Joseph Stanek

Neuroblastomas vary widely in their sensitivities to herpes simplex virotherapy unrelated to virus receptors and susceptibility

Although most high-risk neuroblastomas are responsive to chemotherapy, relapse is common and long-term survival is <40%, underscoring the need for more effective treatments. We evaluated the responsiveness of 12 neuroblastoma cell lines to the Δγ134.5 attenuated oncolytic herpes simplex virus (oHSV), Seprehvir (HSV1716), which is currently used in pediatric phase I trials. We found that entry of Seprehvir in neuroblastoma cells is independent of the expression of nectin-1 and the sum of all four known major HSV entry receptors. We observed varying levels of sensitivity and permissivity to Seprehvir, suggesting that the cellular anti-viral response, not virus entry, is the key determinant of efficacy with this virus. In vivo, we found significant anti-tumor efficacy following Seprehvir treatment, which ranged from 6/10 complete responses in the CHP-134 model to a mild prolonged median survival in the SK-N-AS model. Taken together, these data suggest that anti-tumor efficacy cannot be solely predicted based on in vitro response. Whether or not this discordance holds true for other viruses or tumor types is unknown. Our results also suggest that profiling the expression of known viral entry receptors on neuroblastoma cells may not be entirely predictive of their susceptibility to Seprehvir therapy.

Cooperation of Oncolytic Herpes Virotherapy and PD-1 Blockade in Murine Rhabdomyosarcoma Models

Oncolytic virotherapy is an effective immunotherapeutic approach for cancer treatment via a multistep process including direct tumor cell lysis, induction of cytotoxic or apoptosis-sensitizing cytokines and promotion of antitumor T cell responses. Solid tumors limit the effectiveness of immunotherapeutics in diverse ways such as secretion of immunosuppressive cytokines and expression of immune inhibitory ligands to inhibit antitumor T cell function. Blocking programmed cell death protein (PD)-1 signaling, which mediates T cell suppression via engagement of its inhibitory ligands, PD-L1 or PD-L2, is of particular interest due to recent successes in many types of cancer. In syngeneic murine rhabdomyosarcoma models, we found that M3-9-M (MHC I high) but not 76-9 (MHC I low) tumors respond to oncolytic herpes simplex virus-1 (oHSV-1) and PD-1 blockade combination therapy. In addition, the therapeutic outcomes in M3-9-M tumor models correlated with the increased incidence of CD4+ and CD8+ T cells but not with the CD4+CD25+Foxp3+ regulatory T cell populations in the tumor. Overall, our data suggest the combination of PD-1 blockade and oHSV-1 may be an effective treatment strategy for childhood soft tissue sarcoma.

High Variability in the Reported Management of Hepatic Veno-Occlusive Disease in Children after Hematopoietic Stem Cell Transplantation

Veno-occlusive disease (VOD) is a potentially fatal complication of hematopoietic stem cell transplantation (HSCT). Patients with VOD are often critically ill and require close collaboration between transplant physicians and intensivists. We surveyed members of a consortium of pediatric intensive care unit (PICU) and transplant physicians to assess variability in the self-reported approach to the diagnosis and management of VOD. An internet-based self-administered survey was sent to pediatric HSCT and PICU providers from September 2014 to February 2015. The survey contained questions relating to the diagnosis and treatment of VOD. The response rate was 41% of 382 providers surveyed. We found significant variability in the diagnostic and management approaches to VOD in children. Even though ultrasound is not part of the diagnostic criteria, providers reported using reversal of portal venous flow seen on abdominal ultrasound in addition to Seattle criteria (70%) or Baltimore criteria to make the diagnosis of VOD. Almost 40% of respondents did not diagnose VOD in anicteric patients (bilirubin < 2 mg/dL). Most providers (75%) initiated treatment with defibrotide at the time of diagnosis, but 14%, 7%, and 6% of the providers waited for reversal of portal venous flow, renal dysfunction, or pulmonary dysfunction, respectively, to develop before initiating therapy. Only 50% of the providers restricted fluids to 75% of the daily maintenance, whereas 21% did not restrict fluids at all. Albumin with diuretics was used by 95% of respondents. Platelets counts were maintained at 20,000 to 50,000/mm(3) and 10,000 to 20,000/mm(3) by 64% and 20% of the respondents, respectively. Paracentesis was generally initiated in the setting of oliguria or hypoxia, and nearly 50% of the providers used continuous drainage to gravity, whereas the remainder used an intermittent drainage approach. Nearly 73% of the transplant providers used VOD prophylaxis, whereas the remainder did not use any medications for VOD prophylaxis. There was also considerable variation in the management strategies among the transplant and critical care providers. We conclude that there is considerable self-reported variability in the diagnosis and management of VOD in children. The practice variations reported in this study should encourage the development of standard practice guidelines, which will be helpful in improving the outcome of this potentially fatal complication.

