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Curing the Curable: Managing Low-Risk Acute Lymphoblastic Leukemia in Resource Limited Countries. J Clin Med 2021; 10:jcm10204728. [PMID: 34682851 PMCID: PMC8540602 DOI: 10.3390/jcm10204728] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 10/11/2021] [Accepted: 10/12/2021] [Indexed: 12/15/2022] Open
Abstract
Although childhood acute lymphoblastic leukemia (ALL) is curable, global disparities in treatment outcomes remain. To reduce these global disparities in low-middle income countries (LMIC), a paradigm shift is needed: start with curing low-risk ALL. Low-risk ALL, which accounts for >50% of patients, can be cured with low-toxicity therapies already defined by collaborative studies. We reviewed the components of these low-toxicity regimens in recent clinical trials for low-risk ALL and suggest how they can be adopted in LMIC. In treating childhood ALL, the key is risk stratification, which can be resource stratified. NCI standard-risk criteria (age 1–10 years, WBC < 50,000/uL) is simple yet highly effective. Other favorable features such as ETV6-RUNX1, hyperdiploidy, early peripheral blood and bone marrow responses, and simplified flow MRD at the end of induction can be added depending on resources. With limited supportive care in LMIC, more critical than relapse is treatment-related morbidity and mortality. Less intensive induction allows early marrow recovery, reducing the need for intensive supportive care. Other key elements in low-toxicity protocol designs include: induction steroid type; high-dose versus low-dose escalating methotrexate; judicious use of anthracyclines; and steroid pulses during maintenance. In summary, the first effective step in curing ALL in LMIC is to focus on curing low-risk ALL with less intensive therapy and less toxicity.
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Canellas MC, Bruno-Riscarolli E, Ferreira-Facio CS, Lopes-Alves DV, Botafogo VD, Sutter D, Pontes RM, Land MGP, Bedran Milito C, da Costa ES. Immunophenotypic shifts during minimal residual evaluation in a case of leukemic form of anaplastic large cell lymphoma ALK. Cancer Rep (Hoboken) 2021; 5:e1526. [PMID: 34382381 PMCID: PMC9327670 DOI: 10.1002/cnr2.1526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 06/10/2021] [Accepted: 07/19/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study aims to describe immunophenotypic explorations at diagnosis and follow up of a pediatric patient with leukemic phase of ALK+ anaplastic large cell lymphoma (ALCL) by multiparametric flow cytometry (MFC). CASE An 8-color MFC combination of antibodies allowed to identify neoplastic cells in concentrations until 0.02% during minimal residual disease (MRD) monitoring. Immunophenotypic shifts occurred in key markers as CD30, CD7, CD2, and CD5, however neoplastic cells were clearly discriminated from normal populations. CONCLUSION MFC can be a useful tool for ALCL diagnosis and MRD monitoring and may support therapeutic decisions.
