1
|
Takahashi T, Lake AJ, Wachter F, Calderon FA, Dandoy C, Keating AK. Effects of Total Body Irradiation on Hematopoietic Cell Transplantation Outcomes in Pediatric Acute Myeloid Leukemia with Prior Central Nervous System Involvement. Transplant Cell Ther 2024; 30:812.e1-812.e11. [PMID: 38763417 DOI: 10.1016/j.jtct.2024.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 05/02/2024] [Accepted: 05/13/2024] [Indexed: 05/21/2024]
Abstract
The implications of previous central nervous system (CNS) involvement in children with acute myeloid leukemia (AML) undergoing hematopoietic cell transplantation (HCT) remain inadequately understood. Patients with CNS disease require more upfront CNS-directed intrathecal therapy, but little is known about whether transplant conditioning regimens should be intensified or if previous CNS involvement impacts post-HCT outcomes. While total body irradiation (TBI) remains standard for pediatric acute lymphoblastic leukemia myeloablative conditioning, it has been largely replaced with chemotherapy-only myeloablation in pediatric AML, primarily due to toxicity and late effects associated with TBI. In the setting of previous CNS involvement, it has been suggested that TBI-based myeloablation may have advantages due to superior CNS tissue penetration and thus decreased rates of AML relapse post-HCT. We analyzed a publicly available dataset derived from the Center for International Blood and Marrow Transplantation Research (CIBMTR) registry to characterize the impact of TBI in HCT preparative regimens in pediatric AML patients with a history of CNS involvement. The study dataset was obtained from the CIBMTR data repository. The study cohort included patients aged ≤21 years who underwent initial allogeneic HCT with myeloablative conditioning for de novo AML in the first or second complete remission (CR) between 2008 and 2016, who provided consent for research. Patients with mismatched related donor transplants and noncalcineurin inhibitor graft-versus-host disease (GVHD) prophylaxis were excluded. The dataset was further modified by excluding patients with missing disease site data or those with non-CNS extramedullary disease. Patients were categorized as CNS-positive or -negative AML (AML-CNS(+) and AML-CNS(-), respectively) based on the disease status at diagnosis. The Cox regression model and Fine-Grey methods were employed to delineate the effects of TBI and CNS disease on key HCT outcomes. The study cohort comprised 550 pediatric AML patients, of which 25% (n = 136) were AML-CNS(+). CNS involvement was more prevalent in patients aged 0 to 3 years, patients who were in the second CR, and those with a mismatched unrelated donor or umbilical cord blood. AML-CNS(+) patients demonstrated a lower relapse rate (hazard ratio: 0.50, 95% confidence interval: 0.33 to 0.76) compared to AML-CNS(-) patients, with comparable disease-free survival (DFS) and overall survival (OS) (P = .10 and 0.20, respectively) in the two cohorts. The entire TBI-treated cohort showed an association with increased risks of grade 2 to 4 acute GVHD, bloodstream infections, and endocrine dysfunction. TBI use within the AML-CNS(+) cohort was associated with a lower relapse rate but increased risks of nonrelapse mortality and a trend of higher grade 3 to 4 acute GVHD. In this population-based analysis of pediatric patients with de novo AML undergoing HCT, TBI-based conditioning regimens did not confer an advantage in DFS or OS compared to non-TBI regimens, irrespective of CNS disease status. However, TBI use was associated with increased risks of short- and long-term comorbidities. These findings underscore the need for careful consideration of TBI in pediatric AML.
Collapse
Affiliation(s)
- Takuto Takahashi
- Pediatric Stem Cell Transplant, Boston Children's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts.
| | - Alexander J Lake
- Pediatric Stem Cell Transplant, Boston Children's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Franziska Wachter
- Pediatric Stem Cell Transplant, Boston Children's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Francesca Alvarez Calderon
- Pediatric Stem Cell Transplant, Boston Children's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Christopher Dandoy
- Pediatric Stem Cell Transplant, Boston Children's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Amy K Keating
- Pediatric Stem Cell Transplant, Boston Children's Hospital and Dana-Farber Cancer Institute, Boston, Massachusetts
| |
Collapse
|
2
|
Li W, Shi M, Zhou P, Liu Y, Liu X, Xiao X, Zuo S, Bai Y, Sun K. Extramedullary infiltration in pediatric acute myeloid leukemia: Results from the Therapeutically Applicable Research to Generate Effective Treatments (TARGET) initiative. Pediatr Blood Cancer 2024; 71:e31014. [PMID: 38644612 DOI: 10.1002/pbc.31014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 03/23/2024] [Accepted: 03/28/2024] [Indexed: 04/23/2024]
Abstract
BACKGROUND The outcome of extramedullary infiltration (EMI) in pediatric acute myeloid leukemia (AML) is controversial, and little is known about the implications of stem cell transplantation (SCT) and gemtuzumab ozogamicin (GO) treatment on patients with EMI. METHODS We retrieved the clinical data of 713 pediatric patients with AML from the Therapeutically Applicable Research to Generate Effective Treatments (TARGET) dataset, and analyzed the clinical and prognostic characteristics of patients with EMI at diagnosis and relapse. RESULTS A total of 123 patients were identified to have EMI at diagnosis and 64 presented with EMI at relapse. The presence of EMI was associated with age ≤2 years, M5 morphology, abnormal karyotype, and KMT2A rearrangements. Hyperleukocytosis and complex karyotype were more prevalent in patients with EMI at relapse. Additionally, patients with EMI at diagnosis had a reduced incidence of FLT3 ITD-/NPM1+, whereas those with EMI at relapse displayed a lower frequency of FLT3 ITD+. Patients with EMI at diagnosis exhibited a lower complete remission (CR) rate at the end of Induction Course 1 and higher relapse incidence. Importantly, EMI at diagnosis independently predicted both shorter event-free survival (EFS) and overall survival (OS). Regarding relapse patients, the occurrence of EMI at relapse showed no impact on OS. However, relapse patients with myeloid sarcoma (MS)/no central nervous system (CNS) exhibited poorer OS compared to those with CNS/no MS. Furthermore, regarding patients with EMI at diagnosis, SCT failed to improve the survival, whereas GO treatment potentially enhanced OS. CONCLUSION EMI at diagnosis is an independent adverse prognostic risk factor for pediatric AML, and GO treatment potentially improves survival for patients with EMI at diagnosis.
Collapse
Affiliation(s)
- Weiya Li
- Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Henan, P. R. China
| | - Mingyue Shi
- Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Henan, P. R. China
| | - Pan Zhou
- Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Henan, P. R. China
| | - Ying Liu
- Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Henan, P. R. China
| | - Xiaobo Liu
- Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Henan, P. R. China
| | - Xingjun Xiao
- Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Henan, P. R. China
| | - Suqiong Zuo
- Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Henan, P. R. China
| | - Yanliang Bai
- Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Henan, P. R. China
| | - Kai Sun
- Department of Hematology, Zhengzhou University People's Hospital and Henan Provincial People's Hospital, Henan, P. R. China
- Department of Hematology, Beijing JiShuiTan Hospital, Capital Medical University, Beijing, P. R. China
| |
Collapse
|
3
|
CNS involvement in AML at diagnosis is rare and does not affect response or survival: data from 11 ECOG-ACRIN trials. Blood Adv 2021; 5:4560-4568. [PMID: 34597373 PMCID: PMC8759130 DOI: 10.1182/bloodadvances.2021004999] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 08/07/2021] [Indexed: 11/20/2022] Open
Abstract
There was no significant difference in CR rate and OS among patients with CNS involvement, other EMD, or no EMD. The incidence of CNS involvement of newly diagnosed AML is low, irrespective of whether an LP is mandatory or not.
Central nervous system (CNS) involvement in patients with newly diagnosed acute myeloid leukemia (AML) is rare, and systematic data regarding outcome are scarce. This retrospective study summarized data from 11 consecutive Eastern Cooperative Oncology Group-American College of Radiology Imaging Network (ECOG-ACRIN) clinical trials for patients with newly diagnosed AML. In all, 3240 patients with AML were analyzed, and 36 (1.11%) were found to have CNS involvement at diagnosis. The incidence of CNS disease among the 5 studies with per protocol mandatory lumbar puncture (LP) was similar to the incidence among studies in which LP was performed at the discretion of the investigator (0.86% vs 1.41%; P = .18). There was no significant difference in the rate of complete remission (CR) among patients with CNS involvement and those with other extramedullary disease (EMD) sites or those with no EMD (52.8% vs 59.3%-60%). The median overall survival (OS) for patients who were CNS positive, who had other EMD, or who had no EMD was 11.4, 11.3, and 12.7 months, respectively. There was no difference in OS among patients with CNS involvement, those with other EMD (hazard ratio [HR], 0.96; adjusted P = .84), and those with no EMD (HR, 1.19; adjusted P = .44). In conclusion, the reported incidence of CNS involvement in patients with newly diagnosed AML is low (1.1%), irrespective of whether an LP is mandatory or not. The presence of CNS disease at diagnosis in and of itself does not seem to portend a poor prognosis for achieving an initial CR or for OS.
Collapse
|
4
|
Egan G, Chopra Y, Mourad S, Chiang KY, Hitzler J. Treatment of acute myeloid leukemia in children: A practical perspective. Pediatr Blood Cancer 2021; 68:e28979. [PMID: 33844444 DOI: 10.1002/pbc.28979] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 01/17/2021] [Accepted: 02/07/2021] [Indexed: 12/17/2022]
Abstract
Pediatric acute myeloid leukemia (AML) is a heterogeneous disease that requires a multifaceted treatment approach. Although outcomes for low-risk AML have improved significantly over recent decades, high-risk AML continues to be associated with an adverse prognosis. Recent advances in molecular diagnostics, risk stratification, and supportive care have contributed to improvements in outcomes in pediatric AML. Targeted approaches, for example, the use of tyrosine kinase inhibitors to treat FLT3-ITD AML, offer promise and are currently undergoing clinical investigation in pediatric patients. New approaches to hematopoietic stem cell transplantation, including the use of haploidentical donors, are significantly expanding donor options for patients with high-risk AML. This review provides an overview of recent advances in the treatment of pediatric AML that are likely to have clinical impact and reshape the standard of care.
