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Orgel E, Mueske NM, Sposto R, Gilsanz V, Wren TAL, Freyer DR, Butturini AM, Mittelman SD. A randomized controlled trial testing an adherence-optimized Vitamin D regimen to mitigate bone change in adolescents being treated for acute lymphoblastic leukemia. Leuk Lymphoma 2017; 58:2370-2378. [PMID: 28278717 PMCID: PMC5489365 DOI: 10.1080/10428194.2017.1289526] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 01/09/2017] [Accepted: 01/25/2017] [Indexed: 01/06/2023]
Abstract
Adolescents with acute lymphoblastic leukemia (ALL) develop osteopenia early in therapy, potentially exacerbated by high rates of concurrent Vitamin D deficiency. We conducted a randomized clinical trial testing a Vitamin D-based intervention to improve Vitamin D status and reduce bone density decline. Poor adherence to home supplementation necessitated a change to directly observed therapy (DOT) with intermittent, high-dose Vitamin D3 randomized versus standard of care (SOC). Compared to SOC, DOT Vitamin D3 successfully increased trough Vitamin 25(OH)D levels (p = .026) with no residual Vitamin D deficiency, 100% adherence to DOT Vitamin D3, and without associated toxicity. However, neither Vitamin D status nor supplementation impacted bone density. Thus, this adherence-optimized intervention is feasible and effective to correct Vitamin D deficiency in adolescents during ALL therapy. Repletion of Vitamin D and calcium alone did not mitigate osteopenia, however, and new, comprehensive approaches are needed to address treatment-associated osteopenia during ALL therapy.
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Affiliation(s)
- Etan Orgel
- Children’s Center for Cancer and Blood Diseases, Children’s Hospital Los Angeles, Los Angeles, CA
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Nicole M. Mueske
- Children’s Orthopaedic Center, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Richard Sposto
- Children’s Center for Cancer and Blood Diseases, Children’s Hospital Los Angeles, Los Angeles, CA
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Vicente Gilsanz
- Department of Radiology, Children’s Hospital Los Angeles, Los Angeles, CA
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Tishya AL Wren
- Children’s Orthopaedic Center, Children’s Hospital Los Angeles, Los Angeles, CA
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - David R Freyer
- Children’s Center for Cancer and Blood Diseases, Children’s Hospital Los Angeles, Los Angeles, CA
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Anna M Butturini
- Children’s Center for Cancer and Blood Diseases, Children’s Hospital Los Angeles, Los Angeles, CA
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Steven D. Mittelman
- Center for Endocrinology, Diabetes & Metabolism, Children’s Hospital Los Angeles, Los Angeles, CA
- Keck School of Medicine, University of Southern California, Los Angeles, CA
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252
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Nunes V, Cazzaniga G, Biondi A. An update on PCR use for minimal residual disease monitoring in acute lymphoblastic leukemia. Expert Rev Mol Diagn 2017; 17:953-963. [PMID: 28891364 DOI: 10.1080/14737159.2017.1377073] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Acute lymphoblastic leukemia (ALL) is the first neoplasm where the assessment of early response to therapy by minimal residual disease (MRD) monitoring has proven to be a fundamental tool for guiding therapeutic choices. In recent years, thanks to real-time quantitative PCR (qPCR), MRD monitoring has further achieved higher levels of sensitivity and standardization. However, some outstanding issues still remain to be addressed and emerging technologies hold the promise of improving MRD detection in ALL patients. Areas covered: Through a comprehensive review of the literature, we analyze the state-of-the-art of molecular MRD assessment in ALL to better understand how, in the upcoming years, some of its limitations could be tackled by emerging molecular technologies. Furthermore, we highlight the future role of molecular MRD monitoring in the context of personalized protocols, taking into account the growing genetic complexity in ALL. Expert commentary: Although new molecular technologies are promising tools for MRD assessment, qPCR still remains the gold standard for evaluating MRD in ALL. High-throughput sequencing and droplet digital PCR allow to identify new prognostic factors and/or MRD targets at diagnosis and to perform earlier MRD evaluations, thereby optimizing patient stratification and earlier MRD-based clinical intervention to improve ALL patient outcomes.
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Affiliation(s)
- Vittorio Nunes
- a Tettamanti Research Center, Department of Pediatrics , University of Milano Bicocca , Monza , Italy
| | - Gianni Cazzaniga
- a Tettamanti Research Center, Department of Pediatrics , University of Milano Bicocca , Monza , Italy
| | - A Biondi
- a Tettamanti Research Center, Department of Pediatrics , University of Milano Bicocca , Monza , Italy
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253
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High-dose methotrexate therapy significantly improved survival of adult acute lymphoblastic leukemia: a phase III study by JALSG. Leukemia 2017; 32:626-632. [PMID: 28914260 DOI: 10.1038/leu.2017.283] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Revised: 08/21/2017] [Accepted: 08/23/2017] [Indexed: 12/21/2022]
Abstract
High-dose methotrexate (Hd-MTX) therapy has recently been applied to the treatment of adult acute lymphoblastic leukemia (ALL) based on pediatric protocols; however, its effectiveness for adult ALL has not yet been confirmed in a rigorous manner. We herein conducted a randomized phase III trial comparing Hd-MTX therapy with intermediate-dose (Id)-MTX therapy. This study was registered at UMIN-CTR (ID: C000000063). Philadelphia chromosome (Ph)-negative ALL patients aged between 25 and 64 years of age were enrolled. Patients who achieved complete remission (CR) were randomly assigned to receive therapy containing Hd-MTX (3 g/m2) or Id-MTX (0.5 g/m2). A total of 360 patients were enrolled. The CR rate was 86%. A total of 115 and 114 patients were assigned to the Hd-MTX and Id-MTX groups, respectively. The estimated 5-year disease-free survival rate of the Hd-MTX group was 58%, which was significantly better than that of the Id-MTX group at 32% (P=0.0218). The frequencies of severe adverse events were not significantly different. We herein demonstrated the effectiveness and safety of Hd-MTX therapy for adult Ph-negative ALL. Our results provide a strong rationale for protocols containing Hd-MTX therapy being applied to the treatment of adult ALL.
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254
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Maese L, Tasian SK, Raetz EA. How is the Ph-like signature being incorporated into ALL therapy? Best Pract Res Clin Haematol 2017; 30:222-228. [PMID: 29050695 PMCID: PMC6053910 DOI: 10.1016/j.beha.2017.06.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 06/09/2017] [Indexed: 01/09/2023]
Abstract
Philadelphia chromosome-like acute lymphoblastic leukemia (Ph-like ALL) is a recently identified high risk disease subtype characterized by a gene expression profile similar to that observed in Philadelphia chromosome-positive (Ph-positive) ALL, but without an underlying BCR-ABL1 translocation. Adults and children with Ph-like ALL harbor a diversity of alterations that all lead to activated kinase signaling. Outcomes for patients with Ph-like ALL are poor, which has prompted investigation into the role of tyrosine kinase inhibitor (TKI)-based therapies for this disease. Several clinical trials are now ongoing that include screening for the Ph-like signature and treatment of patients with Ph-like ALL with TKI therapy. This review examines how testing for Ph-like ALL is being incorporated into clinical trials.
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Affiliation(s)
- Luke Maese
- Department of Pediatrics and Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Sarah K Tasian
- Department of Pediatrics, Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Elizabeth A Raetz
- Department of Pediatrics and Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA.
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255
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Giordano L, Akinyede O, Bhatt N, Dighe D, Iqbal A. Methotrexate-Induced Neurotoxicity in Hispanic Adolescents with High-Risk Acute Leukemia—A Case Series. J Adolesc Young Adult Oncol 2017; 6:494-498. [DOI: 10.1089/jayao.2016.0094] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Lisa Giordano
- Department of Pediatrics, Cook County Health and Hospitals System, Chicago, Illinois
| | - Oyinade Akinyede
- Department of Pediatrics, Cook County Health and Hospitals System, Chicago, Illinois
| | - Nidhi Bhatt
- Department of Pediatrics, University of Illinois Hospital and Health Sciences System, Chicago, Illinois
| | - Dipti Dighe
- Department of Pediatrics, Cook County Health and Hospitals System, Chicago, Illinois
| | - Asneha Iqbal
- Department of Pediatrics, Cook County Health and Hospitals System, Chicago, Illinois
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256
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Huynh V, Laetsch TW, Schore RJ, Gaynon P, O'Brien MM. Redefining treatment failure for pediatric acute leukemia in the era of minimal residual disease testing. Pediatr Hematol Oncol 2017; 34:395-408. [PMID: 29190162 DOI: 10.1080/08880018.2017.1397073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Technologies for the detection of minimal residual disease (MRD) in leukemia and our understanding of the prognostic implications of MRD at different phases of treatment have significantly improved over the past decade. As a result, definitions of treatment failure based on bone marrow morphology by light microscopy are becoming increasingly inadequate for clinical care and trial design. In addition, novel therapies that may have increased efficacy and decreased toxicity in the setting of MRD compared to overt disease are changing clinical practice and challenging investigators to redefine treatment failure, the role of disease surveillance in remission, and clinical trial eligibility in the era of MRD.
