Response assessment by positron emission tomography-computed tomography as compared with contrast-enhanced computed tomography in childhood Hodgkin lymphoma can reduce the need for radiotherapy in low- and middle-income countries

INTRODUCTION

The InPOG-HL-15-01, a multicentric prospective study, used a risk-stratified and response-based approach with doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) backbone to treat children and adolescents with newly diagnosed Hodgkin lymphoma (HL) and reduce the use of radiation therapy (RT). Children/adolescents with bulky disease or inadequate response at early response assessment (ERA) after two cycles of chemotherapy were assigned to receive RT. For ERA, positron emission tomography computed tomography (PET-CT) was recommended but not mandatory in view of limited access. This study aimed to compare the impact of using contrast-enhanced computed tomography (CECT) and PET-CT on treatment decisions and outcomes.

METHODOLOGY

396 patients were enrolled and 382 had an ERA at the assigned time point. Satisfactory response was defined as Deauville score 3 or less for patients undergoing PET-CT and complete response (CR)/very good partial response (VGPR) for patients undergoing CECT. Outcomes of interest incorporate 5 year event-free survival (EFS), EFS including abandonment (EFSa), and overall survival (OS).

RESULTS

At ERA, satisfactory response was documented in 277 out of 382 (72.5%) participants and this was significantly higher in PET-CT (151 out of 186, 81.2%) as compared with CECT-based assessments (126 out of 196, 64.3%) respectively (p value < .001). Amongst the 203 patients with nonbulky disease (wherein the indication for RT was entirely dependent on ERA), 96 out of 114 (84.2%) and 61 out of 89 (68.5%) patients achieved a satisfactory response according to the PET-CT and CECT (p value = .008) respectively and hence a lesser proportion of patients in the PET-CT arm received RT. Despite a lower usage of RT the 5 year OS of both groups, ERA based on CECT (91.8%) versus PET-CT (94.1%) was comparable (p value = .391) and so was the 5 year EFS (86.7 vs. 85.5%, p value = .724).

CONCLUSION

Use of PET-CT as the modality for ERA is more likely to indicate a satisfactory response as compared with CECT and thereby decreases the need for RT in response-based treatment algorithm for HL-afflicted children. The reduction in the application of RT did not impact the overall outcome and plausibly would lower the risk of delayed toxic effects.

The Global Impact of COVID-19 on Childhood Cancer Outcomes and Care Delivery - A Systematic Review

Background

Childhood cancer represents a leading cause of death and disease burden in high income countries (HICs) and low-and-middle income countries (LMICs). It is postulated that the current COVID-19 pandemic has hampered global development of pediatric oncology care programs. This systematic review aimed to comprehensively review the global impact of COVID-19 on childhood cancer clinical outcomes and care delivery.

Methods

A systematic search was conducted on PubMed, Embase, Medline, and the African Medical Index from inception to November 3, 2021 following PRISMA guidelines. A manual search was performed to identify additional relevant studies. Articles were selected based on predetermined eligibility criteria.

Findings

The majority of studies reported patients with cancer and COVID-19 presenting as asymptomatic (HICs: 33.7%, LMICs: 22.0%) or with primary manifestations of fever (HICs: 36.1%, LMICs: 51.4%) and respiratory symptoms (HICs: 29.6%, LMICs: 11.7%). LMICs also reported a high frequency of patients presenting with cough (23.6%) and gastrointestinal symptoms (10.6%). The majority of patients were generally noted to have a good prognosis; however the crude mortality rate was higher in LMICs when compared to HICs (8.0% vs 1.8%). Moreover, the pandemic has resulted in delays and interruptions to cancer therapies and delays in childhood cancer diagnoses in both HICs and LMICs. However, these findings were disproportionately reported in LMICs, with significant staff shortages, supply chain disruptions, and limited access to cancer therapies for patients.

Conclusions

The COVID-19 pandemic has resulted in delays and interruptions to childhood cancer therapies and delays in childhood cancer diagnoses, and disproportionately so within LMICs. This review provides lessons learned for future system-wide disruptions to care, as well as provides key points for moving forward better with care through the remainder of this pandemic.

