Robert Krysiak

Early Experience after Developing a Pathology Laboratory in Malawi, with Emphasis on Cancer Diagnoses

Background Despite increasing cancer burden in Malawi, pathology services are limited. We describe operations during the first 20 months of a new pathology laboratory in Lilongwe, with emphasis on cancer diagnoses. Methods and Findings We performed a cross-sectional study of specimens from the Kamuzu Central Hospital pathology laboratory between July 1, 2011 and February 28, 2013. Patient and specimen characteristics, and final diagnoses are summarized. Diagnoses were categorized as malignant, premalignant, infectious, other pathology, normal or benign, or nondiagnostic. Patient characteristics associated with premalignancy and malignancy were assessed using logistic regression. Of 2772 specimens, 2758 (99%) with a recorded final diagnosis were included, drawn from 2639 unique patients. Mean age was 38 years and 63% were female. Of those with documented HIV status, 51% had unknown status, and 36% with known status were infected. Histologic specimens comprised 91% of cases, and cytologic specimens 9%. Malignant diagnoses were most common overall (n = 861, 31%). Among cancers, cervical cancer was most common (n = 117, 14%), followed by lymphoma (n = 91, 11%), esophageal cancer (n = 86, 10%), sarcoma excluding Kaposi sarcoma (n = 75, 9%), and breast cancer (n = 61, 7%). HIV status was known for 95 (11%) of malignancies, with HIV prevalence ranging from 9% for breast cancer to 81% for cervical cancer. Increasing age was consistently associated with malignancy [bivariable odds ratio 1.24 per decade increase (95% CI 1.19–1.29) among 2685 patients with known age; multivariable odds ratio 1.33 per decade increase (95% CI 1.14–1.56) among 317 patients with known age, gender, and HIV status], while HIV infection and gender were not. Conclusions Despite selection and referral bias inherent in these data, a new pathology laboratory in Lilongwe has created a robust platform for cancer care and research. Strategies to effectively capture clinical information for pathologically confirmed cancers can allow these data to complement population-based registration.

Building a pathology laboratory in Malawi

Until recently, the Malawian capital of Lilongwe was without diagnostic pathology services, which left many patients with cancer facing serious diagnostic delays. Through collaboration with the University of North Carolina and other partners, a pathology laboratory was successfully established at Kamuzu Central Hospital in July, 2011, providing an essential foundation for cancer diagnosis and research in the countrys largest city.

Improving the accuracy of syndromic diagnosis of genital ulcer disease in Malawi.

Objectives/Goal: Most resource-poor settings rely on syndromic criteria to diagnose genital ulcer disease (GUD). However, the etiologic pathogens of GUD vary temporally and geographically, and current criteria may not reflect changes in the prevalence of specific pathogens. Study: In 1999, we estimated the prevalence of Treponema pallidum (Tp), herpes simplex virus (HSV), and Haemophilus ducreyi (Hd) in Malawi. We then used regression coefficients of independent correlates of HSV and Hd to develop weighted diagnostic algorithms, in which weights were &bgr;-coefficients corresponding to each factor. Results: Overall, a decrease in the proportion of sexually transmitted disease attributable to GUD was noted in 7 years. Thirty-five percent were attributable to HSV, 30% to H. ducreyi, and 4% to T. pallidum. Areas under the receiver operating characteristic curves for weighted and unweighted HSV diagnostic algorithms were 67.6% and 66.5%, respectively. There was no significant difference in the explanatory performance of the weighted and unweighted algorithms. Conclusions: Unweighted algorithms can therefore be used to improve diagnostic accuracy of GUD.

Outcomes for paediatric Burkitt lymphoma treated with anthracycline-based therapy in Malawi

Burkitt lymphoma (BL) is the most common paediatric cancer in sub‐Saharan Africa (SSA). Anthracyline‐based treatment is standard in resource‐rich settings, but has not been described in SSA. Children ≤18 years of age with newly diagnosed BL were prospectively enrolled from June 2013 to May 2015 in Malawi. Staging and supportive care were standardized, as was treatment with CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) for six cycles. Among 73 children with BL, median age was 9·2 years (interquartile range 7·7–11·8), 48 (66%) were male and two were positive for human immunodeficiency virus. Twelve (16%) had stage I/II disease, 36 (49%) stage III and 25 (34%) stage IV. Grade 3/4 neutropenia occurred in 17 (25%), and grade 3/4 anaemia in 29 (42%) of 69 evaluable children. Eighteen‐month overall survival was 29% (95% confidence interval [CI] 18–41%) overall. Mortality was associated with age >9 years [hazard ratio [HR] 2·13, 95% CI 1·15–3·94], female gender (HR 2·12, 95% CI 1·12–4·03), stage (HR 1·52 per unit, 95% CI 1·07–2·17), lactate dehydrogenase (HR 1·03 per 100 iu/l, 95% CI 1·01–1·05), albumin (HR 0·96 per g/l, 95% CI 0·93–0·99) and performance status (HR 0·78 per 10‐point increase, 95% CI 0·69–0·89). CHOP did not improve outcomes in paediatric BL compared to less intensive regimens in Malawi.

