151
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Mangum R, Bernhardt MB, Cheng WS, Schafer ES, Berg SL, Foster JH. Do intravenous fluid substitutions influence methotrexate clearance? An unanticipated impact of an intravenous sodium bicarbonate drug shortage. Pediatr Blood Cancer 2020; 67:e28334. [PMID: 32608575 DOI: 10.1002/pbc.28334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 03/30/2020] [Accepted: 03/31/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND National drug shortages of essential medications for childhood cancer have increasingly posed a challenge in the treatment of patients. The efficacy of standardized supportive care practices to avoid treatment-related toxicities may be limited during these drug shortages. High-dose methotrexate (HDMTX) plays a critical role in modern treatment protocols for acute lymphoblastic leukemia and requires stringent supportive care measures to mitigate toxicity. As the result of a national intravenous (IV) sodium bicarbonate shortage, institutional standard HDMTX supportive care guidelines had to be modified. We describe the unanticipated consequences on HDMTX clearance. METHODS We performed a retrospective chart review assessing the impact of alternative compositions of IV fluids on the mean 24-h methotrexate levels (Cpss ) of 25 patients receiving 76 total HDMTX infusions at Texas Children's Hospital Cancer Center from March to October 2017. During the sodium bicarbonate drug shortage, all patients received IV hydration consisting of either dextrose 5%, 0.45% normal saline (D5 ½ NS-Group A) or dextrose 5%, 0.2% normal saline (D5 ¼ NS-Group B). RESULTS Patients receiving a higher total sodium dose demonstrated significantly lower Cpss (25.36 ± 16.6 μMol) compared to patients receiving less sodium (53.9 ± 37.9 μMol; P < .001). CONCLUSIONS Our report shows that in the setting of IV sodium bicarbonate shortage, the composition of hydration IV fluids may affect methotrexate clearance. Patient who received a higher sodium load had a lower 24-h methotrexate level. This demonstrates the potential for unanticipated outcomes resulting from national drug shortages.
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Affiliation(s)
- Ross Mangum
- Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, Texas
| | - M Brooke Bernhardt
- Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, Texas
| | - W Susan Cheng
- Department of Public Heath, Benedictine University, Lisle, Illinois
| | - Eric S Schafer
- Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, Texas
| | - Stacey L Berg
- Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, Texas
| | - Jennifer H Foster
- Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, Texas
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152
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McCormick MC, Sharp E, Kalpatthi R, Zullo J, Gurtunca N, Zhang J, Krafty R, Raman S. Hyperglycemia requiring insulin during acute lymphoblastic leukemia induction chemotherapy is associated with increased adverse outcomes and healthcare costs. Pediatr Blood Cancer 2020; 67:e28475. [PMID: 32589365 PMCID: PMC7674257 DOI: 10.1002/pbc.28475] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/06/2020] [Accepted: 05/18/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Hyperglycemia is a complication of induction chemotherapy in 10%-50% of pediatric patients with acute lymphoblastic leukemia (ALL). Though hyperglycemia in ALL patients is usually transient, it may be associated with adverse health outcomes. However, the risk factors for and consequences of hyperglycemia are poorly understood. We hypothesized that hyperglycemia significant enough to require insulin therapy during induction chemotherapy would be associated with increased morbidity and mortality in pediatric ALL patients during induction chemotherapy and in subsequent care. METHODS We abstracted clinical and resource utilization data from the Pediatric Health Information System (PHIS) database utilizing ICD-9 codes and medication charges. We used logistic regression analysis to predict the development of hyperglycemia. The effects of hyperglycemia on binary and count adverse outcomes following induction chemotherapy were modeled using mixed-effect regression models. RESULTS An increased risk of hyperglycemia requiring insulin was associated with older age, female sex, higher risk group and trisomy 21. Patients on insulin for hyperglycemia had increased mortality following induction chemotherapy. These patients were more likely to have subsequent infectious complications, need for bone marrow transplant, and risk of disease relapse. They also had greater length of inpatient stay, higher cost of care, and were more likely to require intensive care unit admission during induction chemotherapy. CONCLUSIONS Hyperglycemia requiring insulin during induction chemotherapy in pediatric ALL is associated with an increased risk of short-term and long-term complications. Prospective studies are needed to analyze formal screening, preventive measures, and optimal management practices for hyperglycemia during ALL induction chemotherapy.
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Affiliation(s)
- Meghan C. McCormick
- Hematology-Oncology, Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Eleanor Sharp
- Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - James Zullo
- Clinical Informatics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Nursen Gurtunca
- Endocrinology, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jun Zhang
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert Krafty
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sripriya Raman
- Endocrinology, Riley Children’s Hospital, Lehigh Valley Health Network, Allentown, PA
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153
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Dunsmore KP, Winter SS, Devidas M, Wood BL, Esiashvili N, Chen Z, Eisenberg N, Briegel N, Hayashi RJ, Gastier-Foster JM, Carroll AJ, Heerema NA, Asselin BL, Rabin KR, Zweidler-Mckay PA, Raetz EA, Loh ML, Schultz KR, Winick NJ, Carroll WL, Hunger SP. Children's Oncology Group AALL0434: A Phase III Randomized Clinical Trial Testing Nelarabine in Newly Diagnosed T-Cell Acute Lymphoblastic Leukemia. J Clin Oncol 2020; 38:3282-3293. [PMID: 32813610 DOI: 10.1200/jco.20.00256] [Citation(s) in RCA: 130] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
PURPOSE Nelarabine is effective in inducing remission in patients with relapsed and refractory T-cell acute lymphoblastic leukemia (T-ALL) but has not been fully evaluated in those with newly diagnosed disease. PATIENTS AND METHODS From 2007 to 2014, Children's Oncology Group trial AALL0434 (ClinicalTrials.gov identifier: NCT00408005) enrolled 1,562 evaluable patients with T-ALL age 1-31 years who received the augmented Berlin-Frankfurt-Muenster (ABFM) regimen with a 2 × 2 pseudo-factorial randomization to receive escalating-dose methotrexate (MTX) without leucovorin rescue plus pegaspargase (C-MTX) or high-dose MTX (HDMTX) with leucovorin rescue. Intermediate- and high-risk patients were also randomly assigned after induction to receive or not receive six 5-day courses of nelarabine that was incorporated into ABFM. Patients who experienced induction failure were nonrandomly assigned to HDMTX plus nelarabine. Patients with overt CNS disease (CNS3; ≥ 5 WBCs/μL with blasts) received HDMTX and were randomly assigned to receive or not receive nelarabine. All patients, except those with low-risk disease, received cranial irradiation. RESULTS The 5-year event-free and overall survival rates were 83.7% ± 1.1% and 89.5% ± 0.9%, respectively. The 5-year disease-free survival (DFS) rates for patients with T-ALL randomly assigned to nelarabine (n = 323) and no nelarabine (n = 336) were 88.2% ± 2.4% and 82.1% ± 2.7%, respectively (P = .029). Differences between DFS in a four-arm comparison were significant (P = .01), with no interactions between the MTX and nelarabine randomizations (P = .41). Patients treated with the best-performing arm, C-MTX plus nelarabine, had a 5-year DFS of 91% (n = 147). Patients who received nelarabine had significantly fewer isolated and combined CNS relapses compared with patients who did not receive nelarabine (1.3% ± 0.63% v 6.9% ± 1.4%, respectively; P = .0001). Toxicities, including neurotoxicity, were acceptable and similar between all four arms. CONCLUSION The addition of nelarabine to ABFM therapy improved DFS for children and young adults with newly diagnosed T-ALL without increased toxicity.
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Affiliation(s)
| | - Stuart S Winter
- Children's Minnesota Cancer and Blood Disorders Program, Minneapolis, MN
| | - Meenakshi Devidas
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - Brent L Wood
- Laboratory Medicine, Seattle Children's Hospital, Seattle, WA
| | - Natia Esiashvili
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, GA
| | - Zhiguo Chen
- Department of Biostatistics, Colleges of Medicine and Public Health and Health Professions, University of Florida, Gainesville, FL
| | - Nancy Eisenberg
- Pediatric Hematology/Oncology, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Nikki Briegel
- Pharmacy Department, Perth Children's Hospital, Nedlands, Western Australia, Australia
| | - Robert J Hayashi
- Pediatric Hematology/Oncology, Washington School of Medicine, St Louis Children's Hospital, St Louis, MO
| | - Julie M Gastier-Foster
- Nationwide Children's Hospital, Columbus OH.,Department of Pathology, The Ohio State University, Columbus, OH
| | - Andrew J Carroll
- Department of Genetics, University of Alabama at Birmingham, Birmingham, AL
| | - Nyla A Heerema
- Department of Pathology, The Ohio State University, Columbus, OH
| | - Barbara L Asselin
- Department of Pediatrics, University of Rochester Medical Center and Wilmot Cancer Institute, Rochester, NY
| | - Karen R Rabin
- Pediatric Hematology/Oncology, Baylor College of Medicine/Dan L. Duncan Comprehensive Cancer Center, Houston TX
| | | | - Elizabeth A Raetz
- Laura and Isaac Perlmutter Cancer Center at New York University Langone Health, New York, NY
| | - Mignon L Loh
- Department of Pediatrics, University of California, San Francisco Benioff Children's Hospital and the Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA
| | - Kirk R Schultz
- Pediatric Hematology-Oncology, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Naomi J Winick
- Pediatric Hematology/Oncology, University of Texas Southwestern/Simmons Cancer Center, Dallas, TX
| | - William L Carroll
- Laura and Isaac Perlmutter Cancer Center at New York University Langone Health, New York, NY
| | - Stephen P Hunger
- Department of Pediatrics and The Center for Childhood Cancer Research, The Children's Hospital of Philadelphia and The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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154
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Díaz-García C, Herraiz S, Such E, Andrés MDM, Villamón E, Mayordomo-Aranda E, Cervera JV, Sanz MA, Pellicer A. Dexamethasone does not prevent malignant cell reintroduction in leukemia patients undergoing ovarian transplant: risk assessment of leukemic cell transmission by a xenograft model. Hum Reprod 2020; 34:1485-1493. [PMID: 31339993 DOI: 10.1093/humrep/dez115] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 05/01/2019] [Indexed: 01/11/2023] Open
Abstract
STUDY QUESTION Does dexamethasone (DXM) incubation avoid the reintroduction of leukemic malignant cells after ovarian tissue retransplantation in vivo? SUMMARY ANSWER DXM incubation prior to retransplantation of ovarian tissue does not prevent reintroduction of leukemic cells. WHAT IS KNOWN ALREADY Retransplantation of cryopreserved ovarian cortex from patients diagnosed with acute lymphoblastic leukemia (ALL) involves a risk of reintroducing malignant cells. DXM treatment is effective at inducing leukemic cell death in vitro. STUDY DESIGN, SIZE, DURATION This was an experimental study where ovarian cortex fragments from patients with ALL were randomly allocated to incubation with or without DXM (n = 11/group) and grafted to 22 immunodeficient mice for 6 months. In a parallel experiment, 22 immunodeficient mice were injected i.p. with varying amounts of RCH-ACV ALL cells (human leukemia cell line) and maintained for 4 months. PARTICIPANTS/MATERIALS, SETTING, METHODS Cryopreserved ovarian fragments from patients with ALL were exposed in vitro to 0.4 μM DXM or basal media (control) prior to xenograft into ovariectomized severe combined immunodeficiency (SCID) mice (experiment 1). After 6 months of monitoring, leukemia cell contamination was assessed in ovarian grafts and mouse organs by histology, PCR (presence of mouse mtDNA and absence of p53 were together considered a negative result for the presence of human cells) and detection of immunoglobulin monoclonality and specific ALL markers if present in the patient.In experiment 2, a series of 22 immunodeficient female mice was injected with specific doses of the leukemia cell line RCH-ACV (103 - 5 × 106, n = 4/group) to assess the engraftment competence of the SCID model. MAIN RESULTS AND THE ROLE OF CHANCE ALL metastatic cells were detected, by PCR, in five DXM-treated and one control human ovarian tissue graft as well as in a control mouse liver, although malignant cell infiltration was not detected by histology in any sample after 6 months. In total, minimal residual disease was present in three DXM-treated and three control mice.RCH-ACV cells were detected in liver and spleen samples after the injection of as little as 103 cells, although only animals receiving 5 × 106 cells developed clinical signs of disease and metastases. LIMITATIONS, REASONS FOR CAUTION This is an experimental study where the malignant potential of leukemic cells contained in human ovarian tissues has been assessed in immunodeficient mice. WIDER IMPLICATIONS OF THE FINDINGS These results indicate that DXM incubation prior to retransplantation of ovarian tissue does not prevent reintroduction of leukemic cells. Therefore, caution should be taken in retransplanting ovarian tissue from patients with leukemia until safer systems are developed, as leukemic cells present in ovarian grafts were able to survive, proliferate and migrate after cryopreservation and xenograft. STUDY FUNDING/COMPETING INTEREST(S) Funded by the Regional Valencian Ministry of Education (PROMETEO/2018/137) and by the Spanish Ministry of Economy and Competitiveness (PI16/FIS PI16/01664 and PTQ-16-08222 for S.H. participation). There are no competing interests.
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Affiliation(s)
- César Díaz-García
- IVI-RMA London, London, UK.,Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
| | - Sonia Herraiz
- Reproductive Medicine Research Group, Instituto de Investigación Sanitaria La Fe, Valencia, Spain.,IVI Foundation, Valencia, Spain
| | - Esperanza Such
- Department of Hematology, La Fe University Hospital, Valencia, Spain
| | - María Del Mar Andrés
- Pediatric Oncology Unit, Child's Health Area, La Fe University Hospital, Valencia, Spain
| | - Eva Villamón
- Department of Hematology, La Fe University Hospital, Valencia, Spain
| | | | - José V Cervera
- Department of Hematology, La Fe University Hospital, Valencia, Spain
| | - Miguel A Sanz
- Department of Hematology, La Fe University Hospital, Valencia, Spain
| | - Antonio Pellicer
- Reproductive Medicine Research Group, Instituto de Investigación Sanitaria La Fe, Valencia, Spain.,IVI Foundation, Valencia, Spain.,IVI-RMA Roma, Rome, Italy
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155
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Babl FE, Kochar A, Osborn M, Borland ML, West A, Williams A, Dalziel SR. Risk of Leukemia in Children With Peripheral Facial Palsy. Ann Emerg Med 2020; 77:174-177. [PMID: 32788067 DOI: 10.1016/j.annemergmed.2020.06.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Indexed: 01/07/2023]
Abstract
Most children with peripheral facial palsy will not have a cause identified. Although leukemia can cause facial nerve palsy, the magnitude of the risk is unknown and recommendations for investigations are variable. We are currently conducting a randomized, placebo-controlled trial of prednisolone for the treatment of Bell's palsy in children within the Paediatric Research in Emergency Departments International Collaborative emergency research network. In the course of the assessment for eligibility of the trial, from 644 acute-onset facial palsy presentations we identified 5 children with previously undiagnosed leukemia. We estimate the rate of leukemia in children with acute-onset facial palsy who present to emergency departments to be 0.6% (95% confidence interval 0.2% to 1.6%). In accordance with these cases, we suggest consideration of a screening CBC count for acute-onset peripheral facial palsy presentations in children before initiation of corticosteroid treatment.