Systematic Review Registration

CRD42021266758, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=266758

Utilizing Multilingual Methods and Rapid Analysis for Global Qualitative Research During a Pandemic

Historically, qualitative research has complemented quantitative biologic and epidemiologic studies to provide a more complete understanding of pandemics. The COVID-19 pandemic has generated unique and novel challenges for qualitative researchers, who have embraced creative solutions including virtual focus groups and rapid analyses to continue their work. We present our experience conducting a multilingual global qualitative study of healthcare resilience among teams of pediatric oncology professionals during the COVID-19 pandemic. We provide an in-depth description of our methodology and an analysis of factors we believe contributed to our study’s success including our use of technology, engagement of a large multilingual team, global partnerships, and framework-based rapid analysis. We hope these techniques may be useful to qualitative researchers conducting studies during the current pandemic, as well as for all pediatric oncology studies including multiple languages or geographically disparate subjects.

Patient tracking during treatment of children with cancer in India - An exploratory study

BACKGROUND

Abandonment of treatment, a major cause of treatment failure in low- and middle-income countries like India, is particularly high during the diagnostic and initial phase of treatment. Tracking of patients during this risk period may reduce treatment abandonment rates and increase quality of care.

AIM

The primary aim was to pilot the use and check the acceptability of a tool for tracking children with cancer in New Delhi during the initial part of their treatment. Secondary aim was to estimate abandonment rates among these patients.

METHODS

This prospective study was carried out in two centers of North India in New Delhi and enrolled children less than 18 years diagnosed with cancer at these centers and who had registered with Cankids for social support. Parent support group (PSG) workers maintained contact with the child's family at least once a week for the first 12 weeks. Details of each contact and subsequent action were recorded in a customized book (called "You are not alone" or YANA Book). Descriptive analysis of these contacts was done in Microsoft Excel and presented in frequencies and percentages. The five-point Likert scale was used to check the acceptability of the tool among the PSG workers.

RESULTS

Seven PSG workers enrolled and tracked 81 patients (73% male with a median age of 6 years). During the 12-week study period, 986 contacts were attempted and three (3.7%) patients had abandoned their treatment. All PSG workers strongly agreed that the YANA book was simple to understand and use, decreased their workload, and helped provide better assistance to patients.

CONCLUSION

The tool for patient tracking was well accepted by the PSG workers and considered easy to use. We now plan to implement our model as a routine service at all the partnering hospitals in India.

Sustainable care for children with cancer: a Lancet Oncology Commission

We estimate that there will be 13·7 million new cases of childhood cancer globally between 2020 and 2050. At current levels of health system performance (including access and referral), 6·1 million (44·9%) of these children will be undiagnosed. Between 2020 and 2050, 11·1 million children will die from cancer if no additional investments are made to improve access to health-care services or childhood cancer treatment. Of this total, 9·3 million children (84·1%) will be in low-income and lower-middle-income countries. This burden could be vastly reduced with new funding to scale up cost-effective interventions. Simultaneous comprehensive scale-up of interventions could avert 6·2 million deaths in children with cancer in this period, more than half (56·1%) of the total number of deaths otherwise projected. Taking excess mortality risk into consideration, this reduction in the number of deaths is projected to produce a gain of 318 million life-years. In addition, the global lifetime productivity gains of US$2580 billion in 2020-50 would be four times greater than the cumulative treatment costs of $594 billion, producing a net benefit of $1986 billion on the global investment: a net return of $3 for every $1 invested. In sum, the burden of childhood cancer, which has been grossly underestimated in the past, can be effectively diminished to realise massive health and economic benefits and to avert millions of needless deaths.

Afatinib versus methotrexate as second-line treatment in Asian patients with recurrent or metastatic squamous cell carcinoma of the head and neck progressing on or after platinum-based therapy (LUX-Head & Neck 3): an open-label, randomised phase III trial

BACKGROUND

Treatment options are limited for patients with recurrent or metastatic squamous cell carcinoma of the head and neck (HNSCC) following progression after first-line platinum-based therapy, particularly in Asian countries.

