Childhood acute lymphoblastic leukemia in the Middle East and neighboring countries: a prospective multi-institutional international collaborative study (CALLME1) by the Middle East Childhood Cancer Alliance (MECCA).

BACKGROUND: Little is known about childhood ALL in the Middle East. This study was undertaken by MECCA as initial efforts in collaborative data collection to provide clinical and demographic information on children with ALL in the Middle East. PROCEDURE: Clinical and laboratory data for patients with ALL between January 2008 and April 2012 were prospectively collected from institutions in 14 Middle East countries and entered into a custom-built-database during induction phase. All laboratory studies including cytogenetics were done at local institutions. RESULTS: The 1,171 voluntarily enrolled patients had a mean age of 6.1 ± 3.9 years and 59.2% were boys. T-ALL represented 14.8% and 84.2% had B-precursor ALL. At diagnosis, 5.6% had CNS disease. The distribution of common genetic abnormalities reflected a similar percentage of hyperdiploidy (25.6%), but a lower percentage of ETV6-RUNX1 translocation (14.7%) compared to large series reported from Western populations. By clinical criteria, 47.1% were low/standard risk, 16.9% were intermediate risk, and 36% were high risk. Most patients received all their care at the same unit (96.9%). Patients had excellent induction response to chemotherapy with an overall complete remission rate of 96%. Induction toxicities were acceptable. CONCLUSIONS: This first collaborative study has established a process for prospective data collection and future multinational collaborative research in the Middle East. Despite the limitations of an incomplete population-based study, it provides the first comprehensive baseline data on clinical characteristics, laboratory evaluation, induction outcome, and toxicity. Further work is planned to uncover possible biologic differences of ALL in the region and to improve diagnosis and management.

Childhood central nervous system tumors at MAHAK's Pediatric Cancer Treatment and Research Center (MPCTRC), Tehran, Iran.

PURPOSE: As central nervous system (CNS) tumors account for second most common childhood malignancies and the first cause of mortality in children with cancer, improving treatment modalities can lead to increase the health care of patients. In this study, we examined the prevalence of childhood brain tumors in patients who referred to MAHAK's Pediatric Cancer Treatment and Research Center (MPCTRC) for treatment. METHODS: A retrospective review of all children less than 15 years old with a CNS histologically proven tumor, who presented to MPCTRC from April 2007 to April 2010, was performed. Data was analyzed by SPSS version 19 with Kolmogorov-Smirnov and Chi-square tests. RESULTS: There were 198 (124 boys) children eligible for the study. The majority of the tumors were infratentorial (n = 134), and the rest were supratentorial (n = 60) and spinal (n = 4) cases. The median age was 6.11 ± 3.65 years old. Medulloblastoma (n = 66), low-grade glioma (n = 52), and high-grade glioma (n = 40) were the most common tumors. The mean duration of follow-up was 21 months. At the time of this analysis, there were 105 (53 %) children alive, 82 (41.4 %) deaths, and 11 (5.6 %) lost for follow-up. The survival rate was 51.68 ± 5.22 %. CONCLUSIONS: In contrast of high rate of death in this study, other general characteristics can serve as benchmark for improving our care for children with brain tumors in Iran.

Low representation of Fc receptor-like 1-5 molecules in leukemic cells from Iranian patients with acute lymphoblastic leukemia.

Recent studies have demonstrated expression of Fc receptor-like (FCRL) molecules, a newly identified family with preferential B-cell lineage expression, in some chronic B-cell leukemias with possible implication for classification and/or targeted immunotherapy. In this study, the expression pattern of FCRL1-5 genes was studied in 73 Iranian ALL patients and 35 normal subjects using semi-quantitative RT-PCR method. FCRL protein expression was also investigated by flow cytometry. Our results indicate significant down-regulation of all FCRL genes in ALL compared to normal subjects. Although, FCRL mRNA expression was almost exclusively confined to normal isolated B-cells compared to T-cells, but these genes were similarly expressed in B-ALL, T-ALL and different B-ALL immunophenotypic subtypes. Surface protein expression of FCRL1, 2, 4, and 5 molecules in 10 ALL and 5 normal samples confirmed the PCR results. Expression profile of FCRL molecules in different subtypes of ALL argues against their potential implication as suitable targets for classification and/or immunotherapy of ALL.

