State of Art in Pediatric Cancer. Surapon Wiangnon

Size: px

Start display at page:

Download "State of Art in Pediatric Cancer. Surapon Wiangnon"

Cecil Miles
5 years ago
Views:

1 State of Art in Pediatric Cancer Surapon Wiangnon

2 Background 68 M Life expectancy 73.6 Male 71.2, Female 76.1 Birth Rate: 12.66/1,000 pop. Death Rate: 7.47/1,000 pop. Infant Mortality Rate: deaths/1,000 live births 0.52% Fertility Rate: 1.66/woman

5 ASEAN Population Country Population <15 % Population >65 % Singapore Brunei 25 5 Malaysia 26 6 Thailand Philippines 34 4 Vietnam 24 7 Indonesia 29 5 Myanmar 24 5 Laos 37 4 Cambodia 31 6

report on cancer burden 2016-8 Second report 100

6 Thai Pediatric Oncology Group (ThaiPOG) Childhood cancer registration 2000 ThaiPOG founded First report on cancer burden Second report 100 Pediatric hemato-oncologists 30 registries Web-based registration

7 Development milestones 2002 Universal Coverage by National Health Security Office (NHSO) 2006 Disease management for leukemia/lymphoma : Risk stratification, National protocol 2016 National Protocol for all childhood cancers including histiocytosis 2017 Stem Cell Donors: 200,000

8 International Classification of Childhood Cancer (ICCC) I. Leukemias Lymphoid Acute non-lymphocytic Chronic myeloid II. Lymphomas Hodgkin s disease Non-Hodgkin lymphomas Burkitt s lymphoma III. Brain and spinal neoplasms Ependymoma Astrocytoma Primitive neuroectodermal tumors IV. Sympathetic nervous system tumors Neuroblastoma V. Retinoblastoma VI. Renal tumors Wilms tumor Renal carcinoma VII. Hepatic tumors Hepatoblastoma Hepatic carcinoma VIII. Malignant bone tumors Osteosarcoma Ewing s sarcoma IX. Soft tissue sarcoma Rhabdomyosarcoma Fibrosarcoma X. Germ cell and gonadal neoplasms Intracranial and intraspinal germ cell Gonadal germ cell Gonadal carcinoma XI. Carcinomas and epithelial neoplasms Thyroid Nasopharyngeal Skin Adrenocortical carcinoma

9 Percentage of Childhood Cancer, Age < 18, Germ cell Tumor 6% Epithelial neoplasm 2% STS4% Bone tumor 6% Hepatic tumors 2% Renal tumors 3% Retinoblastoma 4% Neuroblastoma 6% N=2618 M:F=1.4:1 Leukemia 49% N= 1284 ALL = 67.2% CNS tumors 9% N=241 Lymphomas 9% N= 234, NHL = 57.7%

10 I. Leukemias III. Brain and spinal neoplasms II. Lymphomas IV. Symphathetic nervous system VIII. Malignant bone tumors X. Germ cell and gonadal V. Retinoblastoma IX. Soft tissue sarcoma VI. Renal tumors VII. Hepatic tumors XI. Epithelial neoplasms Age-adjusted Incidence Rates (ASR) for Childhood Cancer, Thailand ASR per million

11 Average annual incidence rates of all cancers per million children aged 0-14 years recorded by cancer registry (CIFC)

12 Regions All cancers (0-14) Hong Kong Singapore Japan Vietnam, Hanoi Korea, Seoul China, Tianjin Philippines, Manila & Rizal Thailand 73.7 SEER ASR (World) per million Data source: International Incidence of Childhood Cancer, IARC 1998

13 Number of OPD visits, 2010 Wiangnon, J Med Assoc Thai 2012 Primary diagnosis Total Age group (Year) Total Count Count Count Count Count 127,597 7,846 35,604 46,725 37,422 D10-D36 Benign neoplasms 34,172 3,478 8,227 10,745 11,722 C81-C96 malignant neoplasms of lymphoid haematopoietic 23, ,387 11,049 6,329 D00-D09 In situ neoplasms C00-C14 Lip, oral cavity and pharynx 16,565 1,095 5,492 5,802 4,176 12, ,604 4,852 2,413 D37-D48 Neoplasms of uncertain or unknown behaviour 9, ,026 3,480 3,861 C30-C39 Respiratory organs 7, ,568 2,688 1,054 C69-C72 Eye, brain and central nervous system 6, ,033 2,374 2,086 C76-C80 malignant neoplasms of illdefined, and unspecified sites 4, ,070 1,874 1,234

14 Number of admissions by primary diagnosis and hospital level Wiangnon J Med Assoc Thai 2012 Primary diagnosis Total C81-C96 Malignant neoplasms, stated or presumed D10-D36 Benign neoplasms C69-C72 Eye, brain and central nervous system D37-D48 Neoplasms of uncertain or unknown behaviour C40-C41 Bone and articular cartilage C73-C75 Thyroid and other endocrine glands C45-C49 Mesothelial and soft tissue C51-C58 Female genital organs C15-C26 Digestive organs C64-C68 Urinary tract C30-C39 Respiratory and intrathoracic organs Hosptital level Total Primary Secondary Tertiary Private N N N N N 19, ,633 16, , , , , , , , , ,

15 Payment schema Payment scheme Percent Universal (30-baht policy) 92 Official service 6 Self payment 2

16 , N=295,634 Lancet Oncol 2017

17 Lancet Oncol , N=115,644

18 The 2016 revision to the WHO classification of myeloid neoplasms and acute leukemia

21 Minimal Residual Disease in ALL Blood 2015

22 Results of prospective clinical trials on adult Ph-ALL according to MRD response Blood 2015

23 Frequency of BCR/ABL1 rearrangement in pediatric and adult ALL Frontiers Oncol 2014

24 Survival of children with Ph + ALL treated with imatinib + chemotherapy on COG AALL0031 Frontiers Oncol 2014

Overall survival for children with leukemia, Thailand 2003-5 vs. 2014-6 Survival probability 0.00 0.25 0.50 0.75 1.