PATIENTS AND METHODS

In this randomised, open-label, phase III trial, we enrolled Asian patients aged ≥18 years, with histologically or cytologically confirmed recurrent/metastatic HNSCC following first-line platinum-based therapy who were not amenable for salvage surgery or radiotherapy, and had an Eastern Cooperative Oncology Group (ECOG) performance status of 0/1. Patients were randomised (2 : 1) to receive oral afatinib (40 mg/day) or intravenous methotrexate (40 mg/m2/week), stratified by ECOG performance status and prior EGFR-targeted antibody therapy. The primary end point was progression-free survival (PFS) assessed by an independent central review committee blinded to treatment allocation.

RESULTS

A total of 340 patients were randomised (228 afatinib; 112 methotrexate). After a median follow-up of 6.4 months, afatinib significantly decreased the risk of progression/death by 37% versus methotrexate (hazard ratio 0.63; 95% confidence interval 0.48-0.82; P = 0.0005; median 2.9 versus 2.6 months; landmark analysis at 12 and 24 weeks, 58% versus 41%, 21% versus 9%). Improved PFS was complemented by quality of life benefits. Objective response rate was 28% with afatinib and 13% with methotrexate. There was no significant difference in overall survival. The most common grade ≥3 drug-related adverse events were rash/acne (4% with afatinib versus 0% with methotrexate), diarrhoea (4% versus 0%), fatigue (1% versus 5%), anaemia (<1% versus 5%) and leukopenia (0% versus 5%).

CONCLUSIONS

Consistent with the phase III LUX-Head & Neck 1 trial, afatinib significantly improved PFS versus methotrexate, with a manageable safety profile. These results demonstrate the efficacy and feasibility of afatinib as a second-line treatment option for certain patients with recurrent or metastatic HNSCC.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01856478.

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

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

Magnitude of Treatment Abandonment in Childhood Cancer

BACKGROUND

Treatment abandonment (TxA) is recognized as a leading cause of treatment failure for children with cancer in low-and-middle-income countries (LMC). However, its global frequency and burden have remained elusive due to lack of global data. This study aimed to obtain an estimate using survey and population data.

METHODS

Childhood cancer clinicians (medical oncologists, surgeons, and radiation therapists), nurses, social workers, and psychologists involved in care of children with cancer were approached through an online survey February-May 2012. Incidence and population data were obtained from public sources. Descriptive, univariable, and multivariable analyses were conducted.

RESULTS

602 responses from 101 countries were obtained from physicians (84%), practicing pediatric hematology/oncology (83%) in general or children's hospitals (79%). Results suggested, 23,854 (15%) of 155,088 children <15 years old newly diagnosed with cancer annually in the countries analyzed, abandon therapy. Importantly, 83% of new childhood cancer cases and 99% of TxA were attributable to LMC. The annual number of cases of TxA expected in LMC worldwide (26,166) was nearly equivalent to the annual number of cancer cases in children <15 years expected in HIC (26,368). Approximately two thirds of LMC had median TxA ≥ 6%, but TxA ≥ 6% was reported in high- (9%), upper-middle- (41%), lower-middle- (80%), and low-income countries (90%, p<0.001). Most LMC centers reporting TxA > 6% were outside the capital. Lower national income category, higher reliance on out-of-pocket payments, and high prevalence of economic hardship at the center were independent contextual predictors for TxA ≥ 6% (p<0.001). Global survival data available for more developed and less developed regions suggests TxA may account for at least a third of the survival gap between HIC and LMC.

