Clofarabine monotherapy in aggressive, relapsed and refractory Langerhans cell histiocytosis.

Over 50% of patients with systemic LCH are not cured with front-line therapies, and data to guide salvage options are limited. We describe 58 patients with LCH who were treated with clofarabine. Clofarabine monotherapy was active against LCH in this cohort, including heavily pretreated patients with a systemic objective response rate of 92.6%, higher in children (93.8%) than adults (83.3%). BRAFV600E+ variant allele frequency in peripheral blood is correlated with clinical responses. Prospective multicentre trials are warranted to determine optimal dosing, long-term efficacy, late toxicities, relative cost and patient-reported outcomes of clofarabine compared to alternative LCH salvage therapy strategies.

Persistent Child Poverty and Mortality in a Cohort of Children with Cancer in Alabama.

BACKGROUND: One-fifth of U.S. counties are designated persistent child poverty counties (≥20% of children in poverty since 1980). The association between a persistent child poverty environment and mortality in children with cancer is unknown. METHODS: Our cohort includes 2,089 children with cancer (2000-2016) in Alabama. We used multivariable Cox proportional hazards modeling (adjusted for sociodemographics/clinical characteristics) to assess mortality by persistent child poverty designation at 1, 5, and 10 years from diagnosis. Distance to treatment was subsequently explored. RESULTS: Forty-two percent of the cohort lived in a persistent child poverty county; they were more likely to be African American (P < 0.0001), have public/no insurance (P = 0.0009), and live >100 miles to treatment (P < 0.0001). Children in persistent child poverty counties were 30% more likely to die by 5 years [95% confidence interval (CI) = 1.06-1.59; P = 0.012]. Distance (per 20-mile increase) to treatment was associated with a 9% increased mortality risk (P < 0.0001). Children with both exposures (distance >100 miles and persistent child poverty) faced the highest mortality risk at 5 years (HR = 1.80; 95% CI = 1.39-2.33; P < 0.0001). In subanalysis, children exposed to persistent child poverty were at higher risk for cancer-related mortality. However, the risk of health-related mortality did not differ. CONCLUSIONS: Among children with cancer from the Deep South, persistent child poverty was a prevalent exposure associated with inferior overall survival. Distance to treatment was independently associated with inferior survival. Children with both exposures had the highest risk of mortality. IMPACT: Persistent child poverty is associated with inferior survival among children with cancer; mechanisms underlying this disparity warrant investigation. See related commentary by Orjuela-Grimm and Beauchemin, p. 295.

Growing Teratoma Syndrome After Chemotherapy For Ovarian Immature Teratoma.

The management of ovarian immature teratoma (IT) presents several challenges. It occurs both in children and adults and therefore is managed by pediatric oncologists as well as adult and gynecologic oncologists. Treatment approach; however, varies significantly. Unlike pediatric patients in whom surgery is considered the mainstay of treatment, adult providers routinely prescribe postoperative chemotherapy. Management of recurrent IT can be challenging. Growing teratoma syndrome may occur after treatment of recurrent IT. We report the development and management of this phenomenon in a pediatric patient who had several recurrences of her IT.

Association of autoimmune hepatitis type 1 in a child with Evans syndrome.

Autoimmune hepatitis (AIH) is a progressive liver disease that is often associated with extrahepatic autoimmune disorders. Evans syndrome (ES) is a rare autoimmune disorder, which is characterized by immune thrombocytopenia and autoimmune hemolytic anemia. Association of AIH with ES is rare, especially in children. We report a 3-year-old female with a past medical history of ES who presented with jaundice and significant transaminitis due to AIH type 1. She required multiple treatments with steroids as well as azathioprine, intravenous immunoglobulin and a course of rituximab.

Organ iron accumulation in chronically transfused children with sickle cell anaemia: baseline results from the TWiTCH trial.

Transcranial Doppler (TCD) With Transfusions Changing to Hydroxyurea (TWiTCH) trial is a randomized, open-label comparison of hydroxycarbamide (also termed hydroxyurea) versus continued chronic transfusion therapy for primary stroke prevention in patients with sickle cell anaemia (SCA) and abnormal TCD. Severity and location of iron overload is an important secondary outcome measure. We report the baseline findings of abdominal organ iron burden in 121 participants. At enrollment, patients were young (9·8 ± 2·9 years), predominantly female (60:40), and previously treated with transfusions (4·1 ± 2·4 years) and iron chelation (3·1 ± 2·1 years). Liver iron concentration (LIC; 9·0 ± 6·6 mg/g dry weight) and serum ferritin were moderately elevated (2696 ± 1678 µg/l), but transferrin was incompletely saturated (47·2 ± 23·6%). Spleen R2* was 509 ± 399 Hz (splenic iron ~13·9 mg/g) and correlated with LIC (r(2)  = 0·14, P = 0·0008). Pancreas R2* was increased in 38·3% of patients but not to levels associated with endocrine toxicity. Kidney R2* was increased in 80·7% of patients; renal iron correlated with markers of intravascular haemolysis and was elevated in patients with increased urine albumin-creatinine ratios. Extra-hepatic iron deposition is common among children with SCA who receive chronic transfusions, and could potentiate oxidative stress caused by reperfusion injury and decellularized haemoglobin.

