Results of a prospective randomized trial of early splenectomy in chronic myeloid leukemia. The Italian Cooperative Study Group on Chronic Myeloid Leukemia

Role of autoimmune hemolytic anemia as an initial indicator for chronic myeloid leukemia: A case report

INTRODUCTION

We report here the case of a patient with chronic myeloid leukemia (CML) in the chronic phase who was diagnosed 1 year after receiving a diagnosis of autoimmune hemolytic anemia (AIHA). The objective was to assess if the CML patient progressed from AIHA and explore the underlying factors of the poor outcome after the achievement of molecular complete remission (MCR).

PATIENT CONCERNS

A patient with AIHA underwent splenectomy because of poor response to immune inhibitors. The spleen biopsy showed reactive hyperplasia.

DIAGNOSIS

The patient was diagnosed with CML because of over-expression of the BCR-ABL (P210) gene in the bone marrow (BM), 1 year after receiving the diagnosis of AIHA.

INTERVENTIONS

The splenectomy was performed as the patient was unresponsive to the standard treatments consisting of immunoglobulin and dexamethasone. The removed spleen was sent for pathological examination. After she was diagnosed with CML, she received imatinib treatment.

OUTCOMES

The spleen biopsy confirmed the translocation of 22q11/9q34. No BCR-ABL kinase domain mutation was detected and there was no expression of the WT1 or EVI1 genes. After splenectomy, the number of peripheral white blood cells was consistently higher than normal during the total therapy time for CML even though she showed MCR. Two years after CML was diagnosed, the patient died from severe infection. The BM gene array analysis displayed 3 types of chromosomal abnormalities: gain (14q32.33), uniparental disomy (UPD) Xp11.22-p11.1), and UPD Xp11.1-q13.1.

LESSONS

AIHA may be a clinical phase of CML progression in this patient. Both splenectomy and prolonged oral tyrosine kinase inhibitors may have contributed to the high risk of infection and her subsequent death. In addition, the gain of chromosome 14q32.33 may be related to her poor outcome.

Predicting complete cytogenetic response and subsequent progression-free survival in 2060 patients with CML on imatinib treatment: the EUTOS score

The outcome of chronic myeloid leukemia (CML) has been profoundly changed by the introduction of tyrosine kinase inhibitors into therapy, but the prognosis of patients with CML is still evaluated using prognostic scores developed in the chemotherapy and interferon era. The present work describes a new prognostic score that is superior to the Sokal and Euro scores both in its prognostic ability and in its simplicity. The predictive power of the score was developed and tested on a group of patients selected from a registry of 2060 patients enrolled in studies of first-line treatment with imatinib-based regimes. The EUTOS score using the percentage of basophils and spleen size best discriminated between high-risk and low-risk groups of patients, with a positive predictive value of not reaching a CCgR of 34%. Five-year progression-free survival was significantly better in the low- than in the high-risk group (90% vs 82%, P = .006). These results were confirmed in the validation sample. The score can be used to identify CML patients with significantly lower probabilities of responding to therapy and survival, thus alerting physicians to those patients who require closer observation and early intervention.

Indications for Splenectomy

In the new millennium, indications for splenectomy have expanded. Proper patient selection based on an understanding of the biology of each individual's disease is essential for a favorable outcome. We review the most common diseases for which surgeons may be called on to perform splenectomy and while highlighting potential pitfalls and caveats.

Splenic malignancy: a minimally invasive approach

Since the advent of laparoscopy and its general acceptance for treating benign diseases, indications for malignant disease have been investigated. Recently, greater evidence shows that laparoscopy for malignant disease is oncologically safe.

DESIGN

We review a minimally invasive approach to splenic malignancy and the common malignant diseases involving the spleen. We outline our preferred technique for splenectomy in detail. Additionally, the recent literature is reviewed regarding outcome after laparoscopic splenectomy for benign and malignant disease. The data from three studies, containing a total of 327 were analyzed. Complication rates, mortality, and length of stay were compared.

RESULTS

There was no statistically significant difference identified between those undergoing laparoscopic splenectomy for benign versus malignant disease in terms of length of stay, complication rate or mortality. There were significant differences between the two groups in terms of operative time and spleen weight.

DISCUSSION

In open splenectomy series for patients with malignant diseases of the spleen, complication and mortality are much higher when compared to those patients undergoing open splenectomy for benign disease. The discussed series show no difference in endpoints when laparoscopy is used. Laparoscopic splenectomy for malignant disease confers significant benefit and rapid recovery for an otherwise at risk population.

