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Background: Central nervous system (CNS) tumors are the most common solid malignancies in children worldwide, including in Armenia. The current study aims to analyze epidemiological data, treatment, and outcomes of children and young adults (≤25 years) with CNS tumors in Armenia during the last 26 years. Methods: We collected data from pediatric and young adult patients treated in selected sites in Armenia from 1 January 1995 to 31 December 2020. Incidence by sex, age at diagnosis, time from first complaints to diagnosis, histopathology results, treatment strategies, complications, and overall survival (OS) rates were calculated. Results: The multicenter data analysis revealed 149 patients with diagnosed primary CNS tumors over 26 years. Among them, 84 (56.4%) were male. The median age at diagnosis was 7 years (range, 3 months to 25 years), and the median time from the first complaints to diagnosis was 2 months (range, 1 week to 70 months). Medulloblastomas and other embryonal tumors (47), low-grade gliomas (32), and high-grade gliomas (22) were the most commonly diagnosed malignancies. Ependymomas, craniopharyngiomas, germ cell tumors, and other malignancies were observed in 22 patients. For 26 patients, no histopathological or radiological diagnosis was available. Follow-up information was available for 98 (65.8%) patients. The 5-year OS rate for the whole study group was 67.7%. Conclusion: Consistent with international data, embryonal tumors, and gliomas were the most commonly diagnosed CNS malignancies in Armenia. Multimodal treatment was often not available in Armenia during the study period, especially for early cases.

Primary myelofibrosis (PMF) is Philadelphia-chromosome-negative myeloproliferative neoplasm (MPN) characterized by bone marrow fibrosis, cytopenias, constitutional symptoms, hepatosplenomegaly, and extramedullary hematopoiesis. PMF-associated anemia is usually treated with androgens, danazol, erythropoiesis-stimulating agents (ESAs), immunomodulatory drugs (such as thalidomide, lenalidomide, pomalidomide), corticosteroids, and red blood cell (RBC) transfusions.The aim of our retrospective study was to evaluate the management of PMF-associated anemia in Armenia.The medical records of all patients diagnosed with PMF in Hematology Center in Armenia were analyzed retrospectively from 01/01/2010 to 12/31/2020.Between 2010-2020 the total number of patients was 238, 112 (47.1%) of which were alive by the time of data collection. Median age was 60 (28-88). Female patients were 102 (42.86%). At the time of diagnosis, 48 (42.86%) patients had anemia (Hb12g/dL) of which 12 (10.71%) mild anemia (Hb 11-11.9g/dL); 20 (17.86%) moderate anemia (Hb 8-10.9g/dL); 16 (14.28%) severe anemia (Hb8g/dL). Erythropoietin level was estimated only in one patient. In the majority of patients, anemia has correlated with chronic transfusions. At different stages of treatment, 23 (20.53%) patients were transfusion-dependent, 4 (3.57%) received androgens, 14 (12.5%) prednisone and 1 patient lenalidomide. Among all transfusion-dependent patients, no one has received iron chelation therapy. None of the patients underwent an allogeneic hematopoietic stem cell transplantation (HSCT) because it is not available in the Republic of Armenia. Treatment restrictions are due to financial reasons.Our work showed that due the significant diagnostic and therapeutic limitations in our country led to Inferior outcomes. The method of correlation of anemia in PMF patients is chronic transfusions, which also impairs the quality of life of patients.