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Affiliation(s)
- Maria Clara Canellas
- Martagão Gesteira Pediatric Institute - Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Enrico Bruno-Riscarolli
- Martagão Gesteira Pediatric Institute - Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Daiana V Lopes-Alves
- Martagão Gesteira Pediatric Institute - Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Vitor D Botafogo
- Martagão Gesteira Pediatric Institute - Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Deborah Sutter
- Martagão Gesteira Pediatric Institute - Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Roberia M Pontes
- Martagão Gesteira Pediatric Institute - Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marcelo G P Land
- Martagão Gesteira Pediatric Institute - Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.,Department of Pediatrics, Faculty of Medicine - Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Cristiane Bedran Milito
- Department of Pathology, Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.,Integrated Morphology Laboratory, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Elaine Sobral da Costa
- Martagão Gesteira Pediatric Institute - Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.,Department of Pediatrics, Faculty of Medicine - Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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Pedrosa F, Coustan-Smith E, Zhou Y, Cheng C, Pedrosa A, Lins MM, Pedrosa M, Lucena-Silva N, Ramos AMDL, Vinhas E, Rivera GK, Campana D, Ribeiro RC. Reduced-dose intensity therapy for pediatric lymphoblastic leukemia: long-term results of the Recife RELLA05 pilot study. Blood 2020; 135:1458-1466. [PMID: 32027741 PMCID: PMC7180080 DOI: 10.1182/blood.2019004215] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 01/28/2020] [Indexed: 12/22/2022] Open
Abstract
Treatment-related mortality is common among children with acute lymphoblastic leukemia (ALL) treated in poor-resource settings. We applied a simplified flow cytometric assay to identify patients with precursor B-cell ALL (B-ALL) at very low risk (VLR) of relapse and treated them with a reduced-intensity treatment plan (RELLA05). VLR criteria include favorable presenting features (age ≥ 1 and < 10 years), white blood cell count of <50 ×109/L, lack of extramedullary leukemia, and minimal residual disease level of <0.01% on remission induction day 19. Except for 2 doses of daunorubicin, treatment of patients with VLR B-ALL consisted of a combination of agents with relatively low myelotoxicity profiles, including corticosteroids, vincristine, L-asparaginase, methotrexate, and 6-mercaptopurine. Cyclophosphamide, systemic cytarabine, and central nervous system radiotherapy were not used. Of 454 patients with ALL treated at the Instituto de Medicina Integral Professor Fernando Figueira in Recife, Brazil, between December 2005 and June 2015, 101 were classified as having VLR B-ALL. There were no cases of death resulting from toxicity or treatment abandonment during remission induction. At a median follow-up of 6.6 years, there were 8 major adverse events: 6 relapses, 1 treatment-related death (from septicemia) during remission, and 1 secondary myeloid leukemia. The estimated 5-year event-free and overall survival rates were 92.0% ± 3.9% and 96.0% ± 2.8%, respectively. The 5-year cumulative risk of relapse was 4.24% ± 2.0%. The treatment was well tolerated. Episodes of neutropenia were of short duration. Patients with B-ALL selected by a combination of presenting features and degree of early response can be successfully treated with a mildly myelosuppressive chemotherapy regimen.
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Affiliation(s)
- Francisco Pedrosa
- Department of Pediatric Oncology, Real Hospital Português, Recife, Brazil
| | - Elaine Coustan-Smith
- Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yinmei Zhou
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN
| | - Cheng Cheng
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN
| | - Arli Pedrosa
- Department of Pediatric Oncology, Real Hospital Português, Recife, Brazil
| | | | - Marcia Pedrosa
- Instituto de Medicina Integral Prof. Fernando Figueira, Recife, Brazil; and
| | - Norma Lucena-Silva
- Instituto de Medicina Integral Prof. Fernando Figueira, Recife, Brazil; and
| | | | - Ester Vinhas
- Department of Pediatric Oncology, Real Hospital Português, Recife, Brazil
| | | | - Dario Campana
- Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Raul C Ribeiro
- Department of Global Pediatric Medicine
- Department of Oncology, and
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN
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Dias ALA, da Silva RG, Cunha FGP, Morcillo AM, Lorand-Metze I, Vilela MMDS, Riccetto AGL. Managing costs in primary immunodeficiency: minimal immunophenotyping and three national references. APMIS 2019; 127:228-235. [PMID: 30908772 DOI: 10.1111/apm.12932] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 01/09/2019] [Indexed: 01/25/2023]
Abstract
Our aim was to evaluate the cost-effectiveness of a minimal lymphocyte subset quantification (LSQ) by flow cytometry as the first screening in children with clinically suspected primary immunodeficiency (PID). Two hundred sixty-eight Brazilian patients (0-21 years old) were studied. They were divided by clinical and phenotypical features into those fulfilling criteria for PID (PID phenotype) according to the 2017 International Union of Immunological Societies (IUIS) classification and those not fulfilling these criteria (non-PID phenotype). We evaluated how many patients had values below the 10th percentile for five lymphocyte subsets in peripheral blood, (suggestive of PID) according to reference values for Brazil, Italy and USA. Three lymphocyte subsets (T CD3/CD4, B CD19 and NK CD16/CD56) had p-value < 0.05 and Odds Ratio (OR) indicating a risk at least two times higher for the diagnosis of a PID phenotype. The application of Kappa coefficient (k) on Brazilian vs Italian and Brazilian vs US data sets resulted in k compatible with strong or excellent level of agreement between the three classification systems. The authors conclude that a number of CD3+ /CD4+ , CD19+ and CD16+ /CD56+ (NK) cells in peripheral blood <10th percentile represented a significant risk for the diagnosis of PID in this cohort. Natural killer (NK) deficiency is quite rare and has a very specific clinical profile. So, the analysis of these cells could be requested only in some cases, saving even more costs. The minimal immunophenotyping, with quantification of T CD4+ , CD19+ and in some cases CD16+ /CD56+ cells, may be a useful tool for the first screening of PID, saving costs, especially in developing countries.