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Affiliation(s)
- Franz E Babl
- Emergency Department, Royal Children's Hospital, and Murdoch Children's Research Institute, Parkville, Victoria, Australia; Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia; Paediatric Research in Emergency Departments International Collaborative (PREDICT), Melbourne, Australia.
| | - Amit Kochar
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Melbourne, Australia; Emergency Department, Women's and Children's Hospital, Adelaide, Australia
| | - Michael Osborn
- Department of Haematology and Oncology, Women's and Children's Hospital, North Adelaide, South Australia, Australia
| | - Meredith L Borland
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Melbourne, Australia; Emergency Department, Perth Children's Hospital, and the Divisions of Emergency Medicine, Faculty of Health and Medical Sciences, University of Western Australia, Perth, Australia
| | - Adam West
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Melbourne, Australia; Monash Emergency Research Collaborative, School of Clinical Sciences at Monash Health, Monash University, and the Paediatric Emergency Department, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Amanda Williams
- Emergency Department, Royal Children's Hospital, and Murdoch Children's Research Institute, Parkville, Victoria, Australia; Paediatric Research in Emergency Departments International Collaborative (PREDICT), Melbourne, Australia
| | - Stuart R Dalziel
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Melbourne, Australia; Emergency Department, Starship Children's Hospital, and the Departments of Surgery and Paediatrics, Child and Youth Health, University of Auckland, Auckland, New Zealand
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156
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Pelland-Marcotte MC, Pole JD, Nathan PC, Sutradhar R, Sung L. Severe infections following treatment for childhood cancer: a report from CYP-C. Leuk Lymphoma 2020; 61:2876-2884. [PMID: 32654563 DOI: 10.1080/10428194.2020.1789626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Little is known about infections occurring after childhood cancer treatment. We assessed the risk of severe infection postcancer therapy in survivors of leukemia compared to other cancer types. We performed a population-based cohort study of children <15 years of age diagnosed with cancer (2001-2016), alive and relapse-free 30 days after treatment completion. The risk of severe infection in both groups was estimated using subdistribution proportional hazard regression. We identified 6148 survivors (1960 with leukemia). The cumulative incidence (95% confidence interval) of severe infections at 3 years was 0.70% (0.40-1.2%) in leukemia and 0.51% (0.32-0.79%) in other cancers. The risk of severe infection was not statistically different in leukemia survivors compared to other cancer types in univariate and multivariate analysis (adjusted hazard ratio: 1.40, 95% CI: 0.69-2.85). No significant association was found between a history of leukemia and an increased risk of severe infection after treatment, compared to other cancer types.
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Affiliation(s)
- Marie-Claude Pelland-Marcotte
- Division of Hematology/Oncology, CHU de Québec - Centre Mère-Enfant Soleil, Quebec City, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Jason D Pole
- ICES, Toronto, Canada.,Centre for Health Services Research, University of Queensland, Woolloongabba, Australia
| | - Paul C Nathan
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada.,Program in Child Health Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, Toronto, Canada
| | | | - Lillian Sung
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada.,Program in Child Health Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, Toronto, Canada
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157
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Mullikin D, Ranch D, Khalfe Y, Lucari B, Zobeck MC, Assanasen C, Gramatges MM, Scheurer ME, Schafer ES. Hispanic ethnicity is associated with prolonged clearance of high dose methotrexate and severe nephrotoxicity in children and adolescents with acute lymphoblastic leukemia. Leuk Lymphoma 2020; 61:2771-2774. [PMID: 32605405 DOI: 10.1080/10428194.2020.1783445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Dolores Mullikin
- Texas Children's Cancer and Hematology Centers, Houston, TX, USA.,Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Daniel Ranch
- Department of Pediatrics, The University of Texas Health Science Center at San Antonio, TX, USA
| | - Yasmin Khalfe
- School of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Brandon Lucari
- School of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Mark C Zobeck
- Texas Children's Cancer and Hematology Centers, Houston, TX, USA.,Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Chatchawin Assanasen
- Department of Pediatrics, The University of Texas Health Science Center at San Antonio, TX, USA
| | - M Monica Gramatges
- Texas Children's Cancer and Hematology Centers, Houston, TX, USA.,Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Michael E Scheurer
- Texas Children's Cancer and Hematology Centers, Houston, TX, USA.,Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Eric S Schafer
- Texas Children's Cancer and Hematology Centers, Houston, TX, USA.,Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
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158
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Jabbour E, Richard-Carpentier G, Sasaki Y, Konopleva M, Patel K, Roberts K, Gu Z, Wang F, Huang X, Sasaki K, Short NJ, Jain N, Ravandi F, Daver NG, Kadia TM, Alvarado Y, DiNardo CD, Issa GC, Pemmaraju N, Garcia-Manero G, Verstovsek S, Wang S, Khoury JD, Jorgensen J, Champlin R, Khouri I, Kebriaei P, Schroeder H, Khouri M, Mullighan CG, Takahashi K, O'Brien SM, Kantarjian H. Hyper-CVAD regimen in combination with ofatumumab as frontline therapy for adults with Philadelphia chromosome-negative B-cell acute lymphoblastic leukaemia: a single-arm, phase 2 trial. Lancet Haematol 2020; 7:e523-e533. [PMID: 32589978 DOI: 10.1016/s2352-3026(20)30144-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 04/20/2020] [Accepted: 04/24/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND The addition of rituximab to intensive chemotherapy improves outcomes in patients with B-cell acute lymphoblastic leukaemia. Ofatumumab is an anti-CD20 monoclonal antibody that binds to the small extracellular loop of CD20 and has greater in vitro complement-mediated cytotoxicity than rituximab. In this study, we assessed the activity and safety of ofatumumab in combination with chemotherapy in patients with Philadelphia chromosome (Ph)-negative CD20-positive B-cell acute lymphoblastic leukaemia. METHODS This was a single-arm, phase 2 trial done at the MD Anderson Cancer Center (Houston, TX, USA). Patients with newly diagnosed, Ph-negative B-cell acute lymphoblastic leukaemia or lymphoblastic lymphoma with CD20 expression of at least 1% were eligible. Patients were treated with up to eight courses of the hyper-CVAD regimen (hyperfractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone) on courses 1, 3, 5, and 7 alternating with high-dose methotrexate and cytarabine on courses 2, 4, 6, and 8. Ofatumumab was administered on days 1 and 11 of courses 1 and 3 and on days 1 and 8 of courses 2 and 4 for a total of eight doses. The first dose of ofatumumab was 300 mg intravenously and all subsequent doses were 2000 mg intravenously. Patients received 30 courses of maintenance therapy with 6-mercaptopurine, vincristine, methotrexate, and prednisone (POMP), with four intensification courses (high-dose methotrexate plus L-asparaginase and hyper-CVAD plus ofatumumab on courses 6-7 and 18-19). The primary endpoints were event-free survival, overall response, and overall survival. All enrolled patients were included in the primary and safety analyses. The trial is registered with ClinicalTrials.gov, NCT01363128. FINDINGS Between Aug 26, 2011, and May 18, 2017, 69 patients (67 patients had B-cell acute lymphoblastic leukaemia and two had B-cell lymphoblastic lymphoma; median age 41 years [IQR 32-50]) were enrolled and treated, including 33 (48%) aged between 18 and 39 years. Nine (27%) of 33 patients had Ph-like acute lymphoblastic leukaemia. With a median follow-up of 44 months (26-53), 4-year event-free survival was 59% (95% CI 48-73); 69% (54-87) in adolescents and young adults aged 18-39 years. 4-year overall survival was 68% (58-81); 74% (60-91) in adolescents and young adults. The overall response rate was 98% (64 of 65 patients). The most common non-haematological grade 3 or 4 adverse events were infections (35 [54%] of 65 patients during induction and 53 [78%] of 68 patients during consolidation). Ten (14%) of 69 patients died in complete remission from sepsis (two [3%]), cardiac arrest (one [1%]), therapy-related acute myeloid leukaemia (two [3%]), and haematopoietic stem-cell transplantation complications (five [7%]). None of these deaths were considered related to ofatumumab treatment by the study investigators. INTERPRETATION The combination of hyper-CVAD plus ofatumumab is safe and active in adults with Ph-negative CD20-positive B-cell acute lymphoblastic leukaemia. Modifications of this regimen with the addition of novel monoclonal and bispecific antibody constructs targeting CD19 and CD22 might further improve outcomes and allow reduction in the intensity and duration of chemotherapy. FUNDING Novartis.
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Affiliation(s)
- Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | | | - Yuya Sasaki
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Marina Konopleva
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Keyur Patel
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kathryn Roberts
- Department of Pathology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Zhaohui Gu
- Department of Pathology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Feng Wang
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Xuelin Huang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Koji Sasaki
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naval G Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tapan M Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yesid Alvarado
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Courtney D DiNardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ghayas C Issa
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Srdan Verstovsek
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sa Wang
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph D Khoury
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey Jorgensen
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Richard Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Issa Khouri
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Partow Kebriaei
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Heather Schroeder
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maria Khouri
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Charles G Mullighan
- Department of Pathology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Koichi Takahashi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Susan M O'Brien
- Division of Hematology/Oncology, Department of Medicine, UCI Health, Orange, CA, USA
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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159
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A Unique Case of a Pediatric Patient With Blastic Plasmacytoid Dendritic Cell Neoplasm, Guillain Barre Syndrome, and Hemophagocytic Lymphohistiocytosis. J Pediatr Hematol Oncol 2020; 42:e392-e393. [PMID: 30933025 DOI: 10.1097/mph.0000000000001464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Blastic plasmacytoid dendritic cell neoplasm is a rare hematopoietic malignancy with a poor prognosis that is seen primarily in the elderly population. We describe a pediatric patient with blastic plasmacytoid dendritic cell neoplasm who subsequently developed Guillain Barre syndrome followed by hemophagocytic lymphohistiocytosis. All 3 conditions are uncommon, particularly in the pediatric population. It is unclear whether this patient developed these disease states independently, whether they were due to a viral trigger or if she has an underlying immune dysfunction that could have contributed to the development of these conditions. The patient is currently in remission and awaiting further immune work-up.
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160
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Chen AR, Wang YM, Lin M, Kuo DJ. High-Dose Methotrexate in Pediatric Acute Lymphoblastic Leukemia: Predictors of Delayed Clearance and the Effect of Increased Hydration Rate on Methotrexate Clearance. Cureus 2020; 12:e8674. [PMID: 32699674 PMCID: PMC7370657 DOI: 10.7759/cureus.8674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Objectives High-dose methotrexate (HDMTX) is an important chemotherapeutic agent in the treatment of many cancers. Identification of the predictors of poor clearance during HDMTX infusions could advance the introduction of improved supportive care to prevent toxicities and reduce hospital length of stay. The purpose of this study was to identify relationships between patient physical characteristics and HDMTX clearance in the treatment of pediatric acute lymphoblastic leukemia (ALL). At our hospital, patients who have delayed methotrexate (MTX) clearance during a cycle of HDMTX receive an increased rate of hydration with subsequent cycles. This increase in hydration rate was examined for its potential to mitigate predictors of poor clearance and to prevent nephrotoxicity. Methods This study retrospectively examined the treatment records of 87 pediatric patients diagnosed with ALL who were treated on or according to Children's Oncology Group (COG) protocols AALL0232, AALL0434, AALL1131, and AALL1231. Each patient received four cycles of HDMTX (5 g/m2 over 24 hours) at two-week intervals. Patients received either 125 ml/m2/hour (standard) or 200 ml/m2/hour (delayed clearance protocol) hydration before, with, and after each infusion. MTX levels taken at 24-, 42-, and 48-hour time points were used as an indirect measure of drug clearance. Two-tailed inference for ordinary least squares regression and both heteroskedastic and paired two-tailed t-tests were performed to identify physical characteristics associated with delayed MTX clearance and the effects of hydration rate on MTX clearance, respectively. Results Patient age and body surface area (BSA) were found to have statistically significant (p<0.05) positive associations with the serum MTX levels at 24, 42, and 48 hours in cycle 1. Age and BSA were significant only at the 24-hour time point in cycles 2 and 4. Weight alone was not associated with delayed MTX clearance. For patients who had delayed MTX clearance once and thus received the delayed clearance protocol in subsequent cycles, increasing the hydration rate from 125 to 200 ml/m2/hour was associated with a statistically significant decrease in average MTX levels as well as serum creatinine levels at the 24-, 42-, and 48-hour time points. Once patients with delayed clearance received the 200 ml/m2/hour rate of hydration, the history of prior poor clearance lost its predictive value for serum MTX levels and delayed clearance. Conclusions These results suggest that patient age and BSA are significant predictors of MTX clearance if all patients receive the same rate of hydration. Age and BSA affect the distribution phase of MTX kinetics, with downstream effects in the elimination phase. Increased hydration mitigates the effects of these physical characteristics on the elimination phase kinetics by improving renal elimination of MTX, causing a loss of significance of age and BSA as predictors of MTX levels in subsequent cycles at the 42- and 48-hour time points, but with less effect at 24 hours. Thus, hyperhydration regimens prior to cycle 1 of HDMTX could be considered for patients presenting with risk factors of advanced age or high BSA to avoid delayed clearance.
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Affiliation(s)
- Aaron R Chen
- Division of Biological Sciences, University of California San Diego, San Diego, USA
| | - YunZu M Wang
- Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Mark Lin
- Department of Pharmacy, University of California San Francisco Benioff Children's Hospital, Oakland, USA
| | - Dennis J Kuo
- Pediatric Hematology/Oncology, University of California San Diego, San Diego, USA
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161
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Salzer WL, Burke MJ, Devidas M, Dai Y, Hardy KK, Kairalla JA, Gore L, Hilden JM, Larsen E, Rabin KR, Zweidler-McKay PA, Borowitz MJ, Wood B, Heerema NA, Carroll AJ, Winick N, Carroll WL, Raetz EA, Loh ML, Hunger SP. Impact of Intrathecal Triple Therapy Versus Intrathecal Methotrexate on Disease-Free Survival for High-Risk B-Lymphoblastic Leukemia: Children's Oncology Group Study AALL1131. J Clin Oncol 2020; 38:2628-2638. [PMID: 32496902 DOI: 10.1200/jco.19.02892] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
PURPOSE The high-risk stratum of Children's Oncology Group Study AALL1131 was designed to test the hypothesis that postinduction CNS prophylaxis with intrathecal triple therapy (ITT) including methotrexate, hydrocortisone, and cytarabine would improve the postinduction 5-year disease-free survival (DFS) compared with intrathecal methotrexate (IT MTX), when given on a modified augmented Berlin-Frankfurt-Münster backbone. PATIENTS AND METHODS Children with newly diagnosed National Cancer Institute (NCI) high-risk B-cell acute lymphoblastic leukemia (HR B-ALL) or NCI standard-risk B-ALL with defined minimal residual disease thresholds during induction were randomly assigned to receive postinduction IT MTX or ITT. Patients with CNS3-status disease were not eligible. Postinduction IT therapy was given for a total of 21 to 26 doses. Neurocognitive assessments were performed during therapy and during 1 year off therapy. RESULTS Random assignment was closed to accrual in March 2018 after a futility boundary had been crossed, concluding that ITT could not be shown to be superior to IT MTX. The 5-year postinduction DFS and overall survival rates (± SE) of children randomly assigned to IT MTX versus ITT were 93.2% ± 2.1% v 90.6% ± 2.3% (P = .85), and 96.3% ± 1.5% v 96.7% ± 1.4% (P = .77), respectively. There were no differences in the cumulative incidence of isolated bone marrow relapse, isolated CNS relapse, or combined bone marrow and CNS relapse rates, or in toxicities observed for patients receiving IT MTX compared with ITT. There were no significant differences in neurocognitive outcomes for patients receiving IT MTX compared with ITT. CONCLUSION Postinduction CNS prophylaxis with ITT did not improve 5-year DFS for children with HR B-ALL. The standard of care for CNS prophylaxis for children with B-ALL and no overt CNS involvement remains IT MTX.