Hodgkin lymphoma, HIV, and Epstein–Barr virus in Malawi: Longitudinal results from the Kamuzu Central Hospital Lymphoma study

Contemporary descriptions of classical Hodgkin lymphoma (cHL) are lacking from sub‐Saharan Africa where human immunodeficiency virus (HIV) and Epstein–Barr virus (EBV) are prevalent.

CHOP Chemotherapy for Aggressive Non-Hodgkin Lymphoma with and without HIV in the Antiretroviral Therapy Era in Malawi.

There are no prospective studies of aggressive non-Hodgkin lymphoma (NHL) treated with CHOP in sub-Saharan Africa. We enrolled adults with aggressive NHL in Malawi between June 2013 and May 2015. Chemotherapy and supportive care were standardized, and HIV+ patients received antiretroviral therapy (ART). Thirty-seven of 58 patients (64%) were HIV+. Median age was 47 years (IQR 39–56), and 35 (60%) were male. Thirty-five patients (60%) had stage III/IV, 43 (74%) B symptoms, and 28 (48%) performance status ≥2. B-cell NHL predominated among HIV+ patients, and all T-cell NHL occurred among HIV- individuals. Thirty-one HIV+ patients (84%) were on ART for a median 9.9 months (IQR 1.1–31.7) before NHL diagnosis, median CD4 was 121 cells/μL (IQR 61–244), and 43% had suppressed HIV RNA. HIV+ patients received a similar number of CHOP cycles compared to HIV- patients, but more frequently developed grade 3/4 neutropenia (84% vs 31%, p = 0.001), resulting in modestly lower cyclophosphamide and doxorubicin doses with longer intervals between cycles. Twelve-month overall survival (OS) was 45% (95% CI 31–57%). T-cell NHL (HR 3.90, p = 0.017), hemoglobin (HR 0.82 per g/dL, p = 0.017), albumin (HR 0.57 per g/dL, p = 0.019), and IPI (HR 2.02 per unit, p<0.001) were associated with mortality. HIV was not associated with mortality, and findings were similar among patients with diffuse large B-cell lymphoma. Twenty-three deaths were from NHL (12 HIV+, 11 HIV-), and 12 from CHOP (9 HIV+, 3 HIV-). CHOP can be safe, effective, and feasible for aggressive NHL in Malawi with and without HIV.

Plasma Epstein-Barr virus DNA for pediatric Burkitt lymphoma diagnosis, prognosis, and response assessment in Malawi.

Point‐of‐care tools are needed in sub‐Saharan Africa (SSA) to improve pediatric Burkitt lymphoma (BL) diagnosis and treatment. We evaluated plasma Epstein–Barr virus (pEBV) DNA as a pediatric BL biomarker in Malawi. Prospectively enrolled children with BL were compared to classical Hodgkin lymphoma (cHL) and nonlymphoma diagnoses. Pediatric BL patients received standardized chemotherapy and supportive care. pEBV DNA was measured at baseline, mid‐treatment, and treatment completion. Of 121 assessed children, pEBV DNA was detected in 76/88 (86%) with BL, 16/17 (94%) with cHL, and 2/16 (12%) with nonlymphoma, with proportions higher in BL versus nonlymphoma (p < 0.001) and similar in BL versus cHL (p = 0.69). If detected, median pEBV DNA was 6.1 log10copies/mL for BL, 4.8 log10copies/mL for cHL, and 3.4 log10copies/mL for nonlymphoma, with higher levels in BL versus cHL (p = 0.029), and a trend toward higher levels in BL versus nonlymphoma (p = 0.062). pEBV DNA declined during treatment in the cohort overall and increased in several children before clinical relapse. Twelve‐month overall survival was 40% in the cohort overall, and for children with baseline pEBV detected, survival was worse if baseline pEBV DNA was ≥6 log10copies/mL versus <6 log10copies/mL (p = 0.0002), and also if pEBV DNA was persistently detectable at mid‐treatment versus undetectable (p = 0.041). Among children with baseline pEBV DNA detected, viremia was the only significant risk factor for death by 12 months in multivariate analyses (adjusted hazard ratio 1.35 per log10copies/mL, 95% CI 1.04–1.75, p = 0.023). Quantitative pEBV DNA has potential utility for diagnosis, prognosis, and response assessment for pediatric BL in SSA.

