Non Hodgkin Lymphoma In Children From Northern Egypt
Authors: El Shazly Mohammed , Arafaat Waleed , el Masry Ashraf , Fahmy Aly , Lehmann Leslie E. 
Published: October 2019

Abstract
Data regarding the presentation and outcome of pediatric malignancies in northern Egypt, a resource-limited area, is limited. Alexandria School of Medicine (ASM) is the only center in Northern Egypt providing therapy to children with oncologic conditions. It serves 4 governorates and a population of 20 million. Initially children were treated as part of a combined adult/pediatric oncology service with therapy based on active adult protocols. In January 2010 a dedicated pediatric oncology service was created and staffed with providers specifically trained to care for children;international pediatric protcols were employed. We here present a comparison of outcomes achieved in children diagnosed with non-Hodgkin's lymphoma (NHL) before and after launching this service.

Methods
A retrospective review of patients <20 years old with NHL treated at ASM was performed. Those treated from 1/1999 to 12/2009 were the historical cohort. This group was compared to patients treated between 1/2010-12/ 2012 on the pediatric service.

Results
There were a total of 92 cases diagnosed with NHL in the historical cohort. This represented 23% of the total pediatric non-leukemic malignancies seen in this time at ASM. 38 cases of NHLwere diagnosed after the pediatric service opened representing 6% of the pediatric non-leukemic malignancies.
In the historical group the most common presentation was abdominal mass (35%) followed by mediastinal lymphadenopathy (26%) , head and neck adenopathy (13%), pancytopenia (20%) , CNS involvement (10%) and other manifestations (10%). After the launch the most common presentation was abdominal mass (63%) followed by mediastinal adenopathy (18%) , pancytopenia ( 18%), head and neck adenopathy (15%) and other manifestations (8 %). ( Totals are >100% as some children had > one symptom at presentation.)
Staging was done according to St. Jude classification of NHL. Historically the majority of patients presented with stage IV disease ( 51%). 25% were Stage III, 19% stage II and 5% stage I. After the launch the most common stage at presentation was stage II ( 42%) followed by stage III (40%) , stage IV ( 16%) and stage I ( 3%).
Diagnosis of lymphoma was pathologically proven in 80% and 20% were treated based on clinical/radiologic signs and symptoms.
Histopathological diagnosis in the older cohort were Burkitt lymphoma (39%), Lymphoblastic Lymphoma (30%), Diffuse large B cell lymphoma (DLBCL) (20%) and anaplastic lymphoma (ALCL) (11%). After the launch diagnoses were Burkitt lymphoma (63%), Lymphoblastic Lymphoma (15%), DLBCL (13%), ALCL (5%) and Natural Killer Cell lymphoma (4%).
In the historical group pediatric patients were treated on adult protocols in use at that time. 60% received only chemotherapy 35% were treated with a combination chemotherapy/radiotherapy and 5% were treated with radiotherapy as the sole modality. After the launch patients were treated on internationally published pediatric protocols employing multiagent chemotherapy. No patients in this group received radiation therapy. With a follow up period of 24-132 (mean 49) months, 25% of historical patients succumbed to disease or therapy related complications for a disease free survival of 75%. After the establishment of a pediatric service with a follow up of 3-30 (mean 12) months 13% had died for a disease free survival of 87% ( p= 0.17).

Conclusion
NHL is one of the most common pediatric oncologic diagnoses and patients in developed countries have very good outcomes with > 80% survival on current protcols. At ASM, where the majority of children residing in northern Egypt receive their oncology care, children were treated as part of an adult oncology service, a common occurrence when resources are limited. 3 years ago the need for a dedicated pediatric service was recognized. We here compare outcomes for children with NHL before and after the establishment of this service. The subtypes seen are similar to those in Northern America and Europe and do not differ between the 2 periods. However disease free survival significantly improved in the recent era and is now similar to international norms. These results indicate that despite limitations encountered in this setting developing a dedicated pediatric oncology program can postivilet impact outcomes in addition to creating a platform for prospective data collection and practice improvement that will continue to improve results for these unfortunate children.

Disclosures:
No relevant conflicts of interest to declare.