Chalinee Monsereenusorn

Purpose: In low‐ and middle‐income countries, including Thailand, pediatric cancer survivorship care is limited by resource constraints, lack of structured programs, and an overemphasis on recurrence surveillance. Understanding healthcare provider (HCP) perceptions is a key first step toward developing sustainable multidisciplinary survivorship guidelines. Methods: The Doctor Assessment in Late‐Effects Treatment (DALET) survey was used to assess HCPs’ perceptions of late‐effect care. The survey was distributed nationwide to physicians involved in childhood cancer care using a targeted dissemination strategy guided by local experts. Results: A total of 114 physicians from 37 centers participated, with only 3 centers (8.1%) having dedicated late‐effect clinics. Most respondents (69.3%) reported prior training in late‐effect care, and 81.6% provided post‐treatment follow‐up. Overall knowledge showed good alignment with the Children's Oncology Group Long‐Term Follow‐Up Guidelines (mean score, 71.7%), with prior training independently associated with higher alignment ( p = 0.034). Confidence in managing physical late effects was significantly associated with physician expertise ( p < 0.001), hospital type ( p = 0.036), and prior training ( p < 0.001), while access to consultation varied by expertise and hospital type. Main barriers to late‐effect clinics were a lack of one‐stop multidisciplinary services (80.7%) and time constraints (78.9%). Conclusions: Gaps in training and confidence persist across specialties and institutions, highlighting the need for national policies that strengthen education, capacity building, multidisciplinary collaboration, and standardized guidelines to ensure equitable late‐effect care for pediatric cancer survivors in Thailand.

Background: The survival outcomes among children with acute myeloid leukemia (AML) in low‐ and middle‐income countries are still poor despite adopting modern treatment regimens from developed countries. The study aimed to identify additional potential determinant factors for relapse and death among children with AML in Thailand. Methods: In all, data from 282 children newly diagnosed with AML between 2015 and 2019 across Thailand were retrospectively reviewed. Data, including initial white blood cell numbers, genetic analysis, post‐induction minimal residual disease (MRD), hematopoietic stem cell transplantation, and supportive care, were analyzed. Results: The probability of 5‐year, event‐free survival, overall survival, and cumulative incidence of relapse were 40.5%, 42.3%, and 47.4%, respectively. The risk of death was significantly increased among patients stratified as high‐risk AML with an adjusted hazard ratio (HR) of 1.8 (95% confidence interval [CI]: 1.1–2.9, p = 0.01). The accessibility to MRD was significantly associated with the risk of death with an adjusted HR of 1.7 (95% CI: 1.1–2.5, p = 0.01). Patients with low‐risk AML did carry a significant risk for both death, with an adjusted HR of 1.8 (95% CI: 1.1–3.0, p = 0.02), and relapse, with an adjusted HR of 2.6 (95% CI: 1.5–4.7, p < 0.001) for initial WBC greater than 100,000/mm ³ . Conclusion: Elevated initial WBC numbers and accessibility to MRD could be considered additional risk factors for unfavorable outcomes in childhood AML.

Background Health-related quality of life (HRQOL) is a vital assessment to demonstrate the achievement in pediatric cancer care parallels that of medical treatment. The Pediatric Quality of Life Inventory (PedsQL) 3.0 Cancer Module in the Thai Version has become a standard tool to access the HRQOL among Thai children with cancer and their families. This study aimed to explore the HRQOL and factors related to HRQOL among pediatric oncology patients using the PedsQL 3.0 Cancer Module. Methods In 2018-2019, a single-institution, cross-sectional study was conducted among children with cancer and their families in Bangkok, Thailand. A paired-sample t-test was performed to evaluate the differences between the HRQOL scores of the child and parents' reports. Linear regression was used to evaluate factors associated with HRQOL and which particular domains of the PedsQL 3.0 Cancer Module were influenced. Results Eighty-five children with cancer and their families were enrolled. The patients' mean age was 10.82 +/- 5.48 years. The most common cancer types included acute lymphoblastic leukemia (n = 32, 67%), central nervous system tumors (n = 13, 15%), osteosarcoma (n = 10, 27%) and neuroblastoma (n = 9, 24%), in rank. The mean HRQOL scores in child and parent reports were 74.37 +/- 15.7 and 70.42 +/- 17.15, respectively (p = 0.034). Factors negatively correlated to HRQOL in parent reports were the number of outpatient visits (p = 0.019) and hospital admissions (p = 0.002). The number of hospitalizations was the only independent factor that affected HRQOL (p = 0.044). The number of outpatient visits and/or hospital admissions was influenced by pain and hurt, nausea, procedural anxiety and communication domains (p < 0.05). Only the number of hospitalizations was an independent factor influencing the procedural anxiety domain in HRQOL (p = 0.005). Conclusion HRQOL among Thai children with cancer was desirable from both children's and parent's perspectives. Differences between child and parent HRQOL scores were observed. The number of outpatient visits and hospital admissions affected HRQOL, particularly in the procedural anxiety aspect. Trial registration Thai Clinical Trials Registry (TCTR) Number: TCTR20200904001 (04/09/2020), https://www.thaiclinicaltrials.org/.

