Epidemiological patterns of leukaemia in 184 countries: a population-based study

What are the volume and budget needs to provide chemotherapy to all children with acute lymphoblastic leukaemia in Thailand? Development and application of an estimation tool

OBJECTIVE

Insufficient access to anticancer medicines may contribute to the wide survival differences of children with cancers across the globe. We developed a tool to estimate the volume of medicines and budget requirements to provide chemotherapy to children with acute lymphoblastic leukaemia (ALL).

DESIGN

Development and application of an estimation tool.

SETTING

Paediatric oncology hospital departments in Thailand.

PARTICIPANTS

318 children aged 0-14 years diagnosed with ALL and 215 children with undiagnosed ALL.

INTERVENTIONS

Estimates of volume and budget requirements for administering a full course of chemotherapy for ALL and a further course for children who relapse, according to National Treatment Guidelines.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome measures were the volume (mg) and cost (US$) of medicines needed to treat children with ALL. For medicines whose main indication is paediatric ALL (asparaginase and 6-mercaptopurine), we estimated the difference between volume needed and actual sales in 2017 (secondary outcome).

RESULTS

Ten anticancer medicines and four chemoprotective agents are needed for the treatment of paediatric ALL according to the Thai treatment guidelines. Of these 14 medicines, 13 are included in the WHO essential medicines list for children. All are available as generics. We estimated that essential chemotherapy and chemoprotective agents to treat all children diagnosed with ALL in Thailand in 2017 would cost US$ 814 952 (US$ 1 365 422 for diagnosed and undiagnosed children), which corresponds to 0.005% (0.008%) of the country's total health expenditure. The volumes of asparaginase and 6-mercaptopurine available on the Thai market in 2017 were more than sufficient (2.3 and 1.5 times the amounts needed, respectively) to treat all children diagnosed with ALL.

CONCLUSIONS

Procuring sufficient quantities of essential medicines to treat children with ALL requires relatively modest resources. Medicine cost should not be a major barrier to ALL treatment in similar settings.

Ethnic and geographic diversity of chronic lymphocytic leukaemia

East Asians, Asian Indians and Amerindians have a five to ten-fold lower age-adjusted incidence rate (AAIR) of chronic lymphocytic leukaemia (CLL) compared with persons of predominately European descent. The data we review suggest a genetic rather than environmental basis for this discordance. All these populations arose from a common African Black ancestor but different clades have different admixture with archaic hominins including Neanderthals, Denisovans and Homo erectus, which may explain different CLL incidences. There are also some differences in clinical laboratory and molecular co-variates of CLL between these populations. Because the true age-adjusted incidence rate in African Blacks is unknown it is not possible to determine whether modern Europeans acquired susceptibility to CLL or the other populations lost susceptibility and/or developed resistance to developing CLL. We also found other B-cell lymphomas and T- and NK-cell cancers had different incidences in the populations we studied. These data provide clues to determining the cause(s) of CLL.

The risk of leukemia in patients with rheumatoid arthritis: a systematic review and meta-analysis

OBJECTIVES

The relationship between rheumatoid arthritis (RA) and the risk of leukemia was still controversial. This study aimed to assess the risk of leukemia in patients with rheumatoid arthritis by systematic review and meta-analysis.

METHODS

Relevant studies were identified by searching PubMed, Embase, Cochrane Library, and SinoMed up to December 2019. Random effects model analysis was used to pool standardized incidence ratios (SIRs) and 95% confidence interval.

RESULTS

A total of 15 relevant studies that met the criteria were included. Compared with the general population, patients with RA showed an increased risk of leukemia (SIR = 1.51, 95% CI: 1.34-1.70). The statistical heterogeneity was moderate with an I² of 55.5%. In subgroup analysis, the source of heterogeneity may be due to differences in sample size. Publication bias was not found in the Begg funnel plot and the Egger test.

CONCLUSION

Our findings suggested that the risk of leukemia in RA was increased compared with the general population. Key points • This is the first systematic review and meta-analysis to assess the risk of leukemia in RA. • Our study suggested that the risk of leukemia in RA was increased compared with the general population. • This study indicated that the risk of leukemia in RA was higher in non-Asian populations.

Analysis of the Global Burden of Disease study highlights the trends in death and disability-adjusted life years of leukemia from 1990 to 2017

Background

The patterns of leukemia burden have dramatically changed in recent years. This study aimed to estimate the global trends of leukemia‐related death and disability‐adjusted life‐years (DALYs) from 1990 to 2017.

Methods

The data was acquired from the latest version of the Global Burden of Disease (GBD) study. Estimated annual percentage changes (EAPCs) were calculated to estimate the trend of age‐standardized rate (ASR) of death and DALYs due to leukemia and its main subtypes from 1990 to 2017.

Results

Globally, the numbers of death and DALYs due to leukemia were 347.58 × 10³ (95% uncertainty interval [UI] = 317.26 × 10³‐364.88 × 10³) and 11975.35 × 10³ (95% UI = 10749.15 × 10³‐12793.58 × 10³) in 2017, with a 31.22% and 0.03% increase in absolute numbers from 1990 to 2017, respectively. Both of their ASR showed decreasing trends from 1990 to 2017 with the EAPCs being −1.04 (95% confidence interval [CI] = (−1.10‐−0.99) and −1.52 (95% CI = −1.59‐−1.44), respectively. Globally, the most pronounced decreasing trend of death and DALYs occurred in chronic myeloid leukemia with EAPCs of −2.76 (95% CI = −2.88‐−2.64) and −2.84 (95% CI = −2.97‐−2.70), respectively, while the trend increased in acute myeloid leukemia. The death and DALYs of leukemia decreased in most areas and countries with high socio‐demographic index (SDI) including Bahrain, Finland, and Australia.

Conclusions

The disease burden of death and DALYs due to leukemia decreased globally, and for most regions and countries from 1990 to 2017. However, the leukemia burden is still a substantial challenge globally and required adequate and affordable medical resources to improve the survival and quality of life of leukemia patients.

