Metro-SMHOP 01: Metronomics combination with cyclophosphamide-etoposide and valproic acid for refractory and relapsing pediatric malignancies.

BACKGROUND: In low- and middle-income countries, therapeutic options for advanced, refractory, or relapsing malignancies are limited due to local constraints such as cost of drugs, distance from oncology centers, and lack of availability of new anticancer drugs. Metronomics, which combines metronomic chemotherapy (MC) and drug repositioning, allows for the provision of new therapeutic options for patients in this setting. AIM OF THE STUDY: To evaluate the activity and toxicity of a metronomic regimen in Moroccan pediatric patients with refractory or relapsing malignancies. PATIENTS AND METHODS: From July 2014 to January 2018, patients with refractory/relapsing solid tumors treated in five pediatric oncology centers were consecutively enrolled. The metronomic regimen consisted of 28-day cycles with daily oral administration of cyclophosphamide (30 mg/m2 ) from days 1 to 21, together with oral etoposide (25 mg/m2 ) from days 1 to 21 followed by break of one week and daily valproic acid (20 mg/kg) from days 1 to 28. RESULTS: Ninety-eight children (median age, 8 years) were included. Underlying malignancies were neuroblastoma (24 patients), Ewing sarcoma (18), osteosarcoma (14), rhabdomyosarcoma (14), and miscellaneous tumors (28). A total of 557 cycles were given (median: 6; range, 1-18 cycles). One-year progression-free survival of our patients was 19%, and one-year overall survival was 22%. Complete response was obtained in three cases (3%), partial response in 11 cases (11%), and tumor stabilization for more than six months in 28 cases (28%). CONCLUSION: This three-drug metronomic combination was well tolerated and associated with tumor response and disease stabilization in 42 patients even for a long period.

Time to diagnosis of pediatric brain tumors: a report from the Pediatric Hematology and Oncology Center in Rabat, Morocco.

OBJECTIVE: Delayed diagnosis of pediatric brain tumors is known to occur worldwide but is not well studied in developing countries. Here, we examined the extent of delayed pediatric brain tumor diagnoses in Rabat, Morocco, and consider its potential causes and possible solutions. METHODS: We conducted a survey and interviews of the parents of children who were admitted to the Department of Hematology and Pediatric Oncology of Rabat Children's Hospital from January 1, 2016 to June 30, 2016. RESULTS: The families of 27 patients (14 girls and 13 boys) participated in the survey and interview. The median patient age was 7 years (range, 1-15 years). The most common presenting symptoms were vomiting (n = 18) and headache (n = 17). The tumor locations were supratentorial in 13 cases and infratentorial in 14 cases. The median time to diagnosis was 2 months (range, 0.25-20 months). The longest times to diagnosis occurred in children older than 5 years and in patients with supratentorial tumors or low-grade glioma. We did not observe any differences in the time to diagnosis according to sex, socioeconomic status, or urban or rural origin. CONCLUSIONS: Delayed diagnosis of pediatric brain tumors is a universal problem, evidenced by many studies in different countries. We propose that a paradigm shift in medical curricula addressing the delayed diagnosis of pediatric brain tumors should occur in medical schools and clinical training programs.

High-dose busulfan-thiotepa with autologous stem cell transplantation followed by posterior fossa irradiation in young children with classical or incompletely resected medulloblastoma.

BACKGROUND: The aim of the study is to evaluate the outcome of young children with high risk localized medulloblastomas (newly diagnosed classical or incompletely resected) treated by high-dose busulfan-thiotepa with autologous stem cell rescue (ASCT) followed by focal radiation therapy (RT). PROCEDURE: Between September 1994 and January 2010, 19 children younger than 5 years old at diagnosis fulfilling the above inclusion criteria were treated at the Institute Gustave Roussy. After conventional chemotherapy, they received busulfan at a dose of 600 mg/m(2) and thiotepa at a dose of 900 mg/m(2) followed by ASCT. Focal RT was delivered at least 70 days after ASCT. RESULTS: The median follow-up was 40.5 months (range, 14.5-191.2 months). The 3-year event-free survival (EFS) and OS were 68% (95% CI 45-84%) and 84% (95% CI 61-94%), respectively. Acute toxicity consisted mainly in hepatic veno-occlusive disease (6/19 patients) and bone marrow aplasia (all patients). No toxic death occurred. The Full Scale Intellectual Quotient tended to decrease over time at a mean rate of 0.9 point per year from the date of diagnosis. CONCLUSIONS: This intensive treatment resulted in a high overall survival rate in young children with newly diagnosed non-metastatic classic or incompletely resected MB. In spite of a high incidence of hepatic veno-occlusive disease (32%), the acute toxicity was manageable. Delayed neuropsychological side effects remain main concerns. These results should to be confirmed in a larger cohort.

