancer Center, NYU Langone Health, New York, NY
| | - Michael Borowitz
- Departments of Pathology and Oncology, Johns Hopkins University, Baltimore, MD
| | - Mignon L Loh
- Department of Pediatrics, Benioff Children's Hospital in the Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA
| | - Stephen P Hunger
- Department of Pediatrics and the Center for Childhood Cancer Research, Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Patrick A Brown
- Division of Pediatric Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
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Salzer WL, Burke MJ, Devidas M, Dai Y, Heerema NA, Carroll AJ, Gore L, Hilden JM, Larsen E, Raetz EA, Winick NJ, Carroll WL, Hunger S, Loh ML, Wood BL, Borowitz MJ. Minimal residual disease at end of induction and consolidation remain important prognostic indicators for newly diagnosed children and young adults with very high-risk (VHR) B-lymphoblastic leukemia (B-ALL): Children’s Oncology Group AALL1131. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.10004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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
10004 Background: Children and young adults with very high risk (VHR) B-acute lymphoblastic leukemia (B-ALL) [13-30 years of age with any features or 1-30 years of age with adverse prognostic features including KMT2A rearrangements, iAMP21, hypodiploidy (<44 chromosomes/DNA index < 0.81), central nervous system disease, end of induction (EOI) minimal residual disease (MRD) >0.01%, or induction failure] collectively have a predicted 4-year disease free survival (DFS) of approximately 70%. Whether patients with VHR B-ALL who are MRD positive at EOI and become MRD negative at the end of consolidation (EOC) will have improved survival versus patients remaining MRD positive at EOC is unknown. Methods: Patients with newly diagnosed NCI high risk B-ALL enrolled on AALL1131 or NCI standard risk B-ALL enrolled on AALL0932 and classified as VHR at EOI were treated on the VHR stratum of AALL1131 which sought to improve DFS with intensive post-Induction therapy using fractionated cyclophosphamide (CPM), etoposide (ETOP) and clofarabine (CLOF).Patients were randomly assigned post-Induction to Control Arm (CA) with modified augmented BFM CPM + fractionated cytarabine + mercaptopurine, Experimental Arm 1 (Exp1) with CPM + ETOP, or Experimental Arm 2 (Exp2) with CLOF + CPM + ETOP during Part 2 of Consolidation and Delayed Intensification. Doses of vincristine and pegaspargase were identical on all arms. Exp2 was permanently closed September 2014 due to excessive toxicities, and these patients are excluded from this report. MRD was measured by 6-color flow cytometry at EOI and for those who consented at the EOC. Results: 4-yr DFS for all patients (n=823) with VHR B-ALL was 76.8 ± 2.0%. As we reported previously, 4-year DFS was not significantly different between CA and Exp 1 (85.5 ± 6.8% versus 72.3 ± 6.3%; p=0.76; Burke, Haematologica 2019). 4-yr DFS for patients who were EOI MRD <0.01%, (n=325) versus >0.01 (n=498) was 83.3% ± 2.6% vs 72.0% ± 2.8%, p=0.0013. 4-Year DFS of Patients EOI MRD > 0.01%. Conclusions: MRD is a powerful prognostic indicator in VHR B-ALL with inferior outcomes in patients who are EOI MRD positive. Among patients who were EOI MRD positive treated on Exp1, outcomes were similar for EOC MRD negative and EOC MRD positive, though numbers were small. In contrast, patients who were EOI MRD positive treated on CA that were EOC MRD negative had significantly improved DFS compared to those that were EOC MRD positive. The CA remains the standard of care for COG ALL trials. With this therapy, patients with VHR B-ALL that are EOI MRD positive and EOC MRD negative have significantly improved DFS compared to those that remain MRD positive at EOC. Clinical trial information: NCT02883049. [Table: see text]
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Affiliation(s)
| | | | | | | | - Nyla A. Heerema
- The Ohio State University Comprehensive Cancer Center, Department of Pathology, Columbus, OH
| | | | - Lia Gore
- Children's Hospital Colorado, University of Colorado Denver, School of Medicine, Aurora, CO
| | | | - Eric Larsen
- Maine Childrens Cancer Program, Scarborough, ME
| | | | - Naomi J. Winick
- The University of Texas Southwestern Medical Center, Dallas, TX
| | | | | | - Mignon L. Loh
- University of California, San Francisco, San Francisco, CA
| | - Brent L. Wood
- Department of Laboratory Medicine, University of Washington, Seattle, WA
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Brown PA, Kairalla JA, Hilden JM, Dreyer ZE, Carroll AJ, Heerema NA, Wang C, Devidas M, Gore L, Salzer WL, Winick NJ, Carroll WL, Raetz EA, Borowitz MJ, Small D, Loh ML, Hunger SP. FLT3 inhibitor lestaurtinib plus chemotherapy for newly diagnosed KMT2A-rearranged infant acute lymphoblastic leukemia: Children's Oncology Group trial AALL0631. Leukemia 2021; 35:1279-1290. [PMID: 33623141 DOI: 10.1038/s41375-021-01177-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 01/11/2021] [Accepted: 01/29/2021] [Indexed: 12/12/2022]
Abstract
Infants with KMT2A-rearranged acute lymphoblastic leukemia (KMT2A-r ALL) have a poor prognosis. KMT2A-r ALL overexpresses FLT3, and the FLT3 inhibitor (FLT3i) lestaurtinib potentiates chemotherapy-induced cytotoxicity in preclinical models. Children's Oncology Group (COG) AALL0631 tested whether adding lestaurtinib to post-induction chemotherapy improved event-free survival (EFS). After chemotherapy induction, KMT2A-r infants received either chemotherapy only or chemotherapy plus lestaurtinib. Correlative assays included FLT3i plasma pharmacodynamics (PD), which categorized patients as inhibited or uninhibited, and FLT3i ex vivo sensitivity (EVS), which categorized leukemic blasts as sensitive or resistant. There was no difference in 3-year EFS between patients treated with chemotherapy plus lestaurtinib (n = 67, 36 ± 6%) vs. chemotherapy only (n = 54, 39 ± 7%, p = 0.67). However, for the lestaurtinib-treated patients, FLT3i PD and FLT3i EVS significantly correlated with EFS. For FLT3i PD, EFS for inhibited/uninhibited was 59 ± 10%/28 ± 7% (p = 0.009) and for FLTi EVS, EFS for sensitive/resistant was 52 ± 8%/5 ± 5% (p < 0.001). Seventeen patients were both inhibited and sensitive, with an EFS of 88 ± 8%. Adding lestaurtinib did not improve EFS overall, but patients achieving potent FLT3 inhibition and those whose leukemia blasts were sensitive FLT3-inhibition ex vivo did benefit from the addition of lestaurtinib. Patient selection and PD-guided dose escalation may enhance the efficacy of FLT3 inhibition for KMT2A-r infant ALL.
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Affiliation(s)
- Patrick A Brown
- Division of Pediatric Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA.
| | - John A Kairalla
- Department of Biostatistics, Colleges of Medicine, Public Health & Health Professions, University of Florida, Gainesville, FL, USA
| | - Joanne M Hilden
- Center for Cancer and Blood Disorders, Children's Hospital Colorado, Aurora, CO, USA
| | | | - Andrew J Carroll
- Department of Genetics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Nyla A Heerema
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Cindy Wang
- Department of Biostatistics, Colleges of Medicine, Public Health & Health Professions, University of Florida, Gainesville, FL, USA
| | - Meenakshi Devidas
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Lia Gore
- Center for Cancer and Blood Disorders, Children's Hospital Colorado, Aurora, CO, USA
| | - Wanda L Salzer
- U.S. Army Medical Research and Materiel Command, Fort Detrick, MD, USA
| | - Naomi J Winick
- Division of Pediatric Hematology/Oncology, University of Texas Southwestern School of Medicine, Dallas, TX, USA
| | - William L Carroll
- Department of Pediatrics and Perlmutter Cancer Center, NYU Langone Health, New York, NY, USA
| | - Elizabeth A Raetz
- Department of Pediatrics and Perlmutter Cancer Center, NYU Langone Health, New York, NY, USA
| | - Michael J Borowitz
- Departments of Pathology and Oncology, Johns Hopkins University, Baltimore, MD, USA
| | - Donald Small
- Division of Pediatric Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA
| | - Mignon L Loh
- Department of Pediatrics, Benioff Children's Hospital and the Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA, USA
| | - Stephen P Hunger
- Department of Pediatrics and the Center for Childhood Cancer Research, Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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5
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Salzer WL, Burke MJ, Devidas M, Dai Y, Hardy KK, Kairalla JA, Gore L, Hilden JM, Larsen E, Rabin KR, Zweidler-McKay PA, Borowitz MJ, Wood B, Heerema NA, Carroll AJ, Winick N, Carroll WL, Raetz EA, Loh ML, Hunger SP. Impact of Intrathecal Triple Therapy Versus Intrathecal Methotrexate on Disease-Free Survival for High-Risk B-Lymphoblastic Leukemia: Children's Oncology Group Study AALL1131. J Clin Oncol 2020; 38:2628-2638. [PMID: 32496902 DOI: 10.1200/jco.19.02892] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
PURPOSE The high-risk stratum of Children's Oncology Group Study AALL1131 was designed to test the hypothesis that postinduction CNS prophylaxis with intrathecal triple therapy (ITT) including methotrexate, hydrocortisone, and cytarabine would improve the postinduction 5-year disease-free survival (DFS) compared with intrathecal methotrexate (IT MTX), when given on a modified augmented Berlin-Frankfurt-Münster backbone. PATIENTS AND METHODS Children with newly diagnosed National Cancer Institute (NCI) high-risk B-cell acute lymphoblastic leukemia (HR B-ALL) or NCI standard-risk B-ALL with defined minimal residual disease thresholds during induction were randomly assigned to receive postinduction IT MTX or ITT. Patients with CNS3-status disease were not eligible. Postinduction IT therapy was given for a total of 21 to 26 doses. Neurocognitive assessments were performed during therapy and during 1 year off therapy. RESULTS Random assignment was closed to accrual in March 2018 after a futility boundary had been crossed, concluding that ITT could not be shown to be superior to IT MTX. The 5-year postinduction DFS and overall survival rates (± SE) of children randomly assigned to IT MTX versus ITT were 93.2% ± 2.1% v 90.6% ± 2.3% (P = .85), and 96.3% ± 1.5% v 96.7% ± 1.4% (P = .77), respectively. There were no differences in the cumulative incidence of isolated bone marrow relapse, isolated CNS relapse, or combined bone marrow and CNS relapse rates, or in toxicities observed for patients receiving IT MTX compared with ITT. There were no significant differences in neurocognitive outcomes for patients receiving IT MTX compared with ITT. CONCLUSION Postinduction CNS prophylaxis with ITT did not improve 5-year DFS for children with HR B-ALL. The standard of care for CNS prophylaxis for children with B-ALL and no overt CNS involvement remains IT MTX.