Chronic myelogenous leukemia

The treatment recommendations for chronic myelogenous leukemia (CML) are evolving rapidly. In the past year, pegylated interferon and STI571 (Gleevec, imatinib mesylate), a Bcr-Abl tyrosine kinase inhibitor, have become commercially available and non-myeloablative stem cell transplants continue to be refined. Clinicians and patients face a bewildering array of treatment options for CML. In this article Dr. Sawyer reviews the clinical results with STI571 and ongoing investigations into mechanisms of resistance to STI571. Given the newness of STI571, a practical overview on the administration of STI571 is presented by Drs. Druker and Ford, focusing on aspects such as optimal dose, management of common side effects, and potential drug interactions. The most recent data on interferon-based regimens are reviewed by Dr. Baccarani in the third section. In the last section Dr. Goldman presents recent results of allogeneic stem cell transplants, including the reduced intensity conditioning regimens. Lastly, the proposed place of each of these treatments in the management of CML patients is addressed to assist in deciding amongst treatment options for CML patients.

Current Treatment of Chronic Myeloid Leukemia

We are entering an exciting era in the management of chronic myeloid leukemia (CML). This, in part is related to our considerable understanding of the molecular lesion associated with the disease-arguably the best characterized of any malignancy. Although allogeneic hematopoietic cell transplantation remains the sole potentially curative therapy at present, newer agents such as the tyrosine kinase inhibitor STI571 show promise and may eventually replace less specific cytotoxic therapy. This review focuses on the numerous options currently available for treating CML and includes a treatment algorithm.

Splenectomy in chronic myeloid leukemia and myelofibrosis with myeloid metaplasia

Myelofibrosis with myeloid metaplasia (MMM) is a collective term that describes the related disorders AMM, PPMM, and PTMM. The chronic myeloid disorders include chronic myeloid leukemia, polycythemia vera, essential thrombocythemia, and agnogenic myeloid metaplasia (myelofibrosis). These disorders display varying propensities for pathologic enlargement of the spleen which can lead to mechanical discomfort, hypercatabolic symptoms, anemia, thrombocytopenia, and portal hypertension. Splenectomy has been found to be of little benefit in the early stages of chronic myeloid leukemia. Similarly, the benefit of splenectomy in advanced cases is limited to symptomatic palliation and treatment of delayed engraftment after allogeneic bone marrow transplantation. Although polycythemia vera and essential thrombocythemia are also characterized by splenomegaly, splenectomy is not considered a therapeutic option in the absence of transformation of the disease into myelofibrosis with myeloid metaplasia. Splenectomy has been studied most in myelofibrosis with myeloid metaplasia. Although there is no clear survival advantage to splenectomy in this disorder, the surgical procedure can result in substantial palliation of mechanical discomfort, hypercatabolic symptoms, portal hypertension, and anemia. However, the procedure is associated with an approximately 9% mortality rate, and the postsplenectomy occurrence of extreme thrombocytosis, hepatomegaly, and leukemic transformation is of major concern.

Monitoring Treatment and Survival in Chronic Myeloid Leukemia

PURPOSE: To monitor treatment results and survival in chronic myeloid leukemia after allogeneic bone marrow transplantation (alloBMT) and the introduction of interferon alpha (IFNα).

PATIENTS AND METHODS: Disease course was monitored in 840 patients younger than 56 years who were registered onto prospective studies between 1984 and 1991 and were assigned to conventional chemotherapy (CHT) or IFNα therapy. One hundred twenty of these patients received allogeneic bone marrow in the chronic phase from an HLA-identical sibling without T-cell depletion (standard alloBMT).

RESULTS: Patient distribution by risk and by presenting features was the same in the transplantation and nontransplantation cohorts, but age was different (median, 32 v 42 years). Results were analyzed by age and by Sokal's relative risk. Among low-risk patients, 10-year survival rates with standard alloBMT versus IFNα therapy versus CHT were 57% v 49% (P = .76) v 25% (P = .001), respectively, and among patients at higher risk, rates were 54% v 17% (P = .01) v 12% (P = .001). Among patients ≤ 32 years old, the 10-year survival rates were 65% v 35% (P = .05) v 24% (P = .001), respectively, but for patients older than 32 years, 10-year survival rates were 46% for standard alloBMT versus 31% for IFNα therapy (P = .62) versus 16% for conventional CHT (P = .05). The data did not change when the calculations were based on the transplantations that were performed within 1 year of diagnosis.

CONCLUSION: Any policy of standard alloBMT was associated with significantly longer survival compared with conventional CHT, irrespective of age and risk. When the comparison was made with IFNα therapy, a policy of standard alloBMT, including early transplantation, was found to increase survival only in those patients who were younger or at intermediate or high risk.

