Palliative care for children with central nervous system tumors: results of a Spanish multicenter study

Background Brain tumors represent the most common cause of cancer-related death in children. Few studies concerning the palliative phase in children with brain tumors are available. Objectives (i) To describe the palliative phase in children with brain tumors; (ii) to determine whether the use of palliative sedation (PS) depends on the place of death, the age of the patient, or if they received specific palliative care (PC). Methods Retrospective multicenter study between 2010 and 2021, including children from one month to 18 years, who had died of a brain tumor. Results 228 patients (59.2% male) from 10 Spanish institutions were included. Median age at diagnosis was 5 years (IQR 2–9) and median age at death was 7 years (IQR 4–11). The most frequent tumors were medulloblastoma (25.4%) and diffuse intrinsic pontine glioma (DIPG) (24.1%). Median number of antineoplastic regimens were 2 (range 0–5 regimens). During palliative phase, 52.2% of the patients were attended by PC teams, while 47.8% were cared exclusively by pediatric oncology teams. Most common concerns included motor deficit (93.4%) and asthenia (87.5%) and communication disorders (89.8%). Most frequently prescribed supportive drugs were antiemetics (83.6%), opioids (81.6%), and dexamethasone (78.5%). PS was administered to 48.7% patients. Most of them died in the hospital (85.6%), while patients who died at home required PS less frequently (14.4%) (p = .01). Conclusion Children dying from CNS tumors have specific needs during palliative phase. The optimal indication of PS depended on the center experience although, in our series, it was also influenced by the place of death (AU)

Palliative care for children with central nervous system tumors: results of a Spanish multicenter study.

BACKGROUND: Brain tumors represent the most common cause of cancer-related death in children. Few studies concerning the palliative phase in children with brain tumors are available. OBJECTIVES: (i) To describe the palliative phase in children with brain tumors; (ii) to determine whether the use of palliative sedation (PS) depends on the place of death, the age of the patient, or if they received specific palliative care (PC). METHODS: Retrospective multicenter study between 2010 and 2021, including children from one month to 18 years, who had died of a brain tumor. RESULTS: 228 patients (59.2% male) from 10 Spanish institutions were included. Median age at diagnosis was 5 years (IQR 2-9) and median age at death was 7 years (IQR 4-11). The most frequent tumors were medulloblastoma (25.4%) and diffuse intrinsic pontine glioma (DIPG) (24.1%). Median number of antineoplastic regimens were 2 (range 0-5 regimens). During palliative phase, 52.2% of the patients were attended by PC teams, while 47.8% were cared exclusively by pediatric oncology teams. Most common concerns included motor deficit (93.4%) and asthenia (87.5%) and communication disorders (89.8%). Most frequently prescribed supportive drugs were antiemetics (83.6%), opioids (81.6%), and dexamethasone (78.5%). PS was administered to 48.7% patients. Most of them died in the hospital (85.6%), while patients who died at home required PS less frequently (14.4%) (p = .01). CONCLUSION: Children dying from CNS tumors have specific needs during palliative phase. The optimal indication of PS depended on the center experience although, in our series, it was also influenced by the place of death.

A phase 1, first-in-child, multicenter study to evaluate the safety and efficacy of the oncolytic herpes virus talimogene laherparepvec in pediatric patients with advanced solid tumors.

