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Thastrup M, Duguid A, Mirian C, Schmiegelow K, Halsey C. Central nervous system involvement in childhood acute lymphoblastic leukemia: challenges and solutions. Leukemia 2022; 36:2751-2768. [PMID: 36266325 PMCID: PMC9712093 DOI: 10.1038/s41375-022-01714-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 09/17/2022] [Accepted: 09/22/2022] [Indexed: 11/10/2022]
Abstract
Delivery of effective anti-leukemic agents to the central nervous system (CNS) is considered essential for cure of childhood acute lymphoblastic leukemia. Current CNS-directed therapy comprises systemic therapy with good CNS-penetration accompanied by repeated intrathecal treatments up to 26 times over 2-3 years. This approach prevents most CNS relapses, but is associated with significant short and long term neurotoxicity. Despite this burdensome therapy, there have been no new drugs licensed for CNS-leukemia since the 1960s, when very limited anti-leukemic agents were available and there was no mechanistic understanding of leukemia survival in the CNS. Another major barrier to improved treatment is that we cannot accurately identify children at risk of CNS relapse, or monitor response to treatment, due to a lack of sensitive biomarkers. A paradigm shift in treating the CNS is needed. The challenges are clear - we cannot measure CNS leukemic load, trials have been unable to establish the most effective CNS treatment regimens, and non-toxic approaches for relapsed, refractory, or intolerant patients are lacking. In this review we discuss these challenges and highlight research advances aiming to provide solutions. Unlocking the potential of risk-adapted non-toxic CNS-directed therapy requires; (1) discovery of robust diagnostic, prognostic and response biomarkers for CNS-leukemia, (2) identification of novel therapeutic targets combined with associated investment in drug development and early-phase trials and (3) engineering of immunotherapies to overcome the unique challenges of the CNS microenvironment. Fortunately, research into CNS-ALL is now making progress in addressing these unmet needs: biomarkers, such as CSF-flow cytometry, are now being tested in prospective trials, novel drugs are being tested in Phase I/II trials, and immunotherapies are increasingly available to patients with CNS relapses. The future is hopeful for improved management of the CNS over the next decade.
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Affiliation(s)
- Maria Thastrup
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Alasdair Duguid
- Centre for Regenerative Medicine, University of Edinburgh, Edinburgh, UK
| | - Christian Mirian
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Novo Nordisk Foundation Center for Protein Research, Proteomics Program, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Christina Halsey
- Wolfson Wohl Cancer Research Centre, School of Cancer Sciences, College of Medical Veterinary and Life Sciences, University of Glasgow, Glasgow, UK.
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Yoshino H, Gemma Y, Miyazawa N, Bessho F, Yan K. Therapy-related acute megakaryoblastic leukemia with severe myelofibrosis. Pediatr Int 2022; 64:e14842. [PMID: 35103363 DOI: 10.1111/ped.14842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 04/24/2021] [Accepted: 05/12/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Hiroshi Yoshino
- Department of Pediatrics, Kyorin University School of Medicine, Tokyo, Japan
| | - Yuki Gemma
- Department of Pediatrics, Kyorin University School of Medicine, Tokyo, Japan
| | - Noritaka Miyazawa
- Department of Pediatrics, Kyorin University School of Medicine, Tokyo, Japan
| | - Fumio Bessho
- Department of Pediatrics, Kyorin University School of Medicine, Tokyo, Japan.,Department of Health Science, Nihon Institute of Medical Science, Moroyama, Japan
| | - Kunimasa Yan
- Department of Pediatrics, Kyorin University School of Medicine, Tokyo, Japan
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3
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Arakawa Y, Masutani S, Oshima K, Mitani Y, Mori M, Fukuoka K, Moriwaki K, Kato M, Taira K, Tanami Y, Nakazawa A, Koh K. Asian population may have a lower incidence of hip osteonecrosis in childhood acute lymphoblastic leukemia. Int J Hematol 2021; 114:271-279. [PMID: 34008044 DOI: 10.1007/s12185-021-03163-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 05/12/2021] [Accepted: 05/12/2021] [Indexed: 11/30/2022]
Abstract
Osteonecrosis (ON), a long-term complication of acute lymphoblastic leukemia (ALL) treatment affects patients' quality of life. Although the incidence of any ON, including asymptomatic, was 21.7% among children with ALL in the U.S., the actual incidence and risk factors in Asia remain unknown. For over 11 years, we performed hip magnetic resonance imaging (MRI) screening to detect asymptomatic ON while initiating maintenance chemotherapy in newly diagnosed children with ALL. Overall, 164 of 175 patients underwent hip MRI screening. The incidence of symptomatic or any ON was 3.0% and 11.6%, respectively. Asymptomatic ON in patients < 10 and ≥ 10 years old was 4.0% and 35.9%, respectively (P < 0.001). In multivariate analysis, age ≥ 10 years was the only significant risk factor. Asymptomatic ON with necrosis of > 30% of the epiphyseal surface of the femoral head was detected in four patients (2.4%). All were ≥ 10 years. Three of them progressed to severe symptomatic ON. The incidence of any ON in Asia may be lower than that seen in the only screening study in the U.S. Future studies should clarify factors affecting such regional differences and develop an effective approach to avoid the progression of ON in children with ALL.
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Affiliation(s)
- Yuki Arakawa
- Department of Hematology/Oncology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuou-ku, Saitama, 330-8777, Japan. .,Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Saitama, Japan.
| | - Satoshi Masutani
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Koichi Oshima
- Department of Hematology/Oncology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuou-ku, Saitama, 330-8777, Japan
| | - Yuichi Mitani
- Department of Hematology/Oncology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuou-ku, Saitama, 330-8777, Japan
| | - Makiko Mori
- Department of Hematology/Oncology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuou-ku, Saitama, 330-8777, Japan
| | - Kohei Fukuoka
- Department of Hematology/Oncology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuou-ku, Saitama, 330-8777, Japan
| | - Koichi Moriwaki
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Motohiro Kato
- Department of Pediatrics, The University of Tokyo, Tokyo, Japan
| | - Katsuaki Taira
- Department of Orthopedics Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Yutaka Tanami
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Atsuko Nakazawa
- Department of Pathology, Saitama Children's Medical Center, Saitama, Japan
| | - Katsuyoshi Koh
- Department of Hematology/Oncology, Saitama Children's Medical Center, 1-2 Shintoshin, Chuou-ku, Saitama, 330-8777, Japan
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In-Hospital Management Might Reduce Induction Deaths in Pediatric Patients With Acute Lymphoblastic Leukemia: Results From a Japanese Cohort. J Pediatr Hematol Oncol 2021; 43:39-46. [PMID: 32852400 DOI: 10.1097/mph.0000000000001926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 06/15/2020] [Indexed: 11/25/2022]
Abstract
Induction deaths (ID) remain a critical issue in the treatment of pediatric patients with acute lymphoblastic leukemia (ALL). The reported rate of ID in this population is 1% or higher. We speculate that this proportion might be lower in Japan because of mandatory hospitalization during induction therapy to manage complications. We retrospectively analyzed the incidence of ID among children with ALL enrolled in 4 Japanese study groups between 1994 and 2013. Among 5620 children, 41 (0.73%) cases of ID were noted. The median age was 6.5 years; 24 children were female, and 7 had T-cell ALL. Infection was the most common cause of ID (n=22), but the incidence (0.39%) was lower than that reported in western countries. Mortality within 48 hours from the onset of infection was low, comprising 25% of infection-related deaths. The incidence of infections caused by Bacillus species was low. Only 1 patient died because of Aspergillus infection. Fatal infections mostly occurred during the third week of induction therapy. Our findings suggest that close monitoring, stringent infection control, and immediate administration of appropriate antibiotics through hospitalization might be important strategies in reducing the rate of infection-related ID in pediatric patients with ALL.