Esthesioneuroblastoma in children and adolescent: experience on 11 cases with literature review.

Esthesioneuroblastoma is a rare tumor of the olfactory epithelium. This report analyzed 11 children and adolescents treated in a single institution between 1982 and 2002. For 9 patients, therapy consisted of an initial course of chemotherapy before surgical resection and postoperative radiotherapy, for 1 patient an initial course of chemotherapy before radiotherapy and for another resection before radiotherapy with no chemotherapy. Response to chemotherapy was assessed in 9 patients of whom 6 achieved a complete or a partial remission. Ten patients are long-term survivors. The 5-year actuarial disease-free survival and overall survival rate was 91% (95% confidence interval, 62%-98%). Our study indicates that esthesioneuroblastoma is sensitive to chemotherapy and supports the role of combined modalities including neoadjuvant chemotherapy, surgery, and radiation therapy.

[Acquired severe aplastic anemia in emerging countries: Management from allogeneic hematopoietic cell transplantation indication until post-transplant follow-up SFGM-TC]. / Aplasies médullaires sévères acquises dans les pays émergents : prise en charge dès l'indication de l'allogreffe de cellules souches hématopoïétiques jusqu'au suivi postgreffe (SFGM-TC).

Management of acquired aplastic anemia (AA) in emerging countries depends on the means of prognostic stratification, treatment and logistics available. During the 13th annual harmonization workshop of the francophone Society of bone marrow transplantation and cellular therapy (SFGM-TC), a designated working group reviewed the literature in order to elaborate unified guidelines for allogeneic hematopoietic cell transplantation (Allo-HCT) in this disease. In terms of practice, the conclusions are as follows; The use of anti-tymocyte globuline (ATG) is mainly from rabbit and very little from horse. Access to bone marrow graft, total body irradiation, and the international unrelated donor registries is limited, which justifies the use of peripheral blood stem cells, chemotherapy-based conditioning, and related alternative donor. The workshop recommends matched sibling allo-HCT in all patients aged less than 40 years with acquired severe or very severe AA. For patients aged over than 40 years, or who lack an HLA-identical donor, treatment with the combination of cyclosporin, horse ATG, eltrombopag or cyclosporine, eltrombopag is recommended. If horse ATG and eltrombopag are not available, matched sibling allo-HCT may be indicated as first-line therapy in patients aged between 40-60 years, and good performance status. Although, in patients who have failed immunosuppressive treatments and thrombopoietin agonists, and in the absence of HLA-matched donor, a haplo-identical allo-HCT with modified Baltimore conditioning is recommended.

[Setting up haploidentical hematopoietic cell transplantation in low- and middle-income countries: The Recommendations of the Francophone Society of Bone Marrow and Cellular Therapy (SFGM-TC)]. / L'allogreffe haplo-identique dans les pays à ressources limitées : recommandations de la Société francophone de greffe de moelle et de thérapie cellulaire (SFGM-TC).

