Epstein-Barr virus and cytomegalovirus infections and their clinical relevance in Egyptian leukemic pediatric patients.

BACKGROUND: Epstein-Barr virus (EBV) and human cytomegalovirus (CMV) infections are environmental risk factors affecting the outcome of cancer due to an impairment in the cell-mediated immunity. Therefore, this study aimed to detect the frequency of EBV and CMV DNA and their association with clinical characteristics and outcome of pediatric leukemic patients. METHODS: Samples of 50 immunocompromised pediatric leukemic patients and 30 apparently healthy children were subjected to the amplification of EBV DNA by one version of PCR targeting the Bam H1 W region of the genomic region of EBV, and the amplification of CMV DNA by targeting the CMV UL97 genomic region by a second round PCR. All investigations were performed on WBCs and sera. Results were correlated with the clinical and laboratory characteristics of the disease, and with overall survival. RESULTS: EBV and CMV DNA were detected in 20 and 54% of leukemic patients, respectively. Nine out of ten patients with EBV DNA (90%) were positive for CMV DNA in their sera. The presence of EBV DNA or CMV DNA was associated with neutropenia and a low total leukocyte count (TLC) (p = 0.02, 0.03, respectively). The presence of severe CMV disease, longer duration of febrile neutropenia, neutropenia, lymphopenia, thrombocytopenia and the presence of EBV DNA in patients' sera were significantly associated with worse overall survival. CONCLUSION: The detection of CMV disease and EBV DNA is relatively common in leukemic children and is significantly associated with a decline in the overall survival.

Bacteremia due to ESKAPE pathogens: An emerging problem in cancer patients.

BACKGROUND AND AIM: In recent years, a few of the antibiotic-resistant bacteria, known as ESKAPE pathogens, have been found responsible for serious infections. We investigated the risk factors, and impact of ESKAPE pathogens on course of blood stream infections (BSIs) in cancer patients in comparison to coagulase negative Staphylococci (CoNS). PATIENTS AND METHODS: The data of patients with ESKAPE positive blood cultures at National Cancer Institute, Cairo University were analyzed. Identification and antimicrobial susceptibility of isolates were done using Microscan Walk Away 96. RESULTS: In a 6month period, ESKAPE pathogens were isolated from non-duplicate blood cultures in 81 episodes of 72 cases of pediatric cancer patients, while CoNS were isolated from 135 blood cultures of 116 patients. The ESKAPE pathogens isolated were Enterobacter spp., methicillin-resistant Staphylococcus aureus (MRSA), Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterococci in 12%, 23%, 37%, 10%, 9%, and 9% of episodes, respectively. Health-care acquired infections constituted 75% of ESKAPE infections. Duration of episodes and overall mortality were significantly higher in ESKAPE BSIs when compared to CoNS (14.5±7.6 versus 09.9±6.9), and (26% versus 4%); respectively, p value <0.001. CONCLUSIONS: ESKAPE pathogens were significantly associated with higher rates of morbidity and mortality indicating the need for improving the means of prevention of these types of infections within health care premises. Microbiology laboratories have a role in defining more dangerous infections and rapid diagnostics are required in the era of resistance.

Increasing Antimicrobial Resistance Monitored in Surveillance Analysis of Blood Stream Infections in Febrile Neutropenic Pediatric Oncology Patients.

BACKGROUND: Continuous surveillance of pattern of blood stream infection is necessary in febrile neutropenia (FN)especially with the recent escalating trend in the management of pediatric cancer patients towards intensified regimens and with the increase in infections caused by resistant organisms limiting the choice of antibiotics. AIM: To monitor change in pattern of blood stream infections (BSI) in FN pediatric cancer patients. MATERIALS AND METHODS: Surveillance of FN episodes with positive BSI was prospectively monitored and compared to a previous surveillance in the same pediatric oncology unit. RESULTS: A total of 232 BSI positive episodes were documented in 192 patients during a 6 months period. The results of recent surveillance analysis showed an increase in intensified regimens of chemotherapy, antimicrobial resistance, fungal infections, and prolonged duration of episodes when compared to previous surveillance, with p value sof <0.001, 0.005, 0.021, and <0.001, respectively. There was an apparent decrease in the crude mortality but this was not statistically significant, to 6% in 2011 from 10 % in 2006. CONCLUSIONS: The pattern of BSI at our institution is still inclining towards gram positive organisms but is showing a shift towards more antibiotic resistance and fungal infections.