Background: One of the main contributors in low survival rate in LMIC is the lack of availability of cancer medications for curative, supportive and palliative care. In many developing countries access to cytotoxic medicine is a major challenge. The information about the availability of essential medicines for pediatric cancer in the country is not known. The main objective of this study was to determine whether the medications used during the treatment of pediatric cancer are available in Armenia. Methods: In summer 2016 we conducted a survey in the 3 main pharmacies in Yerevan, which import pediatric cancer medications to Armenia to evaluate whether medications used during cancer treatment are officially registered and available in the country. In addition, the information on official registration was cross-checked with the Ministry of Health of the Republic of Armenia (MOH). Simultaneously, detailed information about the drugs, on type of produced drug company, doses and price intervals was confined from the price lists of the national drug importer companies. Results: The survey included 64 agents in three classes of medication: anti-neoplastics, anti-microbials, and drugs used in supportive care. All of these medications were included in the recent version of the WHO model list of essential medicines. From 30 anti-neoplastic medications on the essential medicines list 22 (73%) were officially registered in Armenia; from 19 anti-microbial drugs all were registered except caspofungin and from 15 supportive care agents 13 (87%) were registered. From registered anti-neoplastic drugs 18% and from antimicrobial drugs 33% were not available in the drug stores. Conclusion: This study showed that not all the drugs from the SIOP PODC Essential Medication list for pediatric oncology are officially registered and available in Armenia, and effective drug regulation focusing on the childhood cancer care medicine is needed for improving the situation in the country.

Neutropenic enterocolitis (NE) also known as typhlitis is a severe condition usually affecting immunocompromised patients. This is a first documented case of NE in Armenia. 12-years old girl who was diagnosed with Hodgkin Lymphoma IIA in September of 2019 was hospitalized and chemotherapy was initiated with prednisolone, vincristine, doxorubicin and etoposide. On the 9th day of chemotherapy she had abdominal pain, cramps, constipation. Laboratory findings were unremarkable. Empiric Helicobacter Pylori (HP) eradication was prescribed (regimen with amoxicillin and clarithromycin) by gastroenterologist. 2 days later she had fever and CBC showed profound neutropenia (WBC -0.34 neutrophil counts 0.06*103/\(\mu\)L). Meropenem was started for febrile neutropenia. Despite the treatment symptoms were persistent. Based on the symptoms (fever, neutropenia, abdominal pain, diarrhea) NE was suspected and CT scan of abdomen was performed. It revealed the width of the intestinal mucosa 0.5-1.0 cm. Consequently, the diagnosis of NE was confirmed and clarithromycin was switched to metronidazole accordingly. Pseudomonas aeruginosa was detected in blood culture and Proteus vulgaris was detected in stool culture. After 10 days of antibacterial therapy and diet the patient was recovered. CONCLUSION: Awareness of typhlitis and possible risk factors at local institutions might help to modify the incidence and consequences of typhlitis.

Hodgkin lymphoma (HL) accounts for roughly 10% of all lymphomas and 0.6% of all malignant tumours analysed worldwide yearly. Data regarding HL in developing world are exceptionally constrained. The main objective of this research is to investigate the incidence patterns of HL within the Republic of Armenia and to portray disease distribution according to age and sex. There is a very strict evidence on the frequency of HL in Armenia. The results of our research find out that the frequency of HL in Armenia has not changed altogether over the past 15 years and is comparable to that detailed from the USA and Europe.

Context The COVID-19 pandemic has caused healthcare and economic crisis in many countries globally. By 06/08/2020, the number of positive cases in Armenia were 13,325 (∼4,500 per million), with 211 lethal cases. Reports showed that patients with cancer are more vulnerable to COVID-19, and the above-mentioned affected cancer care directly, leading to practice changes. The situation is even more dramatic in developing countries. Objective The purpose of our study was to explore the challenges in hematologic oncology caused by the COVID-19 pandemic in Armenia. Design A survey was conducted at the only hematology institution in Armenia, Hematology Center after Prof. R.H. Yeolyan. Chairs of pediatric and adult hematology departments, two laboratories and a registry, epidemiologists, hospital pharmacy, and administration were interviewed. Results By 06/08/2020, at our institution, 161 PCR tests for COVID-19 were performed, with 13 (8%) positive results. Twelve (92%) positive cases were staff members (one clinical physician, one lab physicians, eight lab technicians, one ancillary worker), six (50%) were symptomatic, and none were hospitalized. Only one patient was positive, a 79-year-old female with chronic lymphocytic leukemia, who expired. Two pediatric patients with Hodgkin lymphoma have pneumonia, and the test results are pending. The main challenges we experienced were staff shortages (positive cases and that direct contacts with infected and elder staff were sent home) and supply chain disruptions and delays: reagents for MTX measurement were delayed for 3 months, HD-MTX infusions were postponed, and bone marrow biopsy single-use needles were non-available for a month. Dacarbazine has been unavailable for 1 month. Certain drugs and supplies increased in price: enoxaparin (2–3 times) and isopropyl alcohol (2×), and personal protective equipment has been in extreme shortage and increased in price (surgical masks more than 10×). Non-urgent visits were postponed and patients were managed mainly by phone. Patients paying out-off-pocket for chemotherapy medications experienced financial difficulties, and this affected the regimen choice. The average number of blood donors decreased by half, although free transportation was offered. Conclusions This is the first study from Armenia to show the challenges of hematologic oncology care during the COVID-19 pandemic in a developing country. Global attention is needed to alleviate the difficulties for these vulnerable patients.

