National Pediatric Oncology Unit

Guatemala City, Guatemala

National Pediatric Oncology Unit

Guatemala City, Guatemala
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Marjerrison S.,The Hospital for Sick Children | Marjerrison S.,McMaster Childrens Hospital | Antillon F.,National Pediatric Oncology Unit | Bonilla M.,Benjamin Bloom National Childrens Hospital | And 7 more authors.
Pediatric Blood and Cancer | Year: 2014

Background: Relapsed childhood acute myeloid leukemia (AML) outcomes have not been documented in resource-limited settings. We examined survival after relapse for children with AML (non-APML) and acute promyelocytic leukemia (APML) in Central America. Procedure: We retrospectively evaluated outcomes of children with first relapse of AML (non-APML) and APML in Guatemala, Honduras, or El Salvador diagnosed between 1997 and 2011. Predictors of subsequent event-free survival (EFS) and overall survival (OS) were examined. Results: We identified 140 children with relapsed AML (non-APML), and 24 with relapsed APML. Two-year subsequent EFS and OS (±SE) were 7.0±2.5% and 9.1±2.8%, respectively. Worse outcomes were associated with Hispanic or Indigenous heritage, white blood cell count at diagnosis ≥50×109/L, and time to relapse <18 months. For those with relapsed APML, subsequent 2-year EFS and OS were 36.7±10.8% and 43.4±12.1%, although few patients survived beyond 3 years. 15.2% of all patients were managed solely with palliative intent following first relapse. Conclusions: Children with relapsed AML in Central America rarely survive, so palliative strategies should be considered following relapse in this population. However, children with late relapse or with APML may have a prolonged period of remission with second treatment, and consideration of re-treatment may be appropriate. Pediatr Blood Cancer 2014;61:1222-1226. © 2014 Wiley Periodicals, Inc.


Ceppi F.,University of Toronto | Ortiz R.,Manuel Of Jesus Rivera Hospital | Antillon F.,National Pediatric Oncology Unit | Vasquez R.,Hospital Benjamin Bloom | And 7 more authors.
Pediatric Blood and Cancer | Year: 2016

Background: Although anaplastic large cell lymphoma (ALCL) is curable in high-income countries (HIC), data from low- and middle-income countries (LMIC) are lacking. We therefore conducted a retrospective study of the Central American Association of Pediatric Hematology Oncology (AHOPCA) experience in treating ALCL. Procedure: We included all patients age <18 years newly diagnosed with ALCL treated between 2000 and 2013 in seven AHOPCA institutions. Retrospective data were extracted from the Pediatric Oncology Network Database. Results: Thirty-one patients met inclusion criteria. Twenty-five (81%) had advanced disease (stages III and IV), six (19%) were treated on the APO (doxorubicin, prednisone, vincristine) regimen, 15 (49%) on multi-agent chemotherapy designed for T-cell lineage malignancies (GuatALCL protocol), and 10 (32%) on BFM-based treatment regimens. Five-year overall event-free survival and overall survival were, respectively, 67.1 ± 8.6% and 66.7 ± 8.7%. All 10 events occurred in patients treated on BFM-based treatment regimens or the GuatALCL protocol, none on APO treatment: two patients experienced relapse, six treatment related mortality (TRM), and two abandonment. Conclusions: Treatment of ALCL in countries with limited resources is feasible with similar outcomes as in HIC, though the causes of treatment failure differ. Less intensive regimens may be preferable in order to decrease TRM and improve outcomes. Prospective clinical trials determining the ideal treatment for LMIC children with ALCL are necessary. © 2015 Wiley Periodicals, Inc.


De Pernillo M.,National Pediatric Oncology Unit | Rivas S.,National Pediatric Oncology Unit | Fuentes L.,National Pediatric Oncology Unit | Antillon F.,National Pediatric Oncology Unit | Barr R.D.,McMaster University
Pediatric Blood and Cancer | Year: 2014

The prospects for survival of children in low and middle income countries are linked to their families socio-economic status (SES), of which income is only one component. Developing a comprehensive measure of SES is required. Informed by clinical experience, a 15-item instrument was designed in Guatemala to categorize SES by five levels in each item. Almost 75% of families attending the Unidad Nacional de Oncología Pediátrica were in the lowest three of six categories, providing a framework for stratified financial and nutritional support. The measure of SES offers an opportunity for examining associations with health outcomes throughout Latin America. © 2014 Wiley Periodicals, Inc.