Collapse
Affiliation(s)
- Grace Egan
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Yogi Chopra
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Stephanie Mourad
- Division of Haematology/Oncology, Montreal Children's Hospital, Montreal, QC, Canada
| | - Kuang-Yueh Chiang
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Johann Hitzler
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada.,Developmental and Stem Cell Biology, The Hospital for Sick Children Research Institute, Toronto, ON, Canada
| |
Collapse
|
5
|
Infant Acute Myeloid Leukemia: A Unique Clinical and Biological Entity. Cancers (Basel) 2021; 13:cancers13040777. [PMID: 33668444 PMCID: PMC7918235 DOI: 10.3390/cancers13040777] [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: 01/10/2021] [Revised: 02/06/2021] [Accepted: 02/10/2021] [Indexed: 12/11/2022] Open
Abstract
Infant acute myeloid leukemia (AML) is a rare subgroup of AML of children <2 years of age. It is as frequent as infant acute lymphoblastic leukemia (ALL) but not clearly distinguished by study groups. However, infant AML demonstrates peculiar clinical and biological characteristics, and its prognosis differs from AML in older children. Acute megakaryoblastic leukemia (AMKL) is very frequent in this age group and has raised growing interest. Thus, AMKL is a dominant topic in this review. Recent genomic sequencing has contributed to our understanding of infant AML. These data demonstrated striking features of infant AML: fusion genes are able to induce AML transformation without additional cooperation, and unlike AML in older age groups there is a paucity of associated mutations. Mice modeling of these fusions showed the essential role of ontogeny in the infant leukemia phenotype compared to older children and adults. Understanding leukemogenesis may help in developing new targeted treatments to improve outcomes that are often very poor in this age group. A specific diagnostic and therapeutic approach for this age group should be investigated.
Collapse
|
6
|
Kandeel EZ, Madney Y, Eldin DN, Shafik NF. Overexpression of CD200 and CD123 is a major influential factor in the clinical course of pediatric acute myeloid leukemia. Exp Mol Pathol 2020; 118:104597. [PMID: 33358743 DOI: 10.1016/j.yexmp.2020.104597] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 12/12/2020] [Accepted: 12/18/2020] [Indexed: 11/16/2022]
Abstract
Acute myeloid leukemia (AML) accounts for approximately 20% of all pediatric acute leukemias. The outcome of AML is still unsatisfactory. CD123 and CD200 were demonstrated to play important roles in hematological malignancies. The aim of this study was to investigate the impact of CD200 and CD123 overexpression and the influence of both proteins on the clinical presentation and disease outcome. Bone marrow (BM) samples from 89 pediatric AML patients were obtained at presentation and after therapy. Cells from the bulk population and from the leukemia stem cell (LSC) compartment were examined by multi parametric flow cytometry. In the bulk population, CD200 was positive in 64/89 (71.9) samples, CD123 was positive in 62/89 (69.7%) samples, and dual CD200 and CD123 positivity was observed in 54/89 (60.7%) samples. CD200/CD123 expressions were observed in LSCs in 64/60 samples respectively (71.9%/67.4%), and co-expressed in 51 samples (57.3%). CD200 was overexpressed in secondary AML (p < 0.05). A multivariate analysis revealed that minimal residual disease (MRD) and lymphadenopathy were associated with CD200 overexpression. Moreover, lymphadenopathy, low platelet count, and MRD were independently associated with CD123 expression. The co-expression of CD200 and CD123 demonstrated a statistically significant relationship with unfavorable cytogenetic karyotypes and high total leucocyte count (TLC). The expression of CD200 and CD123 alone and together had an adverse impact on complete remission (CR), MRD positivity, and overall survival (OS). Cases with MRD on day 28 after induction displayed stable expression patterns of CD200 and CD123. CD200 and CD123 both had a negative influence on clinical presentation and treatment outcome, which remarkably worsened when both were concomitantly overexpressed. CD200 and CD123 can therefore be used as markers of MRD in AML and may also serve as therapeutic targets.
Collapse
Affiliation(s)
- Eman Z Kandeel
- Clinical pathology, National Cancer Institute, Cairo University, Egypt
| | - Youssef Madney
- Pediatric Oncology, National Cancer Institute, Cairo University, Egypt
| | - Dalia Negm Eldin
- Department of Biostatistics and Cancer Epidemiology, National Cancer Institute, Cairo University, Egypt
| | - Nevine F Shafik
- Clinical pathology, National Cancer Institute, Cairo University, Egypt.
| |
Collapse
|
7
|
Bergstrom CP, Dahiya S, Chen W, Zhang CC, Zhu H, Yan J, Madanat Y, Patel P, Vusirkala M, Ramakrishnan P, Rizvi S, Chung S, Awan F, Anderson LD, Collins R, Kansagra A. The association of leukocyte immunoglobulin-like receptor subfamily B-4 expression in acute myeloid leukemia and central nervous system involvement. Leuk Res 2020; 100:106480. [PMID: 33285315 DOI: 10.1016/j.leukres.2020.106480] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/16/2020] [Accepted: 11/17/2020] [Indexed: 11/30/2022]
Abstract
Central nervous system (CNS) involvement in patients with acute myeloid leukemia (AML) varies, ranging from 0.6%-46%. Leukocyte immunoglobulin-like receptor B4 (LILRB4) has been shown to be critical in orchestration of infiltration of AML cells into the CNS in animal models, however it is unknown if an association exists between LILRB4 and CNS involvement (CNS+) in human patients with AML. LILRB4 was measured by flow cytometry in a heterogeneous population of fifty-six AML patients. Patients were then followed clinically for the development of CNS + . LILRB4 was positive in 91 % of patients with CNS + compared to 38 % without CNS involvement (p < 0.002). In logistic analysis: age, BMI, serum albumin and positive LILRB4 were predictive for CNS+ [OR, 95 % CI, p-value]: 0.95, 0.92-0.99, p < 0.01; 0.85, 0.73-0.998, p < 0.05; 0.23, 0.066-0.78, p < 0.02; 16.46, 1.93-140.2, p < 0.02, respectively. This finding of the association of LILRB4 with CNS + in combination with earlier findings suggests that LILRB4 has a mechanistic role in infiltration of the CNS and may provide insight into the pathogenesis of AML seeding the CNS. Moreover, this proof of concept and the findings in the present study may lead to the development of innovative and novel therapies to improve the lives of patients with AML.
Collapse
Affiliation(s)
- Colin P Bergstrom
- Department of Medicine, UT Southwestern Medical Center, Dallas, USA.
| | - Saurabh Dahiya
- Department of Medicine, Department of Hematology and Oncology, Greenebaum Comprehensive Cancer Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Weina Chen
- Department of Pathology, Department of Medicine, UT Southwestern Medical Center, Dallas, USA
| | - Cheng Cheng Zhang
- Department of Physiology, University of Texas Southwestern Medical Center, Dallas, USA
| | - Hong Zhu
- Department of Population and Data Science, Simmons Comprehensive Cancer Center, Dallas, USA
| | - Jingsheng Yan
- Department of Population and Data Science, Simmons Comprehensive Cancer Center, Dallas, USA
| | - Yazan Madanat
- Department of Medicine, Division of Hematology and Oncology, UT Southwestern Medical Center, Dallas, USA
| | - Prapti Patel
- Department of Medicine, Division of Hematology and Oncology, UT Southwestern Medical Center, Dallas, USA
| | - Madhuri Vusirkala
- Department of Medicine, Division of Hematology and Oncology, UT Southwestern Medical Center, Dallas, USA
| | - Praveen Ramakrishnan
- Department of Medicine, Division of Hematology and Oncology, UT Southwestern Medical Center, Dallas, USA
| | - Syed Rizvi
- Department of Medicine, Division of Hematology and Oncology, UT Southwestern Medical Center, Dallas, USA
| | - Stephen Chung
- Department of Medicine, Division of Hematology and Oncology, UT Southwestern Medical Center, Dallas, USA
| | - Farrukh Awan
- Department of Medicine, Division of Hematology and Oncology, UT Southwestern Medical Center, Dallas, USA
| | - Larry D Anderson
- Department of Medicine, Division of Hematology and Oncology, UT Southwestern Medical Center, Dallas, USA
| | - Robert Collins
- Department of Medicine, Division of Hematology and Oncology, UT Southwestern Medical Center, Dallas, USA
| | - Ankit Kansagra
- Department of Medicine, Division of Hematology and Oncology, UT Southwestern Medical Center, Dallas, USA
| |
Collapse
|
8
|
Gupta S, Aitken J, Bartels U, Bhakta N, Bucurenci M, Brierley JD, De Camargo B, Chokunonga E, Clymer J, Coza D, Fraser C, Fuentes-Alabi S, Gatta G, Gross T, Jakab Z, Kohler B, Kutluk T, Moreno F, Nakata K, Nur S, Parkin DM, Penberthy L, Pole J, Poynter JN, Pritchard-Jones K, Ramirez O, Renner L, Steliarova-Foucher E, Sullivan M, Swaminathan R, Van Eycken L, Vora T, Frazier AL. Development of paediatric non-stage prognosticator guidelines for population-based cancer registries and updates to the 2014 Toronto Paediatric Cancer Stage Guidelines. Lancet Oncol 2020; 21:e444-e451. [PMID: 32888473 DOI: 10.1016/s1470-2045(20)30320-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/13/2020] [Accepted: 05/19/2020] [Indexed: 12/24/2022]
Abstract
Population-based cancer registries (PBCRs) generate measures of cancer incidence and survival that are essential for cancer surveillance, research, and cancer control strategies. In 2014, the Toronto Paediatric Cancer Stage Guidelines were developed to standardise how PBCRs collect data on the stage at diagnosis for childhood cancer cases. These guidelines have been implemented in multiple jurisdictions worldwide to facilitate international comparative studies of incidence and outcome. Robust stratification by risk also requires data on key non-stage prognosticators (NSPs). Key experts and stakeholders used a modified Delphi approach to establish principles guiding paediatric cancer NSP data collection. With the use of these principles, recommendations were made on which NSPs should be collected for the major malignancies in children. The 2014 Toronto Stage Guidelines were also reviewed and updated where necessary. Wide adoption of the resultant Paediatric NSP Guidelines and updated Toronto Stage Guidelines will enhance the harmonisation and use of childhood cancer data provided by PBCRs.
