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crizotinib &#40;200&#8239;mg daily&#41; was initiated while awaiting the results of molecular studies&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The patient reported progressive improvement of symptoms&#46; Magnetic resonance and positron-emission tomography &#40;PET-CT&#41; scans revealed a small residual lesion at 1 month of treatment and complete resolution of disease at 4 months &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">After 5 months of treatment&#44; the caregivers reported an abnormal running pattern&#44; and the patient started to experience intermittent&#44; unilateral and localised leg pain&#46; An MRI of the abdomen and pelvis was performed&#44; with no evidence of tumour recurrence but with abnormal signal intensity in the upper femora&#46; Blood tests ruled out inflammation and infection&#46; Neuropathy had been previously described as a common side effect &#40;25&#37;&#41; as well as decreased bone formation &#40;uncommon&#41;&#46; The symptoms did not improve and crizotinib was thought to be the cause&#46; Treatment was discontinued 1 month later &#40;total duration of treatment of 6 months&#41;&#46; The altered gait and joint pain resolved after stopping crizotinib&#46; The patient underwent close follow-up monitoring&#46; At present&#44; it has been 4 years since treatment was completed&#44; and there is no evidence of recurrence and the patient has not required any further treatment&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Whole genome sequencing eventually detected a translocation between ALK and PTRH2&#47;CLTC t&#40;2&#59;17&#41; &#40;p23&#46;2&#59;q23&#46;1&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">A review of the literature allows us to appreciate the important role that molecular biology is playing in paediatric patients with IMT&#46; Firstly&#44; it facilitates diagnosis&#44; which is initially erroneous in up to 20&#37; of cases&#46; Pire et al&#46; used fluorescence in situ hybridisation &#40;FISH&#41; or RNA sequencing to detect specific fusions involving <span class="elsevierStyleItalic">ALK</span>&#44; <span class="elsevierStyleItalic">ROS1</span> or <span class="elsevierStyleItalic">NTRK</span>&#46; These techniques detected tyrosine kinase gene rearrangements in up to 86&#37; of patients with ITM&#44; whereas changes in <span class="elsevierStyleItalic">ALK</span> have been classically reported in approximately 50&#37; of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In terms of prognosis&#44; recent publications postulate that among the ALK&#8239;&#43;&#8239;IMTs&#44; there could be some subtypes with a poor prognosis depending on the detected genetic rearrangements&#46; For example&#44; tumours with <span class="elsevierStyleItalic">RANBP2-ALK</span> rearrangements would not respond adequately to crizotinib and may require treatment with second-generation ALK inhibitors&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Regarding treatment&#44; recent studies conclude that aggressive surgery is not associated with a better prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In inoperable cases&#44; there is controversy about first-line treatment&#46; Some patients have responded to low-dose chemotherapy&#44; but a standard chemotherapy regimen has yet to be established&#44; and there is ample evidence on its side effects&#46; Moreover&#44; the European Paediatric Soft Tissue Sarcoma Study Group and The Children&#8217;s Oncology Group have recently published promising results of targeted therapy with ALK-inhibitors&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">After the case of our patient&#44; who only received treatment for 6 months with an excellent response&#44; and taking into consideration the side effects of ALK-inhibitors&#44;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> we challenge the necessity to continue treatment once complete remission is achieved&#44; regardless of the time it takes to achieve it&#46; In this respect&#44; the question of the long-term efficacy of these treatments also stands out&#46; Our patient has been out of treatment for 4 years&#44; with no signs of recurrence&#46; Therefore&#44; it seems evident that prospective studies with larger cohorts are urgently needed to ascertain the safest way of treating these children&#46; Future trials will need to establish the duration of treatment and the safety of stopping treatment once a complete response has been achieved&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to disclose&#46;</p></span></span>"
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Scientific Letter
Impact of molecular biology in children with ALK+ inflammatory myofibroblastic tumour. A reflexion from a case report
Impacto de la biología molecular en niños con tumor miofibroblástico inflamatorio ALK+. Reflexiones a partir de un caso clínico
Fernando Rafael Aguirregomezcortaa,
Corresponding author
Aguirrefer77@gmail.com

Corresponding author.
