Targeted next generation sequencing for the diagnosis of patients with rare congenital anemias.

BACKGROUND: Most patients with anemia are diagnosed through clinical phenotype and basic laboratory testing. Nonetheless, in cases of rare congenital anemias, some patients remain undiagnosed despite undergoing an exhaustive workup. Genetic testing is complicated by the large number of genes involved in rare anemias and the similarities in the clinical presentation of the different syndromes. OBJECTIVE: We aimed to enhance the diagnosis of patients with congenital anemias by using targeted next-generation sequencing. METHODS: Genetic diagnosis was performed by gene capture followed by next-generation sequencing of 76 genes known to cause anemia syndromes. RESULTS: Genetic diagnosis was achieved in 13 out of 21 patients (62%). Six patients were diagnosed with pyruvate kinase deficiency, 4 with dehydrated hereditary stomatocytosis, 2 with sideroblastic anemia, and 1 with CDA type IV. Eight novel mutations were found. In 7 patients, the genetic diagnosis differed from the pretest presumed diagnosis. The mean lag time from presentation to diagnosis was over 13 years. CONCLUSIONS: Targeted next-generation sequencing led to an accurate diagnosis in over 60% of patients with rare anemias. These patients do not need further diagnostic workup. Earlier incorporation of this method into the workup of patients with congenital anemia may improve patients' care and enable genetic counseling.

Treatment of Nonmetastatic Unilateral Retinoblastoma in Children.

Importance: Multi-institutional collaborative studies that include large patient populations for the management of retinoblastoma with histopathological risk factors could provide important information for patient management. Objective: To evaluate the implementation of a strategy for the management of nonmetastatic unilateral retinoblastoma in children based on standardized diagnostic and treatment criteria. Design, Setting, and Participants: This single-arm prospective study applied a strategy based on a single-center experience. The setting was a multicenter study in Latin America (Grupo de America Latina de Oncologia Pediatrica [GALOP]). Participants were children with nonmetastatic unilateral retinoblastoma (staged with the International Retinoblastoma Staging System). The study opened on July 1, 2008, and closed on December 31, 2014. Follow-up was updated until June 30, 2017. Interventions: Stage 0 patients (without enucleation) were given conservative therapy without a protocol. Stage I patients (with enucleation and no residual tumor) were divided into a high-risk group (retrolaminar invasion and/or scleral invasion) and a low-risk group (all remaining patients). High-risk children received adjuvant chemotherapy with 4 alternating cycles of regimen 1 (cyclophosphamide [65 mg/kg/d] [plus sodium-2-mercaptoethane sulfonate], idarubicin hydrochloride [10 mg/m2/d], and vincristine sulfate [0.05 mg/kg/d]) and 4 cycles of regimen 2 (carboplatin [500 mg/m2/d, days 1 and 2] and etoposide [100 mg/m2/d, days 1-3]). Low-risk children did not receive adjuvant therapy. Children with buphthalmia received neoadjuvant and adjuvant chemotherapy for a total of 8 cycles. Main Outcomes and Measures: Probability of event-free survival (extraocular relapse and death from any cause were considered events). Results: Among 187 children registered in the study, 175 were evaluable (92 [52.5%] female; median age, 22 months; age range, 3-100 months). Forty-two were stage 0 children, 84 were stage I low-risk children, and 42 were stage I high-risk children; there were 7 children in the buphthalmia group. With a median follow-up of 46 months, the 3-year probability of event-free survival was 0.97 (95% CI, 0.94-0.99), and the probability of overall survival was 0.98 (95% CI, 0.94-1.00). Stage 0 patients had no events, stage I low-risk patients had 1 event (orbital relapse treated with second-line therapy), stage I high-risk patients had 2 events (1 central nervous system relapse and 1 death from sepsis), and the buphthalmia group had 1 event (orbital relapse, followed by central nervous relapse and death). Conclusions and Relevance: Adjuvant therapy may be effective for high-risk unilateral retinoblastoma but is toxic, and neoadjuvant chemotherapy for buphthalmus appears feasible.

