Mucormycosis in a Pediatric Oncology Population - Review of Cases and the Literature

Opiod Induced Pruritus: The Need for Palliative Care for a Palliative Medicine (S707)

After obtaining approval from the institutional review boards of the pediatric hospital and collaborating university, we conducted a retrospective chart review and analysis of pediatric cancer patients that

Treatment adherence is an essential component in ensuring best outcomes in the management of paediatric cancers. Compared to the adult population, treatment adherence in the paediatric population is a more complex subject which involves unique dimensions. In this study, we aimed to systematically review the literature to identify factors associated with treatment adherence in the paediatric oncology population. A literature search was carried out using related keywords on electronic databases. A total of 1036 articles were reviewed, and 39 articles were found to be relevant. A comprehensive review of these articles identified 17 factors that influence adherence. These factors were classified into five major categories: patient-/caregiver-related factors; therapy-related factors; condition-related factors; health system-related factors; and social/economic factors. A baby bear model was proposed to better visualize these five categories that affect treatment adherence, and a framework of questions was designed to help clinicians identify those at risk of non-adherence for early intervention. Seventeen factors reviewed were categorized into five main categories, namely patient-/caregiver-related factors, therapy-related factors, condition-related factors, health system factors and social/economic factors, as causes for poor medication adherence in the paediatric oncology population. Clinicians need to be aware that these factors can interact to influence treatment adherence and that some factors may be more relevant in specific contexts (e.g. third world countries, minority groups). The baby bear model is presented to help understand the issues affecting adherence in the paediatric oncology population, and a framework of questions is proposed to help clinicians identify patients at risk of non-adherence.

BackgroundThis study of nutritional patterns in relation to cancers among pediatric oncology population in Tanzania was motivated by the lack of up-to-date information about the nutritional practices, the controversy around the importance of nutritional support and the lack of consistent nutritional criteria among pediatric oncology populations.MethodsA survey study in two cancer referral hospitals of children diagnosed with any cancers, aged between 1 and 17 years inclusive and being eligible for enteral feeding included 131 children. Their demographic, nutritional, feeding and cancer profiles were analyzed descriptively through mapping and other approaches as well as inferentially using multinomial regression models to understand different aspects of nutrition for children suffering from cancers.ResultsThe majority (15% or higher) of pediatric oncology population originated from the lake zone. Between 7 and 12% of pediatric oncology population originated from the Western zone. The top-three cancers with their percentages in the brackets were: Wilms Tumor (32%), Acute Lymphoblastic Leukemia (26%) and Retinoblastoma (13%). About 69% of the pediatric oncology population ate foods that are rich in energy but poor in protein such as rice (21.5%), porridge (19.3%), banana (11.7%) and potatoes (10.2%). On the other hand, only 17.5% ate foods that are generally protein-rich such as meat (8.0%), fish (5.3%) and chicken (4.2%); and 12.7% ate milk (4.2%), beans (3.4%), vegetables (2.7%), eggs (1.9%) and fruits (1.5%). Cancers impacted food intake in about 60% of all children with cancers and affected appetite in 18.3% of them. Cancers caused vomiting in 16% and diarrhea in 6.1% of children. The majority of children with cancers (61.8%) took at least one meal while 34.4% took just snacks (p < 0.001).ConclusionsThe majority of pediatric oncology population had erratic nutritional patterns and took foods high in energy and poor in proteins. There is a two-way interaction between cancers and nutrition in which cancers affect general nutritional intake which could affect the cancer treatment outcomes in return. Therefore, it is important to consider these interactions while managing pediatric oncology populations in this and similar settings.

