1
|
Perruso LL, Velloso E, Rocha V, Rego EM, Silva WF. Patterns and prognostic impact of CNS infiltration in adults with newly diagnosed acute lymphoblastic leukemia. Ann Hematol 2024; 103:2033-2039. [PMID: 38180535 DOI: 10.1007/s00277-023-05609-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 12/22/2023] [Indexed: 01/06/2024]
Abstract
Acute lymphoblastic leukemia (ALL) is highly associated with central nervous system (CNS) infiltration and can be associated with higher risk of relapse. Conventional cytology (CC) is the traditional method for diagnosing CNS infiltration, although the use of immunophenotyping by flow cytometry (FC) has gained prominence in recent years due to its higher sensitivity. Also, some authors have proposed that CSF contamination by a traumatic lumbar puncture (TLP) could have a clinical impact. This retrospective study accessed the impact of CNS infiltration by CC or FC on overall survival, event-free survival, and relapse rate. In a cohort of 105 newly diagnosed ALL patients, CNS1, CNS2, and CNS3 status were found in 84%, 14%, and 2%, respectively. We found that extramedullary disease at the diagnosis, higher leukocyte counts, and higher blast percentage were associated with a positive CC. Sensitivity and specificity of CC were 53% and 98%, respectively. Three-year overall survival was 42.5%. Conversely, TLP was not associated with a positive CC nor had an impact on relapse rates. In multivariate analysis, a positive CC was associated with an increased relapse rate (HR 2.074, p = 0.037), while its detection by FC did not associate with this endpoint. Survival rates seem to be increasing over the last years by the adoption of a stratified CNS prophylaxis risk strategy. CSF contamination does not represent a major concern according to our report, as it did not increase CNS involvement or relapse rates.
Collapse
Affiliation(s)
- Luiza Lapolla Perruso
- Laboratory of Medical Investigation in Pathogenesis and Directed Therapy in Onco-Immuno-Hematology (LIM-31), Division of Hematology and Cell Therapy, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, 01246-000, Brazil
- Instituto Do Cancer Do Estado de São Paulo, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, 251, Cerqueira César, São Paulo, SP, CEP 01246-000, Brazil
| | - Elvira Velloso
- Laboratory of Medical Investigation in Pathogenesis and Directed Therapy in Onco-Immuno-Hematology (LIM-31), Division of Hematology and Cell Therapy, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, 01246-000, Brazil
- Instituto Do Cancer Do Estado de São Paulo, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, 251, Cerqueira César, São Paulo, SP, CEP 01246-000, Brazil
| | - Vanderson Rocha
- Laboratory of Medical Investigation in Pathogenesis and Directed Therapy in Onco-Immuno-Hematology (LIM-31), Division of Hematology and Cell Therapy, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, 01246-000, Brazil
- Instituto Do Cancer Do Estado de São Paulo, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, 251, Cerqueira César, São Paulo, SP, CEP 01246-000, Brazil
| | - Eduardo Magalhaes Rego
- Laboratory of Medical Investigation in Pathogenesis and Directed Therapy in Onco-Immuno-Hematology (LIM-31), Division of Hematology and Cell Therapy, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, 01246-000, Brazil
- Instituto Do Cancer Do Estado de São Paulo, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, 251, Cerqueira César, São Paulo, SP, CEP 01246-000, Brazil
| | - Wellington Fernandes Silva
- Laboratory of Medical Investigation in Pathogenesis and Directed Therapy in Onco-Immuno-Hematology (LIM-31), Division of Hematology and Cell Therapy, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, 01246-000, Brazil.
- Instituto Do Cancer Do Estado de São Paulo, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, 251, Cerqueira César, São Paulo, SP, CEP 01246-000, Brazil.
| |
Collapse
|
2
|
Silva W, Rego E. How to Manage Philadelphia-Positive Acute Lymphoblastic Leukemia in Resource-Constrained Settings. Cancers (Basel) 2023; 15:5783. [PMID: 38136329 PMCID: PMC10741425 DOI: 10.3390/cancers15245783] [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: 09/16/2023] [Revised: 10/17/2023] [Accepted: 10/20/2023] [Indexed: 12/24/2023] Open
Abstract
Recent studies have indicated that more than half of adult patients newly diagnosed with Ph+ ALL can now achieve a cure. However, determining the most suitable protocol for less-resourced settings can be challenging. In these situations, we must consider the potential for treatment toxicity and limited access to newer agents and alloSCT facilities. Currently, it is advisable to use less intensive induction regimens for Ph+ ALL. These regimens can achieve high rates of complete remission while causing fewer induction deaths. For consolidation therapy, chemotherapy should remain relatively intensive, with careful monitoring of the BCR-ABL1 molecular transcript and minimal residual disease. AlloSCT may be considered, especially for patients who do not achieve complete molecular remission or have high-risk genetic abnormalities, such as IKZF1-plus. If there is a loss of molecular response, it is essential to screen patients for ABL mutations and, ideally, change the TKI therapy. The T315I mutation is the most common mechanism for disease resistance, being targetable to ponatinib. Blinatumomab, a bispecific antibody, has shown significant synergy with TKIs in treating this disease. It serves as an excellent salvage therapy, aside from achieving outstanding results when incorporated into the frontline.
