Pediatric Hematology Oncology,

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Pediatric Hematology Oncology, Schneider
Childrens Medical Center of Israel,
Petal-Tikva, Sackler School of Medicine, Tel Aviv
University, Israel.
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Childhood malignancy
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Cancer Cell, 2002
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Childhood leukemia

• 97 Acute leukemia
• 75 Acute lymphoblastic
  leukemia
• 20 Acute myeloblastic leukemia
• Acute mixed lineage leukemia
• Acute undifferentiated leukemia
• 3 Chronic leukemia
• Chronic myelocytic leukemia
• Juvenile myelomonocytic leukemia
  

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Risk Factors for Childhood Acute Leukemia
Genetic Down ALL, AML NF1 ALL, AML,
JMML Bloom ALL, AML Schwachman ALL,
AML Ataxia Telangiectasia ALL Fanconi
Anemia AML Kostmann Granulocytopenia AML Envi
ronmental Ionizing Radiation ALL, AML In
Utero X-ray ALL Benzene AML Pesticide
AML Alkylating /Topo-II Inhib. AML In
Utero Topo II Inhib. Infant Und L. DNA
damaging Higher incidence among identical twins
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ALL- Epidemiology

• The most common malignancy in childhood
• Incidence 3-4 cases per 100000 children
• Peak incidence between 2-5 y
• Boys gt Girls
• White gtBlack
• Genetic predisposition lt5

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Age distribution
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Clinical Features at Diagnosis in Children
withAcute Lymphoblastic Leukemia
Clinical features/ Symptoms of
patients Fever 61 Bleeding (petechiae or
purpura) 48 Bone pain 23 Lymphadenopathy 5
0 Splenomegaly 63 Hepatosplenomegaly 68
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Laboratory Features at Diagnosis in Children
withAcute Lymphoblastic Leukemia
Laboratory features of patients Leukocyte
count (mm3) lt10,000 53 10,000-49,000 30
gt50,000 17 Hemoglobin (g/dl) lt7.0 43 7.
0-11.0 45 gt11.0 12 Platelet count
(mm3) lt20,000 28 20,000-99,000 47 gt100,0
00 25
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ALL testicular involvement
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CNS leukemia
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Differential Diagnosis in Childhood Acute
Lymphoblastic Leukemia
Nonmalignant conditions Juvenile rheumatoid
arthritis Infectious mononucleosis Idiopathic
thrombocytopenic purpura Pertussis
parapertussis Aplastic anemia Acute
infectious lymphocytosis Malignancies Neuroblast
oma Retinoblastoma Rhabdomyosarcoma Unusual
presentations Hypereosinophilic syndrome
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Diagnosis

• Blood count and smear
• Bone marrow Morphology
• 
  Cytochemical stains
• 
  Immunophenotype
• 
  Cytogenetics

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Haemopoiesis
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FAB L1
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FAB L2
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FAB L3
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Cytochemical stains
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Lymphoid differentiation
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T phenotype ALL

• Incidence 15 (Israel 20 )
• Median age 12y
• Male gt Female
• High blood count
• Mediastinal mass
• Organomegaly
• CR lt 90
• High relapse rate, CNS, Extra medullary

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Genetic (somatic) Abnormalities in Childhood
Cancer
Numerical Chromosomal changes Structural
Chromosomal changes Translocation Inversion
Deletion Addition / duplication Amplifica
tion
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Childhood ALL
Hyperdiploid
G-banding
FISH
cep4/cep10
Cep4 centromere 4 Cep10 centromere 10

• Ca-Cytogenet. -SCMCI

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Genetic (somatic) Abnormalities in Childhood
Cancer
Numerical Chromosomal changes Structural
Chromosomal changes Translocation Inversion
Deletion Addition / duplication Amplifica
tion
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Genetic Abnormalities in Childhood Cancer
Protooncogen Activation Suppressor gene
Inactivation Altered function of Growth
factors Growth factor receptors Kinase
inhibitors Signal transducers Transcriptio
n factors Altered down stream Genes Expression
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Childhood ALL
Philadelphia chromosome
G-banding
FISH
bcr/abl
bcr 22q11 abl 9q34
46,XY,t(922)(q34q11)

