Burkitt's acute lymphocytic leukemia (L3ALL) in adults

Intensive chemotherapy regimen (LMB86) for St Jude stage IV AIDS-related Burkitt lymphoma/leukemia: a prospective study

Prognosis of acquired immunodeficiency syndrome (AIDS)–related non-Hodgkin lymphoma has improved since the introduction of highly active antiretroviral therapy. Burkitt lymphomas (BLs) still have poor outcome in patients with bone marrow (BM) or central nervous system (CNS) involvement when treated with standard-dose chemotherapy. We have prospectively evaluated the LMB86 regimen in 63 human immunodeficiency virus (HIV)–infected patients with stage IV (BM and/or CNS involvement) BL consecutively recruited between November 1992 and January 2006. At BL diagnosis, the median CD4 cell count was 239 × 106/L (range, 16-1188 × 106/L). BM and CNS involvement were present in 55 (80%) and 48 (76%) patients, respectively. Forty-four patients (70%) achieved complete response. Seven treatment-related deaths occurred and all patients experienced severe BM toxicity. With a median follow-up of 66 months (range, 6-165 months), 11 patients relapsed. The estimate 2-year overall survival and disease-free survival were 47.1% (95% CI, 34-59.1) and 67.8% (95% CI, 51-80), respectively. We identified 2 poor prognosis factors: low CD4 count and ECOG more than 2. Patients with 0 or 1 factor had good outcome (2-year survival: 60%) contrasting with patients with 2 factors (2-year survival: 12%). We conclude that LMB86 regimen is highly effective in advanced HIV-related BL and should be proposed for patients with CD4 count higher than 200 × 106/L or ECOG of 2 or less.

Adult acute lymphoblastic leukaemia

Acute lymphoblastic leukaemia (ALL) in adults is a relatively rare neoplasm with a curability rate around 30% at 5 years. This consideration makes it imperative to dissect further the biological mechanisms of disease, in order to selectively implement an hitherto unsatisfactory success rate. The recognition of discrete ALL subtypes (some of which deserve specific therapeutic approaches, like T-lineage ALL (T-ALL) and mature B-lineage ALL (B-ALL)) is possible through an accurate combination of cytomorphology, immunophenotytpe and cytogenetic assays and has been a major result of clinical research studies conducted over the past 20 years. Two-three major prognostic groups are now easily identifiable, with a survival probability ranging from <10 to 20% (Philadelphia-positive ALL) to about 50-60% (low-risk T-ALL and selected patients with B-lineage ALL). These issues are extensively reviewed and form the basis of current knowledge. The second major point relates to the emerging importance of studies that reveal a dysregulated gene activity and its clinical counterpart. It is now clear that prognostication is a complex matter ranging from patient-related issues to cytogenetics to molecular biology, including the evaluation of minimal residual disease (MRD) and possibly gene array tests. On these bases, the role of a correct, highly personalised therapeutic choice will soon become fundamental. Therapeutic progress may be obtainable through a careful integration of chemotherapy, stem cell transplantation, and the new targeted treatments with highly specific metabolic inhibitors and humanised monoclonal antibodies.

Galloping Ophthalmoplegia and Numb Chin in Burkitt Lymphoma

A 57-year-old man developed complete bilateral ophthalmoplegia over a period of 10 days, together with bilateral facial pain and numbness of the chin. He had no other clinical manifestations. Findings on brain magnetic resonance imaging and spinal fluid formula from the first lumbar puncture were normal, but cerebrospinal fluid flow cytometry disclosed a kappa restriction monoclonal B-cell population, indicating malignant lymphoma. Computed tomography of the chest, abdomen, and pelvis then revealed multiple enlarged lymph nodes. Biopsy of an inguinal node showed findings consistent with Burkitt lymphoma. Within six weeks, intravenous and intrathecal chemotherapy resolved all neurologic findings except a partial right-side sixth nerve palsy and mild chin numbness. Eighteen months after disease onset, the patient remained in remission. Meningeal spread of Burkitt lymphoma is not commonly a presenting feature in immunocompetent adults. Chin numbness, a characteristic feature caused by infiltration of the mental nerve, should facilitate earlier recognition, which may be life saving.

The biology and therapy of adult acute lymphoblastic leukemia

BACKGROUND

Much progress has been made in understanding the biology of acute lymphoblastic leukemia (ALL). This has translated into the recognition of several subgroups of ALL and the institution of risk-adapted therapies. New therapies are emerging based on the definition of specific cytogenetic-molecular abnormalities.

METHODS

A review from the English literature, including original articles and related reviews from Medline (Pubmed) and abstracts based on publication of meeting material, was performed.

RESULTS

Changes in the pathologic classification of ALL have led to therapeutic consequences. Adaptation of successful treatment strategies in children with ALL has resulted in similar complete response rates in adults. Prognosis has especially improved in mature-B-cell and T-lineage ALL. The role of tyrosine kinase inhibitors in Philadelphia chromosome-positive ALL was evaluated in the current study. However, regardless of the ALL subgroup, long-term survival of adults is still inferior to that in children.

CONCLUSIONS

Intense clinical and laboratory research is attempting to close the gap in outcome between children and adults with ALL. Investigations are focusing on 1) refinement of the basic treatment stratagem of induction, consolidation, and maintenance; 2) expansion of risk-based, subgroup-oriented therapies; 3) assessment of minimal residual disease, its impact on disease recurrence, and its practical implications in clinical practice; 4) salvage strategies; 5) the role of stem cell transplantation in ALL; and 6) the development of new drugs based on a better understanding of disease biology.

Burkitt's and Burkitt-like lymphoma

Burkitt's and Burkitt-like lymphoma (BL/BLL) are aggressive B-cell malignancies with a high proliferative rate that may be fatal within months if not treated promptly. Furthermore, treatment of BL/BLL requires comprehensive supportive care to avoid disease-related complications such as acute renal failure secondary to tumor lysis syndrome. Improvements in our understanding of the biology of BL and BLL have led to more effective therapeutic protocols. Clinical trials have demonstrated that short duration, multi-agent, dose-intensive chemotherapy regimens combined with aggressive central nervous system therapy results in long-term survival rates in children and young adults near 70% to 80%, whereas long-term disease-free survival rates in older adults remains suboptimal at 15% to 25%. Outcomes in HIV-associated BL/BLL are improved because of more effective chemotherapy regimens and enhanced HIV care. Autologous bone marrow transplantation has proven feasible in many patient populations with BL/BLL and may lead to cure in selected patients. Improved therapeutic strategies are warranted, such as integrating agents such as monoclonal antibodies to combination dose-intensive chemotherapy. Moreover, further study into the molecular biology of BL/BLL with attention to the role of c-myc dysregulation is needed to help predict prognostic factors and for the development of molecular targeted therapies. Clinical trials remain critical to determine the most effective treatment regimens that will continue to improve cure rates in this aggressive but treatable disease.