BACKGROUND Every year in Armenia we have approximately 80–90 new pediatric cancer cases from which 10–15 are brain tumors (PBT). Here we try to summarize the current state of pediatric neuro-oncology in Armenia. DISCUSSION: In Armenia pediatric neuro-oncology is still in its first steps. Surgical treatment of PBTs is performed only in one medical center – “Sourb Astvatsamayr” Medical Center, with 7 practicing pediatric neurosurgeons. Radiation therapy service with two linear accelerators is located at the “National Oncology Center”, however there are no dedicated pediatric radiation neuro-oncologists, and 2 specialists are treating pediatric tumors. Chemotherapy for all pediatric cancers currently is performed at the Pediatric Cancer and Blood Disorders Center of Armenia, established in February 2019 as a result of merging of all pediatric oncology units in the country. Among the 11 practicing pediatric hematologist/oncologists no one is dedicated specifically to PBTs. Since September 2017 we have started discussing all PBT cases (up to now 18 cases) through the telemedicine with St. Jude Children’s Research Hospital (SJCRH). In Sept 2019 neuro-oncology multidisciplinary team was created with the involvement of local and foreign specialists. On a weekly basis the multidisciplinary team discusses all new and problematic cases. The team also concentrates on adaptation of diagnostic and treatment guidelines for pediatric CNS tumors, creation of educational materials for different stakeholders, and identification of current problems and their possible solutions. CONCLUSION To the best of our knowledge this is the first report summarizing the current state of pediatric neuro-oncology in Armenia.

Context: Essential thrombocythemia (ET) is a myeloproliferative neoplasm, with an incidence of 1.2 to 3.0 per 100,000 population per year in the United States, with a median age of 58 years. In developing countries, there are certain diagnostic and therapeutic limitations, which affect the outcomes. There were no studies to evaluate the epidemiology, diagnostic and therapeutic patterns of essential thrombocythemia in Armenia. Objective: The purpose of this study is to explore the incidence, diagnostic and therapeutic limitations, and outcomes for patients with ET in Armenia. Design: This nationwide study included all patients with a diagnosis of ET in the Republic of Armenia from 2003 to 2019, which were registered through the registry of the Hematology Center after Prof. Yeolyan. Medical records were reviewed retrospectively and analyzed. Results: A total of 76 patients were registered over a period of 17 years. Incidence was 2 per million, the prevalence was 23 per million in 2019. The median age was 52 years, the mean age was 50 y. 68% were female. Splenomegaly was observed in 40% of patients. The mean platelet count at diagnosis was 1257 × 109/ L; range [429 × 109/L-2747 × 109/ L]. Bone marrow biopsy report on ET confirmation was available for 59 patients (77.6%). The genetic testing was available since 2014, and was done in 13 cases (17.1%). JAK2 V617F mutation was positive in 8 (61.5%) of them. Thrombotic and hemorrhagic complications were reported in 5 and 3 patients, respectively. Hydroxyurea was the most common first-line therapy (92%), second first-line therapies were low-dose aspirin (6.4%) and alpha-interferon (1.6%). The 5-year survival for the group was 87%, the 10-year survival was 70.0%. Conclusions: This is the first study to explore the situation of ET epidemiology, diagnosis, and treatment in Armenia. The incidence was similar to the reported rates from other countries, but the median age was younger in our cohort. Hydroxyurea was the most commonly used cytoreductive therapy, and the study showed certain diagnostic limitations. Further prospective studies to explore these findings are needed.