High Risk Neuroblastoma in Uruguay. Where are we? / Neuroblastoma de Alto Riesgo en Uruguay. ¿Dónde estamos? / Neuroblastoma de Alto Risco no Uruguai. Onde estamos?

Introdução: El neuroblastoma es el tumor sólido extracraneal más frecuente en niños. Aproximadamente el 50 % de los pacientes son clasificados como de alto riesgo, con base en características clínicas, biológicas e histológicas. Objetivo: Describir a la población asistida en el Centro Hemato-Oncológíco Pediátrico (CHOP) del Centro Hospitalario Pereira Rossell (CHPR) con diagnóstico de neuroblastoma de alto riesgo, su tratamiento y sobrevida. Método: Estudio descriptivo y retrospectivo de todos los pacientes con neuroblastoma de alto riesgo diagnosticados en el CHOP entre el 2001 y el 2015. En el CHOP se ubica el Registro Nacional de Cáncer Pediátrico, así como también el Archivo de Historias Clínicas de todos los pacientes. Los datos son recolectados y analizados por el sector de estadística. Resultados: Se diagnosticaron 35 pacientes, de los cuales 20 (57%) eran varones con mediana de edad de 36,6 meses (5-93), localización suprarrenal 23 (66%) y 100% estadio IV. Metástasis, médula ósea y hueso: 27 (71%). Treinta y tres pacientes recibieron autotransplante de progenitores hematopoyéticos (TPH) (94%). Estatus previo a TPH, remisión completa: 19 (58 %), remisión parcial: 14 (42%). Mortalidad relacionada al tratamiento: 15 % y de recaídas: 68 %. Mediana de tiempo de recaída: 15 meses (3-52). La probabilidad de sobrevida global y sobrevida libre de eventos a 5 años fue de 37,8% ± 8,4 y 23,8% ± 7,3 (mediana de seguimiento 40 meses). Conclusión: A pesar del tratamiento intensivo y de las medidas de soporte adecuadas, el pronóstico en los niños con neuroblastoma de alto riesgo sigue siendo pobre en nuestro país. Es necesario incorporar nuevas estrategias terapéuticas aún no disponibles en nuestro medio.

Introduction: Neuroblastoma is the most common extracranial solid tumor in children. Approximately 50% of patients are classified as high risk on the basis of clinical, biological, and histological characteristics. Objective: To describe the population of patients diagnosed with high-risk neuroblastoma at the Centro Hemato-Oncológíco Pediátrico (CHOP, Center for Pediatric Hematology and Oncology) of the Centro Hospitalario Pereira Rossell (CHPR, Pereira Rossell Hospital), in terms of their treatment and survival. Method: Descriptive, retrospective study of all patients diagnosed with highrisk neuroblastoma at the CHOP between 2001 and 2015. The National Registry of Pediatric Cancer is located at the CHOP, as is the Archive of Patient Clinical Histories. The data are collected and analyzed by the statistics sector. Results: Among the 35 patients diagnosed, 20 (57%) were men, the median age was 36.6 months (range, 5-93 months), and the tumor had an adrenal location in 23 (66%). All of the tumors were classified as stage IV. Metastasis to the bone marrow or bone was seen in 27 (71%). Thirty-three patients (94%) received autologous hematopoietic stem-cell transplantation (HSCT). The status prior to HSCT was complete remission in 19 (58%) and partial remission in 14 (42%). The treatment-related mortality rate was 15%, and the relapse rate was 68%. The median time to relapse was 15 months (3-52 months). The probability of overall survival and 5-year event-free survival was 37.8% ± 8.4 and 23.8% ± 7.3 (median follow-up of 40 months), respectively. Conclusion: Despite intensive treatment and adequate support measures, the prognosis for high-risk neuroblastoma in children remains poor in Uruguay. There is a need to incorporate new therapeutic strategies not yet available in our country.

