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Metaiodobenzylguanidine (MIBG) imaging has been the standard for neuroblastoma staging for many decades. Novel agents such as 18F-DOPA and 68Ga-DOTATATE are being used nowadays in academic centers. During the coronavirus disease 2019 (COVID-19) pandemic, procurement of 123I-MIBG has proved particularly challenging, necessitating the use of 68Ga-DOTATATE PET. 68Ga-DOTATATE is Food and Drug Administration–approved for imaging of somatostatin receptor–positive gastroenteropancreatic neuroendocrine tumors. Methods:68Ga-DOTATATE PET/CT imaging was performed for staging of 3 pediatric patients with neuroblastoma at our institution. A review of the literature was also completed. Results:68Ga-DOTATATE PET/CT scans were successfully performed on all patients. All patients showed 68Ga-DOTATATE–avid disease. PET scans showed an excellent spatial resolution and demonstrated high accuracy in concordance with current European Association of Nuclear Medicine guidelines. Conclusion: We have presented 68Ga-DOTATATE PET/CT imaging for staging of neuroblastoma and believe it can reliably be used as an alternative to 123I-MIBG. It has technical, clinical, and practical advantages making it an attractive option. Further multicenter studies are required before it can be recommended for standard clinical use.

Cancer is an evolving cause of morbidity and mortality in children worldwide. In recent decades, there has been a significant increase in the survival of children with cancer, after applying new methods and treatment protocols in practice. However, the complexity of the disease itself, as well as the intensity and toxicity of treatment is such that many children require admission to the pediatric intensive care unit (PICU) which should be well equipped and led by personnel who have adequate training and expertise to provide optimum care to these complex patients. Most oncology patients who require PICU admission categorized into oncological emergencies, and/or decompensation from treatment and its side effects. In this study, we provide a summary of the essential and most recent evidence-based recommendations from published reviews and articles to aid PICU physicians and to ensure the best treatment and outcome possible for the children with such disease. How to cite this article: Al Haj Moussa A, Maaz AUR, Faqih N, Sundaram M. Critically Ill Pediatric Oncology Patients: What the Intensivist Needs to Know? Pediatric Critical Care Medicine. Indian J Crit Care Med 2020;24(12):1256–1263.

Low- and middle-income countries sustain the majority of pediatric cancer burden, with significantly poorer survival rates compared to high-income countries. Collaboration between institutions in low- and middle-income countries and high-income countries is one of the ways to improve cancer outcomes.Patient characteristics and effects of a pediatric neuro-oncology twinning program between the Hospital for Sick Children in Toronto, Canada and several hospitals in Karachi, Pakistan over 7 years are described in this article.A total of 460 patients were included in the study. The most common primary central nervous system tumors were low-grade gliomas (26.7%), followed by medulloblastomas (18%), high-grade gliomas (15%), ependymomas (11%), and craniopharyngiomas (11.7%). Changes to the proposed management plans were made in consultation with expert physicians from the Hospital for Sick Children in Toronto, Canada. On average, 24% of the discussed cases required a change in the original management plan over the course of the twinning program. However, a decreasing trend in change in management plans was observed, from 36% during the first 3.5 years to 16% in the last 3 years. This program also led to the launch of a national pediatric neuro-oncology telemedicine program in Pakistan.Multidisciplinary and collaborative efforts by experts from across the world have aided in the correct diagnosis and treatment of children with brain tumors and helped establish local treatment protocols. This experience may be a model for other low- and middle-income countries that are planning on creating similar programs.