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Arshad U, Jabbar N, Mansoor N, Haider M, Butt Z, Nadeem K. Central Nervous System Involvement in Childhood Acute Lymphoblastic Leukemia: An Analysis of Day-One Versus Day-Eight Lumbar Punctures in Remission Induction Therapy. Cureus 2021; 13:e12464. [PMID: 33552781 PMCID: PMC7856329 DOI: 10.7759/cureus.12464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Introduction Traumatic lumbar puncture (TLP+) can lead to the iatrogenic infiltration of the central nervous system (CNS) by circulating leukemic blast cells in childhood acute lymphoblastic leukemia (ALL). The risk of TLP+ is increased by a number of factors at the time of presentation of the disease, such as a high white cell count (WCC), T-ALL phenotype, and unstable clinical condition of the patient. For this reason, the first lumbar puncture (LP) was deferred until Day Eight of prednisolone prophase during remission induction therapy in one set of patients. The objective was to compare the historical cohort of Day-One LP with Day-Eight LP with respect to the incidence of TLP+ and de novo CNS leukemia. Methods A retrospective comparative data analysis of 1,185 childhood ALL patients aged 1-16 years was conducted based on the electronic medical records of the pediatric hematology-oncology department of The Indus Hospital (TIH), Karachi, from January 2010 to August 2018. A total of 600 patients whose LP was done on Day One (January 2010-May 2015) were placed in cohort A, whereas 585 patients whose LP was performed on Day Eight (June 2015-August 2018) were placed in cohort B. After the examination of the cerebrospinal fluid (CSF), the status of CNS infiltration was classified as CNS-1, CNS-2, CNS-3, and TLP+. Results A total of 1,185 patients were included in the study, of whom 600 patients were in cohort A and 585 patients in cohort B. The incidence of TLP+ was found to be lower in cohort B (1.7%) as compared with the incidence in cohort A (4.3%) (p-value=0.009). However, there was an increase in the incidence of CNS-3 cases in cohort B (8%) as compared to cohort A (3%) (p-value: <0.001). When the CNS status of both the cohorts was compared with that of the internationally published data, a low incidence of TLP+ cases was noted in patients with LP on Day Eight. Conclusion The modified approach of performing the first LP on Day Eight significantly reduced the incidence of TLP+ cases. However, an unusual finding of a significant increase in the CNS-3 leukemia was noted. More prospective studies are needed to investigate this significant increase in CNS-3 cases.
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Affiliation(s)
- Uzma Arshad
- Pediatrics, Jinnah Medical and Dental College, Karachi, PAK
| | - Naeem Jabbar
- Department of Pediatric Oncology, The Indus Hospital, Karachi, PAK
| | - Neelum Mansoor
- Department of Hematology, The Indus Hospital, Karachi, PAK
| | - Maryam Haider
- Pediatrics, Jinnah Medical and Dental College, Karachi, PAK.,Pediatrics, Dr. Ruth K. M. Pfau, Civil Hospital, Karachi, PAK
| | - Zainab Butt
- Department of Pediatric Oncology, The Indus Hospital, Karachi, PAK
| | - Kishwer Nadeem
- Department of Pediatric Oncology, The Indus Hospital, Karachi, PAK
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Prednisolone Prophase for a Week Versus Upfront Multiagent Chemotherapy in Childhood Acute Lymphoblastic Leukemia: An Analysis With Reference to Induction Mortality in a Developing Country. J Pediatr Hematol Oncol 2020; 42:181-184. [PMID: 31688627 DOI: 10.1097/mph.0000000000001636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In childhood acute lymphoblastic leukemia, high treatment-related mortality, especially in the induction phase of treatment, is a major challenge for developing countries. The reasons are multifactorial, including a late presentation with higher disease burden, malnourishment, and limited support services. These factors may aggravate the toxic effects of upfront multiagent chemotherapy in terms of severe neutropenic sepsis and tumor lysis. Therefore, instead of upfront chemotherapy, we offered prednisolone prophase for 1 week with the objective of balancing the antileukemic versus the toxic effect of treatment. The data of 538 patients who received induction with this approach (cohort B) are compared for induction mortality with previous records of 438 patients (cohort A) treated with upfront chemotherapy. In the presence of similar clinical characteristics including age, sex, risk group, and phenotype in both cohorts, a significant difference was found in overall induction mortality of 9% in cohort B versus 14% in cohort A (P<0.05). This difference was also significant in the high-risk and T-cell phenotype, which strengthens our hypothesis that patients with higher burden of disease may experience more fatal toxic effects with upfront intensive chemotherapy. Therefore, we suggest that the prednisolone prophase approach is beneficial to control the disease with less severe toxic effects in our settings.
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Ishimaru S, Okamoto Y, Imai C, Sakaguchi H, Taki T, Hasegawa D, Cho Y, Kakuda H, Sano H, Manabe A, Imamura T, Kato M, Arakawa Y, Shimonodan H, Sato A, Suenobu S, Inukai T, Watanabe A, Kawano Y, Kikuta A, Horibe K, Ohara A, Koh K. Nationwide survey of pediatric hypodiploid acute lymphoblastic leukemia in Japan. Pediatr Int 2019; 61:1103-1108. [PMID: 31519067 DOI: 10.1111/ped.14006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 07/07/2019] [Accepted: 07/26/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Ploidy is a highly significant prognostic factor for pediatric acute lymphoblastic leukemia (ALL). Children with hypodiploid ALL have poor outcomes despite current intensive chemotherapy. Little has been investigated with regard to hypodiploid ALL in Japanese children. METHODS We retrospectively collected clinical data on hypodiploid ALL cases from the registries of prospective multicenter trials conducted by the four independent clinical study groups in Japan between 1997 and 2012. RESULTS A total of 117 ALL patients with hypodiploidy were analyzed in this study. There were 101, eight, and eight patients with 45, 44, and fewer than 44 chromosomes, respectively. The 5 year overall survival rates differed significantly: 86.0%, 87.5%, and 62.5% for patients with 45, 44, and fewer than 44 chromosomes, respectively (P = 0.037). Of the eight patients with 44 chromosomes, seven were alive, including five patients who maintained complete remission without undergoing hematopoietic stem cell transplantation (HSCT). Of the eight patients with fewer than 44 chromosomes, six were good responders to prednisolone and none had induction failure, but the relapse rate was high (5/8). No patients had central nervous system relapse. Four patients underwent HSCT after relapse, but only one survived. CONCLUSIONS Outcomes of Japanese ALL patients with fewer than 44 chromosomes were poor, as previously reported in other countries. Although the sample size was small, patients with 44 chromosomes had better prognoses than those previously reported. Further studies including international collaboration are needed to improve outcomes for pediatric ALL patients with fewer than 44 chromosomes.
