Treatment of childhood acute lymphoblastic leukemia in central America: a lower-middle income countries experience.

BACKGROUND: Five Asociación de Hemato-Oncología de Centroamérica (AHOPCA) countries have used an adapted BFM-based protocol for childhood acute lymphoblastic leukemia (ALL). PROCEDURE: In the AHOPCA-ALL 2008 protocol, patients were stratified by age, white blood cell count, immunophenotype, central nervous system involvement, day 8 prednisone response, and morphologic bone marrow response to induction therapy. Patients at Standard Risk (SR) received a three-drug induction regimen, a reinduction phase, and maintenance with protracted intrathecal therapy. Those at Intermediate (IR) and High Risk (HR) received, in addition, daunorubicin during induction therapy, a consolidation phase and two or three reinduction phases respectively. RESULTS: From August 2008 through July 2012, 1,313 patients were enrolled: 353 in SR, 548 in IR, 412 in HR. During induction therapy, 3.0% of patients died, 2.7% abandoned treatment, 1.1% had resistant ALL, and 93.2% achieved morphological complete remission (CR). Deaths and abandonment in first CR occurred in 2.7% and in 7.0% of patients, respectively. The relapse rate at a median observation time of 2.1 years was 15.0%. At 3 years, the event-free survival (EFS) and overall survival (OS), with abandonment considered as an event, were 59.4% (SE 1.7) and 68.2% (SE 1.6). Three-year EFS was 68.5% (SE 3.0), 62.1% (SE 2.6), and 47.8% (SE 3.2) for SR, IR, and HR groups. Adolescents had a significantly higher relapse rate (P = 0.001). CONCLUSIONS: This experience shows that common international studies are feasible in lower-middle income countries. Toxic deaths, abandonment of treatment, and relapses remain major obstacles to the successful treatment. Alternative treatment strategies may be beneficial.

Treatment of pediatric non-Hodgkin lymphomas in a country with limited resources: results of the first national protocol in Nicaragua.

We report the results of a protocol for the diagnosis and treatment of pediatric non-Hodgkin lymphomas (NHL) conducted in Nicaragua in the context of an international collaborative program. Fifty-three children with NHL treated between 1996 and 2003 were retrospectively evaluated. Therapy was designed based on local drug availability and affordability with dose and schedule adaptations for Burkitt and lymphoblastic lymphomas. With a median follow-up of 3 years, the projected 9-year overall survival was 63% and event-free survival 53%. The treatment was efficacious, feasible, and well tolerated in spite of the local socio-economical conditions.

North-South twinning in paediatric haemato-oncology: the La Mascota programme, Nicaragua.

We describe the La Mascota twinning programme between La Mascota paediatric hospital in Managua, Nicaragua, and hospitals in Monza and Milan, Italy, and Bellinzona, Switzerland. The programme was based on the belief that an attempt to reduce the gap in mortality from cancer in childhood between developed and less developed countries should become an integral part of the care and research activity of a haemato-oncological department of a developed country and not simply an exercise in solidarity. This programme for acute lymphoblastic leukaemia shows that intellectual, organisational, and financial resources can be generated by a twinning programme. What is vital for such programmes is a long-term commitment to a comprehensive and holistic strategy that incorporates supply of drugs, training and supervision of health professionals, and the care of the children and of their parents.

Psychosocial problems and adjustment of children with beta-thalassemia and their families.

This study explores the psychosocial problems experienced by families with children aged 6 to 14 years suffering from beta-thalassemia major (N = 188). The psychosocial problems and the family's adjustment to the effects of the illness were compared across a number of cultures where the disease is prevalent, namely Cyprus, Greece, and Italy. A small number of migrant children in the United Kingdom was also included in the study. Semi-structured interviews were conducted with parents who also completed the Rutter Parental Questionnaire and the Goldberg General Health Questionnaire. Teachers were asked to complete a Children's Behaviour Questionnaire designed by Rutter. In all countries the disease seemed to have a binding effect on the family, thus mobilizing adaptive mechanisms. Father's low education level and the presence of major medical complications were predictors of poor family adjustment. Differences between and within countries may well reflect differences in health policies, existing level of socio-economic development, and in the cultural patterns in coping with a chronic illness.

Use of all-trans retinoic acid to treat acute promyelocytic leukemia: a case with very severe features at the onset in Nicaragua.

We observed a child with acute promyelocytic leukemia (APL) who, at the onset, had extremely severe hemorrhagic and septic complications. According to our experience in Nicaragua, there was a very high risk of early death. The patient was successfully treated with a program that included all-trans retinoic acid (ATRA) followed by cytotoxic chemotherapy. ATRA has two important features: it is effective in initial treatment of APL and it is inexpensive. Because of the high cost and the need for extensive supportive care, optimal myeloablative therapy used in patients with various types of acute myeloid leukemia generally cannot be given in developing countries. ATRA treatment for APL is affordable everywhere.

Total parenteral nutrition and nutritional assessment and leukaemic children undergoing bone marrow transplantation.

The aggressive radiotherapy and chemotherapy used in conditioning regimens for children with leukaemia undergoing bone marrow transplantation (BMT) cause a severe catabolic state. Total parenteral nutrition (TPN) is indispensable in the management of these patients. 25 children with leukaemia undergoing BMT were studied to evaluate the efficacy of TPN and the value of anthropometric parameters and biochemical variables (albumin, retinol-binding protein and prealbumin) in monitoring nutritional status in the critical post-BMT phase. The complications of TPN were mainly metabolic, generally mild and easily controlled. The hyperalimentation solution and infusion line were not responsible for infection in any patient. The marked variations in anthropometric parameters and albumin expected in such patients were not observed in our children due to the nutritional support given. Prealbumin and retinol-binding protein showed statistically significant, positive variations (P less than 0.01), thus proving sensitive indices of the response to nutritional repletion.

[Periodontal conditions in growth age patients treated for leukemia with chemotherapy and radiation therapy protocols]. / Condizioni parodontali di soggetti trattati per leucemia nell'eta evolutiva con protocolli di terapie chemioterapiche radianti.

Patients affected by acute leukemia under radiotherapy and chemotherapy, less them 12 years ols were investigated about periodontal health. Patients were in total remission. Clinical and radiological X-Ray exams investigated soft deposits, calculus, intensive gingivitis, periodontal lesions and CPITN index. The Authors concluded that indices of these patients are better than in normal subjects.