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Affiliation(s)
- Van Huynh
- a CHOC Children's Hospital , University of California Irvine College of Medicine , Orange , CA , USA
| | - Theodore W Laetsch
- b Department of Pediatrics , University of Texas Southwestern Medical Center , Dallas , TX , USA.,c Paulin Allen Gill Center for Cancer and Blood Disorders , Children's Health , Dallas , TX , USA
| | - Reuven J Schore
- d Children's National Health System and George Washington University , School of Medicine and Health Sciences , Washington DC , USA
| | - Paul Gaynon
- e Children's Center for Cancer and Blood Diseases, Children's Hospital of Los Angeles , University of Southern California , Los Angeles , CA , USA
| | - Maureen M O'Brien
- f Cancer and Blood Diseases Institute , Cincinnati Children's Hospital Medical Center , Cincinnati , OH , USA
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257
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Hardy KK, Embry L, Kairalla JA, Helian S, Devidas M, Armstrong D, Hunger S, Carroll WL, Larsen E, Raetz EA, Loh ML, Yang W, Relling MV, Noll RB, Winick N. Neurocognitive Functioning of Children Treated for High-Risk B-Acute Lymphoblastic Leukemia Randomly Assigned to Different Methotrexate and Corticosteroid Treatment Strategies: A Report From the Children's Oncology Group. J Clin Oncol 2017; 35:2700-2707. [PMID: 28671857 DOI: 10.1200/jco.2016.71.7587] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Survivors of childhood acute lymphoblastic leukemia (ALL) are at risk for neurocognitive deficits that are associated with treatment, individual, and environmental factors. This study examined the impact of different methotrexate (MTX) and corticosteroid treatment strategies on neurocognitive functioning in children with high-risk B-lineage ALL. Methods Participants were randomly assigned to receive high-dose MTX with leucovorin rescue or escalating dose MTX with PEG asparaginase without leucovorin rescue. Patients were also randomly assigned to corticosteroid therapy that included either dexamethasone or prednisone. A neurocognitive evaluation of intellectual functioning (IQ), working memory, and processing speed (PS) was conducted 8 to 24 months after treatment completion (n = 192). Results The method of MTX delivery and corticosteroid assignment were unrelated to differences in neurocognitive outcomes after controlling for ethnicity, race, age, gender, insurance status, and time off treatment; however, survivors who were age < 10 years at diagnosis (n = 89) had significantly lower estimated IQ ( P < .001) and PS scores ( P = .02) compared with participants age ≥ 10 years. In addition, participants who were covered by US public health insurance had estimated IQs that were significantly lower ( P < .001) than those with US private or military insurance. Conclusion Children with high-risk B-lineage ALL who were age < 10 years at diagnosis are at risk for deficits in IQ and PS in the absence of cranial radiation, regardless of MTX delivery or corticosteroid type. These data may serve as a basis for developing screening protocols to identify children who are at high risk for deficits so that early intervention can be initiated to mitigate the impact of therapy on neurocognitive outcomes.
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Affiliation(s)
- Kristina K Hardy
- Kristina K. Hardy, Children's National Medical Center, Washington, DC; Leanne Embry, The University of Texas Health Science Center at San Antonio, San Antonio; Naomi Winick, University of Texas Southwestern Medical Center, Dallas, TX; John A. Kairalla and Meenakshi Devidas, Colleges of Medicine, Public Health and Health Professions, University of Florida, Gainesville; Daniel Armstrong, University of Miami, Sylvester Comprehensive Cancer Center, Miami, FL; Shanjun Helian, Merck, Upper Gwynedd; Stephen Hunger, Children's Hospital of Philadelphia, Philadelphia; Robert B. Noll, University of Pittsburgh School of Medicine, Pittsburgh, PA; William L. Carroll, New York University Medical Center, New York, NY; Eric Larsen, Maine Children's Cancer Program, Scarborough, ME; Elizabeth A. Raetz, University of Utah, Salt Lake City, UT; Mignon L. Loh, University of California, San Francisco, San Francisco, CA; and Wenjian Yang and Mary V. Relling, St Jude Children's Research Hospital; University of Tennessee Health Science Center, Memphis, TN
| | - Leanne Embry
- Kristina K. Hardy, Children's National Medical Center, Washington, DC; Leanne Embry, The University of Texas Health Science Center at San Antonio, San Antonio; Naomi Winick, University of Texas Southwestern Medical Center, Dallas, TX; John A. Kairalla and Meenakshi Devidas, Colleges of Medicine, Public Health and Health Professions, University of Florida, Gainesville; Daniel Armstrong, University of Miami, Sylvester Comprehensive Cancer Center, Miami, FL; Shanjun Helian, Merck, Upper Gwynedd; Stephen Hunger, Children's Hospital of Philadelphia, Philadelphia; Robert B. Noll, University of Pittsburgh School of Medicine, Pittsburgh, PA; William L. Carroll, New York University Medical Center, New York, NY; Eric Larsen, Maine Children's Cancer Program, Scarborough, ME; Elizabeth A. Raetz, University of Utah, Salt Lake City, UT; Mignon L. Loh, University of California, San Francisco, San Francisco, CA; and Wenjian Yang and Mary V. Relling, St Jude Children's Research Hospital; University of Tennessee Health Science Center, Memphis, TN
| | - John A Kairalla
- Kristina K. Hardy, Children's National Medical Center, Washington, DC; Leanne Embry, The University of Texas Health Science Center at San Antonio, San Antonio; Naomi Winick, University of Texas Southwestern Medical Center, Dallas, TX; John A. Kairalla and Meenakshi Devidas, Colleges of Medicine, Public Health and Health Professions, University of Florida, Gainesville; Daniel Armstrong, University of Miami, Sylvester Comprehensive Cancer Center, Miami, FL; Shanjun Helian, Merck, Upper Gwynedd; Stephen Hunger, Children's Hospital of Philadelphia, Philadelphia; Robert B. Noll, University of Pittsburgh School of Medicine, Pittsburgh, PA; William L. Carroll, New York University Medical Center, New York, NY; Eric Larsen, Maine Children's Cancer Program, Scarborough, ME; Elizabeth A. Raetz, University of Utah, Salt Lake City, UT; Mignon L. Loh, University of California, San Francisco, San Francisco, CA; and Wenjian Yang and Mary V. Relling, St Jude Children's Research Hospital; University of Tennessee Health Science Center, Memphis, TN
| | - Shanjun Helian
- Kristina K. Hardy, Children's National Medical Center, Washington, DC; Leanne Embry, The University of Texas Health Science Center at San Antonio, San Antonio; Naomi Winick, University of Texas Southwestern Medical Center, Dallas, TX; John A. Kairalla and Meenakshi Devidas, Colleges of Medicine, Public Health and Health Professions, University of Florida, Gainesville; Daniel Armstrong, University of Miami, Sylvester Comprehensive Cancer Center, Miami, FL; Shanjun Helian, Merck, Upper Gwynedd; Stephen Hunger, Children's Hospital of Philadelphia, Philadelphia; Robert B. Noll, University of Pittsburgh School of Medicine, Pittsburgh, PA; William L. Carroll, New York University Medical Center, New York, NY; Eric Larsen, Maine Children's Cancer Program, Scarborough, ME; Elizabeth A. Raetz, University of Utah, Salt Lake City, UT; Mignon L. Loh, University of California, San Francisco, San Francisco, CA; and Wenjian Yang and Mary V. Relling, St Jude Children's Research Hospital; University of Tennessee Health Science Center, Memphis, TN
| | - Meenakshi Devidas
- Kristina K. Hardy, Children's National Medical Center, Washington, DC; Leanne Embry, The University of Texas Health Science Center at San Antonio, San Antonio; Naomi Winick, University of Texas Southwestern Medical Center, Dallas, TX; John A. Kairalla and Meenakshi Devidas, Colleges of Medicine, Public Health and Health Professions, University of Florida, Gainesville; Daniel Armstrong, University of Miami, Sylvester Comprehensive Cancer Center, Miami, FL; Shanjun Helian, Merck, Upper Gwynedd; Stephen Hunger, Children's Hospital of Philadelphia, Philadelphia; Robert B. Noll, University of Pittsburgh School of Medicine, Pittsburgh, PA; William L. Carroll, New York University Medical Center, New York, NY; Eric Larsen, Maine Children's Cancer Program, Scarborough, ME; Elizabeth A. Raetz, University of Utah, Salt Lake City, UT; Mignon L. Loh, University of California, San Francisco, San Francisco, CA; and Wenjian Yang and Mary V. Relling, St Jude Children's Research Hospital; University of Tennessee Health Science Center, Memphis, TN
| | - Daniel Armstrong
- Kristina K. Hardy, Children's National Medical Center, Washington, DC; Leanne Embry, The University of Texas Health Science Center at San Antonio, San Antonio; Naomi Winick, University of Texas Southwestern Medical Center, Dallas, TX; John A. Kairalla and Meenakshi Devidas, Colleges of Medicine, Public Health and Health Professions, University of Florida, Gainesville; Daniel Armstrong, University of Miami, Sylvester Comprehensive Cancer Center, Miami, FL; Shanjun Helian, Merck, Upper Gwynedd; Stephen Hunger, Children's Hospital of Philadelphia, Philadelphia; Robert B. Noll, University of Pittsburgh School of Medicine, Pittsburgh, PA; William L. Carroll, New York University Medical Center, New York, NY; Eric Larsen, Maine Children's Cancer Program, Scarborough, ME; Elizabeth A. Raetz, University of Utah, Salt Lake City, UT; Mignon L. Loh, University of California, San Francisco, San Francisco, CA; and Wenjian Yang and Mary V. Relling, St Jude Children's Research Hospital; University of Tennessee Health Science Center, Memphis, TN
| | - Stephen Hunger
- Kristina K. Hardy, Children's National Medical Center, Washington, DC; Leanne Embry, The University of Texas Health Science Center at San Antonio, San Antonio; Naomi Winick, University of Texas Southwestern Medical Center, Dallas, TX; John A. Kairalla and Meenakshi Devidas, Colleges of Medicine, Public Health and Health Professions, University of Florida, Gainesville; Daniel Armstrong, University of Miami, Sylvester Comprehensive Cancer Center, Miami, FL; Shanjun Helian, Merck, Upper Gwynedd; Stephen Hunger, Children's Hospital of Philadelphia, Philadelphia; Robert B. Noll, University of Pittsburgh School of Medicine, Pittsburgh, PA; William L. Carroll, New York University Medical Center, New York, NY; Eric Larsen, Maine Children's Cancer Program, Scarborough, ME; Elizabeth A. Raetz, University of Utah, Salt Lake City, UT; Mignon L. Loh, University of California, San Francisco, San Francisco, CA; and Wenjian Yang and Mary V. Relling, St Jude Children's Research Hospital; University of Tennessee Health Science Center, Memphis, TN