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Affiliation(s)
- Sae Ishimaru
- Department of Pediatric Oncology, National Cancer Center Hospital, Tokyo, Japan.,Department of Hematology/Oncology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Yasuhiro Okamoto
- Department of Pediatrics, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Chihaya Imai
- Department of Pediatrics, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Hirotoshi Sakaguchi
- Department of Hematology and Oncology, Children's Medical Center, Japanese Red Cross, Nagoya First Hospital, Nagoya, Japan
| | - Tomohiko Taki
- Department of Medical Technology, Kyorin University Faculty of Health Sciences, Tokyo, Japan
| | - Daisuke Hasegawa
- Departments of Pediatrics, St Luke's International Hospital, Tokyo, Japan
| | - Yuko Cho
- Department of Pediatrics, Hokkaido University Hospital, Sapporo, Japan
| | - Harumi Kakuda
- Department of Hematology/Oncology, Chiba Children's Hospital, Chiba, Japan
| | - Hideki Sano
- Department of Pediatric Oncology, Fukushima Medical University Hospital, Fukushima, Japan
| | - Atsushi Manabe
- Departments of Pediatrics, St Luke's International Hospital, Tokyo, Japan
| | - Toshihiko Imamura
- Department of Pediatrics, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Motohiro Kato
- Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Yuki Arakawa
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Hidemi Shimonodan
- Department of Pediatrics, Miyazaki Prefectural Miyazaki Hospital, Miyazaki, Japan
| | - Atsushi Sato
- Department of Hematology and Oncology, Miyagi Children's Hospital, Sendai, Japan
| | - Souichi Suenobu
- Division of General Pediatrics and Emergency Medicine, Department of Pediatrics, Oita University, Faculty of Medicine, Yufu, Japan
| | - Takeshi Inukai
- Department of Pediatrics, University of Yamanashi, Chuo, Japan
| | - Arata Watanabe
- Department of Pediatrics, Nakadori General Hospital, Akita, Japan
| | - Yoshifumi Kawano
- Department of Pediatrics, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Atsushi Kikuta
- Department of Pediatric Oncology, Fukushima Medical University Hospital, Fukushima, Japan
| | - Keizo Horibe
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Akira Ohara
- Department of Pediatrics, Toho University School of Medicine, Tokyo, Japan
| | - Katsuyoshi Koh
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
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Ueda T, Migita M, Itabashi T, Tanabe Y, Uchimura R, Gocho Y, Yamanishi M, Kobayashi F, Yoshino M, Fujita A, Yamanishi S, Kaizu K, Hayakawa J, Asano T, Maeda M, Itoh Y. Therapy-related Secondary Malignancy After Treatment of Childhood Malignancy: Cases from a Single Center. J NIPPON MED SCH 2019; 86:207-214. [DOI: 10.1272/jnms.jnms.2018_86-401] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | - Mio Yoshino
- Department of Pediatrics, Nippon Medical School
| | - Atsushi Fujita
- Department of Pediatrics, Nippon Medical School Chiba Hokusoh Hospital
| | | | | | | | - Takeshi Asano
- Department of Pediatrics, Nippon Medical School Chiba Hokusoh Hospital
| | - Miho Maeda
- Department of Pediatrics, Nippon Medical School
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Takahashi H, Kajiwara R, Kato M, Hasegawa D, Tomizawa D, Noguchi Y, Koike K, Toyama D, Yabe H, Kajiwara M, Fujimura J, Sotomatsu M, Ota S, Maeda M, Goto H, Kato Y, Mori T, Inukai T, Shimada H, Fukushima K, Ogawa C, Makimoto A, Fukushima T, Ohki K, Koh K, Kiyokawa N, Manabe A, Ohara A. Treatment outcome of children with acute lymphoblastic leukemia: the Tokyo Children's Cancer Study Group (TCCSG) Study L04-16. Int J Hematol 2018; 108:98-108. [PMID: 29589281 DOI: 10.1007/s12185-018-2440-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 03/22/2018] [Accepted: 03/22/2018] [Indexed: 12/11/2022]
Abstract
The survival rate of children with acute lymphoblastic leukemia (ALL) has increased to approximately 90% after substantial progress in risk-oriented treatment strategies. Between 2005 and 2013, the Tokyo Children's Cancer Study Group (TCCSG) conducted a risk-oriented, non-randomized study, L04-16. The principal aim of this study was to assemble background characteristics and treatment outcomes, and gather genetic information on leukemic cells under central diagnosis. This report outlines the background characteristics and treatment outcomes of 1033 children with ALL treated according to a TCCSG platform. The 5-year event-free and overall survival (OS) rates for all children were 78.1 ± 1.3 and 89.6 ± 1.0%, respectively. The OS rate was significantly higher in children with B-cell precursor (BCP)-ALL (91.9 ± 1.0%, n = 916) than in those with T-ALL (71.9 ± 4.3%, n = 117, p < 0.001). In univariate analysis for BCP-ALL, children aged 1-6 years (5y-OS: 94.2 ± 1.0%), with an initial white blood cell count of < 20,000/μL (94.0 ± 1.0%), high hyperdiploidy (95.4 ± 1.6%), ETV6-RUNX1 (97.4 ± 1.2%) or TCF3-PBX1 (96.9 ± 2.1%), and "Day8NoBlasts" (96.4 ± 1.1%) had the best outcomes. Genetic investigation revealed two novel fusion genes within this cohort: ETV6-ZNF385A and ZNF362-TCF4. Our study highlighted the clinical aspects of genomic features of ALL in Japanese children. We provide fundamental information for the further molecular investigation of this disease.
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Affiliation(s)
- Hiroyuki Takahashi
- Department of Pediatrics, Toho University, 6-11-1 Omori-Nishi, Ota-ku, Tokyo, 143-8541, Japan.
| | - Ryosuke Kajiwara
- Department of Pediatrics, Yokohama City University, Yokohama, Japan
| | - Motohiro Kato
- Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Daisuke Hasegawa
- Department of Pediatrics, St Luke's International Hospital, Tokyo, Japan
| | - Daisuke Tomizawa
- Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Yasushi Noguchi
- Department of Pediatrics, Japanese Red Cross Narita Hospital, Narita, Japan
| | - Kazutoshi Koike
- Division of Pediatric Hematology and Oncology, Ibaraki Children's Hospital, Mito, Japan
| | - Daisuke Toyama
- Department of Pediatrics, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Hiromasa Yabe
- Department of Cell Transplantation and Regenerative Medicine, Tokai University School of Medicine, Isehara, Japan
| | - Michiko Kajiwara
- Department of Pediatrics, Tokyo Medical and Dental University, Tokyo, Japan
| | - Junya Fujimura
- Department of Pediatrics, Juntendo University, Tokyo, Japan
| | - Manabu Sotomatsu
- Department of Pediatrics, Gunma Children's Medical Center, Shibukawa, Japan
| | - Setsuo Ota
- Department of Pediatrics, Teikyo University Chiba Medical Center, Ichihara, Japan
| | - Miho Maeda
- Department of Pediatrics, Nippon Medical School, Tokyo, Japan
| | - Hiroaki Goto
- Division of Hemato-Oncology/Regenerative Medicine, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Yoko Kato
- Department of Pediatrics, Jikei University School of Medicine, Tokyo, Japan
| | - Tetsuya Mori
- Department of Pediatrics, St. Marianna University, Kawasaki, Japan
| | - Takeshi Inukai
- Department of Pediatrics, University of Yamanashi, Chuo, Japan
| | - Hiroyuki Shimada
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Keitaro Fukushima
- Department of Pediatrics, Dokkyo Medical University, Shimotsuga, Japan
| | - Chitose Ogawa
- Department of Pediatric Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Atsushi Makimoto
- Department of Hematology-Oncology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | | | - Kentaro Ohki
- Department of Pediatric Hematology and Oncology Research, National Research Institute for Child Health and Development, Tokyo, Japan
| | - Katsuyoshi Koh
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Nobutaka Kiyokawa
- Department of Pediatric Hematology and Oncology Research, National Research Institute for Child Health and Development, Tokyo, Japan
| | - Atsushi Manabe
- Department of Pediatrics, St Luke's International Hospital, Tokyo, Japan
| | - Akira Ohara
- Department of Pediatrics, Toho University, 6-11-1 Omori-Nishi, Ota-ku, Tokyo, 143-8541, Japan
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10