28 Overall survival for children with leukemia, Thailand vs Survival probability Survival of Leukemia Patient by Type, analysis time(months) ALL ANLL ALL ANLL

29 Wongmeerit APJCP 2106

30 Trends of survival in leukemia and lymphoma in Srinagarind Hospital, Wongmeerit APJCP 2016

32 Neuroblastoma survival

33 Significance of MYCN amplification in International Neuroblastoma Staging System Stage 1 and 2 Neuroblastoma: A report from the International Neuroblastoma Risk Group Data Base JCO 2009

34 Cochrane Database Syst Rev HD chemotherapy and ASCT for children with high-risk neuroblastoma 3 RCTs N = 739 Significant statistical difference in EFS in favour of myeloablative therapy over conventional chemotherapy (HR 0.78, 95% CI 0.67 to 0.90). CONCLUSIONS: Myeloablative therapy seems to work in terms of event-free survival. For overall survival there is currently no evidence of effect when additional follow-up data are included.

37 Prevention

38 % coverage India Democratic People's Republic of Korea China Kuwait Malaysia Philippines Republic of Korea Singapore Vietnam Thailand Hepatitis vaccine coverage

39 Asian Pac J Cancer Prev. 2008;9:507-9

40 Langerhan cell histiocytosis Reactive vs Neoplastic Reactive No significant mitosis Benign morphology Inflammatory character of LCH lesions No gross chromosomal aberration Spontaneous resolution Association with virus? Immune dysregulation? Neoplastic Clonality Lesions display malignancy-associated mechanisms Recurrent somatic gene BRAF mutations (2010) WHO ICD-10 code of LCH, changed! D76 C96

41 Epidemiology of LCH ThaiPOG, /1,000,000 person-year M:F = 1:1 Wiangnon. APJCP 2011

42 CD1a:stained on cell surface Morpho: Coffee bean cell Definitive Dx of LCH : CD1a and/or Langerin (CD207) is mandatory CD207: stained in cytoplasm Birbeck granule: tennis racket like (EM finding) Langerin is detected in Birbeck granule by EM, but no longer essential for Dx

43 10 yr OS/EFS by RO involvement RO- 98.5±0.9% RO- 73.9±4.4% RO+ 77.3±4.9% RO+ 51.2±6.6% P<0.01 P<0.01

44 J Pediatr Hematol Oncol 2014

45 Vemurafenib and Dabrafenib are selective oral inhibitors of BRAF V600E kinase approved by the US FDA for the Tx of BRAF V600E -mutated metastatic melanoma Dabrafenib

46 Vemurafenib for refractory LCH

47 Hemophagocytic lymphohistiocytosis: HLH Hyperinflammatory disorder: hypercytokinemia, and excessively activated lymphocytes and histiocytes, characterized by cytopenia, hepatosplenomegaly, DIC, hyperferritinemia, and hemophagocytosis Int J Hematol, HLH 2007 Primary Genetic disease Familial HLH: FHL Secondary Infection, autoimmune/inflammatory, lymphoma, post-sct

48 Classification of HLH Primary, genetic FHLH Chromosome 9 linkage (FHL1) PRF1 mutations (FHL2) UNC13D mutations (FHL3) STX11 mutations (FHL4) STXBP2 mutations (FHL5) Albinism syndromes LYST mutations (Chediak-Higashi syndrome) RAB27A mutations (Griscelli syndrome) Other immunodeficiencies SH2D1A mutations (XLP1) XIAP mutations (XLP2) ITK(IL-2-inducible T-cell kinase) deficiency Secondary, acquired Infection associated virus (EBV,CMV,HSV,VSV) bacteria (mycoplasma) parasite, fungus Autoimmune associated sjia, SLE, IBD, Kawasaki disease Malignancy associated T-cell lymphoma Metabolic disease associated Gaucher disease, Lysinuric protein intolerance Post organ transplantation

49 HLH-2004 Dx Guidelines The Dx of HLH can be established if one of either 1 or 2 below is fulfilled (1) A molecular Dx consistent with HLH (2) Dx criteria for HLH fulfilled (5 out of 8 criteria below) Fever Splenomegaly Cytopenias (affecting 2 of 3 lineages in PB): Hgb <90 g/l (in infants <4 weeks: Hgb <100 g/l) Platelets <100ⅹ10 9 /L Neutrophils <1.0ⅹ10 9 /L Hypertriglyceridemia and/or hypofibrinogenemia: Fasting triglycerides 3.0 mmol/l (i.e., 265 mg/dl) Fibrinogen 1.5 g/l Hemophagocytosis in BM or spleen or LN Low or absent NK-cell activity Ferritin 500 mg/l Soluble CD25 (sil-2 receptor) 2,400 U/ml

RESEARCH COMMUNICATION. Childhood Cancer Incidence and Survival , Thailand: Study from the Thai Pediatric Oncology Group

RESEARCH COMMUNICATION. Childhood Cancer Incidence and Survival , Thailand: Study from the Thai Pediatric Oncology Group Childhood Cancer Incidence and Survival 2003-2005, Thailand RESEARCH COMMUNICATION Childhood Cancer Incidence and Survival 2003-2005, Thailand: Study from the Thai Pediatric Oncology Group Surapon Wiangnon