Effect of pre-treatment nutritional status, folate and vitamin B12 levels on induction chemotherapy in children with acute lymphoblastic leukemia

Targeting the sulfur-containing amino acid pathway in leukemia

sulfur-containing amino acids have been reported to patriciate in gene regulation, DNA methylation, protein synthesis and other physiological or pathological processes. In recent years, metabolism-related molecules of sulfur-containing amino acids affecting the occurrence, development and treatment of tumors have been implicated in various disorders, especially in leukemia. Here, we summarize current knowledge on the sulfur-containing amino acid metabolism pathway in leukemia and examine ongoing efforts to target this pathway, including treatment strategies targeting (a) sulfur-containing amino acids, (b) metabolites of sulfur-containing amino acids, and (c) enzymes and cofactors related to sulfur-containing amino acid metabolism in leukemia. Future leukemia therapy will likely involve innovative strategies targeting the sulfur-containing amino acid metabolism pathway.

Nutritional Status of Pediatric Patients With Acute Lymphoblastic Leukemia Under Chemotherapy: A Pilot Longitudinal Study

BACKGROUND

The study investigates the nutritional status in children with acute lymphoblastic leukemia (ALL) during chemotherapy treatment because nourishment is substantial, as much as chemotherapy in children with malignant diseases.

MATERIAL AND METHOD

We enrolled 17 children with ALL (between 1 to 16 year-old, mean age 6.03 ± 4.04 y) from 5 different centers in Istanbul between September 2013 and May 2014. Anthropometric data, prealbumin, B12, and folate levels were assessed, at diagnosis, after the induction phase of chemotherapy, and before maintenance phases of chemotherapy in a longitudinal and prospective study.

RESULTS

Patients remarkably lost weight at the end of the induction phase ( P =0.064) and regained this loss before maintenance chemotherapy ( P =0.001). At the end of induction chemotherapy serum prealbumin level ( P =0.002), weight for height ratios ( P =0.016), weight for age ratios ( P =0.019) significantly decreased. From the end of the induction phase to the beginning of maintenance chemotherapy, weight ( P =0.001) and weight for age ( P =0.017) significantly, and weight for height were remarkably elevated ( P =0.076). At the end of the induction phase, serum prealbumin levels were significantly lower ( P =0.048) and below laboratory reference values ( P =0.009) in children younger than 60 months compared with those older. Serum folate levels increased from the end of the induction phase to the beginning of the maintenance phase ( P =0.025). Serum vitamin B12 levels did not alter significantly.

CONCLUSION

There is malnutrition risk at the end of the induction phase of the ALL-BFM chemotherapy regimen; therefore, clinicians should follow up on nutrition closely, especially in under 5-year-old patients. However, before the beginning of the maintenance phase, children start to gain weight, and obesity risk occurs. Thus , further studies are needed to evaluate nutritional status during childhood ALL chemotherapy.

Folate, folic acid, and chemotherapy-induced toxicities: a systematic literature review

Folate metabolism is a target for various chemotherapeutic drugs. Folate and its synthetic variant folic acid are B-vitamins. To what extent these vitamins impact treatment tolerance in patients with cancer remains unclear. A systematic literature review was conducted on intake and status of folate and folic acid in relation to chemotherapy-induced toxicities in children and adults with cancer. A total of 6,231 publications were identified, of which 40 publications met the inclusion criteria. In 12 out of 22 studies focusing on antifolates, a deficient folate status and lower folate and folic acid intake were associated with a higher risk of toxicities. In 8 out of 14 studies focusing on fluoropyrimidine treatments, a higher folate status and intake were associated with a higher risk of toxicities. These findings might explain interindividual differences in treatment tolerance and highlight the importance of evaluating nutritional status in oncology care.

Changes in Nutritional Status during Induction Phase and Their Association with Fever and Minimal Residual Disease in Paediatric Acute Lymphoblastic Leukaemia