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Affiliation(s)
| | - Michael J Burke
- Department of Pediatrics, Children's Hospital of Wisconsin, Milwaukee, WI
| | - Meenakshi Devidas
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - Yunfeng Dai
- Department of Biostatistics, Colleges of Medicine and Public Health & Health Professions, University of Florida, Gainesville, FL
| | | | - John A Kairalla
- Department of Biostatistics, Colleges of Medicine and Public Health & Health Professions, University of Florida, Gainesville, FL
| | - Lia Gore
- Department of Pediatrics, Center for Cancer and Blood Disorders, Children's Hospital Colorado, Aurora, CO.,University of Colorado School of Medicine, Aurora, CO
| | - Joanne M Hilden
- Department of Pediatrics, Center for Cancer and Blood Disorders, Children's Hospital Colorado, Aurora, CO.,University of Colorado School of Medicine, Aurora, CO
| | - Eric Larsen
- Department of Pediatrics, Maine Children's Cancer Program, Scarborough, ME
| | - Karen R Rabin
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | | | - Michael J Borowitz
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Brent Wood
- Department of Laboratory Medicine, University of Washington, Seattle, WA
| | - Nyla A Heerema
- Department of Pathology, The Ohio State University School of Medicine, Columbus, OH
| | - Andrew J Carroll
- Department of Genetics, University of Alabama at Birmingham, Birmingham, AL
| | - Naomi Winick
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - William L Carroll
- Department of Pediatrics, Perlmutter Cancer Center, New York University Langone Medical Center, New York, NY
| | - Elizabeth A Raetz
- Department of Pediatrics, Perlmutter Cancer Center, New York University Langone Medical Center, New York, NY
| | - Mignon L Loh
- Department of Pediatrics, Benioff Children's Hospital and the Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA
| | - Stephen P Hunger
- Department of Pediatrics and the Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, PA.,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Burke MJ, Salzer WL, Devidas M, Dai Y, Gore L, Hilden JM, Larsen E, Rabin KR, Zweidler-McKay PA, Borowitz MJ, Wood B, Heerema NA, Carroll AJ, Winick N, Carroll WL, Raetz EA, Loh ML, Hunger SP. Replacing cyclophosphamide/cytarabine/mercaptopurine with cyclophosphamide/etoposide during consolidation/delayed intensification does not improve outcome for pediatric B-cell acute lymphoblastic leukemia: a report from the COG. Haematologica 2018; 104:986-992. [PMID: 30545921 PMCID: PMC6518909 DOI: 10.3324/haematol.2018.204545] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 12/06/2018] [Indexed: 01/03/2023] Open
Abstract
With modern chemotherapy, approximately 90% of patients with pediatric acute lymphoblastic leukemia are now cured. However, subsets of patients can be identified who remain at very high risk of relapse with expected 4-year disease-free survival rates <80%; such patients are appropriate candidates for intensive therapeutic strategies designed to improve survival. The AALL1131 trial was designed to determine, in a randomized fashion, whether substitution with cyclophosphamide/etoposide (experimental arm 1) would improve the 4-year disease-free survival of children, adolescents, and young adults with very high-risk B-cell acute lymphoblastic leukemia compared to a modified Berlin-Frankfurt-Münster regimen (control arm). Patients 1-30 years of age with newly diagnosed very high-risk B-cell acute lymphoblastic leukemia were randomized after induction in a 1:2 fashion to the control arm or experimental arm 1 in which they were given cyclophosphamide (440 mg/m2 days 1-5)/etoposide (100 mg/m2 days 1-5) during part 2 of consolidation and delayed intensification. Prospective interim monitoring rules for efficacy and futility were included where futility would be determined for a one-sided P-value ≥0.7664. The study was stopped for futility as the interim monitoring boundary was crossed [hazard ratio 0.606 (95% confidence interval: 0.297 - 1.237)] and the very high-risk arm of AALL1131 was closed in February 2017. Using data current as of December 31, 2017, 4-year disease-free survival rates were 85.5±6.8% (control arm) versus 72.3±6.3% (experimental arm 1) (P-value = 0.76). There were no significant differences in grade 3/4 adverse events between the two arms. Substitution of this therapy for very high-risk B-cell acute lymphoblastic leukemia patients on the Children’s Oncology Group AALL1131 trial (NCT02883049) randomized to cyclophosphamide/etoposide during part 2 of consolidation and delayed intensification did not improve disease-free survival.
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Affiliation(s)
- Michael J Burke
- Department of Pediatrics, Children's Hospital of Wisconsin, Milwaukee, WI
| | - Wanda L Salzer
- U.S. Army Medical Research and Materiel Command, Fort Detrick, MD
| | - Meenakshi Devidas
- Department of Biostatistics, Colleges of Medicine and Public Health & Health Professions, University of Florida, Gainesville, FL
| | - Yunfeng Dai
- Department of Biostatistics, Colleges of Medicine and Public Health & Health Professions, University of Florida, Gainesville, FL
| | - Lia Gore
- Department of Pediatrics, Center for Cancer and Blood Disorders, Children's Hospital Colorado and The University of Colorado School of Medicine, Aurora, CO
| | - Joanne M Hilden
- Department of Pediatrics, Center for Cancer and Blood Disorders, Children's Hospital Colorado and The University of Colorado School of Medicine, Aurora, CO
| | - Eric Larsen
- Department of Pediatrics, Maine Children's Cancer Program, Scarborough, ME
| | - Karen R Rabin
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | | | - Michael J Borowitz
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Brent Wood
- Department of Laboratory Medicine, University of Washington, Seattle, WA
| | - Nyla A Heerema
- Department of Pathology, The Ohio State University School of Medicine, Columbus, OH
| | | | - Naomi Winick
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - William L Carroll
- Department of Pediatrics, Perlmutter Cancer Center, New York University Langone Health, New York, NY
| | - Elizabeth A Raetz
- Department of Pediatrics, Perlmutter Cancer Center, New York University Langone Health, New York, NY
| | - Mignon L Loh
- Department of Pediatrics, Benioff Children's Hospital and the Helen Diller Family Comprehensive Cancer Center, University of California at San Francisco, CA
| | - Stephen P Hunger
- Department of Pediatrics, Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Nycz BT, Dominguez SR, Friedman D, Hilden JM, Ir D, Robertson CE, Frank DN. Correction: Evaluation of bloodstream infections, Clostridium difficile infections, and gut microbiota in pediatric oncology patients. PLoS One 2018; 13:e0197530. [PMID: 29746574 PMCID: PMC5945044 DOI: 10.1371/journal.pone.0197530] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
[This corrects the article DOI: 10.1371/journal.pone.0191232.].
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Salzer WL, Burke MJ, Devidas M, Chen S, Gore L, Larsen EC, Borowitz M, Wood B, Heerema NA, Carroll AJ, Hilden JM, Loh ML, Raetz EA, Winick NJ, Carroll WL, Hunger SP. Toxicity associated with intensive postinduction therapy incorporating clofarabine in the very high-risk stratum of patients with newly diagnosed high-risk B-lymphoblastic leukemia: A report from the Children's Oncology Group study AALL1131. Cancer 2018; 124:1150-1159. [PMID: 29266189 PMCID: PMC5839964 DOI: 10.1002/cncr.31099] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 08/25/2017] [Accepted: 09/20/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND Children, adolescents, and young adults with very high-risk (VHR) B acute lymphoblastic leukemia (B-ALL) have poor outcomes, and novel therapies are needed for this subgroup. The AALL1131 study evaluated postinduction therapy using cyclophosphamide (CPM), etoposide (ETOP), and clofarabine (CLOF) for patients with VHR B-ALL. METHODS Patients who were 1 to 30 years old and had VHR B-ALL received modified Berlin-Frankfurt-Münster therapy after induction and were randomized to 1) CPM, cytarabine, mercaptopurine, vincristine (VCR), and pegaspargase (control arm), 2) CPM, ETOP, VCR, and pegaspargase (experimental arm 1), or 3) CPM, ETOP, CLOF (30 mg/m2 /d × 5), VCR, and pegaspargase (experimental arm 2) during the second half of consolidation and delayed intensification. RESULTS The rates of grade 4/5 infections and grade 3/4 pancreatitis were significantly increased in experimental arm 2. The dose of CLOF was, therefore, reduced to 20 mg/m2 /d × 5, and myeloid growth factor was required after CLOF administration. Despite these changes, 4 of 39 patients (10.3%) developed grade 4 infections, with 1 of these patients developing a grade 5 acute kidney injury attributed to CLOF, whereas only 1 of 46 patients (2.2%) in experimental arm 1 developed grade 4 infections, and there were no grade 4/5 infections in the control arm (n = 20). Four patients in experimental arm 2 had prolonged cytopenias for >60 days, whereas none did in the control arm or experimental arm 1. Counts failed to recover for 2 of these patients, one having a grade 5 acute kidney injury and the other removed from protocol therapy; both events occurred 92 days after the start of consolidation part 2. CONCLUSIONS In AALL1131, CLOF, administered with CPM and ETOP, was associated with unacceptable toxicity. Cancer 2018;124:1150-9. © 2017 American Cancer Society.
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Affiliation(s)
- Wanda L. Salzer
- U.S. Army Medical Research and Materiel Command, Fort Detrick, MD
| | - Michael J. Burke
- Department of Pediatrics, Medical College of Wisconsin, Children’s Hospital of Wisconsin, Milwaukee, WI
| | - Meenakshi Devidas
- Department of Biostatistics, Colleges of Medicine and Public Health & Health Professions, University of Florida, Gainesville, FL
| | - Si Chen
- Department of Biostatistics, Colleges of Medicine and Public Health & Health Professions, University of Florida, Gainesville, FL
| | - Lia Gore
- Center for Cancer and Blood Disorders, Children’s Hospital Colorado and The University of Colorado School of Medicine, Aurora, CO
| | | | - Michael Borowitz
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Brent Wood
- Department of Laboratory Medicine, University of Washington, Seattle, WA
| | - Nyla A. Heerema
- Department of Pathology, The Ohio State University School of Medicine, Columbus, OH
| | | | - Joanne M. Hilden
- Children’s Hospital Colorado and the Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Mignon L. Loh
- Department of Pediatrics, Benioff Children’s Hospital, University of California at San Francisco, CA
| | | | - Naomi J. Winick
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - William L. Carroll
- Department of Pediatrics, Perlmutter Cancer Center, New York University Medical Center, New York, NY
| | - Stephen P Hunger
- Children’s Hospital of Philadelphia and The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Leavey PJ, Hilden JM, Matthews D, Dandoy C, Badawy SM, Shah M, Wayne AS, Hord J. The American Society of Pediatric Hematology/Oncology workforce assessment: Part 2-Implications for fellowship training. Pediatr Blood Cancer 2018; 65. [PMID: 29068565 DOI: 10.1002/pbc.26765] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [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: 04/25/2017] [Accepted: 07/18/2017] [Indexed: 11/10/2022]
Abstract
The American Society of Pediatric Hematology/Oncology (ASPHO) solicited information from division directors and fellowship training program directors to capture pediatric hematology/oncology (PHO) specific workforce data of 6 years (2010-2015), in response to an increase in graduating fellows during that time. Observations included a stable number of physicians and advanced practice providers (APPs) in clinical PHO, an increased proportion of APPs hired compared to physicians, and an increase in training-level first career positions. Rapid changes in the models of PHO care have significant implications to current and future trainees and require continued analysis to understand the evolving discipline of PHO.
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Affiliation(s)
- P J Leavey
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - J M Hilden
- Children's Hospital Colorado, Denver, Colorado
| | - D Matthews
- Fred Hutchinson Cancer Research Center, Seattle Children's Hospital, Seattle, Washington
| | - C Dandoy
- Cincinnati Children's Hospital, Cincinnati, Ohio
| | - S M Badawy
- Ann and Robert Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - M Shah
- Texas Children's Hospital, Houston, Texas
| | - A S Wayne
- Children's Hospital Los Angeles, The Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - J Hord
- Children's Medical Center of Akron, Akron, Ohio
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10
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Nycz BT, Dominguez SR, Friedman D, Hilden JM, Ir D, Robertson CE, Frank DN. Evaluation of bloodstream infections, Clostridium difficile infections, and gut microbiota in pediatric oncology patients. PLoS One 2018; 13:e0191232. [PMID: 29329346 PMCID: PMC5766145 DOI: 10.1371/journal.pone.0191232] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 12/29/2017] [Indexed: 01/11/2023] Open
Abstract
Bloodstream infections (BSI) and Clostridium difficile infections (CDI) in pediatric oncology/hematology/bone marrow transplant (BMT) populations are associated with significant morbidity and mortality. The objective of this study was to explore possible associations between altered microbiome composition and the occurrence of BSI and CDI in a cohort of pediatric oncology patients. Stool samples were collected from all patients admitted to the pediatric oncology floor from Oct.-Dec. 2012. Bacterial profiles from patient stools were determined by bacterial 16S rRNA gene profiling. Differences in overall microbiome composition were assessed by a permutation-based multivariate analysis of variance test, while differences in the relative abundances of specific taxa were assessed by Kruskal-Wallis tests. At admission, 9 of 42 patients (21%) were colonized with C. difficile, while 6 of 42 (14%) subsequently developed a CDI. Furthermore, 3 patients (7%) previously had a BSI and 6 patients (14%) subsequently developed a BSI. Differences in overall microbiome composition were significantly associated with disease type (p = 0.0086), chemotherapy treatment (p = 0.018), BSI following admission from any cause (p < 0.0001) or suspected gastrointestinal organisms (p = 0.00043). No differences in baseline microbiota were observed between individuals who did or did not subsequently develop C. difficile infection. Additionally, multiple bacterial groups varied significantly between subjects with post-admission BSI compared with no BSI. Our results suggest that differences in gut microbiota not only are associated with type of cancer and chemotherapy, but may also be predictive of subsequent bloodstream infection.