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Affiliation(s)
| | - Michael J Burke
- Department of Pediatrics, Children's Hospital of Wisconsin, Milwaukee, WI
| | - Meenakshi Devidas
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - Yunfeng Dai
- Department of Biostatistics, Colleges of Medicine and Public Health & Health Professions, University of Florida, Gainesville, FL
| | | | - John A Kairalla
- Department of Biostatistics, Colleges of Medicine and Public Health & Health Professions, University of Florida, Gainesville, FL
| | - Lia Gore
- Department of Pediatrics, Center for Cancer and Blood Disorders, Children's Hospital Colorado, Aurora, CO.,University of Colorado School of Medicine, Aurora, CO
| | - Joanne M Hilden
- Department of Pediatrics, Center for Cancer and Blood Disorders, Children's Hospital Colorado, Aurora, CO.,University of Colorado School of Medicine, Aurora, CO
| | - Eric Larsen
- Department of Pediatrics, Maine Children's Cancer Program, Scarborough, ME
| | - Karen R Rabin
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | | | - Michael J Borowitz
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Brent Wood
- Department of Laboratory Medicine, University of Washington, Seattle, WA
| | - Nyla A Heerema
- Department of Pathology, The Ohio State University School of Medicine, Columbus, OH
| | - Andrew J Carroll
- Department of Genetics, University of Alabama at Birmingham, Birmingham, AL
| | - Naomi Winick
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - William L Carroll
- Department of Pediatrics, Perlmutter Cancer Center, New York University Langone Medical Center, New York, NY
| | - Elizabeth A Raetz
- Department of Pediatrics, Perlmutter Cancer Center, New York University Langone Medical Center, New York, NY
| | - Mignon L Loh
- Department of Pediatrics, Benioff Children's Hospital and the Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA
| | - Stephen P Hunger
- Department of Pediatrics and the Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, PA.,Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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162
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Amankwah EK, Devidas M, Teachey DT, Rabin KR, Brown PA. Six Candidate miRNAs Associated With Early Relapse in Pediatric B-Cell Acute Lymphoblastic Leukemia. Anticancer Res 2020; 40:3147-3153. [PMID: 32487609 DOI: 10.21873/anticanres.14296] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 04/14/2020] [Accepted: 04/24/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM Few studies have evaluated the role of miRNAs in pediatric acute lymphoblastic leukemia (ALL) relapse and a consensus of a clinically significant miRNA signature is yet to be identified. In this study, we evaluated miRNAs associated with pediatric B-ALL early relapse in two independent sample sets. MATERIALS AND METHODS We performed global miRNA profiling on diagnostic bone marrow specimens from six early relapse (≤3 years after diagnosis) and six age- and cytogenetics-matched prolonged remission (≥4 years) patients (first set) and an independent set of 14 early relapse and 14 matched prolonged remission specimens (second set). RESULTS Twelve and 39 top differentially expressed miRNAs were observed in the first and second sets, respectively; however, there was no overlap between the top candidates. In post-hoc analyses six miRNAs (miR-101-3p, miR-4774-5p, miR-1324, miR-631, miR-4699-5p and miR-922) among the top candidates in the second, but not the first set, were consistently upregulated in early relapse compared to remission specimens in both first (fold change=1.13-2.19, q<0.38) and second (fold change=1.48-4.78, all q<0.05) sets. Four (miR-631, mir-101-3p, miR-922 and miR-1324) of these miRNAs have been previously implicated in key functional oncogenic pathways in adult cancers. CONCLUSION This study suggests that six candidate miRNAs, not previously implicated in pediatric ALL, are associated with early relapse in pediatric B-ALL. Validation and investigation of mechanistic roles of these miRNAs in a larger cohort are warranted, so that they may be used as prognostic markers for early relapse of pediatric B-ALL.
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Affiliation(s)
- Ernest K Amankwah
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, U.S.A. .,Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St. Petersburg, FL, U.S.A
| | - Meenakshi Devidas
- Children's Oncology Group Data Center, University of Florida, Gainesville, FL, U.S.A
| | - David T Teachey
- Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, U.S.A
| | - Karen R Rabin
- Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, TX, U.S.A
| | - Patrick A Brown
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, U.S.A.,Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, U.S.A
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163
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Karol SE, Pui CH. Personalized therapy in pediatric high-risk B-cell acute lymphoblastic leukemia. Ther Adv Hematol 2020; 11:2040620720927575. [PMID: 32537116 PMCID: PMC7268159 DOI: 10.1177/2040620720927575] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/27/2020] [Indexed: 12/14/2022] Open
Abstract
Although cure rates for pediatric acute lymphoblastic leukemia (ALL) have now risen to more than 90%, subsets of patients with high-risk features continue to experience high rates of treatment failure and relapse. Recent work in minimal residual disease stratification and leukemia genomics have increased the ability to identify and classify these high-risk patients. In this review, we discuss this work to identify and classify patients with high-risk ALL. Novel therapeutics, which may have the potential to improve outcomes for these patients, are also discussed.
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Affiliation(s)
- Seth E Karol
- Department of Oncology, St. Jude Children's Research Hospital, 262 Danny Thomas Pl., Mail Stop 260, Memphis, TN 38105, USA
| | - Ching-Hon Pui
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
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164
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Wiernikowski JT, Bernhardt MB. Review of nutritional status, body composition, and effects of antineoplastic drug disposition. Pediatr Blood Cancer 2020; 67 Suppl 3:e28207. [PMID: 32083372 DOI: 10.1002/pbc.28207] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 01/22/2020] [Accepted: 01/23/2020] [Indexed: 12/22/2022]
Abstract
The overall survival for children with cancer in high income countries is excellent. However, there are many disparities that may negatively affect survival, which are particularly problematic in low income countries, such as nutritional status at diagnosis and throughout therapy. Nutritional status as well as concomitant foods, supplements, and medications may play a role in overall exposure and response to chemotherapy. Emerging science around the microbiome may also play a role and should be further explored as a contributor to disease progression and therapeutic response. This article highlights some of these issues and proposes additional areas of research relevant to nutritional status and pharmacology that are needed in pediatric oncology.
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Affiliation(s)
- John T Wiernikowski
- Division of Paediatric Haematology/Oncology, Department of Paediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Melanie Brooke Bernhardt
- Section of Hematology/Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
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165
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Patel AA, Thomas J, Rojek AE, Stock W. Biology and Treatment Paradigms in T Cell Acute Lymphoblastic Leukemia in Older Adolescents and Adults. Curr Treat Options Oncol 2020; 21:57. [PMID: 32468488 DOI: 10.1007/s11864-020-00757-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OPINION STATEMENT T cell acute lymphoblastic leukemia (T-ALL) occurs in approximately 25-30% of adult ALL diagnoses. Historically, B cell ALL (B-ALL) and T-ALL have been treated in the same fashion despite differences in the biology of disease. Outcomes in the adolescent/young adult (AYA) population have improved significantly with the utilization of pediatric-based regimens. In addition, there may now be a role for the addition of nelarabine to frontline treatment in the AYA population. In older adults, choices in which regimen to pursue should account for the potential toxicities associated with pediatric-based regimens. Measurable residual disease (MRD) has taken on increasing prognostic value in T-ALL and may help to identify which patients should receive an allogeneic stem cell transplant. T cell lymphoblastic lymphoma (T-LBL) has traditionally been treated similarly to T-ALL, but additional management questions must be considered. Mediastinal irradiation does not seem to clearly improve outcomes, and there is considerable heterogeneity in the central nervous system (CNS) prophylaxis strategy used in prospective trials. CNS prophylaxis in AYA patients with T-ALL, on the other hand, can be safely achieved with intrathecal chemotherapy alone. Prospective data regarding CNS prophylaxis strategies in older adults are currently not available. Nelarabine-based regimens currently remain the standard in relapsed/refractory T-ALL; however, novel therapies targeting molecular aberrations in T-ALL are actively being investigated.
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Affiliation(s)
- Anand A Patel
- Department of Medicine, Section of Hematology-Oncology, The University of Chicago Medicine, 5841 S. Maryland Avenue, MC 2115, Chicago, IL, 60637, USA
| | - Joseph Thomas
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | | | - Wendy Stock
- Department of Medicine, Section of Hematology-Oncology, The University of Chicago Medicine, 5841 S. Maryland Avenue, MC 2115, Chicago, IL, 60637, USA.
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166
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Feng J, Zhang L, Cao XX, Zhang Y, Yang C, Cai HC, Chen M, Wang W, Zhang W, Zhu TN, Duan MH, Li J, Zhou DB. [A pediatric-inspired regimen for adolescents and young adults with Philadelphia chromosome-negative acute lymphoblastic leukemia: results from a single center]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 41:399-404. [PMID: 32536137 PMCID: PMC7342075 DOI: 10.3760/cma.j.issn.0253-2727.2020.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Indexed: 12/21/2022]
Abstract
Objective: To investigate the efficacy of using a pediatric-inspired regimen for adolescents and young adults (AYA) with Philadelphia chromosome-negative (Ph(-)) acute lymphoblastic leukemia/lymphoblastic lymphoma (ALL/LBL) at a single center in China. Methods: Clinical data of 71 consecutive newly diagnosed AYA patients with Ph(-) ALL/LBL on a pediatric-inspired regimen in Peking Union Medical College Hospital from January 2012 to November 2018 were retrospectively analyzed. Results: Median age at diagnosis was 20 years (range: 15-38) , and 46 patients (64.8%) were male. Forty-nine (69.0%) had B-ALL/LBL. Among 62 ALL patients, 22 (35.5%) were high-risk. Complete remission rate was 93.0%. At follow-up with a median time of 44 months, the estimated 5-year disease-free survival (DFS) and overall survival (OS) was 56.3% and 64.3%, respectively. There was no significant difference in 5-year OS between allogeneic hematopoietic stem cell transplantation group and the continuous chemotherapy group after completion of 4 courses of chemotherapy. The 5-year DFS and OS for the non-high-risk group was 63.1% and 73.7%, respectively, which were significantly higher than 32.0% and 44.4% for the high-risk group, respectively (P<0.001) . Conclusions: The use of pediatric-inspired regimen for AYAs with Ph(-) ALL/LBL was feasible and effective.
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Affiliation(s)
- J Feng
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - L Zhang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - X X Cao
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - Y Zhang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - C Yang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - H C Cai
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - M Chen
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - W Wang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - W Zhang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - T N Zhu
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - M H Duan
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - J Li
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
| | - D B Zhou
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
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167
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Fazio M, Ablain J, Chuan Y, Langenau DM, Zon LI. Zebrafish patient avatars in cancer biology and precision cancer therapy. Nat Rev Cancer 2020; 20:263-273. [PMID: 32251397 PMCID: PMC8011456 DOI: 10.1038/s41568-020-0252-3] [Citation(s) in RCA: 126] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/05/2020] [Indexed: 01/05/2023]
Abstract
In precision oncology, two major strategies are being pursued for predicting clinically relevant tumour behaviours, such as treatment response and emergence of drug resistance: inference based on genomic, transcriptomic, epigenomic and/or proteomic analysis of patient samples, and phenotypic assays in personalized cancer avatars. The latter approach has historically relied on in vivo mouse xenografts and in vitro organoids or 2D cell cultures. Recent progress in rapid combinatorial genetic modelling, the development of a genetically immunocompromised strain for xenotransplantation of human patient samples in adult zebrafish and the first clinical trial using xenotransplantation in zebrafish larvae for phenotypic testing of drug response bring this tiny vertebrate to the forefront of the precision medicine arena. In this Review, we discuss advances in transgenic and transplantation-based zebrafish cancer avatars, and how these models compare with and complement mouse xenografts and human organoids. We also outline the unique opportunities that these different models present for prediction studies and current challenges they face for future clinical deployment.
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Affiliation(s)
- Maurizio Fazio
- Stem Cell Program and Division of Hematology/Oncology, Boston Children's Hospital and Dana-Farber Cancer Institute, Howard Hughes Medical Institute, Harvard Medical School, Boston, MA, USA
- Department of Stem Cell and Regenerative Biology, Harvard Stem Cell Institute, Cambridge, MA, USA
| | - Julien Ablain
- Stem Cell Program and Division of Hematology/Oncology, Boston Children's Hospital and Dana-Farber Cancer Institute, Howard Hughes Medical Institute, Harvard Medical School, Boston, MA, USA
- Department of Stem Cell and Regenerative Biology, Harvard Stem Cell Institute, Cambridge, MA, USA
| | - Yan Chuan
- Molecular Pathology Unit, Cancer Center, Massachusetts General Hospital Research Institute, Charlestown, MA, USA
| | - David M Langenau
- Molecular Pathology Unit, Cancer Center, Massachusetts General Hospital Research Institute, Charlestown, MA, USA
| | - Leonard I Zon
- Stem Cell Program and Division of Hematology/Oncology, Boston Children's Hospital and Dana-Farber Cancer Institute, Howard Hughes Medical Institute, Harvard Medical School, Boston, MA, USA.
- Department of Stem Cell and Regenerative Biology, Harvard Stem Cell Institute, Cambridge, MA, USA.
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168
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Gupta S, Wang C, Raetz EA, Schore R, Salzer WL, Larsen EC, Maloney KW, Mattano LA, Carroll WL, Winick NJ, Hunger SP, Loh ML, Devidas M. Impact of Asparaginase Discontinuation on Outcome in Childhood Acute Lymphoblastic Leukemia: A Report From the Children's Oncology Group. J Clin Oncol 2020; 38:1897-1905. [PMID: 32275469 DOI: 10.1200/jco.19.03024] [Citation(s) in RCA: 116] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Asparaginase (ASNase) is an important component of acute lymphoblastic leukemia (ALL) treatment, but is often discontinued because of toxicity. Erwinia chrysanthemi ASNase (Erwinia) substitution was approved in 2011 for allergic reactions. Erwinia has, however, been intermittently unavailable because of drug supply issues. The impact of Erwinia substitution or complete ASNase discontinuation is unknown. METHODS Patients aged 1-30.99 years in frontline Children's Oncology Group trials for B-cell acute lymphoblastic leukemia between 2004 and 2011 (National Cancer Institute [NCI] standard risk [SR]: AALL0331; NCI high risk: AALL0232) were included. The number of prescribed pegaspargase (PEG-ASNase) doses varied by trial and strata. Maintenance therapy did not contain ASNase. Landmark analyses at maintenance compared disease-free survival (DFS) among those receiving all prescribed PEG-ASNase doses versus switching to Erwinia but receiving all doses versus not receiving all ASNase doses. RESULTS We included 5,195 AALL0331 and 3,001 AALL0232 patients. The cumulative incidence of PEG-ASNase discontinuation was 12.2% ± 4.6% in AALL0331 and 25.4% ± 0.8% in AALL0232. In multivariable analyses, NCI high-risk patients not receiving all prescribed ASNase doses had inferior DFS (hazard ratio [HR], 1.5; 95% CI, 1.2 to 1.9; P = .002) compared with those receiving all prescribed PEG-ASNase doses. Patients with Erwinia substitution who completed subsequent courses were not at increased risk (HR, 1.1; 95% CI, 0.7 to 1.6; P = .69). NCI SR patients who discontinued ASNase were not at elevated risk (HR, 1.2; 95% CI, 0.9 to 1.6; P = .23), except when restricted to those with slow early response, who were prescribed more ASNase because of therapy intensification (HR, 1.7; 95% CI, 1.1 to 2.7; P = .03). CONCLUSION Discontinuation of ASNase doses is associated with inferior DFS in higher-risk patients. Our results illustrate the severe consequences of Erwinia shortages.
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Affiliation(s)
- Sumit Gupta
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Cindy Wang
- Department of Biostatistics, University of Florida, Gainesville, FL
| | | | | | - Wanda L Salzer
- US Army Medical Research and Materiel Command, Fort Detrick, MD
| | - Eric C Larsen
- Department of Pediatrics, Maine Children's Cancer Program, Scarborough, ME
| | | | | | - William L Carroll
- Department of Pediatrics and Perlmutter Cancer Center, New York University Langone Health, New York, NY
| | - Naomi J Winick
- University of Texas Southwestern/Simmons Cancer Center, Dallas, TX
| | - Stephen P Hunger
- Department of Pediatrics and the Center for Childhood Cancer Research, Children's Hospital of Philadelphia, and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Mignon L Loh
- Department of Pediatrics, UCSF Benoiff Childen's Hospital and Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA
| | - Meenakshi Devidas
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
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169
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Abstract
Acute lymphoblastic leukaemia develops in both children and adults, with a peak incidence between 1 year and 4 years. Most acute lymphoblastic leukaemia arises in healthy individuals, and predisposing factors such as inherited genetic susceptibility or environmental exposure have been identified in only a few patients. It is characterised by chromosomal abnormalities and genetic alterations involved in differentiation and proliferation of lymphoid precursor cells. Along with response to treatment, these abnormalities are important prognostic factors. Disease-risk stratification and the development of intensified chemotherapy protocols substantially improves the outcome of patients with acute lymphoblastic leukaemia, particularly in children (1-14 years), but also in adolescents and young adults (15-39 years). However, the outcome of older adults (≥40 years) and patients with relapsed or refractory acute lymphoblastic leukaemia remains poor. New immunotherapeutic strategies, such as monoclonal antibodies and chimeric antigen receptor (CAR) T cells, are being developed and over the next few years could change the options for acute lymphoblastic leukaemia treatment.
