Acute promyelocytic leukaemia is highly frequent among acute myeloid leukaemias in Brazil: a hospital-based cancer registry study from 2001 to 2012

Immunophenotypic characterization of acute leukemias in Bahia, Brazil

OBJECTIVE

To characterize the immunophenotypic profile of acute leukemias in the population of the state of Bahia, Brazil.

METHODS

This is a descriptive, retrospective study. From 2014 to 2018, 796 new cases of acute leukemia were evaluated. The data were obtained from analysis of reports and records of tests performed by flow cytometry immunophenotyping. All individuals of all age groups diagnosed as acute lymphoblastic leukemia or acute myeloid leukemia were included in the study. Demographic variables and expression of leukemia antigens were evaluated.

RESULTS

Most cases were diagnosed as acute myeloid leukemia and 42.7% as acute lymphoblastic leukemia. Significant differences were found in expression of markers in acute leukemias when age groups were compared, as well as in demographic characteristics. B-cell acute lymphoblastic leukemia was more prevalent than cases of T-cell origin. Assessing the aberrant markers in acute myeloid leukemias, the non-acute promyelocytic leukemia group presented expression of CD7 and CD56 as the most frequent ones. In B-cell acute lymphoblastic leukemia, the most frequent aberrant markers were CD66c, CD13 and CD33.

CONCLUSION

Significant differences were found as to several antigens when comparing adults and children, and these findings may contribute to future studies correlating the phenotypic profile to genetic characteristics and therapeutic response, including specific antigen therapies, which may be better targeted.

Evolving of treatment paradigms and challenges in acute promyelocytic leukaemia: A real-world analysis of 1105 patients over the last three decades

Although acute promyelocytic leukaemia (APL) is a highly curable disease, challenges of early death (ED) and relapse still exist, and real-world data are scarce in the ATRA plus ATO era. A total of 1105 APL patients from 1990 to 2020 were enrolled and categorized into three treatment periods, namely ATRA, ATRA plus ATO, and risk-adapted therapy. The early death (ED) rate was 20.2%, 10.1%, and 7.0%, respectively, in three periods, while there was no significant decline in the 7-day death rate. Consistently, the overall survival (OS) and disease-free survival (DFS) of APL patients markedly improved over time. Despite the last two periods exhibiting similar DFS, the chemotherapy load was substantially lower in Period 3. Notably, leveraging older age and higher WBC count (especially > 50 × 10⁹/L), we could identify a small group of extremely high-risk patients who had a very high ED rate and poor prognosis, while those with NRAS mutations and higher WBC tended to relapse, both representing obstacles to curing all patients. In conclusion, the evolvement of treatment paradigms can reduce the ED rate, improve clinical outcomes, and spare patients the toxicity of chemotherapy. Special care and innovative agents are warranted for the particularly high-risk APL.

Early Death and Survival of Patients With Acute Promyelocytic Leukemia in ATRA Plus Arsenic Era: A Population-Based Study

Most randomized trials for acute promyelocytic leukemia (APL) have investigated highly selected patients under idealized conditions, and the findings need to be validated in the real world. We conducted a population-based study of all APL patients in Zhejiang Province, China, with a total population of 82 million people, to assess the generalization of all-trans retinoic acid (ATRA) and arsenic as front-line treatment. The outcomes of APL patients were also analyzed. Between January 2015 and December 2019, 1,233 eligible patients were included in the final analysis. The rate of ATRA and arsenic as front-line treatment increased steadily from 66.2% in 2015 to 83.3% in 2019, with no difference among the size of the center (≥5 or <5 patients per year, p = 0.12) or age (≥60 or <60 years, p = 0.35). The early death (ED) rate, defined as death within 30 days after diagnosis, was 8.2%, and the 3-year overall survival (OS) was 87.9% in the whole patient population. Age (≥60 years) and white blood cell count (>10 × 10⁹/L) were independent risk factors for ED and OS in the multivariate analysis. This population-based study showed that ATRA and arsenic as front-line treatment are widely used under real-world conditions and yield a low ED rate and a high survival rate, which mimic the results from clinical trials, thereby supporting the wider application of APL guidelines in the future.