Background and objectives: Acute lymphoblastic leukaemia (ALL) is associated with a cytokine imbalance and oxidative stress, which can be aggravated by malnutrition. Malnutrition, defined by the World Health Organisation (WHO) as obesity or undernutrition, can affect treatment complications and outcomes. Therefore, we aimed to analyse the change in the body mass index (BMI) z-score during induction, as well as evaluate the impact of childhood malnutrition on fevers at an ALL presentation and early response to therapy. Methods: An observational cohort study of 50 consecutive children with ALL, diagnosed in 2019-2022, was performed. Patients were divided into age groups of 0-5, 6-11, and 12-17 years. BMI-for-age z-scores were used to define undernutrition and overnutrition according to WHO growth standards. Results: The number of patients with an abnormal BMI increased from 3 (6%) at diagnosis to 10 (20%) at the end of induction (from 2 (4%) to 6 (12%) in overweight/obese, and from 1 (2%) to 4 (8%) in underweight patients). At the end of induction, all overweight/obese patients were 0-5 years old. On the other hand, a statistically significant decrease in the mean BMI z-score among patients aged 12-17 was observed (p = 0.005). The mean BMI z-score differed statistically significantly among children aged 0-5 presenting with and without fever (p = 0.001). The minimal residual disease (MRD) level at the end of induction was not related to BMI at diagnosis. Conclusions: Despite the use of steroids, adolescents are prone to losing weight during an ALL induction, in contrast to preschool children, who tend to gain weight under the same treatment. BMI at diagnosis was related to a fever of ≥38 °C (at ALL presentation) in the 0-5 age group. The results emphasise the importance of careful nutritional status monitoring, with younger and older children as important target groups for weight gain and weight loss interventions, respectively.

Prognostic impact of the controlling nutritional status score in patients with hematologic malignancies: A systematic review and meta-analysis

Background

An increasing number of studies have validated the prognostic significance of the controlling nutritional status (CONUT) score in patients with solid tumors. However, the extent of the correlation between the CONUT score and clinical outcomes of patients with hematologic malignancies is unclear.

Objective

This study aimed to investigate the prognostic role of the CONUT score in patients with hematologic malignancies.

Methods

All relevant articles published up to November 15, 2021, were identified by systematically searching PubMed, Embase, Web of Science, and Cochrane Library. Pooled hazard ratios (HRs) and 95% confidence intervals were used to quantitatively analyze the association between the CONUT scores and clinical outcomes of patients with hematologic malignancies. Subgroup and sensitivity analyses were performed. Funnel plots as well as Begg’s and Egger’s tests were used to assess publication bias.

Results

Six studies with 1811 patients were included in the meta-analysis. The results showed that a high CONUT score was associated with worse overall survival (OS) (HR=1.34, 95%CI 1.14-1.59, P < 0.001) and progression-free survival (PFS) (HR=1.20, 95%CI 1.10-1.32, P < 0.001).

Conclusions

The CONUT score is an independent prognostic factor in patients with hematologic malignancies.

Systematic review registration

http://www.crd.york.ac.uk/prospero/, identifier CRD42021292621.

Hypoalbuminemia and not undernutrition predicts high-dose methotrexate-induced nephrotoxicity in children with acute lymphoblastic leukemia in resource-constrained centers

BACKGROUND

The standard practice to mitigate high-dose methotrexate (HD-MTX)-induced nephrotoxicity (HMN) in acute lymphoblastic leukemia (ALL) is to monitor levels until serum MTX falls below a predefined threshold. It is not feasible in most resource-constrained centers. Literature on the various factors affecting HMN in these centers is limited, retrospective, and heterogeneous. Though hypoalbuminemia has been postulated as a risk factor for HMN, the relationship of undernutrition with HMN has not been studied.

PROCEDURE

This prospective observational study consecutively enrolled children < 12 years old with ALL receiving HD-MTX. Children with preexisting renal disease and exposed to nephrotoxic drugs two weeks preceding HD-MTX infusion were excluded. HD-MTX was administered over 24 hours (BFM-2009 protocol) with 12 hours of prehydration. Solitary MTX levels at 36 hours (MTX36) were outsourced, and 6-8 doses of leucovorin were given six-hourly. Hydration was continued till last dose of leucovorin. Various factors affecting HMN (rise in creatinine to 1.5 times baseline) were recorded: age, sex, type of ALL, risk group of ALL, first dose of MTX, dose of MTX, undernourishment, serum protein, and albumin along with C-reactive protein and MTX36 levels.

RESULTS

Forty-four children who received 150 HD-MTX cycles were analyzed. HMN was seen in 14% of cycles. On univariate analysis, undernourishment, MTX36 levels, hypoproteinemia, and hypoalbuminemia were significantly associated with HMN. On multivariate analysis, hypoalbuminemia and MTX36 levels significantly predicted the development of HMN with odds ratios of 4.71 and 1.45.

CONCLUSION

Hypoalbuminemia and solitary serum MTX levels predict HMN in centers where serial MTX level monitoring is not feasible.

Pediatric Acute Myeloid Leukemia in India: A Systematic Review

Background Lower-middle-income countries face unique problems in the management of pediatric acute myeloid leukemia (AML) due to which the outcomes have not kept pace with developed nations. In India, data on childhood AML is sparsely available, thus making a true assessment of disease trends difficult. The current systematic review was undertaken to assess the outcomes of childhood AML from published literature from India over a period of 10 years (2011–2021).