CONCLUSION

Results show TxA is prevalent (compromising cancer survival for 1 in 7 children globally), confirm the suspected high burden of TxA in LMC, and illustrate the negative impact of poverty on its occurrence. The present estimates may appear small compared to the global burden of child death from malnutrition and infection (measured in millions). However, absolute numbers suggest the burden of TxA in LMC is nearly equivalent to annually losing all kids diagnosed with cancer in HIC just to TxA, without even considering deaths from disease progression, relapse or toxicity-the main causes of childhood cancer mortality in HIC. Results document the importance of monitoring and addressing TxA as part of childhood cancer outcomes in at-risk settings.

A practical approach to reporting treatment abandonment in pediatric chronic conditions

Treatment abandonment, the failure to complete therapy that is required for definitive disease control, frequently causes treatment failure for pediatric patients in low- and middle-income countries with chronic conditions, particularly cancer. Other forms of incomplete treatment affecting children in all settings, such as nonadherence and loss to follow-up, are often confused with treatment abandonment. Unclear definitions of incomplete treatment dramatically affect reported outcomes. To facilitate disease-specific and cross-sector analyses, we outline a practical approach to categorize forms of incomplete treatment, present distinct semantic categories with case examples and provide an algorithm that could be tailored to disease- and context-specific needs.

The contrasting age-incidence patterns of bone tumours in teenagers and young adults: Implications for aetiology

Bone tumours comprise 0.2% of cancers overall but 5.7% in 15-24 year olds. To explore the relationship with adolescence we have analysed age-incidence patterns of bone tumours in a large national dataset. Data on incident cases of bone tumours in 0-84 year olds in England, 1979-2003, were extracted from national cancer registration data. Incidence rates per million person-years by 5-year age-group, sex, morphology and primary site were calculated and adjusted to the world standard population. Nine thousand one hundred forty-six cases were identified giving an overall age-standardized rate of 7.19 per million person-years. The distribution by morphology was: osteosarcoma, 34.2%; chondrosarcoma, 27.2%; Ewing sarcoma, 19.3%; other, 19.4%. The distribution varied by age. Ewing sarcoma was most common in 0-9 year olds, osteosarcoma in 10-29 year olds and chondrosarcoma in 30-84 year olds. 29.2% of all tumours occurred in 0-24 year olds. Highest incidence of osteosarcoma and Ewing sarcoma in females was in 10-14 year olds. In males, peak incidence occurred at 15-19 years and exceeded that in females. Chondrosarcoma incidence steadily increased with age. The proportions of Ewing sarcomas occurring in respective bones were consistent with those of the adult skeleton by weight. In osteosarcoma tumours of long bones of lower limb were markedly over-represented in the adolescent peak, being six times more than at any other site. Variation in incidence patterns with age and site suggests pubertal bone growth to be a key factor in osteosarcoma while different biological pathways could be relevant for Ewing sarcoma.

Cancer at ages 15-29 years: the contrasting incidence in India and England

BACKGROUND

There has been a steady increase in published research from Europe and North America on the epidemiology of cancers in young people. There are limited data from the developing world. We contrast the incidence of cancer at ages 15-29 years in India and England.

PROCEDURE

Malignant neoplasms in those aged 15-29 years registered during 2001-2003 in five urban population-based cancer registries (PBCRs) of India and in eight PBCRs in England were included. Site-based classification was used. Age-standardized incidence rates were expressed per 100,000 person years.

RESULTS

In India, 4,864 (5.8%) of 84,450 cases and in England, 8,137 (1.2%) of 65,6752 cancer cases occurred in those aged 15-29 years. For this age group, the incidence rate for males and females in India were 12.91 and 14.19, and in England were 27.75 and 28.88, respectively. In males aged 15-29 years, the three most common cancers in India were leukemia, lymphoma, and central nervous system tumors and in England were cancers of male genital organs, lymphoma, and leukemia. Cancers of female genital organs, breast, and leukemia were most common in females in India and cancers of female genital organs, lymphoma, and melanoma in England. For cancers of mouth, stomach, and gall bladder, the incidence was higher in India.

CONCLUSION

Incidence of cancer at ages 15-29 years in England is higher at most sites than in India. Variation in environmental exposures between the two countries might be an explanation. Under-ascertainment of cases and gender bias in seeking healthcare may also influence reported incidence rates in India.

