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Trivedi M, Thankamony P, Nair M, Rajeswari B, Guruprasad CS, Prasanth VR, Nair RA, Jagathnath Krishna KM. Clinical profile and outcome of children with anaplastic large cell lymphoma treated with short-course chemotherapy - ten years experience from a tertiary care center in a LMIC. Pediatr Hematol Oncol 2023:1-12. [PMID: 37477212 DOI: 10.1080/08880018.2023.2212710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023]
Abstract
Anaplastic large-cell lymphoma (ALCL) constitutes 10-15% of non-Hodgkin lymphoma in children. With short-course chemotherapy, outcome has improved up-to 90% in developed-countries. There is limited-data on outcome of pediatric ALCL treated with ALCL99 protocol from low-middle income countries. Children ≤14 years, diagnosed with ALCL between 1st January 2007 and 31st December 2016 were analyzed. Details regarding clinical-presentation and treatment were recorded and outcome was analyzed. Fourteen-children were diagnosed. Median-age was 114 months (range 24 - 162 months). Male:female ratio was 3.6:1. Stage-I, II and III disease was seen in three (21.4%), three (21.4%), and eight (57.1%) children, respectively. Low, standard and high-risk disease was seen in two (14.2%), six (42.9%) and six (42.9%), respectively. All children were treated using ALCL99 protocol. Three (21.4%) children had disease-progression/relapse and five (35.7%) died (three from treatment-related mortality, and two from disease). At median follow-up of 54-months, four-year EFS and OS were 64.3% and 64.3%, respectively. Log-rank test demonstrated female gender (p = 0.005), stage-III disease (p < 0.001), visceral-organ involvement (p = 0.035), high-risk disease (p = 0.016) and, serum albumin ≤3.5 g/dL (p = 0.031) associated with significantly worse 4-year EFS. Cox-regression analysis demonstrated female gender associated with poor EFS (p = 0.02) and female gender and visceral-organ involvement associated with poor OS (p = 0.02, p = 0.011, respectively). Good survival could be achieved for children with ALCL using uniform treatment protocol in a resource-limited setting, especially among low and standard-risk children. Female-sex, high-risk disease, stage-III disease, visceral organ involvement and low albumin levels were associated with poor outcome, however these findings need to be corroborated in larger studies.
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Affiliation(s)
- Maharshi Trivedi
- Department of Pediatric Oncology, Regional Cancer Centre, Thiruvananthapuram, Kerala, India
| | - Priyakumari Thankamony
- Department of Pediatric Oncology, Regional Cancer Centre, Thiruvananthapuram, Kerala, India
| | - Manjusha Nair
- Department of Pediatric Oncology, Regional Cancer Centre, Thiruvananthapuram, Kerala, India
| | - Binitha Rajeswari
- Department of Pediatric Oncology, Regional Cancer Centre, Thiruvananthapuram, Kerala, India
| | - C S Guruprasad
- Department of Pediatric Oncology, Regional Cancer Centre, Thiruvananthapuram, Kerala, India
| | - V R Prasanth
- Department of Pediatric Oncology, Regional Cancer Centre, Thiruvananthapuram, Kerala, India
| | - Rekha A Nair
- Department of Medical and Pediatric Oncology, Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India
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Rajeswari B, Guruprasad CS, Nair M, Prasanth VR, Sugath BS, Thankamony P. High dose methotrexate containing regimen in pediatric non-metastatic extremity osteosarcoma patients: experience from a tertiary cancer center in India. Pediatr Hematol Oncol 2022; 39:225-232. [PMID: 34378476 DOI: 10.1080/08880018.2021.1963021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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] [Indexed: 10/20/2022]
Abstract
Methotrexate containing chemotherapy is less commonly used for treatment of osteosarcoma in resource limited settings. We present our experience with the administration of high dose methotrexate (HDMTX) containing chemotherapy over a period of three years. Children between 1 and 14 years of age with newly diagnosed nonmetastatic extremity osteosarcoma, registered in Pediatric Oncology Department of a tertiary care cancer center in South India between 1st January 2016 and 31st December 2018 and receiving MAP chemotherapy were included. Patients in this study received HDMTX at 12 g/m2. Twenty two patients were included. After neoadjuvant chemotherapy, 20 patients underwent surgery (limb salvage surgery in 16, amputation in 4). The median time from initiation of chemotherapy to surgery was 97.5 days. Eighteen of 22 patients (81.8%) completed planned chemotherapy in our cohort, one patient was lost to follow up after progression and three patients required change of chemotherapy due to toxicities. Of a total of 227 cycles of HDMTX infusions in 22 patients, delayed clearance occurred in 22 cycles (9.7%). Major toxicities were myelosuppression (30 episodes in 17 patients), blood stream infections (24 episodes in 15 patients) and mucositis (15 episodes in 10 patients). Hearing loss was documented in 7 patients. There was no treatment related mortality. Chemotherapy was completed in a median duration of 38.5 weeks. Administration of high dose methotrexate containing chemotherapy is feasible in pediatric patients with osteosarcoma, even in resource limited settings, if there are facilities for hydration, determination of methotrexate levels and good supportive care.