• Ca-Cytogenet. -SCMCI

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ALL-B lineage Chromosomal rearrangement
Activation of transcriptional control Genes
ALL Translocation Genes
Frequency Early B t(1221)(p12q22) TEL-AML1 25
Pre. B t(119) (q23p13) E2A-PBX1 5 Pro.
B t(1719)(q22p13) E2A-HLF lt1 t(411)
(q21q23) MLL-AF4 4 B cell/Burkitt t(814)
(q24q32) MYC (IgH) 5 t(28)
(p12q24) MYC (IgL) lt1 t(822) (q24q11) MYC
(IgL) lt1 B cell t(311) (q27q23) BCL6 1
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Ca-Cytogenet. -SCMCI
Childhood ALL t(1221) (TEL/AML1),del(12p)
G-band
FISH
SKY
46,XY,t(1221)(p13q22),der(12)t(112p)
H.M.
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Expression profiles of diagnostic bone marrow ALL
blasts
Yeon, Cancer Cel 2002
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Molecular subtypes of ALL
Cancer Cell, 2002
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Childhood ALL, Event Free Survival by Genetic
Features St Jude
Pui, NEJM, 1998
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Prognostic Risk Factors in ALL
Age 1-6, 1-10y WBC 20.000,
50.000 Phenotype. T, B, CALLA
neg. Ploidy lt2n, 3n Cytogenetic t(922),t(
411) t(1221) Gene Expression Profile
? Early response to treatment !!!!!! PB
D8, BM D15, D33 Morphology, MRD Sex, Race,
CNS, Testicular involvement
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Early response to therapy

• D-8 ( PB BM )
• D- 14 ( BM )
• D- 33 ( BM )
• MRD Slop by
• BM aberrant phenotype
• BM clonal Ig/TCR rearrangement

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M R D Minimal Residual Disease

• Precise definition of remission
• Prognostic significance (blast lt0.01 )
• Treatment modification

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Immunogobuline gene rearrangement
van Dongen ASH 2002
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. therapy antileukemic Patterns of early cellular
responses to
Pui, 2000
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International BFM Study Group

• Risk MRD 5 year Relapse
• TP1 TP2 Rate -
• Low lt10-4 lt10-4 2
• Intermediate 24
• High gt10-3 10-3 84

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Combined Information of MRD from Time Points 12
Low risk group pRFS 0.98 0.02 Intermediate
risk group pRFS 0.76 0.06 plt0.001 High risk
group pRFS 0.16 0.08
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Principles of treatment

• Risk group
• Combination chemotherapy
• Remission induction
• CNS prevention
• Consolidation
• Maintenance
• Irradiation
• BMT
• Late effect consideration

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Leukemic cell kinetics
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Event- Free Survival of ALL children- St. Jude
Pui, 1998 NEJM
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Host Pharmacogenetics Affects Treatment Response
excessive toxicity
non-responders
responders
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Determinants of Treatment Response in Leukemia
Leukemia
Tumor burden
Host
Therapy
Growth potential
Drug resistance
Drug dosage
Age
Drug interactions
Pharmacogenomics
Treatment response
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BMT (BFM-95)

• t ( 9 22 ) or BCR /ABL recombination
• t ( 4 11 ) or MLL / AF4 recombination
• No CR D 33
• PPR T immunophenotype
• pre B immunology
• WBC gt 100000

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??????????????? Relapse remains the major
problem of childhood leukemia!!
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Cancer Cell, 2002
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Science, 1997
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AML-M2, t(821)
NEJM, 1999
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AML
G-banding
FISH
Eto 8q22 AML1 21q22

• Ca-Cytogenet. -SCMCI

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Bennet, leukemia 2000
AM-M3, Hypergranular, t(1517)
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AML-MRC-10. Overall Survival by Cytogenetic
abnormalities
Grimwade, Blood, 1998
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AML-MRC-10. Overall Survival by Cytogenetic
abnormalities
Grimwade, Blood, 1998
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Cancer Cell, 2002
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Lymphomas