Wilms Tumor (WT) is one of the most curable childhood cancers. High cure rates seen in the developed countries are not reproduced in developing countries. Lack of access to cancer treatment facilities, financial constraints, late presentation, and abandonment have previously been described. We reviewed our data over the last 20 years to highlight some of these challenges.This is a retrospective chart review of children with WT at our center up to the age of 18 years between 1 November 1997 and 30 November 2017. Demographic details, presentation characteristics and treatment details were recorded. Factors associated with poor outcome were analyzed.Two hundred eleven children were registered; 117(55.5%) were males. Median age at presentation was 3 (range 0 to 18) years. Presentation data were available for 184/211 patients, staging details for 159/211 and metastatic status for 178/211. Of the available dataset, 60% presented without prior treatment, whereas 40% presented atleast after primary surgical excision. High-stage (stage III or above) disease was present in 79 (49.7%) patients; 61 (34.3%) was presented with metastases or recurrence; 63 (29.8%) abandoned or refused treatment; 99/172 (57.6%) patients finished treatment, 23 (13.4%) died during treatment, and 6 died before treatment. Of the 99 patients who finished treatment 83 (83.8%) are well off therapy; 15(15.2%) relapsed; 6 (40%) are alive after salvage therapy, while 9 (60%) died.Our data highlights the challenges of managing WT in resource poor environments. Prior surgery, incomplete staging work-up and abandonment are some of the most frequently encountered barriers. A multipronged approach is required to overcome these challenges.

Although MRI is the workhorse of brain tumor initial evaluation and follow-up, there is a growing amount of data recommending the incorporation of amino-acid PET imaging at different stages of the management of these patients. Recent nuclear medicine and neuro-oncology clinical practice recommendations support the use of amino-acid imaging in brain tumor imaging. Considering

Objective To determine outcome of first relapse of Hodgkin lymphoma with standard dose chemotherapy, and to identify the prognostic factors predicting survival outcome in paediatric patients. Methods The retrospective study was conducted at Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan, and comprised data of Hodgkin lymphoma patients who relapsed at least 3 months after the completion of initial treatment from January 2001 to December 2010. Probabilities of overall survival, event-free survival and cumulative incidence were calculated. Data was analysed using SPSS 21. Results Of the 43 patients, 31(72%) were males and 12(29%) were females. Mean age at relapse was 11±3.3 years (range: 4-17 years). In 31(72%) patients, early post-operative intraperitoneal chemotherapy was employed. Median follow-up of the cohort was 62 months (interquartile range: 4-187 months). Overall survival and event-free survival at 10 years was 23(54%) and 15(35%) respectively. On univariate analysis, initial disease stage (p=0.021), stage at relapse (p=0.003), treatment protocol (p=0.005), treatment responsiveness at initial two cycles of salvage chemotherapy (p=0.002) and at the end of treatment assessment (p=0.0009) were statistically significant factors. Multivariate cox regression analysis revealed disease stage at relapse (p=0.004), chemotherapy regimen (p=0.025) and end-of-treatment disease evaluation (p=0.005) as the significant variables. Conclusions Improved outcome with early post-operative intraperitoneal chemotherapy regimen was noted for Hodgkin lymphoma patients who had disease-free interval >2 years.

Background: MIBG imaging has been the standard for neuroblastoma staging following its discovery 4 decades ago. Novel agents such as 18F-FDOPA and 68Ga-DOTATATE are being widely used nowadays in academic centers. In the midst of the COVID-19 pandemic, procurement of MIBG has proved particularly challenging, necessitating the use of 68Ga DOTATATE positron emission tomography. Methods: 68Ga-DOTATATE PET/CT imaging was carried out for completion of staging investigation for three pediatric patients who were diagnosed with Neuroblastoma at our institution, as 123Iodine MIBG became unavailable during the pandemic. Results: 68Ga-DOTATATE PET/CT scans were carried out in all three pediatric patients without any complications. All patients showed 68Gallium DOTATATE avid disease. PET/CT scans showed better spatial resolution, increased lesion contrast and demonstrated high accuracy in staging neuroblastoma patients in concordance with current EANM guidelines. Conclusion: 68Ga-DOTATATE PET/CT imaging can be reliably used as an alternative to MIBG for staging and evaluation of patients with neuroblastoma. Impact may be best in high risk disease.