Materials and Methods A systematic search of MEDLINE, Google Scholar, and SCOPUS was performed as per preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement from January 1, 2011 to December 31, 2021. In addition, International Society of Pediatric Oncology (SIOP) conference abstracts were also screened for relevant studies on AML from India. This study was registered in PROSPERO (ID42021273218).

Results A total of 1,210 patients from 19 studies were included. Standard 3 + 7 and MRC AML based regimens were commonly adopted regimens for induction. Remission rates varied between 56 and 95%. Overall treatment-related mortality across studies was 23.2% (95% confidence interval [CI]: 10.3–35.9%). The mean incidence of treatment abandonment was 19.3% ( 95% CI: 10.9–27.5%). Event-free survival and overall survival were in the range of 28 to 55% and 15 to 66%, respectively. Hematopoietic stem cell transplantation was performed only on a small subset of patients.

Conclusion  Outcomes of pediatric AML in India continue to be suboptimal with high treatment abandonment and toxic deaths. Ensuring uniform access to therapy and supportive care along with a robust social support system would improve outcomes of childhood AML in India.

Is hypoalbuminemia a risk factor for high-dose methotrexate toxicity in children with acute lymphoblastic leukemia?

Background

Repeated high-dose methotrexate (HDMTX) is a critical component of contemporary childhood acute lymphoblastic leukemia (ALL) treatment regimens. Serum albumin is considered a carrier of methotrexate (MTX) in the blood. Hypoalbuminemia is not a rare finding in children with leukemia. This study aimed to investigate the relationship between pre-infusion serum albumin and possible HDMTX toxicities.

Methods

Thirty Egyptian children with ALL were consecutively enrolled in the study between May 2018 and July 2020. They were prospectively followed up while receiving HDMTX during the consolidation phase of the TOTAL study XV protocol. HDMTX was administered intravenously as a 24-h infusion every 2 weeks. Doses of 2.5 g/m2 were used for low-risk patients and 5 g/m2 for standard/high-risk patients. The Common Terminology Criteria for Adverse Events (V.4.03) was used to report the observed toxicities after HDMTX cycles. Plasma MTX levels were estimated at 24 h (MTX24) from the beginning of HDMTX infusion in the first consolidation cycle. Serum albumin level was determined before HDMTX administration, and pre-infusion hypoalbuminemia was defined when serum albumin was <3.5 g/dL.

Results

The patients’ age ranged from 2.3 to 13.3 years at diagnosis, and most of them had B cell ALL (86.7%). Overall, 120 HDMTX cycles were analyzed, equally distributed between low and standard/high risk. Grade 3–4 anemia, grades 3–4 thrombocytopenia, febrile neutropenia, and oral mucositis were significantly more frequent in HDMTX cycles with pre-infusion hypoalbuminemia than those with normal pre-infusion albumin (p=0.003, p=0.007, p=0.006, and p=0.001, respectively). In addition, pre-infusion hypoalbuminemia was significantly associated with additional hospitalization due to HDMTX toxicity (p=0.031). Most HDMTX toxicities were comparable irrespective of the MTX dose. Oral mucositis was more frequently encountered in the 2.5 g/m2 than the 5 g/m2 HDMTX cycles (46.7 vs. 26.7%, p=0.023). A significantly longer hospitalization (due to HDMTX toxicity) was observed in the 5 g/m2 HDMTX cycles (median= 7 days vs. 4 days, p=0.012).

Conclusions

Serum albumin levels should be checked before starting HDMTX cycles, especially in resource-limited settings where malnutrition is common, and serum MTX monitoring may not be available. Optimizing serum albumin levels before HDMTX may help decrease the possibility of HDMTX toxicities.

Nutritional status alterations after chimeric antigen receptor T cell therapy in patients with hematological malignancies: a retrospective study

PURPOSE

The influence of innovative chimeric antigen receptor T cell (CAR-T) therapy for hematological malignancies on nutritional status remains unknown. Therefore, we aim to explore the alterations of nutritional status after CAR-T cell therapy in patients with hematological malignancies.

METHODS

We retrospectively collected the data of patients with acute leukemia (AL), lymphoma, and multiple myeloma (MM), who underwent CAR-T therapy at our hospital from 2018 to 2020. The serum albumin, triglyceride, and cholesterol before and 7, 14, and 21 days after CAR-T cell infusion were compared and analyzed.

