Acute Myeloid Leukemia in Children: Experience from Tertiary Cancer Centre in India.

There is paucity of data in pediatric Acute Myeloid Leukemia (AML) from developing countries. We analyzed the outcomes of 65 consecutive patients with pediatric AML treated at our centre from January-2008 to May-2013. The median event free survival (EFS) and overall survival (OS) were 12.6 and 14.6 months respectively. Patients with good-risk cytogenetics had a better EFS (p = 0.004) and OS (p = 0.01). Overall, these results are not comparable to that observed in other centres globally and leaves scope for further improvement. This includes implementing allogeneic bone marrow transplantation as a treatment for all children with high-risk AML.

Time trend in frequency of occurrence of major immunophenotypes in paediatric acute lymphoblastic leukemia cases as experienced by Cancer Institute, Chennai, south India during the period 1989-2009.

BACKGROUND: Pediatric acute lymphoblastic leukemia (ALL) is a biologically heterogeneous disease and socioeconomic and environmental factors are considered to be an important determinant of its immunophenotype. The aim of this analysis is to study the time trend in the immunophenotype of pediatric acute lymphoblastic leukemia (ALL) cases in our geographic setting. MATERIALS AND METHODS: A total of 639 new pediatric ALL cases immunophenotyped during 1989-2009 forms the basis of this analysis. Representative bone marrow or peripheral blood of these patients was immunophenotyped flowcytometrically using an extensive panel of monoclonal antibodies. RESULTS: During early phase of our study we noticed a relative excess of T-ALL and a paucity of common acute lymphoblastic leukemia (C-ALL) in contrast to western data. Over a period of 20 years we witnessed a gradual reduction in pediatric T-ALL cases and a proportionate increase in C-ALL cases. CONCLUSION: We find that this change of pattern is synchronizing with the socioeconomic and industrial development prevailing in our geographic setting and suggest a possible link between the predominant immunophenotype of pediatric ALL cases and the environmental and socioeconomic factors prevailing in that locality.

Role of glutathione-s-transferase and CYP1A1*2A polymorphisms in the therapy outcome of south Indian acute lymphoblastic leukemia patients.

BACKGROUND: Polymorphisms in the drug-metabolizing enzymes are found to be associated with the inter-individual variation in response to a particular drug. Glutathione S-transferases (GSTs) are involved in the metabolism of several anticancer drugs, including alkylating agents, anthracyclines, and cyclophosphamides. AIM: The present study is aimed to examine the association of GST and CYP1A1*2A polymorphisms in the susceptibility to acute lymphoblastic leukemia (ALL) and the prognostic significance. MATERIALS AND METHODS: A total of 92 immunophenotyped patients and 150 cord blood controls were genotyped by PCR for GSTM1 and GSTT1, RQ-PCR allelic discrimination assay for GSTP1 and PCR-RFLP for CYP1A1*2A polymorphism. RESULTS: We have previously reported the significant association of GSTM1 (null) and combined GSTP1 {(Ile/Val)/ (Val/Val)} /GSTM1 (null) genotype with the susceptibility to ALL. No significant association was observed with GSTT1 (P=0.75) and CYP1A1*2A (P=0.61 for +/- and P=0.86 for -/- respectively) in the susceptibility to ALL. Survival analysis was performed in 50 of the 92 patients who were followed for three years. Kaplan-Meier survival analysis for three years showed significant lower event-free survival in patients harboring GSTP1 (Ile/Val) and GSTP1 (Val/Val) (P=0.038 and 0.0001, respectively) genotype. Cox regression analysis revealed GSTP1 as an independent prognostic marker with 6-fold higher risk with Val/Val genotype (P=0.003). CONCLUSIONS: Our results show that GSTP1 (Ile/Val) polymorphism has a role in the susceptibility to ALL and also influence treatment outcome.

Does TAL-1 deletion contribute to the high incidence of T-cell acute lymphoblastic leukemia in South Indian patients?