Objectives To review the presentation characteristics and treatment outcomes for pediatric optic pathway gliomas (OPG) in Qatar. Methods Retrospective review of data for children with OPG from January 2009 to February 2021. Presenting features, diagnostic imaging and indications for treatment were reviewed. Progression free survival (PFS) and overall survival(OS) were computed using standard statistical methods. Medical notes were also reviewed for visual outcomes. Results Nineteen patients were diagnosed with OPG during the study period. There were 10 (52%) females. Median age was 29 months (range 6–186) months. Eleven (57%) tumors were related to neurofibromatosis Type 1 (NF-1). Nine (47%) of OPG were located in optic nerves, 5 (26%) were chiasmatic/suprasellar, while the remaining 5(26%) involved a combination of structures. Seven(36%) children presented with oculo-visual symptoms. Another 7 were diagnosed on screening imaging for NF-1. Seven(36%) children had debulking surgery/biopsy, while the remaining patients were diagnosed on neuro-imaging alone. Thirteen (68%) patients were treated with chemotherapy and 2 received additional radiotherapy. Indications for non-surgical treatment included visual impairment (46%) and large/progressive tumor (54%). Carboplatin based regimes were used as first line chemotherapy for 76 % of patients. Five (38%) patients required more than one lines of treatment. OS and PFS at 36 months were 100% and 48%. Baseline visual assessment showed 5 children each (26%) had unilateral and bilateral visual impairment, while 9 (48%) had normal vision. Of the 6 children receiving chemotherapy for visual impairment, 2 (33%) showed improvement. Of the 7 children treated for large/progressive tumors, 3 (42%) showed partial response, 2(28%) had progressive disease and 1 had stable disease after the first line therapy. Conclusions Our results are in-keeping with international data for optic pathway gliomas. Early referral and diagnosis may improve visual outcomes for this group of tumors.

INTRODUCTION Median time to diagnosis for primary CNS tumors for children in Qatar has been reported to be 28 days. However, a wide variation in diagnostic times is seen. This study was undertaken to analyze the factors leading to delay in diagnosis. METHODS Data were retrospectively analyzed for children who had diagnostic delay (more than 28 days) from September 2006 to February 2020. Presenting symptoms, number and type of healthcare contacts and presenting symptom interval (PSI) were reviewed. Parental delay (PSI-1) was defined as the date of onset of first symptom to the date of first healthcare contact. Healthcare delay (PSI-2) was defined as date of first healthcare contact to the date of diagnostic scan. RESULTS Twenty-four patients were identified with diagnostic delay. Median age at diagnosis was 48.2 (range 5.4–171.6) months with an equal sex distribution. Fifteen (62.5%) patients were older than 3 years, 13(54%) patients had low grade glioma, 16 (66.7%) had supratentorial tumors and 12 (50%) presented with raised intracranial pressure. Diagnosis was made after a median 3 (range 1–8) healthcare contacts. Nineteen (79%) patients presented to primary care. Median PSI was 132 (31–783) days. Parental delay (PSI-1) was 35 (0–496) days, while healthcare delay (PSI-2) was 41 (0–562) days. Endocrine (241 days) and oculo-visual (184 days) symptoms were associated with the longest PSI. CONCLUSIONS There was no significant difference between parental and healthcare delay. Endocrine and oculo-visual symptoms were associated with longest PSI. Increased awareness is required for early recognition of signs suggestive of CNS tumors.

Aim: To analyze the clinical characteristics of B-cell non-Hodgkin's lymphoma (NHL) patients and the therapeutic efficacy of French-American-British Lymphoma Malins de Burkitt 96 and the recent United Kingdom Children's Cancer Study Group B-cell NHL guidelines in the tertiary care hospital of a developing country. Methods: Patients aged ≤18 years registered at our hospital between January 1995 and December 2006 with histologically proved B-Cell NHL were selected for retrospective analysis. Results: Of the total of 131 patients registered, 122 patients were eligible for evaluation. Of these 95 had Burkitt's lymphoma, 22 diffuse large B-cell lymphoma and five had B-cell NHL not otherwise specified. The mean age was 8.4 years. Overall 42 children had a baseline weight less than the 10th centile. A total of 37 had uric acid >10 mg/dl and 55 had a lactate dehydrogenase level >500; 73 had stage III and 31 had stage IV while only four presented at stage I and 14 at stage II. The abdomen was the commonest site of disease. A total of 45 patients died; 28 due to infection, nine due to tumor lysis syndrome and six of uncontrolled disease. All deaths occurred within an average of 35 days from starting treatment. Our 5-year overall survival rate was 68 percent and our event-free survival was 55 percent. Conclusion: Late presentation with advanced disease, poor nutritional status and high risk of exposure to infective agents all contribute to the high mortality in patients treated with intensive protocols in resource-poor countries.