Background: Disease reactivation/refractory remains a major challenge in managing Langerhans cell histiocytosis (LCH). Outcomes and late sequelae should be explored. Methods: A multi-institutional retrospective study was conducted to describe clinical characteristics, predictive factors, outcomes and late sequelae of pediatric reactivation/refractory LCH in Thailand. Results: In all, 47 patients were studied, 25 (53.2%) patients had disease reactivation and 22 (46.8%) patients had refractory LCH. The median reactivation and refractory time were 1.59 and 0.33 years from diagnosis, respectively (p <0.001). The most common site of reactivation/refractory was the bone (n = 26, 55%), and 20 (42.6%) patients developed late sequelae. The 5-year overall survival (OS) was 76.1%. Patients with reactivation and refractory LCH performed similarly in 5-year OS (88% vs. 63%, p = 0.055). Prognostic factors associated with mortality were liver, spleen, hematopoietic system and lung reactivation (p <0.05). Lung reactivation was the only independent risk factor associated with the survival outcome (p = 0.002). Conclusions: The outcomes of pediatric patients between reactivation and refractory LCH in Thailand were similarly desirable and mortality was minimal although late sequelae may evolve. Pulmonary reactivation/refractory was an independent risk factor associated with survival.

The diagnostic and treatment outcomes of intracranial germ cell tumors (ICGCTs) among low and middle income countries are limited. A total of 63 ICGCTs patients with a median age of 11.6 years were studied. A 30 (47.6%) and 33 (52.4%) patients were classified as pure germinomas and nongerminomatous germ cell tumors (NGGCTs), respectively. The concordances between serum and cerebrospinal fluid (CSF) alpha-fetoprotein (84.3%) and beta-human chorionic gonadotropin (68.4%) were addressed. The 5-year overall survival (OS) and event-free survival (EFS) rates of pure germinomas versus NGGCTs were 83.9 versus 69.1% and 74.6 versus 57.7%, respectively. Patients undergoing radiation had higher 5-year OS and EFS than those without radiation treatment with P < .001. Chemotherapy combined with radiation is a cornerstone treatment to achieve outcomes. Adverse prognostic factors included age <8 years, surgery, and nonradiation treatment. Either serum or CSF tumor markers were adequately required as a diagnostic test among patients with ICGCTs.

Background: Hemophagocytic lymphohistiocytosis (HLH) is a rare, life‐threatening condition caused by genetic mutation or various triggers disturbing the immune system.Methods: A multicenter retrospective study of pediatric patients with HLH receiving a diagnosis between January 2005 and December 2019 from three pediatric oncology centers was conducted to explore the clinical characteristics and determine prognostic factors associated with outcomes among Thai children.Results: In all, 78 patients with HLH with a median age at diagnosis of 3.17 (range, .08–17.83) years were enrolled. The male to female ratio was 1.2:1. The most common type of HLH was infection‐associated hemophagocytic syndrome (IAHS) (n = 59, 75%) of which Epstein‐Barr virus was the most common pathogen. Thrombocytopenia, hyperbilirubinemia, and treatment response at weeks 2 and 8 after initiating treatment were associated with mortality. Platelet count 3 was the only independent prognostic factor to define survival outcome (p‐value .035). Two‐year overall survival rate was 71.3% (95% confidence interval, 59.2%–80.3%). Survival rates between IAHS, malignant associated HLH, macrophage activation syndrome, and unspecific HLH did not significantly differ (p‐value .571).Conclusion: IAHS was the most common cause among pediatric HLH in Thailand. The outcomes of Thai children with HLH were comparable to those of developed countries. Platelet count 3 was the only independent prognostic factor to define survival outcome.

