Comments on ‘neuroblastoma in Sudan: experience of a single institute’

Dear Editor,

I read with interest the original article about clinical experience with neuroblastoma (NBL) in Sudan by Elhaj et al. [1]. NBL accounts for about 8%–10% of overall childhood malignancies in developed countries. However, it accounts for only 1%–3% in developing countries, but the true incidence is unknown. The children older than 1 year of age with stage 4 NBL constitute the majority of the high-risk category [2]. During the period from 2004 to children out of 964 with childhood malignancies were diagnosed and treated as the cases of NBL at the National Cancer Institute (NCI). Eight of them were less than 2 years, were less than 1 year and were more than 2 years of age. There was no histopathological description of the biopsy according to Shimada classification. In this study, NBL cases accounted for 4% of the overall childhood malignancy in NCI. This result is less than the international data but approximating results from low- and middle-income countries, where the incidence ranged from 1% to 3%. In this study, 76% of cases were classified as high-risk NBL using the modified criteria for risk stratification, which depend mainly on the age of the patients, Lactate Dehydrogenase (LDH) level, and presence of metastasis that is responsible for the poor prognosis even with the use of aggressive treatment. The median age of presentation was 3 years, which is one of the poor prognostic features, and it does not fit with the international data and studies from Saudi Arabia but approximated results from Egypt, which was 2.8 years [3]. The majority were also diagnosed by trucut biopsy, which reflected that the tumor was not accessible for primary surgical reduction. Half of the cases were stage IV which reflects the late presentation of the patients to the oncology centres, either due to the lack of health facilities or because of seeking treatment earlier with traditional healers. About one-third of patients died at home without obvious cause, which means a lack of adherence to treatment and follow-up [2]. These results showed that NBL cases accounted for 4% of overall childhood malignancies in Sudan with a very poor outcome. This is mainly due to the late presentation of the patients, limited diagnostic modalities, lack of knowledge of the caregivers and the majority of primary healthcare providers about childhood malignancy, lack of trained personnel in the field of pediatric oncology, and lack of some chemotherapeutic agents, as some of them are not available in Sudan.