Thrombocytopenia has long been recognized as a significant problem of cancer therapy, but there is still lack of consensus about the optimal approach to prophylaxis and/or treatment of this important complication. In pediatric oncology, since there are very few studies dedicated to this problem, the knowledge gap is even larger and no final conclusions or pediatric evidence based guidelines are available. Those guidelines that are available consist mostly of experts' personal opinions and data extrapolated from the adult studies. In this review we tried to summarize the existing data and approaches in chemotherapy induced thrombocytopenia (CIT) in pediatric oncology.

BACKGROUND Giant cell tumor of bone(GCTB) is a rare neoplasm with unpredictable behavior, possible malignant transformations, and/or lung metastases. Surgery is usually the treatment of choice. In unresectable or metastatic cases, treatment with denosumab is a new treatment option. CASE PRESENTATION: A 14-years-old female presented with cachexia, dysphagia, diplopia, discoordination, strabismus, and multiple cranial nerve palsies in 10.2015. MRI revealed intra-extracranial mass arising from C2 vertebrae, compressing the medulla oblongata and the left cerebellar hemisphere, invading to the sphenoid bone and nasopharynges. Biopsy showed a GCTB. Surgical resection was done, which was incomplete because of tumor location (cranial nerve and vertebral artery involvement). Then local radiation therapy was performed 50.4Gy. During RT patient’s condition declined and MRI showed disease progression. Treatment with denosumab 120mg q4w was initiated in 03.2016, which yielded successful results. Disease was under control for three years until 03.2019. Then she returned with clinical symptoms of diplopia and severe headache. MRI showed local tumor progression. Repeated biopsy revealed undifferentiated pleomorphic sarcoma, which could be either a malignant transformation of GCTB or a new tumor. The patient later underwent two cycles of chemotherapy with Ifosfamide/Doxorubicin. MRI after 2nd cycle showed marked tumor progression. The patient didn’t receive any further treatment because of cachexia and died due to disease progression in 12.2019. CONCLUSION To our knowledge, this is the youngest patient ever reported with a skull base tumor with such a clinical development, successful and long-time remission with denosumab and with such a chemotherapy-resistant malignant transformation or second cancer.

BACKGROUND Pediatric CNS tumors are the most common solid childhood malignancies with many challenges facing optimal outcome due to multimodality complex therapies, abandonment, and long-term morbidity. In our three-decades young, country the field of neuro-oncology is in its infancy. MATERIALS: The aim of our study is to assess incidence, epidemiology and treatment outcomes of children diagnosed and treated with CNS tumors within the last 10 years (2009–2019) in the Chemotherapy Clinic of “Muratsan” Hospital Complex of Yerevan State Medical University. RESULTS During these periods 20 patients with CNS tumors were treated in our clinic. 13 patients (65%) were diagnosed with medulloblastoma (2 patients were infants), two patients (10%) with optic pathway glioma, and 5 patients each with pilocytic astrocytoma, ATRT, ETANTR, DIPG, and glioblastoma. Five patients (3 patients with medulloblastoma, 1 patient with pilocytic astrocytoma, 1 patient with ATRT) had metastatic disease at the time of diagnosis. Seventeen patients (80%) had undergone surgery, 8 patients with medulloblastoma received chemo-RT with vincristine. Median follow up time was 15.5 months (range 5–94). Twelve patients (60%) are alive without evidence of disease. 5 patients had disease progression and three patients relapsed. From them, 3 patients died. Long-term survivors are mainly standard risk medulloblastoma patients. All medulloblastoma patients were treated according to HIT-MED guidelines. CONCLUSION Here we report about the pediatric brain tumors of one of the main pediatric oncology units in Armenia for a period of 10 years. The numbers are quite small for firm conclusions, but it shows the emerging need for further research.