BACKGROUND: The incidence of T-cell acute lymphoblastic leukemia (T-ALL) in South India is very high (43.1%) when compared to the Western countries (10-20%). TAL-1 deletion is the most common genetic abnormality in T-ALL. OBJECTIVES: The present study was aimed to detect the incidence of type 1 and type 2 TAL-1 deletions and assess whether they might contribute to the high incidence of T-ALL in South India. MATERIALS AND METHODS: 45 cases of T-ALL (pediatric-32, adolescents-7 and young adults-6) were studied by DNA-PCR and sequencing. Age of the patients ranged from 3 yrs to 29 yrs (median age 14 yrs). RESULTS: TAL-1 deletion type 1 was detected in 6 (13.3%) cases (3 pediatric and 3 adolescents) and all were males. TAL-1 deletion type 2 was not present. Comparing the clinical features and immunological marker analysis of TAL-1 deletion positive and negative cases did not show any significant differences except in the WBC count, which was significantly higher in cases showing TAL-1 deletion (>100 x 109/L, p value= 0.003). All the positive cases of TAL-1 deletion were confirmed by sequencing, the results showing that the fusion region at SIL gene and TAL-1 gene contained an average 'N region' insertion of 7.8 nucleotides. The numbers of nucleotides deleted at the 5' end and 3' end of TAL-1 gene were averages of 3 and 1, respectively. CONCLUSION: Though the incidence of T-ALL is high in South India, the frequency of TAL-1 deletion and their fusion gene sequences are not unique and are similar to those reported in other ethnic and geographic populations. Hence the present study indicates that TAL-1 deletion alone does not contribute to the high incidence of T-ALL in South Indian patients.

Role of GSTM1 (Present/Null) and GSTP1 (Ile105Val) polymorphisms in susceptibility to acute lymphoblastic leukemia among the South Indian population.

Acute lymphoblastic leukaemia (ALL) is the most common pediatric malignancy worldwide. The origin of this disease may be explained by a combination of genetic and environmental factors. Glutathione-s-transferases are a multi-gene family of enzymes involved in the detoxification of a wide variety of environmental carcinogens. A total of 92 immunophenotyped cases (below 25 years of age) and 150 cord blood controls were here analysed by PCR for GSTM1(Present/Null) and RQ-PCR allelic discrimination assay for GSTP1(Ile105Val). We found a significant increased risk for ALL with the GSTM1 null genotype (OR: 1.96, 95%CI=1.08-3.57), but no significant risk was found with the GSTP1 (Ile/Val) genotype (OR: 1.32, 95%CI = 0.74-2.37) and the GSTP1 Val/Val genotype (OR: 1.41, 95%CI=0.5-3.96) alone. Combined analysis of GSTM1 and GSTP1 showed significant higher risk associated with the GSTM1 (null/null) and GSTP1 [(Ile/Val)/ (Val/Val)] genotype (OR=2.78: 95%CI=1.16-6.69).

Type 1 (11;22)(q24:q12) translocation is common in Ewing's sarcoma/peripheral neuroectodermal tumour in south Indian patients.

The Ewing's sarcoma family can present diagnostic difficulties. In the past the basis of diagnosis has been a exclusion. Identification of a specific translocation especially t(11;22) (EWS-FLI 1 fusion gene), which is seen in nearly 85 percent of Ewing's sarcoma cases can help in precise diagnosis. We have carried out a study on twenty patient samples diagnosed to have Ewing's sarcoma/peripheral neuroectodermal tumour (PNET)/small round cell malignant tumour. The study involved RT-PCR analysis for the fusion transcript, followed by sequencing to identify the specific type of fusion. Ninety percent (18/20) of the samples tested were found to be t(11;22) translocations involving EWS-FLI 1 genes. Sixty-one percent (11/18) were found to be type 1 fusion and seven were type 2 (39 percentage). This is the first study in India with quantitative information about the types of EWS-FLI 1 translocations present in Ewing's family of tumours in south Indian patients.

CDC27 protein is involved in radiation response in squamous cell cervix carcinoma.

In the present study, an attempt was made to identify genes involved in radiation response in cervix carcinoma. Differential display technique was used to study the expression profiles of tumour biopsy samples obtained from patients, responding and not responding to treatment. The samples were obtained prior to radiotherapy and subsequent to treatment with Tele-radiation at 10 Gray (Gy). One of the differentially expressed cDNAs, when sequenced was identified to be CDC27. Immuno-histochemical analysis of pre- and post-treated tumour samples from fifteen patients showed the downregulation of expression of CDC27 protein in seven patients. Down-regulation was associated with poorer response to radiotherapy. Cervical cancer cell lines SiHa and C33A were irradiated and their nuclei were stained for expression of CDC27 and analyzed using fluorescent-activated cell sorting (FACS). Down-regulation of CDC27 protein in the irradiated SiHa cell line was associated with greater survival fraction, compared to the irradiated C33A cell line, which had only slight fall in the level of CDC27 protein. This is the first study to suggest a role for CDC27 in radiation response. However, a larger cohort is needed to further confirm the value of CDC27 protein as a predictive marker, for radiation response in cervix cancer.

PCR-heteroduplex analysis of TCR gamma, delta and TAL-1 deletions in T-acute lymphoblastic leukemias: implications in the detection of minimal residual disease.

