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.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).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).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 literature on B-non-Hodgkin lymphoma (NHL) in India is restricted to individual hospital data. The study aimed to evaluate the epidemiology and outcome of B-NHL in our country. One hundred and ninety-one patients of B-NHL from 10 centers diagnosed between 2013 and 2016 were analyzed retrospectively. B/T lymphoblastic lymphoma and patients with inadequate data were excluded. The median age was 88 months (IQR: 56, 144) with an M:F ratio of 5.6:1. Undernourishment and stunting were seen in 36.5% and 22%. Primary site was abdomen in 66.5%. Hypoalbuminemia was noted in 82/170 (48.2%). Histological subtypes: Burkitt lymphoma (BL): 69.6%, Burkitt-like: 10.4%, and diffuse large B cell lymphoma (DLBCL): 13.6%, unclassified and others (6.4%). Stage distribution: I/II, 33 (17.3%), III, 114 (59.7%), and IV, 44 (23%). One-eighty-six patients took treatment. Protocols used were LMB and BFM in 160/186 (86%). At a median follow-up of 21.34 (IQR: 4.34, 36.57) months, the disease-free-survival (DFS) was 74.4% and event-free-survival (EFS) was 60.7%. Treatment-related mortality (TRM), relapse/progression and abandonment were 14.3%, 14.5%, and 8.4%, respectively. Bone marrow positivity, stage IV disease, and lactate dehydrogenase (LDH) > 2,000 U/l predicted inferior EFS. Stage IV disease, LDH > 2,000 U/l, bone marrow positivity, tumor lysis syndrome and low albumin predicted TRM; LDH retained significance on multivariate analysis for EFS and TRM [OR: 4.54, 95% CI: 1.14–20, p 0.03; OR 20, 95%CI: 1.69–250, p 0.017]. BL was the main histological subtype. High TRM and relapse/progression are hampering survival. An LDH > 2,000 U/l was adversely prognostic. These data demonstrate a need to develop a national protocol that balances toxicity and potential for cure.
Background The survival of children with cancer has improved owing to advances in chemotherapy and better supportive care, and nutritional support is an important component of the latter especially in low- and middle-income countries like India. Materials and Methods A prospective observational study of 137 newly diagnosed children with cancer aged less than 18 years was planned. Nutritional assessment was done using dual-energy X-ray absorptiometry (DXA), anthropometry, and serum albumin. Patients were followed for 3 months for assessment of treatment-related morbidity. Results Lean body mass (LBM; DXA), mid-upper arm circumference (MUAC), and body mass index detected undernutrition in 44, 45, and 14% patients, respectively. Combination of arm anthropometry (MUAC and triceps skinfold thickness) with serum albumin categorized patients as adequately nourished (32%), moderately depleted (18%), and severely depleted (49%). Patients with hematological malignancy had a higher prevalence of undernutrition but there was no difference in morbidities between the undernourished and adequately nourished children by any parameter. Hypoalbuminemia observed in 25% patients was associated with significant chemotherapy delays (p, 0.01) and interval admissions (p, 0.03). Using LBM as a criterion, linear regression analysis revealed MUAC (R 2 = 0.681) as the best predictor of undernutrition with lowest standard error. Conclusion Our study reports undernutrition among two-fifths of newly diagnosed patients of childhood cancer associated with high prevalence of sarcopenia and adiposity. These findings are of utmost clinical relevance in planning interventional strategies.
Background The survival of children with cancer has improved owing to advances in chemotherapy and better supportive care, and nutritional support is an important component of the latter especially in low- and middle-income countries like India. Materials and Methods A prospective observational study of 137 newly diagnosed children with cancer aged less than 18 years was planned. Nutritional assessment was done using dual-energy X-ray absorptiometry (DXA), anthropometry, and serum albumin. Patients were followed for 3 months for assessment of treatment-related morbidity. Results Lean body mass (LBM; DXA), mid-upper arm circumference (MUAC), and body mass index detected undernutrition in 44, 45, and 14% patients, respectively. Combination of arm anthropometry (MUAC and triceps skinfold thickness) with serum albumin categorized patients as adequately nourished (32%), moderately depleted (18%), and severely depleted (49%). Patients with hematological malignancy had a higher prevalence of undernutrition but there was no difference in morbidities between the undernourished and adequately nourished children by any parameter. Hypoalbuminemia observed in 25% patients was associated with significant chemotherapy delays (p, 0.01) and interval admissions (p, 0.03). Using LBM as a criterion, linear regression analysis revealed MUAC (R 2 = 0.681) as the best predictor of undernutrition with lowest standard error. Conclusion Our study reports undernutrition among two-fifths of newly diagnosed patients of childhood cancer associated with high prevalence of sarcopenia and adiposity. These findings are of utmost clinical relevance in planning interventional strategies.
Zygomycetes are one of the less common causes of invasive fungal infections in patients with the hematological malignancies. We report two cases of acute lymphoblastic leukemia in the pediatric age group, complicated by disseminated cutaneous mucormycosis during induction chemotherapy. In one of our cases, cutaneous mucormycosis progressed to osteomyelitis of the proximal ulna while in the other it disseminated to lungs and distant cutaneous site. Aggressive treatment, which included intravenous administration of amphotericin B; radical surgical intervention in the form of serial wound debridement in the former and wedge pulmonary resection in the later, allowed successful salvage, and administration of planned anti-leukemia treatment in both of our cases. High index of suspicion, timely diagnosis, and appropriate treatment are key components of a successful outcome.
Background: Cisplatin and doxorubicin are integral components of chemotherapy regimens in the treatment of osteosarcoma. Choice of third agent high-dose methotrexate (HDMTX) or an alkylating agent such as ifosfamide is debatable. The present study compared the impact of MAP (HDMTX-doxorubicin-cisplatin) and IAP (ifosfamide-doxorubicin-cisplatin) chemotherapy regimens on toxicity and survival in children and adolescents with osteosarcoma. Materials and Methods: This was a retrospective study including patients 18 years and younger with osteosarcoma during the study period. Clinical, demographic, chemotherapy regimen, and surgical details and treatment-related toxicity were retrieved from hospital medical records. Prognostic factors affecting overall survival (OS) and event-free survival (EFS) were analyzed. Results: Among 102 patients included in the study, 59 (57.8%) and 43 (42.2%) patients were treated with MAP and IAP regimens, respectively. Two groups were comparable in terms of pretreatment characteristics and surgical treatment. Overall, 95.9% patients underwent limb salvage surgery. There was a statistically increased incidence in supportive care admissions and delay in starting the next cycle of chemotherapy in the MAP group. Among the MAP cohort, the 5-year OS and EFS were 62% and 55% compared with 47% and 44%, respectively, in the IAP cohort ( P =0.143 and 0.316, respectively). On univariate and multivariate analyses, statistically significant factors affecting EFS of the whole group included tumor size, stage, site of metastasis, histologic necrosis, and type of surgery. Conclusions: OS and EFS with both regimens were similar. However, the MAP regimen was associated with a statistically significant increase in incidence of supportive care admissions, delay in next cycle of chemotherapy, and predicted higher cost of treatment.
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