Collapse
Affiliation(s)
- Wellington Silva
- Discipline of Hematology, Hospital das Clínicas da Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 05403-010, Brazil;
| | | |
Collapse
|
3
|
Rangel-Patiño J, Lee-Tsai YL, Urbalejo-Ceniceros VI, Luna-Perez MEM, Espinosa-Bautista KA, Amador LF, Cabrera-García Á, Balderas-Delgado C, Inclan-Alarcon SI, Neme-Yunes Y, Sanchez-Albarrán JM, Apodaca EI, Meillon-García L, Stock W, Demichelis-Gómez R. A modified CALGB 10403 in adolescents and young adults with acute lymphoblastic leukemia in Central America. Blood Adv 2023; 7:5202-5209. [PMID: 37307212 PMCID: PMC10500455 DOI: 10.1182/bloodadvances.2023009754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 05/05/2023] [Accepted: 05/21/2023] [Indexed: 06/14/2023] Open
Abstract
Mexico and Central America have a high incidence of acute lymphoblastic leukemia (ALL) in adolescents and young adults. Historically, this patient group has been treated using adult-based regimens, which entails a high rate of treatment-related mortality and a poor overall survival (OS). The use of the CALGB 10403, a pediatric-inspired regimen, has been proven effective in this patient subgroup. Nonetheless, low- and middle-income countries (LMICs) may present limited access to standard care treatments implemented elsewhere, warranting the need for further research to improve outcomes among vulnerable populations. In this study, we present the outcomes in terms of safety and effectiveness of using a modified CALGB 10403 regimen to reflect drug and resource availability in LMICs. Modifications included the use of Escherichia coli asparaginase,6-mercaptopurine instead of thioguanine and the use of rituximab among patients with CD20+. A total of 95 patients with a median age of 23 (range, 14-49) years treated with this modified scheme were prospectively assessed at 5 centers in Mexico and 1 in Guatemala. Among these, 87.8% achieved a complete response after induction. During follow-up, 28.3% of patients relapsed. Two-year OS rate was 72.1%. Factors associated with worse OS included hyperleukocytosis (hazard ratio [HR], 4.28; 95% confidence interval [CI], 1.81-10.10) and postinduction minimal residual disease (HR, 4.67; 95% CI, 1.75-12.44). Most patients presented hepatotoxicity (51.6% and 53.7% during induction and consolidation, respectively), and the treatment-related mortality was 9.5%. Overall, results highlight that implementing a modified CALGB 10403 regimen in Central America is feasible, and it is associated with improvements in clinical outcomes and a manageable safety profile.
Collapse
Affiliation(s)
- Juan Rangel-Patiño
- Hematology and Oncology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | | | | | - Karla Adriana Espinosa-Bautista
- Hematology Department, Comisión Coordinadora de Institutos Nacionales de Salud y Hospitales de Alta Especialidad, Mexico City, Mexico
| | - Lauro Fabian Amador
- Hematology Department, Hospital Regional de Alta Especialidad del Bajío, León, Mexico
| | - Álvaro Cabrera-García
- Hematology Department, Hospital Regional de Alta Especialidad de Ixtapaluca, Estado de Mexico, Mexico
| | - Carolina Balderas-Delgado
- Hematology Department, Hospital Regional de Alta Especialidad de Ixtapaluca, Estado de Mexico, Mexico
| | | | | | - Jose Manuel Sanchez-Albarrán
- Hematology and Oncology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Elia Ixel Apodaca
- Hematology and Oncology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | - Wendy Stock
- Department of Medicine, Section of Hematology/Oncology, University of Chicago, Chicago, IL
| | - Roberta Demichelis-Gómez
- Hematology and Oncology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| |
Collapse
|
4
|
Lopez-Garcia YK, Valdez-Carrizales M, Nuñez-Zuno JA, Apodaca-Chávez E, Rangel-Patiño J, Demichelis-Gómez R. Are delays in diagnosis and treatment of acute leukemia in a middle-income country associated with poor outcomes? A retrospective cohort study. Hematol Transfus Cell Ther 2023:S2531-1379(23)00125-6. [PMID: 37442650 DOI: 10.1016/j.htct.2023.05.010] [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: 05/25/2022] [Revised: 02/04/2023] [Accepted: 05/28/2023] [Indexed: 07/15/2023] Open
Abstract
INTRODUCTION Acute leukemias (ALs) are aggressive diseases that lead to death without medical attention. We evaluated the association between delays in diagnosis and poor outcomes in AL by evaluating the symptom onset to treatment intervals in adults with newly diagnosed AL and their effect on an early death (ED). METHODS We assessed adults diagnosed with AL between 2015 and 2020 and evaluated baseline characteristics, the patient interval (PI), diagnostic interval (DI), treatment interval (TI) and the total time interval (TTI) to determine ED-associated factors. MAIN RESULTS We assessed 102 patients with acute lymphoblastic leukemia (ALL), 57 with acute myeloblastic leukemia (AML) and 29 with acute promyelocytic leukemia (APL). Median interval days were PI 14, DI 10, TI 4 and TTI 31.5. The TI and TTI intervals were lower in APL than in ALL and AML; TI 1 vs. 4 and 3 (p = 0.001) and TTI 21 vs. 31 and 35 (p = 0.016). The 30-day and 60-day EDs were 13.8% and 20.7%, mainly infections. ECOG > 2 (OR = 15.0) and PI < 7 days (OR = 4.06) were associated with 30-day ED; AML (OR = 2.69), high-risk (OR = 3.34), albumin < 3.5 g/dl (OR = 5) and platelets < 20 × 103/uL (OR = 2.71) with a 60-day ED. CONCLUSION None of the interval-delays were associated with an ED. Intervals seemed to be longer in patients without an ED, except for the TI, probably because of "the waiting time paradox." Aggressive manifestations of disease may lead to shorter diagnostic intervals, but increased mortality.