Nowadays, haploidentical hematopoietic cell transplantation (haplo-HCT) has been routinely used worldwide. However, this procedure is still rarely proposed in low- or middle-income countries. During the 13th annual harmonization workshops of the Francophone Society of Bone Marrow Transplantation and Cellular Therapy (SFGM-TC), a designated working group has proposed recommendations on how to set up such a transplantation in these countries. This was based on a review of the literature and expert-opinion as well as the previously published workshop on haplo-HCT of SFGM-TC (2016). Haploidentical donors appear to be a first alternative to HLA-matched siblings since the access to unrelated donor international registries are limited for several countries. While the procedure has the advantage of immediate access to several potential donors and of low cost, Haplo-HCT should be performed only in centers with a good experience of HLA-matched related transplantation (>10/year). In the absence of an HLA-matched related donor, haplo-HCT should be offered to all patients who are candidate for allo-HCT. Transplantation modalities should follow the conventional procedures with post-transplant cyclophosphamide as GVHD prophylaxis. Conditioning can be myeloablative or not according to each case. Our recommendations are intended to be general in scope and applicable to the majority of allo-HCT centers in these countries. An evaluation at regular basis is needed to assess the feasibility and to improve results.

Improving the prognosis of pediatric Hodgkin lymphoma in developing countries: a Moroccan Society of Pediatric Hematology and Oncology study.

BACKGROUND: The event-free survival (EFS) of children with Hodgkin lymphoma (HL) exceeds 80% in high income countries (HIC), but little is known about this rate in developing countries. PROCEDURE: A prospective national protocol for children with classical HL was implemented in Morocco to increase EFS by careful risk stratification, providing each cycle of therapy on time, decreasing treatment abandonment, improving communication among healthcare providers, and improving data collection. Patients were stratified into a favorable risk group (Ann Arbor stages I and II, no B symptoms, no bulky disease, and no contiguous (E) lesions) and received four cycles of vinblastine, doxorubicin, methotrexate, and prednisone (VAMP) or an unfavorable risk group (all others) who received two cycles of vincristine, procarbazine, prednisone, and doxorubicin (OPPA) and four cycles of cyclophosphamide, vincristine, procarbazine, and prednisone (COPP). All patients received involved-field radiotherapy 25.5 Gy after completion of chemotherapy. EFS was calculated counting death, relapse/resistant disease, and abandonment as events. RESULTS: From February 2004 to December 2007, 160 patients enrolled; 138 (86%) had unfavorable risk features. Twenty patients (12.5%) abandoned treatment, 16 relapsed or had resistant disease, and 6 died (3 unexplained, 2 varicella, and 1 suicide). The estimated 5-year EFS was 70 ± 4% and overall survival 88 ± 3%. CONCLUSIONS: Good outcomes for pediatric HL patients can be achieved in LMIC using a multidisciplinary team approach, uniform protocol-based therapy, twinning partnership among oncology units in-country and abroad, and a data collection system to monitor compliance and identify gaps in care.

A rare case of Ewing's sarcoma of the maxillary sinus.

Ewing's sarcoma is generally an aggressive, poorly differentiated bone and soft tissue tumor affecting children and young adults, it accounts for 4%-6% of all primary bone tumors and primary facial locations occur in only 1%-4% of all cases, primarily in the mandible and calvaria. Involvement of the paranasal sinuses is rare. Here we report the case of an 11-year-old girl with no medical, surgical, or traumatic history, who presented for 1 month and progressive evolution of swelling of the left cheek, associated with pain, nasal obstruction, rhinorrhea, and a slight weight loss not quantified. A craniofacial computed tomography (CT) scan showed a mixed lytic and condensing lesional tissue process centered on the left maxillary sinus, heterogeneously enhanced after contrast injection, lysing the walls of the sinus extended to the homolateral nasal cavity and slightly infiltrating the adjacent soft tissues. An incisional biopsy was performed and the pathological study proved that it was Ewing's sarcoma. She was put on neoadjuvant chemotherapy using 6 courses of vincristine, doxorubicin, ifosfamide, etoposide which resulted in a partial regression of the tumor size by 50%. Then the patient was put on combined chemotherapy and radiotherapy. A follow-up CT scan after 6 courses of vincristine, actinomycin, cyclophosphamide, and 17 sessions of radiotherapy showed lesion stability. Maxillary Ewing's sarcoma is a rare and aggressive tumor. Therefore, early diagnosis, combination therapy, and long-term follow-up are suggested in such cases to improve the survival rate.

Reversible Encepahlopathy Induced by Ifosfamide with Brain Imaging.