Splenectomy in the accelerated or blastic phase of chronic myelogenous leukemia: a single-institution, 25-year experience

BACKGROUND

Patients in the accelerated or blastic phases of chronic myelogenous leukemia (CML) often have painful splenomegaly and secondary thrombocytopenia. We tested the hypothesis that splenectomy can be performed with minimal complications in advanced CML, thereby alleviating pain, reversing thrombocytopenia, and minimizing transfusion requirements.

METHODS

We reviewed the records of 53 patients in the accelerated or blastic phases of CML who underwent splenectomy between 1970 and 1995 at the U. T. M. D. Anderson Cancer Center.

RESULTS

Twenty-eight patients were in accelerated phase and 25 in blastic phase at the time of splenectomy. The most common indications for splenectomy were symptomatic splenomegaly (median splenic weight, 1000 gm; range, 120 to 6700 gm) or thrombocytopenia (platelet count less than 100,000/microliter) or both. There was 1 death within 30 days of splenectomy. The preoperative platelet count increased 3.72-fold +/- 0.53-fold (mean +/- SEM) by postoperative day 7 (p < 0.001; paired t test). Patients with transfusion-dependent thrombocytopenia had significantly fewer platelet and red blood cell transfusions in the 6 months after splenectomy than in the 6 months before splenectomy (p = 0.016; sign test).

CONCLUSIONS

Splenectomy can be performed with minimal morbidity and mortality in advanced CML, thereby relieving symptomatic splenomegaly, reversing thrombocytopenia, and minimizing transfusion requirements.

Postoperative complications after splenectomy for hematologic malignancies

OBJECTIVE

The authors analyzed the frequency and character of postoperative complications after splenectomy in patients with hematologic malignancies, and correlated these findings with preoperative conditions that could have predicted their outcome.

SUMMARY BACKGROUND DATA

Splenectomy is performed for hematologic malignancies for diagnostic and therapeutic indications. The role of splenectomy for lymphoproliferative and myeloproliferative malignancies is complex and sometimes controversial.

METHODS

The medical records of 135 patients undergoing splenectomies for hematologic malignancies at Roswell Park Cancer Institute from January 1, 1984 to December 31, 1993 were reviewed retrospectively. These included Hodgkin's disease (HD), hairy cell leukemia (HCL), non-Hodgkin's lymphoma (NHL), chronic lymphocytic leukemia (CLL), chronic myelogenous leukemia (CML), and a miscellaneous group.

RESULTS

The overall postoperative complication and mortality rates for all patients were 52% and 9%, respectively. The complication rate was 63% for patients whose spleens weighed greater than 2000 g, and 29% for patients whose spleens weighed less than 2000 g (p = 0.001). Seventy-three percent of the postoperative deaths were due to septic complications, only one of which was caused by an encapsulated organism. Complications occurred in less than 20% of patients with the diagnosis of HD and HCL; more than 50% of patients with NHL, CLL, and CML suffered postoperative complications.

CONCLUSIONS

Splenectomy performed in patients with hematologic malignancies is a potentially morbid procedure. Splenic size was the only preoperative factor found to be predictive of postoperative complications. The complication rate differed significantly between the different diagnostic subgroups.

Prolonged survival (17 years) in a patient with chronic myelogenous leukemia after therapy for Hodgkin's disease

A case of secondary chronic myelogenous leukemia after successful therapy for Hodgkin's disease is reported. The patient was diagnosed as having stage IIIA Hodgkin's disease, at the age of 33. He underwent staging laparosplenectomy and was treated with radiotherapy plus chemotherapy. Forty three months after the diagnosis of Hodgkin's disease, a Philadelphia-positive chronic myelogenous leukemia developed. It required periodic chemotherapy and each time a remission, lasting several months (up to 14 months), was obtained. The disease had an unusually prolonged clinical course, and the blast crisis, of lymphoid type, occurred only 17 years later.

Chemotherapy of chronic haematological malignancies

After years of stagnation in the treatment of chronic haematological malignancies, some interesting agents have emerged which might improve the prognosis of these diseases. For chronic leukaemias of lymphoid lineage, three new chemical agents, all purine analogues, seem to be of particular interest. Pentostatin is a specific inhibitor of ADA and has been shown to be highly efficient in producing CR in patients with HCL. Its relative merit compared with IFN-alpha for the treatment of HCL is being studied in ongoing randomized trials. Pentostatin is also active in B-CLL and promising activities have been demonstrated in T- or B-PLL and ATCL. Fludarabine is an analogue of adenine which is resistant to the deamination of ADA. It has been reported to be highly active for patients with both pretreated or non-treated B-CLL. CR rates of 13% with overall response rates of 57% can be achieved, even in heavily pretreated patients. Its activity in the other lymphoid malignancies is not yet known. CdA, a substrate analogue of ADA, has also produced encouraging results in B-CLL, HCL and T cell malignancies, and in some patients with just one single course. Thus far, experience with this drug comes from one institution and requires further confirmation. For chronic myeloproliferative diseases, little progress has yet been made. Although IFN-alpha seems to be active in CML and to result in cytogenetic remissions in bone marrow, a definite advantage of this biological agent over conventional chemotherapy as regards survival and life quality has not yet been proven. Allogeneic bone marrow transplantation is beneficial for those patients who are eligible. No remarkable advances have been made in the treatment of myeloproliferative disorders except for the development of an antiplatelet drug, anagrelide. This agent seems to be highly effective in controlling thrombocytosis. The relative merit of this agent as compared with IFN-alpha, as well as the impact of this agent on the survival and on life-quality of patients with myeloproliferative disorders, have yet to be defined.