Real-life outcomes of unselected acute promyelocytic leukemia patients: a single-center 14-year experience

BACKGROUND

After the inclusion of all-trans retinoic acid (ATRA) into the treatment of Acute Promyelocytic leukemia (APL), a notable improvement concerning the survival rates of patients with APL has been observed. However, the population-based studies demonstrated that there was no marked improvement in the survival of patients after the 2000s. We aim to describe the clinical response and prognosis of adult patients diagnosed with APL and examine the change in these outcomes by the time period of diagnosis.

METHODS

We retrospectively reviewed thirty-six unselected APL patients who were diagnosed between September 2003 and February 2016.

RESULTS

The probability of survival at two years was 58%, while disease-free survival (DFS) was 87%. The overall early death (ED) rate was 33% and remain stable over time [42% in 2003-2009 vs. 24% in 2010-2016 (p=.20)]. In addition, the 2-year overall survival (OS) rates were 47% in 2003-2009 and 70% in 2010-2016 (p=.29), and no differences were noted. Univariate analyses showed possible predictors of poor OS were defined as leukocytosis (≥10x109/L), high Sanz score, hemorrhage, infection, disseminated intravascular coagulopathy (DIC) at presentation and microgranular morphologic subtype.

CONCLUSIONS

This study shows that long-term survival remains low in APL patients, particularly related to a high ED rate. Initiatives to reduce ED are exceedingly substantial for improving the survival in APL.

Global health disparities in childhood cancers

PURPOSE OF REVIEW

The high cure rates of children with cancer in high-income countries (HICs) are due to the impact of biomedical innovations on children with highly fatal diseases. We discuss why these innovations have not benefitted most children with cancer globally and propose broad strategies to reduce these disparities.

RECENT FINDINGS

Over 85% of children with cancer in HIC are cured while less than 20% in many low-income countries survive the disease. Hence, childhood cancer survival is poor globally since over 80% of children with cancer live in low-income and middle-income countries (LMICs). Inadequate skilled workforce and health infrastructure across all disciplines of pediatrics in LMIC are the main reasons for these disparities. Although biological differences may contribute to these disparities as well, many are unconfirmed because they are confounded by differences in referral patterns and clinical capacity. HIC partnerships with LMIC that focus on locally based pediatrics training and clinical infrastructure building are beginning to close the gap.

SUMMARY

Pediatric oncology is symbolic of the significant disparities in childhood survival arising from poverty, inadequate pediatric infrastructure, and skilled workforce in LMIC. Partnerships with HIC that build multidisciplinary pediatrics capacity and clinical infrastructure are beginning to make transformative improvements.

Epidemiology, management, and economic impact of acute myeloid leukemia and myelodysplastic syndrome in Spain at the hospital level: a claims database analysis

OBJECTIVES

This study reviewed patient characteristics, management, and medical costs of acute myeloid leukemia (AML) and myelodysplastic syndromes (MDSs) in Spanish hospitals.

METHODS

Data were extracted from the Spanish Ministry of Health records via a claims database containing patient records from 192 private and 313 public hospitals between 1997 and 2015 for AML, and 2008 and 2015 for MDS. Direct medical costs at the hospital level were calculated based on mean medical procedure costs determined per the Spanish Ministry of Health.

RESULTS

Records for 39,568 patients with AML and 33,091 with MDS were analyzed. The median age of AML patients was 65 years (interquartile range (IQR) = 27) and of MDS patients was 81 years (IQR = 12). In terms of disease management, 58% and 83% of admissions were due to emergencies for patients with AML and MDS, respectively; median length of hospital stay was 14 days (IQR = 25) for AML and seven days (IQR = 9) for MDS. There was an increase in allogeneic hematopoietic stem cell transplantations over time for patients with AML or MDS. Mean annual direct medical costs of AML and MDS, respectively, were €66,422,245 and €42,635,313 for total costs, and €30,775 and €10,312 per patient. Of the total costs, transplantations contributed total annual costs of €15,843,982 and €2,705,791 for patients with AML and MDS, respectively.