Collapse
Affiliation(s)
| | | | | | - Elia Apodaca-Chávez
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Juan Rangel-Patiño
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | |
Collapse
|
5
|
Aguiar TF, da Conceição Barbosa T, Maciel ALT, Blunck CB, Sellos-Laclette J, de Melo AC, Mansur MB, Emerenciano M. Outcome of adolescents and young adults with acute lymphoblastic leukemia in a single center in Brazil. Hematol Transfus Cell Ther 2023; 45 Suppl 2:S108-S112. [PMID: 35989249 PMCID: PMC10433312 DOI: 10.1016/j.htct.2022.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 05/02/2022] [Accepted: 06/24/2022] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Acute lymphoblastic leukemia (ALL) presents a poor prognosis in adults. The adoption of pediatric protocols has been changing this scenario, especially for adolescents and young adults (AYA). OBJECTIVE AND METHOD We aimed to evaluate a consecutive series of patients treated at the State Institute of Hematology of Rio de Janeiro between 2012 and 2020, focusing on the AYA subgroup. RESULT The B-ALL was the most frequent subtype (81.6%) and AYA, the predominant age group (57.7%). The median overall survival (OS) was 9.4 months. High early mortality was observed and sepsis was the main cause of death. Better OS results were noted in AYA, in comparison to over 39y (13.3 × 6.2 months, respectively), the Berlin-Frankfurt-Münster (BFM) being the protocol of choice in this group. CONCLUSION The use of the pediatric protocol seems to improve the OS of AYA, however, high rates of deaths from infection were observed, demonstrating the need for advances in the Brazilian public system clinical support.
Collapse
Affiliation(s)
- Thais Ferraz Aguiar
- Instituto Nacional de Câncer (INCA), Rio de Janeiro, RJ, Brazil
- Instituto Estadual de Hematologia Arthur Siqueira Cavalcanti, Rio de Janeiro, RJ, Brazil
| | | | | | | | | | | | - Marcela B. Mansur
- Instituto Nacional de Câncer (INCA), Rio de Janeiro, RJ, Brazil
- Children's Hospital, John Radcliffe Hospital, Oxford, UK
- Weatherall Institute of Molecular Medicine -WIMM, University of Oxford, Oxford, UK
| | | |
Collapse
|
6
|
Basquiera AL, Seiwald MC, Best Aguilera CR, Enciso L, Fernandez I, Jansen AM, Nunes E, Sanchez del Villar M, Urbalejo Ceniceros VI, Rocha V. Expert Recommendations for the Diagnosis, Treatment, and Management of Adult B-Cell Acute Lymphoblastic Leukemia in Latin America. JCO Glob Oncol 2023; 9:e2200292. [PMID: 37167576 PMCID: PMC10497277 DOI: 10.1200/go.22.00292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 01/19/2023] [Accepted: 03/13/2023] [Indexed: 05/13/2023] Open
Abstract
PURPOSE Despite strong induction chemotherapy response rates, only 30%-40% of patients with adult B-cell acute lymphoblastic leukemia (ALL) attain long-term remission. This study analyzes ALL in Latin America (LA) and recommends diagnosis, treatment, and management protocols. METHODS The Americas Health Foundation organized a panel of hematologists from Argentina, Brazil, Chile, Colombia, and Mexico to examine ALL diagnosis and therapy and produce recommendations. RESULTS Lack of regional data, unequal access to diagnosis and therapy, inadequate treatment response, and uneven health care distribution complicate adult ALL management. The panel recommended diagnosis, first-line and refractory treatment, and post-transplantation maintenance. Targeted treatments, including rituximab, blinatumomab, and inotuzumab ozogamicin, are becoming available in LA and must be equitably accessed. CONCLUSION This review adapts global information on treating ALL to LA. Governments, the medical community, society, academia, industry, and patient advocates must work together to improve policies.