Marjerrison S.,University of Toronto | Antillon F.,National Pediatric Oncology Unit | Fu L.,Hospital Escuela | Martinez R.,Hospital Mario Catarino Rivas | And 4 more authors.
Cancer | Year: 2013

Background: Outcomes for relapsed childhood acute lymphoblastic leukemia (ALL) have not been documented in resource-limited settings. This study examined survival after relapse for children with ALL in Central America. METHODS: A retrospective cohort study was performed and included children with first relapse of ALL in Guatemala, Honduras, or El Salvador between 1990 and 2011. Predictors of subsequent event-free survival (EFS) and overall survival (OS) were examined. RESULTS: There were 755 children identified with relapsed disease. The median time from diagnosis to relapse was 1.7 years (interquartile range, 0.8-3.1 years). Most relapses occurred during (53.9%) or following (24.9%) maintenance chemotherapy, and the majority occurred in the bone marrow (63.1%). Following the initial relapse, subsequent 3-year EFS (± standard error) and OS were 22.0% ± 1.7%, and 28.2% ± 1.9%, respectively. In multivariable analysis, worse postrelapse survival was associated with age ≥ 10 years, white blood cell count ≥ 50 × 109/L, and positive central nervous system status at the original ALL diagnosis, relapse that was not isolated central nervous system or testicular, and relapse < 36 months following diagnosis. Site and time to relapse were used to identify a favorable risk group whose 3-year EFS and OS were 50.0% ± 8.9% and 68.0% ± 8.1%, respectively. CONCLUSIONS: Prognosis after relapsed ALL in Central America is poor, but a substantial number of those with favorable risk features have prolonged survival, despite lack of access to stem cell transplantation. Stratification by risk factors can guide therapeutic decision-making. Cancer 2013. © 2012 American Cancer Society.


Friedrich P.,Dana Farber Boston Childrens Cancer and Blood Disorders Center | Ortiz R.,La Mascota Childrens Hospital | Fuentes S.,Benjamin Bloom National Childrens Hospital | Gamboa Y.,National Childrens Hospital | And 6 more authors.
Cancer | Year: 2014

BACKGROUND The delivery of effective treatment for pediatric solid tumors poses a particular challenge to centers in middle-income countries (MICs) that already are vigorously addressing pediatric cancer. The objective of this study was to improve the current understanding of barriers to effective treatment of pediatric solid tumors in MICs. METHODS An ecologic model centered on pediatric sarcoma and expanded to country as the environment was used as a benchmark for studying the delivery of solid tumor care in MICs. Data on resources were gathered from 7 centers that were members of the Central American Association of Pediatric Hematologists and Oncologists (AHOPCA) using an infrastructure assessment tool. Pediatric sarcoma outcomes data were available, were retrieved from hospital-based cancer registries for 6 of the 7 centers, and were analyzed by country. Patients who were diagnosed from January 1, 2000 to December 31, 2009 with osteosarcoma, Ewing sarcoma, rhabdomyosarcoma, and other soft tissue sarcomas were included in the analysis. To explore correlations between resources and outcomes, a pilot performance index was created. RESULTS The analyses identified specific deficits in human resources, communication, quality, and infrastructure. The treatment abandonment rate, the proportion of metastatic disease at diagnosis, the relapse rate, and the 4-year abandonment-sensitive overall survival (AOS) rate varied considerably by country, ranging from 1% to 38%, from 15% to 54%, from 24% to 52%, and from 21% to 51%, respectively. The treatment abandonment rate correlated inversely with health economic expenditure per capita (r = -0.86; P =.03) and life expectancy at birth (r = -0.93; P =.007). The 4-year AOS rate correlated inversely with the mortality rate among children aged <5 years (r = -0.80; P = 0.05) and correlated directly with the pilot performance index (r = 0.98; P = 0.005). CONCLUSIONS Initiatives to improve the effectiveness of treatment for pediatric solid tumors in MICs are warranted, particularly for pediatric sarcomas. Building capacity and infrastructure, improving supportive care and communication, and fostering comprehensive, multidisciplinary teams are identified as keystones in Central America. A measure that meaningfully describes performance in delivering pediatric cancer care is feasible and needed to advance comparative, prospective analysis of pediatric cancer care and to define resource clusters internationally. Cancer 2014;120:112-125. © 2013 American Cancer Society. Effective delivery of pediatric solid tumor care poses a challenge to centers in low-income and middle-income countries. However, the complex variety of factors involved in delivery of care can be conceptualized in discrete components, analyzed using transparent methods, and interpreted in ways meaningful to leadership at a pediatric cancer center. © 2013 American Cancer Society.


