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High-dose intense chemotherapy in South African children with B-cell lymphoma: morbidity, supportive measures, and outcome.

BACKGROUND
Twenty-five percent of South African children aged 6-71 months are undernourished and have stunted growth. The tolerance and efficacy of short, high-dose intense chemotherapy for B-cell lymphomas in such a population were unknown.


PROCEDURE
Nineteen consecutive children diagnosed with B-cell lymphoma after 1993 at Tygerberg Hospital (TBH) in the Republic of South Africa (RSA) were treated according to the LMB-89 protocol.


RESULTS
Among the 19 children treated according to the LMB-89 protocol, there were 3 children in group A (completely resected St. Jude stage I and abdominal stage II), 14 in group B (nonresected stage I, nonabdominal stage II, all stage III, stage IV with bone marrow involvement but <70% Burkitt cells and without CNS involvement) and 2 in group C (patients with >70% Burkitt cells in bone marrow and/or CNS involvement). Overall survival for these children was 79% (median follow-up 53.5 months,range 20-70 months) compared to 25% (median follow-up 131 months, range 71-173months) for 24 children who had been treated with COM+/-P prior to 1993 (P = 0.002). Toxicity was noteworthy in the children treated with LMB-89. They had a mean of 2.6 episodes of febrile neutropenia and 1.9 episodes of stomatitis per patient and required intensive support, but there were no toxic deaths.


CONCLUSIONS
A major step forward was achieved for South African children with B-cell lymphoma. Despite a high prevalence of malnutrition and endemic infections in the RSA, the implementation of the LMB-89 protocol significantly improved survival with manageable morbidity. Our findings suggest that treatment centres that cannot measure methotrexate (MTX) serum levels should not exceed 3.0 g/m(2) of MTX. If supportive care facilities are limited, consideration should be given to reducing the doses of cyclophosphamide and of doxorubicin in the treatment schedules.