Focus Area: Alleviating PainAcupuncture is infrequently studied in the pediatric oncology population; however, it has immense potential as a complementary cancer care modality. The aim of our analysis was to characterize the patients and utilization of acupuncture therapy among the pediatric oncology population at a tertiary care pediatric hospital. A retrospective analysis of medical records for patients between the ages of 0 and 18 years who were undergoing treatment for an oncological diagnosis and had received acupuncture therapy between January 2004 and September 2012 was conducted with sub-analysis performed of acupuncture treatments received. A total of 133 patients, comprising 3.2% of the pediatric oncology population at our institution, utilized acupuncture therapy during the years 2004 to 2012. A cumulative 523 acupuncture treatments were provided in both the outpatient and inpatient settings. The majority of patients receiving acupuncture were in their teenage years and received between 1 and 5 treatments. While referrals were mainly received for a pain indication or nausea and vomiting, acupuncture treatments provided addressed a wide variety of patients' complaints. Acupuncture use among the pediatric oncology population is relatively low; however, acupuncture appears to be well tolerated, perceived as beneficial, and without any serious adverse events in this population. These findings help to identify optimal ways in which acupuncture services can be offered clinically to this unique population in the future. Acupuncture therapy demonstrated potential as a beneficial complementary cancer care modality for a wide variety of complaints and cancer treatment-related side effects in patients with varying ages and cancer diagnoses. Further research is warranted to explore evidence-based data with regard to the safety and efficacy of acupuncture use among pediatric oncology patients and to determine its impact on quality of life and treatment outcomes including impact on cancer treatment–related side effects.

Pneumatosis intestinalis (PI) is characterized by the presence of intramural gas in the gastrointestinal (GI) tract. The overall aim of this study was to review risk factors and outcome of pediatric oncology patients at our institution who developed PI. Patients diagnosed with PI between 2007 and 2018 were identified from ICD-10 coding of radiology reports at Memorial Sloan Kettering Kids, a tertiary pediatric oncology center. Outcomes of interest were (a) resolution and time to resolution of PI, (b) surgical intervention within 2weeks of diagnosis of PI, or (c) death secondary to PI. To capture the resolution of PI, we defined the "time to recovery (TTR)" as the time elapsed between date of PI diagnosis and the date of recovery. Forty-two patients were identified. Within 30days of diagnosis of PI, three patients had surgical intervention for PI (7%) and two patients died (5%) due to non-PI causes. Median TTR of PI was 4.5days (95% CI: 3-7days). In univariable and multivariable analyses, only steroid use in the prior 30days was significantly associated with a faster TTR of PI (HR=2.27 [95% CI: 1.17-4.41], p=.02). This is the largest case series of patients with PI in the pediatric oncology population, which reveals significantly lower surgical and mortality rates than other published PI series. For the majority of patients, conservative medical management is indicated. A prospective study is warranted to define diagnosis and management guidelines for PI in the pediatric oncology population in a cooperative group setting.

One of the most common and distressing side effects for cancer patients is chemotherapy-induced nausea and vomiting (CINV). New antiemetics, such as the NK-1 receptor inhibitor aprepitant, have been reported to improve control of this side effect in adults. However, little is known about its effect in the pediatric oncology population, with only a few reported cases in the literature. This was a retrospective chart review on the use of aprepitant in the pediatric oncology population in our institution. Thirty-two charts and a total of 146 cycles of chemotherapy were reviewed. Mean age was 10 years. Highly emetogenic chemotherapy was used in 23/32 patients and moderately emetogenic chemotherapy in 9/32. Antiemetic regimens consisted of aprepitant+5-HT3 RA+dexamethasone (Regimen 1, 20/32 patients) or aprepitant +5-HT3 RA (Regimen 2, in 12/32). Eight out of thirty-two patients were chemotherapy-naïve and received aprepitant on their first cycle. In 24/32 patients, aprepitant was added later in their treatment, with 12/24 reporting resolution of CINV after its addition. Aprepitant when combined with standard antiemetics, was well tolerated in the pediatric oncology population studied. However, there is still a need to conduct prospective studies to determine the optimal efficacy of aprepitant in the pediatric oncology population.