Collapse
Affiliation(s)
- Ana Lisa Basquiera
- Hematology and Oncology Service, Bone Marrow Transplant Program, Hospital Privado Universitario de Cordoba, Instituto Universitario de Ciencias Biomédicas de Cordoba (IUCBC), Cordoba, Argentina
| | - Maria Cristina Seiwald
- Department of Clinical Medicine, Hematology and Hemotherapy, University of Sao Paulo (FMUSP), Sao Paulo, Brazil
| | - Carlos Roberto Best Aguilera
- Conacyt National Quality Postgraduate Program, University of Guadalajara & Western General Hospital, Guadalajara, Mexico
| | | | | | | | - Elenaide Nunes
- Hospital de Clínicas—Federal University of Parana, Parana, Brazil
| | - Matias Sanchez del Villar
- Chief Bone Marrow Transplant Service, Department of Hematology, Clinica Alemana de Santiago, Santiago, Chile
| | | | - Vanderson Rocha
- Department of Clinical Medicine, Hematology and Hemotherapy, University of Sao Paulo (FMUSP), Sao Paulo, Brazil
| |
Collapse
|
7
|
Treatment of Ph-Negative Acute Lymphoblastic Leukemia in Adolescents and Young Adults with an Affordable Outpatient Pediatric Regimen. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:883-893. [PMID: 36057522 DOI: 10.1016/j.clml.2022.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 07/25/2022] [Accepted: 07/26/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND B-cell acute lymphoblastic leukemia is frequent in Hispanic adolescents and young adults. Outcomes of implementation of pediatric-inspired regimens in low-and middle-income countries are not well known. METHODS In this study we treated 94 adolescents and young adults with a local BFM regimen designed to be affordable with the use of native L-asparaginase and mitoxantrone administered in an outpatient fashion, and the of BCR/ABL and measurable residual disease (MRD) determined by high sensitivity flow cytometry for risk stratification. RESULTS Induction mortality was 11%; 25% of patients had to abandon treatment or be transferred to another health system. Two-year overall (OS) and event free survival (EFS) were 61.5% and 49.8%, MRD-negative patients had a 24-month OS of 85.6% vs. 69.6% (p = .024) and EFS of 76% vs. 45.5% (p = .004). Patients older than 40 years and those who abandoned treatment had worse EFS. Overall drug costs in our regimen were 52% lower than those of CALGB10403. CONCLUSION The treatment of AYAs with ALL with an outpatient focus was implemented successfully at a reduced cost. Genetic risk assessment, treatment abandonment and lack of access to novel therapies remain major barriers for improving outcomes.
Collapse
|
8
|
Colunga-Pedraza PR, Colunga-Pedraza JE, Peña-Lozano SP, Gómez-De León A, Ruiz-Delgado GJ, Ribeiro RC. Diagnosis and treatment of acute lymphoblastic leukemia in Latin America. HEMATOLOGY (AMSTERDAM, NETHERLANDS) 2022; 27:971-976. [PMID: 36040187 DOI: 10.1080/16078454.2022.2117119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE to discuss the status and challenges associated with the management of acute lymphoblastic leukemia (ALL) in Latin America. METHODS This review summarizes various insights gained from information regarding diagnostic approaches and treatment strategies in adult patients with ALL in Latin American Countries. RESULTS Information regarding ALL in Latin America is scarce; however, many efforts have been made to overcomes these barriers. Nevertheless, major obstacles to successful treatment in Latin America and LMIC remain poor adherence, abandonment of treatment, and lack of supportive therapy and new therapeutic agents. CONCLUSION Further improvements in survival should be pursued by developing more Latin American registries, forming cooperative groups, developing educational models to facilitate earlier diagnosis and prevention of complications, better support therapy and management of infections, and adapting treatment strategies.