RESULT

A total of 117 patients were enrolled, consisting of 39 AL, 23 lymphoma, and 55 MM patients. The baseline albumin, triglyceride, and cholesterol were 37.43 ± 5.08 mg/L, 1.63 ± 0.74 mmol/L, and 3.62 ± 1.03 mmol/L, respectively. The lowest albumin level was found at 7 days after CAR-T cell infusion compared with baseline (P < 0.001), while the levels of triglyceride increased at 14 and 21 days (P < 0.001, P = 0.036). The levels of cholesterol at 7, 14, and 21 days after CAR-T cell infusion were lower than baseline (all P < 0.05). Spearman's correlation coefficient showed cytokine release syndrome grade was negatively correlated with the levels of albumin at 7 days and cholesterol at 21 days after CAR-T cell infusion (r =  - 0.353, P < 0.001; r =  - 0.395, P = 0.002).

CONCLUSION

The alterations of different nutrition-related biochemical parameters varied after CAR-T cell therapy. The levels of albumin and total cholesterol after CAR-T cell infusion were negatively correlated with the grade of cytokine release syndrome. Specific screening and intervention for malnutrition in patients receiving CAR-T cell therapy need to be explored in further studies.

Assessment of Baseline Nutritional Status, Vitamin B12, and Folate Levels in Patients with Acute Leukemia and Their Effect on Initial Treatment Outcome: A Prospective Observational Study

Introduction Poor nutrition is a common finding in patients with acute leukemia, affecting disease progression, treatment outcome, and survival. Overall nutritional status and micronutrients status evaluation may be an important step in management of acute leukemia.

Objective The objective of this study was to investigate baseline nutritional status, vitamin B12, and folate levels in patients with acute leukemia at the time of admission before starting chemotherapy and their initial treatment outcome.

Materials and Methods This was a prospective observational study. We assessed the pretreatment nutritional status of 73 patients by body mass index (BMI), serum vitamin B12 using a two-step chemiluminescent microparticle immunoassay, and serum folate using electrochemiluminescence by Cobas e411 analyzer before initiation of induction chemotherapy and evaluated for treatment response at the end of induction chemotherapy.

Results Out of a total of 73 patients, 51 (69.8%) completed induction chemotherapy, 36 (49.3%) showed complete remission, and 15 (20.5%) were in incomplete remission. Of the remaining 22 (30.1%) patients, 11 (15.1%) died due to toxicity during therapy. The mean values of baseline BMI, serum vitamin B12, and folate was 20.46 kg/m2, 956.04, and 13.52 ng/mL, respectively. There was no significant association between vitamin B12 (p-value = 0.609) and folate (p-value = 0.404) deficiency and the response to treatment.

Conclusion Baseline nutritional status, serum vitamin B12, and folate levels have no significant role in induction outcome in response to treatment, including mortality in patients with acute leukemia.

Malnutrition in paediatric patients with leukaemia and lymphoma: a retrospective cohort study

Introduction

Paediatric cancer is a potentially curable disease and its prognosis has been linked to several factors, such as nutritional status. The impact of malnutrition on these patients, either by overnutrition or undernutrition, varies and its relationship with outcomes is inconsistent. This study was conducted in order to determine the frequency of malnutrition in children with haematolymphoid malignancies at the time of diagnosis, as well as during treatment and to also investigate its relationship with the development of infections and death.

Materials and Methods

A retrospective cohort study of 191 children with a recent diagnosis of a haematolymphoid malignancy. The risks and nutritional classification were determined using anthropometry, follow-ups were conducted for up to 24 months and the presentation and frequency of infections and/or death were also recorded. Bivariate and multivariate analyses were conducted using binomial logistic regressions, for death and infection outcomes during follow-up. Survival analysis was conducted for various factors and types of cancer.

Results

83.7% of children had a sufficient nutritional classification at diagnosis, 6.8% had malnutrition by undernutrition and 9.4% by overnutrition. 83.8% had at least one infectious complication during follow-up and 47.1% had ≥ 3. This percentage increased to 69.2% when configuring it in the malnutrition by undernutrition group. 18.3% of patients died. When configuring the mortality, the percentage was greater in patients with Acute Myeloid Leukaemia (AML) (57.1%) and malnutrition by undernutrition (30.7%). The multivariate analysis for the outcome of death, only showed a statistically significant variable (AML odds ratio = 26.52; confidence interval = 1.09–643.24; p = 0.04).

Conclusion

No statistically significant relationship was found between the nutritional status of children with haematolymphoid neoplasms, and outcomes such as infections or death. The differences in the results obtained in these investigations may be related to the varied nutritional status definitions and the ways of measuring them, thus limiting comparisons between them.