CONCLUSIONS

This study provides novel data to assist decision makers in allocating resources. AML and MDS represent a significant burden for the National Spanish Healthcare System, with substantial costs incurred in secondary care, principally associated with the increasing number of transplantations.

Early Mortality in Children and Adolescents with Acute Promyelocytic Leukemia: Experience of the Boldrini Children's Center

INTRODUCTION

Acute promyelocytic leukemia (APL) is currently considered a highly curable disease. However, an early death (ED) remains one of the main causes of APL treatment failure.

PATIENTS AND METHODS

In this retrospective study, we aimed to analyze the clinical characteristics of 91 children and adolescents with APL, who were consecutively registered at the (name of institution removed) Children's Center from January 1, 1998 to December 31, 2017. Data were assessed for age, sex, ethnicity, body mass index percentile, initial white blood cell count, peripheral blood blast count, and platelet count, hemoglobin value, partial thromboplastin time, prothrombin time, fibrinogen level, serum creatinine level, APL morphology subtype (classic vs. hypogranular variant M3v), and FLT3 gene mutations.

RESULTS

ED occurred in 12 of 91 (13.1%) patients and was mainly related to cerebral thromboembolism. Overall 66% of deaths occurred in the second week after diagnosis. ED was associated with white blood cell ≥10×10 cells/L (odds ratio of 8.44; 95% confidence interval [CI]=1.48-48.26; P=0.0016), initial promyelocytes ≥20×10/L (odds ratio of 9.29; 95% CI=2.45-35.8; P=0.001), morphologic subtype M3v (odds ratio of 3.63; 95% CI=1.04-12.64; P=0.043), and creatinine serum levels >0.7 mg/dL (odds ratio of 6.78; 95% CI=1.83-25.13; P=0.004). In multivariate analyses, ED was associated with initial peripheral promyelocytes ≥20×10 blasts/L and creatinine serum levels >0.7 mg/dL.

CONCLUSIONS

EDs were mainly caused by thrombohemorrhagic events and occurred within the second week after diagnosis. High peripheral promyelocytes and creatinine levels were predictors of ED in APL.

Incidence and mortality of myeloid malignancies in children, adolescents and Young adults in Brazil: A population-based study

BACKGROUND

Myeloid malignancies (MM) are heterogeneous when it comes to incidence rates and pathogenesis. These variation rates are important to generate hypotheses on causal aetiology. This study aimed to describe incidence and mortality patterns of MM among children, adolescents and young adults (cAYA) in Brazil and to evaluate trends in incidence and mortality rate overtime.

METHODS

Data were extracted from a dataset of 15 Population-based Cancer Registries located in five Brazilian geographical regions and calculated by age-specific, crude, and age-standardized incidence (ASR) and mortality rates per million persons. Joinpoint regression analyses were performed for trends evaluations, regionally. Annual Percent Change (APC) and Average Annual Percent Change (AAPC) were also estimated.

RESULTS

The overall ASR for incidence and mortality of MM in Brazil was 14.57 and 8.83 per million, respectively. The AML (non-APL AML and APL) incidence rate is 8.18 per million, whereas other MM subtypes altogether have an incidence rate of 2.62 per million, and not otherwise specified (NOS) is 3.70 per million. The analysis of incidence trends (AAPC) showed a significant decline in Manaus (-5.6%) and São Paulo (-4.7%), and a significant increase was observed in Fortaleza (5.8%). Mortality trends steadily declined in all registries, with significant declines occurring in Goiânia (-1.5%), Belo Horizonte (-2.3%), São Paulo (-2.5%), Curitiba (-2.8%) and Porto Alegre (-4.1%).

CONCLUSION

Our findings showed differences in the incidence and mortality rates of MM in cAYA in Brazil, geographically. Infants-AML have the highest incidence within the cAYA population (17.42 per million). There was a substantial decrease in mortality rate observed, which was interpreted as an improvement in MM recognition and therapeutic approach.