A Novel Methoxybenzyl 5-Nitroacridone Derivative Effectively Triggers G1 Cell Cycle Arrest in Chronic Myelogenous Leukemia K562 Cells by Inhibiting CDK4/6-Mediated Phosphorylation of Rb

Chronic myeloid leukemia (CML) is a malignant tumor caused by the abnormal proliferation of hematopoietic stem cells. Among a new series of acridone derivatives previously synthesized, it was found that the methoxybenzyl 5-nitroacridone derivative 8q has nanomolar cytotoxicity in vitro against human chronic myelogenous leukemia K562 cells. In order to further explore the possible anti-leukemia mechanism of action of 8q on K562 cells, a metabolomics and molecular biology study was introduced. It was thus found that most of the metabolic pathways of the G1 phase of K562 cells were affected after 8q treatment. In addition, a concentration-dependent accumulation of cells in the G1 phase was observed by cell cycle analysis. Western blot analysis showed that 8q significantly down-regulated the phosphorylation level of retinoblastoma-associated protein (Rb) in a concentration-dependent manner, upon 48 h treatment. In addition, 8q induced K562 cells apoptosis, through both mitochondria-mediated and exogenous apoptotic pathways. Taken together, these results indicate that 8q effectively triggers G1 cell cycle arrest and induces cell apoptosis in K562 cells, by inhibiting the CDK4/6-mediated phosphorylation of Rb. Furthermore, the possible binding interactions between 8q and CDK4/6 protein were clarified by homology modeling and molecular docking. In order to verify the inhibitory activity of 8q against other chronic myeloid leukemia cells, KCL-22 cells and K562 adriamycin-resistant cells (K562/ADR) were selected for the MTT assay. It is worth noting that 8q showed significant anti-proliferative activity against these cell lines after 48 h/72 h treatment. Therefore, this study provides new mechanistic information and guidance for the development of new acridones for application in the treatment of CML.

The impact of immune checkpoint inhibitors in patients with chronic lymphocytic leukemia (CLL): A protocol for a systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

The global burden of chronic lymphocytic leukemia (CLL) has constantly increased over the years, with a current incidence of 3.5 cases per 100,000 people. Although the conventional drugs used to treat CLL patients have been effective treatment failure rate in some of the patients is alarming. Therefore, as a result, novel treatment strategies with improved outcomes such as the blockade of immune checkpoints have emerged. However, consensus on the risk-benefit effects of the using these drugs in patients with CLL is controversial and has not been comprehensively evaluated. This systemic review and meta-analysis provide a comprehensive synthesis of available data assessing adverse events associated with the use of immune checkpoint inhibitors in patients with CLL as well as their influence on the overall survival rate.

METHODS

This protocol for a systematic review and meta-analysis has been prepared in accordance with Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols 2015 guidelines. A search strategy will be developed using medical subject headings words in PubMed search engine with MEDLINE database. The search terms will also be adapted for gray literature, Embase, and Cochrane Central Register of Controlled Trials electronic databases. Two reviewers (AN and SRN) will independently screen studies, with a third reviewer consulted in cases of disagreements using a defined inclusion and exclusion criteria. Data items will be extracted using a predefined data extraction sheet. Moreover, the risk of bias and quality of the included studies will be appraised using the Downs and Black checklist and the quality and strengths of evidence across selected studies will be assessed using the Grading of Recommendations Assessment Development and Evaluation approach. The Cochran's Q statistic and the I statistics will be used to analyze statistical heterogeneity across studies. If the included studies show substantial level of statistical heterogeneity (I > 50%), a random-effects meta-analysis will be performed using R statistical software.

ETHICS AND DISSEMINATION

The review and meta-analysis will not require ethical approval and the findings will be published in peer-reviewed journals and presented at local and international conferences. This review may help provide clarity on the risk-benefit effects of using immune checkpoint inhibitors in patients with CLL.

SYSTEMATIC REVIEW REGISTRATION

International prospective Register of Systematic Reviews (PROSERO) number: CRD42020156926.

Performance of the Sysmex White Precursor Channel to discover circulating leukemic blast cells

INTRODUCTION

Circulating immature precursor cells indicate malignant diseases like acute myeloid or lymphoid leukemia, and blast cells are key finds for disease management. Automatized cell counters are an essential contemporary appliance for blast detection, but false-positive samples remain challenging in terms of time and resources. To reduce this issue, the White Precursor Channel (WPC) was introduced to Sysmex XN series; however, sensitivity may reduce when accommodating low specificity. Therefore, our aim was to evaluate WPC blast alarm flag performance with regard to detecting blast cells.

METHODS

At two major Danish hospitals, random blood samples were collected from the routine setting   in a four-week period and analyzed on WPC XN20 (Sysmex, Japan). Results were compared with manual differential white blood cell count (Manual WBCC) assisted by CellaVisionDM96.

RESULTS

In 117 samples, we found 0.2 to 34.4% blasts, WPC blast flag specificity = 82% and a low sensitivity = 40%. However, other XN alarm flags forwarded samples to Manual WBCC, so blast cells were detected despite missing a specific blast flag: With all alarm flags, combined sensitivity increased to 88%. Overall, the WPC application stopped 18% of the 117 samples going to Manual WBCC (three false negatives). Q values are arbitrary probability measurements for the blast flag, and in five samples (0.5 to 47.3% blasts) imprecision ranged from 5.3 to 122 CV%.

CONCLUSIONS

WPC blast alarm flags are imprecise and inaccurate, especially when blast counts are low. However, the XN20 will alarm samples with other flags so that most samples containing blast cells will be manually reviewed after all. Hence, the presented flag types should not bias the decisions of manual reviewers.

Unmet supportive care needs and its relation to quality of life among adult acute leukaemia patients in China: a cross-sectional study

Background

Patients with acute leukaemia (AL) usually require prolonged periods of hospitalisation. The treatment and clinical symptoms may lead to patients’ supportive care needs (SCNs) not being met and impairs their quality of life (QoL). Studies on QoL and SCNs among AL patients are limited. This study aimed to identify the unmet SCNs and its relation to QoL of adult AL patients in China.