Overexpression of orphan receptor tyrosine kinase Ror1 as a putative tumor-associated antigen in Iranian patients with acute lymphoblastic leukemia.

Receptor tyrosine kinases (RTKs) are a group of enzymes involved in a variety of physiological and pathological processes. The human Ror1 is a member of the RTK family with unknown ligand and biological function. Overexpression of Ror1 has recently been reported in B-cell chronic lymphocytic leukemia. The aim of this study was to explore the expression profile of Ror1 in acute lymphoblastic leukemia (ALL) cells. Therefore, leukemic cells were isolated from the bone marrow and/or peripheral blood (PB) of 57 ALL patients. Immunophenotyping was performed by flow cytometry and mRNA expression was detected by RT-PCR. Overexpression of Ror1 mRNA was detected in 23 of 57 (40%) ALL patients. A similar expression pattern was observed in ALL cell lines, with 4 of 12 (33%) being positive. Stimulation of normal PB mononuclear cells with pokeweed mitogen and phorbol myristate acetate induced substantially higher Ror1 mRNA expression compared to unstimulated cultured cells. There has been neither a significant association between Ror1 expression and the immunophenotypic profile of the leukemic cells, nor with other clinical or hematological features of the patients. In conclusion, our findings propose Ror1 as a new tumor-associated antigen and a potential tool for targeted immunotherapy and monitoring of minimal residual disease in ALL.

Gonadal function and fertility in male survivors treated for Hodgkin's disease in Iran.

OBJECTIVE: To investigate the effect of chemotherapy on gonadal function of young men cured of childhood Hodgkin's disease. METHODS: Young adult males surviving Hodgkin's disease, aged 17 and over at least 2 years after therapy were studied in Ali Asghar Children's Hospital, Tehran, Iran from March 2000 to March 2005. Clinical evaluation for secondary sexual characteristics, semen analysis, follicle stimulating hormone (FSH), luteinizing hormone (LH), and testosterone was studied in 33 survivors of Hodgkin's disease. RESULTS: The age at diagnosis was 5-15 years, median 9 years, age at study 17-29 years, median 19 years old. The median duration off therapy was 7 years (2-20 years). All 33 patients received chemotherapy as follows: 32 patients received nitrogen mustard (mechlorethamine), vincristine (Oncovin), procarbazine, prednisone (MOPP) / doxorubicin (adriamycin), bleomycin, vinblastine, dacarbazine (ABVD) 6-8 cycles, 5 of whom after relapses received other protocols. One received only MOPP. Twenty-seven (81.8%) had azoospermia, 2 had severe oligospermia, 3 had oligospermia, and one had normal sperm count (58000,000). All patients had normal secondary sexual characteristic. The FSH, and LH in 6/33 patients were above normal. Testosterone in 3/33 was below normal. CONCLUSION: A prepubertal status does not protect the gonads from the harmful effect of chemotherapy, and approximately 87% of male survivors of Hodgkin's disease develop azoospermia or severe oligospermia.

Expression of the testis-specific gene, TSGA10, in Iranian patients with acute lymphoblastic leukemia (ALL).

Testis-specific gene antigen (TSGA10) is expressed in fetus, testis and frequently in human solid cancers and acute leukemias, making it a candidate for immunotherapy and for detection of minimal residual disease (MRD). This gene is considered as a member of cancer-testis (CT) genes. We previously demonstrated TSGA10 expression during spermatogenesis. There is also evidence for potential TSGA10 involvement in cell proliferation. TSGA10 expression has been observed in a wide spectrum of cancers but not in hematopoietic neoplasm. Here we demonstrated expression of TSGA10 by semi-quantitative RT-PCR in 44 (84.6%) out of 52 bone marrow samples and all peripheral blood samples from patients with acute lymphoblastic leukemia (ALL). Twenty-seven (52%) cases had high level of gene expression and 16 (30.7%) cases had a lower expression level of the gene in the patients bone marrow. Presence of TSGA10 expression in ALL may open a window to functional study of mitotic checkpoint proteins in leukemia. RT-PCR of TSGA10 may help in detection of residual clonal cells leading to early diagnosis and better prognostic qualification of the disease.