Background: Assent should be obtained in all children involved in research in keeping with their level of maturity. Traditional assent forms contain too much information and are difficult to read. The study aimed to identify an effective tool to enhance children's comprehension during the assent process and focused on those with cancer who are likely more engaged in research involving greater than minimal risk.Methods: In all, 116 children with cancer were randomized to receive either a paper‐based assent document or a multimedia‐based assent document. Open‐ended and multiple‐choice questions were used to assess comprehension and recall. Time spent on the documents and children's behavior during the assent process was recorded to determine their attention and satisfaction.Results: Children randomized to a multimedia‐based assent document achieved significant higher comprehension and recall assessment scores (p‐values <.001). The high score achievement significantly correlated with the child's age with adjusted odds ratio (OR) of 1.90 (p‐value <.001; 95% confidence interval [CI]: 1.35–2.66) for comprehension assessment and 1.59 (p‐value .001; 95% CI: 1.20–2.12) for recall assessment. Children randomized to a multimedia‐based assent document had significant longer time spent on the document (p‐value .001) with less numbers of inattention (p‐value <.001) and expressed more signs of enjoyment during the assent process (p‐values <.001).Conclusion: Multimedia‐based assent document successfully enhanced comprehension, recall, and attention with more satisfaction compared with a traditional paper‐based document among children with cancer. This approach may be considered as an alternative format for children engaging in research involving greater than minimal risk.

Background: Neuroblastoma is the most common extracranial malignant solid tumor during childhood. Despite intensified treatment, patients with high‐risk neuroblastoma (HR‐NBL) still carry a dismal prognosis. The Thai Pediatric Oncology Group (ThaiPOG) proposed the use of a multimodality treatment to improve outcomes of HR‐NBL in non‐immunotherapy settings.Methods: Patients with HR‐NBL undergoing ThaiPOG protocols (ThaiPOG‐NB‐13HR or ‐18HR) between 2013 and 2019 were retrospectively reviewed. Patient demographic data, treatment modalities, outcomes, and prognostic factors were evaluated and analyzed.Results: A total of 183 patients with HR‐NBL undergoing a topotecan containing induction regimen were enrolled in this study. During the consolidation phase (n = 169), 116 patients (68.6%) received conventional chemotherapy, while 53 patients (31.4%) underwent hematopoietic stem cell transplantation (HSCT). The 5‐year overall survival (OS) and event‐free survival (EFS) were 41.2% and 22.8%, respectively. Patients who underwent HSCT had more superior 5‐year EFS (36%) than those who received chemotherapy (17.1%) (p = .041), although they both performed similarly in 5‐year OS (48.7% vs. 39.8%, p = .17). The variation of survival outcomes was observed depending on the number of treatment modalities. HSCT combined with metaiodobenzylguanidine (MIBG) treatment and maintenance with 13‐cis‐retinoic acid (cis‐RA) demonstrated a desirable 5‐year OS and EFS of 65.6% and 58.3%, respectively. Poorly or undifferentiated tumor histology and cis‐RA administration were independent factors associated with relapse and survival outcomes, respectively (p < .05).Conclusion: A combination of HSCT and cis‐RA successfully improved the outcomes of patients with HR‐NBL in immunotherapy inaccessible settings.

Children with cancer often require sedation before undergoing invasive procedures. Fentanyl, ketamine, and midazolam are effective drugs widely used for procedural sedation. This study aimed to investigate the efficacy and safety of midazolam-fentanyl (M-F) compared with midazolam-ketamine (M-K) for bedside procedural sedation among pediatric oncology patients. A randomized, double-blinded, crossover trial was conducted among children with cancer requiring procedural sedation for invasive procedures. Patients were randomly assigned either intravenous M-F or M-K and subsequently received the alternate regimens following the crossover design of the study. The efficacy and safety of the sedations including sedation time intervals, nausea score, vomiting episodes, pain score, adverse effects, and parent’s satisfaction were evaluated. In all, 58 patients with 116 procedural sedations were enrolled. M-K provided a shorter induction time (0:58 vs. 1:23 min) (p = 0.005), but longer sedation (9:02 vs. 5:50 min) (p = 0.019) and emergence time (4:26 vs. 0:56 min) (p = 0.011) compared with M-F. Sedation routes affected the sedation time intervals. Patients had higher rates of vomiting (0, range 0–8 vs. 0, range 0–2) (p = 0.033) but experienced less pain (0 vs. 2) (p = 0.008) in the M-K group. Overall satisfaction and other adverse effects were comparable among both sedation regimens. Combined sedative drugs are recommended to improve the effectiveness of bedside procedural sedation. M-K provided shorter induction, but longer sedation and emergence time compared with M-F. These findings correlated with sedative routes. Patients receiving M-K experienced a higher rate of vomiting, but less painfulness compared with M-F. Overall satisfaction and tolerable side effects were comparable among both sedative regimens.