Understanding refusal and abandonment in the treatment of childhood cancer

Treatment refusal and abandonment is the principal cause of therapy failure in children with cancer in the developing world. A complex interplay of biological, socio-economic and treatment-related factors underlies this problem. Interventions are likely to succeed when they try and address all of these issues simultaneously, as exemplified by the success of twinning programs linking resource-rich and resource-limited countries. Hitherto, there has been no systematic attempt to understand and address this problem in India. Based on the knowledge gained from research in other parts of the developing world, we offer suggestions for dealing with this problem.

Relationship between height at diagnosis and bone tumours in young people: a meta-analysis

OBJECTIVE

Some evidence exists that patients with osteosarcoma and Ewing sarcoma are taller than the general population. However, previous studies are under-powered, lack comprehensive data and show inconsistencies.

METHODS

Relevant studies linking osteosarcoma and Ewing sarcoma with height at diagnosis were identified in two major online databases, Medline (1950 to 2009) and Embase (1980 to 2009). Outcomes in individual studies were reported as standard deviation (SD) scores or percentages of study population with height at diagnosis above the median of the reference population. We performed separate random-effects meta-analyses for each outcome and tumour type.

RESULTS

14 studies examined the height of patients with osteosarcoma or Ewing sarcoma. Meta-analyses on SD scores found patients with osteosarcoma were 0.260 SD (95% CI: 0.088-0.432) taller than the reference population (five studies). A meta-analysis on percentages found 62% (95% CI: 57%-67%) of patients were estimated to have a height above the median (six studies). Patients with Ewing sarcoma were 0.096 SD (95% CI 0.004-0.188) taller (four studies). Only one study reported the percentage of Ewing sarcoma patients with height above the median.

CONCLUSION

The average height of patients with osteosarcoma, but not Ewing sarcoma, was significantly above the average height of the reference population by 2-3 centimetres. The observed differences indicate the involvement of pubertal longitudinal bone growth in osteosarcoma development while different biological pathways could be relevant for Ewing sarcoma.

Assessing the impact of paediatric oncology publications using three citation databases

Despite some reported limitations, Web of Science has been the standard source to assess the impact of individual articles, and consequently journals. By analysing the citations to articles published in the field of paediatric oncology, we demonstrate that Scopus and Google Scholar, the two new citation databases, retrieve more citations than Web of Science. The strength of Scopus lies in identifying non-English literature from Western and Eastern Europe, while Google Scholar is proficient at identifying English and non-English literature from Africa, Asia and Central and South America. These findings have implications for researchers, journals and health libraries.

Interventions other than anticoagulants and systemic antibiotics for prevention of central venous catheter-related infections in children with cancer

BACKGROUND

Use of central venous catheters (CVC) in treatment of children with cancer is associated with infective complications. Current evidence-based guidelines to prevent catheter-related infections are mainly relevant to the adult population. They are not cancer (especially not childhood cancer) specific. Two existing Cochrane reviews have looked at prophylactic antibiotics and anticoagulants to prevent CVC-related infections.

OBJECTIVES

The primary objective was to find which interventions, if any, were effective in preventing CVC-related infections in children with cancer. Further objectives were to examine the effectiveness of each intervention in the following subgroups: implanted versus external catheters, haematological versus non-haematological malignancies, and in those receiving haematopoietic stem cell transplants (HSCT) versus no HSCT.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2008, Issue 4), MEDLINE (January 1950 to January 2009), EMBASE (January 1980 to January 2009) and CINAHL(R) (January 1982 to March 2009). We also searched reference lists of relevant articles and proceedings of relevant international conferences (2004 to 2008).

SELECTION CRITERIA

Randomised and quasi-randomised studies comparing any intervention (other than anticoagulants, systemic antibiotics and antibiotic lock techniques) versus no intervention, placebo or any other intervention to prevent CVC-related infections in children with cancer.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies, assessed trial quality and extracted data. Where necessary, we contacted study authors for further data and clarification of methods.