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Estcourt LJ, Malouf R, Hopewell S, Doree C, Van Veen J. Use of platelet transfusions prior to lumbar punctures or epidural anaesthesia for the prevention of complications in people with thrombocytopenia. Cochrane Database Syst Rev 2018; 4:CD011980. [PMID: 29709077 PMCID: PMC5957267 DOI: 10.1002/14651858.cd011980.pub3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND People with a low platelet count (thrombocytopenia) often require lumbar punctures or an epidural anaesthetic. Lumbar punctures can be diagnostic (haematological malignancies, subarachnoid haematoma, meningitis) or therapeutic (spinal anaesthetic, administration of chemotherapy). Epidural catheters are placed for administration of epidural anaesthetic. Current practice in many countries is to correct thrombocytopenia with platelet transfusions prior to lumbar punctures and epidural anaesthesia, in order to mitigate the risk of serious procedure-related bleeding. However, the platelet count threshold recommended prior to these procedures varies significantly from country to country. This indicates significant uncertainty among clinicians regarding the correct management of these patients. The risk of bleeding appears to be low, but if bleeding occurs it can be very serious (spinal haematoma). Consequently, people may be exposed to the risks of a platelet transfusion without any obvious clinical benefit.This is an update of a Cochrane Review first published in 2016. OBJECTIVES To assess the effects of different platelet transfusion thresholds prior to a lumbar puncture or epidural anaesthesia in people with thrombocytopenia (low platelet count). SEARCH METHODS We searched for randomised controlled trials (RCTs), non-randomised controlled trials (nRCTs), controlled before-after studies (CBAs), interrupted time series studies (ITSs), and cohort studies in CENTRAL (the Cochrane Library 2018, Issue 1), MEDLINE (from 1946), Embase (from 1974), the Transfusion Evidence Library (from 1950), and ongoing trial databases to 13 February 2018. SELECTION CRITERIA We included RCTs, nRCTs, CBAs, ITSs, and cohort studies involving transfusions of platelet concentrates, prepared either from individual units of whole blood or by apheresis, and given to prevent bleeding in people of any age with thrombocytopenia requiring insertion of a lumbar puncture needle or epidural catheter.The original review only included RCTs. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane for including RCTs, nRCTs, CBAs, and ITSs. Two review authors independently assessed studies for eligibility and risk of bias and extracted data. Results were only expressed narratively. MAIN RESULTS We identified no completed or ongoing RCTs, nRCTs, CBAs, or ITSs. No studies included people undergoing an epidural procedure. No studies compared different platelet count thresholds prior to a procedure.In this update we identified three retrospective cohort studies that contained participants who did and did not receive platelet transfusions prior to lumbar puncture procedures. All three studies were carried out in people with cancer, most of whom had a haematological malignancy. Two studies were in children, and one was in adults.The number of participants receiving platelet transfusions prior to the lumbar puncture procedures was not reported in one study. We therefore only summarised in a narrative form the relevant outcomes from two studies (150 participants; 129 children and 21 adults), in which the number of participants who received the transfusion was given.We judged the overall risk of bias for all reported outcomes for both studies as 'serious' based on the ROBINS-I tool.No procedure-related major bleeding occurred in the two studies that reported this outcome (2 studies, 150 participants, no cases, very low-quality evidence).There was no evidence of a difference in the risk of minor bleeding (traumatic tap) in participants who received platelet transfusions before a lumbar puncture and those who did not receive a platelet transfusion before the procedure (2 studies, 150 participants, very low-quality evidence). One of the 14 adults who received a platelet transfusion experienced minor bleeding (traumatic tap; defined as at least 500 x 106/L red blood cells in the cerebrospinal fluid); none of the seven adults who did not receive a platelet transfusion experienced this event. Ten children experienced minor bleeding (traumatic taps; defined as at least 100 x 106/L red blood cells in the cerebrospinal fluid), six out of the 57 children who received a platelet transfusion and four out of the 72 children who did not receive a platelet transfusion.No serious adverse events occurred in the one study that reported this outcome (1 study, 21 participants, very low-quality evidence).We found no studies that evaluated all-cause mortality within 30 days from the lumbar puncture procedure, length of hospital stay, proportion of participants who received platelet transfusions, or quality of life. AUTHORS' CONCLUSIONS We found no evidence from RCTs or non-randomised studies on which to base an assessment of the correct platelet transfusion threshold prior to insertion of a lumbar puncture needle or epidural catheter. There are no ongoing registered RCTs assessing the effects of different platelet transfusion thresholds prior to the insertion of a lumbar puncture or epidural anaesthesia in people with thrombocytopenia. Any future study would need to be very large to detect a difference in the risk of bleeding. A study would need to be designed with at least 47,030 participants to be able to detect an increase in the number of people who had major procedure-related bleeding from 1 in 1000 to 2 in 1000. The use of a central data collection register or routinely collected electronic records (big data) is likely to be the only method to systematically gather data relevant to this population.
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Affiliation(s)
- Lise J Estcourt
- NHS Blood and TransplantHaematology/Transfusion MedicineLevel 2, John Radcliffe HospitalHeadingtonOxfordUKOX3 9BQ
| | - Reem Malouf
- University of OxfordNational Perinatal Epidemiology Unit (NPEU)Old Road CampusOxfordUKOX3 7LF
| | - Sally Hopewell
- University of OxfordNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS)Botnar Research Centre, Windmill RoadOxfordOxfordshireUKOX3 7LD
| | - Carolyn Doree
- NHS Blood and TransplantSystematic Review InitiativeJohn Radcliffe HospitalOxfordUKOX3 9BQ
| | - Joost Van Veen
- Sheffield Teaching Hospitals NHS Foundation TrustDepartment of HaematologyGlossop RoadRoom H101D, H floorSheffieldUKS10 2JF
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11
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Kato M, Manabe A. Treatment and biology of pediatric acute lymphoblastic leukemia. Pediatr Int 2018; 60:4-12. [PMID: 29143423 DOI: 10.1111/ped.13457] [Citation(s) in RCA: 154] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 10/26/2017] [Accepted: 11/10/2017] [Indexed: 12/12/2022]
Abstract
Acute lymphoblastic leukemia (ALL) is the most common pediatric malignancy. In the past ALL was intractable but now the survival probability is as high as 80-90%. Improved supportive care, treatment stratification based on relapse risk, biological features of leukemic cells, and optimization of treatment regimens by nationwide and international collaboration have contributed to this dramatic improvement. While including traditional risk factors (e.g. age and leukocyte count at diagnosis), the treatment has been modified based on biological characteristics (aneuploidy and translocation) and treatment response (assessed by minimal residual disease). Treatment for pediatric ALL typically consists of induction therapy with steroids, vincristine, and asparaginase with or without anthracycline, followed by multi-agent consolidation including high-dose methotrexate and re-induction therapy. After consolidation, less intensive maintenance therapy is required for 1-2 years to maintain event-free survival. Recently, using advanced genomic analysis technology, novel sentinel genomic alterations that may provide more precise stratification or therapeutic targets, were identified. Moreover, in the last decade germline variations have been recognized as similarly important contributors to understanding the etiology and sensitivity of ALL to treatment. A more individualized approach based on genomic features (somatic and germline) and treatment response, the introduction of newly developed agents such as molecular targeted drugs or immunotherapy, and social support including long-term follow up are required for further improvement.
