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לויקמיה ולימפומה בילדים דר. יצחק יניב מנהל המחלקה להמטולוגיה ואונקולוגיה ילדים מרכז שניידר לרפואת ילדים בישראל. Pediatric Hematology Oncology, Schneider Children’s Medical Center of Israel, Petal-Tikva, Sackler School of Medicine, Tel Aviv University, Israel. Childhood malignancy. - PowerPoint PPT Presentation
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לויקמיה ולימפומה לויקמיה ולימפומה בילדיםבילדים
דר. יצחק יניבדר. יצחק יניבמנהל המחלקה להמטולוגיה מנהל המחלקה להמטולוגיה
ואונקולוגיה ילדיםואונקולוגיה ילדיםמרכז שניידר לרפואת ילדים בישראלמרכז שניידר לרפואת ילדים בישראל
Pediatric Hematology Oncology,
Schneider Children’s Medical Center of Israel, Petal-Tikva,
Sackler School of Medicine, Tel Aviv University, Israel.
Childhood malignancy
Cancer Cell, 2002
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
Risk Factors for Childhood Acute Leukemia
Genetic Down ALL, AMLNF1 ALL, AML, JMMLBloom ALL, AMLSchwachman ALL, AMLAtaxia Telangiectasia ALLFanconi Anemia AMLKostmann GranulocytopeniaAML
Environmental Ionizing Radiation ALL, AML
In Utero X-ray ALLBenzene
AMLPesticide AMLAlkylating /Topo-II Inhib.
AMLIn Utero Topo II Inhib.
Infant Und L.DNA damaging
Higher incidence among identical twins
ALL- Epidemiology
The most common malignancy in childhood
Incidence 3-4 cases per 100000 children
Peak incidence between 2-5 y Boys > Girls White >BlackGenetic predisposition <5%
Age distribution
Clinical Features at Diagnosis in Children with
Acute Lymphoblastic Leukemia
Clinical features/ Symptoms % of patients
Fever 61Bleeding (petechiae or purpura) 48Bone pain 23Lymphadenopathy 50Splenomegaly 63Hepatosplenomegaly 68
Laboratory Features at Diagnosis in Children with
Acute Lymphoblastic Leukemia
Laboratory features % of patients
Leukocyte count (mm3)<10,000 5310,000-49,000 30>50,000 17
Hemoglobin (g/dl)<7.0 437.0-11.0 45>11.0 12
Platelet count (mm3)<20,000 2820,000-99,000 47>100,000 25
ALL testicular involvement
CNS leukemia
Differential Diagnosis in Childhood Acute Lymphoblastic Leukemia
Nonmalignant conditionsJuvenile rheumatoid arthritisInfectious mononucleosisIdiopathic thrombocytopenic purpuraPertussis; parapertussisAplastic anemiaAcute infectious lymphocytosis
MalignanciesNeuroblastomaRetinoblastomaRhabdomyosarcoma
Unusual presentationsHypereosinophilic syndrome
Diagnosis
Blood count and smear Bone marrow: Morphology
Cytochemical stains
Immunophenotype
Cytogenetics
Haemopoiesis
FAB L1
FAB L2
FAB L3
Cytochemical stains
Lymphoid differentiation
T phenotype ALL Incidence 15% (Israel – 20 %)
Median age : 12y
Male > Female
High blood count
Mediastinal mass
Organomegaly
CR < 90 %
High relapse rate, CNS, Extra medullary
15 לפני גיל ALL ילדים מפתח 2000אחד מתוך •ברובם הארוע הראשון קורה ברחם• אך רק אחוז אחד מהם 212;1 נןשא טרנסלוקציה 1/100•
יפתח לויקמיהדרוש ארוע נוסף כדי שהלויקמיה תופיע וזה יכול להיות •
קשור בזיהום או בתגובה לזיהום וגם במבנה הגנטי הקיים DNAלגבי מטבוליזם של תרופות ותיקון נזקי
Genetic (somatic) Abnormalities in Childhood Cancer
Numerical Chromosomal changes
Structural Chromosomal changesTranslocationInversionDeletionAddition / duplicationAmplification
Childhood ALL
Hyperdiploid
cep4/cep10
Ca-Cytogenet. -SCMCI
G-banding FISH
Cep4: centromere 4
Cep10: centromere 10
Genetic (somatic) Abnormalities in Childhood Cancer
Numerical Chromosomal changes
Structural Chromosomal changesTranslocationInversionDeletionAddition / duplicationAmplification
Genetic Abnormalities in Childhood Cancer
Protooncogen ActivationSuppressor gene Inactivation