Anicteric veno-occlusive disease after hematopoietic stem cell transplantation in children.

Hepatic veno-occlusive disease (VOD) or sinusoidal obstruction syndrome is a potentially fatal complication following hematopoietic stem cell transplantation (HSCT) and occurs in ~ 30% of the children undergoing HSCT. Two diagnostic criteria have been used for the diagnosis of VOD, the Baltimore criteria by Jones et al. comprising hyperbilirubinemia of42mg/dL and any two of the following: weight gain of 45% from baseline, hepatomegaly or ascites. The diagnosis of VOD based on the Seattle criteria by McDonald et al. can be made if any two of the following are present by day +20 after HSCT: hyperbilirubinemia (42mg/dL), ascites or weight gain of 42% from baseline, or hepatomegaly. Prompt diagnosis and early intervention is crucial as patients with severe VOD may develop multi-organ failure, requiring intensive care and carry a high mortality of up to 84%. Yet there is no consensus on grading severity of VOD. Although liver biopsy is helpful for confirming the diagnosis, in the setting of coagulopathy and thrombocytopenia, it is usually avoided. Ultrasonography has been used in the diagnosis of VOD; in the study by Lassau et al. on multivariate analysis, two ultrasound criteria (splenomegaly and ascites) and one doppler criterion (flow recorded in paraumbilical vein) were correlated with the severity of VOD (P = 0.0001). Demonstration of reversal of portal venous blood flow by ultrasonography can be helpful, but is often a late finding indicating advanced disease. The Baltimore criteria are more often used in adults and appear to be more stringent than the Seattle criteria; as patients without hyperbilirubinemia are excluded. In contrast, the Seattle criteria may lead to over diagnosis, as some patients may meet the diagnostic criteria earlier in the course of the disease. Higher serum bilirubin levels have been associated with increased severity of VOD and worse outcomes. Bearman et al. used total serum bilirubin level and percentage weight gain to create risk curves that would predict the likelihood of developing severe VOD. Total serum bilirubin is often used as a marker for response to treatment with defibrotide, as discussed in studies by Ho et al. and Richardson et al. However some patients with VOD may not have hyperbilirubinemia but still have all the other features consistent with VOD. In a recent study by Myers et al., five patients had a bilirubin of ⩽ 2mg/dL at the time of diagnosis of VOD and reversal of portal venous flow (PVF) by ultrasonography; two of these continued to have a bilirubin of o2mg/dL. There have been few studies focusing specifically on anicteric VOD. The primary aim of this study is to assess the clinical course and outcomes of patients with anicteric VOD after HSCT in children. A retrospective review of the medical charts of all patients diagnosed with VOD while undergoing HSCT from 1992 through June 2014 at Nationwide Children’s Hospital, Columbus, OH, USA was performed. Both Seattle and Baltimore criteria were retrospectively applied to each patient diagnosed and treated as VOD. Patients who were diagnosed with VOD but maintained a total serum bilirubin level ⩽ 2mg/dL during the entire course of treatment for VOD were defined as having ‘Anicteric VOD’. The level of supportive care during treatment for VOD was defined as follows: ‘Level 1’—general floor level management (that is, diuretics, pain control, fluid restriction, transfusion and so on), ‘Level 2’: paediatric intensive care unit level support for ⩽ 2 body systems (that is, mechanical ventilation for respiratory failure, vasopressors for heart failure and so on) and ‘Level 3’: paediatric intensive care unit level support ⩾ 3 body systems (that is, mechanical ventilation+vasopressors+dialysis and so on). Standard descriptive statistical methods were used for analysis. Statistical analysis was done using SAS 9.3 statistical software (SAS Institute, Cary, NC, USA). Categorical variables were compared between VOD groups using a Fisher’s exact test. Continuous variables were compared using a nonparametric twosided Wilcoxon rank-sum test. P-values o0.05 were considered significant. Acquisition of patient data was approved by the Institutional Review Board at Nationwide Children’s Hospital. Thirty patients were diagnosed with VOD during the study period and patient demographics and characteristics are presented in Tables 1 and 2. One patient with undocumented bilirubin level was excluded from the study. The remaining 29 patients were included in the final analysis. Nine of 29 (31%) had anicteric VOD and 20/29 (69%) had VOD with icterus. The majority (n= 26) of the patients received myeloablative conditioning for malignant (n= 24) or non-malignant (n= 5) diseases. There was no difference in the characteristics of patients with anicteric VOD versus icteric VOD with regard to percentage weight gain, hepatomegaly, abdominal pain, demonstration of PVF reversal, duration of treatment or outcome. Ascites was seen in 5 of the 9 (55.6%) and 19 of 20 (95%) cases with anicteric and icteric VOD, respectively. The median level of supportive care was level 2 for the icteric VOD group as compared with level 1 for the anicteric group (P= 0.007). While analysing ultrasonography results for the two groups, of the nine patients with anicteric VOD, data were missing in four (all recovered from VOD), one showed reversal of PVF and recovered, four patients had no reversal of PVF (two recovered and two died). In the icteric VOD group, 12 showed reversal of PVF (five recovered and seven died), five had no reversal of PVF (one recovered and four died) and three had missing data (two recovered and one died). Overall, six patients with no reversal of PVF died from VOD (two with anicteric VOD and four with icteric VOD). Seven cases were diagnosed with VOD by the Seattle criteria at a median of day +15 after transplant. However, curative treatment with defibrotide was delayed by 1–11 days for lack of hyperbilirubinemia; and two of these never developed hyperbilirubinemia. Curative anticoagulation therapy was given in 1/9 (11%) cases with anicteric VOD versus 9/20 (45%) of the icteric VOD. Fourteen (14) of the 29 patients died (48%) from complications of VOD, 2 with anicteric and 12 with icteric VOD died. Although there have been numerous studies characterizing VOD and its treatments, few studies have specifically focused on anicteric VOD. There seems to be a poor understanding and awareness of anicteric VOD as a diagnosis relative to icteric VOD. As patients with anicteric VOD do not meet the Baltimore criteria, the diagnosis of VOD and its treatment may be delayed if only the Baltimore criteria are followed. It is well known that delay in the initiation of supportive care and curative treatment may result in Bone Marrow Transplantation (2016) 51, 135–137

