Burkitt lymphoma (BL) is a B-cell malignancy that disproportionately affects children in sub-Saharan Africa. We performed a genome-wide association study (GWAS) in a combined set of 800 childhood cases and 3865 controls in East Africa, controlling for age, sex, country, population-specific principal components, and a genetic relationship matrix. This analysis identified a BL-protective region within chromosome 21q22.12 tagged by the rs111457485-T allele (odds ratio [OR] = 0.57; p = 5.7 × 10−9). The results were robust in standard meta-analysis (OR = 0.57, p < 1.6 × 10−8), sensitivity analyses (removing genomic outliers and related individuals), and after adjustment for Epstein-Barr virus (EBV) status. Genomic analyses revealed long-range (over ~700 kb) chromatin interactions between the chr21q22.12 locus and the RUNX1-P1 promoter region. The African-specific rs2242780-C allele (r2 = 0.69 with the rs111457485-T allele in the study controls) showed increased enhancer activity in in-vitro Luciferase reporter assays (p = 4.5 × 10−10), nominating it as the likely functional variant for the BL-associated loci. In addition to the association with reduced BL risk in GWAS (OR = 0.62, p = 2.24 × 10−8), the rs2242780-C allele was also associated with better survival in patients with abdominal-only BL in exploratory analyses (hazard ratio = 0.39, p = 0.038, 106 patients, 59 deaths). Our GWAS uncovered novel BL-protective loci near RUNX1, offering insights into the genetic etiology of BL in African children.

Burkitt lymphoma (BL) is responsible for many childhood cancers in sub-Saharan Africa, where it is linked to recurrent or chronic infection by Epstein-Barr virus or Plasmodium falciparum . However, whether human leukocyte antigen ( HLA ) polymorphisms, which regulate immune response, are associated with BL has not been well investigated, which limits our understanding of BL etiology. Here we investigate this association among 4,645 children aged 0-15 years, 800 with BL, enrolled in Uganda, Tanzania, Kenya, and Malawi. HLA alleles are imputed with accuracy >90% for HLA class I and 85-89% for class II alleles. BL risk is elevated with HLA-DQA1*04:01 (adjusted odds ratio [OR] = 1.61, 95% confidence interval [CI] = 1.32-1.97, P = 3.71 × 10 −6 ), with rs2040406(G) in HLA-DQA1 region (OR = 1.43, 95% CI = 1.26-1.63, P = 4.62 × 10 −8 ), and with amino acid Gln at position 53 versus other variants in HLA-DQA1 (OR = 1.36, P = 2.06 × 10 −6 ). The associations with HLA-DQA1*04:01 (OR = 1.29, P = 0.03) and rs2040406(G) (OR = 1.68, P = 0.019) persist in mutually adjusted models. The higher risk rs2040406(G) variant for BL is associated with decreased HLA-DQB1 expression in eQTLs in EBV transformed lymphocytes. Our results support the role of HLA variation in the etiology of BL and suggest that a promising area of research might be understanding the link between HLA variation and EBV control.

Interferon lambda 4 (IFN-λ4) is a novel type-III interferon that can be expressed only by carriers of the genetic variant rs368234815-dG within the first exon of the IFNL4 gene. Genetic inability to produce IFN-λ4 (in carriers of the rs368234815-TT/TT genotype) has been associated with improved clearance of hepatitis C virus (HCV) infection. The IFN-λ4-expressing rs368234815-dG allele (IFNL4-dG) is most common (up to 78%) in West sub-Saharan Africa (SSA), compared to 35% of Europeans and 5% of individuals from East Asia. The negative selection of IFNL4-dG outside Africa suggests that its retention in African populations could provide survival benefits, most likely in children. To explore this hypothesis, we conducted a comprehensive association analysis between IFNL4 genotypes and the risk of childhood Burkitt lymphoma (BL), a lethal infection-associated cancer most common in SSA. We used genetic, epidemiologic, and clinical data for 4,038 children from the Epidemiology of Burkitt Lymphoma in East African Children and Minors (EMBLEM) and the Malawi Infections and Childhood Cancer case-control studies. Generalized linear mixed models fit with the logit link controlling for age, sex, country, P. falciparum infection status, population stratification, and relatedness found no significant association between BL risk and 3 coding genetic variants within IFNL4 (rs368234815, rs117648444, and rs142981501) and their combinations. Because BL occurs in children 6-9 years of age who survived early childhood infections, our results suggest that additional studies should explore the associations of IFNL4-dG allele in younger children. This comprehensive study represents an important baseline in defining the health effects of IFN-λ4 in African populations.