Aberrant expression of cancer stem cell markers (CD44, CD90, and CD133) contributes to disease progression and reduced survival in hepatoblastoma patients: 4-year survival data.

Hepatoblastoma (HB) is an embryonal tumor of the liver in children. Prognosis and response to treatment in HB are highly variable. Cancer stem cells (CSCs) constitute a population of cells, which contribute to the development and progression of many tumors. However, their role in HB is not well defined yet. We assessed the prognostic and predictive values of some CSC markers in HB patients. Protein and messenger RNA expressions of the CSC markers CD133, CD90, and CD44 were assessed in 43 HB patients and 20 normal hepatic tissues using immunohistochemistry and quantitative real-time polymerase chain reaction. The expression levels of these markers were correlated to standard prognostic factors, patients' response to treatment, overall survival (OS), and disease-free survival (DFS). CD44, CD90, and CD133 proteins were detected in 48.8%, 32.6%, and 48.8% compared with 46.5%, 41.7%, and 58.1% RNA, respectively (concordance, 77.8%-96%). None of the normal tissue samples was positive for any of the markers. Significant correlations were reported between α-fetoprotein and both CD44 and CD133 (P = 0.02) as well as between tumor types CD90 and CD133 (P = 0.009). Reduced OS correlated with CD44, CD90, and CD133 expressions (P < 0.001), advanced stage (P < 0.001), response to treatment (P < 0.001), and total excision of the tumor. Reduced DFS correlated with CD44 and CD133 expressions (P < 0.001) only. In conclusion, CD133, CD44, and CD90 could be used as prognostic and predictive markers in HB. High expression of these markers is significantly associated with poor response to treatment and reduced survival. Moreover, complete surgical resection and systemic chemotherapy are essential to achieve good response and prolonged survival, especially in early stage patients.

Different techniques for management of common bile duct stones: a single centre experience.

Local experience on the combined technique of endoscopic sphincterotomy followed by endo: scopic balloon dilation is scarce. This study clarified whether this crombined technique will offer any advantages, with respect to therapeutic outcome and complications rate, as compared with endoscopic sphincterotomy (ES) and endoscopic balloon dilatation (EBD) alone for the extraction of large and/or multiple common bile duct stones. For a total of 76 patients, extraction of large and/or multiple common bile duct (CBD) stones during endoscopic retrograde cholangiopancreatography was performed. According to the used technique, they were categorized into 3 groups; Endoscopic sphincterotomy, endoscopic balloon dilatation or combined technique. The success rate of complete stone removal and the incidence of procedure-related complications were compared among the three groups. Success rate after one session was recorded to be comparable among the three groups. Relative Risk Ratio assessment of success rate after single session among the three groups showed no statistically significant difference. Regarding bleeding, only 3 (10%) cases were recorded in the ES group with no cases in the, other 2 groups. No significant difference was noted among the three groups regarding other complication. The combined technique of ES followed by EBD is an effective and safe technique enables extraction of multiple and/or relatively large stones. It could be a reasonable alternative option when standard techniques are inadequate to remove bile duct stones.

Impact of breast cancer and combination chemotherapy on oxidative stress, hepatic and cardiac markers.