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Affiliation(s)
- Bryan T. Nycz
- Division of Adult Infectious Diseases, University of Colorado School of Medicine, Aurora, Colorado, United States of America
| | - Samuel R. Dominguez
- Division of Pediatric Infectious Diseases, University of Colorado School of Medicine, Aurora, Colorado, United States of America
| | - Deborah Friedman
- Department of Epidemiology, Children’s Hospital Colorado, Aurora, Colorado, United States of America
| | - Joanne M. Hilden
- Center for Blood and Cancer Disorders, Children’s Hospital Colorado, Aurora, Colorado, United States of America
| | - Diana Ir
- Division of Adult Infectious Diseases, University of Colorado School of Medicine, Aurora, Colorado, United States of America
| | - Charles E. Robertson
- Division of Adult Infectious Diseases, University of Colorado School of Medicine, Aurora, Colorado, United States of America
| | - Daniel N. Frank
- Division of Adult Infectious Diseases, University of Colorado School of Medicine, Aurora, Colorado, United States of America
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11
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Warkentin PI, Hilden JM, Kersey JK, Ramsay NK, McCullough J. Transplantation of Major ABO-Incompatible Bone Marrow
Depleted of Red Cells by Hydroxyethyl Starch. Vox Sang 2017. [DOI: 10.1159/000465737] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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12
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Rogers AEJ, Eisenman KM, Dolan SA, Belderson KM, Zauche JR, Tong S, Gralla J, Hilden JM, Wang M, Maloney KW, Dominguez SR. Risk factors for bacteremia and central line-associated blood stream infections in children with acute myelogenous leukemia: A single-institution report. Pediatr Blood Cancer 2017; 64. [PMID: 27616655 DOI: 10.1002/pbc.26254] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [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: 04/06/2016] [Accepted: 08/10/2016] [Indexed: 11/05/2022]
Abstract
BACKGROUND Central line-associated blood stream infections (CLABSIs) are a source of high morbidity and mortality in children with acute myelogenous leukemia (AML). PROCEDURE To understand the epidemiology and risk factors associated with the development of CLABSI in children with AML. METHODS We retrospectively reviewed all patients with AML over a 5-year period between 2007 and 2011 at the Children's Hospital Colorado. Cases and controls were classified on the basis of the presence of a CLABSI as defined by the National Healthcare Safety Network. RESULTS Of 40 patients in the study, 25 (62.5%) developed at least one CLABSI during therapy. The majority of CLABSIs were due to oral or gastrointestinal organisms (83.0%). Skin organisms accounted for 8.5%. In a multivariable analysis, the strongest risk factors associated with CLABSI were diarrhea (odds ratio [OR] 6.7, 95% confidence interval [CI] 1.6-28.7), receipt of blood products in the preceding 4-7 days (OR 10.0, 95%CI 3.2-31.0), not receiving antibiotics (OR 8.3, 95%CI 2.8-25.0), and chemotherapy cycle (OR 3.5, 95%CI 1.4-8.9). CLABSIs led to increased morbidity, with 13 cases (32.5%) versus two controls (1.9%) requiring transfer to the pediatric intensive care unit (P < 0.001). Three (7.5%) of 40 CLABSI events resulted in or contributed to death. CONCLUSIONS Intensified line care efforts cannot eliminate all CLABSIs in the patients with AML. Exploring the role of mucosal barrier breakdown and/or the use of antibiotic prophylaxis may be effective strategies for further prevention of CLABSIs, supporting ongoing trials in this patient population.
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Affiliation(s)
- Ashley E J Rogers
- Department of Pediatric Oncology, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Kristen M Eisenman
- Department of Pediatric Oncology, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Susan A Dolan
- Department of Epidemiology, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Kristin M Belderson
- Department of Pediatric Oncology, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Jocelyn R Zauche
- Department of Pediatric Oncology, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Suhong Tong
- Department of Pediatrics, Biostatistics and Informatics, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Jane Gralla
- Department of Pediatrics, Biostatistics and Informatics, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Joanne M Hilden
- Department of Pediatric Oncology, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Michael Wang
- Department of Pediatric Oncology, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Kelly W Maloney
- Department of Pediatric Oncology, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Samuel R Dominguez
- Department of Epidemiology, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado.,Department of Infectious Disease, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado
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13
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Badawy SM, Black V, Meier ER, Myers KC, Pinkney K, Hastings C, Hilden JM, Zweidler-McKay P, Stork LC, Johnson TS, Vaiselbuh SR. Early career mentoring through the American Society of Pediatric Hematology/Oncology: Lessons learned from a pilot program. Pediatr Blood Cancer 2017; 64:10.1002/pbc.26252. [PMID: 27616578 PMCID: PMC5685518 DOI: 10.1002/pbc.26252] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [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: 06/28/2016] [Revised: 08/06/2016] [Accepted: 08/17/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND Effective networking and mentorship are critical determinants of career satisfaction and success in academic medicine. The American Society of Pediatric Hematology/Oncology (ASPHO) mentoring program was developed to support Early Career (EC) members. Herein, the authors report on the initial 2-year outcomes of this novel program. PROCEDURE Mentees selected mentors with expertise in different subspecialties within the field from mentor profiles at the ASPHO Web site. Of 23 enrolled pairs, 19 mentors and 16 mentees completed electronic program feedback evaluations. The authors analyzed data collected between February 2013 and December 2014. The authors used descriptive statistics for categorical data and thematic analysis for qualitative data. RESULTS The overall response rate was 76% (35/46). At the initiation of the relationship, career development and research planning were the most commonly identified goals for both mentors and mentees. Participants communicated by phone, e-mail, or met in-person at ASPHO annual meetings. Most mentor-mentee pairs were satisfied with the mentoring relationship, considered it a rewarding experience that justified their time and effort, achieved their goals in a timely manner with objective work products, and planned to continue the relationship. However, time constraints and infrequent communications remained a challenge. CONCLUSIONS Participation in the ASPHO mentoring program suggests a clear benefit to a broad spectrum of ASPHO EC members with diverse personal and professional development needs. Efforts to expand the mentoring program are ongoing and focused on increasing enrollment of mentors to cover a wider diversity of career tracks/subspecialties and evaluating career and academic outcomes more objectively.
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Affiliation(s)
- Sherif M. Badawy
- Division of Hematology, Oncology and Stem Cell Transplant, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Feinberg School of Medicine at Northwestern University, Chicago, Illinois,Division of Hematology and Oncology, Department of Pediatrics, Faculty of Medicine at Zagazig University, Zagazig, Egypt
| | - Vandy Black
- Department of Pediatrics, University of Florida College of Medicine, Gainesville, Florida
| | - Emily R. Meier
- Indiana Hemophilia and Thrombosis Center, Indianapolis, Indiana
| | - Kasiani C. Myers
- Division of Bone Marrow Transplantation and Immune Deficiency, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Kerice Pinkney
- Division of Pediatric Hematology/Oncology, Joe DiMaggio’s Children’s Hospital, Hollywood, Florida
| | - Caroline Hastings
- Division of Hematology/Oncology, Department of Pediatrics, UCSF Benioff Children’s Hospital Oakland & Research Center Oakland, Oakland, California
| | - Joanne M. Hilden
- Division of Hematology/Oncology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | | | - Linda C. Stork
- Division Head of Hematology/Oncology, Department of Pediatrics, Oregon Health & Science University, Portland, Oregon
| | - Theodore S. Johnson
- Department of Pediatrics, Georgia Cancer Center, Augusta University, Augusta, Georgia
| | - Sarah R. Vaiselbuh
- Department of Pediatrics, Children’s Cancer Center, Staten Island University Hospital, Staten Island, New York
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14
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Dantes R, Epson EE, Dominguez SR, Dolan S, Wang F, Hurst A, Parker SK, Johnston H, West K, Anderson L, Rasheed JK, Moulton-Meissner H, Noble-Wang J, Limbago B, Dowell E, Hilden JM, Guh A, Pollack LA, Gould CV. Investigation of a cluster of Clostridium difficile infections in a pediatric oncology setting. Am J Infect Control 2016; 44:138-45. [PMID: 26601705 DOI: 10.1016/j.ajic.2015.09.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 09/04/2015] [Accepted: 09/08/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND We investigated an increase in Clostridium difficile infection (CDI) among pediatric oncology patients. METHODS CDI cases were defined as first C difficile positive stool tests between December 1, 2010, and September 6, 2012, in pediatric oncology patients receiving inpatient or outpatient care at a single hospital. A case-control study was performed to identify CDI risk factors, infection prevention and antimicrobial prescribing practices were assessed, and environmental sampling was conducted. Available isolates were strain-typed by pulsed-field gel electrophoresis. RESULTS An increase in hospital-onset CDI cases was observed from June-August 2012. Independent risk factors for CDI included hospitalization in the bone marrow transplant ward and exposure to computerized tomography scanning or cefepime in the prior 12 weeks. Cefepime use increased beginning in late 2011, reflecting a practice change for patients with neutropenic fever. There were 13 distinct strain types among 22 available isolates. Hospital-onset CDI rates decreased to near-baseline levels with enhanced infection prevention measures, including environmental cleaning and prolonged contact isolation. CONCLUSION C difficile strain diversity associated with a cluster of CDI among pediatric oncology patients suggests a need for greater understanding of modes and sources of transmission and strategies to reduce patient susceptibility to CDI. Further research is needed on the risk of CDI with cefepime and its use as primary empirical treatment for neutropenic fever.
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Affiliation(s)
- Raymund Dantes
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA; Epidemic Intelligence Service, Scientific Education and Professional Development Program Office, Centers for Disease Control and Prevention, Atlanta, GA.
| | - Erin E Epson
- Epidemic Intelligence Service, Scientific Education and Professional Development Program Office, Centers for Disease Control and Prevention, Atlanta, GA; Communicable Disease Epidemiology Section, Colorado Department of Public Health and Environment, Denver, CO
| | - Samuel R Dominguez
- Children's Hospital Colorado, Aurora, CO; University of Colorado School of Medicine, Aurora, CO
| | | | - Frank Wang
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | | | - Sarah K Parker
- Children's Hospital Colorado, Aurora, CO; University of Colorado School of Medicine, Aurora, CO
| | - Helen Johnston
- Communicable Disease Epidemiology Section, Colorado Department of Public Health and Environment, Denver, CO
| | - Kelly West
- Children's Hospital Colorado, Aurora, CO
| | - Lydia Anderson
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - James K Rasheed
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Heather Moulton-Meissner
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Judith Noble-Wang
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Brandi Limbago
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | | | - Joanne M Hilden
- Children's Hospital Colorado, Aurora, CO; University of Colorado School of Medicine, Aurora, CO
| | - Alice Guh
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Lori A Pollack
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Carolyn V Gould
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, GA
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15
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Burke M, Devidas M, Chen S, Gore L, Larsen E, Hilden JM, Loh ML, Winick NJ, Carroll WL, Raetz EA, Hunger S, Salzer WL. Feasibility of intensive post-Induction therapy incorporating clofarabine (CLOF) in the very high risk (VHR) stratum of patients with newly diagnosed high risk B-lymphoblastic leukemia (HR B-ALL): Children’s Oncology Group AALL1131. J Clin Oncol 2015. [DOI: 10.1200/jco.2015.33.15_suppl.10007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | - Si Chen
- University of Florida, Gainesville, FL
| | - Lia Gore
- University of Colorado Cancer Center, Aurora, CO
| | - Eric Larsen
- Maine Childrens Cancer Program, Scarborough, ME
| | | | | | - Naomi J. Winick
- The University of Texas Southwestern Medical Center, Dallas, TX
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16
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Acker SN, Linton J, Tan GM, Garrington TP, Bruny J, Hilden JM, Hoffman LM, Partrick DA. A multidisciplinary approach to the management of anterior mediastinal masses in children. J Pediatr Surg 2015; 50:875-8. [PMID: 25783332 DOI: 10.1016/j.jpedsurg.2014.09.054] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [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: 01/03/2014] [Revised: 09/07/2014] [Accepted: 09/08/2014] [Indexed: 12/17/2022]
Abstract
PURPOSE Anterior mediastinal masses (AMM) pose a diagnostic challenge to surgeons, oncologists, anesthesiologists, intensivists, and interventional radiologists as induction of general anesthesia can cause airway obstruction and cardiovascular collapse. We hypothesized that in the majority of patients, diagnosis can be obtained through biopsy of extrathoracic tissue. METHODS We performed a retrospective review of all patients in the solid tumor oncology clinic with a diagnosis of AMM between 2002 and 2012 including preoperative evaluation and management prior to obtaining a tissue diagnosis, clinical course and complications. RESULTS We identified 69 patients with AMM (mean age 12.2±4.4years, 64% male) secondary to Hodgkin lymphoma (34), Non-Hodgkin lymphoma (26), and other diagnoses (9). The majority of patients (56, 81.2%) underwent biopsy of tissue outside of the mediastinal mass. Local anesthesia with sedation was used for successful biopsy in 21 (30%) patients. Four (5.8%) required repeat biopsy due to inadequate sample obtained at initial procedure. Three (4.4%) suffered respiratory complications with no fatalities or severe complications. CONCLUSIONS Our data demonstrate that in the majority of children with AMM, tissue biopsy can be successfully obtained from tissue outside of the mass itself with minimal complications and highlight the importance of multidisciplinary preoperative planning to minimize anesthetic risks.