Methods

This multicentre cross-sectional study recruited 346 participants to complete a self-developed questionnaire, detailing demographic information and disease-related variables. A 34-item Supportive Care Needs Survey (SCNS-SF34) was used to identify unmet SCNs, and the Functional Assessment of Cancer Therapy-Leukaemia (FACT-Leu) questionnaire measured patients’ QoL.

Results

Unmet SCN rates for the 34 items ranged from17.6 to 81.7%. Patients’ needs were high for health systems and information, but low in the sexual domain. The results reveal nine factors associated with the unmet SCNs of adult AL patients, including marital status, original residence, age, education, occupation, other diseases, chemotherapy course, disease course, and treatment stage (p < 0.05). The total score of the FACT-Leu negatively correlated with the SCNS-SF34 in the physical/daily living (r = − 0.527, p < 0.01), psychological (r = − 0.688, p < 0.01), sexual (r = − 0.170, p < 0.01), patient care and support (r = − 0.352, p < 0.01), and health systems and information (r = − 0.220, p < 0.01) domains.

Conclusions

Adult AL patients exhibit a high demand for unmet SCNs, especially in the domain of health systems and information. There was a significant association between patients’ unmet SCNs and QoL. Future research should develop tailored interventions to address the unmet SCNs of adult AL patients, to further improve their QoL.

Inhibition of acute leukemia with attenuated Salmonella typhimurium strain VNP20009

Acute leukemia is a common hematological malignancy. Despite recent promising progress, the prognosis of acute leukemia patients remains to be improved. New therapies are therefore still needed. Salmonella typhimurium has been shown to be highly effective as an anti-tumor agent in many solid cancer models, but it has not been applied in acute leukemia. Here, we report an attenuated Salmonella typhimurium strain, VNP20009, can induce apoptosis in multiple types of leukemia cells both in vivo and in vitro. Furthermore, VNP20009 significantly inhibited the proliferation of MLL-AF9-induced acute myeloid leukemia cells and prolonged the survival of the AML-carrying mice. VNP20009 restored the counts of white blood cell (WBC) and its five subsets in peripheral blood (PB) to near-physiological values, and elevated the levels of certain cytokines, such as tumor necrosis factor-α (TNF-α), leukemia inhibitory factor (LIF), interferon-γ (IFN-γ), chemokine C-X-C motif ligand-10 (CXCL-10) and C-C motif ligand-2 (CCL-2). Moreover, the ratio of immune cells, including natural killer cells (NKs), CD4⁺ Th1-type cells and CD8⁺ IFN-γ-producing effector T cells were highly upregulated in the AML mice treated with VNP20009. The results of the present study potentially provide an alternative therapeutic strategy for hematologic malignancies through boosting the innate and adaptive anti-tumor immunity.

Epidemiology and Etiology of Leukemia and Lymphoma

Available evidence suggests that the incidence of leukemia and lymphoma tends to be higher in highly developed regions of the world and among Whites in the United States. Temporal trends in incidence are dynamic and multifactorial; for instance, the incidence of non-Hodgkin's lymphoma increased around the turn of the century, in part because of the acquired immune deficiency syndrome (AIDS) epidemic. Most leukemias and lymphomas are sporadic and the specific etiology remains elusive. Still, research shows that these malignancies often develop in the context of genetic abnormalities, immunosuppression, and exposure to risk factors like ionizing radiation, carcinogenic chemicals, and oncogenic viruses. The prognosis varies by subtype, with poorer survival outcomes for acute leukemias among adults, and more favorable outcomes for Hodgkin's lymphoma. At a time when specific prevention efforts targeting these malignancies are nonexistent, there is a great need to ensure equitable access to diagnostic services and treatments worldwide.

Investigational treatments for chronic lymphocytic leukemia: a focus on phase 1 and 2 clinical trials

Introduction: During recent years, the introduction of novel drugs, particularly small molecule inhibitors, has led to remarkable progress in both previously untreated and relapsed/refractory (RR) patients in chronic lymphocytic leukemia (CLL). However, further research is necessary to find an optimal cure that responds to the individual needs of the patient. Areas covered: This review discusses new agents in phase 1 and 2 clinical trials currently underway in CLL patients. A literature review of the MEDLINE database for articles in English concerning novel drugs, clinical trials, phase 1, phase 2 and CLL was conducted via PubMed. Publications from 2000 through January 2020 were scrutinized. Conference proceedings from the previous five years of the American Society of Hematology, European Hematology Association and American Society of Clinical Oncology were searched manually. Additional relevant publications were obtained by reviewing the references from the chosen articles. The search also included clinical trials registered in clinicaltrials.gov. Expert opinion: The use of BTK and PI3Kδ inhibitors and BCL-2 antagonist have changed the treatment strategy of CLL. Several clinical trials with novel, unapproved agents are currently ongoing. Their findings should define the role of these novel drugs in the treatment of patients with previously untreated and RR CLL.

GLOBAL Leukemia in Children 0-14 Statistics 2018, Incidence and Mortality and Human Development Index (HDI): GLOBOCAN Sources and Methods

OBJECTIVE

Cancer is the second leading cause of death in children under 15 and leukemia is the most common type of cancer in this age group.  The aim of the present study is to investigate the incidence and mortality of leukemia in children aged 0-14 years and its relationship with Human Development Index (HDI in different countries of the world.  Methods: Incidence and mortality rates were obtained from GLOBOCAN and Country's income from World Bank. The data analysis was conducted using correlation analysis. The association of incidence and mortality rates with HDI was investigated using linear regression models.