| | - William L Carroll
- Kristina K. Hardy, Children's National Medical Center, Washington, DC; Leanne Embry, The University of Texas Health Science Center at San Antonio, San Antonio; Naomi Winick, University of Texas Southwestern Medical Center, Dallas, TX; John A. Kairalla and Meenakshi Devidas, Colleges of Medicine, Public Health and Health Professions, University of Florida, Gainesville; Daniel Armstrong, University of Miami, Sylvester Comprehensive Cancer Center, Miami, FL; Shanjun Helian, Merck, Upper Gwynedd; Stephen Hunger, Children's Hospital of Philadelphia, Philadelphia; Robert B. Noll, University of Pittsburgh School of Medicine, Pittsburgh, PA; William L. Carroll, New York University Medical Center, New York, NY; Eric Larsen, Maine Children's Cancer Program, Scarborough, ME; Elizabeth A. Raetz, University of Utah, Salt Lake City, UT; Mignon L. Loh, University of California, San Francisco, San Francisco, CA; and Wenjian Yang and Mary V. Relling, St Jude Children's Research Hospital; University of Tennessee Health Science Center, Memphis, TN
| | - Eric Larsen
- Kristina K. Hardy, Children's National Medical Center, Washington, DC; Leanne Embry, The University of Texas Health Science Center at San Antonio, San Antonio; Naomi Winick, University of Texas Southwestern Medical Center, Dallas, TX; John A. Kairalla and Meenakshi Devidas, Colleges of Medicine, Public Health and Health Professions, University of Florida, Gainesville; Daniel Armstrong, University of Miami, Sylvester Comprehensive Cancer Center, Miami, FL; Shanjun Helian, Merck, Upper Gwynedd; Stephen Hunger, Children's Hospital of Philadelphia, Philadelphia; Robert B. Noll, University of Pittsburgh School of Medicine, Pittsburgh, PA; William L. Carroll, New York University Medical Center, New York, NY; Eric Larsen, Maine Children's Cancer Program, Scarborough, ME; Elizabeth A. Raetz, University of Utah, Salt Lake City, UT; Mignon L. Loh, University of California, San Francisco, San Francisco, CA; and Wenjian Yang and Mary V. Relling, St Jude Children's Research Hospital; University of Tennessee Health Science Center, Memphis, TN
| | - Elizabeth A Raetz
- Kristina K. Hardy, Children's National Medical Center, Washington, DC; Leanne Embry, The University of Texas Health Science Center at San Antonio, San Antonio; Naomi Winick, University of Texas Southwestern Medical Center, Dallas, TX; John A. Kairalla and Meenakshi Devidas, Colleges of Medicine, Public Health and Health Professions, University of Florida, Gainesville; Daniel Armstrong, University of Miami, Sylvester Comprehensive Cancer Center, Miami, FL; Shanjun Helian, Merck, Upper Gwynedd; Stephen Hunger, Children's Hospital of Philadelphia, Philadelphia; Robert B. Noll, University of Pittsburgh School of Medicine, Pittsburgh, PA; William L. Carroll, New York University Medical Center, New York, NY; Eric Larsen, Maine Children's Cancer Program, Scarborough, ME; Elizabeth A. Raetz, University of Utah, Salt Lake City, UT; Mignon L. Loh, University of California, San Francisco, San Francisco, CA; and Wenjian Yang and Mary V. Relling, St Jude Children's Research Hospital; University of Tennessee Health Science Center, Memphis, TN
| | - Mignon L Loh
- Kristina K. Hardy, Children's National Medical Center, Washington, DC; Leanne Embry, The University of Texas Health Science Center at San Antonio, San Antonio; Naomi Winick, University of Texas Southwestern Medical Center, Dallas, TX; John A. Kairalla and Meenakshi Devidas, Colleges of Medicine, Public Health and Health Professions, University of Florida, Gainesville; Daniel Armstrong, University of Miami, Sylvester Comprehensive Cancer Center, Miami, FL; Shanjun Helian, Merck, Upper Gwynedd; Stephen Hunger, Children's Hospital of Philadelphia, Philadelphia; Robert B. Noll, University of Pittsburgh School of Medicine, Pittsburgh, PA; William L. Carroll, New York University Medical Center, New York, NY; Eric Larsen, Maine Children's Cancer Program, Scarborough, ME; Elizabeth A. Raetz, University of Utah, Salt Lake City, UT; Mignon L. Loh, University of California, San Francisco, San Francisco, CA; and Wenjian Yang and Mary V. Relling, St Jude Children's Research Hospital; University of Tennessee Health Science Center, Memphis, TN
| | - Wenjian Yang
- Kristina K. Hardy, Children's National Medical Center, Washington, DC; Leanne Embry, The University of Texas Health Science Center at San Antonio, San Antonio; Naomi Winick, University of Texas Southwestern Medical Center, Dallas, TX; John A. Kairalla and Meenakshi Devidas, Colleges of Medicine, Public Health and Health Professions, University of Florida, Gainesville; Daniel Armstrong, University of Miami, Sylvester Comprehensive Cancer Center, Miami, FL; Shanjun Helian, Merck, Upper Gwynedd; Stephen Hunger, Children's Hospital of Philadelphia, Philadelphia; Robert B. Noll, University of Pittsburgh School of Medicine, Pittsburgh, PA; William L. Carroll, New York University Medical Center, New York, NY; Eric Larsen, Maine Children's Cancer Program, Scarborough, ME; Elizabeth A. Raetz, University of Utah, Salt Lake City, UT; Mignon L. Loh, University of California, San Francisco, San Francisco, CA; and Wenjian Yang and Mary V. Relling, St Jude Children's Research Hospital; University of Tennessee Health Science Center, Memphis, TN
| | - Mary V Relling
- Kristina K. Hardy, Children's National Medical Center, Washington, DC; Leanne Embry, The University of Texas Health Science Center at San Antonio, San Antonio; Naomi Winick, University of Texas Southwestern Medical Center, Dallas, TX; John A. Kairalla and Meenakshi Devidas, Colleges of Medicine, Public Health and Health Professions, University of Florida, Gainesville; Daniel Armstrong, University of Miami, Sylvester Comprehensive Cancer Center, Miami, FL; Shanjun Helian, Merck, Upper Gwynedd; Stephen Hunger, Children's Hospital of Philadelphia, Philadelphia; Robert B. Noll, University of Pittsburgh School of Medicine, Pittsburgh, PA; William L. Carroll, New York University Medical Center, New York, NY; Eric Larsen, Maine Children's Cancer Program, Scarborough, ME; Elizabeth A. Raetz, University of Utah, Salt Lake City, UT; Mignon L. Loh, University of California, San Francisco, San Francisco, CA; and Wenjian Yang and Mary V. Relling, St Jude Children's Research Hospital; University of Tennessee Health Science Center, Memphis, TN
| | - Robert B Noll
- Kristina K. Hardy, Children's National Medical Center, Washington, DC; Leanne Embry, The University of Texas Health Science Center at San Antonio, San Antonio; Naomi Winick, University of Texas Southwestern Medical Center, Dallas, TX; John A. Kairalla and Meenakshi Devidas, Colleges of Medicine, Public Health and Health Professions, University of Florida, Gainesville; Daniel Armstrong, University of Miami, Sylvester Comprehensive Cancer Center, Miami, FL; Shanjun Helian, Merck, Upper Gwynedd; Stephen Hunger, Children's Hospital of Philadelphia, Philadelphia; Robert B. Noll, University of Pittsburgh School of Medicine, Pittsburgh, PA; William L. Carroll, New York University Medical Center, New York, NY; Eric Larsen, Maine Children's Cancer Program, Scarborough, ME; Elizabeth A. Raetz, University of Utah, Salt Lake City, UT; Mignon L. Loh, University of California, San Francisco, San Francisco, CA; and Wenjian Yang and Mary V. Relling, St Jude Children's Research Hospital; University of Tennessee Health Science Center, Memphis, TN
| | - Naomi Winick
- Kristina K. Hardy, Children's National Medical Center, Washington, DC; Leanne Embry, The University of Texas Health Science Center at San Antonio, San Antonio; Naomi Winick, University of Texas Southwestern Medical Center, Dallas, TX; John A. Kairalla and Meenakshi Devidas, Colleges of Medicine, Public Health and Health Professions, University of Florida, Gainesville; Daniel Armstrong, University of Miami, Sylvester Comprehensive Cancer Center, Miami, FL; Shanjun Helian, Merck, Upper Gwynedd; Stephen Hunger, Children's Hospital of Philadelphia, Philadelphia; Robert B. Noll, University of Pittsburgh School of Medicine, Pittsburgh, PA; William L. Carroll, New York University Medical Center, New York, NY; Eric Larsen, Maine Children's Cancer Program, Scarborough, ME; Elizabeth A. Raetz, University of Utah, Salt Lake City, UT; Mignon L. Loh, University of California, San Francisco, San Francisco, CA; and Wenjian Yang and Mary V. Relling, St Jude Children's Research Hospital; University of Tennessee Health Science Center, Memphis, TN
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258
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Santiago R, Vairy S, Sinnett D, Krajinovic M, Bittencourt H. Novel therapy for childhood acute lymphoblastic leukemia. Expert Opin Pharmacother 2017; 18:1081-1099. [PMID: 28608730 DOI: 10.1080/14656566.2017.1340938] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION During recent decades, the prognosis of childhood acute lymphoblastic leukemia (ALL) has improved dramatically, nowadays, reaching a cure rate of almost 90%. These results are due to a better management and combination of old therapies, refined risk-group stratification and emergence of minimal residual disease (MRD) combined with treatment's intensification for high-risk subgroups. However, the subgroup of patients with refractory/relapsed ALL still presents a dismal prognosis indicating necessity for innovative therapeutic approaches. Areas covered: We performed an exhaustive review of current first-line therapies for childhood ALL in the worldwide main consortia, summarized the major advances for front-line and relapse treatment and highlighted recent and promising innovative therapies with an overview of the most promising ongoing clinical trials. Expert opinion: Two major avenues marked the beginning of 21st century. First, is the introduction of tyrosine-kinase inhibitor coupled to chemotherapy for treatment of Philadelphia positive ALL opening new treatment possibilities for the recently identified subgroup of Ph-like ALL. Second, is the breakthrough of immunotherapy, notably CAR T-cell and specific antibody-based therapy, with remarkable success observed in initial studies. This review gives an insight on current knowledge in these innovative therapeutic directions, summarizes currently ongoing clinical trials and addresses challenges these approaches are faced with.