Background: The purpose of this review was to evaluate the current body of literature on yoga in the pediatric oncology population. Considering the increasing number of studies on yoga indicating improvements in health-related quality of life (HRQL) among the adult oncology population, it is important to explore whether similar benefits have been found in pediatric oncology patients. Methods: CINAHL, Ovid MEDLINE, PsycINFO, PubMed, and Scopus were searched from the years 2010 through 2020 for studies assessing the use of yoga in children and adolescents affected by cancer. Considering the benefits of yoga on HRQL in the adult oncology population, the aim of this review was to evaluate the current body of literature on yoga in the pediatric cancer population. Results: Eight studies, all nonrandomized with single-arm designs, were reviewed. Five of the studies were designed as feasibility studies and while recruitment rates ranged from 34% to 55%, retention rates were ∼70%. Qualitative feedback from participants was very positive and themes related to both physical and psychological benefits. Certain measures of HRQL (i.e., anxiety, pain, and physical functioning) were found to be significantly improved following a yoga intervention. Discussion: Although no randomized clinical trials have been conducted to date on this important topic, the studies reviewed showed that delivering yoga to this population is feasible and safe. Additionally, preliminary findings on the impact of yoga for some of the common symptoms and treatment-related side effects experienced by children and adolescents affected by cancer are promising.

Aim: Despite the growing evidence supporting the use of peripheral nerve stimulation (PNS) for cancer pain in adults, it is underutilized in the pediatric oncology population.Method: We describe the use of temporary, percutaneous PNS for pain management in pediatric patients suffering from cancer related pain.Results: Two adolescent patients underwent an ultrasound-guided suprascapular nerve PNS placement utilizing the percutaneous 60-day therapy system. Both patients reported approximately 60% pain relief during the therapy, as well as up to 90days post lead removal.Conclusion: PNS may play a crucial role in the pediatric oncology population. Further studies are warranted to investigate the efficacy and safety of PNS for various cancer-related pain conditions in pediatric populations.

Little information is available regarding the safety of ultrasound contrast agents in children. The purpose of this article was to assess the safety profile of the i.v. administration of ultrasound contrast agents in the pediatric oncology population. Patients with pediatric solid malignancies who were enrolled on institutional clinical trials conducted between June 2003 and January 2013 and who met our institutional screening criteria for contrast-enhanced ultrasound (CEUS) were eligible. After providing informed consent or assent for CEUS, subjects received i.v. bolus injections of one of two contrast agents for imaging of the primary tumor or a metastatic target lesion. Hemodynamic parameters, including heart rate, cardiac rhythm, and oxygen saturation, were monitored immediately before and for 30 minutes after the administration of the contrast agent. Interviews with the subject or a guardian were conducted by the principal investigator or a radiologist coinvestigator before and after the examination to assess for any adverse effects. Thirty-four subjects (21 male and 13 female) ranging in age from 8 months to 20.7 years (median, 8.7 years) underwent 134 CEUS. No detrimental change in hemodynamic status occurred in any subject. Three subjects (3/134, 2.2%) reported mild transient side effects on one occasion each, two (2/134, 1.5%) had taste alteration, and one (1/134, 0.8%) reported mild transient tinnitus and lightheadedness. These reactions did not recur in these subjects on subsequent CEUS examinations. The i.v. administration of ultrasound contrast agents is safe and well tolerated in the pediatric oncology population. Further studies in children are needed to confirm our findings.