Epidemiologic survey of infantile cancer in Iran based on the data of the largest pediatric cancer referral center (Ali- Asghar Children Hospital), 1996-2005.

BACKGROUND: Cancer in infants younger than one year of age represents a unique problem with distinct epidemiological, clinical and genetic characteristics compared with older age groups. No report is yet available from Iran regarding epidemiological and survival rate of cancers diagnosed in this age group. MATERIALS AND METHODS: The population under study comprised of patients which were diagnosed and admitted to Ali-Asghar hospital between years 1996-2005. In total, 287 infants were included in the retrospective descriptive survey. Patient files were evaluated for age of patient at the time of diagnosis, sex, geographical residence, consanguinity of parents, histological diagnosis, site of cancer involvement, type of therapy, date of last follow-up and cause of death (if applicable). RESULTS: The average age at the time of diagnosis was 7.2 months old. The most frequent malignancy was retinoblastoma (44%), followed by leukemia (19%) and neuroblastoma (10%), with five-year overall survival rates of 77.7%, 41% and 90%, respectively Parents of 40 infants (13.9%) had consanguinity relationships. CONCLUSIONS: Although we cannot make any conclusions regarding the incidence of infant cancer subtypes based on this study, survival rates for major types were similar to the developed countries, which signifies strict adherence to standards of care in Ali-Asghar hospital, the main infant cancer care centre in Iran. A Childhood Cancer Registry with high-resolution data collection and also advanced genetic testing is advocated for in-depth analysis of variation in incidence and survival.

Parental attitudes toward fertility preservation in boys with cancer: context of different risk levels of infertility and success rates of fertility restoration.

OBJECTIVE: To measure the parental attitudes toward fertility preservation in boys with cancer. DESIGN: Retrospective cohort study. SETTING: Questionnaire survey via regular mail. PATIENT(S): A total of 465 families whose sons were already treated for cancer. INTERVENTION(S): The questionnaire was designed for two groups based on child's age at the time of cancer diagnosis: <12 and ≥12 years old. MAIN OUTCOME MEASURE(S): Descriptive statistics regarding a positive or negative attitude of parents toward fertility preservation options in the context of different risk levels of infertility and success rates of fertility restoration. RESULT(S): The response rate was 78%. Sixty-four percent of parents of boys ≥12 years old would agree to store sperm obtained by masturbation and/or electroejaculation, and 54% of parents of boys <12 years old would agree to store a testicular biopsy. If the risk of infertility or the success rate of fertility restoration were ≤20%, more than one-fourth of parents would still opt for fertility preservation. CONCLUSION(S): All parents should be counseled about the risks of infertility due to cancer treatment, because many parents want to preserve their son's fertility even if the risk of becoming infertile or the chances on fertility restoration are low.

Comparative expression profile of orphan receptor tyrosine kinase ROR1 in Iranian patients with lymphoid and myeloid leukemias.

It has recently been shown that ROR1, a member of the receptor tyrosine kinase family, is overexpressed in leukemic B cells of Chronic Lymphocytic Leukemia (CLL) and a subset of Acute Lymphoblastic Leukemia (ALL). In this comparative study the expression profile of ROR1 mRNA was investigated in Iranian patients with CLL and Acute Myelogenous Leukemia (AML) and the results were compared with those previously reported in our Iranian ALL patients. RT-PCR was performed on bone marrow and/or peripheral blood samples of 84 CLL and 12 AML patients. CLL samples were classified into immunoglobulin heavy chain variable region (IGHV) gene mutated (n = 55) and unmutated (n = 29) and also indolent (n = 42) and progressive (n = 39) subtypes. ROR1 expression was identified in 94% of our CLL patients, but none of the AML patients expressed ROR1. No significant differences were observed between different CLL subtypes for ROR1 expression. Taken together the present data and our previous results on ROR1 expression in ALL, our findings propose ROR1 as a tumor-associated antigen overexpressed in a large proportion of lymphoid (CLL and ALL), but not myeloid (AML) leukemias. Expression of ROR1 seems to be associated to lineage and differentiation stages of leukemic cells with a potential implication for immunotherapy.