Chemotherapy may be responsible for central and/or peripheral neurotoxicity. These neurological complications are frequent but little known. Some molecules are more providers, responsible for acute or late complications, sometimes not reversible. Some manifestations such as acute encephalopathy and acute reversible encephalopathy are increasingly understood. We report here a case of acute ifosfamide-induced encephalopathy (EII) with brain damage resolved after discontinuation of this treatment in a 13-years-old child.

Clinical, cytogenetic and molecular findings in nine Moroccan patients with Fanconi anemia.

INTRODUCTION: Fanconi anemia (FA) is a rare inherited hematological disease due to a defect in the DNA repair pathway resulting in congenital abnormalities and high susceptibility to develop cancers. The cytogenetic analysis using alkylating agents is still a reference test to establish the diagnosis. Despite the genetic heterogeneity, the identification of the causal mutation is actually performed especially after the development of next generation sequencing (NGS). METHODS: we report here nine Moroccan patients referred to the department of Medical Genetics for suspicion of FA. We realized a genetic consultation to establish a clinical record with biological data before carrying out the genetic analysis. Karyotyping with mitomycin was performed for all the probands before elaborating molecular study. We used massively parallel sequencing to analyse the three most frequent mutated genes FANCA, FANCC, and FANCG, representing 84% of all genes involved in FA. RESULTS: all the patients showed hematological signs associated with at least one extra-hematological congenital anomaly. The chromosomal breaks were significantly higher for the nine patients, compared to the controls. The molecular diagnosis was confirmed in 8 of the 9 families tested (88.8%) with 4 novel mutations. The next generation based sequencing identified 9 variations: 6 in the FANCA gene (66.6%), 3 in the FANCG gene (33.3%) and no FANCC variation was found. Of those, 7 were homozygous and 2 were compounds heterozygous. CONCLUSION: to the best of our knowledge, this is the first molecular report of Moroccan patients with FA suggesting the predominance of two genes without any recurrent mutation. The molecular analysis of FANCA and FANCG genes should be offered first for all patients in Morocco.

Cytogenetic Profile of Moroccan Pediatric Acute Lymphoblastic Leukemia: Analysis of 155 Cases With a Review of the Literature.

BACKGROUND: Acute lymphoblastic leukemia (ALL) is the most common malignancy in children, with a peak incidence at 2 to 3 years of age and accounting for almost 30% of all cancers in this age group. It is well established that the identification of cytogenetic abnormalities is highly relevant for the prognosis of and therapeutic decisions in ALL. The purpose of the present study was to define the frequency of recurrent chromosomal abnormalities of ALL in Moroccan patients referred exclusively to the BIOLAB Laboratory of the Children's Hospital of Rabat during a 4-year period and compare our findings to the reported data. PATIENTS AND METHODS: We performed conventional karyotyping of 155 ALL cases, with a successful cell culture rate of 94%. RESULTS: We identified chromosomal abnormalities in 66% of the total studied cases, of which 70% revealed important recurrent abnormalities with high prognostic value, such as hyperdiploidy, hypodiploidy, t(9;22), t(8;14), t(1;19), and MLL rearrangements. In total agreement with the reported data, most of the patients (56%) in the present study were aged 1 to 5 years, with a male predominance, and B-ALL was the most common blast phenotype (85%). CONCLUSION: The frequency of most chromosomal rearrangements successfully identified in our study and their lineage correlated with those reported in the published data.

[A hemophagocytic syndrome revealing a Griscelli syndrome type 2]. / Un syndrome d'activation macrophagique révélant un syndrome de Griscelli de type 2.

Griscelli syndrome type 2 is a rare autosomal recessive disorder, due to a mutation in RAB27A gene. It associates partial albinism, silver hair and immune deficiency. We report the case of a 6 year-old boy who was admitted to the Emergency department with severe sepsis complicated by hemophagocytic syndrome. Many clinical and biological criteria leads to the diagnosis of type 2 Griscelli syndrome: consanguineous family, recurrent infection, absence of psychomotor retardation, oculocutaneous albinism, silver hair, occurrence of hemophagocytic syndrome and especially the pathognomonic appearance on microscopic examination of the hair. The absence of giant organelles inclusion in all granulated cells eliminated Chediak-Higashi syndrome.