Detection of MRD remains one of the major goals in the treatment of acute lymphoblastic leukemia (ALL). We have used the polymerase chain reaction (PCR)-heteroduplex (HD) analysis to assess and confirm the clonal expansion of T cell receptor (TCR) gamma and delta gene rearrangements in 24 T-ALL patients at diagnosis. 52.4% revealed Vdelta1-Jdelta1; 48% Vdelta2-Ddelta3; 62.5% Vgamma1-Jgamma1 and 46% both Vdelta1-Jdelta1 and Vgamma1-Jgamma1 clonal rearrangements. 6/24 patients had TAL-1 deletion. These clonal markers were used to monitor MRD in remission/relapse bone marrow samples for periods ranging from 6 to 75 months after diagnosis. Patients who relapsed and died revealed a continuous PCR-HD positivity in their clinical remission bone marrow samples. HD analysis established identical diagnostic clone at relapse. Patients who are in long-term clinical and morphological remission achieved PCR-HD negativity in their 8-12 months bone marrow remission samples and continue to be PCR-HD negative. MRD monitored in six patients with two diagnostic PCR--HD positive clonal markers reveal an identical pattern ensuring circumvention of false positive and negative results. Thus, we conclude that PCR followed by HD analysis is a useful technique to monitor MRD in remission/relapse samples in ALL patients.

Bone marrow involvement in a primary mediastinal extragonadal non-seminomatous germ cell tumour.

A case of primary mediastinal extragonadal germ cell tumour with involvement of bone marrow, a rare finding, is reported with a review of literature.

Immunophenotypic analysis of T-cell acute lymphoblastic leukaemia in Madras, India.

Immunophenotypic analysis of 285 newly diagnosed previously untreated, unselected, acute lymphoblastic leukaemia cases carried out at the Cancer Institute (W.I.A) in Madras reveals that 126 (44.2%) cases showed T-immunophenotype. The study was conducted using flow-cytometric immunofluorescent or immunoperoxidase methods using an extensive panel of monoclonal antibodies comprising CD1, 2, 3, 4, 5, 7, 8, 57, 19, 20 kappa, lambda, IgG, M, D, CIg, CD10, HLA-DR, CD13, 14, 33, 34 and CD61. The study group comprised 73 (57.9%) paediatric cases (<15 years) and 53 (42.1%) adult cases (>15 years). Based on their reactivity with various anti-T-cell monoclonal antibodies, all T-ALL cases were assigned to one of the intrathymic differentiation compartments. 56.2% of paediatric T-ALLs arise from intrathymic compartment II, 34.2% from compartment III and 9.6% from compartment I. Among adults, 45.3% arise from compartment I. 33.9% from compartment III and 20.8% from compartment II. The most frequently observed CD antigens in our study group are CD7, 5, 2 and 3. A correlative study of socioeconomic status reveals that 67.5% of T-ALL cases occurred among lower socioeconomic strata.

Prognostic variables and survival in pediatric acute lymphoblastic leukemias: cancer institute experience.

This presentation is an analysis of front-end prognostic variables in achieving a complete response, a continuous complete remission, and disease-free survival in pediatric acute lymphoblastic leukemia at the Cancer Institute, Madras, India between 1983 and 1988. The clinical characteristics at presentation showed that virtually 100% of patients belong to the poor risk category, age < 3 years of > 6 years 72.2%, WBC > 10,000/mm3 59.8%, blast count > 50% 39.2%, organomegaly 91.8%, and L2 morphology 66.0%. All patients had more than one risk factor. Between 1983 and 1988, 97 children were treated on a pilot protocol designed in collaboration with the Lymphoma Biology Division of the Pediatric Oncology Branch of the National Cancer Institute, Bethesda, Maryland. The protocol was designed for a poor prognostic group. The significance of implicated poor prognostic factors was analyzed using the Cox proportional hazard model. Age at presentation was the only variable that emerged as an independent risk factor, and sex appeared to be a modifier. No other variables attained significance. Survival data were calculated by the Kaplan-Meier method. The relapse-free and event-free survivals up to 10 years were 50.7% and 38.1%, and compare reasonably well with results reported for similar groups elsewhere for the same period.

Immunophenotyping of acute lymphoblastic leukaemia in Madras, India.

At the Cancer Institute, Madras, India, we have performed immunophenotyping in 125 untreated cases of acute lymphoblastic leukaemia using a panel of 16 monoclonal antibodies and the avidin-biotin immunoperoxidase technique in a haematology autoanalyser (Technicon Hi system). Our results demonstrate a marked difference in the phenotypic pattern of ALL compared to Western countries, the predominant finding being a relative excess of T-ALL and a paucity of C-ALL cases. Age distribution of C-ALL reveals a peak at 2-6 years in paediatric ALL cases.