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Affiliation(s)
- Binitha Rajeswari
- Department of Pediatric Oncology, Regional Cancer Centre, Thiruvananthapuram, Kerala, India
| | | | - Manjusha Nair
- Department of Pediatric Oncology, Regional Cancer Centre, Thiruvananthapuram, Kerala, India
| | | | | | - Priyakumari Thankamony
- Department of Pediatric Oncology, Regional Cancer Centre, Thiruvananthapuram, Kerala, India
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Trivedi M, Guruprasad CS, Thankamony P, Sugath S, Raj J, Kattoor J. Langerhans Cell Histiocytosis and Osteosarcoma in Children: A Radiological Mimic. Indian Pediatr 2022; 59:255-256. [PMID: 35315351] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Maharshi Trivedi
- Department of Pediatric Oncology, Regional Cancer Center, Thiruvananthpuram, Kerala
| | - C S Guruprasad
- Department of Pediatric Oncology, Regional Cancer Center, Thiruvananthpuram, Kerala.
| | | | - Subin Sugath
- Department of Surgical Oncology, Regional Cancer Center, Thiruvananthpuram, Kerala
| | - Jubie Raj
- Department of Imageology Regional Cancer Center, Thiruvananthpuram, Kerala
| | - Jayasree Kattoor
- Department of Pathology, Regional Cancer Center, Thiruvananthpuram, Kerala
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Rajeswari B, Sukumaran Nair RK, Guruprasad CS, Nair M, Thankamony P, Parukutty K. Infections during Induction Chemotherapy in Children with Acute Lymphoblastic Leukemia – Profile and Outcomes: Experience from a Cancer Center in South India. Indian J Med Paediatr Oncol 2021. [DOI: 10.4103/ijmpo.ijmpo_95_17] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Abstract
Objective:The objective of this study is to describe the incidence, clinical, laboratory and microbiological profile, treatment, and outcome of infections during induction chemotherapy in children with acute lymphoblastic leukemia (ALL). Materials and Methods: This was prospective, observational study. All children aged 1–14 years, newly diagnosed to have ALL and attending the Pediatric oncology division at our center were included. Induction chemotherapy was administered as per a modified Berlin-Frankfurt-Münster protocol. The study period was from January 2014 to June 2015. Results: Two hundred and twenty-seven patients with ALL were included in the study. One hundred and fifty episodes of infection occurred among 117 patients. Major sites of infection were lung (n = 35) and gastrointestinal tract (n = 30). Blood cultures were positive in 45 episodes (30.6%) with Gram negative organisms being the predominant isolates. The most common organisms isolated were Pseudomonas aeruginosa and Klebsiella spp. The response to antibiotics was good with only 18% of episodes requiring a third-line antibiotic. One hundred and thirty-six (90.6%) episodes resolved without sequelae. Overall induction mortality (12 out of 227-5.3%) was mainly accounted for by infections. Conclusions: Infections are the major cause of mortality and morbidity in patients with ALL on induction chemotherapy. The outcomes are good for the majority of patients if they receive adequate antibiotics early in the course of infection.