Collapse
Affiliation(s)
- Sumit Gupta
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada.
| | | | - Ute Bartels
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Nickhill Bhakta
- Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN, USA
| | | | - James D Brierley
- Radiation Medicine Program, Princess Margaret Hospital, Toronto, ON, Canada
| | - Beatriz De Camargo
- Research Centre, National Cancer Institute National Cancer Institute, Rio de Janeiro, Brazil
| | | | - Jessica Clymer
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA, USA
| | - Dana Coza
- Romanian National Child Cancer Registry, Constanta, Romania
| | - Chris Fraser
- Department of Oncology, Children's Health Queensland Hospital, South Brisbane, QLD, Australia
| | | | | | - Thomas Gross
- National Cancer Institute, National Institute of Health, Bethesda, MD, USA
| | - Zsuzsanna Jakab
- Hungarian Childhood Cancer Registry, Semmelweis University, Budapest, Hungary
| | - Betsy Kohler
- North American Association of Central Cancer Registries, Springfield, IL, USA
| | - Tezer Kutluk
- Department of Paediatric Oncology, Hacettepe University Faculty of Medicine and Cancer Institute, Ankara, Turkey
| | | | - Kayo Nakata
- Cancer Control Centre, Osaka International Cancer Institute, Osaka, Japan
| | - Sari Nur
- Universitas Padjadjaran, Dr. Hasan Sadikin General Hospital, Jawa Barat, Indonesia
| | - D M Parkin
- Nuffield Department of Population Health, University of Oxford, Oxford, UK; Section of Cancer Surveillance, International Agency for Research on Cancer, Lyon, France
| | - Lynne Penberthy
- National Cancer Institute, National Institute of Health, Bethesda, MD, USA
| | - Jason Pole
- Pediatric Group of Ontario, Toronto, ON, Canada
| | - Jenny N Poynter
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | | | - Oscar Ramirez
- Centro Médico Imbanaco, Cali, Valle del Cauca, Colombia
| | - Lorna Renner
- University of Ghana School of Medicine, Accra, Ghana
| | - Eva Steliarova-Foucher
- Section of Cancer Surveillance, International Agency for Research on Cancer, Lyon, France
| | - Michael Sullivan
- Faculty of Medicine, University of Melbourne, Parkville, VIC, Australia
| | | | | | - Tushar Vora
- Tata Memorial Centre, Mumbai, Maharashtra, India
| | - A L Frazier
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, MA, USA
| |
Collapse
|
9
|
Hu GH, Lu AD, Jia YP, Zuo YX, Wu J, Zhang LP. Prognostic Impact of Extramedullary Infiltration in Pediatric Low-risk Acute Myeloid Leukemia: A Retrospective Single-center Study Over 10 Years. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 20:e813-e820. [PMID: 32680776 DOI: 10.1016/j.clml.2020.06.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 06/10/2020] [Accepted: 06/16/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND The impact of extramedullary infiltration (EMI) on the clinical outcomes of pediatric patients with acute myeloid leukemia (AML) are controversial. PATIENTS AND METHODS A total of 214 pediatric patients with low-risk AML were classified as having EMI (central nervous leukemia [CNSL] and/or myeloid sarcoma [MS]) and not having EMI. Patients with isolated MS before AML diagnosis by bone marrow examination were confirmed with histopathologic examination. For patients diagnosed with AML by bone marrow examination, a thorough physical examination and radiologic imaging were used to confirm MS. RESULTS Male gender, a high white blood cell count, the FAB-M5 subtype, t(8;21) and t(1;11) abnormalities, and c-KIT mutations were associated with EMI. The presence of MS was associated with a low complete remission rate (63.6% vs. 79.4%; P = .000) and poor 3-year relapse-free survival (RFS) (62.6% ± 7.5% vs. 87.0% ± 2.8%; P = .000) and 3-year overall survival (73.5% ± 7% vs. 88.8% ± 2.6%; P = .011). Multivariate analysis revealed that MS was a poor prognostic factor for RFS and overall survival. Bone infiltration was an independent risk factor for inferior RFS with MS. Patients with CNSL had a low complete remission rate (58.3% vs. 77.2%; P = .045); however, CNSL did not significantly affect the survival of low-risk patients with AML. CONCLUSION MS should be considered an independent risk factor to guide stratified treatment.
Collapse
Affiliation(s)
- Guan-Hua Hu
- Department of Pediatrics, Peking University People's Hospital, Peking University, Beijing, China
| | - Ai-Dong Lu
- Department of Pediatrics, Peking University People's Hospital, Peking University, Beijing, China
| | - Yue-Ping Jia
- Department of Pediatrics, Peking University People's Hospital, Peking University, Beijing, China
| | - Ying-Xi Zuo
- Department of Pediatrics, Peking University People's Hospital, Peking University, Beijing, China
| | - Jun Wu
- Department of Pediatrics, Peking University People's Hospital, Peking University, Beijing, China
| | - Le-Ping Zhang
- Department of Pediatrics, Peking University People's Hospital, Peking University, Beijing, China.
| |
Collapse
|
10
|
Zhou T, Bloomquist MS, Ferguson LS, Reuther J, Marcogliese AN, Elghetany MT, Roy A, Rao PH, Lopez-Terrada DH, Redell MS, Punia JN, Curry CV, Fisher KE. Pediatric myeloid sarcoma: a single institution clinicopathologic and molecular analysis. Pediatr Hematol Oncol 2020; 37:76-89. [PMID: 31682773 DOI: 10.1080/08880018.2019.1683107] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Myeloid sarcoma (MS) is a neoplastic condition composed of immature myeloid cells involving an extramedullary site. We investigated underlying chromosomal and molecular alterations to assess potential molecular markers of prognosis and outcome in this rare pediatric disease. We conducted a retrospective review of clinicopathologic and cytogenetic data from 33 pediatric patients with MS (ages 1 month-18 years) at our institution over a 32 year period (1984-2016). Tissue-based cancer microarray and targeted next-generation sequencing analysis were performed on six cases. The median age at diagnosis was 2.8 years with a male-to-female ratio of 2.6:1. MS is commonly presented with concomitant marrow involvement (n = 12, 36.4%) or as a recurrence of acute myeloid leukemia (AML; n = 14, 42.4%). The skin (n = 18, 54.5%) and soft tissue (n = 9, 27.3%) were the most common sites of involvement. Twenty-one of 25 samples (84.0%) harbored chromosomal aberrations; KMT2A alterations (n = 10, 40.0%) or complex cytogenetics (n = 7, 28.0%) were most frequent. Mutations in RAS, tyrosine kinase, cell signaling, and chromatin remodeling genes were detected. When compared to pediatric patients with AML without extramedullary involvement (EMI), inferior overall survival (OS) was observed (18.8 months vs. 89.3 months, p = .008). Pediatric patients with MS with non-favorable cytogenetics [abnormalities other than t(8;21), inv(16)/t(16;16), or t(15;17)] had a significantly lower OS compared to patients with AML with non-favorable cytogenetics and no extramedullary involvement (8.0 months vs. 28.1 months, p < .001). Pediatric MS is a rare disease with diverse clinical presentations. Non-favorable cytogenetics may be a poor prognostic marker for pediatric patients with MS and molecular diagnostics can assist with risk stratification and identify potentially actionable targets.
Collapse
Affiliation(s)
- Ting Zhou
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, Texas, USA
| | - M Suzanne Bloomquist
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, Texas, USA
| | | | - Jacquelyn Reuther
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, Texas, USA.,Department of Pathology, Texas Children's Hospital, Houston, Texas, USA
| | - Andrea N Marcogliese
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, Texas, USA.,Department of Pathology, Texas Children's Hospital, Houston, Texas, USA
| | - M Tarek Elghetany
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, Texas, USA.,Department of Pathology, Texas Children's Hospital, Houston, Texas, USA
| | - Angshumoy Roy
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, Texas, USA.,Department of Pathology, Texas Children's Hospital, Houston, Texas, USA.,Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Pulivarthi H Rao
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Dolores H Lopez-Terrada
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, Texas, USA.,Department of Pathology, Texas Children's Hospital, Houston, Texas, USA.,Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Michele S Redell
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Jyotinder N Punia
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, Texas, USA.,Department of Pathology, Texas Children's Hospital, Houston, Texas, USA
| | - Choladda V Curry
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, Texas, USA.,Department of Pathology, Texas Children's Hospital, Houston, Texas, USA
| | - Kevin E Fisher
- Department of Pathology & Immunology, Baylor College of Medicine, Houston, Texas, USA.,Department of Pathology, Texas Children's Hospital, Houston, Texas, USA
| |
Collapse
|
11
|
Xu LH, Wang Y, Chen ZY, Fang JP. Myeloid sarcoma is associated with poor clinical outcome in pediatric patients with acute myeloid leukemia. J Cancer Res Clin Oncol 2020; 146:1011-1020. [PMID: 31919567 DOI: 10.1007/s00432-020-03128-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 01/06/2020] [Indexed: 12/29/2022]
Abstract
PURPOSE The impact of myeloid sarcoma (MS) on clinical outcome of pediatric acute myeloid leukemia (AML) patients remains controversial. Moreover, little is known about the role of stem cell transplantation (SCT) in such patients. METHODS Clinical data of patients with AML under 18 years of age were retrieved from the TARGET dataset. We analyzed the prevalence, clinical profile, molecular characteristics, and prognosis of MS in these patients. RESULTS Among 884 pediatric patients with AML, the frequency of MS was 12.3%. Pediatric AML with MS was associated with age under 1-year, abnormal cytogenetics, and KMT2A rearrangement. Moreover, MS was associated with a low complete remission rate, high induction death, poor 5-year EFS, and OS. KMT2A rearrangement had a negative impact on clinical outcome in AML patients with MS. In addition, SCT had no significant effect on the survival of AML patients with MS. Multivariate analysis revealed that MS was an unfavorable prognostic factor in pediatric AML in terms of EFS (Hazard ratio 1.670, P < 0.001) and OS (Hazard ratio 1.623, P = 0.004). CONCLUSIONS The presence of MS at diagnosis of pediatric AML is associated with poor clinical outcomes, particularly when associated with KMT2A rearrangements. Moreover, pediatric patients with AML and MS may not benefit from SCT.