MAIN RESULTS

Three trials involving two different interventions were included. Two trials involving 680 children compared flushing CVC with urokinase (with or without heparin) versus heparin alone. Neither of these trials reported on the primary outcome of catheter-related blood stream infection (CRBSI). There was a non-significantly decreased rate of catheter-associated infection (CAI) (Rate Ratio 0.72, 95% confidence interval 0.12 to 4.41) in the urokinase (with or without heparin) arm compared with the heparin arm.One trial involving 113 children compared frequency of catheter dressing change every 15 days versus every 4 days. It did not report on CRBSI or CAI. There were no premature catheter removals for infection in either of the trial arms.

AUTHORS' CONCLUSIONS

Three RCTs for only two types of interventions to prevent CVC-related infections in children with cancer have been identified. Flushing CVC with urokinase (with or without heparin) compared to heparin alone possibly leads to decrease in CAI rates. Changing catheter dressings every 15 days versus every 4 days does not lead to more premature catheter removals due to infection although data were insufficient to assess if catheter-related infection rates were changed.

Geographical and temporal distribution of cancer survival in teenagers and young adults in England

Background:

Between 1979 and 2001, an analysis of cancer survival in young people in England, aged 13 to 24 years, showed overall improvements. However, for some diagnostic groups, little or no increases were observed. The aim of this study was to analyse the regional distribution of cancer survival in teenagers and young adults in England in order to identify patterns and potential for improvements at a regional scale.

Methods:

We examined geographical and temporal patterns in relative survival in cancer patients aged 13–24 years in England during the time period 1979–2001. Cancer cases were grouped according to an internationally recognised morphology-based diagnostic scheme.

Results:

For most diagnostic groups, there was little variation in survival between regions, except for testicular germ cell tumours (P=0.006) and colorectal carcinoma (P=0.002). For certain diagnostic groups, the temporal pattern in survival differed between regions. However, in regions that showed poor survival during the early part of the study period, greatest improvements were observed in groups such as acute lymphoid leukaemia, acute myeloid leukaemia, testicular tumours and melanoma.

Conclusion:

In conclusion, there was a reduction in the differences in survival between regions during the study period.

Age-incidence patterns of primary CNS tumors in children, adolescents, and adults in England

Around 25% of all tumors in those 0-14 years of age and 9% in those 15-24 years of age involve the CNS. They are the most common cause of cancer-related deaths in both age groups. In adults 25-84 years of age, the proportion of CNS tumors is 2%; 5-year overall survival is 10%-15%; and survivors have considerable morbidity. Comprehensive up-to-date population-based incidence data on these tumors are lacking. We present incidence rates for primary CNS tumors based on data derived from the high-quality national cancer registration system in England. A total of 54,336 CNS tumors of malignant, benign, and uncertain behavior were registered across the whole of England from 1995 through 2003. The age-standardized rates for all ages (0-84 years) was 9.21 per 100,000 person-years. This is higher than previously reported for England because it includes nonmalignant CNS tumors and hence gives a more accurate picture of burden of disease. The age-standardized rates for those 0-14 years of age, 15-24 years of age, and 25-84 years of age were 3.56, 3.26, and 14.57 per 100,000 person-years, respectively. In this article, we describe the changing patterns in the epidemiology of primary CNS tumors in these three age groups with respect to sex, tumor behavior, and histology using the current WHO classification. This information will provide a reference for future studies nationally and internationally and make comparisons relevant and meaningful.

Chronic eosinophilic leukemia with a unique translocation

We report a case of chronic eosinophilic leukemia in a 9 year old girl who presented with anemia, thrombocytopenia, leucocytosis (mostly dysplastic eosinophils), lymphadenopathy and hepatosplenomegaly. There was no increase in blasts but myelofibrosis was seen in the bone marrow. A previously unreported translocation 46,XX,t(1;4)(q24;q35), was found on cytogenetic analysis and involvement of the myocardium was also present. Shortly after commencing steroids, the family abandoned therapy.