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Affiliation(s)
- Florent Malard
- Department of Clinical Hematology and Cellular Therapy, Saint-Antoine Hospital, AP-HP, Sorbonne University, Paris, France; Sorbonne University, INSERM, Saint-Antoine Research Centre, Paris, France
| | - Mohamad Mohty
- Department of Clinical Hematology and Cellular Therapy, Saint-Antoine Hospital, AP-HP, Sorbonne University, Paris, France; Sorbonne University, INSERM, Saint-Antoine Research Centre, Paris, France.
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170
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Razali RH, Noorizhab MNF, Jamari H, James RJ, Teh KH, Ibrahim HM, Teh LK, Salleh MZ. Association of ABCC2 with levels and toxicity of methotrexate in Malaysian Childhood Acute Lymphoblastic Leukemia (ALL). Pediatr Hematol Oncol 2020; 37:185-197. [PMID: 31870219 DOI: 10.1080/08880018.2019.1705949] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Studies had shown that genetic polymorphism plays a significant role in the pharmacokinetics and pharmacodynamics variation of high dose methotrexate (MTX), 5000 mg/m2 regimen. The objective of this study was to investigate the genetic variations associated with the serum level and toxicity of MTX in Malaysian children with acute lymphoblastic leukemia (ALL). Thirty-eight patients were genotyped for rs717620 (ABCC2), rs4948496 (ARID5B), rs1801133 (MTHFR) and rs4149056 (SLCO1B1). Serum levels of MTX at 48 h post 24 h of intravenous infusion were analyzed by high-performance liquid chromatography-mass spectrometry. The ABCC2 genotype was significantly associated with the serum levels of MTX at 48 h after treatment (p = 0.017). Patients with CT and TT of rs717620 (ABCC2) and TC and CC of rs4948496 (ARID5B) were significantly associated with leukopenia grade I-IV (Fisher Exact Test; p = 0.03 and 0.02, respectively). The three most common MTX related toxicities were leukopenia (60.5%), increased alanine aminotransferase enzyme (47.4%), and thrombocytopenia (47.4%). Our results demonstrate that by prescreening of patients for ABCC2 and ARID5B associated with the serum levels and adverse effects of MTX would identify patients at risk and therefore help a pediatric oncologist to personalize chemotherapy drugs for precision health.
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Affiliation(s)
- Rizal Husaini Razali
- Integrative Pharmacogenomics Institute (iPROMISE), Universiti Teknologi MARA Cawangan Selangor Kampus Puncak Alam, Selangor, Malaysia.,Faculty of Pharmacy Universiti Teknologi MARA Cawangan Selangor, Kampus Puncak Alam, Selangor, Malaysia.,Pharmaceutical Services Programme, Ministry of Health, Petaling Jaya, Malaysia
| | - Mohd Nur Fakhruzzaman Noorizhab
- Integrative Pharmacogenomics Institute (iPROMISE), Universiti Teknologi MARA Cawangan Selangor Kampus Puncak Alam, Selangor, Malaysia.,Faculty of Pharmacy Universiti Teknologi MARA Cawangan Selangor, Kampus Puncak Alam, Selangor, Malaysia
| | - Hisyam Jamari
- Integrative Pharmacogenomics Institute (iPROMISE), Universiti Teknologi MARA Cawangan Selangor Kampus Puncak Alam, Selangor, Malaysia
| | - Richard Johari James
- Integrative Pharmacogenomics Institute (iPROMISE), Universiti Teknologi MARA Cawangan Selangor Kampus Puncak Alam, Selangor, Malaysia.,Faculty of Pharmacy Universiti Teknologi MARA Cawangan Selangor, Kampus Puncak Alam, Selangor, Malaysia
| | - Kok Hoi Teh
- Paediatric Haematology and Oncology Unit, Women & Children's Hospital, Kuala Lumpur, Ministry of Health Malaysia
| | - Hishamshah Mohd Ibrahim
- Paediatric Haematology and Oncology Unit, Women & Children's Hospital, Kuala Lumpur, Ministry of Health Malaysia
| | - Lay Kek Teh
- Integrative Pharmacogenomics Institute (iPROMISE), Universiti Teknologi MARA Cawangan Selangor Kampus Puncak Alam, Selangor, Malaysia.,Faculty of Pharmacy Universiti Teknologi MARA Cawangan Selangor, Kampus Puncak Alam, Selangor, Malaysia
| | - Mohd Zaki Salleh
- Integrative Pharmacogenomics Institute (iPROMISE), Universiti Teknologi MARA Cawangan Selangor Kampus Puncak Alam, Selangor, Malaysia.,Faculty of Pharmacy Universiti Teknologi MARA Cawangan Selangor, Kampus Puncak Alam, Selangor, Malaysia
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171
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McNeer JL, Rau RE, Gupta S, Maude SL, O'Brien MM. Cutting to the Front of the Line: Immunotherapy for Childhood Acute Lymphoblastic Leukemia. Am Soc Clin Oncol Educ Book 2020; 40:1-12. [PMID: 32320280 DOI: 10.1200/edbk_278171] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Although many children and young adults with B-cell acute lymphoblastic leukemia (B-ALL) are cured with modern, risk-adapted chemotherapy regimens, 10% to 15% of patients will experience relapse or have refractory disease. Recent efforts to further intensify cytotoxic chemotherapy regimens in the frontline setting have failed as a result of excessive toxicity or lack of improvement in efficacy. As a result, novel approaches will be required to achieve cures in more newly diagnosed patients. Multiple immune-based therapies have demonstrated considerable efficacy in the setting of relapsed or refractory (R/R) disease, including CD19 targeting with blinatumomab and tisagenlecleucel and CD22 targeting with inotuzumab ozogamicin. These agents are now under investigation by the Children's Oncology Group (COG) in clinical trials for newly diagnosed B-ALL, with integration into standard chemotherapy regimens based on clinically and biology-based risk stratification as well as disease response.
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Affiliation(s)
| | - Rachel E Rau
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Sumit Gupta
- The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Shannon L Maude
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Maureen M O'Brien
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
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172
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Derman BA, Streck M, Wynne J, Christ TN, Curran E, Stock W, Knoebel RW. Efficacy and toxicity of reduced vs. standard dose pegylated asparaginase in adults with Philadelphia chromosome-negative acute lymphoblastic leukemia. Leuk Lymphoma 2020; 61:614-622. [PMID: 31680584 PMCID: PMC7028458 DOI: 10.1080/10428194.2019.1680839] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 09/21/2019] [Accepted: 10/10/2019] [Indexed: 01/01/2023]
Abstract
Incorporation of asparaginase (ASNase) and pegylated asparaginase (PEG-ASP) into pediatric-inspired regimens for adults with acute lymphoblastic leukemia (ALL) has led to improved treatment outcomes albeit with increased toxicities. This study compared the efficacy and safety of the Children's Oncology Group standard PEG-ASP (SD) dosing (>1000, median 2500 IU/m2/dose) in adult Philadelphia chromosome-negative ALL patients receiving multiagent chemotherapy vs reduced dose PEG-ASP (RED) (≤1000, median 500 IU/m2/dose) during induction. 51 patients were included, 26 in RED and 25 in SD (median age 49 vs 37 years, p = .027). Median day 7 ASNase activity level for RED was 0.16 IU/mL. All 11 patients who received PEG-ASP 1000 IU/m2 and 9/11 patients who received 500 IU/m2 achieved an ASNase level ≥0.1 IU/mL. Patients receiving RED experienced fewer total grade 3/4 toxicities during induction compared to SD (p = .02) while still attaining therapeutic ASNase levels. RED permits safer ASNase use in adults with ALL and should be tested in a larger cohort prospectively.
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Affiliation(s)
| | - Mitchell Streck
- Simon Cancer Center, Indiana University Health, Indianapolis, IN
| | - Joseph Wynne
- Section of Hematology/Oncology, University of Chicago, Chicago, IL
| | - Trevor N Christ
- Department of Pharmacy, University of Chicago, Chicago, IL
- Rush University Medical Center, Chicago, IL
| | - Emily Curran
- Section of Hematology/Oncology, University of Chicago, Chicago, IL
| | - Wendy Stock
- Section of Hematology/Oncology, University of Chicago, Chicago, IL
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173
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Wang AY, Muffly LS, Stock W. Philadelphia Chromosome-Negative B-Cell Acute Lymphoblastic Leukemia in Adolescents and Young Adults. JCO Oncol Pract 2020; 16:231-238. [PMID: 32048928 DOI: 10.1200/jop.19.00197] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Adolescents and young adults (AYAs) with Philadelphia chromosome-negative acute lymphoblastic leukemia (ALL) represent a unique patient population with a disproportionate survival disadvantage compared with younger children. Substantial progress has been made as we began to understand and address the multifaceted drivers behind this outcome disparity. New insights into the biology of B-cell ALL have uncovered distinct genetic characteristics more commonly found in AYAs that affect prognosis. Dramatic improvements in survival have been achieved with the use of pediatric-inspired protocols in the front-line setting, as well as antibody-based and chimeric antigen receptor T-cell therapies in the relapsed and refractory setting. Guided by the incorporation of minimal residual disease testing to inform clinical decision making, these represent major paradigm shifts in management. Efforts to design clinical trials geared toward AYAs and to enroll AYAs in available clinical trials will ensure ongoing progress. Holistic care of AYAs with ALL further involves recognition of psychosocial issues arising as a consequence of their diagnosis and the delivery of age-appropriate supportive care.
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174
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Kiem Hao T, Nhu Hiep P, Kim Hoa NT, Van Ha C. Causes of Death in Childhood Acute Lymphoblastic Leukemia at Hue Central Hospital for 10 Years (2008-2018). Glob Pediatr Health 2020; 7:2333794X20901930. [PMID: 32030350 PMCID: PMC6977218 DOI: 10.1177/2333794x20901930] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 12/27/2019] [Accepted: 12/27/2019] [Indexed: 11/17/2022] Open
Abstract
Aim. To analyze the common cause of death in childhood acute lymphoblastic leukemia patients. Methods and Materials. A retrospective descriptive study on children with acute lymphoblastic leukemia who died at Hue Central Hospital between 2008 and 2018. All the patients were treated with the same protocol of modified Children’s Cancer Group 1882 and 1881. Results. A total of 238 children with acute lymphoblastic leukemia who were cared for at our center were enrolled. Of these, there were 74 deaths. Among the death group, the male-to-female ratio was 2.7:1. Twenty-six (35.1%) occurred in maintenance phase, 18 (24.3%) occurred in induction phase, and 9 (12.2%) occurred in delayed intensification. Infection was responsible for deaths in 32 of 74 (43.2%) cases. Pseudomonas aeruginosa was found in 3 of 32 infected cases (9.4%) and resistance to almost all antibiotics in our hospital. Relapse, abandonment, and bleeding were documented in 20 (27.0%), 7 (9.5%), and 6 (8.1%) cases, respectively. Twenty-seven (84.3%) patients had absolute neutrophil count <500/µL. Of 32 infectious deaths, pneumonia occurred in 40.6%. Regarding 20 relapse death, bone marrow was the major site of relapse and it occurred in 13 (65%) cases. And there were 65% patients with very early relapse. Conclusions. Infection is the major cause of mortality in acute lymphoblastic leukemia patients in our study. To improve outcome, we should improve supportive care, especially prevention and control infection.
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Affiliation(s)
| | | | | | - Chau Van Ha
- Pediatric Center, Hue Central Hospital, Vietnam
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175
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Carobolante F, Chiaretti S, Skert C, Bassan R. Practical guidance for the management of acute lymphoblastic leukemia in the adolescent and young adult population. Ther Adv Hematol 2020; 11:2040620720903531. [PMID: 32071710 PMCID: PMC6997963 DOI: 10.1177/2040620720903531] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 12/18/2019] [Indexed: 01/22/2023] Open
Abstract
The outstanding therapeutic progress achieved with modern pediatric regimens in
childhood acute lymphoblastic leukemia (ALL) led efforts to explore whether a
similar treatment approach could be equally effective and safe in older
patients, starting initially with older adolescents and young adults (AYA),
variably defined in different studies by an age between 15–18 and 25–39 years.
Several comparative and noncomparative trials of this type have been carried out
during the last two decades, enrolling thousands of patients. Almost without
exception, the new strategy improved patients’ outcomes compared with
traditional adult treatments in B-lineage and T-lineage Philadelphia (Ph)
chromosome-negative B-ALL, while the use of tyrosine kinase inhibitors (TKI) led
to comparative progress in Ph+ ALL, a former high-risk subset more typically
observed in older age groups. At present, highly effective pediatric-based
regimens warrant 5-year survival rates of 60–70% in AYA patients. In view of
these data, the same approach was progressively extended to older patients,
improving the results up to 55 years of age. Issues of treatment compliance and
drug-related toxicity have thus far prevented a comparable therapeutic
advancement in patients aged >55 years. This critical review updates and
summarizes with pertinent examples this global, positive therapeutic change, and
examines how to promote further progress with new targeted therapies that
include novel immuno-therapeutics and other agents developed against the many
molecular dysfunctions detectable in various ALL subsets. Substantial progress
is expected to occur soon, bringing AYA survival figures very close to that of
children, and also to improve the outcome of ALL at all ages.
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Affiliation(s)
| | | | - Cristina Skert
- UOC Ematologia, Ospedale dell'Angelo, Venezia, Mestre, Italy
| | - Renato Bassan
- UOC Ematologia, Ospedale dell'Angelo, Via Paccagnella 11, Venezia, Mestre, 30174, Italy
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176
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Teachey DT, O'Connor D. How I treat newly diagnosed T-cell acute lymphoblastic leukemia and T-cell lymphoblastic lymphoma in children. Blood 2020; 135:159-166. [PMID: 31738819 PMCID: PMC6966932 DOI: 10.1182/blood.2019001557] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 11/14/2019] [Indexed: 12/11/2022] Open
Abstract
T-cell acute lymphoblastic leukemia (T-ALL) is an aggressive malignancy that has historically been associated with a very poor prognosis. Nevertheless, despite a lack of incorporation of novel agents, the development of intensified T-ALL-focused protocols has resulted in significant improvements in outcome in children. Through the use of several representative cases, we highlight the key changes that have driven these advances including asparaginase intensification, the use of induction dexamethasone, and the safe omission of cranial radiotherapy. We discuss the results of recent trials to explore key topics including the implementation of risk stratification with minimal residual disease measurement and how to treat high-risk subtypes such as early T-cell precursor ALL. In particular, we address current discrepancies in treatment between different cooperative groups, including the use of nelarabine, and provide rationales for current treatment protocols for both T-ALL and T-lymphoblastic lymphoma.