Burkitt lymphoma (BL) is an aggressive B-cell lymphoma that significantly contributes to childhood cancer burden in sub-Saharan Africa. Plasmodium falciparum, which causes malaria, is geographically associated with BL, but the evidence remains insufficient for causal inference. Inference could be strengthened by demonstrating that mendelian genes known to protect against malaria-such as the sickle cell trait variant, HBB-rs334(T)-also protect against BL. We investigated this hypothesis among 800 BL cases and 3845 controls in four East African countries using genome-scan data to detect polymorphisms in 22 genes known to affect malaria risk. We fit generalized linear mixed models to estimate odds ratios (OR) and 95% confidence intervals (95% CI), controlling for age, sex, country, and ancestry. The ORs of the loci with BL and P. falciparum infection among controls were correlated (Spearman's ρ = 0.37, p = .039). HBB-rs334(T) was associated with lower P. falciparum infection risk among controls (OR = 0.752, 95% CI 0.628-0.9; p = .00189) and BL risk (OR = 0.687, 95% CI 0.533-0.885; p = .0037). ABO-rs8176703(T) was associated with decreased risk of BL (OR = 0.591, 95% CI 0.379-0.992; p = .00271), but not of P. falciparum infection. Our results increase support for the etiological correlation between P. falciparum and BL risk.

In high-income countries, mosaic chromosomal alterations in peripheral blood leukocytes are associated with an elevated risk of adverse health outcomes, including hematologic malignancies. We investigate mosaic chromosomal alterations in sub-Saharan Africa among 931 children with Burkitt lymphoma, an aggressive lymphoma commonly characterized by immunoglobulin- MYC chromosomal rearrangements, 3822 Burkitt lymphoma-free children, and 674 cancer-free men from Ghana. We find autosomal and X chromosome mosaic chromosomal alterations in 3.4% and 1.7% of Burkitt lymphoma-free children, and 8.4% and 3.7% of children with Burkitt lymphoma ( P -values = 5.7×10 −11 and 3.74×10 −2 , respectively). Autosomal mosaic chromosomal alterations are detected in 14.0% of Ghanaian men and increase with age. Mosaic chromosomal alterations in Burkitt lymphoma cases include gains on chromosomes 1q and 8, the latter spanning MYC , while mosaic chromosomal alterations in Burkitt lymphoma-free children include copy-neutral loss of heterozygosity on chromosomes 10, 14, and 16. Our results highlight mosaic chromosomal alterations in sub-Saharan African populations as a promising area of research.

