title: Clinical features and induction outcome of childhood acute lymphoblastic leukemia in a lower/middle income population: A multi-institutional report from Pakistan.
abstract: BACKGROUND
  Acute lymphoblastic leukemia (ALL) is the most common cancer of childhood. Some evidence suggests differences in clinical and cytogenetic characteristics of ALL based on geographic and ethnic variations. However, data on ALL characteristics and early outcome of therapy from low/middle-income countries such as Pakistan are scanty.
  
  
  METHODS
  A prospective, multi-institutional cohort study in Karachi enrolled 646 newly diagnosed children with ALL over 3 years. Standard forms were used to collect demographic, clinical, and laboratory data at presentation and at the end of induction.
  
  
  RESULTS
  Of the total, 66.1% (n = 427) were males. Median age was 6 (mean ± SE 6.87 ± 0.16; range 0.16-18) years. The most common clinical presentation was fever (88.7%). BPC-ALL was diagnosed in 78.5%, while 17.5% had T-ALL; 28.8% had a WBC >50 × 10(9) /L. With 316 patients karyotyped, hypodiploidy and hyperdiploidy were seen in 5.1% and 10.7%, respectively. Of those tested, ETV6-RUNX1 translocation was detected in 13.2%, while BCR-ABL1 translocation and MLL gene rearrangements were seen in 7.3% and 4.6%, respectively. The cumulative loss to follow up before and during induction was 12.8% (n = 83) and 11.5% (n = 74) died before or during this phase. Induction was successfully completed by only 75.6% (n = 489) of the entire cohort and 69.6% (n = 450) achieved remission.
  
  
  CONCLUSIONS
  These patients had ALL with higher risk features than that reported from developed countries. One quarter failed to complete induction chemotherapy. This suboptimal result requires further study and development of innovative interventions, particularly focusing on the causes and solutions for late referral, abandonment, and infections.
authors.affiliation: Department of Pediatrics and Child Health and Department of Oncology, Aga Khan University, Karachi, Pakistan.
authors.forename: Zehra
authors.initials: Z
authors.lastname: Fadoo
authors.affiliation: Department of Pediatrics and Child Health and Department of Oncology, Aga Khan University, Karachi, Pakistan.
authors.forename: Imran
authors.initials: I
authors.lastname: Nisar
authors.affiliation: Medical Student, Aga Khan University Medical College, Pakistan.
authors.forename: Fatimah
authors.initials: F
authors.lastname: Yousuf
authors.affiliation: Medical Student, Aga Khan University Medical College, Pakistan.
authors.forename: Laila Saleem
authors.initials: LS
authors.lastname: Lakhani
authors.affiliation: Children's Cancer Hospital, Karachi, Pakistan.
authors.forename: Shamvil
authors.initials: S
authors.lastname: Ashraf
authors.affiliation: Pediatric Oncology Department, National Institute of Child Health, Karachi, Pakistan.
authors.forename: Uzma
authors.initials: U
authors.lastname: Imam
authors.affiliation: Department of Pediatrics and Child Health and Department of Oncology, Aga Khan University, Karachi, Pakistan.
authors.forename: Junaid
authors.initials: J
authors.lastname: Zaheer
authors.affiliation: Department of Pediatrics, the Hospital for Sick Children, University of Toronto, Toronto, Canada.
authors.forename: Ahmed
authors.initials: A
authors.lastname: Naqvi
authors.affiliation: Department of Pediatrics and Child Health and Department of Oncology, Aga Khan University, Karachi, Pakistan.|Department of Pediatric Medicine, Division of Hematology Oncology, Sidra Medical and Research Center, Doha, Qatar.
authors.forename: Asim
authors.initials: A
authors.lastname: Belgaumi
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D005260:Female; D006801:Humans; D060828:Induction Chemotherapy; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D010154:Pakistan / Q000208:ethnology; D054198:Precursor Cell Lymphoblastic Leukemia-Lymphoma / Q000188:drug therapy* / Q000235:genetics / Q000473:pathology*; D011446:Prospective Studies; D012074:Remission Induction; D012923:Social Class; D016896:Treatment Outcome
keywords: childhood ALL; induction outcome; low/middle income country