Introducción:O neuroblastoma é o tumor sólido extracraniano mais frequente em crianças. Aproximadamente 50% dos pacientes são classificados como de alto risco considerando as características clínicas, biológicas e histológicas. Objetivo: Descrever a população atendida no Centro Hemato-Oncológíco Pediátrico (CHOP) do Centro Hospitalario Pereira Rossell (CHPR) com diagnóstico de neuroblastoma de alto risco, seu tratamento e sobrevida. Método: Estudo descritivo, retrospectivo, de todos os pacientes com neuroblastoma de alto risco diagnosticados no CHOP, no período entre 2001 e 2015. O Registro Nacional de Câncer Pediátrico está localizado no CHOP, bem como o Arquivo de Histórias Clínicas de todos os pacientes. Os dados são coletados e analisados pelo setor estatístico. Resultados: Foram diagnosticados 35 pacientes. Vinte (57%) eram do sexo masculino. Mediana de idade: 36,6 meses (5-93). Localização suprarrenal: 23 (66%). Estádio IV 100%. Metástases, medula óssea e osso: 27 (71%). Trinta e três pacientes receberam transplante de células-tronco hematopoiéticas (TCTH) (94%). Status prévio a TCTH, remissão completa: 19 (58%), remissão parcial: 14 (42%). Incidência de mortalidade relacionada ao tratamento: 15% e de recaídas: 68%. Mediana do tempo de recaída: 15 meses (3-52). A probabilidade de sobrevida global e sobrevida livre de eventos aos cinco anos foi de 37,8% ± 8,4 e 23,8% ± 7,3 (mediana de seguimento 40 meses). Conclusão: Apesar do tratamento intensivo e medidas de suporte adequadas, o prognóstico em crianças com neuroblastoma de alto continua sendo pobre no Uruguai. É necessário incorporar novas estratégias terapêuticas que ainda não estão disponíveis em nosso meio

Primera experiencia de tratamiento con everolimus en un paciente con esclerosis tuberosa y astrocitoma subependimario de células gigantes en Uruguay / First experience of everolimus in patients with tuberous sclerosis and subependymal giant cell astrocytoma in Uruguay

Resumen: El complejo esclerosis tuberosa (CET) es una enfermedad genética multisistémica determinada por la pérdida de función del complejo hamartina/tuberina. Esto causa activación del m-TOR con formación de tumores como el astrocitoma subependimario de células gigantes (SEGA). El everolimus inhibe el m-TOR reduciendo el tamaño de los SEGA. El objetivo de este trabajo es mostrar la experiencia del primer caso de SEGA tratado con everolimus en Uruguay. Caso: Escolar de 6 años, con desarrollo normal, sin epilepsia y portador de CET. A los 5 años instala hipertensión intracraneana por hidrocefalia secundaria al SEGA. Se realiza cirugía lográndose resección parcial, con remanente tumoral de 14.3cm³. Se inició everolimus evidenciando las resonancias magnéticas de control una reducción del tamaño tumoral del 54.5% al mes, del 65.5% a los 3 meses y del 68.5% a los 6 meses de iniciado el tratamiento. Presentó efectos secundarios menores (aftas bucales, infecciones respiratorias altas). La buena respuesta obtenida aporta evidencia del uso del everolimus como tratamiento complementario a la cirugía en los pacientes con SEGA.

Abstract: Tuber sclerosis complex (TSC) is a multisystemic genetic disease caused by a loss of function of hamartin/tuberin complex. This results in an m-TOR activation with tumor formation, among which is subependymal giant cell astrocytoma (SEGA). Everolimus inhibits m-TOR reducing SEGA size. The objective of this work is to show the first experience of SEGA treatment with everolimus in Uruguay. Case: 6 years old boy with TSC, with normal development and no history of seizures. At the age of 5 he installed intracranial hypertension due to hydrocephalus secondary to a SEGA. With surgery tumor was partially resect, with a 14.3cm³ tumor remnant. Treatment with everolimus was iniciated with a tumor size reduction of 54.5% after the first month of treatment, 65.5% after 3 months and 68.5% after 6 months. He had minor secondary effects (mouth ulcerations and upper respiratory tract infections). Good response in this patient shows evidence of possible use of everolimus as an adjuvant terapy to surgery in SEGA.