PURPOSE: Carcinoma of the breast is the most prevalent cancer among Egyptian women and constitutes 29% of National Cancer Institute cases. The aim of this study was to determine the effect of breast cancer on oxidative stress, cardiac markers and liver function tests, moreover the role of 5-fluorouracil, doxorubicin, and cyclophosphamide (FAC) in the treatment of breast cancer and its mechanism through changing the measured markers. METHODS: Forty female breast cancer patients who were admitted to the Department of Oncology of the Beni-Suef University Hospital were enrolled in the study. This study included three arms: a control group of healthy age-matched females (n=20), breast cancer patients who weren't receiving treatment (n=20), and patients undergoing treatment with anticancer combination drugs FAC (n=20). Blood samples collected from the control subjects and patients were analysed to determine levels of catalase, reduced glutathione (GSH), uric acid, nitric oxide (NO), malondialdehyde, creatine kinase (CK), lactate dehydrogenase (LDH), liver enzymes (alanine aminotransferase and aspartate aminotransferase), and creatinine. RESULTS: The levels of catalase and GSH were significantly reduced (p<0.05) in breast carcinoma and FAC treated breast cancer patients. The lipid peroxidation and NO levels were significantly enhanced in both untreated and FAC treated breast cancer patients. The CK and LDH were significantly enhanced (p<0.05) in the FAC group. CONCLUSION: The results from the present study show that oxidative stress is implicated in breast carcinoma and chemotherapy aggravates this oxidative stress which causes damage to many cellular targets and has the main side effect of cardiotoxicity.

Role of neuropilin-1 and its expression in Egyptian acute myeloid and acute lymphoid leukemia patients.

Neuropilins are expressed in tumors vasculature and cells. Their expression is thought to be correlated with tumor angiogenesis and progression. In this study, we analyzed NRP-1 expression level in 40 acute leukemia patients [20 acute myeloid leukemia (AML) and 20 acute lymphoblastic leukemia (ALL)] and 10 healthy controls using Real-Time Quantitative Reverse-Transcriptase Polymerase Chain Reaction (RTQ-PCR) aiming to show Neuropilin-1 (NRP-1) gene expression pattern in acute leukemia patients and its role in disease severity and progression. NRP-1 was expressed in 80% and 95% of ALL and AML respectively with levels higher in patients than controls and in ALL than AML patients. NRP-1 levels were significantly correlated with blast percentage and complete remission. We conclude that NRP-1 is significantly associated with acute leukemia and that its level might serve as an indicator for disease severity and progression. NRP-1 signaling may represent a novel therapeutic approach for the treatment of acute leukemia subsets.

Antibiotic resistance is associated with longer bacteremic episodes and worse outcome in febrile neutropenic children with cancer.

PURPOSE: With the increasing emergence of multiresistant pathogens, better understanding of these infections is necessary. The aim of the present study was to evaluate the risk factors associated with isolating a multiresistant organism (MRO) from a positive blood culture in pediatric cancer patients with febrile neutropenia (F&N), and to study its impact on clinical course and outcome of febrile episodes. PATIENTS AND METHODS: The association between MRO with underlying malignancy, age, disease status, hospitalization during episode, absolute neutrophil count, absolute monocyte count, clinical foci of infection, and pathogens isolated was assessed in bacteremic pediatric cancer patients. The MRO phenotype was defined as diminished susceptibility to ≥3 of the broad spectrum antibody classes. RESULTS: Among 239 episodes of blood stream infections (BSI), Gram-positive, and Gram-negative organisms were detected in 180 (75%), and 59(25%) episodes, respectively; with 38% of isolates showing multiresistance (n = 92). Significant risk factors (P < 0.05) for MRO were hospitalization, Gram-negative organisms, presence of clinical focus of infection, reduced ANC, prolonged duration of neutropenia, and previous intake of antibiotics. Of the episodes with prolonged duration of fever extending for more than 7 days 62% (64|93) were associated with a multiresistant phenotype, while it accompanied 72% (18|25) of the cases with an unfavorable outcome; P-value <0.001. CONCLUSION: Isolation of MRO is more likely to be associated with a prolonged course and an unfavorable outcome. Continuous multidisciplinary surveillance of BSI is warranted to develop strategies for antimicrobial resistance control.

Presence of human herpes virus 6 (HHV6) in pediatric lymphomas: impact on clinical course and association with cytomegalovirus infection.

