Wilms tumour in children: 18 years of experience at Vilnius University Hospital Santaros Klinikos, Lithuania.

INTRODUCTION: Wilms tumour (WT) is the most common childhood abdominal malignancy, with an average annual incidence of 1 in 10,000 children. The study published in 2002 reported lower survival rates of WT in Lithuania in comparison to the data of SIOP-9 study and the European Organization for Research and Treatment of Cancer (EORTC). We aimed to assess current diagnostic approach and treatment results of patients with WT treated at our institution and to compare the results with the previously published study. MATERIALS AND METHODS: A retrospective single-centre study was performed. 48 patients with WT registered at the institutional data-base from 2000 to 2018 were enrolled. An estimated 5-year overall survival (OS5y) and 2-year event-free survival (EFS2y) by stage and risk groups was calculated using IBM SPSS. A comparative analysis of two time periods - 2000-2008 and 2009-2018 - was carried out. RESULTS: Forty-two (87.5%) patients presented with localised disease and 6 (12.5%) with primary metastatic disease. The majority of cases were of the intermediate-risk group (77%). The OS5yof all analysed children was 86.4%. The EFS2y was 88.9% in stage I, 91.7% in stage II, 83.3% in stage III, and 50% in stage IV. The EFS2y was 100% in the low-risk group, 86.5% in the intermediate-risk group, and 25% in the high-risk group. Improvement of outcomes was observed over the analysed period: OS5y changed from 81.0% in 2000-2008 to 92.6% in 2009-2018. Among 48 cases, ten patients showed recurrence: eight - early relapse and two - late relapse. Six patients died. CONCLUSIONS: WT was diagnosed at early stages in most cases. The  survival was better among the  patients diagnosed in earlier stages and with favourable risk group. Better survival rates were observed in patients treated in 2009-2018 compared to the 2000-2008 period.

Plasma membrane is the target of rapid antibacterial action of silver nanoparticles in Escherichia coli and Pseudomonas aeruginosa.

INTRODUCTION: Silver nanoparticles (AgNP) are widely used in consumer products and in medicine, mostly due to their excellent antimicrobial properties. One of the generally accepted antibacterial mechanisms of AgNP is their efficient contact with cells and dissolution in the close vicinity of bacterial cell envelope. Yet, the primary mechanism of cell wall damage and the events essential for bactericidal action of AgNP are not elucidated. MATERIALS AND METHODS: In this study we used a combination of various assays to differentiate the adverse effects of AgNP on bacterial cell envelope: outer membrane (OM) and plasma membrane (PM). RESULTS: We showed that PM was the main target of AgNP in gram-negative bacteria Escherichia coli and Pseudomonas aeruginosa: AgNP depolarized PM, induced the leakage of the intracellular K+, and inhibited cellular respiration. The results of bacterial bioluminescence inhibition assay in combination with AgNP dissolution and oxidation assays demonstrated that the adverse effects of AgNP occurred at concentrations 7-160 µM. These toxic effects occurred already within the first few seconds of contact of bacteria and AgNP and were driven by dissolved Ag+ ions targeting bacterial PM. However, the irreversible inhibition of bacterial growth detected after 1-hour exposure occurred at 40 µM AgNP for P. aeruginosa and at 320 µM AgNP for E. coli. In contrast to effects on PM, AgNP and Ag+ ions had no significant effect on the permeability and integrity of bacterial OM, implying that AgNP indeed targeted mainly PM via dissolved Ag+ ions. CONCLUSION: AgNP exhibited antibacterial properties via rapid release of Ag+ ions targeting the PM and not the OM of gram-negative bacteria.

Improved outcome of childhood acute myeloid leukemia in an Eastern European country: Lithuanian experience.