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Affiliation(s)
- David T Teachey
- Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - David O'Connor
- Department of Haematology, University College London (UCL) Cancer Institute, London, United Kingdom; and
- Department of Haematology, Great Ormond Street Hospital for Children, London, United Kingdom
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177
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Harvey RC, Tasian SK. Clinical diagnostics and treatment strategies for Philadelphia chromosome-like acute lymphoblastic leukemia. Blood Adv 2020; 4:218-228. [PMID: 31935290 PMCID: PMC6960477 DOI: 10.1182/bloodadvances.2019000163] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 11/20/2019] [Indexed: 12/13/2022] Open
Abstract
Philadelphia chromosome-like B-cell acute lymphoblastic leukemia (Ph-like ALL) accounts for 15% to 30% of B-cell acute lymphoblastic leukemia in older children, adolescents, and adults and is associated with high rates of conventional treatment failure and relapse. Current clinical trials are assessing the efficacy of the addition of tyrosine kinase inhibitors (TKIs) to chemotherapy for children and adults with Ph-like ALL harboring ABL class translocations or CRLF2 rearrangements and other JAK pathway alterations. However, real-time diagnosis of patients can be quite challenging given the genetic heterogeneity of this disease and the often cytogenetically cryptic nature of Ph-like ALL-associated alterations. In this review, we discuss the complex biologic and clinical features of Ph-like ALL across the age spectrum, available diagnostic testing modalities, and current clinical treatment strategies for these high-risk patients. We further propose a practical and step-wise approach to Ph-like ALL genetic testing to facilitate the identification and allocation of patients to appropriate clinical trials of TKI-based therapies or commercially available drugs. Although the majority of patients with Ph-like ALL can be successfully identified via current clinical assays by the end of induction chemotherapy, increasing diagnostic efficiency and sensitivity and decreasing time to test resulting will facilitate earlier therapeutic intervention and may improve clinical outcomes for these high-risk patients.
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Affiliation(s)
- Richard C Harvey
- Department of Pathology, University of New Mexico School of Medicine, Albuquerque, NM
- University of New Mexico Comprehensive Cancer Center, Albuquerque, NM
| | - Sarah K Tasian
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, PA; and
- Department of Pediatrics and Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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178
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Li B, Brady SW, Ma X, Shen S, Zhang Y, Li Y, Szlachta K, Dong L, Liu Y, Yang F, Wang N, Flasch DA, Myers MA, Mulder HL, Ding L, Liu Y, Tian L, Hagiwara K, Xu K, Zhou X, Sioson E, Wang T, Yang L, Zhao J, Zhang H, Shao Y, Sun H, Sun L, Cai J, Sun HY, Lin TN, Du L, Li H, Rusch M, Edmonson MN, Easton J, Zhu X, Zhang J, Cheng C, Raphael BJ, Tang J, Downing JR, Alexandrov LB, Zhou BBS, Pui CH, Yang JJ, Zhang J. Therapy-induced mutations drive the genomic landscape of relapsed acute lymphoblastic leukemia. Blood 2020; 135:41-55. [PMID: 31697823 PMCID: PMC6940198 DOI: 10.1182/blood.2019002220] [Citation(s) in RCA: 158] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 10/10/2019] [Indexed: 12/23/2022] Open
Abstract
To study the mechanisms of relapse in acute lymphoblastic leukemia (ALL), we performed whole-genome sequencing of 103 diagnosis-relapse-germline trios and ultra-deep sequencing of 208 serial samples in 16 patients. Relapse-specific somatic alterations were enriched in 12 genes (NR3C1, NR3C2, TP53, NT5C2, FPGS, CREBBP, MSH2, MSH6, PMS2, WHSC1, PRPS1, and PRPS2) involved in drug response. Their prevalence was 17% in very early relapse (<9 months from diagnosis), 65% in early relapse (9-36 months), and 32% in late relapse (>36 months) groups. Convergent evolution, in which multiple subclones harbor mutations in the same drug resistance gene, was observed in 6 relapses and confirmed by single-cell sequencing in 1 case. Mathematical modeling and mutational signature analysis indicated that early relapse resistance acquisition was frequently a 2-step process in which a persistent clone survived initial therapy and later acquired bona fide resistance mutations during therapy. In contrast, very early relapses arose from preexisting resistant clone(s). Two novel relapse-specific mutational signatures, one of which was caused by thiopurine treatment based on in vitro drug exposure experiments, were identified in early and late relapses but were absent from 2540 pan-cancer diagnosis samples and 129 non-ALL relapses. The novel signatures were detected in 27% of relapsed ALLs and were responsible for 46% of acquired resistance mutations in NT5C2, PRPS1, NR3C1, and TP53. These results suggest that chemotherapy-induced drug resistance mutations facilitate a subset of pediatric ALL relapses.
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Affiliation(s)
- Benshang Li
- Key Laboratory of Pediatric Hematology & Oncology Ministry of Health, Department of Hematology & Oncology, Shanghai Children's Medical Center-National Children's Medical Center, and
- Pediatric Translational Medicine Institute, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Samuel W Brady
- Department of Computational Biology, St. Jude Children's Research Hospital, Memphis, TN
| | - Xiaotu Ma
- Department of Computational Biology, St. Jude Children's Research Hospital, Memphis, TN
| | - Shuhong Shen
- Key Laboratory of Pediatric Hematology & Oncology Ministry of Health, Department of Hematology & Oncology, Shanghai Children's Medical Center-National Children's Medical Center, and
- Pediatric Translational Medicine Institute, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yingchi Zhang
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital-Center for Stem Cell Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Yongjin Li
- Department of Computational Biology, St. Jude Children's Research Hospital, Memphis, TN
| | - Karol Szlachta
- Department of Computational Biology, St. Jude Children's Research Hospital, Memphis, TN
| | - Li Dong
- Department of Computational Biology, St. Jude Children's Research Hospital, Memphis, TN
| | - Yu Liu
- Department of Computational Biology, St. Jude Children's Research Hospital, Memphis, TN
| | - Fan Yang
- Key Laboratory of Pediatric Hematology & Oncology Ministry of Health, Department of Hematology & Oncology, Shanghai Children's Medical Center-National Children's Medical Center, and
- Pediatric Translational Medicine Institute, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ningling Wang
- Department of Pediatrics, the Second Hospital of Anhui Medical University, Hefei, China
| | - Diane A Flasch
- Department of Computational Biology, St. Jude Children's Research Hospital, Memphis, TN
| | - Matthew A Myers
- Department of Computer Science, Princeton University, Princeton, NJ
| | - Heather L Mulder
- Department of Computational Biology, St. Jude Children's Research Hospital, Memphis, TN
| | - Lixia Ding
- Key Laboratory of Pediatric Hematology & Oncology Ministry of Health, Department of Hematology & Oncology, Shanghai Children's Medical Center-National Children's Medical Center, and
- Pediatric Translational Medicine Institute, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yanling Liu
- Department of Computational Biology, St. Jude Children's Research Hospital, Memphis, TN
| | - Liqing Tian
- Department of Computational Biology, St. Jude Children's Research Hospital, Memphis, TN
| | - Kohei Hagiwara
- Department of Computational Biology, St. Jude Children's Research Hospital, Memphis, TN
| | - Ke Xu
- Department of Computational Biology, St. Jude Children's Research Hospital, Memphis, TN
| | - Xin Zhou
- Department of Computational Biology, St. Jude Children's Research Hospital, Memphis, TN
| | - Edgar Sioson
- Department of Computational Biology, St. Jude Children's Research Hospital, Memphis, TN
| | - Tianyi Wang
- Key Laboratory of Pediatric Hematology & Oncology Ministry of Health, Department of Hematology & Oncology, Shanghai Children's Medical Center-National Children's Medical Center, and
| | - Liu Yang
- Key Laboratory of Pediatric Hematology & Oncology Ministry of Health, Department of Hematology & Oncology, Shanghai Children's Medical Center-National Children's Medical Center, and
| | - Jie Zhao
- Key Laboratory of Pediatric Hematology & Oncology Ministry of Health, Department of Hematology & Oncology, Shanghai Children's Medical Center-National Children's Medical Center, and
| | - Hui Zhang
- Department of Pediatric Hematology/Oncology, Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong, China
| | - Ying Shao
- Department of Computational Biology, St. Jude Children's Research Hospital, Memphis, TN
| | | | - Lele Sun
- WuXi NextCODE Co., Ltd, Shanghai, China
| | - Jiaoyang Cai
- Key Laboratory of Pediatric Hematology & Oncology Ministry of Health, Department of Hematology & Oncology, Shanghai Children's Medical Center-National Children's Medical Center, and
| | - Hui-Ying Sun
- Key Laboratory of Pediatric Hematology & Oncology Ministry of Health, Department of Hematology & Oncology, Shanghai Children's Medical Center-National Children's Medical Center, and
| | | | - Lijuan Du
- Key Laboratory of Pediatric Hematology & Oncology Ministry of Health, Department of Hematology & Oncology, Shanghai Children's Medical Center-National Children's Medical Center, and
- Pediatric Translational Medicine Institute, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hui Li
- Key Laboratory of Pediatric Hematology & Oncology Ministry of Health, Department of Hematology & Oncology, Shanghai Children's Medical Center-National Children's Medical Center, and
- Pediatric Translational Medicine Institute, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Michael Rusch
- Department of Computational Biology, St. Jude Children's Research Hospital, Memphis, TN
| | - Michael N Edmonson
- Department of Computational Biology, St. Jude Children's Research Hospital, Memphis, TN
| | - John Easton
- Department of Computational Biology, St. Jude Children's Research Hospital, Memphis, TN
| | - Xiaofan Zhu
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital-Center for Stem Cell Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Jingliao Zhang
- State Key Laboratory of Experimental Hematology, Institute of Hematology and Blood Diseases Hospital-Center for Stem Cell Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | | | | | - Jingyan Tang
- Key Laboratory of Pediatric Hematology & Oncology Ministry of Health, Department of Hematology & Oncology, Shanghai Children's Medical Center-National Children's Medical Center, and
| | - James R Downing
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, Tennessee, TN
| | - Ludmil B Alexandrov
- Department of Cellular and Molecular Medicine, University of California, San Diego, La Jolla, CA; and
| | - Bin-Bing S Zhou
- Key Laboratory of Pediatric Hematology & Oncology Ministry of Health, Department of Hematology & Oncology, Shanghai Children's Medical Center-National Children's Medical Center, and
- Pediatric Translational Medicine Institute, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ching-Hon Pui
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN
| | | | - Jinghui Zhang
- Department of Computational Biology, St. Jude Children's Research Hospital, Memphis, TN
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179
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Maloney KW, Devidas M, Wang C, Mattano LA, Friedmann AM, Buckley P, Borowitz MJ, Carroll AJ, Gastier-Foster JM, Heerema NA, Kadan-Lottick N, Loh ML, Matloub YH, Marshall DT, Stork LC, Raetz EA, Wood B, Hunger SP, Carroll WL, Winick NJ. Outcome in Children With Standard-Risk B-Cell Acute Lymphoblastic Leukemia: Results of Children's Oncology Group Trial AALL0331. J Clin Oncol 2019; 38:602-612. [PMID: 31825704 DOI: 10.1200/jco.19.01086] [Citation(s) in RCA: 103] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
PURPOSE Children's Oncology Group (COG) AALL0331 tested whether intensified postinduction therapy that improves survival in children with high-risk B-cell acute lymphoblastic leukemia (ALL) would also improve outcomes for those with standard-risk (SR) ALL. PATIENTS AND METHODS AALL0331 enrolled 5,377 patients between 2005 and 2010. All patients received a 3-drug induction with dexamethasone, vincristine, and pegaspargase (PEG) and were then classified as SR low, SR average, or SR high. Patients with SR-average disease were randomly assigned to receive either standard 4-week consolidation (SC) or 8-week intensified augmented Berlin-Frankfurt-Münster (BFM) consolidation (IC). Those with SR-high disease were nonrandomly assigned to the full COG-augmented BFM regimen, including 2 interim maintenance and delayed intensification phases. RESULTS The 6-year event-free survival (EFS) rate for all patients enrolled in AALL0331 was 88.96% ± 0.46%, and overall survival (OS) was 95.54% ± 0.31%. For patients with SR-average disease, the 6-year continuous complete remission (CCR) and OS rates for SC versus IC were 87.8% ± 1.3% versus 89.1% ± 1.2% (P = .52) and 95.8% ± 0.8% versus 95.2% ± 0.8% (P = 1.0), respectively. Those with SR-average disease with end-induction minimal residual disease (MRD) of 0.01% to < 0.1% had an inferior outcome compared with those with lower MRD and no improvement with IC (6-year CCR: SC, 77.5% ± 4.8%; IC, 77.1% ± 4.8%; P = .71). At 6 years, the CCR and OS rates among 635 nonrandomly treated patients with SR-high disease were 85.55% ± 1.49% and 92.97% ± 1.08%, respectively. CONCLUSION The 6-year OS rate for > 5,000 children with SR ALL enrolled in AALL0331 exceeded 95%. The addition of IC to treatment for patients with SR-average disease did not improve CCR or OS, even in patients with higher MRD, in whom it might have been predicted to provide more value. The EFS and OS rates are excellent for this group of patients with SR ALL, with particularly good outcomes for those with SR-high disease.
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Affiliation(s)
- Kelly W Maloney
- Department of Pediatrics, University of Colorado, Aurora, CO.,Children's Hospital Colorado, Aurora, CO
| | - Meenakshi Devidas
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - Cindy Wang
- Department of Biostatistics, Colleges of Medicine, Public Health and Health Professions, University of Florida, Gainesville, FL
| | | | - Alison M Friedmann
- Department of Pediatrics, Massachusetts General Hospital Cancer Center, Boston, MA
| | - Patrick Buckley
- Department of Pathology, Duke University Medical Center, Durham, NC
| | | | - Andrew J Carroll
- Department of Genetics, University of Alabama at Birmingham, Birmingham, AL
| | - Julie M Gastier-Foster
- Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, OH.,Department of Pediatrics, Ohio State University College of Medicine, Columbus, OH
| | - Nyla A Heerema
- Department of Pathology, Wexner Medical Center, Ohio State University, Columbus, OH
| | | | - Mignon L Loh
- Department of Pediatrics, Benioff Children's Hospital, San Francisco, CA.,Helen Diller Family Comprehensive Cancer, University of California, San Francisco, CA
| | - Yousif H Matloub
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - David T Marshall
- Department of Radiation Oncology, Medical University of South Carolina, Charleston, SC
| | - Linda C Stork
- Department of Pediatrics, Oregon Health & Science University, Portland, OR
| | - Elizabeth A Raetz
- Perlmutter Cancer Center, New York University (NYU) Langone Medical Center, New York, NY.,Department of Pediatrics, NYU Langone Medical Center, New York, NY
| | - Brent Wood
- Department of Pathology, University of Washington, Seattle, WA.,Department of Medicine, University of Washington, Seattle, WA
| | - Stephen P Hunger
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA.,Perelman School of Medicine at University of Philadelphia, Philadelphia, PA
| | - William L Carroll
- Perlmutter Cancer Center, New York University (NYU) Langone Medical Center, New York, NY.,Department of Pediatrics, NYU Langone Medical Center, New York, NY
| | - Naomi J Winick
- Department of Pediatrics, University of Texas (UT) Southwestern, Dallas, TX.,Simmons Cancer Center, UT Southwestern, Dallas, TX
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180
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Jeha S, Pei D, Choi J, Cheng C, Sandlund JT, Coustan-Smith E, Campana D, Inaba H, Rubnitz JE, Ribeiro RC, Gruber TA, Raimondi SC, Khan RB, Yang JJ, Mullighan CG, Downing JR, Evans WE, Relling MV, Pui CH. Improved CNS Control of Childhood Acute Lymphoblastic Leukemia Without Cranial Irradiation: St Jude Total Therapy Study 16. J Clin Oncol 2019; 37:3377-3391. [PMID: 31657981 PMCID: PMC7351342 DOI: 10.1200/jco.19.01692] [Citation(s) in RCA: 164] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2019] [Indexed: 12/30/2022] Open
Abstract
PURPOSE Despite contemporary treatment, up to 10% of children with acute lymphoblastic leukemia still experience relapse. We evaluated whether a higher dosage of PEG-asparaginase and early intensification of triple intrathecal therapy would improve systemic and CNS control. PATIENTS AND METHODS Between 2007 and 2017, 598 consecutive patients age 0 to 18 years received risk-directed chemotherapy without prophylactic cranial irradiation in the St Jude Total Therapy Study 16. Patients were randomly assigned to receive PEG-asparaginase 3,500 U/m2 versus the conventional 2,500 U/m2. Patients presenting features that were associated with increased risk of CNS relapse received two extra doses of intrathecal therapy during the first 2 weeks of remission induction. RESULTS The 5-year event-free survival and overall survival rates for the 598 patients were 88.2% (95% CI, 84.9% to 91.5%) and 94.1% (95% CI, 91.7% to 96.5%), respectively. Cumulative risk of any-isolated or combined-CNS relapse was 1.5% (95% CI, 0.5% to 2.5%). Higher doses of PEG-asparaginase did not affect treatment outcome. T-cell phenotype was the only independent risk factor for any CNS relapse (hazard ratio, 5.15; 95% CI, 1.3 to 20.6; P = . 021). Among 359 patients with features that were associated with increased risk for CNS relapse, the 5-year rate of any CNS relapse was significantly lower than that among 248 patients with the same features treated in the previous Total Therapy Study 15 (1.8% [95% CI, 0.4% to 3.3%] v 5.7% [95% CI, 2.8% to 8.6%]; P = .008). There were no significant differences in the cumulative risk of seizure or infection during induction between patients who did or did not receive the two extra doses of intrathecal treatment. CONCLUSION Higher doses of PEG-asparaginase failed to improve outcome, but additional intrathecal therapy during early induction seemed to contribute to improved CNS control without excessive toxicity for high-risk patients.