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Affiliation(s)
- Motohiro Kato
- Department of Pediatric Hematology and Oncology Research, National Research Institute for Child Health and Development, Tokyo, Japan.,Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Atsushi Manabe
- Department of Pediatrics, St Luke's International Hospital, Tokyo, Japan.,Research Center, St Luke's International University, Tokyo, Japan
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12
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Lee JW, Cho B. Prognostic factors and treatment of pediatric acute lymphoblastic leukemia. KOREAN JOURNAL OF PEDIATRICS 2017; 60:129-137. [PMID: 28592975 PMCID: PMC5461276 DOI: 10.3345/kjp.2017.60.5.129] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 03/30/2017] [Accepted: 04/11/2017] [Indexed: 12/13/2022]
Abstract
The event-free survival (EFS) for pediatric acute lymphoblastic leukemia (ALL) has shown remarkable improvement in the past several decades. In Korea also, a recent study showed 10-year EFS of 78.5%. Much of the improved outcome for pediatric ALL stems from the accurate identification of prognostic factors, the designation of risk group based on these factors, and treatment of appropriate duration and intensity according to risk group, done within the setting of cooperative clinical trials. The schema of first-line therapy for ALL remains mostly unchanged, although many groups have now reported on the elimination of cranial irradiation in all patients with low rates of central nervous system relapse. Specific high risk subgroups, such as Philadelphia chromosome-positive (Ph+) ALL and infant ALL continue to have significantly lower survival than other ALL patients. The introduction of tyrosine kinase inhibitors into therapy has led to enhanced outcome for Ph+ ALL patients. Infant ALL patients, particularly those with MLL rearrangements, continue to have poor outcome, despite treatment intensification including allogeneic hematopoietic cell transplantation. Relapsed ALL is a leading cause of mortality in pediatric cancer. Recent advances in immunotherapy targeting the CD19 of the ALL blast have shown remarkable efficacy in some of these relapsed and refractory patients. With improved survival, much of the current focus is on decreasing the long-term toxicities of treatment.
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Affiliation(s)
- Jae Wook Lee
- Division of Hematology and Oncology, Department of Pediatrics, The Catholic University of Korea, College of Medicine, Seoul, Korea
| | - Bin Cho
- Division of Hematology and Oncology, Department of Pediatrics, The Catholic University of Korea, College of Medicine, Seoul, Korea
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13
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Cancela CSP, Murao M, Assumpção JG, Souza MEDL, de Macedo AV, Viana MB, De Oliveira BM. Immunophenotyping of the cerebrospinal fluid as a prognostic factor at diagnosis of acute lymphoblastic leukemia in children and adolescents. Pediatr Hematol Oncol 2017; 34:53-65. [PMID: 28548878 DOI: 10.1080/08880018.2017.1313920] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
This study aimed at evaluating the use of immunophenotyping (IMP) in the identification of blast cells in the cerebrospinal fluid (CSF) of children and adolescents with acute lymphoblastic leukemia (ALL). Sixty-seven patients aged 18 years or younger were included. Fifty-five CSF samples were analyzed at initial diagnosis and 17 at the time of relapse. A cytological analysis (CA) was performed in all 72 samples, while IMP was done in 63. Blasts were identified in only three samples by CA, whereas all three samples were found negative by IMP, one of which had no isolation of nucleated cells after centrifugation. Among the samples analyzed by IMP, 11 showed a positive blast count, two of which had been inconclusive using CA. No equivalence was found between CA and IMP results (p = 0.55). CSF IMP positivity was not associated with other risk factors for ALL relapse. Among the 55 patients included at the time of diagnosis of ALL, eight relapsed during follow-up. Considering the cases of central nervous system (CNS) relapse, one of the patients belonged to the CSF IMP-positive group (11%) at diagnosis, and the other two cases, to the IMP-negative (5%) group. Detection of CSF blast cells using IMP was associated with a worse overall (p < 0.0001) and event-free survival (p < 0.0001). These results show that CSF IMP may be a useful additional method to conventional CA in the diagnosis of CNS involvement in ALL, and for the identification of high-risk subgroups that would benefit from an intensified therapy.
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Affiliation(s)
- Camila Silva Peres Cancela
- a Faculdade de Medicina/Departamento de Pediatria, Bairro Santa Efigenia , Universidade Federal de Minas Gerais , Belo Horizonte , Brazil
| | - Mitiko Murao
- b Hospital das Clinicas da Universidade Federal de Minas Gerais , Serviço de Hematologia , Belo Horizonte , Brazil
| | | | | | - Antonio Vaz de Macedo
- d Hospital das Clinicas da Universidade Federal de Minas Gerais , Belo Horizonte , Brazil
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14
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Li MJ, Liu HC, Yen HJ, Jaing TH, Lin DT, Yang CP, Lin KH, Hung IJ, Jou ST, Lu MY, Hsiao CC, Peng CT, Chang TT, Wang SC, Lin MT, Chen JS, Chang TK, Hung GY, Wu KH, Yang YL, Chang HH, Chen SH, Yeh TC, Cheng CN, Lin PC, Chiou SS, Sheen JM, Cheng SN, Chen SH, Chang YH, Ho WL, Chao YH, Chen RL, Chen BW, Wang JL, Hsieh YL, Liao YM, Yang SH, Chang WH, Chao YMY, Liang DC. Treatment for childhood acute lymphoblastic leukemia in Taiwan: Taiwan Pediatric Oncology Group ALL-2002 study emphasizing optimal reinduction therapy and central nervous system preventive therapy without cranial radiation. Pediatr Blood Cancer 2017; 64:234-241. [PMID: 27696656 DOI: 10.1002/pbc.26142] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 06/04/2016] [Accepted: 06/15/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND Reinduction therapy has improved the outcomes in children with acute lymphoblastic leukemia (ALL). We sought to determine the optimal course(s) of reinduction therapy for standard-risk (SR, or "low-risk" in other groups) patients. Also, we evaluated outcomes using triple intrathecal therapy without cranial radiation (CrRT) for central nervous system (CNS) preventive therapy. PROCEDURE From 2002 to 2012, all newly diagnosed children with ALL in Taiwan were enrolled in Taiwan Pediatric Oncology Group ALL-2002 protocol. SR patients were randomized to receive single or double reinduction courses. The patients enrolled before 2009 received CrRT, while those enrolled later did not. The Kaplan-Meier method was used to estimate survival rates and the difference between two groups was compared by the two-sided log-rank test. RESULTS In 1,366 eligible patients, the 5-year overall survival (OS) was 81.6 ± 1.1% (standard error) and 5-year event-free survival (EFS) was 74.3 ± 1.2%. In SR patients, the 5-year OS for one and two reinduction courses was 91.6 ± 2.1% and 93.7 ± 1.8%, respectively, and the 5-year EFS was 85.2 ± 2.7% and 89.8 ± 2.3%, respectively. There were no significant differences in survival between these two groups. Patients with MLL or BCR-ABL1 had the worst outcomes: 5-year EFS was 23.4 and 31.8% and 5-year OS was 28.6 and 44.7%, respectively. There was no significant difference in CNS relapse or survival between the era with or without CrRT. CONCLUSIONS For SR patients, one-course reinduction was adequate. Triple intrathecal therapy alone successfully prevented CNS relapse.