Background: The survival rates for pediatric patients with relapsed and refractory tumors are poor. Successful treatment strategies are currently lacking and there remains an unmet need for novel therapies for these patients. We report here the results of a phase 1 study of talimogene laherparepvec (T-VEC) and explore the safety of this oncolytic immunotherapy for the treatment of pediatric patients with advanced non-central nervous system tumors. Methods: T-VEC was delivered by intralesional injection at 106 plaque-forming units (PFU)/ml on the first day, followed by 108 PFU/ml on the first day of week 4 and every 2 weeks thereafter. The primary objective was to evaluate the safety and tolerability as assessed by the incidence of dose-limiting toxicities (DLTs). Secondary objectives included efficacy indicated by response and survival per modified immune-related response criteria simulating the Response Evaluation Criteria in Solid Tumors (irRC-RECIST). Results: Fifteen patients were enrolled into two cohorts based on age: cohort A1 (n = 13) 12 to ≤21 years old (soft-tissue sarcoma, n = 7; bone sarcoma, n = 3; neuroblastoma, n = 1; nasopharyngeal carcinoma, n = 1; and melanoma, n = 1) and cohort B1 (n = 2) 2 to <12 years old (melanoma, n = 2). Overall, patients received treatment for a median (range) of 5.1 (0.1, 39.4) weeks. No DLTs were observed during the evaluation period. All patients experienced at least one treatment-emergent adverse event (TEAE), and 53.3% of patients reported grade ≥3 TEAEs. Overall, 86.7% of patients reported treatment-related TEAEs. No complete or partial responses were observed, and three patients (20%) overall exhibited stable disease as the best response. Conclusions: T-VEC was tolerable as assessed by the observation of no DLTs. The safety data were consistent with the patients' underlying cancer and the known safety profile of T-VEC from studies in the adult population. No objective responses were observed. Trial Registration: ClinicalTrials.gov: NCT02756845. https://clinicaltrials.gov/ct2/show/NCT02756845.

Epstein-Barr virus-associated risk factors for post-transplant lymphoproliferative disease in pediatric liver transplant recipients.

BACKGROUND: Post-transplant lymphoproliferative disorder (PTLD) are the most common de novo malignancies after liver transplantation (LT) in children. The aim of our study was to assess the role of pre-LT EBV status and post-LT EBV viral load as risk factors for developing PTLD in a cohort of pediatric LT recipients. METHODS: Data of all children who underwent LT between January 2002 and December 2019 were collected. Two cohorts were built EBV pre-LT primary infected cohort and EBV post-LT primary infected cohort. Moreover, using the maximal EBV viral load, a ROC curve was constructed to find a cutoff point for the diagnosis of PTLD. RESULTS: Among the 251 patients included in the study, fifteen PTLD episodes in 14 LT recipients were detected (2 plasmacytic hyperplasia, 10 polymorphic PTLD, 2 monomorphic PTLD, and 1 Classical-Hodgkin's lymphoma). Patients of the EBV post-LT primary infected cohort were 17.1 times more likely to develop a PTLD than patients of the EBV pre-LT primary infected cohort (2.2-133.5). The EBV viral load value to predict PTLD was set at 211 000 UI/mL (93.3% sensitivity and 77.1% specificity; AUC 93.8%; IC 0.89-0.98). In EBV post-LT primary infected cohort, patients with a viral load above 211 000 were 30 times more likely to develop PTLD than patients with a viral load below this value (OR 29.8; 3.7-241.1; p < 0.001). CONCLUSIONS: The combination of pretransplant EBV serological status with EBV post-transplant viral load could be a powerful tool to stratify the risk of PTLD in pediatric LT patients.

Pubertat precoç com a síndrome paraneoplàstica / Pubertad precoz como síndrome paraneoplásico / Precocious puberty as paraneoplastic syndrome

INTRODUCCIÓ: L'hepatoblastoma és un tumor hepàtic maligne que destaca per la capacitat de secreció hormonal. Aquestes hormones s'utilitzen en el seguiment (alfa-fetoproteïna) o poden provocar complicacions paraneoplàstiques mimetitzant la funció d'altres hormones. Es presenta un cas clínic d'un nen de 18 mesos amb pubertat precoç. CAS CLÍNIC: Pacient diagnosticat d'hepatoblastoma en tractament quimioteràpic segons el protocol SIOPEL-6, que en la valoració clínica prequirúrgica presenta un estadi de Tanner G3 P2 I un volum testicular de 12 cc bilateral. A nivell analític destaca una elevació de la testosterona I de la gonadotrofina coriònica humana (hCG), sense elevació de la hormona luteoestimulant (LH) ni de la hormona estimulant del fol·licle (FSH), compatible amb una pubertat precoç perifèrica. Després de la resecció tumoral es demostra un descens de la testosterona, de l'hCG I de l'alfa-fetoproteïna, I s'orienta com a síndrome paraneoplàstica del tumor. COMENTARIS: Dins del diagnòstic diferencial de la pubertat precoç, cal distingir entre pubertat precoç central (activació de l'eix hipotàlem-hipofític-gonadal) I perifèrica (producció externa d'hormones sexuals independentment de l'activació central). En el cas descrit s'orienta com a pubertat precoç perifèrica a causa de la secreció d'hCG per l'hepatoblastoma. L'hCG presenta una estructura molecular similar a l'LH I en concentracions elevades promou la secreció de testosterona per les cèl·lules de Leydig. En canvi, l'augment de volum testicular depèn directament de l'FSH, de manera que es planteja la hipòtesi que la producció d'esteroides gonadals en una pubertat precoç perifèrica acabaria sensibilitzant I estimulant l'eix hipotàlem-hipofític