• Classification along three axes
• Classification by cell of origin (B vs. T vs. NK)
• Classification by grade Low grade, intermediate
  grade, high-grade
• Hodgkin disease (HD) vs. Non-Hodgkin Lymphoma
  (NHL)

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Lymphoma

• Malignancies of the lymphoid system
• Classification by cell of origin (B vs. T)
• Classification by grade Low/intermediate/high
• In children only high-grade
  lymphomas
• Hodgkin disease (HD) vs. Non-Hodgkin Lymphoma
  (NHL)

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Pediatric lymphomas
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Non-Hodgkin Lymphoma in Children

• B-Cell Burkitts lymphoma (40)
• Diffuse large B-cell (DLBCL)
  (20)
• B-cell lymphoblastic lymphoma (5)
• T-Cell Lymphoblastic Lymphoma (25)
• Anaplastic Large Cell Lymphoma (ALCL) (10)

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Burkitts lymphoma
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Burkitts lymphoma - Pathogenesis

• The B-Lymphocyte is produced in the bone marrow
• It differentiates into an antibody producing cell
  (Immunoglobulin-Ig)
• It can be found in all lymph nodes and
  extra-nodal organs
• Burkitts lymphoma and DLBCL are thought to arise
  in germinal centers of lymph nodes during B-cell
  development

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The normal lymph node
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Malignancies of B-lymphocytes
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Burkitts lymphoma - Pathogenesis

• Cell of origin B-cell centroblast (relatively
  mature B-cell)
• t(814) C-MYC
• Role of EBV
• African (Endemic) vs. Sporadic form

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Burkitts lymphoma - Pathogenesis

• Cytogenetics t(814), t(28), t(228)
• Common theme Chr. 8 C-MYC - a cellular
  oncogene
• Partners Immunoglobulin regulatory regions

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Burkitts lymphoma - Pathogenesis

• Regulator C-MYC
• Chromosome 8 ?_?_?____?__?__
• Regulator Ig
• Chromosome 14
  ?_?_?____?__?__

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Burkitts lymphoma - Pathogenesis

• C-MYC Regulator Ig
• Chromosome 814
  ?_?_?____?__?__
• Ig Regulator C-MYC
• Chromosome 148 ?_?_?____?__?__

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Burkitts lymphoma - Pathogenesis

• The regulatory region of the Ig gene, which is
  usually very active in B-Cells, now drives the
  expression of C-MYC
• C-MYC is an oncogene the cell enters the cell
  cycle and divides
• The result the B-cell is driven to proliferate

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Burkitts lymphoma - Pathogenesis

• Burkitts Lymphoma is the tumor with the
  greatest proliferative capacity with a doubling
  time of 24-48 hours.

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The role of EBV in Burkitts lymphoma

• EBV a DNA herpesvirus
• The cause of infectious mononucleosis a self
  limiting infection of B-cells
• The genome of EBV can be found in Burkitts
  lymphoma cells 100 of cases of African
  Burkitts, 50 of cases in Latin America, and
  only in 20 of cases in the west.
• Its exact role in lymphomagenesis is unclear

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The role of EBV in Burkitts lymphoma

• In normal hosts - EBV causes a transient
  lymphoproliferation that is controlled by the
  immune system
• In the immunocompromised host EBV can cause a
  lymphoproliferative state than can be polycolonal
  or monoclonal (PTLD)
• Immunodeficiency or chronic infection (malaria)
  allows continuous proliferation of EBV-infected
  B-cells that may be the reservoir of cells
  vulnerable to malignant transformation

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Burkitts Lymphoma Clinical Features

• Commonest location abdomen Localized
  (ileocecal intussusception)
• 
  - Disseminated mesenteric, peritoneal
• 
  - Renal involvement
• Head and neck pharynx, Waldeyer ring, paranasal
  sinuses, tonsils, gums
• Epidural, ovary, bone
• African form Jaw tumors
• Spread to extra lymphatic organs CNS, BM (20)
• Rapid growth metabolic derangements

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Burkitts - Diagnostic Evaluation

• Diagnostic biopsy
• - lymph node
• - abdominal mass
• - bone marrow (stage 4 - B-cell leukemia)
• - intestinal resection (intussusception)

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Burkitts lymphoma - Pathology