Background Burkitt lymphoma (BL) is an aggressive B-cell lymphoma that accounts for 50-75% of childhood cancers in sub-Saharan Africa. Recurrent infection with Plasmodium (P.) falciparum is hypothesized to be causally linked to BL, but the epidemiological evidence is limited because it is based on exposures measured after BL onset. The prolonged period before BL onset makes traditional cohort studies impractical. To circumvent this problem, it was proposed that genetic variants that confer genetic resistance to P falciparum, such as heterozygotes for the HBB sickle allele (rs334), could be used to demonstrate a causal link with malaria. However, results from six studies have been conflicting, perhaps, reflecting effects of small sample size, design flaws in the studies or confounding. For example, co-inheritance with other genetic variants, such as a-thalassemia, have been reported to confound the epidemiological associations of severe malaria with rs334. Additionally, resistance against P. falciparum due to "premunition", defined as anti-clinical and anti-parasite resistance due to acquired immunity, could confound genetic associations with BL. To address the hypothesis of whether resistance to malaria protects against BL, we investigated the associations between BL and rs334 and 31 other single nucleotide polymorphisms (SNPs) plus α-thalassemia (hereafter, index malaria resistance SNPs/variants), and premunition, defined as P. falciparum positivity at enrollment, in cases enrolled in Uganda, Tanzania, Kenya, and Malawi, all designated as high malaria burden countries by the World Health Organization. Methods The study cohort consisted of 800 children (<16 years) with BL and 3845 children without BL enrolled in the Epidemiology of Burkitt Lymphoma in East African Children and Minors (EMBLEM) study (2010-2016) and the Infections and Childhood Cancer case-control study conducted in Malawi (2005-2010). P falciparum status was determined by thick-film microscopy, malaria antigen (HRP2/pLDH) rapid diagnostic test, or PCR at enrollment. Malaria protective SNPs were extracted from genome-wide data measured using Infinium Omni5Exome-4 v1.3 BeadChip (Illumina, San Diego, CA, USA). Genotyping for α3.7-thalassemia deletions (/-α3.7)utilized droplet digital polymerase chain reaction. We tested for associations between BL and the malaria index SNPs, a genotypes, and P. falciparum positivity using generalized linear mixed models, controlling for age, sex, and the first 3 population-specific principal components as fixed effects and for genetic relatedness (calculated from genome-wide data) as a random effect. We considered a p-value < 0.05 for statistical significance for malaria index SNPs. Results The mean age was similar for BL cases and controls (7.19 years versus 7.43 years, p= 0.07), but BL cases were more likely to be males (63.2% versus 52.1%, p£0.0001). P. falciparum positivity was lower in BL cases than controls (35.2% versus 48.3%, p<0.0001). Figure 1 shows the associations between 32 malaria index SNPs with BL and with P. falciparum positivity. Odds of BL were significantly decreased in presence of HBB rs334 (odds ratio [OR]= 0·687, 95% CI 0·533-0·885; p=0·0037) and ABO rs8176703 (0·591, 0·379-0·922; p=0.0203). Results for α-genotypes included the normal genotype (αα/αα), triplication (ααα/αα), -α3.7/αα, -α3.7/-α3.7deletions and unknown. Using αα/αα as the reference, the ORs for BL were 1.82, p=0.06 for ααα/αα; 1.07, p=0.469 for -α3.7/αα; and 0.78, p=0.15 for -α3.7/-α3.7. The odds of BL were significantly decreased with P. falciparum positivity in analyses without the two significant index SNPs (OR= 0.526, 95% CI 0.428-0.633, p=9.64x10-12) and changed minimally when the two SNPs were included (OR= 0·524, 0·435-0·630, p=7·291x10-12) . Conclusion Based on 4,581 children in four high malaria burden countries, we found reduced odds of BL among carriers of malaria index variants in HBB and ABO genes which suggests that these variants may protect against BL as well. Additionally, our findings of decreased odds of BL with P. falciparum positivity at enrollment suggest premunition may be protective against BL, independent of the significant associations with SNPs in HBB and ABO. Together, our findings further enhance the evidence of a causal role of malaria in BL; coordination between malaria and BL programs in countries with high malaria/BL burden should be strengthened. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Background Endemic Burkitt lymphoma (eBL), which occurs at a disproportionately high rate among children in Africa, is associated with Plasmodium falciparum (Pf) malaria and Epstein-Barr virus (EBV). Genetic factors, including Human leukocyte antigen (HLA) system, are hypothesized to play a role in eBL by modulating the immune response or susceptibility to associated pathogens. However, the association between HLA and eBL has not been comprehensively evaluated to-date. Methods We investigated the association between HLA variants and eBL among 800 cases and 3,845 controls aged 0-15 years enrolled in two studies: the Epidemiology of Burkitt lymphoma in East African children and minors (EMBLEM) study conducted in Uganda, Tanzania and Kenya (2010-2016) and the Infections and Childhood Cancer Study conducted in Malawi (2005-2008). HLA alleles from eight classical HLA genes were imputed from genome wide data (Illumina 5 M array) with the SNP2HLA program using an updated multi-ancestry HLA reference panel (n=21,456). We demonstrated accurate imputation at 2-field resolution by comparing the imputed HLA alleles against HLA alleles obtained by sequence-based typing of 600 EMBLEM participants (200 cases and 400 controls) from Uganda. We performed country-specific association tests using generalized linear mixed models (GLMMs), adjusting for sex (genetic confirmed), age, falciparum positivity, and population structure using the top 3 principal components and accounting for genetic relatedness. Odds ratios (OR) were used to estimate the effect size for each HLA variant and significance was assessed by Wald tests. Meta-analyses were performed to obtain summary effects across countries. For 12 HLA alleles with previously reported associations with severe malaria (e.g., HLA-B*53), EBV antibodies (e.g., HLA-DRB1*15:01) or eBL (e.g., HLA-A*02), were hypothesized, apriori, that we would observe associations with eBL mirroring biologic effects of prior associations. Thus, a P value of 0.05 was considered sufficient for statistical significance. For all other associations, we adjusted for multiple testing with P<2.7×10-4 (correction for 187 tested HLA alleles) used to determine statistical significance for classical HLA alleles at 1- and 2-field resolution and P<1.1×10-6 (correction for 46,350 HLA variants) for all other variants in the HLA region. Conditional analyses were performed to identify HLA variants that independently influence eBL susceptibility. Results We found high concordance rates (>85%) of HLA imputation at all HLA class I and class II alleles of 2-field resolution. The frequency distribution of imputed HLA alleles was similar to that based on sequencing-based HLA typing in a subset of Ugandan participants (Pearson r=0.97). The expected associations between eBL and HLA alleles were only observed for HLA-A*02 and -B*41 based on a nominal p<0.05. More importantly, we found significant associations between eBL and HLA-DQA1*04:01 (adjusted odds ratio [aOR]= 1.61, 95% confidence interval [CI]=1.32 to 1.97, P=3.71×10-6) and SNP rs2040406, located in the HLA-DQA1 region (aOR=1.43 (95%CI=1.26 to 1.63), P=4.62×10-8) (Figure 1). No other HLA alleles or non-allele variants were significantly associated with eBL in conditional analysis on HLA-DQA*04:01 or rs2040406. The novel association with SNP rs2040406 corresponds to a single residue Gln53 within the HLA-DQA1 peptide-binding groove that tracks with rs2040406 (r2 = 0.88) and showed the strongest association among all residues (aOR=1.36, P=2.06×10-6). Conclusions We present a comprehensive investigation of the associations between eBL and HLA variants utilizing imputed HLA data. Consistent associations were observed for two eBL-based apriori-stipulated hypotheses (HLA-A*02 and-B*41); however, contrary to our expectations, the malaria-based apriori hypotheses were not confirmed. Our agnostic analysis identified new associations between eBL and variants in the HLA-DQB1/DQA1 region, thereby providing new directions to explore the underlying relationship between HLA, immunity and eBL risk. In particular, the association of eBL with rs2040406 was attributed to residue Gln53 within the HLA-DQA1 peptide-binding groove. These associations hint at functional effects, perhaps mediated by stronger binding of EBV glycoproteins. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Introduction: Burkitt lymphoma (BL) is an aggressive B-cell lymphoma with reciprocal IG∷MYC translocations and accounts for 50-75% of childhood cancers in sub-Saharan Africa. Mosaic chromosomal alterations (mCAs) are large, somatically acquired structural chromosomal alterations that are clonal and observed in detectable fractions of circulating mononuclear cells. mCAs have been linked to increased hematologic cancer risk, but their association with BL, a mononuclear B cell tumor, is unknown. We hypothesized that the frequency and distribution of mCAs in peripheral leukocytes would be elevated in children with BL, potentially serving as a biomarker of chromosomal instability relevant to BL risk. Methods: We investigated peripheral leukocyte DNA extracted from children enrolled in the Epidemiology of Burkitt Lymphoma in East African Children and Minors (EMBLEM) study (2010-2016) and the Infections and Childhood Cancer case-control study conducted in Malawi (2005-2010). We used genome-wide single nucleotide polymorphism (SNP) array data to investigate the frequency, type, and distribution of mCAs >2Mb in size detected in peripheral leukocytes of 931 pediatric BL cases with 3,645 healthy children in Uganda, Tanzania, and Kenya, and with 177 non-BL pediatric cancers in Malawi. Eagle2 and SHAPEIT4 software were used for phasing to infer haplotypes for SNP array data and WGS data. MoChA (v2014-05-14) was used to detect mCAs. Parallel analysis using similar methods was performed on whole genome sequences (WGS) from paired tumor-normal blood samples from two Ugandan BL patients from the BL Genome Sequencing Project (BLGSP) and from paired BL- and lymphoblastoid-derived cell lines. Results: Most samples (92%) were from the EMBLEM study, whereas 8% were from Malawi. The mean age of the BL cases and controls was similar (~7.4 years in both, P=0.60). Table 1 shows detected autosomal mCAs for BL cases and controls by country. Overall, a total of 250 autosomal mCAs were detected in 78 (8.4%) of the 931 BL cases. By comparison, a total of 188 autosomal mCAs were detected in 131 (3.4%) of the 3822 controls. Autosomal mCAs were detected in cell fractions ranging from 0.5% to 99.2% (Figure S1). The average number of autosomal mCAs per person (i.e., total of mCAs detected/number of individuals with mCAs detected) was higher in the BL cases compared to controls (3.21 [SD 3.24] versus 1.44 [SD 2.31], P-value=4.50×10-5. The higher frequency of mCAs in blood samples of children with BL compared to controls was independent of age, sex, P falciparum status, and country (OR=2.8, 95% CI=2.06-3.81, P-value=5.70×10-11, Table 1. mCAs on the X chromosome in girls were also associated with BL (5% versus 1.7%, OR=3.12, 95% CI=1.47-6.29, P-value=1.65×10-3). We did not observe an association for mCAs on the Y chromosome in boys. Analysis of paired tumor-normal samples confirmed the presence of the IG∷MYC translocation in tumor, but the same pipelines did not detect the translocation in the corresponding normal blood sample. In informative tumor-normal cases, some mCAs were only detected in tumor, others were detected in both tumor and normal blood, whereas others were detected mCAs in normal only suggesting some mCAs in blood could arise from pre-BL clones. mCAs only observed in BL cases were predominantly gains on chromosome 1q and 8 (Figure 1) which contain major drivers of Burkitt lymphomagenesis including PLEKHO1, MCL1, PSMB4, ILF2, HAX1, ATP8B2 and CKS1B.Conclusion: We report a high frequency of mCAs in healthy sub-Saharan African children and even higher frequency in pediatric BL cases. The mCAs in children with BL clustered on chromosomes 1q and 8 in regions that overlap with several significantly mutated BL genes, suggesting that mCAs may be potential biomarkers important in the natural history of BL. Using paired tumor-normal sample WGS data, we report both similar and unique mCAs in the paired samples suggesting pre-BL clones in blood. These methods are scalable to large cohorts with SNP array data to investigate health effects associated with mCAs in Africa. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Background: Endemic Burkitt lymphoma (eBL) is the most common childhood cancer in Africa and is linked to Plasmodium falciparum (Pf) malaria infection, one of the most common and deadly childhood infections in Africa; however, the role of Pf genetic diversity is unclear. A potential role of Pf genetic diversity in eBL has been suggested by a correlation of age-specific patterns of eBL with the complexity of Pf infection in Ghana, Uganda, and Tanzania, as well as a finding of significantly higher Pf genetic diversity, based on a sensitive molecular barcode assay, in eBL cases than matched controls in Malawi. We examined this hypothesis by measuring diversity in Pf-serine repeat antigen-5 (Pfsera5), an antigenic target of blood-stage immunity to malaria, among 200 eBL cases and 140 controls, all Pf polymerase chain reaction (PCR)-positive, in Malawi. Methods: We performed Pfsera5 PCR and sequencing (~3.3 kb over exons II–IV) to determine single or mixed PfSERA5 infection status. The patterns of Pfsera5 PCR positivity, mixed infection, sequence variants, and haplotypes among eBL cases, controls, and combined/pooled were analyzed using frequency tables. The association of mixed Pfsera5 infection with eBL was evaluated using logistic regression, controlling for age, sex, and previously measured Pf genetic diversity. Results: Pfsera5 PCR was positive in 108 eBL cases and 70 controls. Mixed PfSERA5 infection was detected in 41.7% of eBL cases versus 24.3% of controls; the odds ratio (OR) was 2.18, and the 95% confidence interval (CI) was 1.12–4.26, which remained significant in adjusted results (adjusted odds ratio [aOR] of 2.40, 95% CI of 1.11–5.17). A total of 29 nucleotide variations and 96 haplotypes were identified, but these were unrelated to eBL. Conclusions: Our results increase the evidence supporting the hypothesis that infection with mixed Pf infection is increased with eBL and suggest that measuring Pf genetic diversity may provide new insights into the role of Pf infection in eBL.