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Affiliation(s)
- Sima Jeha
- St Jude Children’s Research Hospital, Memphis, TN
- University of Tennessee Health Science Center, Memphis, TN
| | - Deqing Pei
- St Jude Children’s Research Hospital, Memphis, TN
- University of Tennessee Health Science Center, Memphis, TN
| | - John Choi
- St Jude Children’s Research Hospital, Memphis, TN
- University of Tennessee Health Science Center, Memphis, TN
| | - Cheng Cheng
- St Jude Children’s Research Hospital, Memphis, TN
- University of Tennessee Health Science Center, Memphis, TN
| | - John T. Sandlund
- St Jude Children’s Research Hospital, Memphis, TN
- University of Tennessee Health Science Center, Memphis, TN
| | | | | | - Hiroto Inaba
- St Jude Children’s Research Hospital, Memphis, TN
- University of Tennessee Health Science Center, Memphis, TN
| | - Jeffrey E. Rubnitz
- St Jude Children’s Research Hospital, Memphis, TN
- University of Tennessee Health Science Center, Memphis, TN
| | - Raul C. Ribeiro
- St Jude Children’s Research Hospital, Memphis, TN
- University of Tennessee Health Science Center, Memphis, TN
| | - Tanja A. Gruber
- St Jude Children’s Research Hospital, Memphis, TN
- University of Tennessee Health Science Center, Memphis, TN
| | - Susana C. Raimondi
- St Jude Children’s Research Hospital, Memphis, TN
- University of Tennessee Health Science Center, Memphis, TN
| | - Raja B. Khan
- St Jude Children’s Research Hospital, Memphis, TN
- University of Tennessee Health Science Center, Memphis, TN
| | - Jun J. Yang
- St Jude Children’s Research Hospital, Memphis, TN
- University of Tennessee Health Science Center, Memphis, TN
| | - Charles G. Mullighan
- St Jude Children’s Research Hospital, Memphis, TN
- University of Tennessee Health Science Center, Memphis, TN
| | - James R. Downing
- St Jude Children’s Research Hospital, Memphis, TN
- University of Tennessee Health Science Center, Memphis, TN
| | - William E. Evans
- St Jude Children’s Research Hospital, Memphis, TN
- University of Tennessee Health Science Center, Memphis, TN
| | - Mary V. Relling
- St Jude Children’s Research Hospital, Memphis, TN
- University of Tennessee Health Science Center, Memphis, TN
| | - Ching-Hon Pui
- St Jude Children’s Research Hospital, Memphis, TN
- University of Tennessee Health Science Center, Memphis, TN
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181
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Muffly L, Curran E. Pediatric-inspired protocols in adult acute lymphoblastic leukemia: are the results bearing fruit? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:17-23. [PMID: 31808881 PMCID: PMC6913493 DOI: 10.1182/hematology.2019000009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Observational findings demonstrating improved survival for younger adults following pediatric, as opposed to adult, acute lymphoblastic leukemia (ALL) regimens have been translated into international, prospective multicenter clinical trials testing the pediatric regimen in young adult ALL. The results of these studies confirm the feasibility of delivering the pediatric regimen in the adult oncology setting and establish the superiority of this approach relative to historical adult cooperative group regimen results. Specific toxicities, including thrombosis, hepatotoxicity, and osteonecrosis, are more prevalent in adults receiving the pediatric regimen relative to young children. Persistent minimal residual disease (MRD) is a strong prognostic indicator in adults receiving the pediatric regimen; sensitive, high-quality MRD evaluation should be performed in all patients receiving these therapies. Incorporation of targeted agents, particularly in the frontline and MRD+ setting, will usher in the next era of the pediatric regimen in adult ALL.
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Affiliation(s)
- Lori Muffly
- Department of Medicine, Division of Blood and Marrow Transplantation, Stanford University, Stanford, CA; and
| | - Emily Curran
- Department of Internal Medicine, Division of Hematology & Oncology, The Vontz Center for Molecular Studies, University of Cincinnati College of Medicine, Cincinnati, OH
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182
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Randomized post-induction and delayed intensification therapy in high-risk pediatric acute lymphoblastic leukemia: long-term results of the international AIEOP-BFM ALL 2000 trial. Leukemia 2019; 34:1694-1700. [DOI: 10.1038/s41375-019-0670-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 10/26/2019] [Accepted: 11/17/2019] [Indexed: 12/14/2022]
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183
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Mueske NM, Mittelman SD, Wren TAL, Gilsanz V, Orgel E. Myosteatosis in adolescents and young adults treated for acute lymphoblastic leukemia. Leuk Lymphoma 2019; 60:3146-3153. [PMID: 31264493 PMCID: PMC6923569 DOI: 10.1080/10428194.2019.1623889] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 05/19/2019] [Indexed: 02/06/2023]
Abstract
Myosteatosis refers to fat deposition within muscle and is linked to risk of cardiovascular disease and metabolic disorders. Though these comorbidities are common during and after therapy for acute lymphoblastic leukemia (ALL), little is known about tissue distribution, including myosteatosis, in this population. Using quantitative computed tomography, we assessed the impact of ALL therapy on bone, muscle, subcutaneous, and muscle-associated (MA) fat in 12 adolescents and young adults (AYA) treated for ALL as compared to a healthy control group without ALL (n = 116). AYA had a marked loss of muscle with a gain in MA fat between ALL diagnosis and end of induction. These changes persisted throughout intensive therapy. Lower bone and muscle and higher MA fat were also observed during and after treatment in comparison to controls. Altered lower extremity tissue distribution, specifically myosteatosis and sarcopenia, may contribute to functional declines and increased risk of metabolic disorders and cardiovascular diseases.
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Affiliation(s)
- Nicole M Mueske
- Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Steven D Mittelman
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Center for Endocrinology, Diabetes & Metabolism, Children's Hospital Los Angeles, CA, USA
| | - Tishya A L Wren
- Children's Orthopaedic Center, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Vicente Gilsanz
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Children's Hospital Imaging Research Program, Children's Hospital, Los Angeles, CA, USA
| | - Etan Orgel
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, Los Angeles, CA, USA
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184
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Vijayakrishnan J, Qian M, Studd JB, Yang W, Kinnersley B, Law PJ, Broderick P, Raetz EA, Allan J, Pui CH, Vora A, Evans WE, Moorman A, Yeoh A, Yang W, Li C, Bartram CR, Mullighan CG, Zimmerman M, Hunger SP, Schrappe M, Relling MV, Stanulla M, Loh ML, Houlston RS, Yang JJ. Identification of four novel associations for B-cell acute lymphoblastic leukaemia risk. Nat Commun 2019; 10:5348. [PMID: 31767839 PMCID: PMC6877561 DOI: 10.1038/s41467-019-13069-6] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 10/17/2019] [Indexed: 12/12/2022] Open
Abstract
There is increasing evidence for a strong inherited genetic basis of susceptibility to acute lymphoblastic leukaemia (ALL) in children. To identify new risk variants for B-cell ALL (B-ALL) we conducted a meta-analysis with four GWAS (genome-wide association studies), totalling 5321 cases and 16,666 controls of European descent. We herein describe novel risk loci for B-ALL at 9q21.31 (rs76925697, P = 2.11 × 10-8), for high-hyperdiploid ALL at 5q31.1 (rs886285, P = 1.56 × 10-8) and 6p21.31 (rs210143 in BAK1, P = 2.21 × 10-8), and ETV6-RUNX1 ALL at 17q21.32 (rs10853104 in IGF2BP1, P = 1.82 × 10-8). Particularly notable are the pleiotropic effects of the BAK1 variant on multiple haematological malignancies and specific effects of IGF2BP1 on ETV6-RUNX1 ALL evidenced by both germline and somatic genomic analyses. Integration of GWAS signals with transcriptomic/epigenomic profiling and 3D chromatin interaction data for these leukaemia risk loci suggests deregulation of B-cell development and the cell cycle as central mechanisms governing genetic susceptibility to ALL.
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Affiliation(s)
- Jayaram Vijayakrishnan
- Division of Genetics and Epidemiology, The Institute of Cancer Research, 15 Cotswold Road, Sutton, Surrey, SM2 5NG, UK
| | - Maoxiang Qian
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
- Children's Hospital and Institutes of Biomedical Sciences, Fudan University, Shanghai, China
| | - James B Studd
- Division of Genetics and Epidemiology, The Institute of Cancer Research, 15 Cotswold Road, Sutton, Surrey, SM2 5NG, UK
| | - Wenjian Yang
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Ben Kinnersley
- Division of Genetics and Epidemiology, The Institute of Cancer Research, 15 Cotswold Road, Sutton, Surrey, SM2 5NG, UK
| | - Philip J Law
- Division of Genetics and Epidemiology, The Institute of Cancer Research, 15 Cotswold Road, Sutton, Surrey, SM2 5NG, UK
| | - Peter Broderick
- Division of Genetics and Epidemiology, The Institute of Cancer Research, 15 Cotswold Road, Sutton, Surrey, SM2 5NG, UK
| | - Elizabeth A Raetz
- Division of Pediatric Hematology and Oncology, New York University Langone Health, New York, New York, USA
| | - James Allan
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - Ching-Hon Pui
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
- Hematological Malignancies Program, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | | | - William E Evans
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
- Hematological Malignancies Program, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Anthony Moorman
- Wolfson Childhood Cancer Research Centre, Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, NE1 7RU, UK
| | - Allen Yeoh
- Centre for Translational Research in Acute Leukaemia, Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- VIVA-University Children's Cancer Centre, Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, National University Health System, Singapore, Singapore
| | - Wentao Yang
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Chunliang Li
- Department of Tumor Cell Biology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Claus R Bartram
- Institute of Human Genetics, University Hospital, Heidelberg, Germany
| | - Charles G Mullighan
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
- Hematological Malignancies Program, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Martin Zimmerman
- Department of Paediatric Haematology and Oncology, Hannover Medical School, 30625, Hannover, Germany
| | - Stephen P Hunger
- Department of Paediatrics and Centre for Childhood Cancer Research, Children's Hospital of Philadelphia and the Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Martin Schrappe
- Department of Paediatrics, University Medical Centre Schleswig-Holstein, Kiel, Germany
| | - Mary V Relling
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
- Hematological Malignancies Program, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Martin Stanulla
- Department of Paediatric Haematology and Oncology, Hannover Medical School, 30625, Hannover, Germany
| | - Mignon L Loh
- Department of Pediatrics, Benioff Children's Hospital and the Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California, USA
| | - Richard S Houlston
- Division of Genetics and Epidemiology, The Institute of Cancer Research, 15 Cotswold Road, Sutton, Surrey, SM2 5NG, UK.
| | - Jun J Yang
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA.
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA.
- Hematological Malignancies Program, St. Jude Children's Research Hospital, Memphis, Tennessee, USA.
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185
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Winick N, Martin PL, Devidas M, Shuster J, Borowitz MJ, Paul Bowman W, Larsen E, Pullen J, Carroll A, Willman C, Hunger SP, Carroll WL, Camitta BM. Randomized assessment of delayed intensification and two methods for parenteral methotrexate delivery in childhood B-ALL: Children's Oncology Group Studies P9904 and P9905. Leukemia 2019; 34:1006-1016. [PMID: 31728054 DOI: 10.1038/s41375-019-0642-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 10/11/2019] [Accepted: 11/03/2019] [Indexed: 11/12/2022]
Abstract
The delayed intensification (DI) enhanced outcome for patients with acute lymphoblastic leukemia (ALL) treated on BFM 76/79 and CCG 105 after a prednisone-based induction. Childrens Oncology Group protocols P9904/9905 evaluated DI via a post-induction randomization for eligible National Cancer Institute (NCI) standard (SR) and high-risk (HR) patients. A second randomization compared intravenous methotrexate (IV MTX) as a 24- (1 g/m2) vs. 4-h (2 g/m2) infusion. NCI SR patients received a dexamethasone-based three-drug and NCI HR/CNS 3 SR patients a prednisone-based four-drug induction. End induction MRD (minimal residual disease) was obtained but did not impact treatment. DI improved the 10-year continuous complete remission (CCR) rate; 75.5 ± 2.5% vs. 81.8 ± 2.2% p = 0.002, whereas MTX administration did not; 4-h 80.8 ± 1.9%; 24-h 81.4 ± 1.9% (p = 0.7780). Overall survival (OS) at 10 years did not differ with DI: 91.4 ± 1.6% vs. 90.9 ± 1.7% (p = 0.25) without but was higher with the 24-h MTX infusion; 4-h 91.1 ± 1.4%; 24-h 93.9 ± 1.2% (p = 0.0209). MRD predicted outcome; 10-year CCR 87.7 ± 2.2 and 82.1 ± 2.5% when MRD was <0.01% with/without DI (p = 0.007) and 54.3 ± 8% and 44 ± 8% for patients with MRD ≥ 0.01% with/without DI (p = 0.11). DI improved CCR for patients with B-ALL with and without end induction MRD.
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Affiliation(s)
- Naomi Winick
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Paul L Martin
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Meenakshi Devidas
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Jonathan Shuster
- Department of Health Outcomes and Policy, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Michael J Borowitz
- Department of Pathology and Oncology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - W Paul Bowman
- Department of Pediatrics, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Eric Larsen
- Maine Children's Cancer Program, Scarborough, ME, USA
| | - Jeanette Pullen
- Department of Pediatrics, University of Mississippi, Jackson, MS, USA
| | - Andrew Carroll
- Department of Genetics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Cheryl Willman
- Cancer Center and Departments of Internal Medicine and Pathology, University of New Mexico, Albuquerque, NM, USA
| | - Stephen P Hunger
- Department of Pediatrics and the Center for Childhood Cancer Research, Children's Hospital of Philadelphia, and the Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA
| | - William L Carroll
- Department of Pediatrics and The Perlmutter Cancer Center, New York University Medical Center, New York, NY, USA
| | - Bruce M Camitta
- Department of Pediatrics, Midwest Center for Cancer and Blood Disorders, Medical College of Wisconsin, Milwaukee, WI, USA
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186
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Jastaniah W. Improving survival outcomes of childhood acute lymphoblastic leukemia: A 25-year experience from a single center in Saudi Arabia. Pediatr Blood Cancer 2019; 66:e27782. [PMID: 31184419 DOI: 10.1002/pbc.27782] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 04/10/2019] [Accepted: 04/15/2019] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The development of cancer programs in developing countries to meet the standards observed in high-income developed countries is not well documented. METHODS An analysis of patient care of children with acute lymphoblastic leukemia (ALL) at the Princess Noorah Oncology Center over 25 years was performed. A number of improvements were introduced over time including optimizing the cancer care delivery culture, improving access to care, optimizing supportive care, and refining diagnostic and therapeutic capabilities. Outcomes were evaluated over three time periods (period 1, 1989-2000; period 2, 2001-2007; and period 3, 2008-2014). These findings were compared with results of collaborative clinical trials (CCT). RESULTS Of the 686 patients treated, the five-year overall survival (OS) rate improved from 74% ± 2.7% in period 1 to 89.5% ± 2.3% in period 3 (P < 0.0001). Among all patients, the five-year cumulative incidence of death decreased from 26% in period 1 to 10.5% in period 3 (P < 0.0001). This decrease was mainly due to reduction in the incidence of death from disease (P < 0.00001). In contrast, significant improvement in T-cell ALL survival outcomes (P < 0.0001) was observed overtime (from period 1 to period 3) as a result of significant reduction in both toxic deaths (P = 0.005) and disease-related deaths (P = 0.001). CONCLUSIONS Survival outcomes in Saudi Arabia have improved with five-year OS rate now approaching 90%. However, further population-based research is needed to understand variance in outcomes from those reported by CCT groups.