• Rapidly proliferating B-Cells (MIB1)
• Starry sky appearance (macrophages)
• Subtypes Burkitts, Burkitt-like, (DLBCL)

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Burkitts lymphoma - Pathology
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Burkitts- Diagnostic Evaluation

• Clinical extent
• Lab- CBC, Uric acid, LDH, P, Ca, K,
• renal function
• Imaging CT
• Radionucleide scan Gallium, PET
• Bone marrow, CNS involvement
• Pre-treatment - Echo,Fertility preservation

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Burkitts Lymphoma - Staging

• St. Jude/NCI system
• Stage I One nodal group- resected
• Stage II Localized disease (AR)
  (Intussusception)
• Stage III Extensive abdominal or mediastinal
• disease, epidural
• Stage IV Extra nodal disease CNS, Bone marrow
• (BM - Burkitts (B-cell)
  leukemia)
• Most patients present with advanced disease
  (Stages III, IV)

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Burkitts Lymphoma - Staging

• LMB (FAB International) System
• Group 1 One nodal group- resected
• Group 2 Extensive localized disease -
  abdominal or
• mediastinal, epidural, high
  LDH
• Group 3 Extra nodal disease CNS, Bone marrow
• (BM - Burkitts (B-cell)
  leukemia)

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Burkitts lymphoma - Treatment

• Metabolic stabilization Tumor lysis syndrome
  (TLS)
• Stage (Group) dependent
• Chemotherapy
• Intensive, short duration therapy
• Minimal (if any) role for radiation therapy
• Surgery localized abdominal disease
  (intussusception)
• High cure rate in newly diagnosed patients
• Relapse is rarely curable

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Tumor Lysis Syndrome

• Rapid proliferation and death of cells
• Tumor cells outstrip their own blood supply and
  die
• Breakdown of nucleic acids DNA uric acid,
  phosphate
• Spontaneous cell death ? Severe TLS can occur
  before treatment

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Tumor Lysis Syndrome

• Diseases with rapid cellular
  turnover
• Lymphomas Burkitts, lymphoblastic
• Leukemias ALL, AML
• Solid tumors less common NB, RMS

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Burkitts lymphoma - Chemotherapy

• Begin after metabolic stabilization
• Active agents Cyclophosphamide, HD MTX, HD
  ARA-C, vincristine, doxorubicin, steroids,
  ifosfamide, VP-16,
• CNS directed therapy intrathecal (XRT
  unnecessary)
• Greatest dose-intensity possible (minimal
  interval between cycles)

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Burkitts Lymphoma Treatment The
LMB approach
Reduction phase
Vincristine Cyclophosphamide Total 5.5
grams/M2 Doxorubicin Total 180 mg/M2 MTX -
Total 15 gram/M2 Prednisone ARA-C VP-16
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Burkitts lymphoma - Outcome

• Modern therapy is highly effective.
• Most patients are cured 95 group B, 80 Group
  C.
• Period of risk for relapse is short 9-12
  months
• Acute toxicity is substantial Infections,
  mucositis, acute mortality 1-3.
• Long term toxicity mainly gonadal (cardiac)
• Reduction in therapy?

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Results of LMB-89 trial for Pediatric B-cell NHL
Patte C et al Blood 200197, 3370-9
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B-NHL - Outcome by group
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B-NHL - Outcome by stage
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Outcome in group C Importance of CNS disease
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Gonadal Toxicity

• Mainly caused by alkylating agents
• Cyclophosphamide, ifosfamide, busulfan,
  procarbazine
• Damage to gonads is related to cumulative dose
• Cyclophosphamide gt6 grams is toxic

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Burkitts lymphoma Challenges

• Preserve cure rates while reducing acute and long
  term toxicity
• Treatment of relapse

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Relapsed Burkitts Lymphoma

• Relapse Burkitts lymphoma is currently incurable
  in the overwhelming majority of patients
• Targeted therapy - Anti CD - 20
  (rituximab)
• 
  Ibritumomab-tiuxetan Y90
• 
  Anti CD22 Epratuzumab
• 
  hLL2-DOTA- Y90
• Anti CD52 Campath-1H,
• 
  Alemtuzumab
• Allo-BMT