RESULTS

The results revealed a significant positive correlation between the incidence rate and Gross National Income per capita (r = 0.464, P <0.0001), mean years of schooling (r = 0.566, P <0.0001), life expectancy at birth (r = 0.712, P <0.0001) and expected years of schooling (r = 0.604, P <0.0001). The results also demonstrated a positive and significant correlation between mortality rate and life expectancy at birth (r = 0.199, P <0.0001). An improvement in HDI [Beta = 7.7, CI95% (0.1, 15.3)] and life Expectancy at birth [Beta = 0.1, CI95% (0.03, 0.1)] caused a significantly rise in the incidence of leukemia. Moreover, the improved HDI [Beta = 6.2, CI95% (1.9, 10.5)] was associated with increased mean years of schooling [Beta = -0.1, CI95% (-0.2, -0.01)] and expected years of schooling [Beta = -0.1, CI95% (-0.3, -0.08).

CONCLUSION

As the HDI increases, incidence and mortality from of leukemia increases indicating a change in factors that affects leukemia incidences.

Rates and trends of childhood acute lymphoblastic leukaemia: an epidemiology study

Acute lymphoblastic leukaemia (ALL) is the most common childhood cancer and has a high survival rate when properly managed. Prognosis is correlated with many factors such as age, gender, white blood cell (WBC) count, CD10, French-American-British (FAB) classification, and many others. Many of these factors are included in this study as they play a major role in establishing the best treatment protocol. This study aims to demonstrate clinical and laboratory features of childhood ALL in Syria. They were treated at Children’s University Hospital, the only working major cancer centre in Syria at the time of the study. Data of 203 patients who aged 0–14 years were obtained for this study. Most patients (48.8%) aged (5–9) years with a male predominance (60.9%). The major features for ALL included lymphadenopathy (82.9%), presenting with systemic symptoms (74.9%), T-ALL subclass (20.2%), L2 FAB classification (36.1%), low educational levels for fathers (53%) and mothers (56.2%), having a high risk (48.4%), and having a duration of symptoms before evaluation for more than 4 weeks (42.6%). Only three (1.5%) patients had normal full blood counts (FBC) and only one (0.5%) patient had an isolated high WBC count at time of presentation. Most patients had either abnormal platelet count (89.3%) or low haemoglobin level (88.8%) when presenting with only (2.0%) having normal levels for both. This suggests that having normal haemoglobin and platelet count can be used for quick screening in crisis time like in Syria for prioritising patients. Many prognostic factors were significantly different from medical literature which emphasises the importance of local studies in the developping countries. This study included a high prevalence of T-all, L2 FAB classification, high-risk and other variables which require further studies to evaluate the aetiology of these features, especially that treatment protocols may have a higher mortality in developing countries when not adjusted to local variables.

Evaluation of TP53 Codon 72, P21 Codon 31, and MDM2 SNP309 Polymorphisms in Iranian Patients with Acute Lymphocytic Leukemia

BACKGROUND

The tumor suppressing protein p53 and its downstream effector p21 play important roles in cell cycle regulation. Deficiency or deactivation of these proteins as a result of gene alterations has been indicated in several cancers. Such genetic variations could be considered as susceptibility indicators in acute lymphocytic leukemia (ALL). Therefore, we investigated the associations between ALL risk and TP53 codon 72, p21 codon 31, and MDM2 SNP309 polymorphisms in an Iranian population.

METHODS

Polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) was used to determine the MDM2 T309G (rs2279744), TP53 codon Arg72Pro (rs1042522), and p21 Ser31Arg (rs1801270) single nucleotide polymorphisms (SNPs). This study was performed in 115 ALL patients and 115 healthy controls in Khuzestan province in southwest Iran.

RESULTS

In the control group and ALL patients, p21 Ser/Arg, and MDM2 TG and GG genotypes were associated with significant 1.81-fold (95% confidence interval CI= 1.008-3.267; P < 0.05), 11.07-fold (95% CI= 5.10-24.05; P < 0.0001), and 19.41-fold (95% CI= 8.56-43.99; P < 0.0001) increased risks for ALL, respectively. The TP53 72 Arg allele was significantly more prevalent in ALL patients (56.96%) than in control subjects (47.39%), and was significantly associated with ALL (OR= 1.47; 95% CI = 1.017-2.121, P < 0.05).

CONCLUSION

The MDM2T309G and the p21 Ser31Arg SNPs indicate a significantly increased risk for developing ALL in Khuzestan province.

Nanocarriers as Magic Bullets in the Treatment of Leukemia

Leukemia is a type of hematopoietic stem/progenitor cell malignancy characterized by the accumulation of immature cells in the blood and bone marrow. Treatment strategies mainly rely on the administration of chemotherapeutic agents, which, unfortunately, are known for their high toxicity and side effects. The concept of targeted therapy as magic bullet was introduced by Paul Erlich about 100 years ago, to inspire new therapies able to tackle the disadvantages of chemotherapeutic agents. Currently, nanoparticles are considered viable options in the treatment of different types of cancer, including leukemia. The main advantages associated with the use of these nanocarriers summarized as follows: i) they may be designed to target leukemic cells selectively; ii) they invariably enhance bioavailability and blood circulation half-life; iii) their mode of action is expected to reduce side effects. FDA approval of many nanocarriers for treatment of relapsed or refractory leukemia and the desired results extend their application in clinics. In the present review, different types of nanocarriers, their capability in targeting leukemic cells, and the latest preclinical and clinical data are discussed.

Let's Talk About BiTEs and Other Drugs in the Real-Life Setting for B-Cell Acute Lymphoblastic Leukemia

Background: Therapy for acute lymphoblastic leukemia (ALL) are currently initially efficient, but even if a high percentage of patients have an initial complete remission (CR), most of them relapse. Recent data shows that immunotherapy with either bispecific T-cell engagers (BiTEs) of chimeric antigen receptor (CAR) T cells can eliminate residual chemotherapy-resistant B-ALL cells.

Objective: The objective of the manuscript is to present improvements in the clinical outcome for chemotherapy-resistant ALL in the real-life setting, by describing Romania's experience with bispecific antibodies for B-cell ALL.