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Affiliation(s)
- Shannon N Acker
- Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO USA.
| | - Jacqueline Linton
- Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO USA.
| | - Gee Mei Tan
- Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO USA.
| | - Timothy P Garrington
- Department of Pediatrics, Section of Pediatric Hematology and Oncology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO USA.
| | - Jennifer Bruny
- Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO USA.
| | - Joanne M Hilden
- Department of Pediatrics, Section of Pediatric Hematology and Oncology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO USA.
| | - Lindsey M Hoffman
- Department of Pediatrics, Section of Pediatric Hematology and Oncology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO USA.
| | - David A Partrick
- Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO USA.
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17
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Dreyer ZE, Hilden JM, Jones TL, Devidas M, Winick NJ, Willman CL, Harvey RC, Chen IM, Behm FG, Pullen J, Wood BL, Carroll AJ, Heerema NA, Felix CA, Robinson B, Reaman GH, Salzer WL, Hunger SP, Carroll WL, Camitta BM. Intensified chemotherapy without SCT in infant ALL: results from COG P9407 (Cohort 3). Pediatr Blood Cancer 2015; 62:419-26. [PMID: 25399948 PMCID: PMC5145261 DOI: 10.1002/pbc.25322] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [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: 02/24/2014] [Accepted: 09/23/2014] [Indexed: 11/12/2022]
Abstract
BACKGROUND Infants with acute lymphoblastic leukemia (ALL) present with aggressive disease and a poor prognosis. Early relapse within 6-9 months of diagnosis is common. Approximately 75% of infants have MLL-rearranged (MLL-R) ALL with event free survival (EFS) ranging from 20% to 30%. Children's Oncology Group (COG) P9407 used shortened (46 weeks), intensified therapy to address early relapse and poor EFS. PROCEDURE P9407 therapy was modified three times for induction toxicity resulting in three cohorts of therapy. One hundred forty-seven infants were enrolled in the third cohort. RESULTS We report an overall 5-year EFS and OS of 42.3 ± 6% and 52.9 ± 6.5% respectively. Poor prognostic factors included age ≤90 days at diagnosis, MLL-R ALL and white cell count ≥50,000/μl. For infants ≤90 days of age, the 5-year EFS was 15.5 ± 10.1% and 48.5 ± 6.7% for those >90 days (P < 0.0001). Among infants >90 days of age, 5-year EFS rates were 43.8 ± 8% for MLL-R versus 69.1 ± 13.6% for MLL-germline ALL (P < 0.0001). CONCLUSIONS Age ≤90 days at diagnosis was the most important prognostic factor. Despite shortened therapy with early intensification, EFS remained less than 50% overall in MLL-R ALL.
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Affiliation(s)
- ZoAnn E. Dreyer
- Texas Children’s Cancer Center, Baylor College of Medicine, Houston, TX
| | - Joanne M. Hilden
- University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO
| | - Tamekia L. Jones
- Department of Biostatistics, Colleges of Medicine and Public Health & Health Professions, University of Florida, Gainesville, FL
| | - Meenakshi Devidas
- Department of Biostatistics, Colleges of Medicine and Public Health & Health Professions, University of Florida, Gainesville, FL
| | - Naomi J. Winick
- Pediatric Hematology-Oncology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Cheryl L. Willman
- Department of Pathology and UMN Cancer Center, University of New Mexico Health Services, Albuquerque, NM
| | - Richard C. Harvey
- Department of Pathology and UMN Cancer Center, University of New Mexico Health Services, Albuquerque, NM
| | - I-Ming Chen
- Department of Pathology and UMN Cancer Center, University of New Mexico Health Services, Albuquerque, NM
| | | | - Jeanette Pullen
- Pediatric Hematology/Oncology, University of Mississippi Medical Center, Jackson, MS
| | - Brent L. Wood
- Laboratory Medicine, Seattle Children’s Hospital, Seattle, WA
| | - Andrew J. Carroll
- Department of Genetics, University of Alabama at Birmingham, Birmingham, AL
| | - Nyla A. Heerema
- Department of Pathology, The Ohio State University, Columbus, OH
| | - Carolyn A. Felix
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, PA,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Blaine Robinson
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Gregory H. Reaman
- Hematology-Oncology, Children’s National Medical Center, Washington, DC
| | - Wanda L. Salzer
- Mark O Hatfield-Warren Grant Magnuson Clinical Canter, Pediatric Oncology, Silver Spring, MD
| | - Stephen P. Hunger
- University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO
| | - William L. Carroll
- NYU Cancer Institute, New York University Langone Medical Center, New York, NY
| | - Bruce M. Camitta
- Midwest Center for Cancer and Blood Disorders, Medical College of Wisconsin, Milwaukee, WI
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18
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Salzer WL, Jones TL, Devidas M, Dreyer ZE, Gore L, Winick NJ, Sung L, Raetz E, Loh ML, Wang CY, De Lorenzo P, Valsecchi MG, Pieters R, Carroll WL, Hunger SP, Hilden JM, Brown P. Decreased induction morbidity and mortality following modification to induction therapy in infants with acute lymphoblastic leukemia enrolled on AALL0631: a report from the Children's Oncology Group. Pediatr Blood Cancer 2015; 62:414-8. [PMID: 25407157 PMCID: PMC4480675 DOI: 10.1002/pbc.25311] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [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: 06/04/2014] [Accepted: 09/22/2014] [Indexed: 11/09/2022]
Abstract
BACKGROUND Infants with acute lymphoblastic leukemia (ALL) have a poor prognosis. Intensification of therapy has resulted in fewer relapses but increased early deaths, resulting in failure to improve survival. PROCEDURE AALL0631 is a Phase 3 study for infants (<366 days of age) with newly diagnosed ALL. Induction initially (Cohort 1) consisted of 3 weeks of therapy based on COG P9407. Due to excessive early mortality, induction was amended to a less intensive 5 weeks of therapy based on Interfant-99. Additionally, enhanced supportive care guidelines were incorporated with hospitalization during induction until evidence of marrow recovery and recommendations for prevention/treatment of infections (Cohort 2). RESULTS Induction mortality was significantly lower for patients in Cohort 2 (2/123, 1.6%) versus Cohort 1 (4/26, 15.4%; P = 0.009). All induction deaths were infection related except one due to progressive disease (Cohort 2). Sterile site infections were lower for patients in Cohort 2 (24/123, 19.5%) versus Cohort 1 (15/26, 57.7%; P = 0.0002), with a significantly lower rate of Gram positive infections during induction for patients in Cohort 2, P = 0.0002. No clinically significant differences in grades 3-5 non-infectious toxicities were observed between the two cohorts. Higher complete response rates were observed at end induction intensification for Cohort 2 (week 9, 94/100, 94%) versus Cohort 1 (week 7, 17/25, 68%; P = 0.0.0012). CONCLUSION De-intensification of induction therapy and enhanced supportive care guidelines significantly decreased induction mortality and sterile site infections, without decreasing complete remission rates.
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Affiliation(s)
- Wanda L. Salzer
- U.S. Army Medical Research and Materiel Command, Fort Detrick, MD
| | - Tamekia L. Jones
- Department of Biostatistics, Colleges of Medicine and Public Health & Health Professions, University of Florida, Gainesville, FL
| | - Meenakshi Devidas
- Department of Biostatistics, Colleges of Medicine and Public Health & Health Professions, University of Florida, Gainesville, FL
| | - ZoAnn E. Dreyer
- Texas Children’s Cancer Center, Baylor College of Medicine, Houston, TX
| | - Lia Gore
- Childrens Hospital Colorado and the University of Colorado School of Medicine, Aurora, CO
| | - Naomi J. Winick
- Division of Pediatric Hematology/Oncology, University of Texas Southwestern School of Medicine, Dallas, TX
| | - Lillian Sung
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Elizabeth Raetz
- Department of Pediatrics and Huntsman Cancer Institute, University of Utah
| | - Mignon L. Loh
- Department of Pediatrics, University of California at San Francisco, CA
| | - Cindy Y. Wang
- Children’s Oncology Group Statistics and Data Center University of Florida, Gainesville, FL
| | - Paola De Lorenzo
- Interfant Trial Data Center, Pediatric Clinic, University of Milano-Bicocca, Monza, Italy,Department of Health Sciences, University of Milano Bicocca, Monza, Italy
| | | | - Rob Pieters
- Princess Maxima Center for Pediatric Oncology, Utrecht, Pediatric Oncology, Erasmus MC - Sophia Children’s Hospital, Rotterdam, Netherlands
| | | | - Stephen P Hunger
- Childrens Hospital Colorado and the University of Colorado School of Medicine, Aurora, CO
| | - Joanne M. Hilden
- Childrens Hospital Colorado and the University of Colorado School of Medicine, Aurora, CO
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Dominguez SR, Dolan SA, West K, Dantes RB, Epson E, Friedman D, Littlehorn CA, Arms LE, Walton K, Servetar E, Frank DN, Kotter CV, Dowell E, Gould CV, Hilden JM, Todd JK. High colonization rate and prolonged shedding of Clostridium difficile in pediatric oncology patients. Clin Infect Dis 2014; 59:401-3. [PMID: 24785235 DOI: 10.1093/cid/ciu302] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Surveillance testing for Clostridium difficile among pediatric oncology patients identified stool colonization in 29% of patients without gastrointestinal symptoms and in 55% of patients with prior C. difficile infection (CDI). A high prevalence of C. difficile colonization and diarrhea complicates the diagnosis of CDI in this population.
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Affiliation(s)
| | | | | | - Raymund B Dantes
- Epidemic Intelligence Service Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Erin Epson
- Epidemic Intelligence Service Colorado Department of Public Health and Environment, Denver
| | - Deborah Friedman
- Department of Pediatric Hematology/Oncology/Bone Marrow Transplant Department of Nursing
| | | | | | - Karen Walton
- Department of Pediatric Hematology/Oncology/Bone Marrow Transplant Department of Nursing
| | - Ellen Servetar
- Department of Pediatric Hematology/Oncology/Bone Marrow Transplant Department of Nursing
| | - Daniel N Frank
- Department of Adult Infectious Diseases, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora
| | - Cassandra V Kotter
- Department of Adult Infectious Diseases, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora
| | | | - Carolyn V Gould
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Joanne M Hilden
- Department of Pediatric Hematology/Oncology/Bone Marrow Transplant
| | - James K Todd
- Department of Pediatric Infectious Diseases Department of Epidemiology
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Valentine MC, Linabery AM, Chasnoff S, Hughes AEO, Mallaney C, Sanchez N, Giacalone J, Heerema NA, Hilden JM, Spector LG, Ross JA, Druley TE. Excess congenital non-synonymous variation in leukemia-associated genes in MLL- infant leukemia: a Children's Oncology Group report. Leukemia 2013; 28:1235-41. [PMID: 24301523 PMCID: PMC4045651 DOI: 10.1038/leu.2013.367] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Revised: 11/19/2013] [Accepted: 11/29/2013] [Indexed: 12/11/2022]
Abstract
Infant leukemia (IL) is a rare sporadic cancer with a grim prognosis. Although most cases are accompanied by MLL rearrangements and harbor very few somatic mutations, less is known about the genetics of the cases without MLL translocations. We performed the largest exome-sequencing study to date on matched non-cancer DNA from pairs of mothers and IL patients to characterize congenital variation that may contribute to early leukemogenesis. Using the COSMIC database to define acute leukemia-associated candidate genes, we find a significant enrichment of rare, potentially functional congenital variation in IL patients compared with randomly selected genes within the same patients and unaffected pediatric controls. IL acute myeloid leukemia (AML) patients had more overall variation than IL acute lymphocytic leukemia (ALL) patients, but less of that variation was inherited from mothers. Of our candidate genes, we found that MLL3 was a compound heterozygote in every infant who developed AML and 50% of infants who developed ALL. These data suggest a model by which known genetic mechanisms for leukemogenesis could be disrupted without an abundance of somatic mutation or chromosomal rearrangements. This model would be consistent with existing models for the establishment of leukemia clones in utero and the high rate of IL concordance in monozygotic twins.