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Affiliation(s)
- Raoul Santiago
- a CHU Sainte-Justine Research Center , Charles-Bruneau Cancer Center , Montreal , Quebec , Canada.,b Department of Pediatrics, Faculty of Medicine , University of Montreal , Montreal , Quebec , Canada
| | - Stéphanie Vairy
- a CHU Sainte-Justine Research Center , Charles-Bruneau Cancer Center , Montreal , Quebec , Canada.,b Department of Pediatrics, Faculty of Medicine , University of Montreal , Montreal , Quebec , Canada
| | - Daniel Sinnett
- a CHU Sainte-Justine Research Center , Charles-Bruneau Cancer Center , Montreal , Quebec , Canada.,b Department of Pediatrics, Faculty of Medicine , University of Montreal , Montreal , Quebec , Canada
| | - Maja Krajinovic
- a CHU Sainte-Justine Research Center , Charles-Bruneau Cancer Center , Montreal , Quebec , Canada.,b Department of Pediatrics, Faculty of Medicine , University of Montreal , Montreal , Quebec , Canada.,c Department of Pharmacology and Physiology, Faculty of Medicine , University of Montreal , Montreal , Quebec , Canada
| | - Henrique Bittencourt
- a CHU Sainte-Justine Research Center , Charles-Bruneau Cancer Center , Montreal , Quebec , Canada.,b Department of Pediatrics, Faculty of Medicine , University of Montreal , Montreal , Quebec , Canada
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259
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Lambrecht L, Sleurs C, Labarque V, Dhooge C, Laenen A, Sinnaeve F, Renard M, Uyttebroeck A. The role of the MTHFR C677T polymorphism in methotrexate-induced toxicity in pediatric osteosarcoma patients. Pharmacogenomics 2017; 18:787-795. [PMID: 28592186 DOI: 10.2217/pgs-2017-0013] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
AIM Osteosarcoma patients receive high doses of methotrexate (MTX). However, pharmacogenetic information remains limited and has mainly been investigated in leukemia so far. PATIENTS & METHODS We investigated the link between the MTHFR C677T genotype, toxicity levels (mucositis, MTX plasma level, hematological toxicity and hepatotoxicity) and survival of 48 pediatric osteosarcoma patients. RESULTS The TT genotype did not show more toxicity compared with the CC/CT genotype. However, plasma MTX levels were related with mucositis, but not with hematological toxicity, nor hepatotoxicity. Survival rates did not differ between homozygous and non-homozygous patients. Yet, homozygous patients had higher relapse risk. CONCLUSION The MTHFR C667T polymorphism is not predictive for toxicity or overall survival, but could be used for relapse risk stratification.
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Affiliation(s)
- Loes Lambrecht
- Department of Pediatrics, University Hospital Leuven, Leuven, Belgium
| | - Charlotte Sleurs
- Department of Reproduction & Regeneration, Catholic University Leuven, Leuven, Belgium.,Department of Pediatric Hemato-Oncology, University Hospital Leuven, Leuven, Belgium
| | - Veerle Labarque
- Department of Cardiovascular Science, Catholic University Leuven, Leuven, Belgium.,Department of Pediatric Hemato-Oncology, University Hospital Leuven, Leuven, Belgium
| | - Catharina Dhooge
- Department of Pediatric Hemato-Oncology, University Hospital Ghent, Ghent, Belgium
| | - Annouschka Laenen
- Department of Statistics, University Hospital Leuven, Leuven, Belgium
| | - Friedl Sinnaeve
- Department of Orthopedic Surgery, University Hospital Leuven, Leuven, Belgium
| | - Marleen Renard
- Department of Pediatric Hemato-Oncology, University Hospital Leuven, Leuven, Belgium
| | - Anne Uyttebroeck
- Department of Reproduction & Regeneration, Catholic University Leuven, Leuven, Belgium.,Department of Pediatric Hemato-Oncology, University Hospital Leuven, Leuven, Belgium
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260
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Karol SE, Larsen E, Cheng C, Cao X, Yang W, Ramsey LB, Fernandez CA, McCorkle JR, Paugh SW, Autry RJ, Lopez-Lopez E, Diouf B, Jeha S, Pui CH, Raetz EA, Winick NJ, Carroll WL, Hunger SP, Loh ML, Devidas M, Evans WE, Yang JJ, Relling MV. Genetics of ancestry-specific risk for relapse in acute lymphoblastic leukemia. Leukemia 2017; 31:1325-1332. [PMID: 28096535 PMCID: PMC5462853 DOI: 10.1038/leu.2017.24] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 12/16/2016] [Accepted: 01/09/2017] [Indexed: 02/06/2023]
Abstract
The causes of individual relapses in children with acute lymphoblastic leukemia (ALL) remain incompletely understood. We evaluated the contribution of germline genetic factors to relapse in 2225 children treated on Children's Oncology Group trial AALL0232. We identified 302 germline single-nucleotide polymorphisms (SNPs) associated with relapse after adjusting for treatment and ancestry and 715 additional SNPs associated with relapse in an ancestry-specific manner. We tested for replication of these relapse-associated SNPs in external data sets of antileukemic drug pharmacokinetics and pharmacodynamics and an independent clinical cohort. 224 SNPs were associated with rapid drug clearance or drug resistance, and 32 were replicated in the independent cohort. The adverse risk associated with black and Hispanic ancestries was attenuated by addition of the 4 SNPs most strongly associated with relapse in these populations (for blacks: model without SNPs hazard ratio (HR)=2.32, P=2.27 × 10-4, model with SNPs HR=1.07, P=0.79; for Hispanics: model without SNPs HR=1.7, P=8.23 × 10-5, model with SNPs HR=1.31, P=0.065). Relapse SNPs associated with asparaginase resistance or allergy were overrepresented among SNPs associated with relapse in the more asparaginase intensive treatment arm (20/54 in Capizzi-methorexate arm vs 8/54 in high-dose methotrexate arm, P=0.015). Inherited genetic variation contributes to race-specific and treatment-specific relapse risk.