BACKGROUND:Fine needle aspiration cytology (FNAC) has been widely accepted to be a safe, accurate, prompt and inexpensive procedure for diagnosis of both neoplastic and infectious diseases in adult and pediatric populations. Despite its value for diagnosis, FNAC is underutilized in resource limited countries. We reviewed the utilization of FNAC after it was introduced at Kamuzu Central Hospital (KCH).METHODS:A retrospective review of all FNAC performed at KCH laboratory during the period of January 2012 to July 2014 was conducted using an electronic database from KCH laboratory. We evaluated factors associated with a diagnostic sample using multivariate logistic regression model.RESULTS:750 FNAC were reviewed from 722 patients: 56.9% were adults >15 years and 54% were female. The number of FNAC increased annually from 56 (2012) to 379 (2013) to 315 (up to July 2014). Of 750 FNAC, 56.4% were performed by non-pathologists. The most common sites were lymph nodes (38.1%), abdomen (25.8%), breast (16.3%), and head & neck (15.7%). Most of the samples (77.6%) were diagnostic. FNAC was more likely to be diagnostic if performed by pathologists versus non-pathologists (OR 1.78, 95% CI 1.20-2.64), in 2013 compared to 2012 (OR 1.95, 95% CI 1.05-3.56), or performed on a deep lesion versus a subcutaneous lesion (OR 1.71, 95% CI 1.15-2.5), or if samples were taken from the head and neck (OR 2.4, 95% CI: 1.39-4.39), and abdomen (OR 2.66, 95%CI1.59-4.42) compared to those from the lymph nodes. The odds of a diagnostic test did not differ significantly according to gender, HIV status, or age groups.CONCLUSION:Most FNACs successfully diagnosed the presence or absence of disease, with substantial improvements over time. However, training for non-pathologists may facilitate more diagnostic results.