As pediatric oncologists who both are members of the Children's Oncology Group (COG) and have devoted significant effort to reducing central line–associated bloodstream infections (CLABSIs) in children with cancer, we were excited in 2013 when the COG decided to study the impact of daily chlorhexidine gluconate (CHG) bathing on the incidence of CLABSIs in the pediatric oncology population. Before the opening of COG study ACCL1034, which was conducted under Zerr et al's direction,1 the efficacy of CHG bathing in reducing CLABSIs had been demonstrated only in adults and critically ill children, and there were little data evaluating the impact of CHG bathing on CLABSIs specifically in pediatric oncology patients.2-4 Results from the aforementioned study were published in the October 20, 2020, issue of Cancer,1 and on the basis of those results, the principal investigators concluded that the data “do not support the use of routine CHG bathing in children with cancer or those undergoing allogeneic HCT [hematopoietic stem cell transplantation].” After careful review of the publication, we have several concerns about the study and the conclusions that were drawn. First, in our clinical experience, most children with cancer in the United States complete their therapy with only an implanted tunneled catheter or port. This population was excluded from this study, so the conclusions cannot be applied to all pediatric oncology patients. Among the most striking observations about this study is that the adherence to the CHG and control bathing regimen was very poor, and the rate of refusal to continue assigned therapy was very high. Only 111 of 165 assessed patients (67%) had an adherence rate of ≥80%. It is also unclear why such large proportions of patients in both the CHG group (48 of 88) and the control group (35 of 89) discontinued the intervention before the end of the planned observation period. The authors give “refusal of further therapy” as the explanation for most patients' discontinuation. The majority of subjects reported satisfaction with the bathing cloths and reported that they were easy to use; this raises the question of whether there were other logistical difficulties in conducting the study. The intent-to-treat analysis included an intervention group in which less than half of the enrollees (40 of 88) received the intervention for the full anticipated observation period. Notably, there were 10 more patients with acute myeloid leukemia in the CHG intervention group than the control group (32 vs 22). It is known that pediatric patients with acute myeloid leukemia are among the patients at highest risk for CLABSIs, especially those with external tunneled catheters.5-7 This imbalance between groups is one potential factor in the higher CLABSI rate observed in the CHG group and may have influenced the overall results. Other concerns are the result of poor accrual and early termination of the study. Less than 50% of the accrual goal was achieved during the 4-year study period. The original sample size calculation indicated that 400 total evaluable patients would be required, each with a 90-day observation period, to determine a difference of 2 infections per 1000 line-days with 85% power. This would lead to 18,000 line-days of observation per group, but when the study was stopped early with only 174 evaluable patients and an average of 74 days of observation, there were approximately 6500 line-days observed per group. With the lower than planned accrual, the power to detect a 2 CLABSI/1000 line-day difference dropped to 44%. In our work to better understand and reduce CLABSIs through a national quality collaborative called Solutions for Patient Safety, we have come to believe that multiple interventions performed reliably over a long period of time are necessary to significantly reduce the incidence of CLABSIs in the pediatric oncology population. We feel strongly that it would be a mistake to hastily discard any intervention that might reduce this serious harm without reliable data that refute other published studies' findings. We recommend that readers consider this article's conclusions with caution and keep the previously delineated concerns in mind. No specific funding was disclosed. Jeffrey D. Hord and Christopher E. Dandoy are volunteer leaders for a national quality improvement initiative to reduce central line–associated bloodstream infections that is directed and managed by Solutions for Patient Safety. Christopher E. Dandoy reports a consulting fee from Omeros outside the submitted work.

Platinum-based chemotherapy and cranial radiation are effective treatment options commonly prescribed for a variety of childhood cancers. These therapies can, and often do, result in early- and late-onset adverse health effects such as hearing loss. Undetected hearing loss is particularly concerning in young children developing speech and language skills and can negatively affect academic achievement and the psychosocial well-being of both young and older children. Early detection of hearing loss in pediatric oncology patients and early intervention are critical to help these patients succeed in achieving these developmental milestones. The primary goal of this study was to create a tutorial for audiologists concerning the monitoring of ototoxicity in the pediatric oncology population. Monitoring hearing for children receiving potentially ototoxic cancer treatments presents special issues and challenges for audiologists. This tutorial will orient the reader to these special issues and challenges, and potential solutions will be proposed. This tutorial is organized into sections, including an overview of platinum compound and cranial radiation treatments commonly used to treat pediatric cancer, modifications of the test battery required to appropriately monitor for ototoxic hearing loss in children, a proposal for a monitoring protocol, and descriptions of the grading scales that are frequently used by oncologists to determine the severity of ototoxic hearing loss. Identification of ototoxicity is crucial in children receiving cancer treatments because of the impact that acquired hearing loss has on social and educational outcomes in the developing child. Monitoring hearing in children presents challenges that are unique to this population. Much effort has been put forth in developing and validating the International Society of Pediatric Oncology ototoxicity grading scale for international use in reporting auditory outcomes in clinical trials. In the future, the development of standardized monitoring protocols will assist audiologists in providing optimal care to children treated for cancer.