Administration and Toxicity Profile of the Capizzi Interim Maintenance—Retrospective Study from a Tertiary Care Cancer Centre

Introduction The Capizzi-style methotrexate (MTX) is an integral part of acute lymphoblastic leukemia (ALL) treatment. The escalating dose of MTX originally used in the United Kingdom and Children’s Oncology Group protocols along with L-asparaginase has been modified in the Indian Childhood Collaborative Leukemia (ICiCLe) group protocol where L-asparaginase has been omitted. The data regarding the incidence of toxicities and ease of administration on the Capizzi-style interim maintenance is not robust.

Objectives We have compiled our experience with administration and toxicity profile in children with intermediate-risk ALL.

Materials and Methods A retrospective data collection of all children diagnosed with intermediate-risk ALL as per the ICiCLe risk stratification in the year 2019 was included in the analysis. Each cycle of MTX was started after ensuring an absolute neutrophil count of >750/mm3 and transaminases <2 upper limit of normal. As a unit protocol, pre- and post-MTX hydration was administered in all our children. No urine pH or midcycle biochemical parameter monitoring was done. Statistical analysis was done using Microsoft Excel and SPSS version 24 IBM Corp. in Armonk, New York, United States.

Results Forty-six children were included in the study. The median age of children in our study was 6 years (range: 1 year 2 months–12 years). Undernutrition was associated with a significant increase in toxicity (p = 0.02). Fifty-two percent of children had evidence of toxicity, elevated transaminases being the most common. There were recurring symptoms resulting in 53 episodes of toxicities overall. Incidence of toxicity was more in the early cycles (<3).

Conclusion The pre- and post-MTX hydration is an effective way to reduce toxicities with the Capizzi-style MTX and this course can be administered with ease on outpatient basis with minimal need for monitoring or admission.

Validity and Reliability of a Nutritional Screening Tool (SCAN) in Children Newly Diagnosed with Cancer

No standardized approach towards nutritional screening and assessment of pediatric oncology patients has been established. The nutrition screening tool for childhood cancer (SCAN) has been previously published as an effective screening method. This is an observational cross-sectional study to assess the validity and reliability of the SCAN tool, compare it to the detection of undernutrition using standard measures of assessment, and determine the overall prevalence of malnutrition and micronutrients alterations in our cohort. We included children newly diagnosed with cancer in a pediatric tertiary hospital in Madrid, Spain from August 2018 to May 2019. The following measurements were performed: SCAN questionnaire, anthropometric measurements, nutritional markers in blood, and micronutrient levels. A total of 49 patients were included. 22 patients (45%) were at risk of malnutrition according to the SCAN questionnaire. Four patients (8%) could be diagnosed with moderate undernutrition. These undernourished patients were distributed homogeneously among at-risk and not at-risk populations identified by the SCAN tool. Several micronutrient deficiencies were identified. We conclude that the SCAN questionnaire is an easy-to-use tool for everyday clinical practice. By not including anthropometric measurements it misses patients considered to be malnourished. Future data might help clarify if it is an effective tool in predicting a higher nutritional risk during the entire treatment course.

Outcome of Core Binding Factor Acute Myeloid Leukemia in Children: A Single-Center Experience

Childhood acute myeloid leukemia (AML) harboring core binding factor (CBF)-associated translocations are considered as a favorable cytogenetic subgroup. The 2 major subtypes of CBF-AML include t(8;21) and inversion of chromosome 16, accounting for ∼25% of patients. Because of expensive and toxic treatment, which may require hospitalization during the entire course of induction chemotherapy, most of the centers in Pakistan neither workup for this low-risk entity nor offer curative treatment. Therefore, we adopted an approach of screening AML cases for the presence of CBF with the rationale of offering curative treatment to this subgroup. Data of 244 cases were reviewed, and translocations were found in 72 (34%) patients among them, 59 (82%) had t(8;21) and 13 (18%) showed inversion of chromosome 16. The event-free survival with and without abandonment was 36% and 40%, respectively. Among 44 patients who completed treatment, 26 (59%) are leukemia-free, while 18 (41%) relapsed. None of the relapsed patients received salvage chemotherapy or hematopoietic stem cell transplant. Treatment-related mortality and abandonment was found in 24% and 10% of patients, respectively. The frequency of CBF-AML is higher in our study; however, poor outcome demands holistic measures in supportive care to improve the survival.