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Affiliation(s)
- M C Valentine
- 1] Department of Genetics, Washington University School of Medicine, St Louis, MO, USA [2] Department of Pediatrics, Washington University School of Medicine, St Louis, MO, USA
| | - A M Linabery
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - S Chasnoff
- 1] Department of Genetics, Washington University School of Medicine, St Louis, MO, USA [2] Department of Pediatrics, Washington University School of Medicine, St Louis, MO, USA
| | - A E O Hughes
- 1] Department of Genetics, Washington University School of Medicine, St Louis, MO, USA [2] Department of Pediatrics, Washington University School of Medicine, St Louis, MO, USA
| | - C Mallaney
- Department of Genetics, Washington University School of Medicine, St Louis, MO, USA
| | - N Sanchez
- Department of Genetics, Washington University School of Medicine, St Louis, MO, USA
| | - J Giacalone
- 1] Department of Genetics, Washington University School of Medicine, St Louis, MO, USA [2] Department of Pediatrics, Washington University School of Medicine, St Louis, MO, USA
| | - N A Heerema
- Department of Pathology, Ohio State University, Columbus, OH, USA
| | - J M Hilden
- Department of Oncology/Hematology, Peyton Manning Children's Hospital at St Vincent, Indianapolis, IN, USA
| | - L G Spector
- 1] Department of Pediatrics, Washington University School of Medicine, St Louis, MO, USA [2] Masonic Cancer Center, University of Minnesota, Minneapolis, MN, USA
| | - J A Ross
- 1] Department of Pediatrics, Washington University School of Medicine, St Louis, MO, USA [2] Masonic Cancer Center, University of Minnesota, Minneapolis, MN, USA
| | - T E Druley
- 1] Department of Genetics, Washington University School of Medicine, St Louis, MO, USA [2] Department of Pediatrics, Washington University School of Medicine, St Louis, MO, USA
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Ross JA, Linabery AM, Blommer CN, Langer EK, Spector LG, Hilden JM, Heerema NA, Radloff GA, Tower RL, Davies SM. Genetic variants modify susceptibility to leukemia in infants: a Children's Oncology Group report. Pediatr Blood Cancer 2013; 60:31-4. [PMID: 22422485 PMCID: PMC3381932 DOI: 10.1002/pbc.24131] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [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: 01/17/2012] [Accepted: 02/13/2012] [Indexed: 11/11/2022]
Abstract
BACKGROUND The mixed lineage leukemia (MLL) gene is commonly rearranged in infant leukemia (IL). Genetic determinants of susceptibility to IL are unknown. Recent genome-wide association studies for childhood acute lymphoblastic leukemia (ALL) have identified susceptibility loci at IKZF1, ARID5B, and CEBPE. PROCEDURE We genotyped these loci in 171 infants with leukemia and 384 controls and evaluated associations overall, by subtype [ALL, acute myeloid leukemia (AML)], and by presence (+) or absence (-) of MLL rearrangements. RESULTS Homozygosity for a variant IKZF1 allele (rs11978267) increased risk of infant AML [Odds ratio (OR) = 3.9, 95% confidence interval (CI) = 1.8-8.4]; the increased risk was similar for AML/MLL+ and MLL- cases. In contrast, risk of ALL/MLL- was increased in infants homozygous for the IKZF1 variant (OR = 5.1, 95% CI = 1.8-14.5) but the variant did not modify risk of ALL/MLL+. For ARID5B (rs10821936), homozygosity for the variant allele increased risk for the ALL/MLL- subgroup only (OR = 7.2, 95% CI = 2.5-20.6). There was little evidence of an association with the CEBP variant (rs2239633). CONCLUSION IKZF1 is expressed in early hematopoiesis, including precursor myeloid cells. Our data provide the first evidence that IKZF1 modifies susceptibility to infant AML, irrespective of MLL rearrangements, and could provide important new etiologic insights into this rare and heterogeneous hematopoietic malignancy.
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Affiliation(s)
- Julie A. Ross
- Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | - Amy M. Linabery
- Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | | | - Erica K. Langer
- Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | - Logan G. Spector
- Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | - Joanne M. Hilden
- Pediatric Hematology/Oncology, Children’s Hospital Colorado, Aurora, CO
| | - Nyla A. Heerema
- Department of Pathology, The Ohio State University, Columbus, OH
| | - Gretchen A. Radloff
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | | | - Stella M. Davies
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
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22
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Salzer WL, Jones TL, Devidas M, Hilden JM, Winick N, Hunger S, Carroll WL, Camitta B, Dreyer ZE. Modifications to induction therapy decrease risk of early death in infants with acute lymphoblastic leukemia treated on Children's Oncology Group P9407. Pediatr Blood Cancer 2012; 59:834-9. [PMID: 22488662 PMCID: PMC4008315 DOI: 10.1002/pbc.24132] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [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: 10/31/2011] [Accepted: 02/14/2012] [Indexed: 12/28/2022]
Abstract
BACKGROUND Infants (<366 days of age) with acute lymphoblastic leukemia (ALL) have a poor prognosis. Most treatment failures occur within 6-9 months of diagnosis, primarily from relapse. PROCEDURE The Children's Oncology Group P9407 study was designed to test if early intensified treatment would improve outcome for infants with ALL. Due to a significant number of early deaths (< 90 days from enrollment), Induction therapy was amended three times. Cohorts 1 + 2 (n = 68), received identical Induction therapy except for reduced daunorubicin dose in Cohort 2. Cohort 3 (n = 141) received prednisone (40 mg/m(2)/day) instead of dexamethasone (10 mg/m(2)/day) and short infusion daunorubicin (30 minutes) instead of continuous infusion (48 hours), as well as additional supportive care measures throughout therapy. RESULTS Early deaths occurred in 17/68 (25%) infants in Cohorts 1 + 2 and 8/141 (5.7%) infants in Cohort 3 (P < 0.0001). Among infants ≤90 days of age at diagnosis, early death occurred in 10/17 (58.8%) in Cohorts 1 + 2 and 4/27 (14.8%) in Cohort 3 (P = 0.006). Among infants >90 days of age at diagnosis, early death occurred in 7/51 (13.7%) in Cohorts 1 + 2 and 4/114 (3.5%) in Cohort 3 (P = 0.036). Bacterial, viral, and fungal infections were more common in Cohorts 1 + 2 versus Cohort 3. CONCLUSIONS Early morbidity and mortality for infants with ALL were reduced by substitution of prednisone (40 mg/m(2)/day) for dexamethasone (10 mg/m(2)/day), the delivery of daunorubicin over 30 minutes instead of a continuous infusion for 48 hours, and the provision of more specific supportive care measures.
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Affiliation(s)
- Wanda L. Salzer
- Pediatric Oncology Branch, National Cancer Institute, Bethesda, Maryland,Correspondence to: Wanda L. Salzer, MD, 1335 East West Hwy, 9th Floor, Silver Spring, MD 20910.
| | - Tamekia L. Jones
- Department of Biostatistics, Colleges of Medicine and Public Health and Health Professions, University of Florida, Gainesville, Florida
| | - Meenakshi Devidas
- Department of Biostatistics, Colleges of Medicine and Public Health and Health Professions, University of Florida, Gainesville, Florida
| | - Joanne M. Hilden
- Department of Pediatrics, The Children’s Hospital, University of Colorado, Aurora, Colorado
| | - Naomi Winick
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Stephen Hunger
- Department of Pediatrics, The Children’s Hospital, University of Colorado, Aurora, Colorado
| | | | - Bruce Camitta
- Midwest Center for Cancer and Blood Disorders, Medical College of Wisconsin and Children’s Hospital, Milwaukee, Wisconsin
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23
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Sam TN, Kersey JH, Linabery AM, Johnson KJ, Heerema NA, Hilden JM, Davies SM, Reaman GH, Ross JA. MLL gene rearrangements in infant leukemia vary with age at diagnosis and selected demographic factors: a Children's Oncology Group (COG) study. Pediatr Blood Cancer 2012; 58:836-9. [PMID: 21800415 PMCID: PMC3208122 DOI: 10.1002/pbc.23274] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [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: 04/12/2011] [Accepted: 06/20/2011] [Indexed: 11/11/2022]
Abstract
BACKGROUND Infant leukemias have a high frequency of mixed lineage leukemia (MLL) gene rearrangements. PROCEDURE Using data from a large etiologic study, we evaluated the distribution of selected demographic factors among 374 infant leukemia cases by leukemic subtype, MLL status and diagnosis age. RESULTS Overall, 228 cases were MLL+. Compared to white infants, black infants were significantly less likely to have MLL+ leukemia. Further, there was a statistically significantly higher age at diagnosis for infants with t(9;11) translocations compared to all other translocation partners in both acute lymphoblastic leukemia and acute myeloid leukemia cases. CONCLUSION These patterns may provide important etiological insight into the biology of infant leukemia.
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Affiliation(s)
- Thien N. Sam
- University of Minnesota Masonic Cancer Center, Minneapolis, MN
| | - John H. Kersey
- University of Minnesota Masonic Cancer Center, Minneapolis, MN
| | - Amy M. Linabery
- Division of Pediatric Epidemiology and Clinical Research, Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | - Kimberly J. Johnson
- George Warren Brown School of Social Work, Washington University in St. Louis, St. Louis, MO
| | - Nyla A. Heerema
- Department of Pathology, The Ohio State University, Columbus, OH
| | - Joanne M. Hilden
- Department of Oncology/Hematology, Peyton Manning Children’s Hospital at St. Vincent, Indianapolis, IN
| | - Stella M. Davies
- Division of Hematology/Oncology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Gregory H. Reaman
- Department of Hematology/Oncology, Children’s National Medical Center, Washington, DC
| | - Julie A. Ross
- University of Minnesota Masonic Cancer Center, Minneapolis, MN, Division of Pediatric Epidemiology and Clinical Research, Department of Pediatrics, University of Minnesota, Minneapolis, MN
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24
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Sun D, Kaeding A, Magoon D, Jones T, Devidas M, Carroll AJ, Heerema NA, Loh ML, Raetz EA, Winick NJ, Carroll WL, Dreyer ZE, Hunger S, Hilden JM, Brown PA. Safety and biological activity of the FLT3 inhibitor lestaurtinib in infant MLL-rearranged (MLL-r) ALL: Children's Oncology Group protocol AALL0631. J Clin Oncol 2012. [DOI: 10.1200/jco.2012.30.15_suppl.9548] [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: 11/20/2022] Open
Abstract
9548 Background: MLL-r infant ALL overexpresses activated FLT3. Lestaurtinib potentiates chemotherapy(chemo)-induced cytotoxicity in MLL-r ALL. AALL0631 therapy is stratified based on age and MLL status: high risk (HR) <90 days, MLL-r; intermediate risk (IR) ≥ 90 days, MLL-r; standard risk any age, not MLL-r. IR and HR patients (pts) get intensive chemo and are eligible for lestaurtinib. A safety/activity (S/A) phase to determine a safe and biologically active dose of lestaurtinib is followed by an efficacy phase randomizing MLL-r patients to chemo +/- lestaurtinib. The S/A phase proceeds independently for IR & HR pts, as optimal lestaurtinib dosing may differ between neonates and older infants. We previously reported successful completion of the S/A phase for IR pts; here, we report results of the S/A phase for HR pts. Methods: Lestaurtinib-related dose limiting toxicities (DLTs) were defined as grade ≥ 3 non-heme toxicities excluding those expected with chemo alone (e.g., F&N/infection); a dose of lestaurtinib was “safe” if 0 or 1 DLTs were seen in 5 evaluable pts. FLT3 inhibition was assessed using a plasma inhibitory activity (PIA) assay that measures % inhibition of phospho-FLT3 at 5 trough time points relative to pre-treatment baseline. A dose of lestaurtinib was “biologically active” if PIA was > 90% for the majority (≥3 of 5) of troughs in at least 3 of 5 pts. Results: 11 eligible HR pts received lestaurtinib, 6 at dose level 1 (DL1, 3.5 mg/kg/day) and 5 at DL2 (4.25 mg/kg/day). There were no DLTs in 5 evaluable pts at DL1. The inevaluable pt discontinued lestaurtinib due to parental refusal, not toxicity. There was 1 DLT in 5 evaluable pts at DL2. The DLT was grade 4 intestinal perforation secondary to severe typhlitis during neutropenia following reinduction, possibly related to lestaurtinib. The pt was taken off protocol and chemo and died of progressive disease. By PIA assay, 2 of 5 pts treated at DL1, and 4 of 5 at DL2 demonstrated FLT3 inhibitory biologic activity. Conclusions: DL2 is safe and biologically active in HR pts. The efficacy phase of AALL0631 is expanding such that HR pts will join IR pts in being randomized (1:1) post-induction to chemo +/- lestaurtinib at DL2.