The reported treatment outcomes of children treated for cancer in Eastern European countries are inferior to those in Northern/Western Europe. We hypothesized that recent survival rates could be comparable to the current standards and performed a population-based analysis of treatment outcome of childhood acute myeloid leukemia (AML) in Lithuania, a small Eastern European country. Children < 18 years old who were treated for AML from 2000 to 2013 were included (n = 54). Estimates of 5-year event-free (EFS5y) and overall survival (OS5y) rates were analyzed. Comparing periods 2000-2006 (n = 32) and 2007-2013 (n = 22), the EFS5y improved from 31 to 63% (p = 0.04), and the OS5y improved from 31 to 72% (p = 0.02) because of reductions in toxicity-related mortality (42 vs. 15%, p = 0.08) and relapse (43 vs. 25%, p = 0.08). The most significant improvement was demonstrated in high-risk patients (OS5y improved from 26 to 75%, p = 0.02) who benefited from hematopoietic stem cell transplantation: the post-transplant EFS5y increased from 13 to 86% (p = 0.01). CONCLUSIONS: The current survival rate of Lithuanian children treated for AML was comparable to the expected rate in other parts of Europe. What is Known: • In the last three decades, significant improvement has been achieved in treating childhood cancer, with an overall survival (OS) rate of > 80% in high-income countries. The difference in survival rates between Northern/Western and Eastern European countries as well as between high- and middle-/low-income countries is as much as 20%. Recently, the 5-year event-free survival rate of acute myeloid leukemia (AML) has reached > 60% in high-income countries. The survival rates for myeloproliferative diseases were the lowest in Eastern European countries. • The reported inferior survival rates were calculated based on outcome data of patients treated until 2007. The recent survival rates in Eastern European countries are unknown. What is New: • Being a small Eastern European country, Lithuania has experienced good economic growth during the last decade. We hypothesized that economic growth and gain of experience could result in better survival rates of children treated for cancer in our country in recent years. • A population-based analysis of treatment outcome of childhood AML treated in Lithuania in the recent years was performed for the first time. The survival rates of childhood AML in Lithuania are comparable to those of other high-income countries. Current survival rates of children treated for cancer in Eastern European countries could be comparable to the best current standards contributing to better European survival rates of childhood cancer in general.

Safety and efficacy of a glycoPEGylated rFVIII (turoctocog alpha pegol, N8-GP) in paediatric patients with severe haemophilia A.

Turoctocog alfa pegol (N8-GP, Novo Nordisk, Bagsværd, Denmark), an extended half-life glycoPEGylated recombinant factor VIII (rFVIII), is being developed for prophylaxis and treatment of bleeds in haemophilia A patients. pathfinder™5 is a multinational, open-label, single-arm trial to assess safety, efficacy and pharmacokinetics of N8-GP in paediatric (<12 years), previously treated patients. Boys with severe haemophilia A (<1 % FVIII), no history of inhibitors and previously treated with FVIII products (>50 exposure days [ED] for patients aged 0-5 years [younger cohort]; >150 ED for patients aged 6-11 years [older cohort]) were included. For prophylaxis, N8-GP was dosed at 50-75 IU/kg twice weekly; bleeds were treated with 20-75 IU/kg. Half-life was estimated for the patients' previous FVIII product and for N8-GP. Sixty-eight patients received N8-GP; none developed inhibitors and no other concerns were identified. Median annualised bleeding rate was 1.95 (1.94 and 1.97 in the younger and older cohorts, respectively). Twenty-nine patients (42.6 %; 15 younger and 14 older children, respectively) did not report any bleeding while on N8-GP prophylaxis; 39 patients (57.4 %; 19 younger and 20 older children, respectively) reported 70 bleeds (all mild/moderate). N8-GP treatment was successful for 78.6 % of bleeds in all patients, 80.0 % in younger and 77.5 % in older patients. Most bleeds (80.0 %) were treated with ≤2 injections. Half-life ratio between N8-GP and the patients' previous FVIII product was 1.85. N8-GP was well tolerated and provided effective prophylaxis and treatment of bleeds in paediatric patients with severe haemophilia A.

Survival of children treated for Ewing sarcoma in Lithuania: a single centre experience.