Background. Although Burkitt lymphoma (BL) is the most common childhood lymphoma in sub-Saharan Africa, Hodgkin lymphoma (HL) and other non-Hodgkin lymphomas occur. Diagnosing non-jaw mass presentations is challenging with limited pathology resources. Procedure. We retrospectively analyzed 114 pediatric lymphomas in Lilongwe, Malawi, from December 2011 to June 2013 and compared clinical versus pathology-based diagnoses over two time periods. Access to pathology resources became more consistent in 2013 compared with 2011-2012; pathology interpretations were based on morphology only. Results. Median age was 8.4 years (2.1-16.3). The most common anatomical sites of presentation were palpable abdominal mass 51%, peripheral lymphadenopathy 35%, and jaw mass 34%. There were 51% jaw masses among clinical diagnoses versus 11% in the pathology-based group (P < .01), whereas 62% of pathology diagnoses involved peripheral lymphadenopathy versus 16% in the clinical group (P < .01). The breakdown of clinical diagnoses included BL 85%, lymphoblastic lymphoma (LBL) 9%, HL 4%, and diffuse large B-cell lymphoma (DLBCL) 1%, whereas pathology-based diagnoses included HL 38%, BL 36%, LBL 15%, and DLBCL 11% (P < .01). Lymphoma diagnosis was pathology confirmed in 19/66 patients (29%) in 2011-2012 and 28/48 (60%) in 2013 (P < .01). The percentage of non-BL diagnoses was consistent across time periods (35%); however, 14/23 (61%) non-BL diagnoses were pathology confirmed in 2011-2012 versus 16/17 (94%) in 2013. Conclusions. Lymphomas other than Burkitt accounted for 35% of childhood lymphoma diagnoses. Over-reliance on clinical diagnosis for BL was a limitation, but confidence in non-BL diagnoses improved with time as pathology confirmation became standard. Increased awareness of non-BL lymphomas in equatorial Africa is warranted.