Collapse
Affiliation(s)
- Perla R Colunga-Pedraza
- Universidad Autónoma de Nuevo León, Facultad de Medicina, Servicio de Hematología, Hospital Universitario "Dr. José E. González", Monterrey, Mexico
| | - Julia E Colunga-Pedraza
- Universidad Autónoma de Nuevo León, Facultad de Medicina, Servicio de Hematología, Hospital Universitario "Dr. José E. González", Monterrey, Mexico
| | - Samantha P Peña-Lozano
- Universidad Autónoma de Nuevo León, Facultad de Medicina, Servicio de Hematología, Hospital Universitario "Dr. José E. González", Monterrey, Mexico
| | - Andrés Gómez-De León
- Universidad Autónoma de Nuevo León, Facultad de Medicina, Servicio de Hematología, Hospital Universitario "Dr. José E. González", Monterrey, Mexico
| | - Guillermo J Ruiz-Delgado
- Centro de Hematología y Medicina Interna, Clínica RUIZ, Puebla, Mexico.,Universidad Popular Autónoma del Estado de Puebla, Puebla, México
| | - Raul C Ribeiro
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| |
Collapse
|
9
|
Silva WF, Amano MT, Perruso LL, Cordeiro MG, Kishimoto RK, de Medeiros Leal A, Nardinelli L, Bendit I, Velloso ED, Rego EM, Rocha V. Adult acute lymphoblastic leukemia in a resource-constrained setting: outcomes after expansion of genetic evaluation. Hematology 2022; 27:396-403. [PMID: 35344469 DOI: 10.1080/16078454.2022.2052602] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Acute lymphoblastic leukemia (ALL) is a challenging disease with a growing genetic landscape, even though there is substantial gap between developed and non-developed countries when it comes to availability of such new technologies. This manuscript reports a 5-year retrospective cohort of newly diagnosed ALL patients and their genetic findings and outcomes. An expanded genetic evaluation by using FISH and RT-PCR was implemented, aiming to identify Ph-like alterations. Patients were treated according to our local protocol, which allocated patients according to age and Philadelphia-chromosome status. A total of 104 patients was included, with median age of 37.5 years. Philadelphia chromosome was detected in 33 cases of B-lineage. Among 45 Ph-negative B-lineage, after excluding KMT2A or TCF3-PBX1 cases, we identified 9 cases with Ph-like fusion. Ph-positive and Ph-like patients had higher initial WBC (p = 0.06). Out of 104 cases, two cases did not start chemotherapy and an early death rate of 10.8% was found. Allogeneic transplantation was performed in 18 cases, being ten performed in first CR. Three-year overall survival (OS) and 3-year event-free survival were 42.8% and 30.8%, respectively. For patients treated with a pediatric regimen, 3-year OS was 52.5%. Extramedullary disease (HR 0.42) and platelet counts (HR 0.9) were independently associated with OS. We still face excessive non-relapse mortality that compromises our results. Alternative strategies implementing FISH and RT-PCR are feasible and able to identify Ph-like fusions. Delays in allogeneic transplantation, as well as the unavailability of new agents, impact long-term survival. Measures to decrease early infection are desirable.
Collapse
Affiliation(s)
- Wellington F Silva
- Division of Hematology, Instituto do Cancer do Estado de São Paulo, São Paulo, Brazil.,Division of Hematology, Hospital das Clinicas da Faculdade de Medicina (HCFMUSP), Universidade de Sao Paulo, Sao Paulo, Brazil.,Laboratory of Medical Investigation in Pathogenesis and targeted therapy in Onco-Immuno-Hematology (LIM-31), Department of Hematology, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Mariane T Amano
- Instituto Sírio-Libanês de Ensino e Pesquisa, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Luiza L Perruso
- Division of Hematology, Instituto do Cancer do Estado de São Paulo, São Paulo, Brazil
| | - Maria Gabriella Cordeiro
- Division of Hematology, Hospital das Clinicas da Faculdade de Medicina (HCFMUSP), Universidade de Sao Paulo, Sao Paulo, Brazil.,Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | - Aline de Medeiros Leal
- Division of Hematology, Hospital das Clinicas da Faculdade de Medicina (HCFMUSP), Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Luciana Nardinelli
- Division of Hematology, Hospital das Clinicas da Faculdade de Medicina (HCFMUSP), Universidade de Sao Paulo, Sao Paulo, Brazil.,Laboratory of Medical Investigation in Pathogenesis and targeted therapy in Onco-Immuno-Hematology (LIM-31), Department of Hematology, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Israel Bendit
- Division of Hematology, Hospital das Clinicas da Faculdade de Medicina (HCFMUSP), Universidade de Sao Paulo, Sao Paulo, Brazil.,Laboratory of Medical Investigation in Pathogenesis and targeted therapy in Onco-Immuno-Hematology (LIM-31), Department of Hematology, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Elvira Drp Velloso
- Division of Hematology, Instituto do Cancer do Estado de São Paulo, São Paulo, Brazil.,Division of Hematology, Hospital das Clinicas da Faculdade de Medicina (HCFMUSP), Universidade de Sao Paulo, Sao Paulo, Brazil.,Laboratory of Medical Investigation in Pathogenesis and targeted therapy in Onco-Immuno-Hematology (LIM-31), Department of Hematology, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil.,Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Eduardo M Rego
