Early Deaths in Pediatric Acute Leukemia: A Major Challenge in Developing Countries.

Children with acute leukemia may experience high treatment-related mortality, which often occurs early in the induction phase. The aim of the study was to assess the incidence and risk factors related to increased mortality during induction therapy of pediatric patients with acute leukemia. This is a retrospective study that included pediatric acute leukemia patients who presented to the National Cancer Institute, Cairo University, between January 2011 and December 2013. The study included 370 patients, 253 with acute lymphoblastic leukemia, 100 with acute myeloid leukemia, and 17 with mixed phenotype acute leukemia. The total and induction death rates were 40.5% and 19.2%, respectively. Most of the early deaths were attributed to infections (64.7%) and cerebrovascular accidents (18.3%). Using enhanced supportive care measures during 2013 had significantly reduced the overall and induction mortality rates (29% and 13.6%, respectively, in 2013 vs. 46% and 20.3% in 2011). Induction deaths in pediatric acute leukemia remain a major challenge in developing countries, and using enhanced supportive care measures is effective to improve the survival outcome in this group of patients.

The role of surgical management in pediatric germ cell tumors (GCTs), NCI case series.

PURPOSE: To review the experience of a tertiary referral center in pediatric germ cell tumors (GCTs) in the last 8 years and to investigate the impact of surgery and site of disease on prognosis. PATIENTS AND METHODS: We retrospectively analyzed the cases of pediatric germ cell tumors at National Cancer Institute over an 8 years period. Data concerning diagnosis, surgery and medical decisions were reviewed and analyzed for all patients. A total of 34 children with (GCTS) were found, with a mean age, at presentation, of 6.7 years and a follow-up period ranging from 3-52 months. One patient with benign GCT was excluded during analysis of the results. RESULTS: Among the 34 patients, there were 14 males and 20 females with mean age of 6.7 years (range: 9 months-15 years), with male to female ratio 1:1.4. All patients were symptomatic at presentation, most commonly with abdominal swelling (18 patients; 52.9%). Anatomic distribution of GCTs according to sex organ involvement was either gonadal in 21 patients (61.8%) or extragonadal in 13 patients (38.2%). All patients had surgery either in the form of curative resection or biopsy after formal exploration and evidence of irresectability. No significant surgical morbidity or mortality were encountered in our patients. Yolk sac tumor and malignant teratoma were the commonest histologic subtypes in our series. Metastatic disease was encountered in nine out of 33 patients (27.2%). Adjuvant chemotherapy was administered in 28 out of 33 patients (84.8%), following surgery, including all patients with extragonadal disease. Our patients were followed-up to 52 months. Twenty-two patients (66.7%) had no recurrence while two patients (6.1%) died from disease. Pelvic extragonadal site was the worst site regarding resectability. Complete surgical resection showed better disease free survival, while those with irresectable disease had comparable overall survival while none could be rendered disease free with chemotherapy. CONCLUSION: The initial surgical approach to malignant GCTs at all sites should be complete resection when possible; the morbidity of extensive surgical resection should be weighed carefully against the good tumor control with chemotherapy. Surgical staging does not preclude preservation of fertility, which should always be considered in this young age. The site of primary disease plays a role in the prognosis of pediatric germ cell tumors with the extragonadal pelvic tumors being the worst regarding resectability. Good tumor response can be achieved with surgery and chemotherapy even for advanced stage and metastatic disease.

The diagnostic value of C-reactive protein, interleukin-8, and monocyte chemotactic protein in risk stratification of febrile neutropenic children with hematologic malignancies.

BACKGROUND AND AIM: Recent advances in febrile neutropenia have highlighted the value of risk stratification especially that it can have important implications in terms of management. We aimed to identify a serum marker that may help to stratify febrile neutropenic pediatric patients treated for hematologic malignancies at the time of first evaluation. Thus, C-reactive protein (CRP), interleukin-8 (IL-8), and monocyte chemotactic protein-1-alpha (MCP-1-alpha) were evaluated for their predictive and diagnostic relevance in febrile episodes of cancer patients. PATIENTS AND METHODS: Within 24 hours of fever, CRP, IL-8, and MCP-1 serum levels were measured and the levels of these markers were related to the clinical findings of the patients. For this purpose, we collected and analyzed clinical data of 85 fever episodes occurring in 76 patients with hematologic malignancies, presenting to the Department of Pediatric Oncology, National Cancer Institute, Cairo University, during a 6-month period. RESULTS: Neutropenic children with febrile episodes were classified into 2 groups, a group with unexplainable fever (group I, n=26) and another group with either blood culture positive, and/or fever periods with a documented clinical sepsis and/or local infection (group II, n=59). Clinically, local sites of infection were encountered in 39 cases (45.9%), whereas a positive blood culture was detected in 20 cases. CRP, IL-8, and MCP-1 levels were significantly lower in group I versus group II (P value <0.001). There were overlaps of values between groups. CRP > or =90 mg/L was significantly associated with chemotherapy-related neutropenia and fever owing to bacteremia (P=0.038). The sensitivity, specificity, negative and positive predictive values of CRP, MCP-1, and IL-8 were (70%, 73%, 51%, and 85%), (64%, 92%, 53%, and 95%), and (71%, 77%, 54%, and 88%), respectively. Combining 2 or 3 markers improved the diagnostic performance of these test, as 78% of group II had elevated 2 or 3 markers versus 16% of the group with no evident infection. CONCLUSIONS: Low levels of CRP, MCP-1, and IL-8 could identify patients with unexplainable fever; whereas, high levels of these markers were of help in the diagnosis of infectious episodes. A model combining more than 1 marker is recommended in the assessment of febrile neutropenia.