Effects of hydroxyurea treatment for patients with hemoglobin SC disease.

Although hemoglobin SC (HbSC) disease is usually considered less severe than sickle cell anemia (SCA), which includes HbSS and HbS/ß(0) -thalassemia genotypes, many patients with HbSC experience severe disease complications, including vaso-occlusive pain, acute chest syndrome, avascular necrosis, retinopathy, and poor quality of life. Fully 20 years after the clinical and laboratory efficacy of hydroxyurea was proven in adult SCA patients, the safety and utility of hydroxyurea treatment for HbSC patients remain unclear. Recent NHLBI evidence-based guidelines highlight this as a critical knowledge gap, noting HbSC accounts for ∼30% of sickle cell patients within the United States. To date, only 5 publications have reported short-term, incomplete, or conflicting laboratory and clinical outcomes of hydroxyurea treatment in a total of 71 adults and children with HbSC. We now report on a cohort of 133 adult and pediatric HbSC patients who received hydroxyurea, typically for recurrent vaso-occlusive pain. Hydroxyurea treatment was associated with a stable hemoglobin concentration; increased fetal hemoglobin (HbF) and mean corpuscular volume (MCV); and reduced white blood cell count (WBC), absolute neutrophil count (ANC), and absolute reticulocyte count (ARC). Reversible cytopenias occurred in 22% of patients, primarily neutropenia and thrombocytopenia. Painful events were reduced with hydroxyurea, more in patients >15 years old. These multicenter data support the safety and potentially salutary effects of hydroxyurea treatment for HbSC disease; however, a multicenter, placebo-controlled, Phase 3 clinical trial is needed to determine if hydroxyurea therapy has efficacy for patients with HbSC disease.

Hydroxycarbamide versus chronic transfusion for maintenance of transcranial doppler flow velocities in children with sickle cell anaemia-TCD With Transfusions Changing to Hydroxyurea (TWiTCH): a multicentre, open-label, phase 3, non-inferiority trial.

BACKGROUND: For children with sickle cell anaemia and high transcranial doppler (TCD) flow velocities, regular blood transfusions can effectively prevent primary stroke, but must be continued indefinitely. The efficacy of hydroxycarbamide (hydroxyurea) in this setting is unknown; we performed the TWiTCH trial to compare hydroxyurea with standard transfusions. METHODS: TWiTCH was a multicentre, phase 3, randomised, open-label, non-inferiority trial done at 26 paediatric hospitals and health centres in the USA and Canada. We enrolled children with sickle cell anaemia who were aged 4-16 years and had abnormal TCD flow velocities (≥ 200 cm/s) but no severe vasculopathy. After screening, eligible participants were randomly assigned 1:1 to continue standard transfusions (standard group) or hydroxycarbamide (alternative group). Randomisation was done at a central site, stratified by site with a block size of four, and an adaptive randomisation scheme was used to balance the covariates of baseline age and TCD velocity. The study was open-label, but TCD examinations were read centrally by observers masked to treatment assignment and previous TCD results. Participants assigned to standard treatment continued to receive monthly transfusions to maintain 30% sickle haemoglobin or lower, while those assigned to the alternative treatment started oral hydroxycarbamide at 20 mg/kg per day, which was escalated to each participant's maximum tolerated dose. The treatment period lasted 24 months from randomisation. The primary study endpoint was the 24 month TCD velocity calculated from a general linear mixed model, with the non-inferiority margin set at 15 cm/s. The primary analysis was done in the intention-to-treat population and safety was assessed in all patients who received at least one dose of assigned treatment. This study is registered with ClinicalTrials.gov, number NCT01425307. FINDINGS: Between Sept 20, 2011, and April 17, 2013, 159 patients consented and enrolled in TWiTCH. 121 participants passed screening and were then randomly assigned to treatment (61 to transfusions and 60 to hydroxycarbamide). At the first scheduled interim analysis, non-inferiority was shown and the sponsor terminated the study. Final model-based TCD velocities were 143 cm/s (95% CI 140-146) in children who received standard transfusions and 138 cm/s (135-142) in those who received hydroxycarbamide, with a difference of 4·54 (0·10-8·98). Non-inferiority (p=8·82 × 10(-16)) and post-hoc superiority (p=0·023) were met. Of 29 new neurological events adjudicated centrally by masked reviewers, no strokes were identified, but three transient ischaemic attacks occurred in each group. Magnetic resonance brain imaging and angiography (MRI and MRA) at exit showed no new cerebral infarcts in either treatment group, but worsened vasculopathy in one participant who received standard transfusions. 23 severe adverse events in nine (15%) patients were reported for hydroxycarbamide and ten serious adverse events in six (10%) patients were reported for standard transfusions. The most common serious adverse event in both groups was vaso-occlusive pain (11 events in five [8%] patients with hydroxycarbamide and three events in one [2%] patient for transfusions). INTERPRETATION: For high-risk children with sickle cell anaemia and abnormal TCD velocities who have received at least 1 year of transfusions, and have no MRA-defined severe vasculopathy, hydroxycarbamide treatment can substitute for chronic transfusions to maintain TCD velocities and help to prevent primary stroke. FUNDING: National Heart, Lung, and Blood Institute, National Institutes of Health.