Altered function of: Growth factorsGrowth factor receptorsKinase inhibitorsSignal transducersTranscription factors
Altered down stream Genes Expression
bcr/abl
Childhood ALL
Ca-Cytogenet. -SCMCI
Philadelphia chromosomeG-banding FISH
46,XY,t(9;22)(q34;q11)
bcr: 22q11
abl: 9q34
ALL-B lineage Chromosomal rearrangement
Activation of transcriptional control Genes
ALL Translocation Genes Frequency
Early B t(12;21)(p12;q22) TEL-AML1 25%Pre. B t(1;19) (q23;p13) E2A-PBX1 5%Pro. B t(17;19)(q22;p13) E2A-HLF <1%
t(4;11) (q21;q23) MLL-AF4 4%
B cell/Burkitt t(8;14) (q24;q32) MYC (IgH) 5%t(2;8) (p12;q24) MYC (IgL) <1%t(8;22) (q24;q11) MYC (IgL) <1%
B cell t(3;11) (q27;q23) BCL6 1%
46,XY,t(12;21)(p13;q22),der(12)t(1;12p)
SKY
FISH
Childhood ALL – t(12;21) (TEL/AML1),del(12p)
H.M. Ca-Cytogenet. -SCMCI
G-band
Expression profiles of diagnostic bone marrow ALL blasts
Yeon, Cancer Cel 2002
Cancer Cell, 2002
Molecular subtypes of ALL
Pui, NEJM, 1998
Childhood ALL, Event Free Survival by Genetic Features St Jude
Prognostic Risk Factors in ALL
Age: 1-6, 1-10yWBC: 20.000, 50.000Phenotype.: T, “B”, CALLA neg.
Ploidy: <2n, 3nCytogenetic:t(9;22),t(4;11)
t(12;21)Gene Expression Profile ?
Early response to treatment !!!!!!
PB D8, BM D15, D33Morphology, MRD
Sex, Race, CNS, Testicular involvement
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
M R D Minimal Residual Disease
Precise definition of remission
Prognostic significance (blast <0.01% )
Treatment modification
Immunogobuline gene rearrangement
van Dongen ASH 2002
.therapy antileukemic Patterns of early cellular responses to
Pui, 2000
International BFM Study Group
Risk MRD 5 year Relapse
TP1 TP2 Rate - %
Low <10-4 <10-4 2
Intermediate 24
High >10-3 10-3 84
Combined Information of MRD from Time Points 1+2
Low risk group pRFS = 0.98 ± 0.02Intermediate risk group pRFS = 0.76 ± 0.06 p<0.001High risk group pRFS = 0.16 ± 0.08
0 1 2 3 4 5 6 7 8 9
years from time point 2
0.0
0.2
0.4
0.6
0.8
1.0Low risk group (n=55)neg at tp 1
Intermediate risk group (n=55)< 10e-3 at tp 2
High risk group (n=19)≥ 10e-3 at tp 2
Principles of treatmentRisk group
Combination chemotherapy:
Remission induction
• CNS prevention
Consolidation
Maintenance
Irradiation
BMT
Late effect consideration
Leukemic cell kinetics
Event- Free Survival of ALL children- St. Jude
Pui, 1998 NEJM
CHILDHOOD-ALL
ISRAEL NATIONAL STUDIES. EFS
Years Aug 2002
181614121086420
Cum
Sur
viva
l
1.0
.9
.8
.7
.6
.5
.4
.3
.2
.1
0.0
INS-98
INS-89
INS-84
CHILDHOOD ALL-INS 89
EFS by RISK-GROUPS
Years Aug 2002
1614121086420
Cu
m S
urv
iva
l
1.0
.9
.8
.7
.6
.5
.4
.3
.2
.1
.0
Non-HRG: 79%
(N=259)
HRG: 33%
(N=43)
Host Pharmacogenetics Affects Treatment Response
excessive toxicity
responders
non-
responders
Determinants of Treatment Response in Leukemia
Drug resistanceGrowth potential
Leukemia
Host Tumor burden
Age
Pharmacogenomics
Therapy
Drug dosage
Drug interactions
Treatment response
Same treatmentto all patients
Impact of Pharmacogenomics on Treatment Response
No Benefit+ Toxicity
No BenefitNo Toxicity
Treat with alternative drug
+ Benefit+ Toxicity
+ Benefit+ No Toxicity
Optimizetreatment
withindividualized
dose
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 > 100000
סיבוכים מאוחרים של קרינה למ.ע.מ. וכמותרפיה אינטנסיבית
קרינהגדולי מח משניים -אפיפודופילוטוקסינים. תרופות מאלקלותלאוקמיה משנית -
אנטרהציקליניםאנטרהציקליניםקרדיומיופתיה - גלוקוקורטיקואידים,קרינה, מטוטרקסאתאנצפלופתיה -קרינה, גלוקוקורטיקואידיםקומה נמוכה -
קרינההשמנה - קרינה, גלוקוקורטיקואיד, אנטימטבוליטיםאוסטאופורוזיס -
גלוקוקורטיקואיד נמק אווסקולרי לעצמות -
Relapse remains the major problem of childhood leukemia!!