Characteristics and survival for HIV-associated multicentric Castleman disease in Malawi

Clinical reports of multicentric Castleman disease (MCD) from sub‐Saharan Africa (SSA) are scarce despite high prevalence of HIV and Kaposi sarcoma‐associated herpesvirus (KSHV). Our objective is to describe characteristics and survival for HIV‐associated MCD patients in Malawi. To our knowledge, this is the first HIV‐associated MCD case series from the region.

Multicentric Castleman's disease in Malawi

A 51-year-old man was referred to our hospital in Lilongwe with 6 months of diffuse progressive lymphadenopathy and hepatosplenomegaly with fever, chills, night sweats, and weight loss. He had been on antiretroviral therapy for HIV for 5 years, and his CD4 cell count was 234 cells per μL and HIV RNA was 357 copies per mL. Fine needle aspiration of a lymph node suggested Hodgkin’s lymphoma. Immunohistochemistry reagents were temporarily out of stock, as sometimes happens in Malawi. We started chemotherapy with doxorubicin, bleomycin, vinblastine, and dacarbazine while waiting for results of a confirmatory biopsy sample. Lymphoma is often diagnosed by fine needle aspiration in sub-Saharan African settings,1 and we often have to start treatment on the basis of less complete diagnostic information than is available in resource-rich settings. The patient responded to his first chemotherapy dose, but on review in our weekly telepathology conference we felt the lymph node biopsy sample might have been reactive to infection, possibly to his HIV, and after extensive discussion we stopped chemotherapy. 2 months later he developed worsening hepatosplenomegaly, lymphadenopathy, fatigue, and oedema. Blood tests showed progressive anaemia (haemoglobin 57 g/L), thrombocytopenia (platelets 32 × 109/L), hyponatraemia (sodium 123 mmol/L), and hypoalbuminaemia (albumin 21 g/L), and bone marrow biopsy sampling showed reactive plasmacytosis. Immunohistochemistry reagents had been resupplied in the interim, and latency-associated nuclear antigen (LANA) staining of repeat lymph node specimen showed multicentric Castleman’s disease (figure). Plasma viral load of Kaposi sarcoma-associated herpesvirus (KSHV), tested with research collaborators in the USA, was 50 000 copies per mL. We started the patient on etoposide, with improvement of his lymphadenopathy, hepatosplenomegaly, and laboratory values. We are monitoring him closely for relapse. We have not seen Kaposi sarcoma clinically or on examination of lymph node specimens. Figure Lymph nodes showing multicentric Castleman’s disease and Kaposi sarcoma-associated herpesvirus The plasmablastic variant of multicentric Castleman’s disease is caused by KSHV.2 The disease is characterised by waxing and waning lymphadenopathy and hepatosplenomegaly, anaemia, thrombocytopenia, hyponatraemia, hypoalbuminaemia, raised C-reactive protein, and high KSHV viral load. The most widely accepted therapy is rituximab. Chemotherapy can induce remission although it is often transient. We chose etoposide for our patient because of our experience of its use in resource-rich settings, and its availability in Malawi, where rituximab is neither available nor well studied. High burden of Kaposi sarcoma is widely recognised in sub-Saharan Africa, but multicentric Castleman’s disease is reported surprisingly infrequently. This under-reporting probably reflects underdiagnosis, because it has been described among several recent African immigrants at the National Cancer Institute in the USA.2 Even in African settings where awareness of Kaposi sarcoma is high, familiarity with multicentric Castleman’s disease is low. Histological features can overlap with other diseases such as HIV lymphadenitis, and are challenging to diagnose without KSHV stains, which are often not available in sub-Saharan Africa. A pathology review of lymph nodes from Uganda showed LANA positivity in two of 64 reactive nodes, suggesting multicentric Castleman’s disease.3 A pathology review from South Africa reported many HIV-associated B-cell lymphoproliferations, although neither multicentric Castleman’s disease nor LANA staining were described.4 Our case highlights the need to increase familiarity with multicentric Castleman’s disease among clinicians and pathologists in KSHV-endemic regions, and to develop high-quality diagnostic pathology services throughout sub-Saharan Africa.5 Without such investments, the diversity of KSHV-associated diseases will remain underappreciated. Clinical research collaborations can help to address these limitations and inform care at the individual patient level.

Establishing sickle cell diagnostics and characterizing a paediatric sickle cell disease cohort in Malawi

poor accrual. In summary, this study provides preliminary data on the efficacy of the combination of alisertib and bortezomib for relapsed MM. The duration of response varied widely with one patient staying on therapy for more than 3 years. Nevertheless, the contribution of alisertib to bortezomib activity cannot be determined without additional Phase II testing. Further studies looking at inhibition of Aurora kinase A alone or in combination with established or novel anti-MM therapies will be necessary.