BACKGROUND:Head and neck squamous cell carcinoma (HNSCC) is common in sub-Saharan Africa, but the aetiologic contribution of human papillomavirus (HPV) is not well established.METHODS:We assessed HNSCC cases for HPV using p16 immunohistochemistry (IHC) in Malawi. Associations between p16 IHC and tumour site, behavioural risk factors, demographic characteristics, and HIV status were examined.RESULTS:From 2010 to 2014, 77 HNSCC cases were identified. Mean age was 52 years, 50 cases (65%) were male, and 48 (62%) were in the oropharynx (OP) or oral cavity (OC). HIV status was known for 35 patients (45%), with 5 (14%) HIV-infected. Substance use was known for 40 patients (52%), with 38% reporting any tobacco and 31% any alcohol. Forty-two cases (55%) had adequate tissue for p16 IHC, of which seven (17%) were positive, including 22% of OP/OC tumours.CONCLUSIONS:Despite high cervical cancer burden, HPV-associated HNSCC is not very common in Malawi.

Point-of-care tools are needed in sub-Saharan Africa (SSA) to improve pediatric Burkitt lymphoma (BL) diagnosis and treatment. We evaluated plasma Epstein-Barr virus (pEBV) DNA as a pediatric BL biomarker in Malawi. Prospectively enrolled children with BL were compared to classical Hodgkin lymphoma (cHL) and nonlymphoma diagnoses. Pediatric BL patients received standardized chemotherapy and supportive care. pEBV DNA was measured at baseline, mid-treatment, and treatment completion. Of 121 assessed children, pEBV DNA was detected in 76/88 (86%) with BL, 16/17 (94%) with cHL, and 2/16 (12%) with nonlymphoma, with proportions higher in BL versus nonlymphoma (p<0.001) and similar in BL versus cHL (p=0.69). If detected, median pEBV DNA was 6.1 log(10)copies/mL for BL, 4.8 log(10)copies/mL for cHL, and 3.4 log(10)copies/mL for nonlymphoma, with higher levels in BL versus cHL (p=0.029), and a trend toward higher levels in BL versus nonlymphoma (p=0.062). pEBV DNA declined during treatment in the cohort overall and increased in several children before clinical relapse. Twelve-month overall survival was 40% in the cohort overall, and for children with baseline pEBV detected, survival was worse if baseline pEBV DNA was 6 log(10)copies/mL versus <6 log(10)copies/mL (p=0.0002), and also if pEBV DNA was persistently detectable at mid-treatment versus undetectable (p=0.041). Among children with baseline pEBV DNA detected, viremia was the only significant risk factor for death by 12 months in multivariate analyses (adjusted hazard ratio 1.35 per log(10)copies/mL, 95% CI 1.04-1.75, p=0.023). Quantitative pEBV DNA has potential utility for diagnosis, prognosis, and response assessment for pediatric BL in SSA.What's new? Burkitt lymphoma (BL) is the most frequent childhood cancer in sub-Saharan Africa. Although it is highly curable in resource-rich settings, outcomes are much worse in the region and point-of-care tools are needed to improve diagnosis and treatment. Epstein-Barr virus (EBV) is causally associated with the most common endemic form of the disease. This is the first study to systematically assess plasma EBV DNA for pediatric BL diagnosis, prognosis, and response assessment in sub-Saharan Africa. The results show that plasma EBV DNA may be an implementable biomarker to facilitate diagnosis and risk-stratified, response-guided therapy for this challenging population in the region.

There are no prospective studies of aggressive non-Hodgkin lymphoma (NHL) treated with CHOP in sub-Saharan Africa. We enrolled adults with aggressive NHL in Malawi between June 2013 and May 2015. Chemotherapy and supportive care were standardized, and HIV+ patients received antiretroviral therapy (ART). Thirty-seven of 58 patients (64%) were HIV+. Median age was 47 years (IQR 39-56), and 35 (60%) were male. Thirty-five patients (60%) had stage III/IV, 43 (74%) B symptoms, and 28 (48%) performance status ≥ 2. B-cell NHL predominated among HIV+ patients, and all T-cell NHL occurred among HIV- individuals. Thirty-one HIV+ patients (84%) were on ART for a median 9.9 months (IQR 1.1-31.7) before NHL diagnosis, median CD4 was 121 cells/μL (IQR 61-244), and 43% had suppressed HIV RNA. HIV+ patients received a similar number of CHOP cycles compared to HIV- patients, but more frequently developed grade 3/4 neutropenia (84% vs 31%, p = 0.001), resulting in modestly lower cyclophosphamide and doxorubicin doses with longer intervals between cycles. Twelve-month overall survival (OS) was 45% (95% CI 31-57%). T-cell NHL (HR 3.90, p = 0.017), hemoglobin (HR 0.82 per g/dL, p = 0.017), albumin (HR 0.57 per g/dL, p = 0.019), and IPI (HR 2.02 per unit, p<0.001) were associated with mortality. HIV was not associated with mortality, and findings were similar among patients with diffuse large B-cell lymphoma. Twenty-three deaths were from NHL (12 HIV+, 11 HIV-), and 12 from CHOP (9 HIV+, 3 HIV-). CHOP can be safe, effective, and feasible for aggressive NHL in Malawi with and without HIV.

