الفهرس 
Toxic deaths during treatment of childhood acute lymphoblastic leukemia, national cancer institute, Cairo university experience
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Abstract
Background: Despite recent improvement in the supportive care services,
treatment related deaths remain one of the major problems that affect the outcome
of pediatric acute lymphoblastic leukemia (ALL), especially in middle income
countries. Objective: the study aimed to assess the incidence, risk factors and
outcomes of treatment related complications during therapy of pediatric ALL.
Patients and methods: A Retrospective study included patients ≤ 18 years old
with ALL, treated according to St. Jude total XV protocol at the National Cancer
Institute, Cairo University from January 2012 to December 2017. All patients were
reviewed and analyzed for treatment related toxicities, overall and attributable
mortality rates. Results: The study included 434 patients with a median age of 5
years and M/F ratio was 1.3:1. Out of the total group, there were 367 patients
(84.5%), developed documented infectious complications, 58 (13%) had
cerebrovascular complications, and 18 (4%) had organ damage. Bacterial infection
was the most frequent throughout all treatment phases, diagnosed in 68.8%,
followed by invasive fungal infection in 16.3% and viral infections in 14.9% of the
patients. Gram negative infections were more predominant during all treatment
phases (66% compared to 34% gram positive). The most frequent Gram negative
was E-coli (39.3%), klebsiella (25.4%) and Acinetobacter (13.1%). Multi drug
resistance (MDR) was more frequently found among E-coli infection (35%). With
median follow up of 101 months, the 5-year overall survival (OS) and event free
survival (EFS) for the whole group were 65.6% and was 58.8% respectively.
Overall mortality rate was 32.7%, infection related mortality constitutes 85.2% of
them while the remaining was either due to organ damage or disease related. The
attributable mortality rate was highest among E-coli (50.0%) followed by Klebsiella and Acinetobacter (42.0% & 25.0%) respectively. The 5-year OS and
EFS were significantly worse in those with infection complications (OS 61.4%
versus 87.7%, P<; 0.001) and (EFS 57% versus 84.6%, P= 0.006) respectively.
Conclusion: Infectious complications are major obstacle to reach desirable
outcome for pediatric patients with ALL in developing countries. Gram negative
infection especially MDR remains a major challenge that warrants more attention
and prompt intervention during treatment of those patients.