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Affiliation(s)
- Di Sun
- Oncology and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Allison Kaeding
- Oncology and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Daniel Magoon
- Oncology and Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Tamekia Jones
- Children's Oncology Group-Data Center, Gainesville, FL
| | | | | | - Nyla A. Heerema
- The Ohio State University Comprehensive Cancer Center and Arthur G. James Cancer Hospital and Solove Research Institute, Columbus, OH
| | - Mignon L. Loh
- University of California, San Francisco, San Francisco, CA
| | | | - Naomi Joan Winick
- UTSW and Center for Cancer and Blood Disorders, Children's Medical Center Dallas, Dallas, TX
| | | | | | - Stephen Hunger
- University of Colorado Denver School of Medicine, Aurora, CO
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25
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Sorrell AD, Alonzo TA, Hilden JM, Gerbing RB, Loew TW, Hathaway L, Barnard D, Taub JW, Ravindranath Y, Smith FO, Arceci RJ, Woods WG, Gamis AS. Favorable survival maintained in children who have myeloid leukemia associated with Down syndrome using reduced-dose chemotherapy on Children's Oncology Group trial A2971: a report from the Children's Oncology Group. Cancer 2012; 118:4806-14. [PMID: 22392565 DOI: 10.1002/cncr.27484] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2011] [Revised: 12/08/2011] [Accepted: 01/04/2012] [Indexed: 11/12/2022]
Abstract
BACKGROUND Children who are treated for myeloid leukemia associated with Down syndrome (DS) experience superior survival compared with children who have myeloid leukemia without DS. To maintain excellent outcomes while avoiding toxicity, the Children's Oncology Group (COG) conducted the phase 3 trial COG A2971, the first trial solely designed to provide uniform treatment of myeloid leukemia in North American children with DS. A2971 eliminated 2 induction drugs and 3 months of maintenance therapy from the standard-timing regimen of dexamethasone, cytarabine, 6-thioguanine, etoposide, and rubidomycin/daunomycin (DCTER) used in the previous study (Children's Cancer Group [CCG] 2891). METHODS COG A2971 was a multi-institutional, nonrandomized, clinical trial that enrolled 132 patients who had DS with either acute myeloid leukemia (n = 91) or myelodysplastic syndrome (n = 41). RESULTS The median follow-up was 4.8 years (range, 0.8-8.6 years), the median age at diagnosis was 1.7 years (range, 0.3-13.6 years), and the median white blood cell count was 6200/μL (range, 900-164,900/μL). The remission rate (92.7% ± 6%) was similar to that reported in the CCG 2891 study (91.3% ± 5%; P = .679). The 5-year event free survival (EFS) rate was 79% ± 7% (vs 77% ± 7% in CCG 2891; P = .589), the disease-free survival (DFS) rate was 89% ± 6% (vs 85% ± 6% in CCG 2891; P = .337), and the overall survival rate was 84% ± 6% (vs 79% ± 7% in CCG 2891; P = .302). Induction day-14 bone marrow response trended toward a more favorable outcome (EFS: P = .12). Age >4 years was an adverse risk factor (5-year EFS rate: 33% ± 38% for children aged >4 years [median, 8.5 years; n = 6] vs 81% ± 7% for children ages 0-4 years [median, 1.7 years; n = 126]; P = .001). CONCLUSIONS The COG A2971 trial reduced the chemotherapy dose and maintained survival to that achieved by the CCG 2891 trial in children who had myeloid leukemia associated with DS.
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Affiliation(s)
- April D Sorrell
- Department of Pediatrics, City of Hope National Medical Center, Duarte California, USA.
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26
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Slater ME, Linabery AM, Spector LG, Johnson KJ, Hilden JM, Heerema NA, Robison LL, Ross JA. Maternal exposure to household chemicals and risk of infant leukemia: a report from the Children's Oncology Group. Cancer Causes Control 2011; 22:1197-204. [PMID: 21691732 DOI: 10.1007/s10552-011-9798-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2010] [Accepted: 06/09/2011] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Utilizing data from the largest study to date, we examined associations between maternal preconception/prenatal exposure to household chemicals and infant acute leukemia. METHODS We present data from a Children's Oncology Group case-control study of 443 infants (<1 year of age) diagnosed with acute leukemia [including acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML)] between 1996 and 2006 and 324 population controls. Mothers recalled household chemical use 1 month before and throughout pregnancy. We used unconditional logistic regression adjusted for birth year, maternal age, and race/ethnicity to calculate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS We did not find evidence for an association between infant leukemia and eight of nine chemical categories. However, exposure to petroleum products during pregnancy was associated with AML (OR = 2.54; 95% CI:1.40-4.62) and leukemia without mixed lineage leukemia (MLL) gene rearrangements ("MLL-") (OR = 2.69; 95% CI: 1.47-4.93). No associations were observed for exposure in the month before pregnancy. CONCLUSIONS Gestational exposure to petroleum products was associated with infant leukemia, particularly AML, and MLL- cases. Benzene is implicated as a potential carcinogen within this exposure category, but a clear biological mechanism has yet to be elucidated.
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Affiliation(s)
- Megan E Slater
- Division of Pediatric Epidemiology and Clinical Research, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
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27
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Dussel V, Bona K, Heath JA, Hilden JM, Weeks JC, Wolfe J. Unmeasured costs of a child's death: perceived financial burden, work disruptions, and economic coping strategies used by American and Australian families who lost children to cancer. J Clin Oncol 2011; 29:1007-13. [PMID: 21205758 DOI: 10.1200/jco.2009.27.8960] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [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
PURPOSE Financial concerns represent a major stressor for families of children with cancer but remain poorly understood among those with terminally ill children. We describe the financial hardship, work disruptions, income loss, and coping strategies of families who lost children to cancer. METHODS Retrospective cross-sectional survey of 141 American and 89 Australian bereaved parents whose children died between 1990 and 1999 and 1996 to 2004, respectively, at three tertiary-care pediatric hospitals (two American, one Australian). Response rate: 63%. RESULTS Thirty-four (24%) of 141 families from US centers and 34 (39%) of 88 families from the Australian center reported a great deal of financial hardship resulting from their children's illness. Work disruptions were substantial (84% in the United States, 88% in Australia). Australian families were more likely to report quitting a job (49% in Australia v 35% in the United States; P = .037). Sixty percent of families lost more than 10% of their annual income as a result of work disruptions. Australians were more likely to lose more than 40% of their income (34% in Australia v 19% in the United States; P = .035). Poor families experienced the greatest income loss. After accounting for income loss, 16% of American and 22% of Australian families dropped below the poverty line. Financial hardship was associated with poverty and income loss in all centers. Fundraising was the most common financial coping strategy (52% in the United States v 33% in Australia), followed by reduced spending. CONCLUSION In these US and Australian centers, significant household-level financial effects of a child's death as a result of cancer were observed, especially for poor families. Interventions aimed at reducing the effects of income loss may ease financial distress.
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Affiliation(s)
- Veronica Dussel
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, 44 Binney St (SM-206), Boston, MA 02115, USA.
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28
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Dreyer ZE, Dinndorf PA, Camitta B, Sather H, La MK, Devidas M, Hilden JM, Heerema NA, Sanders JE, McGlennen R, Willman CL, Carroll AJ, Behm F, Smith FO, Woods WG, Godder K, Reaman GH. Analysis of the role of hematopoietic stem-cell transplantation in infants with acute lymphoblastic leukemia in first remission and MLL gene rearrangements: a report from the Children's Oncology Group. J Clin Oncol 2010; 29:214-22. [PMID: 21135279 DOI: 10.1200/jco.2009.26.8938] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [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
PURPOSE Although the majority of children with acute lymphoblastic leukemia (ALL) are cured with current therapy, the event-free survival (EFS) of infants with ALL, particularly those with mixed lineage leukemia (MLL) gene rearrangements, is only 30% to 40%. Relapse has been the major source of treatment failure for these patients. The parallel Children's Cancer Group (CCG) 1953 and Pediatric Oncology Group (POG) 9407 studies were designed to test the hypothesis that more intensive therapy, including dose intensification of chemotherapy, and hematopoietic stem-cell transplantation (HSCT) would improve the outcome for this group of patients. PATIENTS AND METHODS One hundred eighty-nine infants (CCG 1953, n = 115; POG 9407, n = 74) were enrolled between October 1996 and August 2000. For infants with the MLL gene rearrangement and an appropriate donor, HSCT was the preferred treatment on CCG 1953 and investigator option on POG 9407 after completion of the second phase of therapy. Fifty-three infants underwent HSCT. RESULTS The 5-year EFS rate was 48.8% (95% CI, 33.9% to 63.7%) in patients who received HSCT and 48.7% (95% CI, 33.8% to 63.6%) in patients treated with chemotherapy alone (P = .60). Transplantation outcomes were not affected by the preparatory regimen or donor source. CONCLUSION Our data suggest that routine use of HSCT for infants with MLL-rearranged ALL is not indicated. However, limited by small numbers, this study should not be considered the definitive answer to this question.
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29
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Linabery AM, Puumala SE, Hilden JM, Davies SM, Heerema NA, Roesler MA, Ross JA. Maternal vitamin and iron supplementation and risk of infant leukaemia: a report from the Children's Oncology Group. Br J Cancer 2010; 103:1724-8. [PMID: 20978510 PMCID: PMC2994226 DOI: 10.1038/sj.bjc.6605957] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: Prenatal supplementation has been inversely associated with childhood, but not with infant, leukaemia. Methods: Mothers of 443 cases of infant leukaemia diagnosed during 1996–2006 and 324 frequency-matched controls completed interviews. Associations were evaluated by unconditional logistic regression. Results: We observed no associations between prenatal vitamin (odds ratio (OR)=0.79, 95% confidence interval (CI): 0.44–1.42) or iron supplementation (OR=1.07, 95% CI: 0.75–1.52) and infant leukaemia after adjustment for race/ethnicity and income. Similar results were observed for leukaemia subtypes analysed separately. Conclusion The observed null associations may be attributable to high supplementation rates and/or national fortification programmes.
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Affiliation(s)
- A M Linabery
- Division of Pediatric Epidemiology and Clinical Research, Department of Pediatrics, University of Minnesota, 420 Delaware Street SE, MMC 422, Minneapolis, MN 55455, USA
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Ullrich CK, Dussel V, Hilden JM, Sheaffer JW, Moore CL, Berde CB, Wolfe J. Fatigue in children with cancer at the end of life. J Pain Symptom Manage 2010; 40:483-94. [PMID: 20678889 DOI: 10.1016/j.jpainsymman.2010.02.020] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2009] [Revised: 01/29/2010] [Accepted: 02/01/2010] [Indexed: 11/30/2022]
Abstract
CONTEXT Fatigue is a prevalent source of suffering in children with advanced cancer; yet, little is known about it. OBJECTIVES This study aimed to describe fatigue experienced by children with advanced cancer and to identify the factors associated with suffering from fatigue and its treatment. METHODS A retrospective cross-sectional study of 141 parents of children who died of cancer (response rate: 64%) was conducted in two tertiary-level U.S. pediatric hospitals. RESULTS By parent report, 96% of children experienced fatigue in the last month of life. Nearly 50% experienced significant suffering from fatigue; this was associated with suffering from pain, dyspnea, anorexia, nausea/vomiting, diarrhea, anxiety, sadness, or fear (P<0.05), and with side effects from pain or dyspnea treatment (P<0.05). In multivariate analysis of symptom-related factors, suffering from nausea/vomiting (odds ratio [OR]=3.93, 95% confidence interval [CI]=1.23-12.61, P=0.02); anorexia (OR=7.52, 95% CI=1.87-30.25, P=0.005); and fear (OR=5.13, 95% CI=2.03-12.96, P ≤ 0.001) remained independently associated with fatigue. Children suffering from fatigue had primary oncologists with fewer years' experience than children who did not suffer from fatigue (mean=7.7 years, standard deviation [SD]=4.9 vs. mean of 9.9 years, SD=6.0, P=0.02). Among children with fatigue, 17 of 129 (13%) received fatigue-directed treatment, which was successful in 3 of 12 (25%). Children experiencing side effects from dyspnea or pain treatment were more likely to be treated for fatigue (relative risk=1.25, 95% CI=1.06-1.47, P=0.009). CONCLUSION Fatigue is a common source of suffering in children with cancer at the end of life. Palliation of this symptom is rarely successful. Increased attention to factors associated with fatigue and effective interventions to ameliorate fatigue are needed.
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Affiliation(s)
- Christina K Ullrich
- Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, Massachusetts 02115, USA.