INTRODUCCIÓN: El hepatoblastoma es un tumor hepático maligno que destaca por su capacidad de secreción hormonal. Estas hormonas se utilizan en el seguimiento (alfafetoproteína) o pueden provocar complicaciones paraneoplásicas simulando la función de otras hormonas. Se presenta un caso clínico de un niño de 18 meses con pubertad precoz. CASO CLÍNICO: Paciente diagnosticado de hepatoblastoma en tratamiento quimioterápico según protocolo SIOPEL-6, que en la valoración clínica prequirúrgica presenta un estadio de Tanner G3 P2 y un volumen testicular de 12 cc bilateral. A nivel analítico destaca una elevación de testosterona y gonadotrofina coriónica humana (hCG) sin elevación de la hormona luteinizante (LH) ni de la hormona estimulante del folículo (FSH), compatible con una pubertad precoz periférica. Tras la resección tumoral se demuestra el descenso de testosterona y hCG, orientándose como síndrome paraneoplásico del tumor. COMENTARIOS: Dentro del diagnóstico diferencial de la pubertad precoz, hay que distinguir entre pubertad precoz central (activación del eje hipotálamo-hipofisario-gonadal) y periférica (producción externa de hormonas sexuales independientemente de la activación central). En el caso descrito se orienta como pubertad precoz periférica, debido a la secreción de hCG por el hepatoblastoma. La hCG presenta una estructura molecular similar a la LH y en elevadas concentraciones promueve la secreción de testosterona por las células de Leydig. Dado que el aumento del volumen testicular depende directamente de la FSH, se plantea la hipótesis de que la producción de esteroides gonadales en la pubertad precoz periférica acabaría sensibilizando y estimulando el eje hipotálamo-hipofisario

INTRODUCTION: Hepatoblastoma is a malignant liver tumour characterized by its hormonal secretion. The secreted hormones are used in the follow-up (alpha-fetoprotein) or can cause paraneoplastic complications simulating the function of other hormones. We present a clinical case of an 18-month-old boy with precocious puberty. CASE REPORT: Patient with diagnosis of hepatoblastoma undergoing chemotherapy treatment according to SIOPEL-6 protocol, which presents Tanner G3 P2 stage and testicular volume of 12cc bilateral in the presurgical clinical assessment. In the blood test, there is an elevation of testosterone and human chorionic gonadotropin (hCG) without elevation of luteinising hormone (LH) and follicle-stimulating hormone (FSH), compatible with peripheral precocious puberty. After tumour resection, decrease in testosterone and hCG blood levels are demonstrated, pointing itself as a paraneoplastic tumour syndrome. COMMENTS: In the differential diagnosis of precocious puberty, one must distinguish between central precocious puberty (activation of hypothalamic-pituitary-gonadal axis) and peripheral precocious puberty (external production of sex hormones independently of central activation). The case is an example of peripheral precocious puberty, due to the secretion of hCG by hepatoblastoma. HCG has a molecular structure similar to LH and in high concentrations promotes secretion of testosterone by Leydig cells. However, the increase in testicular volume depends directly on FSH and one hypothesis would be that the production of gonadal steroids in peripheral precocious puberty would end up sensitizing and stimulating the hypothalamic-pituitary axis