Light Transmission Aggregometry Does Not Correlate With the Severity of δ-Granule Platelet Storage Pool Deficiency.

Delta-granule platelet storage pool deficiency (&dgr;-PSPD) is a poorly studied bleeding diathesis resulting from either decreased granule content or decreased average number of platelet &dgr;-granules. Light transmission aggregometry (LTA) is commonly used to evaluate for &dgr;-PSPD and platelet electron microscopy (EM) is used to confirm the diagnosis. Currently, little data exist examining the relationship between the likelihood of abnormal platelet aggregation findings, severity of &dgr;-granule deficiency on platelet EM, and severity of bleeding symptoms in patients with &dgr;-PSPD. Patients diagnosed with &dgr;-PSPD by platelet EM who also underwent LTA testing were identified at a single institution for correlation between severity of bleeding, average number of platelet &dgr;-granules, and number of agonist abnormalities on LTA. No statistically significant association was identified between the average number of &dgr;-granules per platelet and likelihood of an abnormal LTA. LTA abnormalities were quite varied and only 50% diagnosed with &dgr;-PSPD on EM had abnormal aggregation testing. Also, no correlation was seen between the number of clinical bleeding symptoms, number of average &dgr;-granules per platelet, and the number of LTA agonist abnormalities. Our findings highlight the difficulties inherent in the laboratory evaluation of platelet function.

The Effects of Hospital Length of Stay on Readmissions for Children With Newly Diagnosed Acute Lymphoblastic Leukemia.

Although regimens for induction therapy in children with acute lymphoblastic leukemia (ALL) are similar across the United States, typical practice with regard to inpatient length of stay (LOS) varies by institution. US children’s hospitals were categorized by typical induction LOS; and readmissions, pediatric intensive care unit (PICU) admissions, and average adjusted charges were compared for the first 30 days from initial admission. Using Pediatric Health Information System data, we extracted ALL induction admissions from 2007 to 2013. We categorized hospitals into 3 categories based on median LOS: short (⩽7 d), medium (8 to 15 d), or long (≥16 d). Median LOS varied from 5 to 31 days across hospitals. Thirty-day median inpatient costs per patient ranged from

VIncristine, irinotecan, and temozolomide in children and adolescents with relapsed rhabdomyosarcoma

32 K for short LOS,

Venous Thromboembolism in Pediatric Hematopoietic Cell Transplant: a Multicenter Cohort Study

40 K for medium LOS, and

Intravenous iron therapy in non-anemic iron-deficient menstruating adolescent females with fatigue

47 K for long LOS. Compared with short LOS hospitals (n=14), medium LOS (n=8) and long LOS hospitals (n=8) had lower odds of PICU readmissions (odds ratio [OR], 0.68; P=0.0124 and OR, 0.31; P<0.001, respectively), and long LOS hospitals had lower odds of any readmission (OR, 0.44; P<0.0001). Average LOS for children with newly diagnosed ALL varies widely by institution. Children’s hospitals that typically admit new ALL patients for >7 days have fewer PICU readmissions but substantial increase in total induction inpatient costs.

Prevalence and risk factors for venous thromboembolism in children with sickle cell disease: an administrative database study

The combination of vincristine, irinotecan, and temozolomide (VIT) is often used to treat children and adolescents with relapsed rhabdomyosarcoma (RMS); however, the outcome of these patients has not been previously described.