BACKGROUND: Activation of herpes virus 6 (HHV6) has seen in Hodgkin's and non-Hodgkin's Lymphoma (HL&NHL) as a result of lymphoma associated immunosuppression. Multiple studies have suggested an association between both HHV6 and cytomegalovirus CMV for development of CMV disease affecting the pathogenesis of lymphoma. Therefore, this study investigated the frequency of HHV6, its impact on clinical manifestations of lymphoma and its possible association with risk for development of CMV infection in pediatric lymphoma patients. METHODS: Presence of HHV6 DNA and CMV DNA was investigated by PCR assay in both WBC's and plasma samples from 50 patients diagnosed with HL or NHL. CMV antibody titer was also determined in sera obtained from each patient. Twenty apparently healthy siblings were used as a control group. RESULTS: In a study group of 50 patients diagnosed with HL or NHL, 23/50 (46%) were found to be positive for herpes virus DNA (HHV6 or CMV) in WBC's or plasma by PCR assay and this was significantly higher than its presence in the pediatric control group 2/20 (10%) (p = 0.005). Ten out of these 23 (43%) were found to have active CMV infection. Fifty six percent of patients with CMV infection were found among NHL cases with B- subtype. The presence of both herpes viruses DNA was significantly associated with more frequent episodes of febrile neutropenia (median 3 episodes), absolute neutrophil count (< 0.8), lymphocytes (< 0.5), and low hemoglobin level (< 9.1), (p < 0.05). CONCLUSION: The presence of HHV6 can be considered as a predicting indicator of cellular immunosuppression preceding the onset of CMV infection which may result in a severe outcome among pediatric lymphoma patients.

Telomerase expression as complementary prognostic factor in neuroblastoma.

BACKGROUND: Neuroblastoma (NB) is an aggressive tumor of childhood with a highly heterogeneous course. Identification of standard prognostic factors has several limitations. Hence, there is an increasing demand to identify new prognostic factors and tools that help in risk stratification of patients for proper treatment. OBJECTIVE: To assess the prognostic and predictive impact of quantitative telomerase expression in NB patients. METHODS: We investigated quantitative telomerase expression by immunohistochemistry in 44 neuroblastoma patients. Results were correlated with standard prognostic factors, n-myc amplification by chromogen in situ hybridization (CISH) and patients' response to treatment and survival. RESULTS: High telomerase expression and n-myc expression were reported in 52.3% and 56.8% ; respectively. There was a significant relation between telomerase expression and n-myc amplification. Stage 3 and 4 represented 91% of patients. Thirteen patients showed complete remission, 9 partial remission, 19 no response and 3 showed progressive disease. The median followup was 3 years with 80% overall and 72% progression free survival for the low teleomerase expression group; and 52.2% and 55.4% for high teleomerase expression group. High Telomerase expression by immunohistochemistry was significantly associated with n-myc amplification and with poor response to treatment with a trend toward lower overall and progression free survival. CONCLUSIONS: Telomerase expression by immunohistochemistry is a simple potential tool for risk stratification of NB patients. CISH can serve as a readily available alternative simple tool, compared to FISH, in identifying neuroblastoma cases with abnormal n-myc gene copy number. KEY WORDS: Telomerase expression- N-myc amplification- Prognosis- Neuroblastoma.

Clinical implications of icaA and icaD genes in coagulase negative staphylococci and Staphylococcus aureus bacteremia in febrile neutropenic pediatric cancer patients.

BACKGROUND: Staphylococci are the most frequently isolated organisms from blood cultures of febrile neutropenic (FN) cancer patients. We aimed to define the nature of these isolates by studying the prevalence of icaA and icaD genes in coagulase-negative staphylococci (CoNS) and Staphylococcus aureus isolates in relation to clinical and microbiological features. PROCEDURE: Fifty-five CoNS and S. aureus isolates from blood cultures of FN pediatric patients receiving chemotherapy were tested for slime production using Congo red agar plate test (CRA test), and for the presence of icaA and icaD genes by PCR. RESULTS: Of the CoNS isolates, eight were positive for ica genes, and three were slime positive/ica negative. A total of 11 (24.4%) cases of CoNS bacteremia were either ica genes or CRA test positive. There was a concordance between ica genes and CRA test positivity (P < 0.001). S. aureus isolates exhibited icaA and icaD genes more than CoNS isolates (P = 0.03). Vancomycin was significantly more prescribed in episodes of ica-positive cases (P = 0.029). CONCLUSIONS: The results of the present study support the hypothesis that the ica genes are important virulence markers for clinically significant CoNS isolates, indicating their ability to produce slime. This could be used to assign a group with higher risk FN. On the other hand, absence of these genes may permit, along with other clinical criteria, the consideration of a low-risk FN episode and allow for safe early discharge.