Benefits of delayed fetal hemoglobin (HbF) switching in sickle cell disease (SCD): a case report and review of the literature.

Sickle cell disease is an autosomal recessive hemoglobinopathy with significant morbidity and mortality. Complications include: vasoocclusive pain crisis, bacterial infection, cerebral vascular accident, acute chest syndrome, and chronic lung and kidney disease. Among many other factors affecting the severity of sickle cell disease, synthesis of fetal hemoglobin (HbF) emerged as an important prognostic factor and has long been recognized to decrease disease severity. This report discusses the attenuated clinical course of a child who continued to produce HbF well beyond the reported age of fetal switching. We further discuss the underlying genetic aspects of HbF production and review the pertinent literature.

Prevalence of pneumococcal bacteremia in children with sickle cell disease.

We performed a retrospective chart review of children with sickle cell disease hospitalized for fever at our local institution. We reviewed 456 hospitalizations in 133 patients between January 2006 and June 2012. The prevalence of true bacteremia was 4%. The mean C-reactive protein values and temperatures were nonsignificantly higher in patients with positive blood cultures. The mean time to detection was 22.5 hours in bacteremia compared to 32.6 hours in blood cultures that grew contaminants (p = .034). Only two (0.4%) cases of pneumococcal bacteremia were reported and both occurred before May 2010, which marks the introduction of 13-valent pneumococcal vaccine (PCV13). Both patients with pneumococcal bacteremia had discontinued penicillin prophylaxis after the age of 5 years. The first patient was immunized but contracted a nonvaccine serotype (23B). The second patient was partially vaccinated and acquired a vaccine-preventable serotype (23F). Both serotypes were sensitive to ceftriaxone and vancomycin; one was resistant to penicillin. This is the first study reporting the prevalence of pneumococcal bacteremia since the introduction of PCV13.

Successful treatment of rhino-orbital mucormycosis with posaconazole and hyperbaric oxygen therapy.

Mucormycosis is a rare, but invasive infection caused by ubiquitous molds. Amphotericin B and surgery have been known to help improve the outcome. Sporadic case reports support the use of posaconazole in adults. We report a toddler with acute lymphoblastic leukemia who acquired rhino-orbital mucormycosis caused by Rhizopus species at the end of induction chemotherapy. She was successfully treated with multiple surgical debridements, amphotericin B, posaconazole and hyperbaric oxygen therapy. In conclusion, mucormycosis is a serious infection that requires aggressive surgical and medical therapy. To the best of our knowledge the use of posaconazole combined with hyperbaric oxygen therapy has not been reported in a toddler with leukemia and invasive Rhizopus sp. infection. This approach was found to be safe and effective in our patient.

Pulmonary function abnormalities and asthma are prevalent in children with sickle cell disease and are associated with acute chest syndrome.

Pulmonary diseases form major sources of morbidity and mortality in children with sickle cell disease (SCD). The objective of the study was to determine the prevalence of lung function abnormalities and asthma and their association with acute chest syndrome (ACS) in children with SCD. This was a cross-sectional retrospective study of 127 children with SCD; we collected information regarding ACS and asthma and pulmonary function test (PFT) data. Based on PFT results, the patients were assigned to one pattern of lung function [normal, obstructive lung disease (OLD), restrictive lung disease (RLD)]. Statistical analyses included Pearson correlation, prevalence odds ratio (POR), cross-tabulation, and multiple binary logistic regression. OLD was noted in 35% and RLD in 23% of the patients, with the remainder exhibiting a normal PFT pattern. Forty-six percent of patients had asthma, 64% of whom had a history of ACS. OLD (r = .244, P = .008, POR = 2.8) and asthma (r = .395, P < .001, POR = 5.4) were significantly associated with a history of ACS. There was a negative correlation between having normal PFT data and a history of ACS (r = -.289, P = .002, POR = .3). Asthma and pulmonary function abnormalities are prevalent in children with SCD, with OLD being more common than RLD. There is an association between asthma, OLD, and ACS, however causality cannot be proven due to the study design. We stress the importance of actively investigating for a clinical diagnosis of asthma in all patients with SCD and suggest that PFT data may help detect patients at lower risk for ACS.