BACKGROUND Pilomyxoid astrocytoma (PMA) is a glial tumor that occurs predominantly in the hypothalamic-chiasmatic region and rarely in spinal cord. It has similar features as pilocytic astrocytomas, with some distinct histological characteristics and worse prognosis. The 2007 WHO recognized PMA as a Grade II glioma due to its aggressive behavior and dissemination tendency, but according to 2016 version grading of the pilomyxoid variant is under research. Here we report a case with a rare location, aggressive behavior and rapid progression. CASE PRESENTATION: A 7-year-old boy presented with headache, nausea, vomiting. Imaging revealed an intramedullary tumor extending from C2 to C6 with hydrocephalus. A ventriculo-peritoneal shunt and complete surgical resection were performed with significant improvement in the patient’s condition. Histopathological findings were consistent with pilomyxoid variant of pilocytic astrocytoma, with negative BRAF V600E and MGMT. Three months later, the follow-up imaging revealed disease recurrence with leptomeningeal metastases, for which the patient received standard-dose craniospinal irradiation 35.2 Gy with boosts to tumor bed and metastatic sites 49.6 Gy and 54 Gy respectively. 11 months later tumor progression was revealed with new metastatic lesions in the bones. Patient received 6 cycles of chemotherapy with TMZ and Avastin, but continued to suffer disease progression on therapy and he succumbed to his disease at 24 months from diagnosis. CONCLUSION Given the rarity of documented patients with spinal pilomyxoid astrocytoma with rapid progression, as well as the lack of certain WHO classification and treatment guidelines, this case report might be useful for development of more efficient treatment strategies.

INTRODUCTION Embryonal tumor with abundant neuropil and true rosettes (ETANTR) is a rare aggressive brain tumor with low survival rates. There are about 80 cases reported in literature since 2000 when it was first described. There is no standard treatment scheme for ETANTR yet. CASE REPORT: A 2 years old boy presented with a month-long of headache and inability to hold his head. CT scan and MRI revealed a large mass in the right frontal lobe with midline shift. Subtotal tumor resection was done. Histological and immunohistochemical analyses was consistent with ETANTR in one laboratory and PNET in another. The second opinion suggested by the Center of Pediatric Oncology, Hematology and Immunology in Moscow the diagnosis ETANTR was confirmed. Taking into account certain similarities with medulloblastoma was decided to provide treatment according to HIT-2014 protocol. Control MRI done after 2 cycles of Block SKK Carboplatin/Etoposide found tumor progression and for that reason patient underwent second surgical resection. Considering the age of the child radiation therapy was not expedient and the decision was to continue treatment with HIT 2014 intensified regimen, which includes Cisplatin, Vincristine, Etoposide, Cyclophosphamide and intravenous High dose Methotrexate with intrathecal Methotrexate. Aiming to evaluate the effectiveness of treatment we are planning to perform MRI after this 2nd cycle of intensified regimen. DISCUSSION There are difficulties in diagnosis of rare types of cancers in Armenia. Since there is no approved treatment for ETANTR, there is a need for ongoing research to improve its prognosis.

BACKGROUND Central nervous system (CNS) tumors are the second most common malignant neoplasms among children worldwide. The current paper aims to analyze the situation in pediatric neuro-oncology in Armenia from the neurosurgical perspective. METHODS We have collected data of pediatric patients with CNS tumors treated in the Neurosurgery department of “Surb Astvasamayr” Medical Center from 01.01.2010 till 01.12.2019. Incidence by gender, age at diagnosis, and histopathology results were calculated. Survival rates were calculated based on the follow-up results performed until 30.12.2019. RESULTS Hospital-based data showed that during the previous 10 years 47 patients with CNS tumors received neurosurgical treatment in the unit, among them 66% were females. 38.3%, 31.9% and 29.8% of diagnosed patients were aged 0–4, 5–9, and 10–18 respectively. In 41 cases, the disease was not disseminated at diagnosis. The most common observed malignancies were low-grade gliomas (21.3%) and embryonal tumors (19.1%), followed by high-grade gliomas (14.9%) and ependymal tumors (8.5%). Follow-up information only for 33 patients is available. From them, 14 are dead and 19 alive. Survival rates in most common groups were 62.5%, 80%, 50%, and 50% respectively. The median follow-up time was 18 months (range 1–113 months). CONCLUSION Similar to the data reported in the literature, low-grade gliomas, and embryonal tumors are the most frequent pediatric CNS tumors in Armenia. On the other hand, the pediatric CNS tumor survival rates are lower compared to those reported in developed countries.