Chronic leukemias of childhood

Chronic leukemias account for fewer than 5 per cent of childhood hematologic malignancies. The various subtypes are chronic mylocytic leukemia (adult, juvenile, and familial), chronic myelomonocytic leukemia chronic monocytic leukemia, and chronic lymphocytic leukemia. The most common of these, adult-type chronic myelocytic leukemia, is characterized by specific cytogenetic alterations; recent advances in molecular biology are linking these genetic events to the pathophysiology and course of this fascinating neoplasm.

Chronic myelogenous leukemia in blast crisis. Analysis of 242 patients

Two hundred forty-two patients with Philadelphia chromosome-positive chronic myelogenous leukemia in blast crisis were reviewed to identify significant biologic and prognostic associations. Twenty percent of patients had lymphoid blast crisis. Clonal evolution was present in 60 percent of patients at blast crisis and involved most frequently the development of a double Philadelphia chromosome, trisomy 8, or isochromosome 17. The overall median survival from blast crisis was 18 weeks. Patient characteristics demonstrated to have significant association with short survival were: anemia; thrombocytopenia; myeloid or undifferentiated blast cell morphology; clonal evolution involving the presence of a double Philadelphia chromosome, trisomy 8, or isochromosome 17; and low marrow blast percentage. Of 195 patients who received therapy for blast crisis, complete remission was achieved in 44 (23 percent) patients, and 24 (13 percent) patients had a partial remission or hematologic improvement. Lower complete remission rates were associated with old age, thrombocytopenia, myeloid or undifferentiated blast cell morphology, clonal evolution--especially isochromosome 17 and trisomy 8--and long interval from diagnosis to onset of blast crisis. A multivariate analysis identified two characteristics to have independent prognostic importance for both survival and remission: platelet counts and blast cell morphology. In addition, clonal evolution had additive prognostic value for survival (double Philadelphia chromosome) and for response (isochromosome 17). The beneficial association of therapy with survival was demonstrated by the significantly longer median survival of patients treated since 1981 compared with those treated earlier, even after accounting for the pretreatment prognostic factors, and by the significant improvement in survival of patients achieving remission using the "landmark" analysis technique.

Splenectomy in the management of haematological disease

Patients, both adults and children, with various haematological disorders who had splenectomy electively in the diagnosis, staging or treatment of their condition during a 15-year period in the Aberdeen hospitals were reviewed. The outcome regarding the disease and the immediate and long-term complications of splenectomy in this group of 185 patients are presented. Splenectomy has an acceptably low morbidity, even in patients with serious haematological disease, in the hands of an experienced surgical team, where there is close co-operation between surgeon and haematologist. Occasionally, late overwhelming infections may occur, despite prophylaxis with penicillin and pneumococcal vaccination. It seems likely that, in their zeal to report such hazards, authors may allow the pendulum against splenectomy to swing too far, in the direction of leaving patients, especially adults, with considerable symptoms and poor health, rather than risk the occasional consequences of the asplenic state.

Postsplenectomy infection in patients with chronic leukemia

The added risk of infectious complications due to splenectomy in patients already immunocompromised because of chronic leukemia was studied over a 22 year period. When compared to patients with chronic leukemia who did not undergo splenectomy, survival was not influenced. Splenectomy did significantly increase the total number of serious infections (65 percent versus 35 percent, p less than 0.001), the number of infections per patient (p less than 0.05), and the interval between infections (p less than 0.01) in this patient population. Fatal septic episodes were not due to Streptococcus pneumoniae, but did occur significantly more often in the splenectomy group (22 percent versus 7 percent, p less than 0.05). Although the location of infection was similar, there was a significant difference in the number of Pseudomonas aeruginosa infections in the patients who had undergone splenectomy (p less than 0.05). Consideration must be given to the significantly increased risk of postoperative infectious morbidity in patients with chronic leukemia when evaluating the usefulness of splenectomy.