State of Art in Pediatric Cancer Surapon Wiangnon
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: 15.41 deaths/1,000 live births 0.52% Fertility Rate: 1.66/woman
ASEAN Population Country Population <15 % Population >65 % Singapore 16 11 Brunei 25 5 Malaysia 26 6 Thailand 18 11 Philippines 34 4 Vietnam 24 7 Indonesia 29 5 Myanmar 24 5 Laos 37 4 Cambodia 31 6
Thai Pediatric Oncology Group (ThaiPOG) Childhood cancer registration 2000 ThaiPOG founded 2003-5 First report on cancer burden 2016-8 Second report 100 Pediatric hemato-oncologists 30 registries Web-based registration
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
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
Percentage of Childhood Cancer, Age < 18, 2014-2016 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%
2014-2016 2003-2005 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 7.05 6.3 6.33 6.4 5.15 4.9 4.2 1.9 3.98 4.3 3.45 3.1 3.24 3.7 2.33 3 2.1 2.3 1.52 0.7 Age-adjusted Incidence Rates (ASR) for Childhood Cancer, Thailand ASR 78.25 per million 38.94 38 0 5 10 15 20 25 30 35 40 45
Average annual incidence rates of all cancers per million children aged 0-14 years recorded by cancer registry (CIFC)
Regions All cancers (0-14) Hong Kong Singapore 132.1 129.3 Japan Vietnam, Hanoi Korea, Seoul China, Tianjin Philippines, Manila & Rizal 116.3 109.7 108.4 104.9 100.8 Thailand 73.7 SEER 150.3 0 20 40 60 80 100 120 140 160 ASR (World) per million Data source: International Incidence of Childhood Cancer, IARC 1998
Number of OPD visits, 2010 Wiangnon, J Med Assoc Thai 2012 Primary diagnosis Total Age group (Year) Total 0-1 1-5 6-12 13-18 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 23,102 337 5,387 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 12,525 656 4,604 4,852 2,413 D37-D48 Neoplasms of uncertain or unknown behaviour 9,903 536 2,026 3,480 3,861 C30-C39 Respiratory organs 7,970 660 3,568 2,688 1,054 C69-C72 Eye, brain and central nervous system 6,872 379 2,033 2,374 2,086 C76-C80 malignant neoplasms of illdefined, and unspecified sites 4,319 141 1,070 1,874 1,234
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 19,159 817 1,633 16,504 205 9,167 307 463 8,368 29 2,743 172 531 1,944 96 1,484 51 81 1,343 9 1,300 113 298 860 29 1,106 39 41 1,014 12 927 18 37 870 2 559 12 37 509 1 400 10 15 363 12 360 29 30 296 5 359 10 32 317 0 229 10 7 212 0
Payment schema Payment scheme Percent Universal (30-baht policy) 92 Official service 6 Self payment 2
2001-2010, N=295,634 Lancet Oncol 2017
Lancet Oncol 2017 2001-2010, N=115,644
The 2016 revision to the WHO classification of myeloid neoplasms and acute leukemia
Minimal Residual Disease in ALL Blood 2015
Results of prospective clinical trials on adult Ph-ALL according to MRD response Blood 2015
Frequency of BCR/ABL1 rearrangement in pediatric and adult ALL Frontiers Oncol 2014
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 1.00 Survival of Leukemia Patient by Type, 2014-2016 0 20 40 60 80 analysis time(months) ALL ANLL ALL ANLL 2003-5 2014-2016
Wongmeerit APJCP 2106
Trends of survival in leukemia and lymphoma in Srinagarind Hospital, 1993-2012 Wongmeerit APJCP 2016
Neuroblastoma survival
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
Cochrane Database Syst Rev. 2015 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.
Prevention
% coverage 100.0 90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 India Democratic People's Republic of Korea China Kuwait Malaysia Philippines Republic of Korea Singapore Vietnam Thailand Hepatitis vaccine coverage
Asian Pac J Cancer Prev. 2008;9:507-9
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
Epidemiology of LCH ThaiPOG, 2003-5 2.03/1,000,000 person-year M:F = 1:1 Wiangnon. APJCP 2011
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
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
J Pediatr Hematol Oncol 2014
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
Vemurafenib for refractory LCH
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
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
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) 1 2 3 4 5 6 7 8 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