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Affiliation(s)
- Binitha Rajeswari
- Division of Pediatric Oncology, Regional Cancer Centre, Thiruvananthapuram, Kerala State, India
| | - Reghu K Sukumaran Nair
- Division of Pediatric Oncology, Regional Cancer Centre, Thiruvananthapuram, Kerala State, India
| | - C S Guruprasad
- Division of Pediatric Oncology, Regional Cancer Centre, Thiruvananthapuram, Kerala State, India
| | - Manjusha Nair
- Division of Pediatric Oncology, Regional Cancer Centre, Thiruvananthapuram, Kerala State, India
| | - Priyakumari Thankamony
- Division of Pediatric Oncology, Regional Cancer Centre, Thiruvananthapuram, Kerala State, India
| | - Kusumakumary Parukutty
- Division of Pediatric Oncology, Regional Cancer Centre, Thiruvananthapuram, Kerala State, India
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Seetharam S, Thankamony P, Gopakumar KG, Nair RA, Jacob PM, Jagathnath Krishna KM, Rajeswari B, Nair M, Guruprasad CS, Prasanth VR. Outcomes of pediatric mixed phenotype acute leukemia treated with lymphoid directed therapy: Analysis of an institutional series from India. Pediatr Hematol Oncol 2021; 38:358-366. [PMID: 33635170 DOI: 10.1080/08880018.2020.1871453] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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] [Indexed: 12/12/2022]
Abstract
There is limited data regarding pediatric mixed phenotype acute leukemia (MPAL) and there is no global consensus on its management yet. In this retrospective study, we analyzed the outcomes of children diagnosed with MPAL at our institute. This study included children ≤ 14 years with MPAL who presented to a tertiary cancer center in India from January 1st 2009 to December 31st 2015. Over a seven-year period, 1390 patients with leukemia presented to our institute of which 22 patients (1.5%) had MPAL. Sixteen patients (72.7%) had B/myeloid leukemia, while 4 (18.1%) and 2 (9%) patients had T/myeloid and B/T leukemia respectively. Twenty-one patients were treated with a modified BFM ALL 95 protocol. 76.1% (n = 16) of patients had a good prednisolone response (GPR) on day 8 and end-of-induction (EOI) marrow was in remission in 90.5% (n = 19). A poor prednisolone response (PPR) on day 8 correlated with an inferior relapse-free survival (25% vs 79.5%, P=.025). The 4-year event-free survival (EFS) and overall survival (OS) for the entire group was 60.8% and 64.9% respectively while the EFS for patients who had a GPR and remission at the EOI (n = 15) was 80% as compared to 16.7% in patients with PPR or induction failure. Lymphoid directed chemotherapy is seen to have good survival outcomes in pediatric MPAL. However, a PPR on day 8 or a positive EOI marrow may be an indication for more aggressive treatment.
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Affiliation(s)
- Shwetha Seetharam
- Department of Pediatric Oncology, Regional Cancer Centre, Thiruvananthapuram, India
| | | | | | | | - Priya Mary Jacob
- Department of Pathology, Regional Cancer Centre, Thiruvananthapuram, India
| | - K M Jagathnath Krishna
- Department of Cancer Epidemiology and Biostatistics, Regional Cancer Centre, Thiruvananthapuram, India
| | - Binitha Rajeswari
- Department of Pediatric Oncology, Regional Cancer Centre, Thiruvananthapuram, India
| | - Manjusha Nair
- Department of Pediatric Oncology, Regional Cancer Centre, Thiruvananthapuram, India
| | - C S Guruprasad
- Department of Pediatric Oncology, Regional Cancer Centre, Thiruvananthapuram, India
| | - V R Prasanth
- Department of Pediatric Oncology, Regional Cancer Centre, Thiruvananthapuram, India
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Abstract
Imatinib is a preferred drug for pediatric Chronic Myeloid Leukemia (CML). Long-term use has inhibitory effects on other tyrosine kinase pathways causing off-target complications such as growth impairment. Our aim was to evaluate impact of long-term use on longitudinal growth in children with CML in Kerala. We hypothesized that the impact would be lesser compared to Northern India as Kerala has the lowest rates of underweight and stunting, with a high literacy rate and per capita income. Children ≤14 years of age, diagnosed with CML and received imatinib for at least 1 year were included. Girls >9 years of age and boys >11 years were considered pubertal. Height Z scores were derived using WHO AnthroPlus. Paired t test compared difference of Z scores in prepubertal and postpubertal age groups. Height Z scores were compared with mid-parental height and sibling height Z scores. Thirty-six children were included (M = 21; F = 15). Median duration of imatinib exposure was 84 months. Decrease in longitudinal growth affected children in both prepubertal and postpubertal age groups. Decrease in height Z scores was more in prepubertal age group when imatinib therapy was initiated (p = .0018). Of 10 patients currently above 19 years (of whom 8 were in pubertal age and 2 in prepubertal age at start of imatinib) none are stunted. Patient's height Z scores was lesser compared to sibling height Z scores (p = .027). Children on continuous imatinib showed a significant stunting when treatment was initiated during prepubertal age. There is a catch-up of growth as the final height reached is within normal limits of WHO reference values.
