Pattern of relapse in childhood ALL: challenges and lessons from a uniform treatment protocol.

This retrospective analysis of 254 children less than 15 years of age treated with MCP-841 protocol from June 1992 to June 2002 was undertaken to identify the pattern of relapse and determine management lacunae. Two hundred twenty-three (87.8%) children achieved a complete remission of whom 40 (17.9%) relapsed. The mean age of relapsed patients was 6.5 years. The male/female ratio was 9:1. There were 23 (57.5%) isolated bone marrow (BM), 7 (17.5%) isolated central nervous system (CNS), 2 (5%) isolated testicular, 5 (12.5%) BM+testes and 1 each of BM+CNS, CNS+testes, and isolated bone relapses. Twenty-seven children (67.5%) relapsed on-therapy whereas 13 (32.5%) relapsed posttherapy. All 9 CNS relapses occurred on-therapy whereas 5/8 (62.5%) of testicular relapses occurred posttherapy. Lymphadenopathy was the only significant predictor for relapse. High-risk features such as age less than 1 year and greater than 10 years (P=0.047) and white cell count greater than 50.0 x 10(9)/L (P=0.044) were significantly more frequent in patients with early on-therapy relapse than in patients with off-therapy relapse. The overall survival in the entire study cohort was 67+/-3.5%. Modest survival outcome, relapse while on chemotherapy and the higher incidence of CNS and testicular relapse indicate the need for reappraisal of our treatment protocol. There is a need of identifying risk factors and high-risk groups in our set of patients and risk-stratified intensification of chemotherapy in them.

Pediatric hospital dying trajectories: what we learned and can share.

Diverse settings, diagnoses, and time constraints challenge a small hospital's ability to provide comprehensive care to all dying children and their families. Children who died at a regional hospital in southeast Georgia were studied to document the circumstances under which they died and the palliative and end-of-life care provided. The most common causes of death were injury and circulatory events. At the time of death, 56% of the children studied were in the care of the Emergency Department. Seventy-two percent were previously healthy children; 78% were hospitalized for less than 24 hours prior to death. Based on previous medical history and length of final hospitalization, four hospital dying trajectories were defined. Hospital dying trajectories provide a basis for planning comprehensive hospital pediatric palliative and end-of-life care program by identifying the settings, time limitations, and key personnel.

Long-term follow-up of survivors of childhood cancer.

OBJECTIVE: This study was designed to improve the long-term follow-up of childhood cancer survivors by developing standard monitoring for adverse effects; Providing concise treatment summaries for each patient and identifying already existing adverse effects; Determining patient risks for long-term adverse effects; and providing individualized 10-year of plans for follow-up. METHODS: A retrospective chart review of long-term childhood cancer survivors followed by the institution's pediatric oncologists was performed. Criteria for review included being at least 5 years from diagnosis and 2 years off chemotherapy. Patients are followed annually by the pediatric oncologists. RESULTS: At the time of review, there were 26 long-term survivors of childhood cancers enrolled at the clinic. Their charts have been reviewed and treatment summaries formulated. Fifty-four adverse effects have been detected. 74% of the patients have long-term adverse effects from receiving cancer therapy. The most common were growth hormone deficiency, hypothyroidism, seizures, and hearing loss. Ten year follow-up plans have been devised for each patient. CONCLUSION: The presence of long-term adverse effects is common in childhood cancer survivors. The pediatrician is pivotal in helping assure their patients are receiving adequate follow-up to detect these complications as well as assisting in the transition to care as an adult.