Although complementary and alternative medicine (CAM) is widely used in the pediatric population, research on the use of these therapies in the pediatric oncology population is of mixed quality. In this multicenter survey, we investigated the prevalence of CAM use, possible determinants of use, and parental attitude towards communication and research on CAM therapies. The prevalence of CAM use in the past 12 months was assessed by using a questionnaire based on the European guidelines on CAM research, filled out by parents of children visiting pediatric oncology outpatient clinics of six academic hospitals in the Netherlands. The questionnaire consisted of 26 questions on the child's clinical status, CAM use, and attitude towards communication and research on CAM therapies. One hundred and twenty-two of 288 respondents (42.4 %) reported CAM use. The most frequently used categories were homeopathy (18.8 %) and dietary supplements (11.5 %). Female gender and parental CAM use were significant predictors for the use of CAM (p < 0.001). Only one third of the parents had discussed CAM use with their pediatric oncologist. More than 80 % of the respondents identified a need for information about CAM from their pediatrician and 85.7 % was positive towards research on CAM. Half of the parents were interested in participating in future CAM trials. Conclusion, with more than 40 % of parents of Dutch pediatric oncology patients providing complementary and alternative medicine to their child and with lacking evidence on efficacy and safety of most CAM modalities, there is a clear need for high-quality research in this field. This study shows that most parents have an open attitude towards CAM research and that almost half of the parents would consider participating in future CAM trials, paving the way for research on CAM and aiming for its evidence-based use in pediatric oncology.

Complementary and alternative medicine is increasing in use in the pediatric oncology population. Although there is a multitude of herbal therapies used, the focus of this article is a review of the literature addressing some herbal therapies used to treat the symptoms of cancer and side effects of traditional methods of treatment. Ginger is used in the treatment of nausea and vomiting. St. John's wort is successful in treating depression and anxiety. Echinacea is used as an immunostimulant. Herbal therapies in the pediatric oncology population are usually initiated and managed by parents. Many herbal therapies are beneficial, but some potential herb-drug interactions should be considered. This poses a challenge to the oncology nurse because herbal treatments are managed by the parents and pharmaceuticals are managed by the practitioner. Educating the patient, family, and practitioner is important in ensuring a thorough health history assessment and, subsequently, safe and effective herbal and pharmacological therapies.

ObjectivesThe objectives are to examine the reproducibility of functional MR imaging in children with solid tumours using quantitative parameters derived from diffusion-weighted (DW-) and dynamic contrast enhanced (DCE-) MRI.MethodsPatients under 16-years-of age with confirmed diagnosis of solid tumours (n = 17) underwent free-breathing DW-MRI and DCE-MRI on a 1.5 T system, repeated 24 hours later. DW-MRI (6 b-values, 0-1000 sec/mm2) enabled monoexponential apparent diffusion coefficient estimation using all (ADC0-1000) and only ≥100 sec/mm2 (ADC100-1000) b-values. DCE-MRI was used to derive the transfer constant (Ktrans), the efflux constant (kep), the extracellular extravascular volume (ve), and the plasma fraction (vp), using a study cohort arterial input function (AIF) and the extended Tofts model. Initial area under the gadolinium enhancement curve and pre-contrast T1 were also calculated. Percentage coefficients of variation (CV) of all parameters were calculated.ResultsThe most reproducible cohort parameters were ADC100-1000 (CV = 3.26 %), pre-contrast T1 (CV = 6.21 %), and Ktrans (CV = 15.23 %). The ADC100-1000 was more reproducible than ADC0-1000, especially extracranially (CV = 2.40 % vs. 2.78 %). The AIF (n = 9) derived from this paediatric population exhibited sharper and earlier first-pass and recirculation peaks compared with the literature’s adult population average.ConclusionsFree-breathing functional imaging protocols including DW-MRI and DCE-MRI are well-tolerated in children aged 6 - 15 with good to moderate measurement reproducibility.Key Points• Diffusion MRI protocol is feasible and well-tolerated in a paediatric oncology population.• DCE-MRI for pharmacokinetic evaluation is feasible and well tolerated in a paediatric oncology population.• Paediatric arterial input function (AIF) shows systematic differences from the adult population-average AIF.• Variation of quantitative parameters from paired functional MRI measurements were within 20 %.