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Affiliation(s)
- Meng-Ju Li
- Department of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Pediatrics, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Hsi-Che Liu
- Department of Pediatrics, Mackay Memorial Hospital, Mackay Medical College, Taipei, Taiwan
| | - Hsiu-Ju Yen
- Department of Pediatrics, Taipei Veterans General Hospital and School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Tang-Her Jaing
- Department of Hematology-Oncology, Chang Gung Children's Hospital-Linkou, Taoyuan, Taiwan
| | - Dong-Tsamn Lin
- Department of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chao-Ping Yang
- Department of Hematology-Oncology, Chang Gung Children's Hospital-Linkou, Taoyuan, Taiwan
| | - Kai-Hsin Lin
- Department of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Iou-Jih Hung
- Department of Hematology-Oncology, Chang Gung Children's Hospital-Linkou, Taoyuan, Taiwan
| | - Shiann-Tarng Jou
- Department of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Meng-Yao Lu
- Department of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chih-Cheng Hsiao
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ching-Tien Peng
- Division of Pediatric Hematology & Oncology, China Medical University Children's Hospital, Taichung, Taiwan.,Department of Biotechnology, Asia University, Wufeng, Taichung, Taiwan
| | | | - Shih-Chung Wang
- Department of Pediatrics, Changhua Christian Hospital, Changhua, Taiwan
| | - Ming-Tsan Lin
- Department of Pediatrics, Changhua Christian Hospital, Changhua, Taiwan
| | - Jiann-Shiuh Chen
- Department of Pediatrics, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Te-Kau Chang
- Department of Pediatrics, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Giun-Yi Hung
- Department of Pediatrics, Taipei Veterans General Hospital and School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Kang-Hsi Wu
- Division of Pediatric Hematology & Oncology, China Medical University Children's Hospital, Taichung, Taiwan
| | - Yung-Li Yang
- Department of Laboratory Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Hsiu-Hao Chang
- Department of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Shih-Hsiang Chen
- Department of Hematology-Oncology, Chang Gung Children's Hospital-Linkou, Taoyuan, Taiwan
| | - Ting-Chi Yeh
- Department of Pediatrics, Mackay Memorial Hospital, Mackay Medical College, Taipei, Taiwan
| | - Chao-Neng Cheng
- Department of Pediatrics, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Pei-Chin Lin
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Shyh-Shin Chiou
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Jiunn-Ming Sheen
- Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Shin-Nan Cheng
- Department of Pediatrics, Tungs' Taichung Metro Harbor Hospital, Taichung, Taiwan
| | - Shu-Huey Chen
- Department of Pediatrics, Taipei Medical University-Shuang Ho Hospital, Taipei, Taiwan
| | - Yu-Hsiang Chang
- Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Wan-Ling Ho
- Department of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Pediatrics, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan.,School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Yu-Hua Chao
- Department of Pediatrics, Chung Shan Medical University Hospital, School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Rong-Long Chen
- Division of Pediatric Hematology and Oncology, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan
| | - Bow-Wen Chen
- Division of Pediatric Hematology and Oncology, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan
| | - Jinn-Li Wang
- Department of Pediatrics, Wanfang Hospital Taipei Medical University, Taipei, Taiwan
| | - Yuh-Lin Hsieh
- Department of Pediatrics, Cathay General Hospital, Taipei, Taiwan
| | - Yu-Mei Liao
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Shang-Hsien Yang
- Department of Pediatrics, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
| | | | | | - Der-Cherng Liang
- Department of Pediatrics, Mackay Memorial Hospital, Mackay Medical College, Taipei, Taiwan
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15
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Cohler C, Jumanne S, Kaijage J, DuBois SG, Scanlan P, Matthay KK. Evaluation and Outcome of Central Nervous System Involvement in Pediatric Acute Lymphoblastic Leukemia in Dar es Salaam, Tanzania. Pediatr Blood Cancer 2016; 63:458-64. [PMID: 26529141 DOI: 10.1002/pbc.25829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 10/04/2015] [Accepted: 10/05/2015] [Indexed: 11/10/2022]
Abstract
BACKGROUND Outcomes for acute lymphoblastic leukemia (ALL) in low-income countries lag far behind high-income countries (HIC). We explored the impact of central nervous system (CNS) involvement on outcome of pediatric patients with ALL in Tanzania. PROCEDURE Comprehensive chart review was performed to characterize CNS involvement, treatment, and outcomes of pediatric patients with ALL at Muhimbili National Hospital in Dar es Salaam, Tanzania between January 1, 2011 and December 31, 2013. RESULTS One hundred fifty-six patients with confirmed ALL had accessible data, and 128 initiated therapy. Sixteen percent of 156 patients had a documented cerebral spinal fluid analysis by cytospin. Seventy patients (45%) had a documented lumbar puncture with intrathecal (IT) therapy within 1 week of diagnosis. Thirteen patients presented with CNS involvement at diagnosis based on cytospin and/or unequivocal symptoms. Twenty-one patients (16%) experienced CNS relapse, three of whom had CNS disease at diagnosis. Median event-free survival (EFS) for all patients was 7.9 months and estimated EFS at 24 months was 31%. For the patients with CNS involvement at diagnosis, the estimated EFS at 24 months was 45%. Only three of 21 patients with CNS relapse were still alive with a median follow up of 3 months. CONCLUSIONS The rate of CNS disease in patients with ALL in Dar es Salaam at diagnosis and relapse was higher than that reported in HIC, and overall survival was lower. Improving outcomes will require further advances including consistent CNS prophylaxis and may include targeting high-risk patients with additional IT treatments.
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Affiliation(s)
- Cheryl Cohler
- Department of Pediatrics, UCSF School of Medicine and UCSF Benioff Children's Hospital, University of California, San Francisco, California
| | - Shakilu Jumanne
- Department of Pediatrics, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Jane Kaijage
- Department of Pediatrics, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Steven G DuBois
- Department of Pediatrics, UCSF School of Medicine and UCSF Benioff Children's Hospital, University of California, San Francisco, California
| | - Patricia Scanlan
- Department of Pediatrics, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Katherine K Matthay
- Department of Pediatrics, UCSF School of Medicine and UCSF Benioff Children's Hospital, University of California, San Francisco, California
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16
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Tomizawa D, Kato M, Takahashi H, Fujimura J, Inukai T, Fukushima T, Kiyokawa N, Koh K, Manabe A, Ohara A. Favorable outcome in non-infant children with MLL-AF4-positive acute lymphoblastic leukemia: a report from the Tokyo Children’s Cancer Study Group. Int J Hematol 2015; 102:602-10. [DOI: 10.1007/s12185-015-1869-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 09/09/2015] [Accepted: 09/17/2015] [Indexed: 11/28/2022]
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17
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Association between traumatic lumbar puncture and the risk of central nervous system relapse in adults with acute lymphoblastic leukaemia. REVISTA MÉDICA DEL HOSPITAL GENERAL DE MÉXICO 2015. [DOI: 10.1016/j.hgmx.2015.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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18
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Kato M, Manabe A, Saito AM, Koh K, Inukai T, Ogawa C, Goto H, Tsuchida M, Ohara A. Outcome of pediatric acute lymphoblastic leukemia with very late relapse: a retrospective analysis by the Tokyo Children's Cancer Study Group (TCCSG). Int J Hematol 2014; 101:52-7. [PMID: 25432437 DOI: 10.1007/s12185-014-1710-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 11/17/2014] [Accepted: 11/19/2014] [Indexed: 01/08/2023]
Abstract
Relapse period is strongly associated with second relapse risk in relapsed acute lymphoblastic leukemia (ALL) in children. In this context, the treatment outcome of very late relapse should be better; however, data regarding very late relapse is limited. We retrospectively analyzed the outcomes of two consecutive Tokyo Children's Cancer Study Group (TCCSG) ALL trials (1995-2004) with a focus on late relapse, which was divided into two categories: late relapse (6-24 months from the end of therapy, n = 48) and very late relapse (>24 months from the end of therapy, n = 57). Forty-three patients (29 late relapse and 14 very late relapse) received allogeneic hematopoietic stem cell transplantation (HSCT) at second remission. The event-free survival (EFS) probabilities of late relapse and very late relapse were 54.5 ± 7.3 and 64.8 ± 6.8 % at 7 years, respectively (P = 0.36), and were not significantly different. However, the second relapse incidence of late relapse (34.7 ± 7.1 %) was higher than that of very late relapse (15.5 ± 5.1 %, P = 0.03). The second relapse risk was low for very late relapse ALL, which suggests that these patients should be treated without allogeneic HSCT.