- Division of Hematology, Instituto do Cancer do Estado de São Paulo, São Paulo, Brazil.,Division of Hematology, Hospital das Clinicas da Faculdade de Medicina (HCFMUSP), Universidade de Sao Paulo, Sao Paulo, Brazil.,Laboratory of Medical Investigation in Pathogenesis and targeted therapy in Onco-Immuno-Hematology (LIM-31), Department of Hematology, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Vanderson Rocha
- Division of Hematology, Instituto do Cancer do Estado de São Paulo, São Paulo, Brazil.,Division of Hematology, Hospital das Clinicas da Faculdade de Medicina (HCFMUSP), Universidade de Sao Paulo, Sao Paulo, Brazil.,Laboratory of Medical Investigation in Pathogenesis and targeted therapy in Onco-Immuno-Hematology (LIM-31), Department of Hematology, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| |
Collapse
|
10
|
Inclan-Alarcon SI, Riviello-Goya S, Teran-De-la-Sancha K, Fierro-Angulo OM, Acosta-Medina AA, Demichelis-Gomez R, Bourlon C. Induction-related mortality in adolescents and young adults with acute lymphoblastic leukemia in a resource-limited setting: do treatment-related complications create more impact than disease biology? Blood Res 2022; 57:29-33. [PMID: 35197368 PMCID: PMC8958371 DOI: 10.5045/br.2021.2021058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 12/23/2021] [Accepted: 12/24/2021] [Indexed: 11/17/2022] Open
Abstract
Background Acute lymphoblastic leukemia (ALL) is a malignant clonal bone marrow disorder with a high mortality rate during the initial therapy. This retrospective study aimed to describe and analyze the risk factors and causes of induction-related mortality (IRM) in an adolescent and adult ALL population treated in a low- and middle-income country. Methods From 2009 to 2016, a total of 167 patients were included, of which 50.9% were male with a median age of 28 years. B-immunophenotype represented 97.6%, and high-risk cytogenetics were present in 23.3%. During induction therapy, 91% had at least 1 complication, most of which were infectious, with an IRM of 12%. Results Factors associated with increased mortality rate were central nervous system (CNS) status [CNS-3: hazard ratio (HR) 3.029; 95% confidence interval (CI), 0.79-11.49; P=0.103 and CNS-2: HR, 9.98; 95% CI, 2.65-37.65; P=0.001] and dialysis requirement (HR, 9.15; 95% CI, 2.44-34.34; P=0.001). Conclusion Our study confirms that ALL patients treated in resource-constrained settings have high rates of IRM, mainly attributed to advanced disease and high tumor burden at diagnosis.
Collapse
Affiliation(s)
- Sergio I Inclan-Alarcon
- Department of Hematology and Oncology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Santiago Riviello-Goya
- Department of Hematology and Oncology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Kevin Teran-De-la-Sancha
- Department of Hematology and Oncology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Oscar M Fierro-Angulo
- Department of Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Aldo A Acosta-Medina
- Department of Hematology and Oncology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Roberta Demichelis-Gomez
- Department of Hematology and Oncology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Christianne Bourlon
- Department of Hematology and Oncology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| |
Collapse
|
11
|
Spontaneous apoptosis and BCL2 gene expression as predictors of early death and short overall survival in acute leukemia patients: a prospective, case cohort study. EGYPTIAN JOURNAL OF MEDICAL HUMAN GENETICS 2021. [DOI: 10.1186/s43042-021-00210-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Spontaneous apoptosis and expression of MCL1, BCL2, and BCL-XL may be useful prognostic markers in acute leukemia patients. The purpose of this study is to examine the prognosis in adult leukemia patients based on spontaneous apoptosis and anti-apoptosis gene expressions in circulating leukocytes.
Results
Early, late, and total apoptosis were significantly increased in peripheral blood leukocytes from patients diagnosed with acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL) compared to controls and in cases of ALL versus AML (P < 0.001). Total apoptosis decreased significantly in AML and ALL patients who died early (ED); P = 0.001 and P = 0.002, respectively. Anti-apoptosis genes MCL1, BCL2, and BCL-XL were upregulated in 62.4%, 64.2%, and 62.4% of the acute leukemia patients, respectively. Among the AML patients, the up-regulation of BCL2 was paradoxically associated with increased apoptosis and low rates of ED. The expression levels of MCL1 and BCL-XL had no significant prognostic values; among patients diagnosed with non-acute promyelocytic leukemia (non-APL-AML), total spontaneous apoptosis, expression of BCL2, and performance status were independent predictors of overall survival (OS).
Conclusion
Total spontaneous apoptosis and BCL2 gene expression may be valuable independent markers for OS in patients with non-APL-AML. Moreover, in ALL patients decreased levels of spontaneous apoptosis were associated with ED, although this was not a significant predictor of OS.