Methods: We present the role of novel therapies for relapsed B-cell ALL, including the drugs under investigation in phase I-III clinical trials, as a potential bridge to transplant. Blinatumomab is presented in a critical review, presenting both the advantages of this drug, as well as its limitations.

Results: Bispecific antibodies are discussed, describing the clinical trials that resulted in its approval by the FDA and EMA. The real-life setting for relapsed B-cell ALL is described and we present the patients treated with blinatumomab in Romania.

Conclusion: In the current manuscript, we present blinatumomab as a therapeutic alternative in the bridge-to-transplant setting for refractory or relapsed ALL, to gain a better understanding of the available therapies and evidence-based data for these patients in 2019.

Efficacy and safety of tisagenlecleucel in Japanese pediatric and young adult patients with relapsed/refractory B cell acute lymphoblastic leukemia

Tisagenlecleucel is an autologous T cell genetically modified ex vivo using a lentiviral vector encoding an anti-CD19 chimeric antigen receptor. Here, we present the efficacy and safety of tisagenlecleucel in a subgroup of Japanese patients with relapsed/refractory (r/r) B-cell acute lymphoblastic leukemia (ALL). ELIANA was a single-arm, open-label, multicenter, phase 2 study. Patients were aged ≥ 3 years at screening to ≤ 21 years at the time of diagnosis, and had ≥ 5% lymphoblasts in bone marrow at screening. Primary endpoint was overall remission rate [ORR; complete remission (CR) + CR with incomplete blood recovery (CRi)] within 3 months after infusion. As of April 13, 2018, eight patients were enrolled and six had been infused. ORR was 66.7% (95% confidence interval 22.3-95.7); three patients achieved CR and one patient had CRi. All patients with CR/CRi were negative for minimal residual disease. One patient had CR/CRi lasting 19.5 + months. Cytokine release syndrome (CRS) and neurological events occurred in 83% and 17% of patients, respectively. CRS resolved with anti-cytokine therapy and supportive care. Two deaths occurred due to disease progression. No cases of cerebral edema were observed. Tisagenlecleucel produced high remission rates and durable responses offering a new treatment option for Japanese pediatric and young adults with r/r B-ALL.

Global Burden of Multiple Myeloma: A Systematic Analysis for the Global Burden of Disease Study 2016

Question

What is the burden of multiple myeloma globally and by country, how has it changed over time, and how widely available are treatments for this disease?

Findings

Myeloma incident cases and deaths increased from 1990 to 2016, with middle-income countries contributing the most to this increase. Treatment availability is very limited in countries with low socioeconomic development.

Meaning

Marked variation in myeloma incidence and mortality across countries highlights the need to improve access to diagnosis and effective therapy and to expand research on etiological determinants of myeloma.

Introduction

Multiple myeloma (MM) is a plasma cell neoplasm with substantial morbidity and mortality. A comprehensive description of the global burden of MM is needed to help direct health policy, resource allocation, research, and patient care.

Objective

To describe the burden of MM and the availability of effective therapies for 21 world regions and 195 countries and territories from 1990 to 2016.

Design and Setting

We report incidence, mortality, and disability-adjusted life-year (DALY) estimates from the Global Burden of Disease 2016 study. Data sources include vital registration system, cancer registry, drug availability, and survey data for stem cell transplant rates. We analyzed the contribution of aging, population growth, and changes in incidence rates to the overall change in incident cases from 1990 to 2016 globally, by sociodemographic index (SDI) and by region. We collected data on approval of lenalidomide and bortezomib worldwide.

Main Outcomes and Measures

Multiple myeloma mortality; incidence; years lived with disabilities; years of life lost; and DALYs by age, sex, country, and year.

Results

Worldwide in 2016 there were 138 509 (95% uncertainty interval [UI], 121 000-155 480) incident cases of MM with an age-standardized incidence rate (ASIR) of 2.1 per 100 000 persons (95% UI, 1.8-2.3). Incident cases from 1990 to 2016 increased by 126% globally and by 106% to 192% for all SDI quintiles. The 3 world regions with the highest ASIR of MM were Australasia, North America, and Western Europe. Multiple myeloma caused 2.1 million (95% UI, 1.9-2.3 million) DALYs globally in 2016. Stem cell transplantation is routinely available in higher-income countries but is lacking in sub-Saharan Africa and parts of the Middle East. In 2016, lenalidomide and bortezomib had been approved in 73 and 103 countries, respectively.

Conclusions and Relevance

Incidence of MM is highly variable among countries but has increased uniformly since 1990, with the largest increase in middle and low-middle SDI countries. Access to effective care is very limited in many countries of low socioeconomic development, particularly in sub-Saharan Africa. Global health policy priorities for MM are to improve diagnostic and treatment capacity in low and middle income countries and to ensure affordability of effective medications for every patient. Research priorities are to elucidate underlying etiological factors explaining the heterogeneity in myeloma incidence.

The Top 100 Highly Cited Original Articles on Immunotherapy for Childhood Leukemia

Background: Childhood leukemia is one of the most common cancers in children. As a potential treatment for leukemia, immunotherapy has become a new research hotspot. This research aimed at exploring the status and trends of current researches on immunotherapy for childhood leukemia through bibliometric analysis.

Methods: The Institute for Scientific Information Web of Science core collection database was searched for articles on immunotherapy and childhood leukemia using a computer. Time period for retrieval was from the beginning of the database to June 15, 2019. The top 100 highly cited articles were selected to extract their information on publication year, authors, title, publication journal, number of citations, author’s affiliations, country, and so on. These general information and bibliometric data were collected for analysis. VOSviewer software was used to generate a figure for keywords’ co-occurrence network and a figure for researcher’s coauthorship network that visualized reference and cooperation patterns for different terms in the 100 articles.