Collapse
Affiliation(s)
- Lu-Hong Xu
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Department of Pediatrics, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, No. 107, West Yan Jiang Road, Guangzhou, Guangdong Province, People's Republic of China.
| | - Yin Wang
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Department of Pediatrics, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, No. 107, West Yan Jiang Road, Guangzhou, Guangdong Province, People's Republic of China
| | - Zhi-Yuan Chen
- Department of Pulmonary, The First Medical Center, Chinese PLA General Hospital, Beijing, 100853, People's Republic of China
| | - Jian-Pei Fang
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Department of Pediatrics, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, No. 107, West Yan Jiang Road, Guangzhou, Guangdong Province, People's Republic of China.
| |
Collapse
|
12
|
Del Principe MI, De Bellis E, Gurnari C, Buzzati E, Savi A, Consalvo MAI, Venditti A. Applications and efficiency of flow cytometry for leukemia diagnostics. Expert Rev Mol Diagn 2019; 19:1089-1097. [PMID: 31709836 DOI: 10.1080/14737159.2019.1691918] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Introduction: Multiparametric flow cytometry immunophenotype (MFCI) plays a crucial role in the diagnosis of acute leukemia (AL). Through the comprehensive assessment of surface and intracellular antigens expressed by blasts, MFCI permits to distinguish myeloid or B/T lymphoid AL, or AL of ambiguous lineages. By means of MFCI, the blasts can be characterized in bone marrow, peripheral blood, and body fluids, such as cerebrospinal fluid.Area covered: This review discusses how MFCI is currently applied in the diagnostic evaluation of AL; it also focuses on 'peculiar' issues such as the role of MFCI for the diagnosis of central nervous system leukemic involvement.Expert commentary: Despite the improved knowledge about the biology of AL, MFCI remains a fundamental tool to make a prompt and accurate diagnosis. MFCI also provides prognostic information for some antigens are associated with specific cytogenetic/genetic abnormalities and, recently, it became a powerful tool to evaluate the quality and depth of response (the so called 'measurable residual disease'). Its role as an efficient detector of residual disease paved the way to the investigation of tissues other than bone marrow and peripheral blood, demonstrating that even small amounts of AL appear to have a prognostic impact and may require personalized intervention.
Collapse
Affiliation(s)
- Maria Ilaria Del Principe
- Cattedra di Ematologia, Dipartimento di Biomedicina e Prevenzione, Università Tor Vergata, Roma, Italia.,Ematologia, Dipartimento di Onco-Ematologia, Fondazione Policlinico Tor Vergata, Roma, Italia
| | - Eleonora De Bellis
- Cattedra di Ematologia, Dipartimento di Biomedicina e Prevenzione, Università Tor Vergata, Roma, Italia.,Ematologia, Dipartimento di Onco-Ematologia, Fondazione Policlinico Tor Vergata, Roma, Italia
| | - Carmelo Gurnari
- Cattedra di Ematologia, Dipartimento di Biomedicina e Prevenzione, Università Tor Vergata, Roma, Italia.,Ematologia, Dipartimento di Onco-Ematologia, Fondazione Policlinico Tor Vergata, Roma, Italia
| | - Elisa Buzzati
- Cattedra di Ematologia, Dipartimento di Biomedicina e Prevenzione, Università Tor Vergata, Roma, Italia.,Ematologia, Dipartimento di Onco-Ematologia, Fondazione Policlinico Tor Vergata, Roma, Italia
| | - Arianna Savi
- Cattedra di Ematologia, Dipartimento di Biomedicina e Prevenzione, Università Tor Vergata, Roma, Italia.,Ematologia, Dipartimento di Onco-Ematologia, Fondazione Policlinico Tor Vergata, Roma, Italia
| | | | - Adriano Venditti
- Cattedra di Ematologia, Dipartimento di Biomedicina e Prevenzione, Università Tor Vergata, Roma, Italia.,Ematologia, Dipartimento di Onco-Ematologia, Fondazione Policlinico Tor Vergata, Roma, Italia
| |
Collapse
|
13
|
Murthy H, Anasetti C, Ayala E. Diagnosis and Management of Leukemic and Lymphomatous Meningitis. Cancer Control 2018; 24:33-41. [DOI: 10.1177/107327481702400105] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Hemant Murthy
- From the University of South Florida Morsani College of Medicine, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Claudio Anasetti
- From the University of South Florida Morsani College of Medicine, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Ernesto Ayala
- From the University of South Florida Morsani College of Medicine, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| |
Collapse
|
14
|
Del Principe MI, Buccisano F, Soddu S, Maurillo L, Cefalo M, Piciocchi A, Consalvo MI, Paterno G, Sarlo C, De Bellis E, Zizzari A, De Angelis G, Fraboni D, Divona M, Voso MT, Sconocchia G, Del Poeta G, Lo-Coco F, Arcese W, Amadori S, Venditti A. Involvement of central nervous system in adult patients with acute myeloid leukemia: Incidence and impact on outcome. Semin Hematol 2018; 55:209-214. [PMID: 30502849 DOI: 10.1053/j.seminhematol.2018.02.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 12/23/2017] [Accepted: 02/17/2018] [Indexed: 12/21/2022]
Abstract
Incidence and effect on outcome of central nervous system (CNS) involvement in adult patients with acute myeloid leukemia (AML) is not clearly defined. To address this issue, 103 consecutive adult patients with newly diagnosed AML, regardless of neurologic symptoms, were submitted to a routine explorative lumbar puncture. Cerebrospinal fluid (CSF) samples were collected from 65 males and 38 females. All 103 CSF samples were examined by conventional cytology (CC) whereas 95 (92%) also by flow cytometry (FCM). At diagnosis, 70 patients (68%) were CNS negative (CNS-), whereas 33 (32%) were CNS positive (CNS+). In 11 of 33 (33%), CNS infiltration was documented either by CC or FCM , in 21 (67%) only by FCM. CNS positivity was significantly associated with a M4-M5 phenotype of the underlying AML (P = .0003) and with high levels of lactate dehydrogenase (P = .006). Overall, 80 of 103 (78%) achieved complete remission with no significant differences between CNS+ and CNS- patients. Five-year disease-free survival and overall survival were found to be shorter in CNS+ patients than in those CNS- (18% vs 50%, P = .006 and 19% vs 46%, P = .02, respectively). In multivariate analysis, CNS status and age were found to affect independently overall survival. In conclusion, the incidence of CNS involvement in adult patients with newly diagnosed AML is higher than expected. Regardless of neurologic symptoms, it should always be searched at diagnosis; CSF samples should routinely be investigated by FCM since a certain proportion of CNS involvements might remain undetected if examination is exclusively CC based.
Collapse
Affiliation(s)
- Maria Ilaria Del Principe
- Hematology, Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Rome, Italy.
| | - Francesco Buccisano
- Hematology, Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Rome, Italy
| | | | - Luca Maurillo
- Hematology, Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Rome, Italy
| | - Mariagiovanna Cefalo
- Hematology, Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Rome, Italy
| | | | - Maria Irno Consalvo
- Hematology, Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Rome, Italy
| | - Giovangiacinto Paterno
- Hematology, Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Rome, Italy
| | - Chiara Sarlo
- Hematology, University Campus Biomedico, Rome, Italy
| | - Eleonora De Bellis
- Hematology, Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Rome, Italy
| | - Annagiulia Zizzari
- Hematology, Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Rome, Italy
| | - Gottardo De Angelis
- Hematology, Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Rome, Italy
| | - Daniela Fraboni
- Hematology, Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Rome, Italy
| | - Mariadomenica Divona
- Hematology, Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Rome, Italy
| | - Maria Teresa Voso
- Hematology, Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Rome, Italy
| | - Giuseppe Sconocchia
- Laboratoy of Tumor Immunology and Immunotherapy, Institute of Translation Pharmacology, Department of Medicine, National Research Council of Italy (CNR), Rome, Italy
| | - Giovanni Del Poeta
- Hematology, Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Rome, Italy
| | - Francesco Lo-Coco
- Hematology, Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Rome, Italy; Laboratory of Neuro-Oncohematology Unit, Santa Lucia Foundation, Rome, Italy
| | - William Arcese
- Hematology, Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Rome, Italy
| | - Sergio Amadori
- Hematology, Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Rome, Italy
| | - Adriano Venditti
- Hematology, Department of Biomedicine and Prevention, University of Rome "Tor Vergata", Rome, Italy
| |
Collapse
|
15
|
Acute Myeloid Leukemia With Central Nervous System Involvement in Children: Experience From the French Protocol Analysis ELAM02. J Pediatr Hematol Oncol 2018; 40:43-47. [PMID: 29189507 DOI: 10.1097/mph.0000000000001034] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Central nervous system (CNS) involvement at diagnosis of pediatric acute myeloid leukemia (AML) is not considered as an independent prognostic factor. This study describes the prognostic value of pediatric AML with CNS involvement at diagnosis. Pediatric patients were treated for de novo AML in the French multicenter trial ELAM02. Lumbar puncture was carried out in the first week, and the treatment was adapted to the CNS status. No patient received CNS radiotherapy. The patients were classified into 2 groups: CNS+ and CNS-. Of the 438 patients, 16% (n=70) had CNS involvement at diagnosis, and 29% showed clinical signs. The patients with CNS disease were younger (40% were below 2 y old), had a higher white blood cell count (median of 45 vs. 13 G/L), and had M4 and M5 morphologies. The complete remission rate was similar at 92.8% for CNS+ and 88.5% for CNS-. There was no significant difference between the CNS+ and the CNS- group in overall survival (76% and 71%, respectively) and event-free survival (57% and 52%, respectively). Regarding the occurrence of first relapse, the CNS+ group had a higher combined relapse rate of 26.1% compared with 10% for the CNS- group. The results indicate that CNS involvement at diagnosis of pediatric AML is not an independent prognostic factor. Triple intrathecal chemotherapy combined with high-dose intravenous cytarabine should be the first-line treatment for CNS disease.