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Affiliation(s)
- S E Karol
- Comprehensive Cancer Center, St Jude Children's Research Hospital, Memphis, TN, USA
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - E Larsen
- Department of Pediatrics, Maine Medical Center, Portland, ME, USA
| | - C Cheng
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, TN, USA
| | - X Cao
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, TN, USA
| | - W Yang
- Department of Pharmaceutical Sciences, St Jude Children's Research Hospital, Memphis, TN, USA
| | - L B Ramsey
- Department of Pharmacy Research, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - C A Fernandez
- Department of Pharmaceutical Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - J R McCorkle
- Department of Pharmaceutical Sciences, St Jude Children's Research Hospital, Memphis, TN, USA
| | - S W Paugh
- Department of Pharmaceutical Sciences, St Jude Children's Research Hospital, Memphis, TN, USA
| | - R J Autry
- Department of Pharmaceutical Sciences, St Jude Children's Research Hospital, Memphis, TN, USA
| | - E Lopez-Lopez
- Department of Pharmaceutical Sciences, St Jude Children's Research Hospital, Memphis, TN, USA
| | - B Diouf
- Department of Pharmaceutical Sciences, St Jude Children's Research Hospital, Memphis, TN, USA
| | - S Jeha
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - C-H Pui
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - E A Raetz
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - N J Winick
- Department of Pediatrics, University of Texas, Southwestern Medical Center, Dallas, TX, USA
| | - W L Carroll
- Perlmutter Cancer Center, Department of Pediatrics and Pathology, New York University Langone Medical Center, New York, NY, USA
| | - S P Hunger
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - M L Loh
- Department of Pediatrics, University of California School of Medicine, San Francisco, CA, USA
| | - M Devidas
- Department of Biostatistics, Colleges of Medicine, Public Health and Health Professions, University of Florida, Gainesville, FL, USA
| | - W E Evans
- Department of Pharmaceutical Sciences, St Jude Children's Research Hospital, Memphis, TN, USA
| | - J J Yang
- Department of Pharmaceutical Sciences, St Jude Children's Research Hospital, Memphis, TN, USA
| | - M V Relling
- Department of Pharmaceutical Sciences, St Jude Children's Research Hospital, Memphis, TN, USA
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261
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Abstract
The central nervous system (CNS) is an important site of involvement by acute lymphoblastic leukemia (ALL) in adults. The prevalence is sufficiently high that prophylactic treatment is routinely given to this sanctuary site in order to eradicate occult disease that might otherwise lead to a relapse. A lumbar puncture should be routinely performed in all newly diagnosed patients with ALL. The risks of CNS leukemia vary by phenotype and genotype. Preventive treatment of the CNS during post-remission therapy has become an integral part of all current ALL treatment protocols. Most treatment regimens combine multiple doses of intrathecal chemotherapy with high-dose systemic methotrexate and/or cytarabine. Cranial irradiation is less commonly used for prophylaxis but is still the most effective treatment for overt CNS leukemia. Recurrences within the CNS usually coincide with or predict soon afterwards for systemic relapse in the marrow and blood.
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Affiliation(s)
- Richard A Larson
- a Department of Medicine, Section of Hematology/Oncology, and Comprehensive Cancer Center , The University of Chicago , Chicago , IL , USA
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262
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Winick N, Devidas M, Chen S, Maloney K, Larsen E, Mattano L, Borowitz MJ, Carroll A, Gastier-Foster JM, Heerema NA, Willman C, Wood B, Loh ML, Raetz E, Hunger SP, Carroll WL. Impact of Initial CSF Findings on Outcome Among Patients With National Cancer Institute Standard- and High-Risk B-Cell Acute Lymphoblastic Leukemia: A Report From the Children's Oncology Group. J Clin Oncol 2017; 35:2527-2534. [PMID: 28535084 DOI: 10.1200/jco.2016.71.4774] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose To determine the prognostic significance of blasts, and of white and red blood cells, in CSF samples at diagnosis of acute lymphoblastic leukemia (ALL), a uniform CSF and risk group classification schema was incorporated into Children's Oncology Group B-cell ALL (B-ALL) clinical trials. Methods CSF status was designated as follows: CNS1, no blasts; CNS2a to 2c, < 5 WBCs/μL and blasts with/without ≥ 10 RBCs/μL or ≥ 5 WBCs/μL plus blasts, with WBCs ≥ 5 times the number of RBCs; CNS3a to 3c, ≥ 5 WBCs/μL plus blasts with/without ≥ 10 RBCs/μL or clinical signs of CNS disease. CNS2 status did not affect therapy; patients with CNS3 status received two extra intrathecal treatments during induction and augmented postinduction therapy with 18 Gy of cranial radiation. Results Among 8,379 evaluable patients enrolled from 2004 to 2010, 7,395 (88.3%) had CNS1 status; 857 (10.2%), CNS2; and 127 (1.5%), CNS3. The 5-year event-free and overall survival rates were, respectively, 85% and 92.7% for CNS1, 76% and 86.8% for CNS2, and 76% and 82.1% for CNS3 ( P < .001). In multivariable analysis that included age, race/ethnicity, initial WBC, and day-29 minimal residual disease < 0.1%, CSF blast, regardless of cell count, was an independent adverse predictor of outcome for patients with standard- or high-risk disease according to National Cancer Institute criteria. The EFS difference reflected a significant difference in the incidence of CNS, not marrow, relapse in patients with CNS1 versus CNS2 and/or CNS3 status. Conclusion Low levels of CNS leukemia, regardless of RBCs, predict inferior outcome and higher rates of CNS relapse. These data suggest that additional augmentation of CNS-directed therapy is warranted for CNS2 disease.
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Affiliation(s)
- Naomi Winick
- Naomi Winick, University of Texas Southwestern Medical Center, Dallas, TX; Meenakshi Devidas and Si Chen, University of Florida, Gainesville, FL; Kelly Maloney, Children's Hospital Colorado, Aurora, CO; Eric Larsen, Maine Children's Cancer Program, Scarborough, ME; Leonard Mattano, HARP Pharma Consulting, Mystic, CT; Michael J. Borowitz, Johns Hopkins Medical Institutions, Baltimore, MD; Andrew Carroll, University of Alabama at Birmingham, AL; Julie M. Gastier-Foster, Institute for Genomic Medicine, Nationwide Children's Hospital; Julie M. Gastier-Foster and Nyla A. Heerema, The Ohio State University School of Medicine, Columbus, OH; Cheryl Willman, University of New Mexico, Albuquerque, NM; Brent Wood, University of Washington, Seattle, WA; Mignon L. Loh, University of California, San Francisco, San Francisco, CA; Elizabeth Raetz, University of Utah, Salt Lake City, UT; Stephen P. Hunger, Children's Hospital of Philadelphia, Philadelphia, PA; and William L. Carroll, New York University Medical Center, New York, NY
| | - Meenakshi Devidas
- Naomi Winick, University of Texas Southwestern Medical Center, Dallas, TX; Meenakshi Devidas and Si Chen, University of Florida, Gainesville, FL; Kelly Maloney, Children's Hospital Colorado, Aurora, CO; Eric Larsen, Maine Children's Cancer Program, Scarborough, ME; Leonard Mattano, HARP Pharma Consulting, Mystic, CT; Michael J. Borowitz, Johns Hopkins Medical Institutions, Baltimore, MD; Andrew Carroll, University of Alabama at Birmingham, AL; Julie M. Gastier-Foster, Institute for Genomic Medicine, Nationwide Children's Hospital; Julie M. Gastier-Foster and Nyla A. Heerema, The Ohio State University School of Medicine, Columbus, OH; Cheryl Willman, University of New Mexico, Albuquerque, NM; Brent Wood, University of Washington, Seattle, WA; Mignon L. Loh, University of California, San Francisco, San Francisco, CA; Elizabeth Raetz, University of Utah, Salt Lake City, UT; Stephen P. Hunger, Children's Hospital of Philadelphia, Philadelphia, PA; and William L. Carroll, New York University Medical Center, New York, NY
| | - Si Chen
- Naomi Winick, University of Texas Southwestern Medical Center, Dallas, TX; Meenakshi Devidas and Si Chen, University of Florida, Gainesville, FL; Kelly Maloney, Children's Hospital Colorado, Aurora, CO; Eric Larsen, Maine Children's Cancer Program, Scarborough, ME; Leonard Mattano, HARP Pharma Consulting, Mystic, CT; Michael J. Borowitz, Johns Hopkins Medical Institutions, Baltimore, MD; Andrew Carroll, University of Alabama at Birmingham, AL; Julie M. Gastier-Foster, Institute for Genomic Medicine, Nationwide Children's Hospital; Julie M. Gastier-Foster and Nyla A. Heerema, The Ohio State University School of Medicine, Columbus, OH; Cheryl Willman, University of New Mexico, Albuquerque, NM; Brent Wood, University of Washington, Seattle, WA; Mignon L. Loh, University of California, San Francisco, San Francisco, CA; Elizabeth Raetz, University of Utah, Salt Lake City, UT; Stephen P. Hunger, Children's Hospital of Philadelphia, Philadelphia, PA; and William L. Carroll, New York University Medical Center, New York, NY