Results: The number of citations in the top 100 articles ranged from 17 to 471. These articles were published in 52 different publications. The top four journals in terms of the number of our selected articles were Leukemia (11 articles), Blood (10 articles), Bone Marrow Transplantation (6 articles), and Clinical Cancer Research. The most frequently nominated author was T. Klingebiel from Goethe University Frankfurt, and of the top 100 articles, 12 listed his name. These top 100 articles were published after the year 2000. Most of these articles were original (67%). The United States and Germany were the major countries researching immunotherapy for childhood leukemia and made significant contributions to the combat against the disease. Adoptive immunotherapy and stem cell transplantation appeared more frequently in keywords.

Conclusions: This study analyzed the top 100 highly cited articles on immunotherapy for childhood leukemia and provided insights into the features and research hotspots of the articles on this issue.

Wikipedia network analysis of cancer interactions and world influence

We apply the Google matrix algorithms for analysis of interactions and influence of 37 cancer types, 203 cancer drugs and 195 world countries using the network of 5 416 537 English Wikipedia articles with all their directed hyperlinks. The PageRank algorithm provides a ranking of cancers which has 60% and 70% overlaps with the top 10 deadliest cancers extracted from World Health Organization GLOBOCAN 2018 and Global Burden of Diseases Study 2017, respectively. The recently developed reduced Google matrix algorithm gives networks of interactions between cancers, drugs and countries taking into account all direct and indirect links between these selected 435 entities. These reduced networks allow to obtain sensitivity of countries to specific cancers and drugs. The strongest links between cancers and drugs are in good agreement with the approved medical prescriptions of specific drugs to specific cancers. We argue that this analysis of knowledge accumulated in Wikipedia provides useful complementary global information about interdependencies between cancers, drugs and world countries.

Frequency of hematologic malignancies in the population of Arica, Chile

Hematologic diseases are a heterogeneous group of malignancies that affect people worldwide such as leukemia, lymphoma and multiple myelomas. The aim of this study was to characterize the frequency of hematological diseases in the population of Arica, Chile (18°S, 70°W), between 2011 and 2014. A total of 108 cases of hematologic malignancies were registered at Dr. Juan Noé Crevani Regional Hospital in this period; 40 male and 52 female cases were included in this retrospective and descriptive analysis. The overall median age at diagnosis for hematological malignancies was 59 years (range, 17 to 96 years). The results indicated that the frequency of hematological diseases such as non-Hodgkin lymphoma and leukemia was not associated with sex, ethnicity and type of disease. However, in 2012 there was an increased number of cases of Hodgkin lymphoma compared with any other year in the study, whereas the number of multiple myeloma cases decreased between 2011 and 2014. No significant differences were observed among different types of disease, nor among the types of leukemia. However, when intervals of age were considered, it was revealed that patients >75 years had the highest incidence of hematological malignancies, mainly multiple myeloma, compared with other age groups. However, young adults were more commonly diagnosed with Hodgkin lymphoma than other disease types. A non-significant difference was observed in leukemia between 2011 and 2014 when sex was taken into consideration, in which the incidence rate was higher in females compared with males. Hodgkin lymphoma was most commonly at stage II and non-Hodgkin lymphoma was most commonly at stage IV. No significant differences were observed between the nodal and extranodal type, mixed cellularity and nodular sclerosis or in the morphology of non-Hodgkin lymphoma cell type. Overall, there was a decrease in the frequency of hematological malignancies between 2011 and 2014, but no significant differences were observed in males or females. This study provided for the first time the pattern and distribution of hematological diseases in Arica, Chile.

Machine learning applications in the diagnosis of leukemia: Current trends and future directions

Machine learning (ML) offers opportunities to advance pathological diagnosis, especially with increasing trends in digitalizing microscopic images. Diagnosing leukemia is time-consuming and challenging in many areas globally and there is a growing trend in utilizing ML techniques for its diagnosis. In this review, we aimed to describe the literature of ML utilization in the diagnosis of the four common types of leukemia: acute lymphocytic leukemia (ALL), chronic lymphocytic leukemia (CLL), acute myeloid leukemia (AML), and chronic myelogenous leukemia (CML). Using a strict selection criterion, utilizing MeSH terminology and Boolean logic, an electronic search of MEDLINE and IEEE Xplore Digital Library was performed. The electronic search was complemented by handsearching of references of related studies and the top results of Google Scholar. The full texts of 58 articles were reviewed, out of which, 22 studies were included. The number of studies discussing ALL, AML, CLL, and CML was 12, 8, 3, and 1, respectively. No studies were prospectively applying algorithms in real-world scenarios. Majority of studies had small and homogenous samples and used supervised learning for classification tasks. 91% of the studies were performed after 2010, and 74% of the included studies applied ML algorithms to microscopic diagnosis of leukemia. The included studies illustrated the need to develop the field of ML research, including the transformation from solely designing algorithms to practically applying them clinically.

Observational evidence from patients diagnosed with chronic lymphocytic leukaemia (CLL) in Finland between 2005-2015 show improved survival over time

OBJECTIVES

We aimed to describe treatment patterns of chronic lymphocytic leukaemia (CLL) patients in routine practice settings, compare overall survival and time-to-next-treatment among patients treated in different time periods (2005-2008, 2009-2013, 2014-2015), and explore associated factors.

METHODS

This retrospective cohort study included adult CLL patients from the Finnish Hematology Registry.

RESULTS

In total, 124 and 64 CLL patients received first- and second-line treatments, respectively. The use of first- and second-line treatments with bendamustine-rituximab (BR) increased, while chlorambucil-based treatments decreased over time. Patients treated in more recent years showed a trend towards longer first- and second-line survival. A trend towards inferior overall survival was detected in first- and second-line treatment with B/BR. First-line time-to-next-treatment was longer for patients treated in the later years towards 2015, while second-line time-to-next-treatment did not improve over time.

CONCLUSIONS

This study identified that improved treatment outcomes over time were likely influenced by patient characteristics and treatments, but also through other factors unexplored in this study. Hence, further research on the factors influencing patients' survival over time is needed. In particular, research on using B/BR in clinical practice is warranted.