Background: Breast cancer awareness and early detection are limited in sub-Saharan Africa. Resource limitations make screening mammography or clinical breast examination (CBE) by physicians or nurses impractical in many settings. We aimed to assess feasibility and performance of CBE by laywomen in urban health clinics in Malawi.Methods: Four laywomen were trained to deliver breast cancer educational talks and conduct CBE. After training, screening was implemented in diverse urban health clinics. Eligible women were >= 30 y, with no prior breast cancer or breast surgery, and clinic attendance for reasons other than a breast concern. Women with abnormal CBE were referred to a study surgeon. All palpable masses confirmed by surgeon examination were pathologically sampled. Patients with abnormal screening CBE but normal surgeon examination underwent breast ultrasound confirmation. In addition, 50 randomly selected women with normal screening CBE underwent breast ultrasound, and 45 different women with normal CBE were randomly assigned to surgeon examination.Results: Among 1220 eligible women, 1000 (82%) agreed to CBE. Lack of time (69%) was the commonest reason for refusal. Educational talk attendance was associated with higher CBE participation (83% versus 77%, P = 0.012). Among 1000 women screened, 7% had abnormal CBE. Of 45 women with normal CBE randomized to physician examination, 43 had normal examinations and two had axillary lymphadenopathy not detected by CBE. Sixty of 67 women (90%) with abnormal CBE attended the referral visit. Of these, 29 (48%) had concordant abnormal physician examination. Thirty-one women (52%) had discordant normal physician examination, all of whom also had normal breast ultrasounds. Compared with physician examination, sensitivity for CBE by laywomen was 94% (confidence interval [CI] 79%-99%), specificity 58% (CI, 46%-70%), positive predictive value 48% (CI, 35%-62%), and negative predictive value 96% (CI, 85%-100%). Of 13 women who underwent recommended pathologic sampling of a breast lesion, two had cytologic dysplasia and all others benign results.Conclusions: CBE uptake in Lilongwe clinics was high. CBE by laywomen compared favorably with physician examination and follow-up was good. Our intervention can serve as a model for wider implementation. Performance in rural areas, effects on cancer stage and mortality, and cost effectiveness require evaluation. (C) 2016 Elsevier Inc. All rights reserved.

Objectives: The incidence of lymphoproliferative disorders (LPDs) is increasing in sub-Saharan Africa (SSA) due to population growth, aging, and human immunodeficiency virus (HIV). Despite significant burden, resources for diagnosis and treatment of LPDs are limited, with little infrastructure to deliver modern pathology services. Diagnostic and therapeutic decisions are therefore frequently made without tissue confirmation, leading to high rates of misdiagnosis and inappropriate treatment.Methods: We have established a laboratory in Malawi to support clinical and research efforts at a national teaching hospital. Consensus real-time diagnoses are rendered by local pathologists after weekly clinicopathologic teleconferences involving clinicians and pathologists from the United States and Malawi. Additional ancillary studies are then performed in the United States prior to final diagnosis.Results: We report our first 2 years' experience and demonstrate high concordance between real-time diagnoses in Malawi and final diagnoses in the United States (5% major discordance rate for formalin-fixed, paraffin-embedded samples). In addition, we describe characteristics of pathologically confirmed LPDs in Malawi, highlighting differences by HIV status.Conclusions: Our multidisciplinary approach can be a model for strong pathology services that provide direct, real-time support to clinical care and research in SSA.