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Affiliation(s)
- Wasil Jastaniah
- College of Medicine, Department of Pediatrics, Umm AlQura University, Makkah, Saudi Arabia.,Princess Noorah Oncology Center, Ministry of National Guard-Health Affairs, Jeddah, Saudi Arabia
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187
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Population pharmacokinetics of methotrexate in Mexican pediatric patients with acute lymphoblastic leukemia. Cancer Chemother Pharmacol 2019; 85:21-31. [DOI: 10.1007/s00280-019-03977-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 10/15/2019] [Indexed: 12/20/2022]
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188
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Metabolomic profiling identifies pathways associated with minimal residual disease in childhood acute lymphoblastic leukaemia. EBioMedicine 2019; 48:49-57. [PMID: 31631039 PMCID: PMC6838385 DOI: 10.1016/j.ebiom.2019.09.033] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 09/29/2019] [Accepted: 09/30/2019] [Indexed: 12/11/2022] Open
Abstract
Background End-induction minimal residual disease (MRD) is the strongest predictor of relapse in paediatric acute lymphoblastic leukaemia (ALL), but an understanding of the biological pathways underlying early treatment response remains elusive. We hypothesized that metabolomic profiling of diagnostic bone marrow plasma could provide insights into the underlying biology of early treatment response and inform treatment strategies for high-risk patients. Methods We performed global metabolomic profiling of samples from discovery (N = 93) and replication (N = 62) cohorts treated at Texas Children's Hospital. Next, we tested the cytotoxicity of drugs targeting central carbon metabolism in cell lines and patient-derived xenograft (PDX) cells. Findings Metabolite set enrichment analysis identified altered central carbon and amino acid metabolism in MRD-positive patients from both cohorts at a 5% false discovery rate. Metabolites from these pathways were used as inputs for unsupervised hierarchical clustering. Two distinct clusters were identified, which were independently associated with MRD after adjustment for immunophenotype, cytogenetics, and NCI risk group. Three nicotinamide phosphoribosyltransferase (NAMPT) inhibitors, which reduce glycolytic/TCA cycle activities, demonstrated nanomolar-range cytotoxicity in B- and T-ALL cell lines and PDX cells. Interpretation This study provides new insights into the role of central carbon metabolism in early treatment response and as a potential targetable pathway in high-risk disease. Funding American Society of Hematology; Baylor College of Medicine Department of Paediatrics; Cancer Prevention and Research Institute of Texas; the Lynch family; St. Baldrick's Foundation with support from the Micaela's Army Foundation; United States National Institutes of Health.
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189
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Torre M, Solomon IH, Sutherland CL, Nikiforow S, DeAngelo DJ, Stone RM, Vaitkevicius H, Galinsky IA, Padera RF, Trede N, Santagata S. Neuropathology of a Case With Fatal CAR T-Cell-Associated Cerebral Edema. J Neuropathol Exp Neurol 2019; 77:877-882. [PMID: 30060228 DOI: 10.1093/jnen/nly064] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Chimeric antigen receptor (CAR) T cells are a new and powerful class of cancer immunotherapeutics that have shown potential for the treatment of hematopoietic malignancies. The tremendous promise of this approach is tempered by safety concerns, including potentially fatal neurotoxicity, sometimes but not universally associated with cytokine release syndrome. We describe the postmortem examination of a brain from a 21-year-old patient with relapsed pre-B cell acute lymphoblastic leukemia (ALL) who died from fulminant cerebral edema following CAR T-cell infusion. We found a range of changes that included activation of microglia, expansion of perivascular spaces by proteinaceous exudate, and clasmatodendrosis-a beading of glial fibrillary acidic protein consistent with astrocyte injury. Notably, within the brain parenchyma, we identified only infrequent T cells and did not identify ALL cells or CAR T cells. The overall findings are nonspecific but raise the possibility of astrocyte and blood-brain barrier dysfunction as a potential etiology of fatal CAR T-cell neurotoxicity in this patient.
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Affiliation(s)
- Matthew Torre
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Isaac H Solomon
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Sarah Nikiforow
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Daniel J DeAngelo
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Richard M Stone
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Henrikas Vaitkevicius
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ilene A Galinsky
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Robert F Padera
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Sandro Santagata
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Oncologic Pathology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Lab for Systems Pharmacology, Harvard Medical School, Boston, Massachusetts
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190
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Brace KM, Lee WW, Cole PD, Sussman ES. Childhood leukemia survivors exhibit deficiencies in sensory and cognitive processes, as reflected by event-related brain potentials after completion of curative chemotherapy: A preliminary investigation. J Clin Exp Neuropsychol 2019; 41:814-831. [PMID: 31156064 PMCID: PMC6663575 DOI: 10.1080/13803395.2019.1623865] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 05/20/2019] [Indexed: 10/26/2022]
Abstract
Objective: The purpose of this study was to characterize post-chemotherapy sensory, memory, and attention abilities in childhood survivors of acute lymphoblastic leukemia (ALL) to better understand how treatment affects cognitive functioning. Methods: Eight ALL survivors and eight age-matched, healthy children between the ages of 5-11 years participated in the study. Among the ALL survivors, a median of 63 days (range 22-267 days) elapsed between completion of chemotherapy and this assessment. Sounds were presented in an oddball paradigm while recording the electroencephalogram in separate conditions of passive listening and active task performance. To assess different domains of cognition, we measured event-related brain potentials (ERPs) reflecting sensory processing (P1 component), working memory (mismatch negativity [MMN] component), attentional orienting (P3a), and target detection (P3b component) in response to the sounds. We also measured sound discrimination and response speed performance. Results: Relative to control subjects, ALL survivors had poorer performance on auditory tasks, as well as decreased amplitude of the P1, MMN, P3a, and P3b components. ALL survivors also did not exhibit the amplitude gain typically observed in the sensory P1 component when attending to the sound input compared to when passively listening. Conclusions: Atypical responses were observed in brain processes associated with sensory discrimination, auditory working memory, and attentional control in pediatric ALL survivors indicating deficiencies in all cognitive domains compared to age-matched controls. Significance: ERPs differentiated aspects of cognitive functioning, which may provide a useful tool for assessing recovery and risk of post-chemotherapy cognitive deficiencies in young children. The decreased MMN amplitude in ALL survivors may indicate (N-methyl D-aspartate) NMDA dysfunction induced by methotrexate, and thus provides a potential therapeutic target for chemotherapy-associated cognitive impairments.
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Affiliation(s)
- Kelin M. Brace
- Department of Neuroscience, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461, United States
| | - Wei Wei Lee
- Department of Neuroscience, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461, United States
| | - Peter D. Cole
- Department of Pediatrics, Rutgers Cancer Institute of New Jersey, 195 Little Albany Street, New Brunswick, NJ 08901, United States
| | - Elyse S. Sussman
- Department of Neuroscience, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461, United States
- Department of Otorhinolaryngology, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461, United States
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191
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Wang SS, Kotecha RS, Bernard A, Blyth CC, McMullan BJ, Cann MP, Yeoh DK, Bartlett AW, Ryan AL, Moore AS, Bryant PA, Clark J, Haeusler GM. Invasive fungal infections in children with acute lymphoblastic leukaemia: Results from four Australian centres, 2003-2013. Pediatr Blood Cancer 2019; 66:e27915. [PMID: 31309711 DOI: 10.1002/pbc.27915] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 05/29/2019] [Accepted: 06/24/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Invasive fungal infections (IFI) are an important complication of acute lymphoblastic leukaemia (ALL) treatment. Our study describes the prevalence and outcomes of IFI in children with ALL. METHODS IFI episodes in children with primary or relapsed ALL, identified for The Epidemiology and Risk Factors for Invasive Fungal Infections in Immunocompromised Children study, were analysed. IFI were classified according to European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group criteria with a 'modified-possible' category included. RESULTS A total of 123 IFI episodes in 119 patients with ALL were included. A proven, probable, possible and modified-possible IFI was diagnosed in 56 (45.5%), 22 (17.9%), 39 (31.7%) and six (4.9%) episodes, respectively. The prevalence was 9.7% (95% confidence interval [CI] 8-11.4%) overall and 23.5% (95% CI 14.5-32.5%) for relapsed/refractory ALL. For non-relapsed ALL, the IFI prevalence was significantly higher for children with high-risk compared to standard-risk ALL (14.5% vs 7.3%, P = .009), and IFI were more common during induction, consolidation and delayed intensification phases. Mould infections occurred more frequently than non-mould infections. Thirteen children (10.9%) died within 6 months of IFI diagnosis with five deaths (4.2%) attributable to an IFI. CONCLUSIONS IFI is more common in children with high-risk ALL and in relapsed disease. Overall survival was encouraging, with IFI contributing to very few deaths.
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Affiliation(s)
- Stacie S Wang
- Children's Cancer Centre, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Rishi S Kotecha
- Department of Haematology and Oncology, Perth Children's Hospital, Perth, Western Australia, Australia.,Telethon Kids Cancer Centre, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia.,School of Pharmacy and Biomedical Sciences, Curtin University, Perth, Western Australia, Australia
| | - Anne Bernard
- QFAB Bioinformatics, Institute for Molecular Bioscience, The University of Queensland, Brisbane, Queensland, Australia
| | - Christopher C Blyth
- School of Medicine and Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia.,Department of Infectious Diseases, Perth Children's Hospital, Perth, Western Australia, Australia.,Department of Microbiology, PathWest Laboratory Medicine, Perth, Western Australia, Australia
| | - Brendan J McMullan
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia.,Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Sydney, New South Wales, Australia.,School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Megan P Cann
- Infection Management Service, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Daniel K Yeoh
- Department of Infectious Diseases, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Adam W Bartlett
- Department of Immunology and Infectious Diseases, Sydney Children's Hospital, Sydney, New South Wales, Australia.,School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia.,Biostatistics and Databases Program, Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia
| | - Anne L Ryan
- Department of Haematology and Oncology, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Andrew S Moore
- Oncology Services Group, Queensland Children's Hospital, Brisbane, Queensland, Australia.,Diamantina Institute & Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia
| | - Penelope A Bryant
- Infectious Diseases Unit, Department of General Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia.,Clinical Paediatrics, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Julia Clark
- Infection Management Service, Queensland Children's Hospital, Brisbane, Queensland, Australia.,School of Clinical Medicine, University of Queensland, Brisbane, Queensland, Australia.,Centre for Children's Health Research, Children's Health Queensland, Brisbane, Queensland, Australia
| | - Gabrielle M Haeusler
- NHMRC National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia.,Infectious Diseases Unit, Department of General Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia.,Clinical Paediatrics, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,The Paediatric Integrated Cancer Service, Melbourne, Victoria, Australia.,Department of Infectious Diseases, Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
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192
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Gaynon PS. Methotrexate and asparaginase: not so simple. Leuk Lymphoma 2019; 60:2849-2850. [PMID: 31558076 DOI: 10.1080/10428194.2019.1668941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Paul S Gaynon
- Children's Hospital Los Angeles, University of Southern California, Los Angeles, CA, USA
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193
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Siegel SE, Stock W, Johnson RH, Advani A, Muffly L, Douer D, Reed D, Lewis M, Freyer DR, Shah B, Luger S, Hayes-Lattin B, Jaboin JJ, Coccia PF, DeAngelo DJ, Seibel N, Bleyer A. Pediatric-Inspired Treatment Regimens for Adolescents and Young Adults With Philadelphia Chromosome-Negative Acute Lymphoblastic Leukemia: A Review. JAMA Oncol 2019; 4:725-734. [PMID: 29450465 DOI: 10.1001/jamaoncol.2017.5305] [Citation(s) in RCA: 105] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Importance The incidence of acute lymphoblastic leukemia (ALL) and lymphoblastic lymphoma (LBL) in adolescent and young adult (AYA) patients (age range, 15-39 years) in the United States is increasing at a greater rate than in younger or older persons. Their optimal treatment has been increasingly debated as pediatric regimens have become more widely used in the age group. This review compares the basic features of pediatric and adult chemotherapy regimens for ALL and LBL, recognizes and describes the challenges of the pediatric regimen, and suggests strategies to facilitate its adoption for AYAs with ALL and LBL. Observations All but 2 of 25 published comparisons of outcomes with pediatric and adult regimens for ALL and LBL in AYAs and 1 meta-analysis favor the pediatric regimen. After more than a half-century of clinical trials of the pediatric regimens, including at least 160 phase 3 trials in the United States, the pediatric regimens have become far more complex than most adult regimens. Asparaginase, a critical component of the pediatric regimens, is more difficult to administer to AYAs (and older patients) but nonetheless has a favorable benefit to toxicity ratio for AYAs. A dramatic reduction in outcome of ALL and LBL during the AYA years (the "survival cliff") is coincident with similar reductions in proportions of AYAs referred to academic centers and enrolled on clinical trials (the "accrual cliff" and "referral cliff"). Conclusions and Relevance The accumulating data increasingly support treating AYAs with ALL and LBL with a pediatric-inspired regimen or an approved institutional or national clinical trial tailored for this patient group. A need to develop clinical trials specifically for AYAs and to encourage their participation is paramount, with a goal to improve both the quantity and quality of survival.