Adverse effects with intravenous methotrexate in children with acute lymphoblastic leukemia/lymphoma: a retrospective study

Methotrexate (MTX) forms the backbone of maintenance cycles in childhood acute lymphoblastic leukemia (ALL) chemotherapy, including interim maintenance. There is sufficient published data describing toxicities of high dose MTX (HD-MTX), but toxicities with escalating doses of MTX (Capizzi regimen) is not well documented. Capizzi regimen is thought to be relatively safe; we contend that even low escalating doses of MTX have significant toxicities. Our study intends to characterise such events with Capizzi MTX in comparison to that seen with HD-MTX. The retrospective study was conducted at a tertiary care centre of North India. We looked for the presence of six main toxicities: febrile neutropenia, thrombocytopenia, mucositis, hepatic toxicity, renal toxicity and skin toxicity from the clinical records of children with newly diagnosed acute lymphoblastic leukemia and lymphoma (intermediate and high risk disease), treated at our centre from November 2013 to July 2018. Intermediate risk ALL (IR-ALL) received Capizzi MTX, whereas high risk ALL (HR-ALL/T-NHL), received HD-MTX. Both these regimens do not use L-asparaginase. A total of 237 cycles of Capizzi escalating MTX and 151 cycles of HD-MTX (B cell: 3 gm/m² and T cell ALL/T-NHL: 5 gm/m²) during interim maintenance were studied in 93 children. Fifty-four (54) children were of IR (all B cell ALL) and 39 of HR-ALL (21 B-ALL, 18 T-ALL/T-NHL). The combined incidence of toxicities, were similar between the two groups: 68/237 cycles (28.7%) of Capizzi MTX and 45/151 cycles (29.8%) of HD-MTX (P = 0.815). However, mucositis was more commonly witnessed in the later group at 22/151 cycle (14.6%) versus 13/237 cycles (5.5%) in Capizzi MTX (P = 0.002). Nephrotoxicity and skin toxicity was seen only in the HD-MTX group. There was no difference in the severity of toxicity, graded using NCI CTCAE v 5.0, between the two groups. There was no mortality directly attributable to methotrexate toxicity (Grade V toxicity). Serum MTX levels were available in 69/151 (45.7%) cycles of HD-MTX and showed no association with toxicity in this group. Also, there was no difference in the incidence of combined toxicities between groups with (19/69 cycles) or without (26/82 cycles) available serum MTX levels in the HR group (P = 0.577). Male gender, lower baseline ANC and lower BMI had significant association with toxicity. Methotrexate related toxicity is common with both Capizzi and HD-MTX schedule in childhood ALL with a correlation of lower BMI, baseline ANC and male gender. However, it is possible to administer Capizzi as well as HD-MTX in lower middle income countries, with manageable toxicity. Further studies will be required to substantiate our findings and determine the predictors of such events.

Prognostic value of hypoalbuminemia at diagnosis in de novo non-M3 acute myeloid leukemia

The association between serum albumin level and clinical outcomes has been reported for several hematological malignancies. Our study aimed to identify the relationship between serum albumin level at the time of diagnosis and subsequent clinical outcomes in patients with newly diagnosed acute myeloid leukemias (AMLs) other than acute promyelocytic leukemias (APLs). A total of 243 patients with de novo non-M3 AML were enrolled in this study. Variables including gender, age, serum albumin, white blood cell (WBC) count, hemoglobin (Hb), platelet (PLT) count, blasts at peripheral blood (PB) and bone marrow (BM), immunophenotype and cytogenetics at diagnosis, BM response after one course of chemotherapy and hematopoietic stem cell transplantation (HSCT) treatment were studied. We found that normal albumin level (serum albumin >3.5 g/dL) was significantly associated with superior overall survival (HR = 0.375, p < .001) and leukemia-free survival (HR = 0.411, p < .001). These results demonstrate that albumin could serve as a simple, cheap, and objective prognostication factor in refinement of AML regimens.

Incidence of vincristine induced neurotoxicity in children with acute lymphoblastic leukemia and its correlation with nutritional deficiencies

Injection vincristine is an important component of therapy for acute lymphoblastic leukemia (ALL). An important adverse effect of vincristine is neurotoxicity. The incidence of this adverse effect is well studied. The present was undertaken to determine the incidence of vincristine-induced neurotoxicity in children with ALL after the induction of remission phase of chemotherapy and to ascertain its correlation with undernutrition, vitamin B12, folate and iron deficiency. Thirty children (1-18 years) with ALL were enrolled at the commencement of chemotherapy. The electrophysiological evaluation was done at baseline and repeated after four doses of vincristine (1.5 mg/m²/dose). Clinical evaluation was done regularly. Anthropometry and serum B12, folate and ferritin levels were assessed at baseline. Twelve children over a 4-week period of observation had peripheral neuropathy clinically. The autonomic system was most commonly involved followed by motor and sensory system respectively. On electrophysiological testing, half of the patients had evidence of neuropathy. Micronutrient deficiencies were present in a significant number of patients-63.3% had a B12 deficiency, 20% were deficient in folate and 43.3% in iron. The incidence of vincristine-induced neuropathy in patients with/without these micro-nutrient deficiencies was not statistically significantly different. Vincristine-induced neuropathy is common in Indian children with ALL. The present study did not find any correlation between the occurrences of vincristine-induced neuropathy and nutritional deficiencies. Larger studies are warranted to evaluate the contribution of micronutrient deficiencies to the development of peripheral neuropathy in childhood ALL.