Collapse
|
12
|
Silva WFD, Massaut IHB, Bendlin RM, Rosa LI, Velloso EDRP, Rego EM, Rocha V. Toxicity Profile of PEG-Asparaginase in Adult Patients With Acute Lymphoblastic Leukemia in Brazil: A Multicenter Cross-Sectional Study. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 20:e523-e528. [PMID: 32389674 DOI: 10.1016/j.clml.2020.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 03/31/2020] [Accepted: 04/01/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Currently, pediatric-inspired regimens are commonly applied to adults with acute lymphoblastic leukemia (ALL) after the recent recognition that these protocols improve survival. While asparaginase in whatever available formulation is a key component of modern treatment of ALL, many adult oncologists and hematologists struggle to deal with its particular toxicities in clinical practice. We reviewed toxicity outcomes of pegylated asparaginase (PEG-ASP) in adults with ALL treated in 3 reference centers in Brazil. PATIENTS AND METHODS This was a cross-sectional retrospective chart-review study encompassing patients aged 15 years and older diagnosed with ALL or ambiguous-lineage leukemia who received at least one dose of PEG-ASP, regardless of the adopted regimen. RESULTS A total of 57 patients were included (age range, 15-57 years). Most patients (70%) received 2000 IU/m2 as the initial dose, by intravenous route (72%). The incidence of thromboembolic events was 17.5%, and the main site was cerebral venous sinus (4/10). Thrombosis was more frequent in patients receiving second-line treatment. In obese patients, grade 3 hepatotoxicity and hyperbilirubinemia were more common. Clinical pancreatitis (grade 3 or higher) was found in 2 of 57 cases. PEG-ASP had to be discontinued in 19.3% of exposed patients (11/57). CONCLUSION By reviewing the medical charts of adult patients with ALL from 3 reference centers, we found that our incidence of thrombotic and hepatic adverse events is similar to those reported in other trials involving PEG-ASP. Usually these effects should not preclude further use of the drug because most events are manageable in routine clinical practice.
Collapse
Affiliation(s)
- Wellington F da Silva
- Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil.
| | - Ires H B Massaut
- Hematologia, Centro de Pesquisas Oncológicas (CEPON), Florianópolis, Brazil
| | - Rodrigo M Bendlin
- Hematologia, Hospital de Clínicas da Universidade Federal do Paraná (UFPR), Curitiba, Brazil
| | - Lidiane I Rosa
- Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | - Elvira D R P Velloso
- Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | - Eduardo M Rego
- Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
| | - Vanderson Rocha
- Instituto do Câncer do Estado de São Paulo (ICESP), Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, Brazil
| |
Collapse
|
13
|
da Silva WF, da Rosa LI, Seguro FS, Silveira DRA, Bendit I, Buccheri V, Velloso EDRP, Rocha V, Rego EM. Salvage treatment for refractory or relapsed acute myeloid leukemia: a 10-year single-center experience. Clinics (Sao Paulo) 2020; 75:e1566. [PMID: 32294670 PMCID: PMC7134553 DOI: 10.6061/clinics/2020/e1566] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 01/27/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES The outcomes of refractory and relapsed acute myeloid leukemia (AML) patients in developing countries are underreported, even though the similar classic regimens are widely used. METHODS We conducted a retrospective comparison of "MEC" (mitoxantrone, etoposide, and cytarabine) and "FLAG-IDA" (fludarabine, cytarabine, idarubicin, and filgrastim) in adults with first relapse or refractory AML. RESULTS In total, 60 patients were included, of which 28 patients received MEC and 32 received FLAG-IDA. A complete response (CR) rate of 48.3% was observed. Of the included patients, 16 (27%) died before undergoing bone marrow assessment. No statiscally significant difference in CR rate was found between the two protocols (p=0.447). The median survival in the total cohort was 4 months, with a 3-year overall survival (OS) rate of 9.7%. In a multivariable model including age, fms-like tyrosine kinase 3 (FLT3) status, and stem-cell transplantation (SCT), only the last two indicators remained significant: FLT3-ITD mutation (hazard ratio [HR]=4.6, p<0.001) and SCT (HR=0.43, p=0.01). CONCLUSION In our analysis, there were no significant differences between the chosen regimens. High rates of early toxicity were found, emphasizing the role of supportive care and judicious selection of patients who are eligible for intensive salvage therapy in this setting. The FLT3-ITD mutation and SCT remained significant factors for survival in our study, in line with the results of previous studies.