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31
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Abstract
BACKGROUND Leukemia in infants is rare and has not been well studied apart from leukemia in older children. Differences in survival and the molecular characteristics of leukemia in infants versus older children suggest a distinct etiology, likely involving prenatal factors. PROCEDURE We examined the association between eight categories of maternally reported congenital abnormalities (CAs) (cleft lip or palate, spina bifida or other spinal defect, large or multiple birthmarks, other chromosomal abnormalities, small head or microcephaly, rib abnormalities, urogenital abnormalities, and other) and infant leukemia in a case-control study. The study included 443 cases diagnosed at <1 year of age at a Children's Oncology Group Institution in the United States or Canada from 1996 to 2006 and 324 controls. Controls were recruited from the cases' geographic area either by random digit dialing (1999-2002) or through birth certificates (2003-2008) and were frequency-matched to cases on birth year. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated by unconditional logistic regression after adjustment for birth year and a measure of follow-up time to account for differences in the CA observation period. RESULTS No statistically significant associations were observed between infant leukemia and any CA (OR = 1.2; 95% CI: 0.8-1.9), birthmarks (OR = 1.4; 95% CI: 0.7-2.5), urogenital abnormalities (OR = 0.7; 95% CI: 0.2-2.0), or other CA (OR = 1.4; 95% CI: 0.7-2.8). Results were similar for acute lymphoblastic and myeloid leukemia cases. Fewer than five subjects were in the remaining CA categories precluding analysis. CONCLUSIONS Overall, we did not find evidence to support an association between CAs and infant leukemia.
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Affiliation(s)
- Kimberly J. Johnson
- Department of Pediatrics, Division of Epidemiology/Clinical Research, University of Minnesota, Minneapolis, MN
| | - Michelle A. Roesler
- Department of Pediatrics, Division of Epidemiology/Clinical Research, University of Minnesota, Minneapolis, MN
| | - Amy M. Linabery
- Department of Pediatrics, Division of Epidemiology/Clinical Research, University of Minnesota, Minneapolis, MN
| | - Joanne M. Hilden
- Department of Pediatric Hematology/Oncology, Peyton Manning Children’s Hospital at St. Vincent, Indianapolis, IN
| | | | - Julie A. Ross
- Department of Pediatrics, Division of Epidemiology/Clinical Research, University of Minnesota, Minneapolis, MN
,Masonic Cancer Center, University of Minnesota, Minneapolis, MN 55455
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Dussel V, Joffe S, Hilden JM, Watterson-Schaeffer J, Weeks JC, Wolfe J. Considerations about hastening death among parents of children who die of cancer. ACTA ACUST UNITED AC 2010; 164:231-7. [PMID: 20194255 DOI: 10.1001/archpediatrics.2009.295] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVES To estimate the frequency of hastening death discussions, describe current parental endorsement of hastening death and intensive symptom management, and explore whether children's pain influences these views in a sample of parents whose child died of cancer. DESIGN Cross-sectional survey. SETTING Two tertiary-care US pediatric institutions. PARTICIPANTS A total of 141 parents of children who died of cancer (response rate, 64%). OUTCOME MEASURES Proportion of parents who (1) considered or (2) discussed hastening death during the child's end of life and who endorsed (3) hastening death or (4) intensive symptom management in vignettes portraying children with end-stage cancer. RESULTS A total of 19 of 141 (13%; 95% confidence interval [CI], 8%-19%) parents considered requesting hastened death for their child and 9% (95% CI, 4%-14%) discussed hastening death; consideration of hastening death tended to increase with an increase in the child's suffering from pain. In retrospect, 34% (95% CI, 26%-42%) of parents reported that they would have considered hastening their child's death had the child been in uncontrollable pain, while 15% or less would consider hastening death for nonphysical suffering. In response to vignettes, 50% (95% CI, 42%-58%) of parents endorsed hastening death while 94% (95% CI, 90%-98%) endorsed intensive pain management. Parents were more likely to endorse hastening death if the vignette involved a child in pain compared with coma (odds ratio, 1.4; 95% CI, 1.1-1.8). CONCLUSIONS More than 10% of parents considered hastening their child's death; this was more likely if the child was in pain. Attention to pain and suffering and education about intensive symptom management may mitigate consideration of hastening death among parents of children with cancer.
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Affiliation(s)
- Veronica Dussel
- Center for Outcomes and Policy Research and Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, 44 Binney St., Boston, MA 02115, USA.
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Bhat R, Malinge S, Gamis AS, Sorrell AD, Hilden JM, Ketterling RP, Paietta E, Tallman MS, Crispino JD. Mutational analysis of candidate tumor-associated genes in acute megakaryoblastic leukemia. Leukemia 2009; 23:2159-60. [DOI: 10.1038/leu.2009.159] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [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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Dussel V, Kreicbergs U, Hilden JM, Watterson J, Moore C, Turner BG, Weeks JC, Wolfe J. Looking beyond where children die: determinants and effects of planning a child's location of death. J Pain Symptom Manage 2009; 37:33-43. [PMID: 18538973 PMCID: PMC2638984 DOI: 10.1016/j.jpainsymman.2007.12.017] [Citation(s) in RCA: 140] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2007] [Revised: 12/13/2007] [Accepted: 12/28/2007] [Indexed: 11/23/2022]
Abstract
While dying at home may be the choice of many, where people die may be less important than argued. We examined factors associated with parental planning of a child's location of death (LOD) and its effects on patterns of care and parent's experience. In a cross-sectional study of 140 parents who lost a child to cancer at one of two tertiary-level U.S. pediatric hospitals, 88 (63%) planned the child's LOD and 97% accomplished their plan. After adjusting for disease and family characteristics, families whose primary oncologist clearly explained treatment options during the child's end of life and who had home care involved were more likely to plan LOD. Planning LOD was associated with more home deaths (72% vs. 8% among those who did not plan, P<0.001) and fewer hospital admissions (54% vs. 98%, P<0.001). Parents who planned were more likely to feel very prepared for the child's end of life (33% vs. 12%, P=0.007) and very comfortable with LOD (84% vs. 40%, P<0.001), and less likely to have preferred a different LOD (2% vs. 46%, P<0.001). Among the 73 nonhome deaths, planning was associated with more deaths occurring in the ward than in the intensive care unit or other hospital (92% vs. 33%, P<0.001), and fewer children being intubated (21% vs. 48%, P=0.029). Comprehensive physician communication and home care involvement increase the likelihood of planning a child's LOD. Opportunity to plan LOD is associated with outcomes consistent with high-quality palliative care, even among nonhome deaths, and thus may represent a more relevant outcome than actual LOD.
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Affiliation(s)
- Veronica Dussel
- Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, MA 02115, USA
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Mack JW, Joffe S, Hilden JM, Watterson J, Moore C, Weeks JC, Wolfe J. Parents' views of cancer-directed therapy for children with no realistic chance for cure. J Clin Oncol 2008; 26:4759-64. [PMID: 18779605 DOI: 10.1200/jco.2007.15.6059] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [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
PURPOSE Previous literature suggests that parents often wish to continue cancer-directed therapy for their children with incurable cancer. We assessed parents' experiences with treatment for their children with cancer and no realistic chance of cure. PATIENTS AND METHODS We administered questionnaires to 141 parents of children with cancer who died after receiving care at one of two cancer centers. Parents were asked whether the child benefited and suffered from treatment administered after the parent recognized that cure was not a realistic expectation, and whether they would recommend cancer-directed therapy to other families of children with advanced cancer. RESULTS Fifty-three (38%) of 141 children received cancer-directed therapy after the parent recognized that the child had no realistic chance for cure. Most of these parents felt that their child had experienced at least some suffering resulting from the therapy (61%, 31 of 51) and little to no benefit (57%, 29 of 51). Fifty-one (38%) of 135 parents overall would recommend standard chemotherapy and 46 (33%) of 140 would recommend experimental chemotherapy to families of children with advanced cancer. Even parents who would not recommend standard chemotherapy generally felt the physician should offer it (91%, 88 of 97). Parents who reported that their children experienced suffering resulting from cancer-directed therapy (odds ratio = 0.46; P = .02) were less likely to recommend standard chemotherapy to other families. CONCLUSION Although many parents choose treatment for their children with incurable cancer, bereaved parents often would not recommend such therapy. Parents who felt their children suffered as a result of cancer treatment were particularly unlikely to recommend it.
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Affiliation(s)
- Jennifer W Mack
- Center for Outcomes and Policy Research and Department of Pediatric Oncology, Dana-Farber Cancer Institute, 44 Binney St, Boston, MA 02115, USA.
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Affiliation(s)
- Patrick A Zweidler-McKay
- The Children's Cancer Hospital at the University of Texas M.D. Anderson Cancer Center, Houston, Texas, USA
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Heald B, Hilden JM, Zbuk K, Norton A, Vyas P, Theil KS, Eng C. Severe TMD/AMKL with GATA1 mutation in a stillborn fetus with Down syndrome. ACTA ACUST UNITED AC 2007; 4:433-8. [PMID: 17597708 DOI: 10.1038/ncponc0876] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2007] [Accepted: 04/03/2007] [Indexed: 11/09/2022]
Abstract
BACKGROUND A 34-year-old woman was referred for evaluation of a recent stillborn male fetus, gestational age 27 6/7 weeks, found to have congenital myeloid leukemia at autopsy. Autopsy findings included high weight for gestational age, hepatomegaly, and extensive intravascular leukemic infiltrates in the placenta, heart, liver, thymus, lung, kidneys, and brain. Genetic consultation and examination of photographs of the fetus revealed dysmorphic features. INVESTIGATIONS Immunoperoxidase staining of placental tissue, fluorescence in situ hybridization of paraffin-embedded sections of the placenta using probes for t(12;21)(p13;q22), t(8;21)(q22;q22) and t/del(11q23), cytogenetic analysis of fetal tissue (tendon), sequence analysis of GATA1 in placental leukemic cells, and parental chromosome studies. DIAGNOSIS Down syndrome with in utero onset of GATA1 mutation-positive severe transient myeloproliferative disorder/acute megakaryoblastic leukemia. MANAGEMENT Genetic counseling for the recurrence risk of Down syndrome on the basis of maternal age.
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Affiliation(s)
- Brandie Heald
- Center for Personalized Genetic Healthcare, Cleveland Clinic, Cleveland, OH 44195, USA
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38
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Spector LG, Davies SM, Robison LL, Hilden JM, Roesler M, Ross JA. Birth characteristics, maternal reproductive history, and the risk of infant leukemia: a report from the Children's Oncology Group. Cancer Epidemiol Biomarkers Prev 2007; 16:128-34. [PMID: 17220341 DOI: 10.1158/1055-9965.epi-06-0322] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Leukemias with MLL gene rearrangements predominate in infants (<1 year of age), but not in older children, and may have a distinct etiology. High birth weight, higher birth order, and prior fetal loss have, with varying consistency, been associated with infant leukemia, but no studies have reported results with respect to MLL status. Here, we report for the first time such an analysis. During 1999 to 2003, mothers of 240 incident cases (113 MLL(+), 80 MLL(-), and 47 indeterminate) and 255 random digit dialed controls completed a telephone interview. Odds ratios and 95% confidence intervals for quartile of birth weight, birth order, gestational age, maternal age at delivery, prior fetal loss, pre-pregnancy body mass index, and weight gain during pregnancy were obtained using unconditional logistic regression; P for linear trend was obtained by modeling continuous variables. There was a borderline significant linear trend of increasing birth weight with MLL(+) (P = 0.06), but not MLL(-) (P = 0.93), infant leukemia. Increasing birth order showed a significant inverse linear trend, independent of birth weight, with MLL(+) (P = 0.01), but not MLL(-) (P = 0.18), infant leukemia. Other variables of interest were not notably associated with infant leukemia regardless of MLL status. This investigation further supports the contention that molecularly defined subtypes of infant leukemia have separate etiologies.
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Affiliation(s)
- Logan G Spector
- Division of Epidemiology/Clinical Research, Department of Pediatrics, University of Minnesota, 420 Delaware Street Southeast, MMC 715, Minneapolis, MN 55455, USA.
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39
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Johnston DL, Nagel K, O'Halloran C, Sencer SF, Kelly KM, Friebert S, Hilden JM, Friedman DL. Complementary and alternative medicine in pediatric oncology: availability and institutional policies in Canada--a report from the Children's Oncology Group. Pediatr Blood Cancer 2006; 47:955-8. [PMID: 16411194 DOI: 10.1002/pbc.20772] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Complementary and alternative medicine (CAM) is used frequently by pediatric oncology patients. A survey exploring the institutional practices and policies surrounding CAM use in pediatric oncology patients was completed by 17 pediatric hematology/oncology centers in Canada. We found that CAM was offered in only 18% of the institutions, but 94% of the communities. Only 6% of oncology divisions made direct referrals to community CAM providers, and only 20% of the centers had policies regarding use of CAM therapies for their patients. Despite published widespread use of CAM therapies, our study demonstrates that institutional CAM resources and policies on CAM are present in much lower proportions.