Collapse
|
16
|
Ranta S, Palomäki M, Levinsen M, Taskinen M, Abrahamsson J, Hasle H, Jahnukainen K, Heyman M, Harila-Saari A. Presenting features and imaging in childhood acute myeloid leukemia with central nervous system involvement. Pediatr Blood Cancer 2017; 64. [PMID: 28233411 DOI: 10.1002/pbc.26459] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 11/29/2016] [Accepted: 12/25/2016] [Indexed: 11/05/2022]
Abstract
Central nervous system (CNS) involvement in childhood acute myeloid leukemia (AML) can manifest as leukemic cells in the cerebrospinal fluid, a solid CNS tumor, or as neurological symptoms. We evaluated the presenting symptoms and neuroimaging findings in 33 of 34 children with AML and CNS involvement at diagnosis in the period 2000-2012 in Sweden, Finland, and Denmark. Imaging was performed in 22 patients, of whom 16 had CNS-related symptoms. Seven patients, including all but two with facial palsy, had mastoid cell opacification, considered an incidental finding. The frequent involvement of the mastoid bone with facial palsy warrants evaluation in larger series.
Collapse
Affiliation(s)
- Susanna Ranta
- Department of Women's and Children's Health, Childhood Cancer Research Unit, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
| | - Maarit Palomäki
- Department of Radiology, Helsinki University Central Hospital, Helsinki, Finland
| | - Mette Levinsen
- Department of Pediatrics and Adolescent Medicine, The University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Mervi Taskinen
- Division of Pediatric Hematology-Oncology and Stem Cell Transplantation, Children's Hospital, University of Helsinki and Helsinki University Hospital, Finland
| | - Jonas Abrahamsson
- Department of Pediatrics, Division of Pediatric Hematology-Oncology and Stem Cell Transplantation, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Henrik Hasle
- Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark
| | - Kirsi Jahnukainen
- Division of Pediatric Hematology-Oncology and Stem Cell Transplantation, Children's Hospital, University of Helsinki and Helsinki University Hospital, Finland
| | - Mats Heyman
- Department of Women's and Children's Health, Childhood Cancer Research Unit, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
| | - Arja Harila-Saari
- Department of Women's and Children's Health, Childhood Cancer Research Unit, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
| | | |
Collapse
|
17
|
Gruber TA, Zwaan CM. Central nervous system disease in pediatric acute myeloid leukemia. Pediatr Blood Cancer 2017; 64. [PMID: 28853216 DOI: 10.1002/pbc.26782] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 08/02/2017] [Indexed: 12/23/2022]
Affiliation(s)
- Tanja A Gruber
- St. Jude Children's Research Hospital, Memphis, Tennessee
| | - C Michel Zwaan
- Erasmus MC-Sophia, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
| |
Collapse
|
18
|
Johnston DL, Alonzo TA, Gerbing RB, Aplenc R, Woods WG, Meshinchi S, Gamis AS. Central nervous system disease in pediatric acute myeloid leukemia: A report from the Children's Oncology Group. Pediatr Blood Cancer 2017; 64:10.1002/pbc.26612. [PMID: 28453910 PMCID: PMC5647219 DOI: 10.1002/pbc.26612] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 03/19/2017] [Accepted: 03/27/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND The prognostic impact of central nervous system (CNS) involvement in children with acute myeloid leukemia (AML) has varied in past trials, and controversy exists over the degree of involvement requiring intensified CNS therapy. Two recent Children's Oncology Group protocols, AAML03P1 and AAML0531, directed additional intrathecal (IT) therapy to patients with CNS2 (≤5 white blood cell [WBC] with blasts) or CNS3 (>5 WBC with blasts or CNS symptoms) disease at diagnosis. METHODS We examined disease characteristics and outcomes of the 1,344 patients on these protocols, 949 with CNS1 (no blasts), 217 with CNS2, and 178 with CNS3, with the latter two receiving additional IT therapy. RESULTS Young age (P = 0.003), hyperleukocytosis (P < 0.001), and the presence of inversion 16 (P < 0.001) were the only factors more prevalent in patients with CNS2 or CNS3 disease. Complete remission at the end of induction (EOI) 2 was achieved less often in patients with CNS involvement (P < 0.001). From diagnosis, event-free survival (EFS) for patients with CNS involvement was significantly worse (P < 0.001), whereas overall survival (OS) was not (P = 0.16). From the EOI1, there was a higher relapse rate (RR) and worse disease-free survival (DFS), but less impact on OS (CNS1:DFS 58.9%, RR 34.1%, OS 69.3%; CNS2:DFS 53.2%, RR 40.9%, OS 74.7%; CNS3:DFS 45.2%, RR 48.8%, OS 60.8%; P = 0.006, P < 0.001, P = 0.045, respectively). Multivariable analysis showed that independently CNS2 and CNS3 status adversely affected RR and DFS. Traumatic diagnostic lumbar puncture was not associated with worse outcome. CONCLUSIONS CNS leukemia confers greater relapse risk despite more aggressive locally directed therapy. Novel approaches need to be investigated in this group of patients.
Collapse
Affiliation(s)
- Donna L. Johnston
- Division of Hematology/Oncology, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Todd A. Alonzo
- Department of Preventive Medicine, University of Southern California, Los Angeles, California
| | | | - Richard Aplenc
- Division of Hematology/Oncology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - William G. Woods
- Aflac Cancer Center and Blood Disorders Service, Children’s Healthcare of Atlanta, Emory University, Atlanta, Georgia
| | - Soheil Meshinchi
- Division of Hematology Oncology, Seattle Children’s Hospital, Seattle, Washington
| | - Alan S. Gamis
- Division of Hematology/Oncology/Bone Marrow Transplantation, Children’s Mercy Hospitals and Clinic, Kansas City, Missouri
| |
Collapse
|
19
|
Støve HK, Sandahl JD, Abrahamsson J, Asdahl PH, Forestier E, Ha SY, Jahnukainen K, Jónsson ÓG, Lausen B, Palle J, Zeller B, Hasle H. Extramedullary leukemia in children with acute myeloid leukemia: A population-based cohort study from the Nordic Society of Pediatric Hematology and Oncology (NOPHO). Pediatr Blood Cancer 2017; 64. [PMID: 28333413 DOI: 10.1002/pbc.26520] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2016] [Revised: 01/16/2017] [Accepted: 02/10/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND The prognostic significance of extramedullary leukemia (EML) in childhood acute myeloid leukemia is not clarified. PROCEDURE This population-based study included 315 children from the NOPHO-AML 2004 trial. RESULTS At diagnosis, 73 (23%) patients had EML: 39 (12%) had myeloid sarcoma, 22 (7%) had central nervous system disease, and 12 (4%) had both. EML was associated with young age (median age: 2.6 years), a high white blood cell count (median: 40 × 109 /l), M5 morphology (40%), and 11q23/MLL (KMT2A) rearrangements (34%). No patient received involved field radiotherapy. Five-year event-free survival did not differ significantly between the EML and the non-EML patients (54% vs. 45%, P = 0.57), whereas 5-year overall survival (OS) was significantly lower in the EML group (64% vs. 73%, P = 0.04). The risk of induction death was significantly higher for EML patients (8% vs. 1%, P = 0.002). There was a trend toward a lower risk of relapse for EML patients (5-year cumulative incidence of relapse 33% vs. 49%, P = 0.16). Traumatic lumbar puncture did not adversely affect survival in this cohort. CONCLUSIONS EML was associated with increased risk of induction death impacting the OS. No patients relapsed at the primary site of the myeloid sarcoma despite management without radiotherapy.
Collapse
Affiliation(s)
| | | | - Jonas Abrahamsson
- Department of Pediatrics, Institution for Clinical Sciences, Queen Silvia Children's Hospital, Gothenburg, Sweden
| | - Peter H Asdahl
- Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark
| | - Erik Forestier
- Department of Medical Biosciences and Genetics, Umeå University Hospital, Umeå, Sweden
| | - Shau-Yin Ha
- Department of Pediatrics, Hong Kong Pediatric Hematology & Oncology Study Group, Queen Mary Hospital, Hong Kong, China
| | - Kirsi Jahnukainen
- Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | - Birgitte Lausen
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Josefine Palle
- Department of Woman's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Bernward Zeller
- Department of Pediatric Medicine, Oslo University Hospital, Oslo, Norway
| | - Henrik Hasle
- Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark
| |
Collapse
|
20
|
Creutzig U, Dworzak MN, Zimmermann M, Reinhardt D, Sramkova L, Bourquin JP, Hasle H, Abrahamsson J, Kaspers G, van den Heuvel MM, Reedijk AMJ, De Moerloose B, Locatelli F, Masetti R. Characteristics and outcome in patients with central nervous system involvement treated in European pediatric acute myeloid leukemia study groups. Pediatr Blood Cancer 2017; 64. [PMID: 28598536 DOI: 10.1002/pbc.26664] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 04/21/2017] [Accepted: 04/30/2017] [Indexed: 11/11/2022]
Abstract
BACKGROUND There is no consensus on the treatment for pediatric patients with acute myeloid leukemia and initial central nervous system (CNS) involvement. METHODS To evaluate different CNS-directed treatment options (intrathecal [IT] therapy, CNS irradiation, hematopoietic stem cell transplantation [HSCT]), 261 patients (excluding acute promyelocytic leukemia) with initial CNS involvement treated in trials with similar intensive chemotherapy by four cooperative European study groups (1998-2013) were studied and compared with CNS-negative patients from the Berlin-Frankfurt-Münster group. RESULTS Patient characteristics in the different study groups were comparable. Young age, high white blood cell count, extramedullary involvement other than the CNS, monoblastic morphology, and inv(16) were associated with CNS involvement (each P < 0.0001). There were no major differences in outcome between the study groups. The cumulative incidence of relapse (CIR) regarding the CNS was higher in initially CNS-positive versus initially CNS-negative patients (all: 8 ± 2% vs. 3 ± 1%, P(Gray) = 0.001; isolated: 4 ± 1% vs. 1 ± 0%, P(Gray) = 0.03). However, global outcome of the CNS-positive cohort (overall survival, 64 ± 3%; event-free survival 48 ± 3%; and CIR 33% ± 3%) did not differ significantly from CNS-negative patients. Risk groups defined by cytogenetics were of likewise prognostic significance in CNS-positive and -negative patients. CNS treatment with cranial irradiation was not superior compared to IT therapy and systemic chemotherapy (± HSCT). CONCLUSION Although CNS relapses occurred more frequently in initially CNS-positive patients, their global outcome was similar as in CNS-negative patients. Intensified IT therapy was heterogeneous; however, at least eight applications, preferably with triple IT chemotherapy, seem to be appropriate to accompany dose-intensive systemic chemotherapy.