, Kriti Hedgea, Olga Slatera, Ana Isabel Benitob, Mette Jorgensena
a Great Ormond Street Hospital, London, United Kingdom
b Hospital Infantil Universitario Niño Jesús, Madrid, Spain
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the optimal duration of treatment is not well established&#44; and treatment is generally prolonged if the patient maintains response and has significant adverse effects&#46; In fact&#44; it lasts approximately 2 years on average&#44; which is an issue the scientific community should reconsider&#44; given its side effects &#40;vomiting&#44; diarrhoea&#44; neutropaenia&#44; vision disorders&#44; neuropathy&#41;&#44; its high cost and the possible emergence of resistance&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 6-year-old girl who presented with a 2-month history of abdominal pain&#44; fatigue&#44; pyrexia&#44; and weight loss&#46; A magnetic resonance imaging &#40;MRI&#41; scan found a mass&#46; It was located on the right side&#44; within the small bowel mesentery&#44; measured 6&#8239;&#215;&#8239;4&#8239;&#215;&#8239;6&#8239;cm&#44; with homogeneous signal and restricted diffusion&#44; as well as enhancement after gadolinium&#46; It seemed to impair venous drainage from the caecum and terminal ileum&#44; as there were dilated blood vessels surrounding the caecum and hepatic flexure&#46; No lymphadenopathy or other abnormalities were seen&#46; The morphological features were those of a low-grade spindle cell tumour&#46; The immunostaining was positive for SMA&#44; CD117 &#40;cytoplasmic&#41;&#44; ALK &#40;cytoplasmic&#41;&#44; desmin &#40;patchy&#41;&#44; MNF116 &#40;patchy&#41; and vimentin&#46; The expression of INI-1 was preserved&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">The findings were suggestive of an IMT</span><p id="par0015" class="elsevierStylePara elsevierViewall">Surgery&#44; usually the preferred treatment for localised IMT&#44; could potentially result in short-gut syndrome&#44; making the patient dependent on lifelong parenteral nutrition&#59; therefore&#44; further treatment options were explored&#46; Given the promising results of targeted therapy compared to classic chemotherapy regimens&#44; crizotinib &#40;200&#8239;mg daily&#41; was initiated while awaiting the results of molecular studies&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The patient reported progressive improvement of symptoms&#46; Magnetic resonance and positron-emission tomography &#40;PET-CT&#41; scans revealed a small residual lesion at 1 month of treatment and complete resolution of disease at 4 months &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">After 5 months of treatment&#44; the caregivers reported an abnormal running pattern&#44; and the patient started to experience intermittent&#44; unilateral and localised leg pain&#46; An MRI of the abdomen and pelvis was performed&#44; with no evidence of tumour recurrence but with abnormal signal intensity in the upper femora&#46; Blood tests ruled out inflammation and infection&#46; Neuropathy had been previously described as a common side effect &#40;25&#37;&#41; as well as decreased bone formation &#40;uncommon&#41;&#46; The symptoms did not improve and crizotinib was thought to be the cause&#46; Treatment was discontinued 1 month later &#40;total duration of treatment of 6 months&#41;&#46; The altered gait and joint pain resolved after stopping crizotinib&#46; The patient underwent close follow-up monitoring&#46; At present&#44; it has been 4 years since treatment was completed&#44; and there is no evidence of recurrence and the patient has not required any further treatment&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Whole genome sequencing eventually detected a translocation between ALK and PTRH2&#47;CLTC t&#40;2&#59;17&#41; &#40;p23&#46;2&#59;q23&#46;1&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">A review of the literature allows us to appreciate the important role that molecular biology is playing in paediatric patients with IMT&#46; Firstly&#44; it facilitates diagnosis&#44; which is initially erroneous in up to 20&#37; of cases&#46; Pire et al&#46; used fluorescence in situ hybridisation &#40;FISH&#41; or RNA sequencing to detect specific fusions involving <span class="elsevierStyleItalic">ALK</span>&#44; <span class="elsevierStyleItalic">ROS1</span> or <span class="elsevierStyleItalic">NTRK</span>&#46; These techniques detected tyrosine kinase gene rearrangements in up to 86&#37; of patients with ITM&#44; whereas changes in <span class="elsevierStyleItalic">ALK</span> have been classically reported in approximately 50&#37; of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In terms of prognosis&#44; recent publications postulate that among the ALK&#8239;&#43;&#8239;IMTs&#44; there could be some subtypes with a poor prognosis depending on the detected genetic rearrangements&#46; For example&#44; tumours with <span class="elsevierStyleItalic">RANBP2-ALK</span> rearrangements would not respond adequately to crizotinib and may require treatment with second-generation ALK inhibitors&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Regarding treatment&#44; recent studies conclude that aggressive surgery is not associated with a better prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In inoperable cases&#44; there is controversy about first-line treatment&#46; Some patients have responded to low-dose chemotherapy&#44; but a standard chemotherapy regimen has yet to be established&#44; and there is ample evidence on its side effects&#46; Moreover&#44; the European Paediatric Soft Tissue Sarcoma Study Group and The Children&#8217;s Oncology Group have recently published promising results of targeted therapy with ALK-inhibitors&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">After the case of our patient&#44; who only received treatment for 6 months with an excellent response&#44; and taking into consideration the side effects of ALK-inhibitors&#44;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> we challenge the necessity to continue treatment once complete remission is achieved&#44; regardless of the time it takes to achieve it&#46; In this respect&#44; the question of the long-term efficacy of these treatments also stands out&#46; Our patient has been out of treatment for 4 years&#44; with no signs of recurrence&#46; Therefore&#44; it seems evident that prospective studies with larger cohorts are urgently needed to ascertain the safest way of treating these children&#46; Future trials will need to establish the duration of treatment and the safety of stopping treatment once a complete response has been achieved&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to disclose&#46;</p></span></span>"
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ISSN: 23412879
Original language: English
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Idiomas
Anales de Pediatría (English Edition)
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¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?