| | - Kelly Maloney
- Naomi Winick, University of Texas Southwestern Medical Center, Dallas, TX; Meenakshi Devidas and Si Chen, University of Florida, Gainesville, FL; Kelly Maloney, Children's Hospital Colorado, Aurora, CO; Eric Larsen, Maine Children's Cancer Program, Scarborough, ME; Leonard Mattano, HARP Pharma Consulting, Mystic, CT; Michael J. Borowitz, Johns Hopkins Medical Institutions, Baltimore, MD; Andrew Carroll, University of Alabama at Birmingham, AL; Julie M. Gastier-Foster, Institute for Genomic Medicine, Nationwide Children's Hospital; Julie M. Gastier-Foster and Nyla A. Heerema, The Ohio State University School of Medicine, Columbus, OH; Cheryl Willman, University of New Mexico, Albuquerque, NM; Brent Wood, University of Washington, Seattle, WA; Mignon L. Loh, University of California, San Francisco, San Francisco, CA; Elizabeth Raetz, University of Utah, Salt Lake City, UT; Stephen P. Hunger, Children's Hospital of Philadelphia, Philadelphia, PA; and William L. Carroll, New York University Medical Center, New York, NY
| | - Eric Larsen
- Naomi Winick, University of Texas Southwestern Medical Center, Dallas, TX; Meenakshi Devidas and Si Chen, University of Florida, Gainesville, FL; Kelly Maloney, Children's Hospital Colorado, Aurora, CO; Eric Larsen, Maine Children's Cancer Program, Scarborough, ME; Leonard Mattano, HARP Pharma Consulting, Mystic, CT; Michael J. Borowitz, Johns Hopkins Medical Institutions, Baltimore, MD; Andrew Carroll, University of Alabama at Birmingham, AL; Julie M. Gastier-Foster, Institute for Genomic Medicine, Nationwide Children's Hospital; Julie M. Gastier-Foster and Nyla A. Heerema, The Ohio State University School of Medicine, Columbus, OH; Cheryl Willman, University of New Mexico, Albuquerque, NM; Brent Wood, University of Washington, Seattle, WA; Mignon L. Loh, University of California, San Francisco, San Francisco, CA; Elizabeth Raetz, University of Utah, Salt Lake City, UT; Stephen P. Hunger, Children's Hospital of Philadelphia, Philadelphia, PA; and William L. Carroll, New York University Medical Center, New York, NY
| | - Leonard Mattano
- Naomi Winick, University of Texas Southwestern Medical Center, Dallas, TX; Meenakshi Devidas and Si Chen, University of Florida, Gainesville, FL; Kelly Maloney, Children's Hospital Colorado, Aurora, CO; Eric Larsen, Maine Children's Cancer Program, Scarborough, ME; Leonard Mattano, HARP Pharma Consulting, Mystic, CT; Michael J. Borowitz, Johns Hopkins Medical Institutions, Baltimore, MD; Andrew Carroll, University of Alabama at Birmingham, AL; Julie M. Gastier-Foster, Institute for Genomic Medicine, Nationwide Children's Hospital; Julie M. Gastier-Foster and Nyla A. Heerema, The Ohio State University School of Medicine, Columbus, OH; Cheryl Willman, University of New Mexico, Albuquerque, NM; Brent Wood, University of Washington, Seattle, WA; Mignon L. Loh, University of California, San Francisco, San Francisco, CA; Elizabeth Raetz, University of Utah, Salt Lake City, UT; Stephen P. Hunger, Children's Hospital of Philadelphia, Philadelphia, PA; and William L. Carroll, New York University Medical Center, New York, NY
| | - Michael J Borowitz
- Naomi Winick, University of Texas Southwestern Medical Center, Dallas, TX; Meenakshi Devidas and Si Chen, University of Florida, Gainesville, FL; Kelly Maloney, Children's Hospital Colorado, Aurora, CO; Eric Larsen, Maine Children's Cancer Program, Scarborough, ME; Leonard Mattano, HARP Pharma Consulting, Mystic, CT; Michael J. Borowitz, Johns Hopkins Medical Institutions, Baltimore, MD; Andrew Carroll, University of Alabama at Birmingham, AL; Julie M. Gastier-Foster, Institute for Genomic Medicine, Nationwide Children's Hospital; Julie M. Gastier-Foster and Nyla A. Heerema, The Ohio State University School of Medicine, Columbus, OH; Cheryl Willman, University of New Mexico, Albuquerque, NM; Brent Wood, University of Washington, Seattle, WA; Mignon L. Loh, University of California, San Francisco, San Francisco, CA; Elizabeth Raetz, University of Utah, Salt Lake City, UT; Stephen P. Hunger, Children's Hospital of Philadelphia, Philadelphia, PA; and William L. Carroll, New York University Medical Center, New York, NY
| | - Andrew Carroll
- Naomi Winick, University of Texas Southwestern Medical Center, Dallas, TX; Meenakshi Devidas and Si Chen, University of Florida, Gainesville, FL; Kelly Maloney, Children's Hospital Colorado, Aurora, CO; Eric Larsen, Maine Children's Cancer Program, Scarborough, ME; Leonard Mattano, HARP Pharma Consulting, Mystic, CT; Michael J. Borowitz, Johns Hopkins Medical Institutions, Baltimore, MD; Andrew Carroll, University of Alabama at Birmingham, AL; Julie M. Gastier-Foster, Institute for Genomic Medicine, Nationwide Children's Hospital; Julie M. Gastier-Foster and Nyla A. Heerema, The Ohio State University School of Medicine, Columbus, OH; Cheryl Willman, University of New Mexico, Albuquerque, NM; Brent Wood, University of Washington, Seattle, WA; Mignon L. Loh, University of California, San Francisco, San Francisco, CA; Elizabeth Raetz, University of Utah, Salt Lake City, UT; Stephen P. Hunger, Children's Hospital of Philadelphia, Philadelphia, PA; and William L. Carroll, New York University Medical Center, New York, NY
| | - Julie M Gastier-Foster
- Naomi Winick, University of Texas Southwestern Medical Center, Dallas, TX; Meenakshi Devidas and Si Chen, University of Florida, Gainesville, FL; Kelly Maloney, Children's Hospital Colorado, Aurora, CO; Eric Larsen, Maine Children's Cancer Program, Scarborough, ME; Leonard Mattano, HARP Pharma Consulting, Mystic, CT; Michael J. Borowitz, Johns Hopkins Medical Institutions, Baltimore, MD; Andrew Carroll, University of Alabama at Birmingham, AL; Julie M. Gastier-Foster, Institute for Genomic Medicine, Nationwide Children's Hospital; Julie M. Gastier-Foster and Nyla A. Heerema, The Ohio State University School of Medicine, Columbus, OH; Cheryl Willman, University of New Mexico, Albuquerque, NM; Brent Wood, University of Washington, Seattle, WA; Mignon L. Loh, University of California, San Francisco, San Francisco, CA; Elizabeth Raetz, University of Utah, Salt Lake City, UT; Stephen P. Hunger, Children's Hospital of Philadelphia, Philadelphia, PA; and William L. Carroll, New York University Medical Center, New York, NY
| | - Nyla A Heerema
- Naomi Winick, University of Texas Southwestern Medical Center, Dallas, TX; Meenakshi Devidas and Si Chen, University of Florida, Gainesville, FL; Kelly Maloney, Children's Hospital Colorado, Aurora, CO; Eric Larsen, Maine Children's Cancer Program, Scarborough, ME; Leonard Mattano, HARP Pharma Consulting, Mystic, CT; Michael J. Borowitz, Johns Hopkins Medical Institutions, Baltimore, MD; Andrew Carroll, University of Alabama at Birmingham, AL; Julie M. Gastier-Foster, Institute for Genomic Medicine, Nationwide Children's Hospital; Julie M. Gastier-Foster and Nyla A. Heerema, The Ohio State University School of Medicine, Columbus, OH; Cheryl Willman, University of New Mexico, Albuquerque, NM; Brent Wood, University of Washington, Seattle, WA; Mignon L. Loh, University of California, San Francisco, San Francisco, CA; Elizabeth Raetz, University of Utah, Salt Lake City, UT; Stephen P. Hunger, Children's Hospital of Philadelphia, Philadelphia, PA; and William L. Carroll, New York University Medical Center, New York, NY
| | - Cheryl Willman
- Naomi Winick, University of Texas Southwestern Medical Center, Dallas, TX; Meenakshi Devidas and Si Chen, University of Florida, Gainesville, FL; Kelly Maloney, Children's Hospital Colorado, Aurora, CO; Eric Larsen, Maine Children's Cancer Program, Scarborough, ME; Leonard Mattano, HARP Pharma Consulting, Mystic, CT; Michael J. Borowitz, Johns Hopkins Medical Institutions, Baltimore, MD; Andrew Carroll, University of Alabama at Birmingham, AL; Julie M. Gastier-Foster, Institute for Genomic Medicine, Nationwide Children's Hospital; Julie M. Gastier-Foster and Nyla A. Heerema, The Ohio State University School of Medicine, Columbus, OH; Cheryl Willman, University of New Mexico, Albuquerque, NM; Brent Wood, University of Washington, Seattle, WA; Mignon L. Loh, University of California, San Francisco, San Francisco, CA; Elizabeth Raetz, University of Utah, Salt Lake City, UT; Stephen P. Hunger, Children's Hospital of Philadelphia, Philadelphia, PA; and William L. Carroll, New York University Medical Center, New York, NY
| | - Brent Wood