Collapse
Affiliation(s)
- Ursula Creutzig
- Department of Pediatric Hematology and Oncology, Children's Hospital, Hannover Medical School, Hannover, Germany
| | - Michael N Dworzak
- Department of Pediatrics, St. Anna Children's Hospital and Children's Cancer Research Institute, Medical University of Vienna, Vienna, Austria
| | - Martin Zimmermann
- Department of Pediatric Hematology and Oncology, Children's Hospital, Hannover Medical School, Hannover, Germany
| | - Dirk Reinhardt
- Department of Pediatric Hematology-Oncology, University of Duisburg-Essen, Essen, Germany
| | - Lucie Sramkova
- Department of Pediatric Hematology and Oncology, Charles University Prague, Czech Pediatric Hematology Working Group (CPH), Prague, Czech Republic
| | - Jan Pierre Bourquin
- Department of Pediatric Hematology/Oncology, University of Zurich, Zurich, Switzerland
| | - Henrik Hasle
- Department of Pediatrics, Aarhus University Hospital Skejby, Aarhus, Denmark
| | - Jonas Abrahamsson
- Department of Pediatrics, Institution of Clinical Sciences, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Gertjan Kaspers
- Pediatric Oncology, VU University Medical Center, Amsterdam, The Netherlands.,Dutch Childhood Oncology Group (DCOG), The Hague, The Netherlands
| | - Mary M van den Heuvel
- Dutch Childhood Oncology Group (DCOG), The Hague, The Netherlands.,Princess Maxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | | | - Barbara De Moerloose
- Department of Pediatric Hematology-Oncology and Stem Cell Transplantation, Ghent University Hospital, Ghent, Belgium
| | - Franco Locatelli
- Department of Pediatric Hematology and Oncology, IRCCS Ospedale Pediatrico Bambino Gesù, University of Pavia, Rome, Italy
| | - Riccardo Masetti
- Oncologia ed Ematologia Pediatrica "Lalla Seràgnoli" Ospedale Sant'Orsola Malpighi Università di Bologna, Bologna, Italy
| |
Collapse
|
21
|
Arber DA, Borowitz MJ, Cessna M, Etzell J, Foucar K, Hasserjian RP, Rizzo JD, Theil K, Wang SA, Smith AT, Rumble RB, Thomas NE, Vardiman JW. Initial Diagnostic Workup of Acute Leukemia: Guideline From the College of American Pathologists and the American Society of Hematology. Arch Pathol Lab Med 2017; 141:1342-1393. [PMID: 28225303 DOI: 10.5858/arpa.2016-0504-cp] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT - A complete diagnosis of acute leukemia requires knowledge of clinical information combined with morphologic evaluation, immunophenotyping and karyotype analysis, and often, molecular genetic testing. Although many aspects of the workup for acute leukemia are well accepted, few guidelines have addressed the different aspects of the diagnostic evaluation of samples from patients suspected to have acute leukemia. OBJECTIVE - To develop a guideline for treating physicians and pathologists involved in the diagnostic and prognostic evaluation of new acute leukemia samples, including acute lymphoblastic leukemia, acute myeloid leukemia, and acute leukemias of ambiguous lineage. DESIGN - The College of American Pathologists and the American Society of Hematology convened a panel of experts in hematology and hematopathology to develop recommendations. A systematic evidence review was conducted to address 6 key questions. Recommendations were derived from strength of evidence, feedback received during the public comment period, and expert panel consensus. RESULTS - Twenty-seven guideline statements were established, which ranged from recommendations on what clinical and laboratory information should be available as part of the diagnostic and prognostic evaluation of acute leukemia samples to what types of testing should be performed routinely, with recommendations on where such testing should be performed and how the results should be reported. CONCLUSIONS - The guideline provides a framework for the multiple steps, including laboratory testing, in the evaluation of acute leukemia samples. Some aspects of the guideline, especially molecular genetic testing in acute leukemia, are rapidly changing with new supportive literature, which will require on-going updates for the guideline to remain relevant.
Collapse
|
22
|
Sato Y, Koyama S, Kuwashima S, Kato M, Okuya M, Fukushima K, Kurosawa H, Arisaka O. Central hypothyroidism in a pediatric case of primary acute monoblastic leukemia with central nervous system infiltration: A case report. Medicine (Baltimore) 2017; 96:e7329. [PMID: 28658145 PMCID: PMC5500067 DOI: 10.1097/md.0000000000007329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Central nervous system (CNS) leukemia is a frequent diagnosis in pediatric acute myeloblastic leukemia (AML) and includes neural symptoms. However, CNS leukemia is rarely associated with central hypsothyroidism. PATIENT CONCERNS AND DIAGNOSES A 2-year-old female with AML with MLL rearrangement presented with CNS infiltration. Laboratory tests suggested the presence of central hypothyroidism (thyroid-stimulating hormone [TSH]: 0.48 mIU/ml, normal range 0.7-6.4 mIU/ml; serum free thyroxine [FT4]: 0.62 ng/dl, normal range 0.8-2.2 ng/dl; free triiodothyronine: 1.57 pg/ml, normal range 2.7-5.6 pg/ml). Magnetic resonance imaging detected no lesions in the hypothalamus, pituitary, or thyroid. INTERVENTIONS AND OUTCOMES Levothyroxine (2.5 mg/kg/day) was administered together with chemotherapy and intrathecal injection of methotrexate, cytarabine, and hydrocortisone into the cerebrospinal fluid. The FT4 concentration increased after levothyroxine treatment, but later decreased after relapse of CNS leukemia. The TSH concentrations remained low. After remission of CNS leukemia, the TSH and FT4 concentrations quickly recovered to their normal ranges. LESSONS We believe that the CNS leukemia directly affected TSH and thyroid hormone secretion in our patient.
Collapse
MESH Headings
- Central Nervous System Neoplasms/complications
- Central Nervous System Neoplasms/diagnostic imaging
- Central Nervous System Neoplasms/drug therapy
- Central Nervous System Neoplasms/metabolism
- Child, Preschool
- Diagnosis, Differential
- Female
- Humans
- Hypothyroidism/complications
- Hypothyroidism/diagnostic imaging
- Hypothyroidism/drug therapy
- Leukemia, Monocytic, Acute/complications
- Leukemia, Monocytic, Acute/diagnostic imaging
- Leukemia, Monocytic, Acute/drug therapy
- Leukemia, Monocytic, Acute/pathology
- Thyrotropin/blood
Collapse
Affiliation(s)
| | | | - Shigeko Kuwashima
- Department of Radiology, Dokkyo Medical University School of Medicine, Mibu, Tochigi, Japan
| | | | | | | | | | | |
Collapse
|
23
|
Kwon JH, Koh YI, Yoon SS, Park S, Kim I. Clinical outcome and efficacy of current anti-leukemic therapy for leptomeningeal involvement in acute myeloid leukemia. Int J Hematol 2016; 104:574-581. [PMID: 27431487 DOI: 10.1007/s12185-016-2063-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 07/13/2016] [Accepted: 07/13/2016] [Indexed: 10/21/2022]
Abstract
We investigated risk factors and outcome in acute myeloid leukemia (AML) patients with leptomeningeal involvement. Medical records of patients with non-promyelocytic AML at Seoul National University Hospital from January of 2000 to November of 2013 were reviewed. Leptomeningeal involvement was defined as the presence of atypical or malignant hematopoietic cells in the cerebrospinal fluid. Among 775 patients with AML, 141 patients (18.2 %) underwent cerebrospinal fluid examination. Leptomeningeal involvement of AML, confirmed in 38 patients (4.9 %), was associated with high white blood cell count and high level of lactic. There were seven patients in the favorable risk group (19.4 %), 21 in the intermediate risk group (58.3 %), and eight in the adverse risk group (22.2 %). Twenty-eight patients (85.7 %) developed leptomeningeal involvement during relapse status or refractory status. Thirty-one patients (81.6 %) received intrathecal chemotherapy, and whole-brain and/or craniospinal radiotherapy was conducted in 10 patients (27.0 %). The rate of complete remission after induction chemotherapy was 63.2 %. Median overall survival was 9.9 months. Radiotherapy and complete remission after the first induction chemotherapy were associated with longer overall survival. Leptomeningeal involvement in acute myeloid leukemia is rare, but relatively common in relapsed status or refractory status. Craniospinal radiotherapy and complete remission after induction chemotherapy were found to favorable prognostic factors.
Collapse
Affiliation(s)
- Ji Hyun Kwon
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University, College of Medicine, 101 Daehak-ro, Chongno-gu, Seoul, 110-744, Republic of Korea.,Department of Internal Medicine, ChungBuk National University Hospital, 776, 1 Sunhwan-ro, Seowon-gu, Cheongju, Chungchungbuk-do, Republic of Korea
| | - Young-Il Koh
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University, College of Medicine, 101 Daehak-ro, Chongno-gu, Seoul, 110-744, Republic of Korea.,Cancer Research Institute, College of Medicine, Seoul National University, 101 Daehak-ro, Chongno-gu, Seoul, Republic of Korea
| | - Sung-Soo Yoon
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University, College of Medicine, 101 Daehak-ro, Chongno-gu, Seoul, 110-744, Republic of Korea.,Cancer Research Institute, College of Medicine, Seoul National University, 101 Daehak-ro, Chongno-gu, Seoul, Republic of Korea
| | - Seonyang Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University, College of Medicine, 101 Daehak-ro, Chongno-gu, Seoul, 110-744, Republic of Korea.,Cancer Research Institute, College of Medicine, Seoul National University, 101 Daehak-ro, Chongno-gu, Seoul, Republic of Korea
| | - Inho Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University, College of Medicine, 101 Daehak-ro, Chongno-gu, Seoul, 110-744, Republic of Korea. .,Cancer Research Institute, College of Medicine, Seoul National University, 101 Daehak-ro, Chongno-gu, Seoul, Republic of Korea.
| |
Collapse
|
24
|
Solh M, Solomon S, Morris L, Holland K, Bashey A. Extramedullary acute myelogenous leukemia. Blood Rev 2016; 30:333-9. [PMID: 27094614 DOI: 10.1016/j.blre.2016.04.001] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 03/28/2016] [Accepted: 04/01/2016] [Indexed: 12/26/2022]
Abstract
Extramedullary leukemia (EM AML), also known as myeloid sarcoma, is a rare manifestation of acute myelogenous leukemia and often accompanies bone marrow involvement. EM AML is diagnosed based on H&E stains with ancillary studies including flow cytometry and cytogenetics. Isolated EM AML is often misdiagnosed as large cell lymphoma or other lymphoproliferative disorder. The clinical presentation is often dictated by the mass effect and the location of the tumor. The optimal treatment remains unclear. High-dose chemotherapy, radiation, surgical resection, and allogeneic stem cell transplantation are all modalities that can be incorporated into the therapy of EM AML. Cytarabine-based remission induction regimens have been the most commonly used in the upfront setting. There are limited data about the optimal consolidation. Transplantation is ideally offered for high risk disease or in the relapsed setting. In this manuscript, we will review the recent literature about EM AML, focusing on therapy and proposing a treatment algorithm for managing this rare form of leukemia. Further studies addressing risk stratification, role of molecular and genetic aberrations, and optimal treatment strategies are warranted.