Ortho-Topolin Riboside Induced Differentiation through Inhibition of STAT3 Signaling in Acute Myeloid Leukemia HL-60 Cells

Objective:

We previously demonstrated that ortho-topolin riboside (oTR) as a naturally occurring cytokinin secreted from Populus × robusta has great potential anticancer effects via the mitochondrial apoptotic pathway and endoplasmic reticulum stress pathway. In the present study, we reveal that oTR induced the differentiation of acute myeloid leukemia (AML) HL-60 cells, which represent the M2 subtype of AML.

Materials and Methods:

After the incubation of HL-60 cells with oTR, its effect was analyzed with cell viability assay, Wright-Giemsa staining, CD11b protein expression analysis, western blot analysis, and polymerase chain reaction.

Results:

We found that oTR arrested the cell cycle at the S phase, upregulated the expression of myeloid surface marker CD11b, reduced the nuclear cytoplasmic ratio, and altered the horseshoe shape of nuclei, as evidenced by Wright-Giemsa staining. Furthermore, we found that the protein level of phosphorylated STAT3 was decreased when cells were treated with oTR, while phosphorylated STAT1 was activated. Moreover, the protein level of phosphorylated STAT3 and its upstream kinase, Janus kinase 2, were also inhibited when cells were treated with oTR after increased time. Additionally, the levels of phosphorylated SHP-1 were increased while phosphorylated SHP-2 was decreased.

Conclusion:

Collectively, our data indicate a differentiation-induced mechanism underlying the inhibition of STAT3 signaling upon treatment with oTR. Therefore, oTR may constitute a novel differentiation-induced therapeutic for use in clinical treatment of AML.

Survival and risk factors for mortality in pediatric patients with acute myeloid leukemia in a single reference center in low-middle-income country

Despite advances in therapy and care for children with acute myeloid leukemia (AML), survival rates for children in low- and middle-income countries (LMICs) remain poor. We studied risk factors for mortality and survival in children with AML in a LMIC to develop strategies to improve survival for AML children in these countries. This retrospective cohort (2000-2014) analyzed newly diagnosed AML patients (age < 19 years) at a reference center in Brazil. Demographic and clinical variables were reviewed by AML subtype: acute promyelocytic leukemia (APL), AML with Down syndrome (AML-DS), and other AML subtypes. Cumulative hazard risk for early death (ED) until 6 weeks of treatment and risk factors for mortality were determined by the multivariate Cox hazard models. Survival was assessed for each AML subtypes. A total of 220 patients were diagnosed: APL 50 (22.7%), AML-DS 16 (7.3%), and other AML subtypes 154 (70.0%). The cumulative hazard function values for ED for all patients with AML were 12.5% (95% CI 8.5-18.4%); for each AML patients subtypes: APL, 21.7% (95% CI 11.7-40.5%); AML-DS, 6.2% (95% CI 0.9-44.4%); and other AML subtypes, 10.2% (95% CI 6.2-17.0%). White blood cell count (cutoff 10 × 10⁹/L for APL and 100 × 10⁹/L for other AML subtypes) and Afro-descendance were significant risk factors for mortality in APL and other AML subtypes, respectively. Overall survival for patients with APL, AML-DS, and other AML subtypes was 66.8%, 62.5%, and 38.0%, respectively. APL patients had the highest incidence of ED and those with other subtypes had increased relapse risk. We also observed high rates of death in complete remission mainly due to infection. Better risk classification and identification of risk factors for infection may improve the survival of these patients.

Incidence, Survival, and Risk Factors for Adults with Acute Myeloid Leukemia Not Otherwise Specified and Acute Myeloid Leukemia with Recurrent Genetic Abnormalities: Analysis of the Surveillance, Epidemiology, and End Results (SEER) Database, 2001-2013

BACKGROUND/AIM

As the knowledgebase of acute myeloid leukemia (AML) has grown, classification systems have moved to incorporate these new findings.

METHODS

We assessed 32,941 patients with AML whose records are contained in the Surveillance, Epidemiology, and End Results (SEER) database.