Childhood cancer in Sudan: 1999–2007

There is paucity of information on childhood cancer from Sudan with the last studies published more than 20 years ago. This study aims to provide a current picture of childhood cancer in Sudan. Data was obtained from the hospital registry for the period May 1999 to June 2007 on all paediatric patients presenting to the Institute of Nuclear Medicine and Oncology, University of Gezira, Wad Madani, Sudan. There were 322 children with cancer during this time period with a male:female ratio of 1.6:1. Lymphomas (111, 35%), leukaemia (83, 26%) and Wilms' tumour (43, 13%) were the three most common groups of tumours. Thirty percent of all lymphomas were Burkitt's lymphoma; 3.4% of all childhood cancer cases were nasopharyngeal carcinomas.

Wilms tumour in Sudan

BACKGROUND

Wilms tumour is one of the commonest childhood solid tumours which has an excellent outlook in the developed world with 5-year overall survival exceeding 90%. There is little information from Sudan regarding Wilms tumour.

PROCEDURE

Records of patients with Wilms tumour diagnosed and treated at Institute of Nuclear Medicine, Molecular Biology and Oncology (INMO) in the University of Gezira from May 1999 to June 2007 were reviewed.

RESULTS

Thirty-seven children presented at a mean age of 4.1 years (range 2 months-13 years). The male to female ratio was 0.9-1. Abdominal swelling or mass was the commonest symptom. There was 1 child with Stage I (2.7%), 7 with stage II (18.9%), 25 with Stage III (67.6%) and 4 with Stage IV (10.8%). Following diagnosis 27% of children did not receive further treatment (5.4% died prior to treatment, 5.4% were not able to finance treatment and for the rest 16.2% no cause was identified). More than half of the children did not have a nephrectomy and only 4 (11%) completed treatment.

CONCLUSIONS

The poor outlook is related to several factors. Delayed presentation, poor awareness of treatment options, lack of finances, no provision of food, lodging and transport, absence of paediatric trained staff are the obstacles to better outcomes. Empowering parents with information, giving chemotherapy prior to nephrectomy, training staff and establishing links with a tertiary cancer centre in the developed world are some of the options to improve survival.

Enzyme replacement therapy in 12 patients with MPS I-H/S with homozygous p.Leu490Pro mutation

We describe a cohort of 14 Hurler-Scheie patients homozygous for the p.Leu490Pro missense mutation in the alpha-L-iduronidase gene. Now based in the UK, they are all of Pakistani/Kashmiri descent; 64% were female; 11/14 (79%) had a sibling or cousin with MPS I and the parents are consanguineous in all cases. The median age at diagnosis was 1.8 years (range from antenatal diagnosis to 16.5 years). Twelve were on ERT with recombinant human alpha-L-iduronidase (IDUA; Laronidase, Genzyme) for a median duration of 22.5 months (range 2-71 months) and median age at commencement of ERT was 8.6 years (range 0.4-23.1 years). There was clear improvement in the size of liver and spleen as well as reduction in urine glycosaminoglycans (GAGs). The mean (range) urine GAG levels in mg/mmol creatinine were 63.4 (28.9-105.6), 28.3 (10.9-41.4), 22.8 (12.1-43.1), 15.7 (9.2-24.8) and 16.3 (10.1-21.0) at commencement, 3 months post ERT, 6 months post ERT, 12 months post ERT and 24 months post ERT, respectively. Effects on growth were not clear as there does not seem to be an obvious trend of increase or decrease in height after commencement of ERT and this seems to be the case regardless of the age at which ERT was started.

Tolbutamide loading in the initial therapy of diabetes mellitus

A controlled study has been made comparing a loading dose schedule of tolbutamide with a maintenance dose schedule in the initial therapy of fourteen patients with maturity-onset diabetes mellitus. No advantage of one dose schedule over another was found. Since hypoglycemia may occur when large doses of tolbutamide are used, these results provide supporting evidence for those who recommend use of low doses of this drug in the initial therapy of patients with diabetes mellitus.