- Naomi Winick, University of Texas Southwestern Medical Center, Dallas, TX; Meenakshi Devidas and Si Chen, University of Florida, Gainesville, FL; Kelly Maloney, Children's Hospital Colorado, Aurora, CO; Eric Larsen, Maine Children's Cancer Program, Scarborough, ME; Leonard Mattano, HARP Pharma Consulting, Mystic, CT; Michael J. Borowitz, Johns Hopkins Medical Institutions, Baltimore, MD; Andrew Carroll, University of Alabama at Birmingham, AL; Julie M. Gastier-Foster, Institute for Genomic Medicine, Nationwide Children's Hospital; Julie M. Gastier-Foster and Nyla A. Heerema, The Ohio State University School of Medicine, Columbus, OH; Cheryl Willman, University of New Mexico, Albuquerque, NM; Brent Wood, University of Washington, Seattle, WA; Mignon L. Loh, University of California, San Francisco, San Francisco, CA; Elizabeth Raetz, University of Utah, Salt Lake City, UT; Stephen P. Hunger, Children's Hospital of Philadelphia, Philadelphia, PA; and William L. Carroll, New York University Medical Center, New York, NY
| | - Mignon L Loh
- Naomi Winick, University of Texas Southwestern Medical Center, Dallas, TX; Meenakshi Devidas and Si Chen, University of Florida, Gainesville, FL; Kelly Maloney, Children's Hospital Colorado, Aurora, CO; Eric Larsen, Maine Children's Cancer Program, Scarborough, ME; Leonard Mattano, HARP Pharma Consulting, Mystic, CT; Michael J. Borowitz, Johns Hopkins Medical Institutions, Baltimore, MD; Andrew Carroll, University of Alabama at Birmingham, AL; Julie M. Gastier-Foster, Institute for Genomic Medicine, Nationwide Children's Hospital; Julie M. Gastier-Foster and Nyla A. Heerema, The Ohio State University School of Medicine, Columbus, OH; Cheryl Willman, University of New Mexico, Albuquerque, NM; Brent Wood, University of Washington, Seattle, WA; Mignon L. Loh, University of California, San Francisco, San Francisco, CA; Elizabeth Raetz, University of Utah, Salt Lake City, UT; Stephen P. Hunger, Children's Hospital of Philadelphia, Philadelphia, PA; and William L. Carroll, New York University Medical Center, New York, NY
| | - Elizabeth Raetz
- Naomi Winick, University of Texas Southwestern Medical Center, Dallas, TX; Meenakshi Devidas and Si Chen, University of Florida, Gainesville, FL; Kelly Maloney, Children's Hospital Colorado, Aurora, CO; Eric Larsen, Maine Children's Cancer Program, Scarborough, ME; Leonard Mattano, HARP Pharma Consulting, Mystic, CT; Michael J. Borowitz, Johns Hopkins Medical Institutions, Baltimore, MD; Andrew Carroll, University of Alabama at Birmingham, AL; Julie M. Gastier-Foster, Institute for Genomic Medicine, Nationwide Children's Hospital; Julie M. Gastier-Foster and Nyla A. Heerema, The Ohio State University School of Medicine, Columbus, OH; Cheryl Willman, University of New Mexico, Albuquerque, NM; Brent Wood, University of Washington, Seattle, WA; Mignon L. Loh, University of California, San Francisco, San Francisco, CA; Elizabeth Raetz, University of Utah, Salt Lake City, UT; Stephen P. Hunger, Children's Hospital of Philadelphia, Philadelphia, PA; and William L. Carroll, New York University Medical Center, New York, NY
| | - Stephen P Hunger
- Naomi Winick, University of Texas Southwestern Medical Center, Dallas, TX; Meenakshi Devidas and Si Chen, University of Florida, Gainesville, FL; Kelly Maloney, Children's Hospital Colorado, Aurora, CO; Eric Larsen, Maine Children's Cancer Program, Scarborough, ME; Leonard Mattano, HARP Pharma Consulting, Mystic, CT; Michael J. Borowitz, Johns Hopkins Medical Institutions, Baltimore, MD; Andrew Carroll, University of Alabama at Birmingham, AL; Julie M. Gastier-Foster, Institute for Genomic Medicine, Nationwide Children's Hospital; Julie M. Gastier-Foster and Nyla A. Heerema, The Ohio State University School of Medicine, Columbus, OH; Cheryl Willman, University of New Mexico, Albuquerque, NM; Brent Wood, University of Washington, Seattle, WA; Mignon L. Loh, University of California, San Francisco, San Francisco, CA; Elizabeth Raetz, University of Utah, Salt Lake City, UT; Stephen P. Hunger, Children's Hospital of Philadelphia, Philadelphia, PA; and William L. Carroll, New York University Medical Center, New York, NY
| | - William L Carroll
- Naomi Winick, University of Texas Southwestern Medical Center, Dallas, TX; Meenakshi Devidas and Si Chen, University of Florida, Gainesville, FL; Kelly Maloney, Children's Hospital Colorado, Aurora, CO; Eric Larsen, Maine Children's Cancer Program, Scarborough, ME; Leonard Mattano, HARP Pharma Consulting, Mystic, CT; Michael J. Borowitz, Johns Hopkins Medical Institutions, Baltimore, MD; Andrew Carroll, University of Alabama at Birmingham, AL; Julie M. Gastier-Foster, Institute for Genomic Medicine, Nationwide Children's Hospital; Julie M. Gastier-Foster and Nyla A. Heerema, The Ohio State University School of Medicine, Columbus, OH; Cheryl Willman, University of New Mexico, Albuquerque, NM; Brent Wood, University of Washington, Seattle, WA; Mignon L. Loh, University of California, San Francisco, San Francisco, CA; Elizabeth Raetz, University of Utah, Salt Lake City, UT; Stephen P. Hunger, Children's Hospital of Philadelphia, Philadelphia, PA; and William L. Carroll, New York University Medical Center, New York, NY
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263
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Cohen IJ. Neurotoxicity after high-dose methotrexate (MTX) is adequately explained by insufficient folinic acid rescue. Cancer Chemother Pharmacol 2017; 79:1057-1065. [PMID: 28455583 DOI: 10.1007/s00280-017-3304-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Accepted: 04/11/2017] [Indexed: 11/26/2022]
Abstract
PURPOSE To challenge the view that the dose of folinic acid rescue after high-dose methotrexate (MTX) has no significance in the prevention of neurotoxicity and to present the minority view that neurotoxicity can be prevented by an adequate dose of folinic acid, without compromising treatment results. Several fallacies that led to the misunderstanding of post MTX neurotoxicity are presented. METHODS Data mining using search engines was used to find relevant publications, and an e-mail survey of more than 60 authors of articles in this field was performed. All relevant articles identified were read in their entirety. RESULTS Examples of clinical studies with neurotoxicity following inadequate rescue are given. Some studies demonstrated no neurotoxicity when adequate doses of folinic acid rescue were started 24-36 h after the start of HDMTX rescue even after mega doses of MTX. Rescue started after 42 h was associated with neurotoxicity except in patients with low serum MTX levels after 24 and 36 h. ALL protocols with neurotoxicity, especially BFM-like protocols, are presented. Protocol is reported in which single protocol changes prevented neurotoxicity. CONCLUSIONS From the published data, when folinic acid rescue is given in a sufficiently high enough dose and is started 24-36 h after the beginning of the methotrexate exposure, and virtually all forms of post MTX neurotoxicity can be prevented without compromising therapeutic results.
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Affiliation(s)
- Ian Joseph Cohen
- The Rina Zaizov Department of Pediatric Hematology-Oncology, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel.
- , 139 Shir Hashirim St., 44814, Elkana, Israel.
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264
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Liu Y, Fernandez CA, Smith C, Yang W, Cheng C, Panetta JC, Kornegay N, Liu C, Ramsey LB, Karol SE, Janke LJ, Larsen EC, Winick N, Carroll WL, Loh ML, Raetz EA, Hunger SP, Devidas M, Yang JJ, Mullighan CG, Zhang J, Evans WE, Jeha S, Pui CH, Relling MV. Genome-Wide Study Links PNPLA3 Variant With Elevated Hepatic Transaminase After Acute Lymphoblastic Leukemia Therapy. Clin Pharmacol Ther 2017; 102:131-140. [PMID: 28090653 DOI: 10.1002/cpt.629] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 01/04/2017] [Accepted: 01/11/2017] [Indexed: 12/12/2022]
Abstract
Remission induction therapy for acute lymphoblastic leukemia (ALL) includes medications that may cause hepatotoxicity, including asparaginase. We used a genome-wide association study to identify loci associated with elevated alanine transaminase (ALT) levels after induction therapy in children with ALL enrolled on St. Jude Children's Research Hospital (SJCRH) protocols. Germline DNA was genotyped using arrays and exome sequencing. Adjusting for age, body mass index, ancestry, asparaginase preparation, and dosage, the PNPLA3 rs738409 (C>G) I148M variant, previously associated with fatty liver disease risk, had the strongest genetic association with ALT (P = 2.5 × 10-8 ). The PNPLA3 rs738409 variant explained 3.8% of the variability in ALT, and partly explained race-related differences in ALT. The PNPLA3 rs738409 association was replicated in an independent cohort of 2,285 patients treated on Children's Oncology Group protocol AALL0232 (P = 0.024). This is an example of a pharmacogenetic variant overlapping with a disease risk variant.