Sensitivity and specificity of bone marrow hemophagocytosis in hemophagocytic lymphohistiocytosis.

Hemophagocytic lymphohistiocytosis (HLH) is a potentially fatal disease characterized by abnormal activation of T-lymphocytes and macrophages. The diagnosis of HLH can be established if there is a family history of HLH, or evidence of genetic defects, or if 5 of 8 clinicopathologic criteria are fulfilled. This case-control study aimed to examine the extent of hemophagocytosis on the bone marrow examination of patients fulfilling diagnostic criteria for HLH. Hemophagocytosis in 6 bone marrow aspirates from 3 HLH patients was compared with 20 random control bone marrows. Macrophages with hemophagocytosis were counted using a Miller ocular disc in fields corresponding to 9,000 nucleated cells. Mean hemophagocytosis count in the HLH cases was estimated at 0.082% (range 0-0.31%), whereas in the controls it was 0.009% (range 0-0.04%). The sensitivity of hemophagocytosis was 83% with a specificity of only 60%. This demonstrates that rare hemophagocytosis can be seen in bone marrow aspirates from patients without a clinical diagnosis of HLH. It also shows that hemophagocytosis has too low a specificity to be a screening test for HLH. While the hemophagocytosis counts are significantly higher in HLH cases than in controls, overlap of the counts precludes using hemophagocytosis as a reliable indicator of HLH. A rise in the hemophagocytosis count threshold of 0.05-0.13% would increase the specificity to 100%. We suggest that the diagnostic scheme for HLH needs revision, and can be improved by addressing minimum hemophagocytosis count threshold.

Eastern equine encephalitis virus infection and hemophagocytic lymphohistiocytosis in a 5-month-old infant.

Eastern equine encephalitis virus infection is a rare sporadic central nervous system infection transmitted by a mosquito vector. Hemophagocytic lymphohistiocytosis (HLH) is a rare life-threatening disease associated with the inability of an overactive immune system to effectively respond to infections. Many viruses are known to trigger primary, as well as secondary, HLH. We report a pediatric case of eastern equine encephalitis virus-associated HLH which caused severe neurologic injury and death.

Effect of time to resumption of chemotherapy after definitive surgery on prognosis for non-metastatic osteosarcoma.

BACKGROUND: The dose intensity of chemotherapy has been described as affecting the outcome of the treatment of a number of different types of tumors. A delay in the resumption of chemotherapy after definitive surgery for the treatment of osteosarcoma can decrease the overall dose intensity. The goal of this study was to assess the prognostic significance of the time to resumption of chemotherapy after definitive surgery in patients with localized osteosarcoma in an extremity. METHODS: The relationships of the time between definitive surgery and resumption of chemotherapy with death and adverse events in 703 patients with a localized resectable osteosarcoma in an extremity (556 treated in the Children's Oncology Group [COG] Study [INT 0133] and 147 treated at five tertiary care cancer centers) were assessed with use of Cox proportional hazards models. RESULTS: The twenty-fifth, fiftieth, and seventy-fifth percentiles of time from definitive surgery to resumption of chemotherapy were twelve, sixteen, and twenty-one days, respectively. Overall survival was poorer for patients who had had a delay of greater than twenty-one days before the resumption of chemotherapy compared with those who had had a shorter delay (hazard ratio = 1.57 [95% confidence interval = 1.04 to 2.36]; p = 0.03). Of seventy-one COG-study patients with postoperative complications, 32% (twenty-three) had a delay of more than twenty-one days before resumption of chemotherapy, but 20% (eighty-nine) of 444 patients with no complications had a similar delay. CONCLUSIONS: In this retrospective analysis, increased time from the definitive surgery to the resumption of chemotherapy was found to be associated with an increased risk of death of patients with localized osteosarcoma in an extremity. Within the limitations of a retrospective study, the data indicate that it is best to resume chemotherapy within twenty-one days after definitive surgery. Surgeons, oncologists, patients, and those responsible for scheduling need to work together to ensure timely resumption of chemotherapy after surgery.