Neuroblastoma en niños menores de 18 meses. Experiencia de 10 años en Centro Hematooncológico / Neuroblastoma less than 18 months of age. 10 years experience in pediatric hematooncologic of the Pereira Rossell Hospital Center

Introducción: el neuroblastoma es el tumor maligno más frecuente en los lactantes. Su curso clínico es variable, desde la regresión espontánea a la progresión maligna, y los factores pronósticos son múltiples, como edad, estadio, amplificación de N-myc y ploidía tumoral. Se describen las características de todos los pacientes con neuroblastoma menores de 18 meses asistidos en CHOP. Pacientes y métodos: estudio observacional, descriptivo y retrospectivo en el período entre 31 de enero de 2000 y 31 de enero de 2011. El diagnóstico se realizó por histología y aspirado de médula ósea. Los pacientes se estadificaron por INSS; el tratamiento se decidió según estadio y riesgo. Resultados: se incluyeron 22 pacientes menores de 18 meses (52% de todos los neuroblastomas), con una media de edad de 9,6 meses. Once pacientes se encontraban en estadio 4. La localización más frecuente fue suprarrenal; presentaban metástasis 13 pacientes. Quince niños recibieron poliquimioterapia y 20 fueron tratados quirúrgicamente. La amplificación del gen N-myc se demostró en tres pacientes. La sobrevida global fue de 77% y la sobrevida libre de enfermedad fue de 77%. Discusión y conclusiones: la mayor parte de los casos fueron diagnosticados en niños menores de 9 meses. Fueron más frecuentes los estadios 4 y 1. No se pudo demostrar asociación entre N-myc y estadio de enfermedad. La sobrevida fue excelente.

Introduction: neuroblastoma is the most common malignant tumor in infants. Its clinical behavior is variable, from spontaneous regression to malignant progression; prognostic factors are multiple, such as age, stage, N-myc amplification and tumor ploidy. We describe the characteristic of all patients with neuroblastoma less than 18 months of age assisted in CHOP. Patients and methods: retrospective, observational and descriptive study in the period between 31/1/00 y 31/01/11. Diagnose was made from histology and bone marrow aspirate. Patients were classified by INSS stage; treatment was decided according to stage and risk. Results: 22 patients were included (52% of all neuroblastomas), with a mean age of 9,6 months. Eleven patients were classified in stage 4. The most frequent localization was adrenal; 14 patients presented methastasis. Fifteen patients received chemotherapy and 20 were surgically intervened. N-myc amplification was detected in 3 patients. Overall survival was 77% and event-free survival was 77%. Discussion and conclusions: the majority of cases were diagnosed in children younger than 9 months. Stages 4 and 1 were the most frequent. No association between N-myc and stage could be determined. Overall and event-free survival were excellent.

Trasplante alogénico haploidéntico de progenitores hematopoyéticos en pediatría en Uruguay / Haploidentical allogeneic hematopoietic transplant of hematopoietic parents in pediatrics in Uruguay

Introducción: el trasplante alogénico de progenitores hematopoyéticos (TPH) es actualmente la única opción de tratamiento curativo disponible para un número de neoplasias hematológicas de alto riesgo, así como para algunas enfermedades no malignas hereditarias o adquiridas. El TPH haploidéntico (HI) es una opción válida para pacientes que no tienen un hermano HLA-idéntico. Objetivo: describir los resultados obtenidos con TPH HI en pediatría. Material y método: en el año 2005 se inició en el Centro Hemato-Oncológico Pediátrico del Centro Hospitalario Pereira Rossell un programa de TPH HI para aquellos pacientes sin donante relacionado HLA-idéntico. Resultados: se trasplantaron 32 pacientes, 24 con neoplasias hematológicas y 8 con enfermedades no malignas. Se utilizaron dos estrategias de prevención de la enfermedad injerto contra huésped (EICH), depleción de linfocitos T (DLT) in vitro (28 pacientes) y DLT alorreactivos in vivo con altas dosis de ciclofosfamida postrasplante (4 pacientes). Veintisiete pacientes (84%) tuvieron un implante con quimerismo total del donante. La incidencia de EICH agudo y crónico fue de 26,9% y 11,8%, respectivamente. La muerte no relacionada a recaída al año del trasplante fue de 21,9%. Con una mediana de seguimiento de 32 meses, la sobrevida global a dos años fue de 52,4%. Conclusiones: el TPH HI ha demostrado ser una opción factible en nuestro medio para aquellos pacientes sin donante HLA-idéntico. Los resultados son comparables a los obtenidos con otros donantes alternativos y con costos más accesibles. Uruguay está hoy día mejor posicionado para ofrecer un TPH a los pacientes que así lo requieran...