RESULTS

Half of all patients diagnosed between 2001 and 2013 did not have a World Health Organization (WHO) classification. Acute promyelocytic leukemia and acute panmyelosis with myelofibrosis were associated with the longest leukemia-specific survival (110 and 115 months, respectively), and AML with minimal differentiation and acute megakaryoblastic leukemia with the shortest (30 and 28 months, respectively). For patients in the WHO groups AML not otherwise specified (AML-NOS) and AML with recurrent genetic abnormalities (AML-RGA), the risk of death was greater for older patients and less for married patients. Black patients with any type of AML-NOS also had a higher risk of death. Patients whose case of AML did not receive a WHO classification were older and this group had a higher risk of death when compared to patients with a WHO type of AML-NOS.

CONCLUSION

Our findings highlight the divergent outcomes of patients with AML and the importance of using the WHO classification system and demographic factors to gauge their prognosis.

Characteristics of De Novo Acute Myeloid Leukemia Patients in Palestine: Experience of An-Najah National University Hospital

Objective:

To describe the characteristics of de novo acute myeloid leukemia (AML) in the Palestinian population.

Study design and setting:

A retrospective chart review study was conducted at An-Najah National University Hospital (NNUH) during the period of January, 2014 to December, 2016.

Methodology:

The medical records of AML patients treated at NNUH were reviewed. All patients at least 16 years of age diagnosed with de novo AML and started on induction chemotherapy were included. Descriptive statistics were employed to analyze the data.

Results:

Out of 88 patients diagnosed with AML during the study period, 64 had de novo AML and were included. Median age at diagnosis was 36 years, with a male to female ratio of 1.13:1. Two thirds of the cases were from the West Bank and the remainder were from Gaza. Major complaints at presentation were fatigue (64.1%), fever (46.9%), respiratory tract infections (39.1%) and bruising (28.1%). Hepatomegaly was present in 23.4% and splenomegaly in 34.4%. At presentation, the median white blood cells (WBC) count, hemoglobin (Hb) concentration and platelet count were 30. 5x10⁹/L, 9.3g/dL, and 39.5 x10⁹/L, respectively. According to the French American British (FAB) classification, M4 was the most common subtype (32.8%) followed by M3 (21.9%). After a single cycle of induction chemotherapy complete remission (CR) was seen in 26 (41.9%) and non-remission (NR) in 17 (27.4%), while 19 patients (30.6%) died during the first admission for induction.

Conclusion:

The characteristics of de novo AML in Palestinian patients are comparable to published data elsewhere. M4 was the most common subtype. The outcome of the first cycle of induction chemotherapy was slightly inferior to the published data for M3 patients. Further studies are warranted to identify possible causes.

Effect of YAP Inhibition on Human Leukemia HL-60 Cells

Background: Yes-associated protein (YAP), the nuclear effector of the Hippo pathway, is a candidate oncoprotein and participates in the progression of various malignancies. However, few reports have examined the effect of YAP inhibition in human leukemia HL-60 cells. Methods: We examined the effects of YAP knockdown or inhibition using short hairpin RNA (shRNA) or verteporfin (VP), respectively. Western blot assays were used to determine the expression levels of YAP, Survivin, cyclinD1, PARP, Bcl-2, and Bax. Cell proliferation was assessed using the cell counting kit (CCK-8) assay. Cell cycle progression and apoptosis were evaluated by flow cytometry, and apoptotic cell morphology was observed by Hoechst 33342 staining. Results: Knockdown or inhibition of YAP led to cell cycle arrest at the G0/G1 phase and increased apoptosis, inhibited cell proliferation, increased levels of Bax and cleaved PARP, and decreased levels of PARP, Bcl-2, Survivin, and cyclinD1. Moreover, Hoechst 33342 staining revealed increased cell nuclear fragmentation. Conclusion: Collectively, these results show that inhibition of YAP inhibits proliferation and induces apoptosis in HL-60 cells. Therefore, a novel treatment regime involving genetic or pharmacological inhibition of YAP could be established for acute promyelocytic leukemia.