Autologous stem cell transplantation for acute lymphocytic leukemia in adults

Initial and late prognostic factors to predict survival in adult acute lymphoblastic leukaemia

Factors able to predict overall survival in adult patients with acute lymphoblastic leukaemia were assessed according to the period since initiation of the treatment using a Cox proportional hazards model. This period covers successively an initial period during the induction treatment and a consolidation period during the postinduction treatment. From 1994 to 2002, 922 patients with acute lymphoblastic leukaemia (excluding French-American-British L3 subtype) were enrolled in a multicentre protocol and followed, with a mean follow up of 58 months. A multivariate time-segmented analysis was performed on 658 patients. Analyses of the initial (before 100 d) and the late phases were realised after stratification on the type of induction treatment and on the different treatment strategies respectively. Age was the sole factor that influenced survival during the initial phase (hazard ratio 1.48 per 10-yr increase; P < 0.01). Factors that predicted survival during the late phase were age (hazard ratio 1.12, P = 0.02), white blood cells count (hazard ratio 1.01 per 10(10) cells/L increase; P < 0.05), lactic dehydrogenase level (hazard ratio 1.001 for 10 IU/L increase; P < 0.01) and t(9;22) karyotype or miscellaneous others vs. normal karyotype (hazard ratios 1.40; P < 0.01 and 1.06; P = 0.04 respectively). This analysis suggests that predictive factors may be split into tolerance factors and haematological factors. Determination of such factors is crucial to adapt postremission therapeutic strategies in acute lymphoblastic leukaemia.

Autologous stem cell transplantation in adults with acute lymphoblastic leukemia in first complete remission: analysis of the LALA-85, -87 and -94 trials

To evaluate the results of autologous stem cell transplantation (ASCT) in a large population of adults with acute lymphoblastic leukemia (ALL) in first complete remission (CR), we performed an individual data-based overview of the last three trials from the LALA group. Overall, 349 patients with ALL prospectively randomized in the consecutive LALA-85, -87, and -94 trials to receive either ASCT or chemotherapy as post-CR treatment were analyzed. Eligibility criteria were 15-50-year-old patients without sibling donors in both LALA-85/87 trials and 15-55-year-old patients with high-risk ALL and no sibling donors in the LALA-94 trial. Intent-to-treat analysis, which compared 175 patients from the ASCT arm to 174 patients from the chemotherapy arm, showed that ASCT was associated with a lower cumulative incidence of relapse (66 vs 78% at 10 years; P=0.05), without significant gain in disease-free or overall survival. Despite a possible lack of statistical power, a nested case-control analysis performed in 85 patient pairs adjusted for time to transplant and prognostic covariates confirmed these intent-to-treat results in patients actually transplanted. Of interest, the reduced relapse risk after ASCT translated in better disease-free survival in the 300 rapid responders who reached CR after the first induction course.

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.

Re-186 HEDP conditioning therapy in patients with advanced acute lymphoblastic leukemia before allogeneic bone marrow transplantation

The authors present their experience with dose calculation of Retin1,1-hydroxyethylidene-186-diphosphonate (Re-186 HEDP) therapy used as part of an intensified conditioning regimen before allogeneic stem cell transplantation in 2 patients with advanced acute lymphoblastic leukemia during the second partial or third complete remission. Kidneys were shielded during total-body irradiation (TBI) to limit the TBI-mediated renal radiation dose to 7 Gy. The aim of this dose calculation of Re-186 HEDP therapy was to deliver additional radiotherapy to the red bone marrow without exposing more than an additional 5 Gy to the kidneys in addition to the TBI standard dose of 12.6 Gy. Pretherapeutic kidney scintigraphy (Tc-99m mercaptoacetyltriglycine) showed normal results. Thus, dynamic Tc-99m methylene diphosphonate bone scintigraphy was used to calculate the expected bone marrow and kidney doses. A total amount of 8.8 GBq (238 mCi) Re-186 HEDP was given to patient no. 1 and 14.3 GBq (387 mCi) Re-186 HEDP was given to patient no. 2. Re-186 HEDP activity was monitored based on its gamma radiation measurement daily for 5 days in patient no. 1 and 7 days in patient no. 2. Therapeutic Re-186 isotope distribution and biologic half-life correlated well with the prediction by a pretherapeutic Tc-99m methylene diphosphonate scan. The calculated effective Re-186 bone marrow dose was 3.3 Gy for patient no. 1 and 5.6 Gy for patient no. 2. Effective kidney doses were 1.6 Gy and 2.1 Gy respectively. No unexpected complications occurred after completing conditioning and allogeneic stem cell transplantation. Posttransplant kidney function remained normal. Patient no. 1 remains in a second complete remission of his advanced acute lymphoblastic leukemia 18 months after HEDP therapy. Patient no. 2 relapsed 5 months after transplantation and eventually died as a result of progressive disease. The authors conclude that Re-186 HEDP will be able to increase the total additional bone marrow dose. In patients in whom the kidney dose is limited to 5 Gy in addition to TBI, doses near 10 Gy can be achieved on the bone marrow.