Context The incidence and severity of transfusion reactions in children with AML differ from those in adults. Published data on this problem is limited, especially from the developing world. Objective The aim of our nationwide study was to evaluate the necessity of blood products transfusions and the incidence of transfusion reactions among children with acute myeloid leukemia (AML) during their hospitalization in Armenia between 1995 and 2014. Design The medical records of all children with different types of AML receiving treatment in 2 main hospitals (Hematology Center after Prof. R.H.Yeolyan and Muratsan Hospital Complex of Yerevan State Medical University) of Armenia within 20 years (1995-2014) were retrospectively reviewed and analyzed. Results Data of 91 pediatric patients with AML with a median age of 12 y and mean age of 10.7 y were collected. Fifty-six (61.5%) patients were male. From the entire cohort, 61 (67%) patients received RBC transfusions overall 423 times (on average 7 transfusions per patient). Information about pretransfusion Hb level was available in 132 cases: in 102 (77.3%) cases, it was below 70 g/L, in 24 (18.2%) cases, between 70 and 80 g/L, and in 6 (4.5%) cases, it was above 80 g/L. Only one transfusion reaction (chills) was documented. Platelets (PLT) were transfused to 36 (39.6%) patients: 522 (14.5 units per patient) units of whole blood platelets (WBT) were administered overall 292 times (1.8 unit per transfusion). In 149 (51%) transfusions, the pretransfusion PLT levels were below 10 × 109/L. In the entire group, WBT transfusion-related reactions were documented 2 times (1 urticaria and 1 febrile reaction with chills). Twelve packs of apheresis platelets were used and only 1 case of urticaria was reported. 286 packs (6 packs per patient) of fresh-frozen plasma (FFP) were administered to 48 (52.75%) patients. In this subgroup 10 cases of urticaria, 1 case of vomiting, and 1 febrile reaction were documented. Whole blood was transfused to 2 (2.2%) patients 4 times. Conclusions In our study cohort, no life-threatening transfusion reactions were reported for any blood product transfusion, which proves that blood transfusions are quite safe in children with AML. Larger studies need to explore these findings.

Background Chemotherapy-induced thrombocytopenia (CIT) is a significant complication of cancer therapy. Data on the optimal management approaches of this morbidity in children and young adults are still limited. Aim The aim of the study is to estimate the frequency and severity of CIT and associated clinically significant bleeding in children and young adults with solid tumours and haematologic malignancies. Methods For this retrospective, hospital-based study, children (0–18 y) and young adults (19–40 y) with different types of solid tumours and haematologic malignancies who received chemotherapy at the Muratsan Hospital Complex of Yerevan State Medical University were identified from the patients’ database and included in the study (overall 122 patients). Thrombocytopenia was defined as a decrease of platelet count below

e19002 Background: In Armenia the incidence of pediatric cancer accounts for around 80-100 cases per year. This qualitative study was conducted in 2018 to evaluate the needs and challenges in a provision of pediatric cancer care in Armenia. Comparative qualitative study was conducted in 2020 to evaluate the progress in the field. Methods: Qualitative research methods were incorporated to evaluate the achievements, needs and challenges in a provision of childhood cancer care in Armenia. Semi-structured in-depth interviews were conducted with selected study participants including pediatric oncologist/hematologists, pediatric surgeons, who also treat cancer patients, and radiation oncologists. Purposive sampling technique and qualitative conventional content analysis methods were used. Results: Data collected in January 2020 has shown significant improvements in the field of pediatric oncology in Armenia. In the 2018 study, some of the major issues included lack of centralized pediatric cancer care, pediatric cancer registry, palliative care center, possibility of providing high-dose methotrexate, limited nursing training, multidisciplinary team approaches and use of central catheters. Within two years, majority of these problems were solved or are in the process. In 2019 all 3 pediatric oncology and hematology units were merged and the Pediatric Cancer and Blood Disorders of Armenia was created; with the support from charitable foundations all children with cancer receive free medical and psychosocial coverage; a 25 year data has been collected from all the possible sites, the first pediatric cancer palliative care is under construction, 4 multidisciplinary cancer teams were created, pediatric oncology and hematology fellowship was created at the Yerevan State Medical University to prepare for the first time "pediatric oncologist-hematologist" as a one profession. The existing major problems include very limited provision of pediatric cancer medications by the government, as well as lack of the official registration of the number of essential drugs included in the WHO list. Conclusions: Twinning programs, multidisciplinary team discussions with international experts, improvement in availability of several resources, professional development of the staff are major tools for the progress of pediatric oncology in Armenia. Poor provision and official registration of anti-neoplastic medications by the government still remain a major obstacle.