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Affiliation(s)
| | - Wendy Stock
- Alliance for Clinical Trials in Oncology (National Cancer Institute-Sponsored National Clinical Trials Network Cooperative Group).,Section of Hematology/Oncology, University of Chicago Comprehensive Cancer Center, Chicago, Illinois
| | - Rebecca H Johnson
- SWOG (National Cancer Institute-Sponsored National Clinical Trials Network Cooperative Group).,Children's Oncology Group (National Cancer Institute-Sponsored National Clinical Trials Network Cooperative Group).,National Clinical Oncology Research Program (All in the National Cancer Institute National Clinical Trials Network).,Pediatric Hematology/Oncology, Mary Bridge Children's Hospital and Health Center and Tacoma General Hospital, Tacoma, Washington
| | - Anjali Advani
- SWOG (National Cancer Institute-Sponsored National Clinical Trials Network Cooperative Group).,Hematology/Oncology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Lori Muffly
- SWOG (National Cancer Institute-Sponsored National Clinical Trials Network Cooperative Group).,Blood and Marrow Transplantation, Department of Medicine, Stanford University, Palo Alto, California
| | - Dan Douer
- ECOG-ACRIN Cancer Research Group (National Cancer Institute-Sponsored National Clinical Trials Network Cooperative Group).,Keck Medicine, University of Southern California Norris Comprehensive Cancer Center, Los Angeles
| | - Damon Reed
- National Pediatric Cancer Foundation, Tampa, Florida.,Moffitt Cancer Center, Tampa, Florida
| | - Mark Lewis
- SWOG (National Cancer Institute-Sponsored National Clinical Trials Network Cooperative Group).,Hematology/Oncology, Intermountain Healthcare, Salt Lake City, Utah
| | - David R Freyer
- Children's Oncology Group (National Cancer Institute-Sponsored National Clinical Trials Network Cooperative Group).,Keck Medicine, University of Southern California Norris Comprehensive Cancer Center, Los Angeles
| | - Bijal Shah
- SWOG (National Cancer Institute-Sponsored National Clinical Trials Network Cooperative Group).,Moffitt Cancer Center, Tampa, Florida.,National Comprehensive Cancer Network
| | - Selina Luger
- ECOG-ACRIN Cancer Research Group (National Cancer Institute-Sponsored National Clinical Trials Network Cooperative Group).,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Brandon Hayes-Lattin
- SWOG (National Cancer Institute-Sponsored National Clinical Trials Network Cooperative Group).,Department of Radiation Medicine, Oregon Health and Science University, Portland
| | - Jerry J Jaboin
- Department of Radiation Medicine, Oregon Health and Science University, Portland.,NRG Oncology (National Cancer Institute-Sponsored National Clinical Trials Network Cooperative Group), National Cancer Institute, Bethesda, Maryland
| | - Peter F Coccia
- Children's Oncology Group (National Cancer Institute-Sponsored National Clinical Trials Network Cooperative Group).,National Comprehensive Cancer Network.,Department of Pediatrics, University of Nebraska Medical Center, Omaha
| | - Daniel J DeAngelo
- Alliance for Clinical Trials in Oncology (National Cancer Institute-Sponsored National Clinical Trials Network Cooperative Group).,Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Nita Seibel
- SWOG (National Cancer Institute-Sponsored National Clinical Trials Network Cooperative Group).,Cancer Therapy Evaluation Program, National Cancer Institute, Bethesda, Maryland
| | - Archie Bleyer
- SWOG (National Cancer Institute-Sponsored National Clinical Trials Network Cooperative Group).,Department of Radiation Medicine, Oregon Health and Science University, Portland
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194
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Geerlinks A, Keis J, Ngan B, Shammas A, Vali R, Hitzler J. Unusual lymphoid malignancy and treatment response in two children with Down syndrome. Pediatr Blood Cancer 2019; 66:e27822. [PMID: 31136091 DOI: 10.1002/pbc.27822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 05/07/2019] [Accepted: 05/08/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND Lymphoid malignancies other than acute lymphoblastic leukemia (ALL) are rare in children with Down syndrome (DS). Information about the toxicity of chemotherapy and prognosis is largely derived from the experience of children with DS and ALL or children without DS. PROCEDURE We describe the treatment and outcome of two unusual lymphoid malignancies in children with DS. One patient was diagnosed with Burkitt lymphoma (BL) and the second, after treatment for B precursor ALL, with T-cell EBV-positive proliferative disorder (LPD). RESULTS BL was treated with standard doses of LMB group B therapy subsequently intensified to group C therapy, including high-dose methotrexate (HD-MTX, 3-8 g/m2 ). The patient did not experience excessive toxicity and remains in complete remission 13 months later. Despite presentation with disseminated disease the patient with T-cell EBV-positive LPD after treatment for B precursor ALL responded to dexamethasone and rituximab and remains in complete remission two years later. CONCLUSIONS Upfront reduction of the high treatment intensity, which is associated with excellent survival outcomes in BL, may not be warranted in all children with DS. Response to therapy and prognosis of T-cell EBV-positive LPD in a patient with DS was not predicted by reported experience in the absence of DS.
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Affiliation(s)
- Ashley Geerlinks
- Division of Hematology/Oncology, The Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer Keis
- Division of Hematology/Oncology, The Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Bo Ngan
- Division of Pathology, Department of Paediatric Laboratory Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Amer Shammas
- Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Reza Vali
- Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Johann Hitzler
- Division of Hematology/Oncology, The Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada.,Developmental and Stem Cell Biology, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
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195
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Advani AS, Hanna R. The treatment of adolescents and young adults with acute lymphoblastic leukemia. Leuk Lymphoma 2019; 61:18-26. [PMID: 31452423 DOI: 10.1080/10428194.2019.1658103] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Adolescents and young adults (AYAs) with ALL represent a unique population in terms of their biology and treatment. Studies have demonstrated an improved outcome when these patients are treated with pediatric-inspired regimens. Novel antibody based therapies have demonstrated impressive results in relapsed/refractory B-ALL and are starting to be evaluated in the upfront setting. Immunotherapy with CAR T cells had great success in ALL and clinical trials are ongoing and further studies are being done to expand access to this therapy and decrease toxicities. Although our outcomes with this disease have improved significantly, transplant still plays a role for high risk patients in CR1 (based on MRD status) and for patients with relapsed/refractory ALL.
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Affiliation(s)
- Anjali S Advani
- Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA
| | - Rabi Hanna
- Cleveland Clinic Pediatric Hematology-Oncology, Cleveland, OH, USA
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196
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Maternal Haplotypes in DHFR Promoter and MTHFR Gene in Tuning Childhood Acute Lymphoblastic Leukemia Onset-Latency: Genetic/Epigenetic Mother/Child Dyad Study (GEMCDS). Genes (Basel) 2019; 10:genes10090634. [PMID: 31443485 PMCID: PMC6770441 DOI: 10.3390/genes10090634] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 08/16/2019] [Accepted: 08/19/2019] [Indexed: 12/15/2022] Open
Abstract
Childhood acute lymphoblastic leukemia (ALL) peaks around age 2–4, and in utero genetic epigenetic mother-fetus crosstalk might tune ALL onset during childhood life. Folate genes variably interact with vitamin status on ALL risk and prognosis. We investigated DHFR and MTHFR gene variants in 235 ALL children and their mothers to disclose their role in determining ALL onset age and survival. Pyrosequence of DHFR 19bp ins/del (rs70991108; W/D), MTHFR C677T (rs1801133; C>T), and MTHFR A1298C (rs1801131; A>C) was assessed in children and in 72% of mothers for dyad-analysis comparison. DHFR DD-children had delayed ALL onset compared to WW-children (7.5 ± 4.8 vs. 5.2 ± 3.7 years; P = 0.002) as well as MTHFR 1298 CC-children compared to AA-children (8.03 ± 4.8 vs. 5.78 ± 4.1 years; P = 0.006), and according to the strong linkage disequilibrium between MTHFR 677 T-allele and 1298C-allele, MTHFR TT-children showed early mean age of onset though not significant. Offspring of MTHFR 677 TT-mothers had earlier ALL onset compared to offspring of 677 CC-mothers (5.4 ± 3.3 vs. 7 ± 5.3 years; P = 0.017). DHFR/MTHFR 677 polymorphism combination influenced onset age by comparing DD/CC vs. WW/TT children (8.1 ± 5.7 vs. 4.7 ± 2.1 years; P = 0.017). Moreover, mother-child genotype combination gave 5.5-years delayed onset age in favor of DD-offspring of 677 CC-mothers vs. WW-offspring of 677 TT-mothers, and it was further confirmed including any D-carrier children and any 677 T-carrier mothers (P = 0.00052). Correction for multiple comparisons maintained statistical significance for DHFR ins/del and MTHFR A1298C polymorphisms. Unexpectedly, among the very-early onset group (<2.89 years; 25th), DD-genotype inversely clustered in children and mothers (4.8% vs. 23.8% respectively), and accordingly ALL offspring of homozygous DD-mothers had increased risk to have early-onset (adjusted OR (odds ratio) = 3.08; 1.1–8.6; P = 0.03). The opposite effect DHFR promoter variant has in tuning ALL onset-time depending on who is the carrier (i.e., mother or child) might suggest a parent-origin-effect of the D-allele or a two-faced epigenetic role driven by unbalanced folate isoform availability during the in-utero leukemogenesis responsible for the wide postnatal childhood ALL latency.
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197
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Pelland-Marcotte MC, Pole JD, Hwee J, Sutradhar R, Science M, Nathan PC, Sung L. Long-Term Risk of Infections After Treatment of Childhood Leukemia: A Population-Based Cohort Study Using Administrative Health Data. J Clin Oncol 2019; 37:2651-2660. [PMID: 31393747 DOI: 10.1200/jco.19.00570] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Infections are a frequent complication during childhood leukemia treatment. Little is known about the infectious risk in survivors. We compared the relative rate (RR) of infections after treatment completion between pediatric leukemia survivors and the general population. METHODS We performed a retrospective, population-based cohort study of children diagnosed with leukemia between 1992 and 2015 in Ontario, Canada, who were alive and relapse free 30 days after treatment completion (index date). Leukemia survivors were matched 5:1 with the general population by year of birth, sex, and rural status and stratified by initial treatment, including and excluding hematopoietic stem-cell transplantation (HSCT). The primary outcome was time to infections, as identified using validated diagnostic codes from administrative databases. Individuals were censored at the earliest of death, first relapse, loss to follow-up, or end of study. RESULTS A total of 2,204 leukemia survivors were included and matched with 11,020 controls. The rate of infections was elevated after treatment completion compared with controls (RR, 1.51; 95% CI, 1.45 to 1.57) and at less than 1 year (RR, 1.77; 95% CI, 1.69 to 1.86); 1 to 4.99 years (RR, 1.66; 95% CI, 1.62 to 1.71), and 5 or more years (RR, 1.29; 95% CI, 1.22 to 1.36) from the index date. Among those whose initial treatment excluded HSCT, the rate remained elevated more than 5 years from the index date (RR, 1.29; 95% CI, 1.23 to 1.35). Infection-related death was significantly increased in leukemia survivors both among the entire cohort (hazard ratio, 149.3; 95% CI, 20.4 to 1,091.9) and among those without HSCT (hazard ratio, 92.7; 95% CI, 12.4 to 690.7). CONCLUSION A significant association was found between a history of leukemia therapy and an increased risk of infections. Additional study is needed to establish which exposures in patients with leukemia lead to late infections.
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Affiliation(s)
| | - Jason D Pole
- The Hospital for Sick Children, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Services, Toronto, Ontario, Canada
| | - Jeremiah Hwee
- University of Toronto, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Services, Toronto, Ontario, Canada.,Trillium Health Partners, Mississauga, Ontario, Canada
| | - Rinku Sutradhar
- University of Toronto, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Services, Toronto, Ontario, Canada
| | | | - Paul C Nathan
- The Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - Lillian Sung
- The Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
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198
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Carroll AJ, Shago M, Mikhail FM, Raimondi SC, Hirsch BA, Loh ML, Raetz EA, Borowitz MJ, Wood BL, Maloney KW, Mattano LA, Larsen EC, Gastier-Foster J, Stonerock E, Ell D, Kahwash S, Devidas M, Harvey RC, Chen IML, Willman CL, Hunger SP, Winick NJ, Carroll WL, Rao KW, Heerema NA. Masked hypodiploidy: Hypodiploid acute lymphoblastic leukemia (ALL) mimicking hyperdiploid ALL in children: A report from the Children's Oncology Group. Cancer Genet 2019; 238:62-68. [PMID: 31425927 DOI: 10.1016/j.cancergen.2019.07.009] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 06/28/2019] [Accepted: 07/27/2019] [Indexed: 10/26/2022]
Abstract
Hyperdiploidy with greater than 50 chromosomes is usually associated with favorable prognosis in pediatric acute lymphoblastic leukemia (ALL), whereas hypodiploidy with ≤43 chromosomes is associated with extremely poor prognosis. Sometimes, hypodiploidy is "masked" and patients do not have a karyotypically visible clone with ≤43 chromosomes. Instead, their abnormal karyotypes contain 50-78 or more chromosomes from doubling of previously hypodiploid cells. When the hypodiploid and doubled hyperdiploid clones are both present, patients can be identified by traditional test methods [karyotype, DNA Index (DI), fluorescence in situ hybridization (FISH)], but the incidence of masked hypodiploid cases in which only the doubled clone is visible is unknown. We analyzed 7013 patients with B-ALL enrolled in COG AALL03B1 (2003-2011) for whom chromosome studies were available. Of 115 patients with hypodiploidy (25-39 chromosomes), karyotypes of 40 showed only the hypodiploid clone, 47 showed mosaicism with both hypodiploid and hyperdiploid (doubled) karyotypes, and 28 with masked hypodiploidy showed only a hyperdiploid (doubled) clone. Unique karyotypic signatures were identified, and widespread loss of heterozygosity (LOH) was seen in the microsatellite panel for all patients with masked hypodiploidy. An increased awareness of the unusual karyotypic profile associated with a doubled hypodiploid clone and coordinated use of DI, FISH, and LOH studies when indicated can identify patients with masked hypodiploidy and allow appropriate treatment selection.
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Affiliation(s)
- Andrew J Carroll
- Department of Genetics, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Mary Shago
- Department of Pathobiology and Laboratory Medicine, University of Toronto, Toronto, ON, Canada
| | - Fady M Mikhail
- Department of Genetics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Susana C Raimondi
- Department of Pathology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Betsy A Hirsch
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Mignon L Loh
- Department of Pediatrics, UCSF Medical Center-Mission Bay, San Francisco, CA, USA
| | - Elizabeth A Raetz
- Department of Pediatrics, New York University Medical Center, New York, NY, USA
| | - Michael J Borowitz
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Brent L Wood
- Department of Laboratory Medicine, University of Washington, Seattle, WA, USA
| | | | | | - Eric C Larsen
- Maine Children's Cancer Program, Scarborough, ME, USA
| | - Julie Gastier-Foster
- Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, USA; Department of Pathology, The Ohio State University, Columbus, OH, USA
| | - Eileen Stonerock
- Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Denise Ell
- Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Samir Kahwash
- Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Meenakshi Devidas
- Department of Biostatistics, University of Florida, Gainesville, FL, USA
| | | | - I-Ming L Chen
- University of New Mexico Cancer Center, Albuquerque, NM, USA
| | | | - Stephen P Hunger
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Naomi J Winick
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - William L Carroll
- Department of Pediatrics, New York University Medical Center, New York, NY, USA
| | - Kathleen W Rao
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Nyla A Heerema
- Department of Pathology, The Ohio State University, Columbus, OH, USA
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199
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Duffy EA, Adams T, Thornton CP, Fisher B, Misasi J, McCollum S. Evidence-Based Recommendations for the Appropriate Level of Sedation to Manage Pain in Pediatric Oncology Patients Requiring Procedures: A Systematic Review From the Children's Oncology Group [Formula: see text]. J Pediatr Oncol Nurs 2019; 37:6-20. [PMID: 31303100 PMCID: PMC7492720 DOI: 10.1177/1043454219858610] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Repeated invasive and painful procedures are often necessary components of pediatric cancer treatment. Adequate pain control during procedures is essential; however, procedure-related pain may be underestimated and undertreated. Currently, there is not a standard approach for the appropriate level of sedation to manage procedure-related pain in children with cancer. A team was assembled to review the evidence and develop recommendations to determine the appropriate level of sedation necessary for pain control in patients undergoing pediatric oncology procedures. After a systematic search of the literature, 15 research-based articles were synthesized and critically appraised. A recommendation was made related to the level of sedation utilized for bone marrow aspirates and bone marrow biopsies. There is a need for further research related to the necessary level of sedation for patients undergoing pediatric oncology procedures.
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Affiliation(s)
| | - Tara Adams
- Dell Children’s Medical Center, Austin,
TX, USA
| | - Clifton P. Thornton
- Johns Hopkins School of Nursing,
Baltimore MD, USA
- Herman and Walter Samuelson Children’s
Hospital at Sinai, Baltimore, MD, USA
| | - Beth Fisher
- Aflac Cancer and Blood Disorder Center,
Atlanta, GA, USA
- Clemson University, Clemson, SC,
USA
- Prisma Health, Greenville, SC, USA
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Hunger SP. More Is Not Always Better: The Perils of Treatment Intensification in Pediatric Acute Lymphoblastic Leukemia. J Clin Oncol 2019; 37:1601-1603. [DOI: 10.1200/jco.19.00889] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Stephen P. Hunger
- Children’s Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA
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