Collapse
Affiliation(s)
- Melhem Solh
- The Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA, USA.
| | - Scott Solomon
- The Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA, USA
| | - Lawrence Morris
- The Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA, USA
| | - Kent Holland
- The Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA, USA
| | - Asad Bashey
- The Blood and Marrow Transplant Program at Northside Hospital, Atlanta, GA, USA
| |
Collapse
|
25
|
Cheng CL, Li CC, Hou HA, Fang WQ, Chang CH, Lin CT, Tang JL, Chou WC, Chen CY, Yao M, Huang SY, Ko BS, Wu SJ, Tsay W, Tien HF. Risk factors and clinical outcomes of acute myeloid leukaemia with central nervous system involvement in adults. BMC Cancer 2015; 15:344. [PMID: 25934556 PMCID: PMC4419415 DOI: 10.1186/s12885-015-1376-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 04/27/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Acute myeloid leukaemia (AML) with central nervous system (CNS) involvement in adults is uncommon, and studies of this subject are scant. METHODS We conducted a retrospective study to investigate the clinical aspects, cytogenetic abnormalities, molecular gene mutations and outcomes of adult AML patients with CNS involvement. Three hundred and ninety-five patients with newly diagnosed AML were reviewed. RESULTS Twenty (5.1%) patients had CNS involvement, including 7 (1.8%) with initial CNS disease and 4 (1%) who suffered an isolated CNS relapse. The patients with CNS involvement were younger, had higher leukocyte, platelet, and peripheral blast cell counts, FAB M4 morphology, and chromosome translocations involving 11q23 (11q23 abnormalities) more frequently than did the patients without CNS involvement. No differences in sex, haemoglobin levels, serum LDH levels, immunophenotype of leukaemia cells, or molecular gene mutations were observed between the two groups. Multivariate analyses showed that age ≤ 45 years (OR, 5.933; 95% CI, 1.82 to 19.343), leukocyte counts ≥ 50,000/μl (OR, 3.136; 95% CI, 1.083 to 9.078), and the presence of 11q23 abnormalities (OR, 5.548; 95% CI, 1.208 to 25.489) were significant predictors of CNS involvement. Patients with initial CNS disease had 5-year overall survival and relapse-free survival rates that were similar to those without initial CNS disease. However, three of four patients who suffered an isolated CNS relapse died, and their prognosis was as poor as that of patients who suffered a bone marrow relapse. CONCLUSION CNS involvement in adult patients with AML is rare. Three significant risk factors for CNS involvement including age ≤ 45 years, leukocyte counts ≥ 50,000/μl and the presence of 11q23 abnormalities were identified in this study. Future investigations to determine whether adult AML patients having these specific risk factors would benefit from CNS prophylactic therapy are necessary.
Collapse
Affiliation(s)
- Chieh-Lung Cheng
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, No. 7, Chung-Shan South Road, Taipei, 100, Taiwan.
| | - Chi-Cheng Li
- Taicheng stem cell therapy center, National Taiwan University, Taipei, Taiwan.
| | - Hsin-An Hou
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, No. 7, Chung-Shan South Road, Taipei, 100, Taiwan.
| | - Wei-Quan Fang
- Taiwan Clinical Trial Bioinformatics and Statistical Center, Training Center, and Pharmacogenomics Laboratory, Taipei, Taiwan.
| | - Chin-Hao Chang
- Department of Medical Research, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan.
| | - Chien-Ting Lin
- Taicheng stem cell therapy center, National Taiwan University, Taipei, Taiwan.
| | - Jih-Luh Tang
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, No. 7, Chung-Shan South Road, Taipei, 100, Taiwan.
| | - Wen-Chien Chou
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, No. 7, Chung-Shan South Road, Taipei, 100, Taiwan. .,Department of Laboratory Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan.
| | - Chien-Yuan Chen
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, No. 7, Chung-Shan South Road, Taipei, 100, Taiwan.
| | - Ming Yao
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, No. 7, Chung-Shan South Road, Taipei, 100, Taiwan.
| | - Shang-Yi Huang
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, No. 7, Chung-Shan South Road, Taipei, 100, Taiwan.
| | - Bor-Sheng Ko
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, No. 7, Chung-Shan South Road, Taipei, 100, Taiwan.
| | - Shang-Ju Wu
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, No. 7, Chung-Shan South Road, Taipei, 100, Taiwan.
| | - Woei Tsay
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, No. 7, Chung-Shan South Road, Taipei, 100, Taiwan.
| | - Hwei-Fang Tien
- Division of Hematology, Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, No. 7, Chung-Shan South Road, Taipei, 100, Taiwan.
| |
Collapse
|
26
|
Masetti R, Vendemini F, Zama D, Biagi C, Pession A, Locatelli F. Acute myeloid leukemia in infants: biology and treatment. Front Pediatr 2015; 3:37. [PMID: 25973412 PMCID: PMC4411976 DOI: 10.3389/fped.2015.00037] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 04/11/2015] [Indexed: 11/30/2022] Open
Abstract
Children aged 0-2 years (i.e., infants) with acute myeloid leukemia (AML) are a peculiar subgroup of patients in the childhood AML scenario. They present with distinctive biological and clinical characteristics, including a high prevalence of prognostically unfavorable risk factors and an increased susceptibility to therapy-related toxicity. Remarkable improvements have been achieved over the last two decades in the treatment of these patients and their outcome is becoming superimposable to that of the older age groups. In this review, we will focus on peculiarities of this young subgroup of children with AML, describing their clinical presentation, the biology of disease, and factors influencing outcome. Treatment results and toxicity data reported by major collaborative groups are also summarized and compared.
Collapse
Affiliation(s)
- Riccardo Masetti
- Hematology-Oncology Unit "Lalla Seràgnoli", Department of Pediatrics, University of Bologna , Bologna , Italy
| | - Francesca Vendemini
- Hematology-Oncology Unit "Lalla Seràgnoli", Department of Pediatrics, University of Bologna , Bologna , Italy
| | - Daniele Zama
- Hematology-Oncology Unit "Lalla Seràgnoli", Department of Pediatrics, University of Bologna , Bologna , Italy
| | - Carlotta Biagi
- Hematology-Oncology Unit "Lalla Seràgnoli", Department of Pediatrics, University of Bologna , Bologna , Italy
| | - Andrea Pession
- Hematology-Oncology Unit "Lalla Seràgnoli", Department of Pediatrics, University of Bologna , Bologna , Italy
| | - Franco Locatelli
- Department of Pediatric Hematology-Oncology, IRCCS Ospedale Bambino Gesù, University of Pavia , Pavia , Italy
| |
Collapse
|
27
|
Rozovski U, Ohanian M, Ravandi F, Garcia-Manero G, Faderl S, Pierce S, Cortes J, Estrov Z. Incidence of and risk factors for involvement of the central nervous system in acute myeloid leukemia. Leuk Lymphoma 2014; 56:1392-7. [PMID: 25110819 DOI: 10.3109/10428194.2014.953148] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
It is thought that the low incidence of central nervous system (CNS) involvement in acute myeloid leukemia (AML) does not justify routine CNS prophylaxis, as high-dose cytarabine eliminates CNS disease. To investigate whether chemotherapy that does not include high-dose cytarabine increases the risk of CNS involvement, the medical records of 1412 newly diagnosed patients with AML were reviewed. In 1370 patients, lumbar puncture (LP) was performed only if clinically indicated, and CNS disease was detected in 45 (3.3%) patients. Another 42 patients underwent routine LP as part of an investigational protocol, and in eight (19%) CNS disease was detected (p < 0.0001). Risk factors included high lactate dehydrogenase, African-American ethnicity and young age. Patients receiving high-dose cytarabine and those who did not had similar rates of CNS involvement. Disease-free survival (DFS) and overall survival were shorter in patients with CNS involvement. It remains to be determined whether routine CNS prophylaxis would improve DFS.
Collapse
Affiliation(s)
- Uri Rozovski
- Department of Leukemia, The University of Texas M. D. Anderson Cancer Center , Houston, TX , USA
| | | | | | | | | | | | | | | |
Collapse
|
28
|
Ofran Y, Rowe JM. Acute myeloid leukemia in adolescents and young adults: challenging aspects. Acta Haematol 2014; 132:292-7. [PMID: 25228554 DOI: 10.1159/000360200] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Treating adolescents and young adults (AYAs) diagnosed with cancer is a challenge. Acute myeloid leukemia (AML) which is usually diagnosed in a previously healthy kid, requiring immediate aggressive chemotherapy, brings difficulties and conflicts associated with severe illness to extremes. The incidence of AML in adolescents aged 15-19 years approaches 8.5 per million. Only in recent years has it become evident that the prognosis of AYAs diagnosed with AML is poorer compared to younger children diagnosed with AML with similar characteristics. No specific genetic aberration or other known poor risk factor was found to explain the inferior prognosis of AYAs. In acute lymphoblastic leukemia the contribution of differences between adult and pediatric protocols to AYA outcome is established. It has been suggested that pediatric protocols should also apply to AYAs with AML; however, data supporting this are vague. Herein, existing evidence regarding special considerations in treating AYAs with AML is discussed. Mental and psychological age-specific aspects important to consider when treating AYAs with AML are overviewed. Awareness for adolescent special needs, adherence to protocols and intensive supportive care are important. Multidisciplinary adolescent-oriented staff should be involved in the therapy of any AYA with AML escorting this special patient population on the road to cure.