Ceppi F.,University of Toronto | Antillon F.,National Pediatric Oncology Unit | Pacheco C.,Manuel Of Jesus Rivera Hospital | Sullivan C.E.,Outreach | And 5 more authors.
Expert Review of Hematology | Year: 2015

In the last two decades, remarkable progress in the treatment of children with acute lymphoblastic leukemia has been achieved in many low-and middle-income countries (LMIC), but survival rates remain significantly lower than those in high-income countries. Inadequate supportive care and consequent excess mortality from toxicity are important causes of treatment failure for children with acute lymphoblastic leukemia in LMIC. This article summarizes practical supportive care recommendations for healthcare providers practicing in LMIC, starting with core approaches in oncology nursing care, management of tumor lysis syndrome and mediastinal masses, nutritional support, use of blood products for anemia and thrombocytopenia, and palliative care. Prevention and treatment of infectious diseases are described in a parallel paper. © 2015 © Informa UK, Ltd.


Gupta S.,University of Toronto | Antillon F.A.,National Pediatric Oncology Unit | Bonilla M.,Benjamin Bloom National Childrens Hospital | Fu L.,Hospital Escuela | And 3 more authors.
Cancer | Year: 2011

BACKGROUND: The objectives of this study were to describe the incidence, timing, and predictors of treatment-related mortality (TRM) among children with acute lymphoblastic leukemia (ALL) in El Salvador, Guatemala, and Honduras. METHODS: Patients aged <20 years who were diagnosed with ALL between January 2000 and March 2008, who received treatment in any of the 3 countries, and who started induction chemotherapy were included in the study. Almost all patients were treated on the El Salvador-Guatemala-Honduras II protocol, which was based on the St. Jude Total XIII and XV protocols. Biologic, socioeconomic, and nutritional variables were examined as predictors of TRM. RESULTS: Of 1670 patients, TRM occurred as a first event in 156 children (9.3%); TRM occurred during remission induction therapy in 92 of 156 children (59%), between remission induction and maintenance therapy in 27 of 156 children (17%), and during maintenance therapy in 37 of 156 children (24%). Although the TRM rate decreased in patients who were diagnosed after July 1, 2004 (11.2% vs 7.9%; P =.02), the rate of induction death did not change (5.2% vs 5.8%; P =.58). Independent predictors of induction death included higher risk ALL (odds ratio [OR], 1.84; 95% confidence interval [CI], 1.03-3.27; P =.04), lower initial platelet counts (OR per 10 × 109/L, 0.94; 95% CI, 0.89-0.98; P =.005), and longer travel time to the clinic (OR, 1.06 per hour; 95% CI, 1.01-1.14; P =.03). CONCLUSIONS: In Central America, TRM remains an important cause of treatment failure in children with ALL. A large proportion of TRM occurs in maintenance, although this proportion has decreased over time. Supportive care interventions should especially target children who present with low platelet counts. Further study on transfusion ability and the location of induction deaths is required. Cancer 2011;. © 2011 American Cancer Society. Rates of treatment-related mortality (TRM) were significantly higher in patients with acute lymphoblastic leukemia (ALL) in low-income countries compared with similar patients in high-income countries. In a cohort of children with ALL across 3 Central American countries, the authors observed that the timing, causes, and predictors of TRM were different in this population than in high-income settings, suggesting that different interventions are required to improve outcomes. Copyright © 2011 American Cancer Society.