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Affiliation(s)
- Y Liu
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - C A Fernandez
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - C Smith
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - W Yang
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - C Cheng
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - J C Panetta
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - N Kornegay
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - C Liu
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - L B Ramsey
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - S E Karol
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - L J Janke
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - E C Larsen
- Maine Children's Cancer Program, Scarborough, Maine, USA
| | - N Winick
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - W L Carroll
- Department of Pediatrics, New York University Langone Medical Center, New York, New York, USA
| | - M L Loh
- Department of Pediatrics, University of California School of Medicine, San Francisco, California, USA
| | - E A Raetz
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - S 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, Pennsylvania, USA
| | - M Devidas
- Department of Biostatistics, Colleges of Medicine, Public Health & Health Professions, University of Florida, Gainesville, Florida, USA
| | - J J Yang
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - C G Mullighan
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - J Zhang
- Department of Computational Biology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - W E Evans
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - S Jeha
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - C-H Pui
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - M V Relling
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
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265
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Christ TN, Stock W, Knoebel RW. Incidence of asparaginase-related hepatotoxicity, pancreatitis, and thrombotic events in adults with acute lymphoblastic leukemia treated with a pediatric-inspired regimen. J Oncol Pharm Pract 2017; 24:299-308. [PMID: 28355969 DOI: 10.1177/1078155217701291] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Asparaginase is a critical component of acute lymphoblastic leukemia (ALL) treatment in children; however, its use in adults is often avoided as a result of toxicities including hepatotoxicity, thrombosis, and pancreatitis which have been reported more commonly in adults than in children. In this retrospective analysis, short-acting L-asparaginase (L-ASP) and long-acting polyethylene glycol (PEG)-asparaginase (PEG-ASP) were compared for grade 3-4 toxicities and characterized by patient and drug-related factors to identify strategies for toxicity avoidance in adults with ALL. Asparaginase was administered during sequential courses of chemotherapy using a pediatric-inspired treatment regimen. Forty-eight patients who received PEG-ASP and nine patients who received L-ASP were identified. The rates of toxicity were as follows for the PEG-ASP and L-ASP groups, respectively: hepatotoxicity (60% vs. 33%, P = 0.275), pancreatitis (17% vs. 22%, P = 0.650), thrombosis (19.0% vs. 0%, P = 0.328), or any grade 3-4 toxicity (71% vs. 44%, P = 0.143). Toxicity did not correlate with dose, either by individual dose based on flat or BSA-based measures. Logistic regression identified obesity as a risk factor for heptatotoxicity (OR = 8.44, 95% CI: 1.395-51.117). Hypofibrinogenemia was identified as a pharmacodynamic marker for predicting hepatotoxicity. In conclusion, grade 3-4 toxicity was not statistically different between adult ALL patients receiving PEG-ASP and L-ASP, but toxicity was strongly associated with obesity and hypofibrinogenemia, not dose.
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Affiliation(s)
- Trevor N Christ
- 1 Department of Pharmacy, University of Chicago Medicine, IL, USA
| | - Wendy Stock
- 2 Department of Medicine, Section of Hematology/Oncology, University of Chicago, IL, USA
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266
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Chan BS, Dawson AH, Buckley NA. What can clinicians learn from therapeutic studies about the treatment of acute oral methotrexate poisoning? Clin Toxicol (Phila) 2017; 55:88-96. [DOI: 10.1080/15563650.2016.1271126] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Betty S. Chan
- Clinical Toxicology Unit & Emergency Department, Prince of Wales Hospital, Sydney, Australia
- New South Wales Poisons Information Centre, Sydney, Australia
| | - Andrew H. Dawson
- New South Wales Poisons Information Centre, Sydney, Australia
- Drug Health, Royal Prince Alfred Hospital, Sydney, Australia
| | - Nicholas A. Buckley
- New South Wales Poisons Information Centre, Sydney, Australia
- Clinical Pharmacology Department, University of Sydney, Sydney, Australia
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267
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Muffly L, Lichtensztajn D, Shiraz P, Abrahão R, McNeer J, Stock W, Keegan T, Gomez SL. Adoption of pediatric-inspired acute lymphoblastic leukemia regimens by adult oncologists treating adolescents and young adults: A population-based study. Cancer 2017; 123:122-130. [PMID: 27622953 PMCID: PMC5161602 DOI: 10.1002/cncr.30322] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 07/14/2016] [Accepted: 08/11/2016] [Indexed: 01/07/2023]
Abstract
BACKGROUND Studies have demonstrated superior outcomes for adolescent and young adult (AYA) patients with acute lymphoblastic leukemia (ALL) who are treated using pediatric versus adult therapeutic regimens. To the best of our knowledge, whether adult oncologists in the United States have adopted this approach to ALL in AYA patients is currently unknown. The objective of the current study was to provide a population-based description of ALL treatment patterns in AYA individuals over the past decade. METHODS Data regarding AYA patients aged 15 to 39 years and diagnosed with ALL between 2004 and 2014 while living in the Greater Bay Area were obtained from the Greater Bay Area Cancer Registry (GBACR). Treating facilities were designated as pediatric or adult centers; induction treatment regimens were abstracted from registry text data fields. RESULTS Of 304 patients diagnosed in the GBACR catchment region, complete treatment data were available for 229 (75%). The location of care was identified for 296 patients (97%) treated at 31 unique centers. Approximately 70% of AYA patients received induction therapy at an adult treatment center. All AYA patients who were treated at pediatric centers received pediatric ALL regimens. Among AYA patients treated by adult oncologists with complete treatment data, none received a pediatric regimen before 2008. Between 2008 and 2012, while the US Adult Intergroup C10403 pediatric-inspired ALL protocol was open to accrual, 31% of AYA patients treated by adult oncologists received pediatric regimens. This rate fell to 21% from 2013 through 2014. Adult facilities treating ≥ 2 AYA patients with ALL per year captured in the GBACR were more likely to administer pediatric regimens than lower volume centers (P = .03). CONCLUSIONS As of 2014, only a minority of AYA patients with ALL received pediatric ALL regimens at adult cancer centers. Cancer 2017;122-130. © 2016 American Cancer Society.
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Affiliation(s)
- Lori Muffly
- Division of Blood and Marrow Transplantation, Department of Medicine, Stanford University, Stanford, California
- Stanford Cancer Institute, Stanford University, Stanford, California
| | | | - Parveen Shiraz
- Division of Blood and Marrow Transplantation, Department of Medicine, Stanford University, Stanford, California
| | - Renata Abrahão
- Cancer Prevention Institute of California, Freemont, California
| | - Jennifer McNeer
- Section of Hematology/Oncology, Department of Pediatrics, University of Chicago, Chicago, Illinois
| | - Wendy Stock
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Theresa Keegan
- Division of Hematology and Oncology, Department of Medicine, University of California at Davis School of Medicine, Sacramento, California
| | - Scarlett Lin Gomez
- Stanford Cancer Institute, Stanford University, Stanford, California
- Cancer Prevention Institute of California, Freemont, California
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268
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Raetz EA, Teachey DT. T-cell acute lymphoblastic leukemia. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:580-588. [PMID: 27913532 PMCID: PMC6142501 DOI: 10.1182/asheducation-2016.1.580] [Citation(s) in RCA: 160] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
T-cell acute lymphoblastic leukemia (T-ALL) is biologically distinct from its B lymphoblastic (B-ALL) counterpart and shows different kinetic patterns of disease response. Although very similar regimens are used to treat T-ALL and B-ALL, distinctions in response to different elements of therapy have been observed. Similar to B-ALL, the key prognostic determinant in T-ALL is minimal residual disease (MRD) response. Unlike B-ALL, other factors including age, white blood cell count at diagnosis, and genetics of the ALL blasts are not independently prognostic when MRD response is included. Recent insights into T-ALL biology, using modern genomic techniques, have identified a number of recurrent lesions that can be grouped into several targetable pathways, including Notch, Jak/Stat, PI3K/Akt/mTOR, and MAPK. With contemporary chemotherapy, outcomes for de novo T-ALL have steadily improved and now approach those observed in B-ALL, with approximately 85% 5-year event-free survival. Unfortunately, salvage has remained poor, with less than 25% event-free and overall survival rates for relapsed disease. Thus, current efforts are focused on preventing relapse by augmenting therapy for high-risk patients, sparing toxicity in favorable subsets and developing new approaches for the treatment of recurrent disease.
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Affiliation(s)
- Elizabeth A. Raetz
- Department of Pediatrics and Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - David T. Teachey
- Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
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269
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Abstract
Acute lymphoblastic leukemia (ALL) is the most common malignancy in childhood. Despite enormous improvement of prognosis during the last half century, ALL remains a major cause of childhood cancer-related mortality. During the past decade, whole genomic methods have enhanced our knowledge of disease biology. Stratification of therapy according to early treatment response measured by minimal residual disease allows risk group assignment into different treatment arms, ranging from reduction to intensification of treatment. Progress has been achieved in academic clinical trials by optimization of combined chemotherapy, which continues to be the mainstay of contemporary treatment. The availability of suitable volunteer main histocompatibility antigen-matched unrelated donors has increased the rates of hematopoietic stem cell transplantation (HSCT) over the past two decades. Allogeneic HSCT has become an alternative treatment for selected, very-high-risk patients. However, intensive treatment burdens children with severe acute toxic effects that can cause permanent organ damage and even toxic death. Immunotherapeutic approaches have recently come to the forefront in ALL therapy. Monoclonal antibodies blinatumomab and inotuzumab ozogamicin as well as gene-modified T cells directed to specific target antigens have shown efficacy against resistant/relapsed leukemia in phase I/II studies. Integration of these newer modalities into combined regimens with chemotherapy may rescue a subset of children not curable by contemporary therapy. Another major challenge will be to incorporate less toxic regimens into the therapy of patients with low-risk disease who have a nearly 100% chance of being cured, and the ultimate goal is to improve their quality of life while maintaining a high cure rate.
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Affiliation(s)
- Jan Starý
- Department of Pediatric Hematology and Oncology, 2nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Ondřej Hrušák
- Department of Pediatric Hematology and Oncology, 2nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
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270
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Kim H. Recent advances in the treatment of pediatric acute leukemia. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2016. [DOI: 10.5124/jkma.2016.59.9.690] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Hyery Kim
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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