Collapse
Affiliation(s)
- Wellington Fernandes da Silva
- Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Corresponding author. E-mail:
| | - Lidiane Inês da Rosa
- Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Fernanda Salles Seguro
- Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | | | - Israel Bendit
- Hematologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Valeria Buccheri
- Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | | | - Vanderson Rocha
- Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Eduardo M Rego
- Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| |
Collapse
|
14
|
Silva WFD, Garibaldi PMM, Rosa LID, Bellesso M, Clé DV, Delamain MT, Rego EM, Pereira J, Rocha V. Outcomes of HIV-associated Burkitt Lymphoma in Brazil: High treatment toxicity and refractoriness rates - A multicenter cohort study. Leuk Res 2019; 89:106287. [PMID: 31864677 DOI: 10.1016/j.leukres.2019.106287] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 11/30/2019] [Accepted: 12/09/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Although the increased use of combined antiretroviral therapy (cART) has decreased the incidence of lymphomas HIV-associated, Burkitt lymphoma (BL) incidence remains stable. Reported outcomes on HIV-associated BL from developed countries seem to corroborate that the regimens do not need to be tailored to the HIV-positive population. MATERIALS AND METHODS This is a retrospective multicenter cohort study from Brazil, including HIV-positive patients aged 15 years and above diagnosed with BL. RESULTS A total of 54 patients were included. Median age was 39 years (range, 15-64). At diagnosis, advanced disease was found in 86% and 52% had a CD4+ count lower than 200 cells/mm3. Five patients died before starting any regimen. Among the remaining 49 patients, most were treated with Hyper-CVAD (53%) and CODOX-M IVAC (18%). Rituximab was used in frontline in only 16% of the patients. Primary refractory disease was found in 14%. A treatment-related mortality of 38.7% and a complete response rate of 44.9% were found. At 4 years, estimated overall survival (OS) was 39.8%. All relapsed and primary refractory patients eventually died. Remaining patients died from infections (24/34), despite antimicrobial prophylaxis and associated cART. CONCLUSION Early mortality and toxicity were higher in our cohort than in developed countries. A faster diagnosis, better understanding of the biology of the disease, establishment of low toxicity regimens, inclusion of rituximab and improvement of supportive care may decrease the mortality of HIV-associated BL in developing countries.
Collapse
Affiliation(s)
- Wellington F da Silva
- Instituto do Cancer de Sao Paulo (ICESP), Universidade de São Paulo, Av. Dr. Arnaldo, 251 - Cerqueira César, São Paulo, SP, 01246-000, Brazil.
| | - Pedro Manoel Marques Garibaldi
- Hospital das Clínicas da Faculdade de Medicina de Ribeirao Preto (HCRP), Av. Bandeirantes, 3900 - Vila Monte Alegre, Ribeirão Preto, SP, 14049-900, Brazil
| | - Lidiane Inês da Rosa
- Instituto do Cancer de Sao Paulo (ICESP), Universidade de São Paulo, Av. Dr. Arnaldo, 251 - Cerqueira César, São Paulo, SP, 01246-000, Brazil; HEMOMED - Instituto de Oncologia e Hematologia, Av. Arnolfo Azevedo, 121 - Pacaembu, São Paulo, SP, 01236-030, Brazil
| | - Marcelo Bellesso
- Instituto do Cancer de Sao Paulo (ICESP), Universidade de São Paulo, Av. Dr. Arnaldo, 251 - Cerqueira César, São Paulo, SP, 01246-000, Brazil; HEMOMED - Instituto de Oncologia e Hematologia, Av. Arnolfo Azevedo, 121 - Pacaembu, São Paulo, SP, 01236-030, Brazil
| | - Diego Villa Clé
- Hospital das Clínicas da Faculdade de Medicina de Ribeirao Preto (HCRP), Av. Bandeirantes, 3900 - Vila Monte Alegre, Ribeirão Preto, SP, 14049-900, Brazil
| | - Márcia Torresan Delamain
- Hospital de Clínicas da Universidade Estadual de Campinas (Unicamp), R. Vital Brasil, 251 - Cidade Universitária, Campinas, SP, 13083-888, Campinas, Brazil
| | - Eduardo Magalhães Rego
- Instituto do Cancer de Sao Paulo (ICESP), Universidade de São Paulo, Av. Dr. Arnaldo, 251 - Cerqueira César, São Paulo, SP, 01246-000, Brazil; Laboratory of Medical Investigation on Pathogenesis and Targeted Therapy in Onco-immuno-hematology (LIM-31), Universidade de São Paulo, Av. Dr. Enéas Carvalho de Aguiar, 155 - Cerqueira César, São Paulo, SP, 05403-000, Brazil
| | - Juliana Pereira
- Instituto do Cancer de Sao Paulo (ICESP), Universidade de São Paulo, Av. Dr. Arnaldo, 251 - Cerqueira César, São Paulo, SP, 01246-000, Brazil; Laboratory of Medical Investigation on Pathogenesis and Targeted Therapy in Onco-immuno-hematology (LIM-31), Universidade de São Paulo, Av. Dr. Enéas Carvalho de Aguiar, 155 - Cerqueira César, São Paulo, SP, 05403-000, Brazil
| | - Vanderson Rocha
- Instituto do Cancer de Sao Paulo (ICESP), Universidade de São Paulo, Av. Dr. Arnaldo, 251 - Cerqueira César, São Paulo, SP, 01246-000, Brazil; Laboratory of Medical Investigation on Pathogenesis and Targeted Therapy in Onco-immuno-hematology (LIM-31), Universidade de São Paulo, Av. Dr. Enéas Carvalho de Aguiar, 155 - Cerqueira César, São Paulo, SP, 05403-000, Brazil
| |
Collapse
|