Cross-sectional monitoring of Wilms' tumor gene 1 (WT1) expression in Iranian patients with acute lymphoblastic leukemia at diagnosis, relapse and remission.

Wilms' tumor gene 1 (WT1) is a universal tumor-associated antigen (TAA) expressed in a variety of malignancies. High WT1 mRNA expression has been detected in the majority of acute leukemias and has been identified as a convenient marker for disease monitoring. The aim of this study was to evaluate WT1 expression in Iranian ALL patients at diagnosis, relapse and remission. WT1 mRNA was detected in leukemic cells of ALL patients obtained at diagnosis (n = 62), relapse (n = 19) and remission (n = 35) using a semi-quantitative RT-PCR method. In addition, peripheral blood samples from 36 healthy donors were included as controls. Only 3 out of 36 normal samples gave a weak WT1 mRNA band and the ratio of WT1 to beta-actin band densities was calculated to obtain an arbitrary cut-off value for analysis of WT1 gene expression in patients. On the basis of the baseline value, leukemic cells from 51.6% (32/62) of the newly diagnosed patients and 57.9% (11/19) of the relapsed patients were WT1 positive; however, all of the patients in remission (35/35) were WT1 negative. WT1 expression in newly diagnosed and relapsed ALL patients was significantly higher than that of the ALL patients at remission and normal subjects (p < 0.0001). Our results indicate that WT1 could be employed as a reliable TAA to monitor minimal residual disease in Iranian patients with ALL.

Expression profile of orphan receptor tyrosine kinase (ROR1) and Wilms' tumor gene 1 (WT1) in different subsets of B-cell acute lymphoblastic leukemia.

Recent molecular investigations have demonstrated over-expression of a large number of tumor associated antigens (TAAs) in a variety of malignancies. Over-expression of ROR1 gene, a member of the receptor tyrosine kinase family, has recently been reported in B-cell chronic lymphocytic leukemia. Wilms' tumor gene 1 (WT1) has long been known as a universal TAA expressed in a variety of solid and hematopoietic malignancies. In the present study, the expression profile of ROR1 and WT1 was investigated in different immunophenotypic subsets of B-cell acute lymphoblastic leukemia (B-ALL) patients. RT-PCR method was used to determine the ROR1 and WT1 genes expression in bone marrow (BM) and peripheral blood (PB) samples from 51 newly diagnosed Iranian B-ALL patients. Isolated tumor cells from all patients were immunophenotyped by flow cytometry. Based on immunophenotypic results, our B-ALL patients were classified in four differentiation subsets; Pro-B (n = 7), Pre-B I (n = 29), Pre-B II (n = 13) and Immature/mature B-ALL (n = 2). Although ROR1 was over-expressed in more mature subsets (16.7%, 42.9%, 45.5% and 100%, respectively), WT1 was more represented in immature subsets of B-ALL patients (57.1%, 64.3%, 38.5% and 0%, respectively). Comparison of the frequency of ROR1 and WT1 positive samples at each immunophenotypic subtype revealed statistically significant difference only in Pre B I subtype (p = 0.02). Our results suggest that expression of ROR1 and WT1 in B-ALL is associated with the differentiation stage of the leukemic cells.

Expression profile of Wnt molecules in leukemic cells from Iranian patients with acute myeloblastic leukemia.