INTRODUCTION: Ewing sarcoma (ES) is a rare and aggressive malignant neoplasm that mostly affects children and adolescents. Recent studies reported a gap of 20% in childhood cancer survival rates between the Northern/Western and the Eastern European countries. We aimed to analyse the survival of patients treated for ES at our institution, to evaluate its correspondence to current survival rates in the expert centres, and to assess changes in treatment outcomes over time. MATERIALS AND METHODS: A retrospective single-centre study was performed. Children under 18 years of age, diagnosed and treated for Ewing sarcoma/PNET at our institution from 2000 to 2014 were included. To assess the hypothesized improvement of treatment outcomes over time, a comparative analysis of two time periods - 2000-2007 and 2008-2014 - was carried out. Five-year overall survival (OS5y) and disease-free survival (DFS5y) were chosen as primary study end-points. Clinical and laboratory data were retrieved from patient records. RESULTS: In total, 40 patients were included in the study: 24 (60%) males and 16 (40%) females. Twenty-eight children (70%) presented with local and 12 (30%) with primary metastatic disease. Over the analysed time frame, improvement in treatment outcomes was observed: DFS5y improved from 46% in 2000-2007 to 61% in 2008-2014 (p = 0.27), whereas OS5y changed minimally from 62% in 2000-2007 to 65% in 2008-2014. Increase in DFS5y was more prominent for localized disease -from 50% in 2000-2007 to 74% in 2008-2014 (p = 0.14). Prognosis of initial metastatic disease remained poor with DFS5y: 25% in 2000-2007 and 38% in 2008-2014. Patients' median follow-up was 12.3 years (the range from 8.1 to 15.6) and 3.9 years (the range from 1.1 to 8.0) in the first and second study groups, respectively. CONCLUSIONS: OS5y of the entire patient cohort did not change considerably over time and remained slightly inferior compared to the best reported survival rates. There was an evident trend for improvement of DFS5y in localized disease. Survival of children with primary metastases remained poor despite slight increase in DFS5y. Implementation of international clinical trials, consolidation of multidisciplinary approach, patients' concentration and widening of research activities could be beneficial for the treatment of children in the future.

Reduction in Proportion of Senescent CD8+ T Lymphocytes During Chemotherapy of Children with Acute Lymphoblastic Leukemia.

AIM: To evaluate quantitative changes in B, NK and T lymphocyte subsets in peripheral blood of children with acute lymphoblastic leukemia (ALL) undergoing chemotherapy. PATIENTS AND METHODS: Children with ALL were treated according to NOPHO ALL 2008 protocol. Levels of B lymphocytes (CD19+), NK cells (CD3-CD56+) and subsets of T lymphocytes (CD3+CD4+, CD4+CD25+Foxp3+, CD3+CD8+, CD3+CD8+CD57+, CD3+CD8+CD57-) in peripheral blood were analyzed by flow cytometry prior and during treatment with cytotoxic drugs. RESULTS: Immunological analyses were performed in 25 children with ALL. Levels of B and NK lymphocytes decreased continuously during chemotherapy. In contrast, levels of most T lymphocyte subsets decreased only transiently and returned to pretreatment levels by days 78 to 85. The only T lymphocyte subset that did not return to the pretreatment level contained senescent CD3+CD8+CD57+ lymphocytes. CONCLUSION: Immunomodulating action of chemotherapy in children with ALL results in reduction of proportion of senescent CD8+ T lymphocytes.

Intravesical cidofovir to treat BK virus-associated hemorrhagic cystitis in children after hematopoietic stem cell transplantation.

HC related to BK virus replication might be a severe complication following allogeneic HSCT. There are no clearly defined treatment guidelines in pediatric population. The data on the effectiveness of ICI to manage severe bleeding in children are very limited. We report our experience of intravesical cidofovir in four children, 6-15 yr of age, to manage grade III-IV BK virus-associated HC. Three of four children had high CSA serum level prior to developing cystitis. Intravesical instillations of cidofovir resulted only in temporal relief of bleeding. After immune suppression was withdrawn or tapered, intravesical instillations of formalin solution had to be undertaken to abort severe bleeding. We concluded that intravesical cidofovir alone did not appear to be sufficiently effective in case of severe HC, necessitating complimentary procedures to stop macrohematuria.

Cure rates of childhood acute lymphoblastic leukemia in Lithuania and the benefit of joining international treatment protocol.