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Affiliation(s)
- Motohiro Kato
- Department of Pediatrics, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan,
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19
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Treatment outcomes of adolescent acute lymphoblastic leukemia treated on Tokyo Children’s Cancer Study Group (TCCSG) clinical trials. Int J Hematol 2014; 100:180-7. [DOI: 10.1007/s12185-014-1622-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 06/11/2014] [Accepted: 06/11/2014] [Indexed: 10/25/2022]
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20
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Liu HC, Yeh TC, Hou JY, Chen KH, Huang TH, Chang CY, Liang DC. Triple Intrathecal Therapy Alone With Omission of Cranial Radiation in Children With Acute Lymphoblastic Leukemia. J Clin Oncol 2014; 32:1825-9. [DOI: 10.1200/jco.2013.54.5020] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose To eliminate the toxicities and sequelae of cranial irradiation (CrRT) and to minimize the adverse impact of traumatic lumbar puncture (TLP) with blasts, a prospective study of a modified CNS-directed therapy was conducted in children with acute lymphoblastic leukemia (ALL). Patients and Methods Since June 1999, children with newly diagnosed ALL have been treated with triple intrathecal therapy (TIT) alone without CrRT. The first TIT was delayed until the disappearance of blasts from peripheral blood (PB) for up to 10 days of multidrug induction, and CrRT was omitted in all patients. If PB blasts persisted on treatment day 10 (d10), the TIT was then performed. Results Of a total of 156 patients, 152 were eligible. Seventeen patients did not have PB blasts at diagnosis. Three fourths of the remaining patients achieved complete clearance of PB blasts by d10. Only hyperleukocytosis at diagnosis showed a significantly lower clearance rate. Six standard-risk patients were upgraded to high risk because of detectable PB blasts on d10. TLPs were encountered in four patients (2.6%), but none were contaminated with lymphoblasts. Neither CNS-2 (less than 5 WBCs/μL with blasts in a nontraumatic sample) nor CNS-3 (≥ 5 WBCs/μL with blasts in a nontraumatic sample or the presence of cranial nerve palsy) was present. The 5-year event-free survival and overall survival rates ± SE were 84.2% ± 3.0% and 90.6% ± 2.4%, respectively. No isolated CNS relapse occurred, but two patients experienced combined CNS relapses. The 7-year cumulative risk of any CNS relapse was 1.4% ± 1.0%. Conclusion Delaying first TIT until circulating blasts have cleared may improve CNS control in children with newly diagnosed ALL and preclude the need for CrRT.
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Affiliation(s)
- Hsi-Che Liu
- Hsi-Che Liu, Ting-Chi Yeh, Jen-Yin Hou, and Der-Cherng Liang, Mackay Medical College, New Taipei; and Hsi-Che Liu, Ting-Chi Yeh, Jen-Yin Hou, Kuan-Hao Chen, Ting-Huan Huang, Ching-Yi Chang, and Der-Cherng Liang, Mackay Memorial Hospital, Taipei, Taiwan
| | - Ting-Chi Yeh
- Hsi-Che Liu, Ting-Chi Yeh, Jen-Yin Hou, and Der-Cherng Liang, Mackay Medical College, New Taipei; and Hsi-Che Liu, Ting-Chi Yeh, Jen-Yin Hou, Kuan-Hao Chen, Ting-Huan Huang, Ching-Yi Chang, and Der-Cherng Liang, Mackay Memorial Hospital, Taipei, Taiwan
| | - Jen-Yin Hou
- Hsi-Che Liu, Ting-Chi Yeh, Jen-Yin Hou, and Der-Cherng Liang, Mackay Medical College, New Taipei; and Hsi-Che Liu, Ting-Chi Yeh, Jen-Yin Hou, Kuan-Hao Chen, Ting-Huan Huang, Ching-Yi Chang, and Der-Cherng Liang, Mackay Memorial Hospital, Taipei, Taiwan
| | - Kuan-Hao Chen
- Hsi-Che Liu, Ting-Chi Yeh, Jen-Yin Hou, and Der-Cherng Liang, Mackay Medical College, New Taipei; and Hsi-Che Liu, Ting-Chi Yeh, Jen-Yin Hou, Kuan-Hao Chen, Ting-Huan Huang, Ching-Yi Chang, and Der-Cherng Liang, Mackay Memorial Hospital, Taipei, Taiwan
| | - Ting-Huan Huang
- Hsi-Che Liu, Ting-Chi Yeh, Jen-Yin Hou, and Der-Cherng Liang, Mackay Medical College, New Taipei; and Hsi-Che Liu, Ting-Chi Yeh, Jen-Yin Hou, Kuan-Hao Chen, Ting-Huan Huang, Ching-Yi Chang, and Der-Cherng Liang, Mackay Memorial Hospital, Taipei, Taiwan
| | - Ching-Yi Chang
- Hsi-Che Liu, Ting-Chi Yeh, Jen-Yin Hou, and Der-Cherng Liang, Mackay Medical College, New Taipei; and Hsi-Che Liu, Ting-Chi Yeh, Jen-Yin Hou, Kuan-Hao Chen, Ting-Huan Huang, Ching-Yi Chang, and Der-Cherng Liang, Mackay Memorial Hospital, Taipei, Taiwan
| | - Der-Cherng Liang
- Hsi-Che Liu, Ting-Chi Yeh, Jen-Yin Hou, and Der-Cherng Liang, Mackay Medical College, New Taipei; and Hsi-Che Liu, Ting-Chi Yeh, Jen-Yin Hou, Kuan-Hao Chen, Ting-Huan Huang, Ching-Yi Chang, and Der-Cherng Liang, Mackay Memorial Hospital, Taipei, Taiwan
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21
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Kato M, Imamura T, Manabe A, Hashii Y, Koh K, Sato A, Takahashi H, Hori H, Taki T, Inoue M, Hayashi Y, Horibe K, Tsuchida M, Kojima S, Oda M, Ohara A. Prognostic impact of gained chromosomes in high-hyperdiploid childhood acute lymphoblastic leukaemia: a collaborative retrospective study of the Tokyo Children's Cancer Study Group and Japan Association of Childhood Leukaemia Study. Br J Haematol 2014; 166:295-8. [DOI: 10.1111/bjh.12836] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Motohiro Kato
- Department of Cell Therapy and Transplantation Medicine; University of Tokyo; Tokyo Japan
- Department of Paediatrics; University of Tokyo; Tokyo Japan
| | - Toshihiko Imamura
- Department of Paediatrics; Kyoto Prefectural University of Medicine; Kyoto Japan
| | - Atsushi Manabe
- Department of Paediatrics; St. Luke's International Hospital; Tokyo Japan
| | - Yoshiko Hashii
- Department of Developmental Medicine; Osaka University; Osaka Japan
| | - Katsuyoshi Koh
- Department of Haematology/Oncology; Saitama Children's Medical Centre; Saitama Japan
| | - Atsushi Sato
- Department of Haematology/Oncology; Miyagi Children's Hospital; Sendai Japan
| | | | - Hiroki Hori
- Department of Paediatrics; Mie University; Tsu Japan
| | - Tomohiko Taki
- Department of Molecular Diagnostics and Therapeutics; Kyoto Prefectural University of Medicine; Kyoto Japan
| | - Masami Inoue
- Department of Haematology/Oncology; Osaka Medical Centre and Research Institute for Maternal of Child Health; Osaka Japan
| | - Yasuhide Hayashi
- Department of Haematology/Oncology; Gunma Children's Medical Centre; Maebashi Japan
| | - Keizo Horibe
- Clinical Research Centre; National Hospital Organization Nagoya Medical Centre; Nagoya Japan
| | - Masahiro Tsuchida
- Department of Haematology/Oncology; Ibaraki Children's Medical Centre; Mito Japan
| | - Seiji Kojima
- Department of Paediatrics; Nagoya University; Nagoya Japan
| | - Megumi Oda
- Department of Paediatrics; Okayama University; Okayama Japan
| | - Akira Ohara