BACKGROUND: Wnt molecules play a key role in growth, proliferation and development of some embryonic and adult organs as well as hematopoietic stem cells. Wnt signaling pathways are aberrantly activated in many tumor types, including solid tumors and hematologic malignancies. OBJECTIVE: To investigate the expression profile of a large number of Wnt genes in leukemic cells from Iranian patients with acute myeloblastic leukemia. METHODS: RT-PCR method was used to determine the Wnt genes expression in bone marrow (BM) and/or peripheral blood (PB) samples from 16 patients with AML and PB samples of 36 normal subjects. RESULTS: Among 14 Wnt molecules included in this study, Wnt-7A and Wnt-10A were significantly down-regulated (p = 0.002 and p < 0.0001, respectively) and Wnt-3 was significantly over-expressed (p < 0.02) in AML patients compared to normal subjects. No significant association was found between Wnt expression and FAB classification of the patients. CONCLUSION: Our results demonstrated for the first time aberrant expression of Wnt-7A, Wnt-10A and Wnt-3 genes in Iranian AML patients. This may be of relevance to the tumorigenesis process in this malignancy.

Immunophenotypic subtyping of leukemic cells from Iranian patients with acute lymphoblastic leukaemia: association to disease outcome.

BACKGROUND: Immunophenotypic characterization of the leukemic cells has been widely used as a tool for diagnosis, classification, stratification and prognosis of leukaemia. OBJECTIVE: To investigate the immunophenotypic subtype profiles of Iranian patients with acute lymphoblastic leukemia (ALL) and its association to disease outcome. METHODS: In this study, a total of 60 Iranian patients with ALL were immunophenotyped by flow cytometry using a panel of monoclonal antibodies specific for CD2, CD3, CD5, CD10, CD13, CD14, CD19, CD20, CD33, CD34, CD45, HLA-DR and TdT molecules. RESULTS: The samples were initially categorized into T-ALL (n=9), B-ALL (n=50) and mixed lineage (n=1) based on the expression patterns of CD3 and CD19 molecules. B-ALL patients could further be classified into four subtypes, including Pro-B (n=7, 11.7%), Pre-B I (n=28, 46.7%), Pre-B II (n=13, 21.7%) and immature/mature B cells (n=2, 3.3%) on the basis of expression of CD10, CD19, CD20, HLA-DR and TdT. Clinical manifestations and laboratory findings of the patients did not reveal association with immunophenotypic subtypes of ALL, with the exception of mediastinal mass and WBC count at the time of diagnosis which were found to be significantly higher in patients with T-ALL compared with B-ALL (p=0.001 and 0.014), respectively. CONCLUSION: Our results indicate that overall the immunophenotypic profile of Iranian ALL patients is similar to previous reports and it might be used for monitoring of minimal residual disease and prognosis.

Aggressive intra-abdominal fibromatosis in children and response to chemotherapy.

Intra-abdominal fibromatosis (IAF) is a rare benign neoplasm arising from the abdominal fibrous tissue, mostly in the mesentery. IAF is characterized by a tendency to infiltrate the surrounding vessels and vital structures and recurrence after usually incomplete surgical removal. Accordingly, IAF is associated with considerable morbidity and mortality. The authors report on a boy who presented with a large IAF at the age of 5 years. Within 6 months after initial presentation, he underwent 4 subsequent abdominal explorations for diagnosis, tumor reduction, and intestinal obstructions. IAF was confirmed by the presence of vimentin and absence of other biological cell markers. Due to accelerated tumor growth and deteriorated general condition, as a last resort, a chemotherapy trial with vincristin and methotrexate was carried out. This regimen proved to be effective in reducing the tumor burden and improving the patient's general condition. Outcome of IAF depends on early diagnosis and complete tumor resection, and, if indicated, timely employment of neo/adjuvant chemotherapy. Radiotherapy must be considered in life-threatening conditions as the last resort in a growing child [2-4].

Acute lymphoblastic leukemia and hepatoblastoma in a family.

Acute lymphoblastic leukemia is the most common and hepatoblastoma is a rare malignancy diagnosed in children. Their report on an Iranian boy with acute lymphoblastic leukemia diagnosed at the age of 2 years; 20 months later his 10-month-old sister was referred to their hospital with hepatoblastoma. The occurrence of such two types of cancer is rare in a family.