Profile of anemia in acute lymphoblastic leukemia patients on maintenance therapy and the effect of micronutrient supplementation

BACKGROUND

Anemia is a common finding and important cause of morbidity in patients with acute lymphoblastic leukemia (ALL) at diagnosis or during the course of its protracted treatment. We studied profile of anemia in ALL patients on maintenance therapy and evaluated specific micronutrients as cause of this anemia.

PATIENTS AND METHODS

ALL patients who were on maintenance therapy and had grade ≥ 2 anemia were recruited for the study. Serum iron studies, folate, and vitamin B12 were done to identify micronutrient deficiency and to initiate supplementation with specific components if found to be deficient. Toxicities, improvement of anemia, micronutrient levels, and disease outcome were studied after 3 months.

RESULTS

From March 2015 to September 2016, 105 ALL patients were found to be on maintenance fulfilling the inclusion criteria. Overall, the proportion of anemia was 80%(N = 84). Majority had normocytic normochromic anemia (71%). Macrocytic anemia was seen in 18% and microcytic hypochromic in 9.5%. In patients with anemia of grade ≥ 2 (N = 84), 38 patients (45%) had biochemical deficiency of serum folate, and 7 (8%) had vitamin B12 deficiency. No biochemical evidence of iron deficiency was found. Supplementation of deficient micronutrients improved anemia: mean hemoglobin significantly increased from 8.06 ± 1.63 to 10.78 ± 1.53 (p < 0.001) at 3 months; and reduced treatment toxicities, mean number of febrile neutropenia episodes (p = 0.007), and treatment interruptions of > 2 weeks (p = 0.002) were lowered. Patients with anemia had significantly more relapses (N = 14,64%) compared to patients without anemia (N = 8,36%), (p = 0.040).

CONCLUSION

Timely identification and correction of micronutrient deficiencies causing anemia in ALL patients on maintenance can enhance treatment outcomes.

Folic acid, one-carbon metabolism & childhood cancer

Folate has been studied in relation to many diseases, especially cancer. Although it has been postulated to exert a dual effect on development of cancer, its role remains to be clearly defined. Its effect on cancer is the result of gene-nutrient interaction between the genes in folate metabolic pathway and dietary folate availability; mutations in genes of folate metabolism have been shown to alter individual susceptibility to certain childhood cancers as well as response to cancer chemotherapy. Although mandatory fortification of food items with folate has been initiated in some countries, many countries are yet to adopt this due to concerns about undesired adverse effects of high folate levels on health, especially cancer. However, initial reports suggest that folate fortification has led to reduction in incidence of certain childhood cancers such as neuroblastoma, wilms tumour and leukaemias. Despite studies showing folate depletion during antifolate chemotherapy and higher toxicity of chemotherapy in folate-depleted individuals, folate supplementation during cancer chemotherapy is not routinely recommended. Studies investigating the precise effect of folate supplementation during chemotherapy on both short- and long-term outcomes of cancer are needed to arrive at a consensus guideline.

Folate deficiency in north Indian children undergoing maintenance chemotherapy for acute lymphoblastic leukemia-Implications and outcome

BACKGROUND

Treatment-related toxicity and mortality are not uncommon during maintenance chemotherapy for childhood acute lymphoblastic leukemia (ALL), especially in the low- and middle-income countries (LMIC). Undernutrition and micronutrient deficiencies are commonly seen in children from LMICs undergoing treatment for ALL. The present study examines the prevalence and clinical implications of folate deficiency in north Indian children with ALL during the maintenance phase of treatment in view of prolonged antifolate treatment and high population prevalence of folate deficiency.

PROCEDURES

Pre-cycle folate levels/deficiency as well as weight for age z-score and serum albumin level were determined and correlated with complications of treatment and mortality encountered during the maintenance phase of treatment.