Background Giant cell tumor of bone (GCT) is a rare primary bone tumor, which can metastasize and undergo malignant transformation. The standard treatment of GCT is surgery. In patients with unresectable or metastatic disease, additional therapeutic options are available. These include blocking of the receptor activator of NF-kappa B ligand (RANKL) signaling pathway, which plays a role in the pathogenesis of GCT of bone, via the anti-RANKL monoclonal antibody denosumab. Case Presentation Herein we report on a female teenager who presented in a very poor clinical condition (cachexia, diplopia, strabismus, dysphonia with palsy of cranial nerves V, VI, VIII, IX, X, XI and XII) due to progressive disease, after incomplete resection and adjuvant radiotherapy, of a GCT which affected the cervical spine (C1 and C2) as well as the skull base; and who had an impressive clinical response to denosumab therapy. To the best of our knowledge, this is the youngest patient ever reported with a skull base tumor treated with denosumab. Conclusion In situations when surgery can be postponed and local aggressiveness of the tumor does not urge for acute surgical intervention, upfront use of denosumab in order to reduce the tumor size might be considered. Principally, the goal of denosumab therapy is to reduce tumor size as much as possible, with the ultimate goal to make local surgery (or as in our case re-surgery) amenable. However, improvement in quality of life, as demonstrated in our patient, is also an important aspect of such targeted therapies. Electronic supplementary material The online version of this article (doi:10.1186/s13052-017-0353-0) contains supplementary material, which is available to authorized users.

We performed a literature review to examine barriers for rhabdomyosarcoma treatment in low-resource settings, and identified 29 articles from 14 middle-income countries, with none from low-income countries. Notable findings included inconsistent use of local control modalities, lack of diagnostics in some settings, and high rate of abandonment specifically in low middle-income countries. Reported limitations included lack of surgical expertise and/or radiation therapy, advanced stage of disease, and absence of health insurance. Although very poor outcomes were prevalent in several settings, good outcomes were achievable in others when multidisciplinary therapy and financial coverage of medical care were made available.

Background With advances in diagnostics and treatment approaches, patients with Hodgkin's lymphoma (HL) in developed countries can nowadays expect to have excellent outcomes. However, information about the characteristics and outcomes in the developing world is very scarce, and this is important given the fact that there are several reports about differences of disease characteristics depending on geographic location and the development level of the country. Materials and methods In this retrospective study we assessed the features of 36 adult (≥18 years old) patients with HL and their diagnosis and treatment and outcomes in the Clinic of Chemotherapy of Muratsan University Hospital of Yerevan State Medical University, Armenia, between 2008- 2014. Results All patients had classic HL and among them 19 (53%) had nodular sclerosis subtype, 8 (22%) mixed cellularity and 9 (25%) lymphocyte-rich. 16 (44.5%) patients were at stage II, 13 (36%) stage III and 7 (19.5%) stage IV. Median follow-up time was 24.5 months (range 1-71 months) and during the whole follow- up period only two relapses (early) were documented and there were no deaths. Twenty-three (64%) patients received a BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone) regimen, and 13 (36%) ABVD (doxorubicin, bleomycin, vinblastine and dacarbazine) regimen. A total of 25 (69.5%) patients received radiation in addition to chemotherapy. Conclusions Although the number of patients involved in the study is small and the median follow-up time was just two years, this retrospective study shows that treatment of HL can be successfully organized in a resource-limited setting.