Quality of life in childhood immune thrombocytopenia: international validation of the kids' ITP tools.

BACKGROUND: The Kids ITP Tools (KIT) is a disease-specific measure of health-related quality of life for children with immune thrombocytopenia (ITP). To facilitate use in international trials it has been cross-culturally adapted for France, Germany, the United Kingdom and Uruguay. This study assessed the validity and reliability of the translated KIT in comparison to generic quality of life measures. METHODS: Children 2-18 years of age with ITP and their parents were recruited in France, Germany, the United Kingdom and Uruguay. Participants completed the KIT, PedsQL and KINDL. We examined the Pearson's correlation between these measures for our pooled sample and estimated the reliability over a 2-week time period. Findings were further explored by country. RESULTS: A total of 127 families (81 children self-reported) participated. Mean child-reported scores were: KIT 74.3 (SD = 15.3), PedsQL 81.3 (SD = 13.0), and KINDL 70.5 (SD = 14.3). Corresponding mean parent proxy-reported scores were: 70.6 (SD = 18.1), 75.7 (SD = 16.8) and 72.3 (SD = 12.7), respectively. Correlation between KIT and the generic measures was consistent with our a priori hypothesis (PedsQL r = 0.54, KINDL r = 0.48, both P < 0.0001). Child KIT scores for newly diagnosed ITP patients were significantly lower than for chronic ITP patients (67.3 vs. 77.3; P = 0.005). There was a significant correlation (P < 0.001) between the child and parent proxy KIT scores (ICC = 0.52). Child KIT test-retest reliability was acceptable at 0.71. CONCLUSIONS: The cross-culturally translated KIT is valid and reliable with acceptable correlation to the PedsQL and KINDL. There is a significant difference in child self-reported KIT scores between newly diagnosed and chronic ITP.

Neuroblastoma en niños menores de 18 meses. Experiencia de 10 años en Centro Hematooncológico Pediátrico del Centro Hospitalario Pereira Rossel / Neuroblastome in children younger than 18 months. Ten years experience at the Pediatric Hemato Oncological Center of the Centro Hospitalario Pereira Rossell

El neuroblastoma es el tumor maligno más frecuente en los lactantes. Su curso clínico es variable, desde la regresión espontánea a la progresión maligna, y los factores pronósticos son múltiples, como edad, estadio, amplificación de N-myc y ploidía tumoral. Se describen las características de todos los pacientes con neuroblastoma menores de 18 meses asistidos en CHOP. Pacientes y métodos: estudio observacional, descriptivo y retrospectivo en el período entre 31 de enero de 2000 y 31 de enero de 2011. El diagnóstico se realizó por histología y aspirado de médula ósea. Los pacientes se estadificaron por INSS; el tratamiento se decidió según estadio y riesgo. Resultados: se incluyeron 22 pacientes menores de 18 meses (52% de todos los neuroblastomas), con una media de edad de 9,6 meses. Once pacientes se encontraban en estadio 4. La localización más frecuente fue suprarrenal; presentaban metástasis 13 pacientes. Quince niños recibieron poliquimioterapia y 20 fueron tratados quirúrgicamente. La amplificación del genN-myc se demostró en tres pacientes. La sobrevida global fue de 77% y la sobrevida libre de enfermedad fuede 77%. Discusión y conclusiones: la mayor parte de los casosfueron diagnosticados en niños menores de 9 meses. Fueron más frecuentes los estadios 4 y 1. No se pudo demostrar asociación entre N-myc y estadio de enfermedad. La sobrevida fue excelent...