RESULTS

Twenty-nine of 52 children enrolled in the study had folate deficiency at some point during maintenance chemotherapy. Neutropenia (18 of 29 vs. 4 of 23; P = 0.002), thrombocytopenia (17 of 29 vs. 4 of 23; P = 0.005), febrile neutropenia (17 of 29 vs. 4 of 23; P = 0.005), and need for chemotherapy dose reduction (20 of 29 vs. 7 of 21; P = 0.01) were more common in folate-deficient children. Maintenance deaths were higher (8 of 29 vs. 1 of 23; P = 0.03) and survival lower (P = 0.02) in deficient children. In multivariate analysis, hypoalbuminemia (P = 0.02) and folate deficiency (P = 0.01) were associated with febrile neutropenia, and folate deficiency with maintenance deaths (P = 0.03).

CONCLUSIONS

Folate deficiency was associated with treatment-related complications and adverse outcome in our patients. The risks and benefits of folate supplementation in deficient children during maintenance chemotherapy need to be explored with properly designed randomized studies in similar settings.

Characteristics of Vitamin B12 Deficiency in Patients With Plasma Cell Disorders

BACKGROUND

Although increased rates of vitamin B12 deficiency have been reported in patients with plasma cell dyscrasias (PCDs), no mechanism has been identified. Excess free light chains (FLCs) could disrupt the renal proximal tubule receptors where B12 is reabsorbed. We sought to characterize the relationship between B12 deficiency and PCDs. We hypothesized that rates of B12 deficiency would be highest in patients with PCDs with high FLC burdens.

METHODS

We reviewed the electronic medical records of 501 patients who met inclusion criteria (diagnosed PCD with documented serum B12 and FLC levels) to obtain clinical data recorded prior to patients' lowest B12 levels.

RESULTS

Overall, 20.0% of patients had low vitamin B12. There was an expected negative correlation between estimated glomular filtration rate and FLC (r_s = -0.317; P < .001). However, low B12 levels were more prevalent in patients with preserved renal function (P = .047). Low B12 was associated with lower mean corpuscular volume (P = .037).

CONCLUSION

Higher FLC burden was associated with poor kidney function but not with low B12. Low B12 was seen more commonly in patients with preserved kidney function. Mean corpuscular volume was statistically but not clinically different between patients with low and normal B12 and, therefore, may not be a reliable indicator of B12 deficiency in PCDs. Prospective studies should compare B12 metabolites with FLC levels. Detection of B12 deficiency among patients with PCDs remains important to reduce neurologic dysfunction and cytopenias, sequelae common to B12 deficiency and PCDs.

The Impact of Socioeconomic Factors on the Outcome of Childhood Acute Lymphoblastic Leukemia (ALL) Treatment in a Low/Middle Income Country (LMIC)

Survival for childhood acute lymphoblastic leukemia (ALL) has improved significantly, but these benefits may not be available to many children from low and middle income countries, where reasons for treatment failure may be unique to their environment. We retrospectively reviewed data on pediatric (1 to 18 y or younger) patients with newly diagnosed ALL treated over 5 years at a children's cancer hospital in Pakistan. Patients were treated with modified Berlin-Frankfurt-Muenster -based therapy without risk stratification. There were 255 children with a median age of 7 years (mean, 7.65 y) and a male preponderance (M:F=1.6:1). 20% had T-ALL, one-third had white blood cells >50×10/L and 13.7% central nervous system disease. A majority (56.5%) was malnourished. In total, 49 (19.2%) died before the end of induction and 21 died in complete remission. Most deaths were infection-related. A total of 50 patients relapsed and 19 abandoned therapy after complete remission. Five-year overall survival is 52.9% with abandonment censored and 45.8% with abandonment as an event. Overall survival was related to socioeconomic status but not to known risk factors. The outcome of ALL at our center is suboptimal and associated with factors not commonly seen in developed countries. Special attention to early diagnosis, infection control, and parental educational are needed to improve the survival.

Tracking children with acute lymphoblastic leukemia who abandoned therapy: Experience, challenges, parental perspectives, and impact of treatment subsidies and intensified counseling

Refusal for treatment and therapy abandonment are important reasons for unfavorable outcome of childhood acute lymphoblastic leukemia (ALL) in resource-poor countries. The present study, conducted on children with ALL whose treatment was abandoned, attempted to track all these children to ascertain the causes and outcome of therapy abandonment/refusal. In order to improve outcome of ALL, measures to prevent abandonment were introduced in the form of treatment subsidies and intensified multistage counseling. Of the 77 (of 418) children abandoning therapy, 17 (22%) refused upfront, whereas the rest abandoned during various phases of chemotherapy. Only 39 (50.6%) of these 77 families could be subsequently contacted. Financial problems, too many dependents at home, and wrong perceptions about cancer led to abandonment in majority. Children abandoning treatment before completion of induction had a significantly shorter survival than who abandoned post induction (P < .0001). Intensified preabandonment counseling and subsidized treatment led to significant reduction in abandonment rates (P < .0001).