PubMed | Columbia University, Benjamin Bloom National Childrens Hospital, National Pediatric Oncology Unit, Harvard University and St Jude Childrens Research Hospital
Type: Journal Article | Journal: Pediatric blood & cancer | Year: 2016

Global variations in the incidence of pediatric cancers have been described; however, the causes of such differences are not known. We investigated the relationship between the incidence of embryonal tumors and human development index on a global scale. Increasing incidence of neuroblastoma correlates significantly with an increasing index of human development, with greater incidence among countries with high socioeconomic development, in apparent contrast to the incidence of retinoblastoma. While more data are needed to corroborate this observation, our findings suggest new avenues for etiological research and serve as a call for support of population-based cancer registries in low-middle-income countries.


PubMed | Hospital Benjamin Bloom, Hospital Nacional Of Ninos Dr Carlos Saenz Herrera, Dr Robert Reid Cabral Childrens Hospital, University of Toronto and 4 more.
Type: Journal Article | Journal: Pediatric blood & cancer | Year: 2015

Although anaplastic large cell lymphoma (ALCL) is curable in high-income countries (HIC), data from low- and middle-income countries (LMIC) are lacking. We therefore conducted a retrospective study of the Central American Association of Pediatric Hematology Oncology (AHOPCA) experience in treating ALCL.We included all patients age <18 years newly diagnosed with ALCL treated between 2000 and 2013 in seven AHOPCA institutions. Retrospective data were extracted from the Pediatric Oncology Network Database.Thirty-one patients met inclusion criteria. Twenty-five (81%) had advanced disease (stages III and IV), six (19%) were treated on the APO (doxorubicin, prednisone, vincristine) regimen, 15 (49%) on multi-agent chemotherapy designed for T-cell lineage malignancies (GuatALCL protocol), and 10 (32%) on BFM-based treatment regimens. Five-year overall event-free survival and overall survival were, respectively, 67.18.6% and 66.78.7%. All 10 events occurred in patients treated on BFM-based treatment regimens or the GuatALCL protocol, none on APO treatment: two patients experienced relapse, six treatment related mortality (TRM), and two abandonment.Treatment of ALCL in countries with limited resources is feasible with similar outcomes as in HIC, though the causes of treatment failure differ. Less intensive regimens may be preferable in order to decrease TRM and improve outcomes. Prospective clinical trials determining the ideal treatment for LMIC children with ALCL are necessary.


PubMed | Outreach, University of Milan Bicocca, Flow Cytometry Laboratory Dr Rodolfo Lorenzana, National Pediatric Oncology Unit and St Jude Childrens Research Hospital
Type: | Journal: Cancer | Year: 2016

The National Pediatric Oncology Unit (UNOP) is the only pediatric hemato-oncology center in Guatemala.Patients ages 1 to 17 years with acute lymphoblastic leukemia (ALL) were treated according to modified ALL Intercontinental Berlin-Frankfurt-Mnster (IC-BFM) 2002 protocol. Risk classification was based on age, white blood cell count, immunophenotype, genetics (when available), and early response to therapy.From July 2007 to June 2014, 787 patients were treated, including 160 who had standard-risk ALL, 450 who had intermediate-risk ALL, and 177 who had high-risk ALL. The induction death rate was 6.6%, and the remission rate was 92.9%. The rates of death and treatment abandonment during first complete remission were 4.8% and 2.5%, respectively. At a median observation time of 3.6 years, and with abandonment considered an event, the 5-year event-free survival and overall survival estimates (standard error) were 56.2%2.1% and 64.1%2.1%, respectively, with a 5-year cumulative incidence of relapse of 28.9%2.0%. Twenty-one of 281 patients (7.5%) investigated were positive for the ets variant 6/runt-related transcription factor 1 (ETV6/RUNX1) fusion.A well organized center in a low-middle-income country can overcome the disadvantages of malnutrition and reduce abandonment. Outcomes remain suboptimal because of late diagnosis, early death, and a high relapse rate, which may have a partly genetic basis. Earlier diagnosis, better management of complications, and better knowledge of ALL will improve outcomes. Cancer 2016. 2016 American Cancer Society.

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