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Affiliation(s)
- Donna L Johnston
- Division of Hematology/Oncology, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.
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Abstract
When a child is diagnosed with a life-threatening or life-limiting condition, their physical and affective world is immediately changed, regardless of the outcome of treatment. Pediatric care providers are in a unique position to offer hope to children and families even when cure is not possible. This hope focuses not only on cure, but incorporates the understanding that quality of life is not commensurate with length of life and that compassionate care can be provided in all stages of treatment.
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Affiliation(s)
- Nancy Hutton
- Division of General Pediatrics and Adolescent Medicine, The Johns Hopkins University School of Medicine, 200 North Wolfe Street, Baltimore, MD 21287, USA.
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41
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Abstract
An analogy may be drawn between readying a family for the birthof a child and readying a family for the death of a child. Both ex-periences bring about an intense fusion of the emotional, physical,and spiritual realms for those bearing witness. Preparation, com-munication, and collaboration are essential to provide optimalsupport for the children at the end of life, the parents, and thebrothers and sisters.
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Affiliation(s)
- Janet Duncan
- Pediatric Advanced Care Team, Children's Hospital Boston and Dana-Farber Cancer Institute, 44 Binney Street, Dana 3, Boston, MA 02115, USA.
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42
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Hilden JM, Dinndorf PA, Meerbaum SO, Sather H, Villaluna D, Heerema NA, McGlennen R, Smith FO, Woods WG, Salzer WL, Johnstone HS, Dreyer Z, Reaman GH. Analysis of prognostic factors of acute lymphoblastic leukemia in infants: report on CCG 1953 from the Children's Oncology Group. Blood 2006; 108:441-51. [PMID: 16556894 PMCID: PMC1895499 DOI: 10.1182/blood-2005-07-3011] [Citation(s) in RCA: 203] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Infant acute lymphoblastic leukemia (ALL) has a poor therapeutic outcome despite attempts to treat it based on prognostic factor-guided therapy. This is the first cooperative group trial characterizing all infants at the molecular level for MLL/11q23 rearrangement. All infants enrolled on Children's Cancer Group (CCG) 1953 were tested for MLL rearrangement by Southern blot and the 11q23 translocation partner was identified (4;11, 9;11, 11;19, or "other") by reverse-transcriptase polymerase chain reaction (PCR). One hundred fifteen infants were enrolled; overall event-free survival (EFS) was 41.7% (SD = 9.2%) and overall survival (OS) was 44.8% at 5 years. Five-year EFS for MLL-rearranged cases was 33.6% and for MLL-nonrearranged cases was 60.3%. The difference in EFS between the 3 major MLL rearrangements did not reach statistical significance. Multivariate Cox regression analyses showed a rank order of significance for negative impact on prognosis of CD10 negativity, age younger than 6 months, and MLL rearrangement, in that order. Toxicity was the most frequent cause of death. Relapse as a first event in CCG 1953 was later (median, 295 days) compared with CCG 1883 historic control (median, 207 days). MLL/11q23 rearrangement, CD10 expression, and age are important prognostic factors in infant ALL, but molecular 11q23 translocation partners do not predict outcome.
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Affiliation(s)
- Joanne M Hilden
- The Children's Hospital at The Cleveland Clinic, OH 44195, USA.
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Mack JW, Hilden JM, Watterson J, Moore C, Turner B, Grier HE, Weeks JC, Wolfe J. Parent and physician perspectives on quality of care at the end of life in children with cancer. J Clin Oncol 2005; 23:9155-61. [PMID: 16172457 DOI: 10.1200/jco.2005.04.010] [Citation(s) in RCA: 220] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
PURPOSE To ascertain parents' and physicians' assessments of quality of end-of-life care for children with cancer and to determine factors associated with high-quality care as perceived by parents and physicians. METHODS A survey was conducted between 1997 and 2001 of 144 parents of children who received treatment at the Dana-Farber Cancer Institute and Children's Hospital (Boston, MA) or Children's Hospitals and Clinics of St Paul and Minneapolis, MN, between 1990 and 1999 (65% of those located and eligible) and 52 pediatric oncologists. RESULTS In multivariable models, higher parent ratings of physician care were associated with physicians giving clear information about what to expect in the end-of-life period (odds ratio [OR] = 19.90, P = .02), communicating with care and sensitivity (OR = 7.67, P < .01), communicating directly with the child when appropriate (OR = 11.18, P < .01), and preparing the parent for circumstances surrounding the child's death (OR = 4.84, P = .03). Parent reports of the child's pain and suffering were not significant correlates of parental ratings of care (P = .93 and .35, respectively). Oncologists' ratings of care were inversely associated with the parent's report of the child's experience of pain (OR = 0.15, P = .01) and more than 10 hospital days in the last month of life (OR = 0.24, P < .01). Parent-rated communication factors were not correlates of oncologist-rated care. No association was found between parent and physician care ratings (P = .88). CONCLUSION For parents of children who die of cancer, doctor-patient communication is the principal determinant of high-quality physician care. In contrast, physicians' care ratings depend on biomedical rather than relational aspects of care.
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Affiliation(s)
- Jennifer W Mack
- Department of Pediatric Oncology, Center for Outcomes and Policy Research, Dana-Farber Cancer Institute, Boston, MA 02115, USA
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44
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Abstract
Although the majority of children with cancer are cured of their illness, the children who die from their disease or complications require special care at the end of life. We present special issues and challenges unique to pediatric palliative care and suggest ways in which we can face these issues and address the challenges. The care must be family centered and balance the needs of the health-care system, the child, and the family. The way in which the care is delivered, the services provided, and the place in which that care is given are not carved into a simple protocol. Quality of life is an important concept that is often overlooked. Educational initiatives for patients, families, health-care providers, and third-party payers are essential. Reimbursement for palliative care services presents a large barrier to provision of appropriate services to all children and families in need. Hypothesis-driven research must be developed to help us learn more about how best to deliver end-of-life care to children and their families.
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Affiliation(s)
- Debra L Friedman
- Division of Hematology/Oncology, University of Washington, Children's Hospital and Regional Medical Center, 4800 Sand Point Way NE, Seattle, WA 98105, USA.
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45
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Spector LG, Xie Y, Robison LL, Heerema NA, Hilden JM, Lange B, Felix CA, Davies SM, Slavin J, Potter JD, Blair CK, Reaman GH, Ross JA. Maternal diet and infant leukemia: the DNA topoisomerase II inhibitor hypothesis: a report from the children's oncology group. Cancer Epidemiol Biomarkers Prev 2005; 14:651-5. [PMID: 15767345 DOI: 10.1158/1055-9965.epi-04-0602] [Citation(s) in RCA: 131] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The MLL 11q23 translocation arises in utero and is present in 75% of infant leukemias. That MLL+ acute myeloid leukemia (AML) can arise following chemotherapy with DNA topoisomerase II (DNAt2) inhibitors suggests that these substances, which also occur naturally in foods, may contribute toward infant leukemia. We hypothesized that maternal consumption of dietary DNAt2 inhibitors during pregnancy would increase the risk of infant leukemia, particularly AML(MLL+). METHODS This Children's Oncology Group case-control study consisted of 240 incident cases of infant acute leukemia [AML and acute lymphoblastic leukemia (ALL)] diagnosed during 1996 to 2002 and 255 random digit dialed controls. Maternal diet during pregnancy was determined through a food frequency questionnaire. An index of specific foods identified a priori to contain DNAt2 inhibitors as well as vegetables and fruits were created and analyzed using unconditional logistic regression. RESULTS There was little evidence of an association between the specific DNAt2 index and leukemia overall and by subtype. An exception was AML(MLL+); odds ratios (95% confidence intervals) comparing the second to fourth quartiles to the first were 1.9 (0.5-7.0), 2.1 (0.6-7.7), and 3.2 (0.9-11.9), respectively (P for trend = 0.10). For the vegetable and fruit index, there were significant or near-significant inverse linear trends for all leukemias combined, ALL(MLL+), and AML(MLL-). CONCLUSION Overall, maternal consumption of fresh vegetables and fruits during pregnancy was associated with a decreased risk of infant leukemia, particularly MLL+. However, for AML(MLL+) cases, maternal consumption of specific DNAt2 inhibitors seemed to increase risk. Although based on small numbers, these data provide some support for distinct etiologic pathways in infant leukemia.
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Affiliation(s)
- Logan G Spector
- Division of Pediatric Epidemiology and Clinical Research, Department of Pediatrics, University of Minnesota, Minneapolis, MN 55455, USA.
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Abstract
Pediatric brain tumors are a challenging group of very divergent diseases. Considerable controversy exists concerning the accurate diagnosis and treatment of these patients. Aggressive therapy is often needed to cure aggressive and potentially lethal disease, yet late effects, especially injury to the developing brain, remain a profound problem. The discipline of pediatric neuro-oncology remains one of the most productive areas for continued clinical and basic research because of these and other challenges.
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Affiliation(s)
- Andrew W Walter
- Pediatric Hematology/Oncology and Neuro-Oncology, Thomas Jefferson Medical College, A. I. duPont Hospital for Children, 1600 Rockland Road, Wilmington, DE 19899, USA.
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47
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Abstract
Although the majority of children with cancer are cured of their illness, the children who die from their disease or complications require special care at the end of life. We present special issues and challenges unique to pediatric palliative care and suggest ways in which we can face these issues and address the challenges. The care must be family centered and balance the needs of the health-care system, the child, and the family. The way in which the care is delivered, the services provided, and the place in which that care is given are not carved into a simple protocol. Quality of life is an important concept that is often overlooked. Educational initiatives for patients, families, health-care providers, and third-party payers are essential. Reimbursement for palliative care services presents a large barrier to provision of appropriate services to all children and families in need. Hypothesis-driven research must be developed to help us learn more about how best to deliver end-of-life care to children and their families.
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Affiliation(s)
- Debra L Friedman
- Division of Hematology/Oncology, University of Washington, Children's Hospital and Regional Medical Center, 4800 Sand Point Way NE, Seattle, WA 98105, USA.
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Hilden JM, Meerbaum S, Burger P, Finlay J, Janss A, Scheithauer BW, Walter AW, Rorke LB, Biegel JA. Central nervous system atypical teratoid/rhabdoid tumor: results of therapy in children enrolled in a registry. J Clin Oncol 2004; 22:2877-84. [PMID: 15254056 DOI: 10.1200/jco.2004.07.073] [Citation(s) in RCA: 273] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
PURPOSE Atypical teratoid/rhabdoid tumor (AT/RT) of the CNS is an extremely rare and aggressive tumor of early childhood. The poor outcome with conventional infant brain tumor therapy has resulted in a lack of clear treatment guidelines. A registry has been established to create an outcomes database and to facilitate biology studies for this tumor. MATERIALS AND METHODS A standardized data sheet was provided to treating physicians listing the reports that were to be sent to the registry for abstraction. Follow-up information was sought twice yearly. RESULTS Information was complete for 42 patients. Median age at diagnosis was 24 months. Nine patients (21%) had disseminated disease at diagnosis. Sixteen tumors were infratentorial; 26 were supratentorial. Twenty patients (48%) received a primary complete resection. Primary therapy included chemotherapy in all patients, radiotherapy in 13 patients (31%), stem-cell rescue in 13 patients (31%), and intrathecal chemotherapy in 16 patients (38%). Recurrent or progressive disease was reported in nine and 19 patients, respectively. Twenty-seven patients (64%) are dead of disease (3 to 62 months from diagnosis) and one patient died of toxicity. Fourteen patients (33%) show no evidence of disease (9.5 to 96 months from diagnosis). The median survival is 16.75 months and the median event-free survival is 10 months. CONCLUSION Aggressive therapy has prolonged the natural history in a subset of children. Prospective multi-institutional and national clinical trials designed specifically for AT/RT are needed. Enrollment onto the AT/RT registry should be continued.
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Affiliation(s)
- Joanne M Hilden
- Department of Pediatric Hematology/Oncology, The Children's Hospital, The Cleveland Clinic, 9500 Euclid Avenue, Desk S20, Cleveland, OH 44195, USA.
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Affiliation(s)
- Bruce P Himelstein
- Pediatric Palliative Care Program, Children's Hospital of Wisconsin, Milwaukee, USA.
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Affiliation(s)
- Joanne M Hilden
- Department of Hematology/Oncology, Children's Hospitals and Clinics, St Paul, MN 55102, USA.
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