Role of 131-I MIBG Therapy in the Treatment of Advanced Neuroblastoma.

INTRODUCTION: Neuroblastoma, a neoplasm of the sympathetic nervous system, is the second most extracranial malignant solid tumor of childhood. Many therapeutic strategies has evolved over the last 20 years, based upon work by international cooperative groups and smaller cohort studies. Novel therapies to improve initial disease response and treatment of minimal residual disease are required to improve survival for these children with highrisk neuroblastoma. Radio-labeled MIBG therapy has been tried in the treatment of advanced stage 3&4 neuroblastoma in an attempt to improve patients' outcome. The use of radio-labeled MIBG to treat neuroblastoma has arisen from the high sensitivity and specificity of in-vivo MIBG imaging for detection of primary and metastatic tumors. AIM OF WORK: To determine the impact of MIBG therapy on neuroblastoma patients' outcome and its impact on their quality of life. PATIENTS AND METHODS: Thirty pediatric patients with stage 4 pathologically proven neuroblastoma are included in this study. Eighteen of the study patients (60%) were males and 12 (40%) were females. All the patients had partially responsive tumor to first-line therapy +/- surgey. 131-I MIBG doses ranged from 100 to 150mCi with number of courses ranged from 1-7 according to response and toxicity. RESULTS: Two patients achieved complete remission (CR) and were still disease-free after 64 &69 months. Nine patients showed partial remission (PR) to 131-I MIBG, all the nine patients were alive at 16-57 months (mean 30.6 months) among whom seven were alive with stable disease and two patients were alive with progressive disease (PD) at the end of study. Eighteen patients remained stable after 131-I MIBG therapy, among them six were alive with PD and four were alive with stable disease at the end of study, while the remaining eight patients died. The last patient developed PD and died within 15 months. The 5 years event free survival (EFS) was 48.2% and the overall survival (OS) was 69%. CONCLUSIONS: We concluded that 131-I MIBG therapy has favorable therapeutic effect for advanced neuroblastoma patients. Controlled clinical trials should be considered to evaluate the true potential of 131-I MIBG therapy. KEY WORDS: MIBG therapy - Advanced neuroblastoma.

Pediatric Non Metastatic Non Rhabdomyosarcoma Soft Tissue Sarcomas (NRSTSS): Five Years Experience from NCI-Egypt.

PURPOSE: Evaluation of demographic, pathological, and clinical patterns in addition to treatment outcome of pediatric NRSTS patients treated at the NCI, Egypt. PROCEDURE: 21 pediatric patients of NRSTS between 2001 and 2006 were included. Clinical and pathological diagnosis and subtyping verification were done. Patients' cohort formed of 3 treatment groups. (1) Patients who underwent complete surgical resection with no adjuvant therapies. (2) Patients who received chemotherapy and complete surgical resection, and group (3) Patients with localized unrersectable tumors for whom systemic chemotherapy only was given. Demographic, clinicopathological variables, and treatment modalities were statistically evaluated and compared with the outcome. RESULTS: Tumors of unknown histiogenesis followed by MPNST and myxofibrosarcoma were the most frequent tumor subtypes. Low tumor grade was in favor of better outcome. With a median follow up of 2-years; respectively 100% and 81.1% of patients who had complete surgical resection of a localized disease with or without chemotherapy entered in CR (p=0.01). Local failure rate was 27.2% among CR patients (n=17). Two patients suffered local recurrance and one had distant disease metastasis. CONCLUSIONS: Complete surgical resection with or without chemotherapy is the mainstay of therapy for localized NRSTS. Tumor grade and surgical resection of NRSTS are 2 important predictors of prognosis. KEY WORDS: Nonrhabdomyosarcoma - Soft tissue sarcoma - Pediatric.