Collapse
Affiliation(s)
- Yishai Ofran
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
| | | |
Collapse
|
29
|
El Rassi F, Arellano M. Update on optimal management of acute myeloid leukemia. CLINICAL MEDICINE INSIGHTS-ONCOLOGY 2013; 7:181-97. [PMID: 23997579 PMCID: PMC3748090 DOI: 10.4137/cmo.s8528] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Acute myeloid leukemia (AML) represents a malignant accumulation of immature myeloid cells in the marrow, presenting with impaired hematopoiesis and its attendant complications, including bleeding, infection, and organ infiltration. Chromosomal abnormalities remain the most powerful predictors of AML prognosis and help to identify a subgroup with favorable prognosis. However, the majority of AML patients who are not in the favorable category succumb to the disease. Therefore, better efforts to identify those patients who may benefit from more aggressive and investigational therapeutic approaches are needed. Newer molecular markers aim at better characterizing the large group of intermediate-risk patients and to identify newer targets for therapy. A group that has seen little improvement over the years is the older AML group, usually defined as age ≥ 60. Efforts to develop less intensive but equally efficacious therapy for this vulnerable population are underway.
Collapse
Affiliation(s)
- Fuad El Rassi
- Winship Cancer Institute of Emory University, Atlanta, Georgia, USA
| | | |
Collapse
|
30
|
Diagnosis and management of acute myeloid leukemia in children and adolescents: recommendations from an international expert panel. Blood 2012; 120:3187-205. [PMID: 22879540 DOI: 10.1182/blood-2012-03-362608] [Citation(s) in RCA: 363] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Despite major improvements in outcome over the past decades, acute myeloid leukemia (AML) remains a life-threatening malignancy in children, with current survival rates of ∼70%. State-of-the-art recommendations in adult AML have recently been published in this journal by Döhner et al. The primary goal of an international expert panel of the International BFM Study Group AML Committee was to set standards for the management, diagnosis, response assessment, and treatment in childhood AML. This paper aims to discuss differences between childhood and adult AML, and to highlight recommendations that are specific to children. The particular relevance of new diagnostic and prognostic molecular markers in pediatric AML is presented. The general management of pediatric AML, the management of specific pediatric AML cohorts (such as infants) or subtypes of the disease occurring in children (such as Down syndrome related AML), as well as new therapeutic approaches, and the role of supportive care are discussed.
Collapse
|
31
|
Johnston DL, Alonzo TA, Gerbing RB, Lange BJ, Woods WG. Superior outcome of pediatric acute myeloid leukemia patients with orbital and CNS myeloid sarcoma: a report from the Children's Oncology Group. Pediatr Blood Cancer 2012; 58:519-24. [PMID: 21618422 PMCID: PMC3165066 DOI: 10.1002/pbc.23201] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2011] [Accepted: 04/20/2011] [Indexed: 11/08/2022]
Abstract
BACKGROUND Extramedullary leukemia (EML) is common in pediatric acute myeloid leukemia (AML) and occurs as leukemia cells within the cerebrospinal fluid (CSF) or as a solid tumor (myeloid sarcoma-MS). The effect of MS on survival is unknown. METHODS Patients on CCG protocols 2861, 2891, 2941, and 2961 being treated for AML with intensive-timing chemotherapy were classified for the presence of EML (CSF leukemia, CNS-MS, orbital-MS, or non-CNS MS). CSF leukemia was classified as CNS3 (>5 WBC in the CSF with blasts) and non-CSF leukemia as CNS1/2 (<5 WBC in the CSF with or without blasts). Characteristics and outcomes of these patients were compared. RESULTS Of the 1,459 total patients, 1,206 (82%) had no EML, 154 (11%) had CSF leukemia, 19 (1%) had CNS-MS, 23 (2%) had orbital-MS, and 57 (4%) had non-CNS MS. The CR rate was significantly higher in patients with orbital-MS and CNS-MS than in those with non-MS and non-CNS MS (96% and 95% vs. 78% and 78%, P = 0.034). Patients with orbital-MS and CNS-MS had significantly higher overall survival than patients with non-CNS MS (92% and 73% vs. 38%, P < 0.001), CNS3 patients (92% and 73% vs. 51, P < 0.001), and CNS1/2 patients (92% and 73% vs. 50%, P < 0.001). Patients with orbital-MS had a significantly lower relapse rate. CONCLUSION Patients with MS involving orbital and CNS sites had a significantly better survival than patients with non-CNS MS, with CSF leukemia, or with no EML.
Collapse
Affiliation(s)
- Donna L. Johnston
- Division of Hematology/Oncology, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Todd A. Alonzo
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA
| | | | - Beverly J. Lange
- Pediatric Oncology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - William G. Woods
- Aflac Cancer Center and Blood Disorders Service Children’s Healthcare of Atlanta, Emory University, Atlanta, GA
| |
Collapse
|
32
|
Shihadeh F, Reed V, Faderl S, Medeiros LJ, Mazloom A, Hadziahmetovic M, Kantarjian H, Allen P, Ballas L, Pierce S, Dabaja B. Cytogenetic profile of patients with acute myeloid leukemia and central nervous system disease. Cancer 2012; 118:112-7. [PMID: 21692072 DOI: 10.1002/cncr.26253] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2010] [Revised: 04/14/2011] [Accepted: 04/15/2011] [Indexed: 02/03/2023]
Abstract
BACKGROUND Acute myeloid leukemia (AML) infrequently involves the central nervous system (CNS). This study was undertaken in patients with AML to determine whether cytogenetic findings predict CNS involvement. METHODS The medical records of 1354 patients with AML who were treated at The University of Texas MD Anderson Cancer Center between January 2000 and December 2008 were reviewed. Forty patients (3%) had CNS involvement at time of presentation or disease recurrence, of whom 37 had conventional cytogenetics performed on bone marrow aspirate material. Demographics, treatment, and status at last follow-up were collected. RESULTS Eleven patients (30%) had a diploid karyotype, and 14 patients (38%) had complex cytogenetics. Only 5 of the 40 patients had CNS disease at diagnosis, and the remaining patients had CNS disease at relapse. Patients who developed CNS disease were younger (P = .019), had a higher white blood cell (WBC) count at diagnosis (P = .001), had higher lactate dehydrogenase level (LDH) levels (P < .0001), and had higher percentages peripheral blast cells (P = .024) at diagnosis compared with the rest of the population. In addition, patients with CNS disease had higher rates of chromosome 16 inversion (P < .001), chromosome 11 abnormality (P = .005), and trisomy 8 (P = .02) and had a tendency toward complex cytogenetics (P = .2) compared with the control group (patients who had AML with no CNS involvement). CONCLUSIONS Patients with AML and CNS disease often had higher LDH levels and WBC counts at diagnosis, and they often presented with chromosome 16 inversion and chromosome 11 abnormalities. The current study indicated that the overall survival of patients with AML who had CNS involvement is poor.
Collapse
Affiliation(s)
- Ferial Shihadeh
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas 77030, USA
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Macpherson GR, Hanson CA, Thompson DM, Perella CM, Cmarik JL, Ruscetti SK. Retrovirus-transformed erythroleukemia cells induce central nervous system failure in a new syngeneic mouse model of meningeal leukemia. Leuk Res 2011; 36:369-76. [PMID: 21924771 DOI: 10.1016/j.leukres.2011.08.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2011] [Revised: 08/15/2011] [Accepted: 08/22/2011] [Indexed: 12/25/2022]
Abstract
Lack of suitable mouse models for central nervous system (CNS)-associated leukemias has hindered mechanism-guided development of therapeutics. By transplanting retrovirus-transformed mouse erythroleukemia cells into syngeneic mice, we developed a new animal model of meningeal leukemia associated with rapid paralysis. Necropsy revealed massive proliferation of the leukemic cells in the bone marrow (BM) followed by pathological angiogenesis and invasion of the leukemic cells into the meninges of the CNS. Further analysis demonstrated that the erythroleukemia cells secreted high levels of VEGF and preferentially adhered in vitro to fibronectin. This unique animal model for meningeal leukemia should facilitate studies of engraftment and proliferation of leukemic cells in the BM and their invasion of the CNS as well as pre-clinical evaluation of experimental therapeutics for CNS-associated leukemias.
Collapse
Affiliation(s)
- Gordon R Macpherson
- Laboratory of Cancer Prevention, National Cancer Institute-Frederick, Frederick, MD 21702-1201, USA
| | | | | | | | | | | |
Collapse
|
34
|
Abstract
Cure rates of childhood malignancies are inferior in India as compared to developed nations. There is paucity of data addressing outcome of childhood acute myeloid leukemia (AML) from India. Hence, this study was designed to assess the outcome of childhood AML in India over the last 2 decades, identify shortcomings and suggest remedial measures. A comprehensive search to identify studies addressing outcome of childhood AML from India was carried out. International Society of Paediatric Oncology annual meeting abstracts were searched to identify unpublished data. Clinicodemographic and outcome data were extracted from these abstracts. Outcomes of <500 patients have been published to date, with predominantly small single-center series from 5 cities. Several AML protocols with modifications to suit the logistics in India have been used. Administration of chemotherapy (standard as well as oral and outpatient based) with manageable toxicity has been deemed feasible. Survival outcomes are modest (23% to 53.8%) except for AML M3 (over 80%), with high early-death rates, relapse, along with abandonment. Few series have identified prognostic parameters and disease burden at diagnosis, and used cytogenetics (for risk stratification) or bone marrow transplant (BMT). There is a need for assessment of risk factors in Indian patients; administration of adequate and appropriate therapy, both upfront and after relapse; improvement in supportive care; and national data management infrastructure with updating/monitoring of registries along with better financial and social support initiatives. These multimodal and additive remedial measures could significantly improve outcome of childhood AML in India by reducing mortality, relapse, and abandonment.
Collapse
Affiliation(s)
- Ketan Prasad Kulkarni
- Division of Pediatric Hematology Oncology, Stollery Children Hospital, University of Alberta, Canada
| | | |
Collapse
|
35
|
Nagpal S, Recht L. Treatment and Prophylaxis of Hematologic Malignancy in the Central Nervous System. Curr Treat Options Neurol 2011; 13:400-12. [DOI: 10.1007/s11940-011-0128-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|