Looking at cancer health disparities without the colored lenses

Cancer health disparities (CHDs), defined as the adverse differences in cancer incidence and mortality, are prevalent in certain racial and ethnic groups. Underlying causes of CHDs are multi-factorial and debatable. While low socioeconomic status, geographical location, lifestyle and behavioral factors are mostly believed to contribute to CHDs, regardless of ethnic and racial background, significant data now also exist to support a genetic basis of such disparities as well. Clearly, CHDs could best be understood by studying the interplay of multiple (genetic and non-genetic) factors and then translating the resulting knowledge into effective approaches for reducing the existing disparity gaps. This review article highlights these aspects in brief and calls the people of different expertise to work together to make an impact and tackle the challenges associated with CHDs.

Acute lymphoid and myeloid leukemia in a Brazilian Amazon population: Epidemiology and predictors of comorbidity and deaths

Introduction

Leukemia is the most common cancer in children and has the highest rates of incidence in industrialized countries, followed by developing countries. This epidemiologic profile can mainly be attributed to the availability of diagnostic resources. In Brazil, leukemia diagnosis is a challenge due to financial viability, lack of hemovigilance services in isolated regions and the vast size of the territory. Its incidence in the state of Amazonas has been increasing since 2010. Therefore, this study aims to describe the epidemiological pattern and spatial distribution of patients with acute lymphoid leukemia and acute myeloid leukemia in Amazonas and identify the predictors of comorbidity and death.

Materials and methods

A retrospective cross-sectional study was carried out based on patients’ data which was obtained from the database of a referral center for the period of 2005 to 2015. Variables included age, gender, ethnicity, civil status, schooling, income, location of residence, subtype of leukemia, comorbidities, and date of death. The spatial distribution was performed using QGIS v.2.18. Stata software was used for univariable and multivariable logistic regression to evaluate the association between both comorbidities and death for all characteristic groups of ALL and AML.

Results

The group that was studied was composed of 577 ALL and 266 AML patients. For both, most patients were male, with a schooling period of 1–4 years, received<1 minimum wage, and lived mostly in Manaus, followed by the municipality of Tefé. There was no association between the development of comorbidities and analyzed variables in patients with ALL. AML patients that were >60 years old and with family history of the disease had the highest risk of developing comorbidities (OR = 5.06, p = 0.038; OR = 2.44, p = 0.041, respectively). Furthermore, patients with ALL and in the 41-50-year age group had a higher risk of death (OR = 31.12; p = 0.001). No association between death and explanatory variables were found in patients with AML. In addition, significant difference was observed in time to death (chi2 = 4,098.32, p = 0.000), with 50% of patients with AML dying within two years after diagnosis, whereas in ALL, this percentual of death only is reached in approximately 5 years.

Conclusion

Our study describes the data of patients with acute leukemia in Amazonas, a remote region in the north of Brazil. In addition, it highlights the importance of hemovigilance in an Amazon region state, while focusing on peripheral areas which don't have prevention, diagnosis and treatment tools for this disease.

Genetic alteration patterns and clinical outcomes of elderly and secondary acute myeloid leukemia

To illustrate the clinical and genetic features of elderly and secondary acute myeloid leukemia (AML) patients, we compared 145 elderly AML (e‐AML) and 55 secondary AML (s‐AML) patients with 451 young de novo AML patients. Both e‐AML and s‐AML patients showed lower white blood cell (WBC) and bone marrow (BM) blasts at diagnosis. NPM1, DNMT3A, and IDH2 mutations were more common while biallelic CEBPA and IDH1 mutations were less seen in e‐AML patients. s‐AML patients carried a higher frequency of KMT2A‐AF9. In treatment response and survival, e/s‐AML conferred a lower complete remission (CR) rate and shorter duration of event‐free survival (EFS) and overall survival (OS) compared with young patients. In multivariate analysis, s‐AML was an independent risk factor for OS but not EFS in the whole cohort. Importantly, intensive therapy tended to improve the survival of e/s‐AML patients without increasing the risk of early death, and hematopoietic stem cell transplantation (HSCT) could rescue the prognosis of s‐AML, which should be recommended for the treatment of fit patients.

Genotypes and population genetics of cryptococcus neoformans and cryptococcus gattii species complexes in Europe and the mediterranean area

A total of 476 European isolates (310 Cryptococcus neoformans var. grubii, 150 C. neoformans var. neoformans, and 16 C. gattii species complex) from both clinical and environmental sources were analyzed by multi-locus sequence typing. Phylogenetic and population genetic analyses were performed. Sequence analysis identified 74 sequence types among C. neoformans var. neoformans (VNIV), 65 among C. neoformans var. grubii (56 VNI, 8 VNII, 1 VNB), and 5 among the C. gattii species complex (4 VGI and 1 VGIV) isolates. ST23 was the most frequent genotype (22%) among VNI isolates which were mostly grouped in a large clonal cluster including 50% of isolates. Among VNIV isolates, a predominant genotype was not identified. A high percentage of autochthonous STs were identified in both VNI (71%) and VNIV (96%) group of isolates. The 16 European C. gattii species complex isolates analyzed in the present study originated all from the environment and all belonged to a large cluster endemic in the Mediterranean area. Population genetic analysis confirmed that VNI group of isolates were characterized by low variability and clonal expansion while VNIV by a higher variability and a number of recombination events. However, when VNI and VNIV environmental isolates were compared, they showed a similar population structure with a high percentage of shared mutations and the absence of fixed mutations. Also linkage disequilibrium analysis reveals differences between clinical and environmental isolates showing a key role of PLB1 allele combinations in host infection as well as the key role of LAC1 allele combinations for survival of the fungus in the environment. The present study shows that genetic comparison of clinical and environmental isolates represents a first step to understand the genetic characteristics that cause the shift of some genotypes from a saprophytic to a parasitic life style.