Measuring disease-specific quality of life in rare populations: a practical approach to cross-cultural translation.

BACKGROUND: Disease-specific quality of life (QoL) measures have enhanced the capacity of outcome measures to evaluate subtle changes and differences between groups. However, when the specific disease is rare, the cohort of patients is small and international collaboration is often necessary to accomplish meaningful research. As many of the QoL measures have been developed in North American English, they require translation to ensure their usefulness in a multi-cultural and/or international society. Published guidelines provide formal methods to achieve cross-culturally comparable versions of a QoL tool. However, these guidelines describe a rigorous process that is not always feasible, particularly in rare disease groups. The objective of this manuscript is to describe the process that was developed to achieve accurate cross-cultural translations of a disease-specific QoL measure, to overcome the challenges of a small sample size, i.e. children with a rare disorder. PROCEDURE: A measurement study was conducted in the United Kingdom (UK), France, Germany and Uruguay, during which the validated measure was translated into the languages of the respective countries. RESULTS: This is a report of a modified, child-centric, cross-cultural translation and adaptation process in which culturally appropriate and methodologically valid translations of a disease-specific QoL measure, the Kids' ITP Tools (KIT), were performed in children with immune thrombocytopenic purpura (ITP). The KIT was translated from North American English into UK English, French, German, and Spanish. CONCLUSION: This study was a successful international collaboration. The modified process through which culturally appropriate and methodologically valid translations of QoL measures may be achieved in a pediatric population with a relatively rare disorder is reported.

Shock séptico por Pseudomonas aeruginosa adquirido en la comunidad asociado a neutropenia, en un paciente previamente sano

Resumen La sepsis por Pseudomonas aeruginosa adquirida en la comunidad en niños previamente sanos es una entidad excepcional. Se presenta el caso clínico de una niña previamente sana que presentó un shock séptico refractario, asociado a neutropenia, ectima gangrenoso, enterocolitis necrotizante y abscesos hepáticos causado por Pseudomonas aeruginosa. La incorporación de antibióticos con acción anti-Pseudomonas en el régimen empírico inicial de la sepsis adquirida en la comunidad, cuando se sospeche esta etiología, puede mejorar el pronóstico de estos pacientes.

Summary Community-acquired sepsis by Pseudomonas aeruginosa in previously healthy children is exceptional. A clinical case of a previously healthy child with refractary septic shock associated with neutropenia, ecthyma gangrenosum, necrotizing colitis and hepatic abscess due to Pseudomonas aeruginosa is presented. The fast application of an anti Pseudomona treatment with empiric antibiotics may improve the prognosis of these patients.

Enfermedad de Castleman en una adolescente / Castleman's disease in an adolescent female

La enfermedad de Castleman es una enfermedad linfoproliferativa de las células B, de la cual existen escasas publicaciones en la edad pediátrica. Histológicamente benigna, pero que puede comportarse como maligna, su etiología aún es desconocida. Existen dos formas clínicas bien definidas: o localizada y multicéntrica o diseminada. Se describen tres tipos histológicos: hialino-vascular, plasmocítico y mixto. Puede presentarse como masa tumoral asintomática o como una enfermedad sistémica con fiebre y repercusión general. El tratamiento óptimo no se conoce. La evolución es buena en la enfermedad de Castleman unicéntrica tras la exéresis quirúrgica, mientras que la presentación multicéntrica es de difícil manejo, con pobre respuesta a los tratamientos ensayados y mal pronóstico. Se presenta el caso clínico de una adolescente de 14 años, con enfermedad de Castleman localizada en mediastino, que se presentó con sintomatología caracterizada por fiebre, anemia y adelgazamiento, a la cual se le practicó una resección quirúrgica completa. De los exámenes paraclínicos se destaca la presencia de una plasmocitosis en médula ósea. La respuesta al tratamiento quirúrgico fue la mejoría de los síntomas clínicos y de las alteraciones de laboratorio