BACKGROUND: Childhood acute lymphoblastic leukemia (ALL) represents the largest group of pediatric malignancies with long-term survival rates of more than 80% achieved in developed countries. Epidemiological data and survival rates of childhood ALL in Lithuania were lacking. Therefore, the aim of this study was to analyze the population-based long-term treatment results of childhood ALL in Lithuania during 1992-2012. MATERIALS AND METHODS: Data of all 459 children with T-lineage and B-cell precursor ALL treated in Lithuania from 1992 to 2012 were collected and analyzed. Results were compared among four time-periods: 1992-1996 (N=132), 1997-2002 (N=136), 2003-2008 (N=109) and 2009-2012 (N=82). RESULTS: The incidence of childhood ALL in Lithuania was 3.2-3.6 cases per 100000 children per year during the study period. Five-year probability of event-free survival increased from 50%± 4% in 1992-1996 to 71%± 4% in 2003-2008 (P<0.001). Five-year cumulative incidence of relapses reduced from 27%± 4.5% in 1992-1996 to 14%± 3.6% in 2003-2008 (P=0.042). After introduction of high-dose methotrexate of 5 g/m(2), cumulative incidence of CNS-involving relapses reduced from 17%± 3.9% in 1992-1996 to 1%± 1.0% in 2003-2008 (P<0.001). Trend for further improvement in survival was seen in 2009-2012 when Lithuania joined international the Nordic Society of Pediatric Hematology and Oncology (NOPHO) ALL-2008 treatment protocol. CONCLUSIONS: Cure rates of childhood ALL in Lithuania are improving steadily and are now approaching those reported by the largest international study groups. The reasons for such a positive effect are both better financial support for treatment of children with cancer in Lithuania and international collaboration with joining international treatment protocol for childhood ALL.

An assessment of iron overload in children treated for cancer and nonmalignant hematologic disorders.

UNLABELLED: Our goal was to assess the natural fate of iron overload (IO) following transfusions of packed red blood cells (PRBCs) in children treated for cancer and nonmalignant disorders according to the intensity level of their treatment. Sixty-six children were followed up from February 2010 to March 2013. The transfusion burden was compared between three treatment intensity groups assigned according to the Intensity of Treatment Rating Scale 3.0 (ITR-3). IO was assessed by serial measurements of serum ferritin (SF) (n= 66) and quantification of tissue iron by magnetic resonance imaging (MRI) (n=12). Of the children studied, 36 % (24/66) received moderately intensive treatment (level 2), 21 % (14/ 66) received very intensive treatment (level 3), and 42 % (28/ 66) received the most intensive treatment (level 4). The number of PRBC (p=0.016), the total transfused volume (p= 0.026), and transfused volume adjusted to body weight (p= 0.004) were significantly higher in the level 4 group. By the median follow-up time of 35.5 months (range 8­133), 21­ 29 % of patients (including level 2 and level 3 children) had SF >1,000 µg/l 1 year after cessation of transfusions. The slowest decrease of SF was observed in the level 4 group. Initial MRI examination demonstrated either mild or moderate IO in the liver and spleen. Repetitive MRI showed significant improvement in relaxation time between the initial and follow-up MRI performances in the liver (5.9 vs. 8.6 ms, p= 0.03) and the spleen (4.3 vs. 8.8 ms, p=0.03). CONCLUSION: IO diminished over time, but in the level 4 patients, it was detectable for years after cessation of transfusions.

[The quality of life of children suffering from oncologic diseases in Lithuania]. / Onkologinemis ligomis serganciu vaiku gyvenimo kokybe Lietuvoje.

Nearly 80 new cases of pediatric cancer are diagnosed in Lithuania each year. Since 2005, we have been conducting a study evaluating the quality of life of children suffering from cancer in Lithuania. The participants were children between the ages of 2 and 18 years, diagnosed with oncologic diseases during the period from March 2005 to March 2006, and their parents. The PedsQL (Pediatric Quality of Life Inventory(TM)) was used. This questionnaire is specifically designed for investigating the quality of life in children between the ages of 2 and 18 years. The PedsQL questionnaire is designed according to the level of cognitive activity of children and applied to children of four age groups: 2-4, 5-7, 8-12, and 13-18 years of age. The questionnaires were completed by children between the ages of 8 and 18 years in addition to parents of children from all age groups. The families of 63 children suffering from cancer participated in the study. A total of 44 children and teenagers between the ages of 5 and 18 years and 53 parents (mother, father, close relative) filled out the questionnaire. Data from the study showed that children suffering from cancer (irrespective of their age) in addition to their parents evaluated their physical health as being worse than their psychosocial health. The parents had the opinion that children from all age groups experienced negative emotions: the younger children were afraid of giving blood for tests, whereas the older children were worried about the future. In the oldest age group of participants (13-18 years), children felt disease-related fatigue more often than their younger counterparts.