Aggressive Infection Related East Africa Lymphoma Evaluation and Transfer of mobile whole slide tissue scanners and liquid
biopsies to deliver fast and precise diagnosis for improved outcomes of children and young adults with EBV-driven lymphoma: a joint Tanzanian and Ugandan
Paediatric Oncology Network Initiative Summary:

Sub-Saharan Africa (SSA) is facing a major public health challenge from non-communicable diseases. The
disease burden attributable to cancer is rapidly rising, with a predicted 85% increase in incidence by
2030. In a region where 40% of the entire population is under the age of 15, cancer is more likely to
present in younger patients in sub-Saharan Africa, evidenced by a rising paediatric/adolescent
incidence.

Aggressive lymphoma accounts for nearly 10% of all cancer diagnosis in the region, due to a strong
association with Epstein Barr virus (EBV) infection(5,7,8). Despite established diagnostic pathways,
treatments and improving outcomes in developed countries, diagnostics, treatment and support are
severely limited in SSA and outcomes poor(2,9,10). Tissue diagnosis in particular poses a significant challenge with a single pathologist being responsible for millions of patients within a region(9).

Furthermore, there are significant practical challenges to obtaining tumour tissue from children.
With the availability of digital pathology and low-cost peripheral blood DNA analysis, we now have
the potential to rapidly and accurately screen, diagnose and monitor children and young adults with
EBV associated lymphoma (EBVL) without the specific need for tissue biopsy. We already have
preliminary results from our laboratory demonstrating high sensitivity and specificity of this method
for lymphoma diagnosis(11).

This liquid biopsy only requires an additional 4-10ml (1-3 teaspoons) of peripheral venous blood collected
into a specified blood tube. Given that all patients currently have standard of care (SOC) testing, including
routine blood tests and often an insertion of a long-term venous access line, this additional sample poses
minimal if any risk to the patient.

Our proposal also aims to address issues surrounding pathological diagnosis. Currently in East Africa,
a single pathologist is responsible for 3.2m patients. Thus, despite tissue biopsy remaining as the gold
standard diagnostic test, a major hurdle to diagnosis is obtaining a result in a timely manner. Samples
are often transported overseas for reporting in large established tertiary labs.

We will therefore assess the utility of a digital microscopy platform which we are already using for teaching
and training in the region. This technology will enable local scientists of obtain diagnostic quality digital
images of traditional histopathology glass slides that can be shared immediately for reporting.
In collaboration with our partners across SSA, we will assess the accuracy of these two low cost novel
technologies for diagnosing EBVL in East African patients aged 5 to 21 suspected of having the condition.
Technology 1: Liquid biopsy – detection of fragments of lymphoma specific DNA shed into the peripheral
blood from tumours. Also known as circulating tumour DNA (ctDNA). Testing requires collection of 10ml
(2 teaspoons) or peripheral blood. We already have pilot data in an Oxford cohort of lymphoma patients
that demonstrates a high sensitivity and specificity for ctDNA as a diagnostic tool.

Technology 2: Mobile digital microscopy – device that can reproduce high-resolution, diagnostic
quality, whole slide digital images from blood smears and tissue biopsy slides.
Aim: to improve diagnosis of childhood lymphoma in sub-Saharan Africa by making it faster and more
precise using mobile digital pathology devices and liquid biopsy

Objectives
1. Assess the diagnostic accuracy of liquid biopsy testing
2. Asses the diagnostic accuracy of digital pathology
3. Development of a digital pathology machine learning algorithm
4. Transfer of above novel tests and associated expertise to local laboratories
Patients Children and adolescents aged 3 to 30 suspected of having EBVL.

Design
Retrospective Case control study.

Method
All patients recruited will continue to have routine local standard of care testing.
We will compare the two technologies against current local ‘gold standard’ tests for diagnosing EBVL.
- Gold Standard tissue glass slide light-microscopy versus liquid biopsy (single blood test, 4-10ml at study
entry)
- Gold Standard tissue glass slide light-microscopy versus whole slide digital images (WSI)
The results of the novel tests will be analysed retrospectively, therefore therapeutic decisions will only be
made based upon the gold standard test results.

Provided we observe a strong correlation between WSI, ctDNA and the gold standard test, we will plan to
proceed to a second study where we will assess the time-to-diagnosis for these three methods.