Burkitt lymphoma (BL) is the most common paediatric cancer in sub-Saharan Africa (SSA). Anthracyline-based treatment is standard in resource-rich settings, but has not been described in SSA. Children ≤18 years of age with newly diagnosed BL were prospectively enrolled from June 2013 to May 2015 in Malawi. Staging and supportive care were standardized, as was treatment with CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) for six cycles. Among 73 children with BL, median age was 9·2 years (interquartile range 7·7-11·8), 48 (66%) were male and two were positive for human immunodeficiency virus. Twelve (16%) had stage I/II disease, 36 (49%) stage III and 25 (34%) stage IV. Grade 3/4 neutropenia occurred in 17 (25%), and grade 3/4 anaemia in 29 (42%) of 69 evaluable children. Eighteen-month overall survival was 29% (95% confidence interval [CI] 18-41%) overall. Mortality was associated with age >9 years [hazard ratio [HR] 2·13, 95% CI 1·15-3·94], female gender (HR 2·12, 95% CI 1·12-4·03), stage (HR 1·52 per unit, 95% CI 1·07-2·17), lactate dehydrogenase (HR 1·03 per 100 iu/l, 95% CI 1·01-1·05), albumin (HR 0·96 per g/l, 95% CI 0·93-0·99) and performance status (HR 0·78 per 10-point increase, 95% CI 0·69-0·89). CHOP did not improve outcomes in paediatric BL compared to less intensive regimens in Malawi.

Abstract 68 Background: Cancer burden is increasing in Malawi, particularly for HIV-associated malignancies. Methods: With support from the National Cancer Institute, the Malawi Cancer Consortium (MCC) was initiated in September 2014. Partners include the UNC Lineberger Comprehensive Cancer Center, Malawi Ministry of Health, University of Malawi College of Medicine, and Lighthouse Trust. Spanning Malawi’s two major cities, Lilongwe and Blantyre, MCC includes three support cores (administration, analysis, mentoring) and three multi-institution research projects: (1) a national HIV-cancer match study to assess cancer incidence in the ART era; (2) a longitudinal cohort to identify clinical and molecular correlates of KS chemotherapy response; and (3) a longitudinal cohort to elucidate lymphoma biology and develop better treatments for HIV-associated lymphoma. Results: For project 1, 65,500 records from the Malawi National Cancer Registry and Malawi HIV cohorts have been abstracted, and initial data harmonization completed. Record linkage is planned for February 2016, will be updated at regular intervals, and will contribute to regional analyses through the IeDEA- Southern Africa network. For project 2, KS studies through MCC have led to descriptions of KS biologic subtypes defined by viral gene expression profiling, and detailed characterization of multicentric Castleman disease. Malawi has also led enrollment into multinational phase III KS clinical trials implemented by the AIDS Clinical Trials Group and AIDS Malignancy Consortium. For project 3, more than 300 adults and children with lymphoma have been enrolled since June 2014, with approximately 2/3 of adults being HIV-infected. Patients receive standardized treatment and supportive care, and standardized clinical and laboratory evaluations. Specimen-based correlative studies (virologic, genomic, biomarker studies) are ongoing. Finally, the consortium provides a platform for pilot studies in breast and esophageal cancer, and facilitates career development for Malawian cancer investigators. Conclusions: MCC has initiated a national coalition to address cancer in Malawi, and continued progress is anticipated. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST: Sam Phiri No relationship to disclose Joe Gumulira No relationship to disclose Hannock Tweya No relationship to disclose Lameck Chinula No relationship to disclose Agnes Moses No relationship to disclose Bongani Kaimila No relationship to disclose Christopher Stanley No relationship to disclose Edwards Kasonkanji No relationship to disclose Steady Chasimpha No relationship to disclose Richard Nyasosela No relationship to disclose Leo Masamba No relationship to disclose Tamiwe Tomoka No relationship to disclose Steve Kamiza No relationship to disclose Mina Hosseinipour No relationship to disclose Nora Rosenberg Research Funding: NIH/NCI Ron Mataya No relationship to disclose Charles Dzamalala No relationship to disclose George Liomba No relationship to disclose Irving Hoffman No relationship to disclose Dirk Dittmer No relationship to disclose Yuri Fedoriw Honoraria: Alexion Pharmaceuticals Blossom Damania No relationship to disclose Satish Gopal No relationship to disclose

Cervical cancer is the most common cancer among women in Malawi. National guidelines recommend screening women aged 30–45 years every five years; however, no specific recommendations exist for women with HIV. We aimed to assess the frequency of high-grade dysplasia (CIN 2 or CIN3) and cervical cancer among women in central Malawi and to examine associations with CIN2+ (CIN2/3 or cancer). We extracted cervical Pap smear, biopsy, loop electrosurgical excision procedure and uterine specimen reports from a hospital pathology database from November 2012 to November 2013. We used logistic regression to estimate associations with CIN2+. We reviewed specimens from 824 women; we excluded 194 with unknown HIV status, leaving 630 in the analytic sample. Twelve percent had high-grade dysplasia and 109 women (17%) had cancer. Twenty-five percent of high-grade dysplasia cases and 35% of cancers occurred among women outside recommended screening ages. The odds of having CIN2+ were 6.55 times (95% CI 4.44-9.67) greater for HIV+ women. High-grade dysplasia and cervical cancer are very common among Malawian women, especially HIV+ women. HIV infection was strongly associated with CIN2+. Expanding screening to women not covered by current guidelines could avert a substantial proportion of cervical cancer cases in Malawi.