- Department of Paediatrics; Toho University; Tokyo Japan
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22
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Kato M, Koh K, Manabe A, Saito T, Hasegawa D, Isoyama K, Kinoshita A, Maeda M, Okimoto Y, Kajiwara M, Kaneko T, Sugita K, Kikuchi A, Tsuchida M, Ohara A. No impact of high-dose cytarabine and asparaginase as early intensification with intermediate-risk paediatric acute lymphoblastic leukaemia: results of randomized trial TCCSG study L99-15. Br J Haematol 2013; 164:376-83. [DOI: 10.1111/bjh.12632] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 09/18/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Motohiro Kato
- Department of Haematology/Oncology; Saitama Children's Medical Centre; Saitama Japan
- Department of Paediatrics; the University of Tokyo; Tokyo Japan
| | - Katsuyoshi Koh
- Department of Haematology/Oncology; Saitama Children's Medical Centre; Saitama Japan
| | - Atsushi Manabe
- Department of Paediatrics; St. Luke's International Hospital; Tokyo Japan
| | - Tomohiro Saito
- Department of Health Policy; National Research Institute for Child Health and Development; Tokyo Japan
| | - Daisuke Hasegawa
- Department of Paediatrics; St. Luke's International Hospital; Tokyo Japan
| | - Keiichi Isoyama
- Department of Paediatrics; Showa University Fujigaoka Hospital; Yokohama Japan
| | - Akitoshi Kinoshita
- Department of Paediatrics; St. Marianna University School of Medicine; Kawasaki Japan
| | - Miho Maeda
- Department of Paediatrics; Nippon Medical School; Tokyo Japan
| | - Yuri Okimoto
- Department of Haematology/Oncology; Chiba Children's Hospital; Chiba Japan
| | - Michiko Kajiwara
- Department of Paediatrics; Tokyo Medical and Dental University; Tokyo Japan
| | - Takashi Kaneko
- Department of Haematology/Oncology; Tokyo Metropolitan Children's Medical Centre; Tokyo Japan
| | - Kanji Sugita
- Department of Paediatrics; University of Yamanashi; Yamanashi Japan
| | - Akira Kikuchi
- Department of Paediatrics; Teikyo University; Tokyo Japan
| | - Masahiro Tsuchida
- Department of Paediatrics; Ibaraki Children's Hospital; Ibaraki Japan
| | - Akira Ohara
- Department of Paediatrics; Toho University; Tokyo Japan
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23
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Ishida Y, Maeda M, Urayama KY, Kiyotani C, Aoki Y, Kato Y, Goto S, Sakaguchi S, Sugita K, Tokuyama M, Nakadate N, Ishii E, Tsuchida M, Ohara A. Secondary cancers among children with acute lymphoblastic leukaemia treated by the Tokyo Children's Cancer Study Group protocols: a retrospective cohort study. Br J Haematol 2013; 164:101-12. [DOI: 10.1111/bjh.12602] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2013] [Accepted: 09/06/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Yasushi Ishida
- Department of Paediatrics; St. Luke's International Hospital; Tokyo Japan
- Centre of Clinical Epidemiology; St. Luke's Life Science Institute; Tokyo Japan
| | - Miho Maeda
- Department of Paediatrics; Nippon Medical School; Tokyo Japan
| | - Kevin Y. Urayama
- Centre of Clinical Epidemiology; St. Luke's Life Science Institute; Tokyo Japan
- School of Public Health; University of California; Berkeley CA USA
| | - Chikako Kiyotani
- Division of Oncology; National Centre for Child Health and Development; Tokyo Japan
| | - Yuki Aoki
- Department of Paediatrics and Developmental Biology; Tokyo Medical and Dental University; Tokyo Japan
| | - Yoko Kato
- Department of Paediatrics; Jikei University School of Medicine; Tokyo Japan
| | - Shoko Goto
- Department of Paediatrics; Yokohama City University School of Medicine; Yokohama Japan
| | - Sachi Sakaguchi
- Department of Paediatrics and Adolescent Medicine; Juntendo University School of Medicine; Tokyo Japan
| | - Kenichi Sugita
- Department of Paediatrics; Dokkyo Medical University; Tochigi Japan
| | - Mika Tokuyama
- Department of Paediatrics; Yachimata Hospital; Chiba Japan
| | - Naoya Nakadate
- Department of General Paediatrics; National Centre for Child Health and Development; Tokyo Japan
| | - Eizaburo Ishii
- Department of Paediatrics; Nagano Prefectural Suzaka Hospital; Nagano Japan
| | | | - Akira Ohara
- First Department of Paediatrics; Toho University; Tokyo Japan
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24
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Cancela CSP, Murao M, Viana MB, de Oliveira BM. Incidence and risk factors for central nervous system relapse in children and adolescents with acute lymphoblastic leukemia. Rev Bras Hematol Hemoter 2012; 34:436-41. [PMID: 23323068 PMCID: PMC3545431 DOI: 10.5581/1516-8484.20120109] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2012] [Accepted: 09/03/2012] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Despite all the advances in the treatment of childhood acute lymphoblastic leukemia, central nervous system relapse remains an important obstacle to curing these patients. This study analyzed the incidence of central nervous system relapse and the risk factors for its occurrence in children and adolescents with acute lymphoblastic leukemia. METHODS This study has a retrospective cohort design. The studied population comprised 199 children and adolescents with a diagnosis of acute lymphoblastic leukemia followed up at Hospital das Clinicas, Universidade Federal de Minas Gerais (HC-UFMG) between March 2001 and August 2009 and submitted to the Grupo Brasileiro de Tratamento de Leucemia da Infância - acute lymphoblastic leukemia (GBTLI-LLA-99) treatment protocol. RESULTS The estimated probabilities of overall survival and event free survival at 5 years were 69.5% (± 3.6%) and 58.8% (± 4.0%), respectively. The cumulative incidence of central nervous system (isolated or combined) relapse was 11.0% at 8 years. The estimated rate of isolated central nervous system relapse at 8 years was 6.8%. In patients with a blood leukocyte count at diagnosis ≥ 50 x 10(9)/L, the estimated rate of isolated or combined central nervous system relapse was higher than in the group with a count < 50 x 10(9)/L (p-value = 0.0008). There was no difference in cumulative central nervous system relapse (isolated or combined) for the other analyzed variables: immunophenotype, traumatic lumbar puncture, interval between diagnosis and first lumbar puncture and place where the procedure was performed. CONCLUSIONS These results suggest that a leukocyte count > 50 x 10(9)/L at diagnosis seems to be a significant prognostic factor for a higher incidence of central nervous system relapse in childhood acute lymphoblastic leukemia.
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Affiliation(s)
| | - Mitiko Murao
- Universidade Federal de Minas Gerais - UFMG, Belo Horizonte, MG, Brazil
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