Trends in International Incidence of Pediatric Cancers in Children Under 5 Years of Age: 1988-2012

BACKGROUND

Pediatric cancer incidence has been steadily increasing over the last several decades with the largest increases reported in infants. Few evaluations have looked at international pediatric cancer incidence trends in the youngest children. The aim of this analysis was to evaluate trends in cancer incidence in children under 5 years of age, overall and by type, using data from Cancer Incidence in 5 Continents (CI5) from 1988 to 2012 (CI5 volumes VII-XI).

METHODS

Rates of cancers in children ages 0-4 years were extracted from registries available in CI5 from 1988 to 2012. To overcome small numbers in individual registries, numerators and denominators were aggregated within regions corresponding to the United Nations' geoscheme. Average annual percent change (AAPC) was estimated using Poisson regression.  Robust standard errors were used in all models to correct for overdispersion in some regions, and 95% Wald confidence intervals and P values were reported. The top five cancers by increasing AAPC were ranked within each region.

RESULTS

Overall, in children under 5 years, increasing incidence was seen in multiple regions for acute lymphoblastic leukemia, acute myeloid leukemia, ependymal tumors, neuroblastoma, and hepatoblastoma. Hepatoblastoma had the largest AAPC in 11 out of 15 regions and showed an increase in all regions except southern Asia. Astrocytic tumors were the only cancer that decreased over the time period.

CONCLUSIONS

We evaluated 25 years of cancer incidence in children ages 0-4 years and observed increases in incidence for hepatoblastoma, leukemia, neuroblastoma, and ependymal tumors. Further etiologic evaluation will be required to explain these increases in incidence.

Childhood cancer burden: a review of global estimates

5-year net survival of children and adolescents diagnosed with cancer is approximately 80% in many high-income countries. This estimate is encouraging as it shows the substantial progress that has been made in the diagnosis and treatment of childhood cancer. Unfortunately, scarce data are available for low-income and middle-income countries (LMICs), where nearly 90% of children with cancer reside, suggesting that global survival estimates are substantially worse in these regions. As LMICs are undergoing a rapid epidemiological transition, with a shifting burden from infectious diseases to non-communicable diseases, cancer care for all ages has become a global focus. To improve outcomes for children and adolescents diagnosed with cancer worldwide, an accurate appraisal of the global burden of childhood cancer is a necessary first step. In this Review, we analyse four studies of the global cancer burden that included data for children and adolescents. Each study used various overlapping and non-overlapping statistical approaches and outcome metrics. Moreover, to provide guidance on improving future estimates of the childhood global cancer burden, we propose several recommendations to strengthen data collection and standardise analyses. Ultimately, these data could help stakeholders to develop plans for national and institutional cancer programmes, with the overall aim of helping to reduce the global burden of cancer in children and adolescents.

Leukemia therapy by flavonoids: Future and involved mechanisms

Flavonoids are a varied family of phytonutrients (plant chemicals) usually are detected in fruits and vegetables. In this big family, there exist more than 10,000 members that is separated into six chief subtypes: isoflavonols, flavonoenes, flavones, flavonols, anthocyanins, and chalcones. The natural compounds, such as fruits, have visible positive effects in regulating of survival involved signaling pathways that performance as the regulator of cell survival, growth, and proliferation. Researchers have established that commonly consumption up flavonoids decreases incidence and development risk of certain cancers, especially leukemia. Flavonoids have been able to induce apoptosis and stimulate cell cycle arrest in cancer cells via different pathways. Similarly, they have antiangiogenesis and antimetastasis capability, which were shown in wide ranges of cancer cells, particularly, leukemia. It seems that flavonoid because of their widespread approval, evident safety and low rate of side effects, have hopeful anticarcinogenic potential for leukemia therapy. Based on the last decade reports, the most important acting mechanisms of these natural compounds in leukemia cells are stimulating of apoptosis pathways by upregulation of caspase 3, 8, 9 and poly ADP-ribose polymerase (PARP) and proapoptotic proteins, particularly Bax activation. As well, they can induce cell cycle arrest in target cells not only via increasing of activated levels of p21 and p53 but also by inhibition of cyclins and cyclin-dependent kinases. Furthermore, attenuation of neclear factor-κB and signal transducer and activator of transcription 3 activation, suppression of signaling pathway and downregulation of intracellular antiapoptotic proteins are other significant antileukemic function mechanism of flavonoids. Overall, it appears that flavonoids are promising and effective compounds in the field of leukemia therapy. In this review, we tried to accumulate and revise most promising flavonoids and finally declared their major working mechanisms in leukemia cells.

Screening of ferrocenyl–phosphines identifies a gold-coordinated derivative as a novel anticancer agent for hematological malignancies

The development of new organometallic compounds as anticancer agents is currently an active area of research. Here, we report the design, synthesis and characterization of a panel of 10 new ferrocenyl–phosphine derivatives (FD1–FD10) and the analysis of their anti-proliferative activities in hematolymphoid cells representing non-Hodgkin cutaneous T-cell lymphoma (CTCL). The gold-coordinated ferrocenyl–phosphine complex FD10 exhibited a significant and dose-dependent cytotoxicity in 4 different CTCL cell lines – HuT78, HH, MJ and MyLa. FD10 concentrations causing 50% cell growth inhibition (IC₅₀) of HuT78, HH, MJ and MyLa cells at 24 h were recorded to be 5.55 ± 0.20, 7.80 ± 0.09, 3.16 ± 0.10 and 6.46 ± 0.24 μM respectively. Further mechanistic studies showed that FD10 induced apoptosis in CTCL cells by an intrinsic pathway mediated via the activation of caspase-3 and poly(ADP-ribose)polymerase. It suppressed the expression and activity of STAT3 oncoprotein in CTCL cells. FD10 caused robust G0/G1 phase cell cycle arrest and reduced the expression levels of Akt S473 phosphorylation and c-Myc, both are key cell cycle regulator proteins. Taken together, this study highlights anticancer properties of the ferrocenyl–phosphine gold organometallic complex FD10 and suggests that further development of this novel class of molecule may contribute to new drug discovery for certain hematolymphoid malignancies.

Development of organometallic compounds as novel anticancer agents.