Cancer Cell, 2002
Science, 1997
AML-M2, t(8;21)
NEJM, 1999
AML
Ca-Cytogenet. -SCMCI
G-banding FISH
Eto: 8q22
AML1: 21q22
Bennet, leukemia 2000
AM-M3, Hypergranular, t(15;17)
Grimwade, Blood, 1998
AML-MRC-10. Overall Survival by Cytogenetic abnormalities
AML-MRC-10. Overall Survival by Cytogenetic abnormalities
Grimwade, Blood, 1998
Cancer Cell, 2002
LymphomasClassification 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)
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)
Pediatric lymphomas
Non-Hodgkin Lymphoma in Children
• B-Cell – Burkitt’s lymphoma (40%)
Diffuse large B-cell (DLBCL) (20%)
B-cell lymphoblastic lymphoma (5%)
• T-Cell – Lymphoblastic Lymphoma (25%)
• Anaplastic Large Cell Lymphoma (ALCL) (10%)
Burkitt’s lymphoma
Burkitt’s 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
• Burkitt’s lymphoma and DLBCL are thought to arise in germinal centers of lymph nodes during B-cell development
The normal lymph node
Malignancies of B-lymphocytes
Burkitt’s lymphoma - Pathogenesis
• Cell of origin – B-cell centroblast (relatively mature B-cell)
• t(8;14) – C-MYC
• Role of EBV
• African (Endemic) vs. Sporadic form
Burkitt’s lymphoma - Pathogenesis
• Cytogenetics t(8;14), t(2;8), t(22;8)
• Common theme – Chr. 8 – C-MYC - a cellular oncogene
• Partners – Immunoglobulin regulatory regions
Burkitt’s lymphoma - Pathogenesis
Regulator C-MYC
Chromosome 8 ¥▅_▅_▅____▅__▅__
Regulator Ig
Chromosome 14 ¥ ▅_▅_▅____▅__▅__
Burkitt’s lymphoma - Pathogenesis
C-MYC Regulator Ig
Chromosome 8;14 ▅_▅_▅____▅__▅__
Ig Regulator C-MYC
Chromosome 14;8
▅_▅_▅____▅__▅__
Burkitt’s 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
Burkitt’s lymphoma - Pathogenesis
Burkitt’s Lymphoma is the tumor with the greatest proliferative capacity with a doubling time of 24-48 hours.
The role of EBV in Burkitt’s 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 Burkitt’s lymphoma cells: 100% of cases of African Burkitt’s, ~50% of cases in Latin America, and only in 20% of cases in the west.
• Its exact role in lymphomagenesis is unclear
The role of EBV in Burkitt’s 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
Burkitt’s 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
Burkitt’s - Diagnostic Evaluation
• Diagnostic biopsy
- lymph node
- abdominal mass
- bone marrow (stage 4 - B-cell leukemia)
- intestinal resection (intussusception)
Burkitt’s lymphoma - Pathology
• Rapidly proliferating B-Cells (MIB1)
• Starry sky appearance (macrophages)
• Subtypes – Burkitt’s, Burkitt-like, (DLBCL)
Burkitt’s lymphoma - Pathology
Burkitt’s- 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
Burkitt’s 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 - Burkitt’s (B-cell) leukemia) Most patients present with advanced disease (Stages III, IV)
Burkitt’s 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 - Burkitt’s (B-cell) leukemia)
Burkitt’s 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
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
Tumor Lysis Syndrome
Diseases with rapid cellular turnover
• Lymphomas – Burkitt’s, lymphoblastic
• Leukemias – ALL, AML
• Solid tumors – less common – NB, RMS
Burkitt’s 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)
Vincristine Cyclophosphamide –– Total 5.5 grams/M2Doxorubicin –– Total 180 mg/M2MTX -– Total 15 gram/M2PrednisoneARA-CVP-16
Burkitt’s Lymphoma – Treatment The LMB approach
Reductionphase
Burkitt’s 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?
Results of LMB-89 trial for Pediatric B-cell NHL
Patte C et al Blood 2001:97, 3370-9
B-NHL - Outcome by group
B-NHL - Outcome by stage
Outcome in group C – Importance of CNS disease
Gonadal Toxicity
• Mainly caused by alkylating agents
Cyclophosphamide, ifosfamide, busulfan, procarbazine
• Damage to gonads is related to cumulative dose
• Cyclophosphamide >6 grams is toxic
Burkitt’s lymphoma – Challenges
• Preserve cure rates while reducing acute and long term toxicity
• Treatment of relapse
Relapsed Burkitt’s Lymphoma
• Relapse Burkitt’s 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