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Affiliation(s)
- Deepthi Boddu
- a Department of Pediatric Oncology, Regional Cancer Centre , Thiruvananthapuram , Kerala, India
| | - Priyakumari Thankamony
- a Department of Pediatric Oncology, Regional Cancer Centre , Thiruvananthapuram , Kerala, India
| | - C S Guruprasad
- a Department of Pediatric Oncology, Regional Cancer Centre , Thiruvananthapuram , Kerala, India
| | - Manjusha Nair
- a Department of Pediatric Oncology, Regional Cancer Centre , Thiruvananthapuram , Kerala, India
| | - Binitha Rajeswari
- a Department of Pediatric Oncology, Regional Cancer Centre , Thiruvananthapuram , Kerala, India
| | - Shwetha Seetharam
- a Department of Pediatric Oncology, Regional Cancer Centre , Thiruvananthapuram , Kerala, India
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Guruprasad CS, Reghu KS, Nair M, Kumary PK. Asymptomatic Hyperamylasemia / Hyperlipasemia due to Pancreatic Infiltration in Acute Lymphoblastic Leukemia. Indian J Pediatr 2016; 83:81-2. [PMID: 25893529 DOI: 10.1007/s12098-015-1754-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 03/26/2015] [Indexed: 11/29/2022]
Affiliation(s)
- C S Guruprasad
- Division of Pediatric Oncology, Regional Cancer Center, Goverment Medical College Campus, Thiruvananthapuram, Kerala, 695011, India.
| | - K S Reghu
- Division of Pediatric Oncology, Regional Cancer Center, Goverment Medical College Campus, Thiruvananthapuram, Kerala, 695011, India
| | - Manjusha Nair
- Division of Pediatric Oncology, Regional Cancer Center, Goverment Medical College Campus, Thiruvananthapuram, Kerala, 695011, India
| | - P Kusuma Kumary
- Division of Pediatric Oncology, Regional Cancer Center, Goverment Medical College Campus, Thiruvananthapuram, Kerala, 695011, India
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Kumar A, Kesavadev J, Sethi B, Jain SM, Guruprasad CS, Shah SN. Intensifying Insulin Therapy in Type 2 Diabetes: Choices & Challenges. J Assoc Physicians India 2015; 63:8-14. [PMID: 26548029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Insulin therapy remains the cornerstone of effective diabetes management. Timely intensification of insulin therapy reduces the progression of diabetes and the development of diabetes-related complications. Given that overall hyperglycaemia is a relative contribution of both fasting and postprandial hyperglycaemia, use of basal insulin alone may not achieve optimal glucose control due to its inability to cover postprandial glucose excursions. Intensifying therapy with addition of bolus insulin or switching to premixed insulin is a viable option in patients failing on basal alone therapy. Although the benefits of early insulin treatment are well established, a considerable delay in intensifying insulin therapy in patients with sub-optimal glycaemic control is still observed. Most of the patients and physicians are reluctant to intensify therapy due to the fear of hypoglycaemia, regimen complexity, and increased burden of multiple daily injections. In this context, there is a need for a flexible, alternative intensification option taking into account individual patient considerations to achieve or maintain individual glycaemic targets. An ideal insulin regimen should mimic physiological insulin release while providing optimal glycaemic control with low risk of hypoglycaemia, weight gain and fewer daily injections. The current paper reviews the challenges of insulin intensification in patients with type 2 diabetes mellitus poorly controlled on current treatment regimens.
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Elizabeth KE, Guruprasad CS, Sindhu TG. Hopkins syndrome and phantom hernia: a rare association. Indian Pediatr 2011; 48:483-485. [PMID: 21743115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Acute flaccid paralysis (AFP), other than paralytic poliomyelitis, are usually due to demyelination like Guillian Barre syndrome (GBS), transverse myelitis and traumatic neuritis. Poliomyelitis like illness, Hopkins syndrome or Post Asthmatic Amotrophy, associated with bronchial asthma and hyperIgEemia has been reported in literature. We present a two and a half year old child who developed AFP with phantom hernia following an episode of bronchial asthma.
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Affiliation(s)
- K E Elizabeth
- Department of Pediatrics, SAT Hospital, Government Medical College Trivandrum, Kerala, India.
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