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Affiliation(s)
- Ana Luisa Abrahão Dias
- Pediatric Allergy and Immunology/Center of Investigation in Pediatrics (CIPED), Faculty of Medical Sciences, State University of Campinas - Unicamp, Sao Paulo, Brazil
| | - Raquel Gomes da Silva
- Laboratory of Cell Markers - Hematology/Hemotherapy Center, Faculty of Medical Sciences, State University of Campinas - Unicamp, Sao Paulo, Brazil
| | - Fernanda Gonçalves Pereira Cunha
- Laboratory of Cell Markers - Hematology/Hemotherapy Center, Faculty of Medical Sciences, State University of Campinas - Unicamp, Sao Paulo, Brazil
| | - André Moreno Morcillo
- Pediatric Department, Faculty of Medical Sciences, State University of Campinas - Unicamp, Sao Paulo, Brazil
| | - Irene Lorand-Metze
- Laboratory of Cell Markers - Hematology/Hemotherapy Center, Faculty of Medical Sciences, State University of Campinas - Unicamp, Sao Paulo, Brazil
| | - Maria Marluce Dos Santos Vilela
- Pediatric Allergy and Immunology/Center of Investigation in Pediatrics (CIPED), Faculty of Medical Sciences, State University of Campinas - Unicamp, Sao Paulo, Brazil
| | - Adriana Gut Lopes Riccetto
- Pediatric Allergy and Immunology/Center of Investigation in Pediatrics (CIPED), Faculty of Medical Sciences, State University of Campinas - Unicamp, Sao Paulo, Brazil
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Pui CH, Yang JJ, Bhakta N, Rodriguez-Galindo C. Global efforts toward the cure of childhood acute lymphoblastic leukaemia. THE LANCET. CHILD & ADOLESCENT HEALTH 2018; 2:440-454. [PMID: 30169285 PMCID: PMC6467529 DOI: 10.1016/s2352-4642(18)30066-x] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 01/31/2018] [Accepted: 02/13/2018] [Indexed: 12/18/2022]
Abstract
Improvements in risk-directed treatment and supportive care, together with increased reliance on both national and international collaborative studies, have made childhood acute lymphoblastic leukaemia (ALL) one of the most curable human cancers. Next-generation sequencing studies of leukaemia cells and the host germline provide new opportunities for precision medicine and thus potential improvements in the cure rate and quality of life of patients. Efforts are underway to assess the global impact of childhood ALL and develop initiatives that can meet the long-term challenge of providing quality care to children with this disease worldwide and improving cure rates globally. This ambitious task will rely on increased collaborative research and international networking so that the therapeutic gains in high-income countries can be translated to patients in low-income and middle-income countries. Ultimately, the greatest obstacle to overcome will be to fully understand leukaemogenesis, enabling measures to decrease the risk of leukaemia development and thus close the last major gap in offering a cure to any child who might have the disease.
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Affiliation(s)
- Ching-Hon Pui
- Department of Oncology, St Jude Children's Research Hospital, University of Tennessee Health Science Center, Memphis, TN, USA.
| | - Jun J Yang
- Department of Pharmaceutical Science, St Jude Children's Research Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Nickhill Bhakta
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Carlos Rodriguez-Galindo
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
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