Risk assessment in adult acute lymphoblastic leukaemia before early haemopoietic stem cell transplantation with a geno-identical donor: an easy clinical prognostic score to identify patients who benefit most from allogeneic haemopoietic stem cell transplantation

In 1402 patients allografted in Europe during the period 1990-2000 with an HLA-identical sibling in first remission (CR1), the median interval from CR1 to allotransplant (96 days) was a major prognostic factor, patients transplanted earlier having a worse outcome. We studied in depth the 414 fully evaluable patients transplanted less than 96 days after achieving CR1; in these patients, only three factors predicted for the outcome by multivariate analysis: patient age, CR1 achievement with one or more induction courses and the recipient/donor sex combination. These three factors overcame the information from cytogenetics and source of stem cells. Three prognostic groups could be identified in relation to the outcome, using a prognostic score affecting 1 to each poor risk factor (total from 0 to 3): Group 1 (good prognosis) includes patients <35 years old, achieving CR1 with one induction course and to be transplanted with any other sex combination than female to male (score 0); group 2 (intermediate) with one adverse factor (score 1); and group 3 (bad prognosis) with two or three adverse criteria (scores 2 and 3). In these three groups, the 3-year leukaemia-free survival was 56+/-5%, 48+/-4% and 29+/-4% and the overall survival was 65+/-5, 53+/-4 and 29+/-5%, respectively. Therefore, adult patients with ALL and a score of 0 or 1 are good candidates for an early transplant if they have an identical sibling donor. Patient age, response to induction and the sex of the HLA-identical family donor (if existing) are the strongest easy predictors of the outcome for an early transplant in an adult patient with ALL. No additional information is mandatory.

Diagnosis, treatment, and nursing care of acute leukemia

OBJECTIVE

To review the clinical presentation, current methods of diagnosis and classification, treatment modalities, and novel treatment approaches of acute myelogenous and lymphoblastic leukemia.

DATA SOURCES

Professional journals, web sites, and books.

CONCLUSION

The incidence of acute leukemia is increasing. As the population ages, it is anticipated that an even greater number will be diagnosed with this malignancy. The development of monoclonal antibodies, the recognition of the benefit of graft versus leukemia effect, and targeted therapies have improved overall survival rates. Still, age remains a significant prognostic variable. More research is needed to improve both the quality and the quantity of life for these patients.

IMPLICATIONS FOR NURSING PRACTICE

Nurses must understand the rationale and implications of each phase of treatment to educate patients, administer treatments, manage side effects, and provide support throughout the continuum of care.

Autologous stem cell transplantation for adult acute leukemia

Autologous stem cell transplantation using marrow or peripheral blood is routinely used to consolidate patients with acute myelocytic leukemia in complete remission. The situation is less clear for adult acute lymphocytic leukemia in which results achieved with all strategies are disappointing. In acute myelocytic leukemia, autografts should be done in patients with good and standard risk factors. Patients with high-risk acute myelocytic leukemia defined by poor cytogenetics or failure to achieve remission with the first induction course, should proceed to allogeneic stem cell transplantation with the best available human leukocyte antigen-identical donor (family or unrelated), and the nature of the conditioning regimen (myelo-ablative or non-myelo-ablative) should be decided in relation to age, and the patient's clinical condition. Results of autografting in acute myelocytic leukemia rely strongly on the quality of the graft. Higher doses of infused stem cells translate into lower relapse rates. Marrow purging with cyclophosphamide derivatives also diminishes the relapse incidence. Autologous stem cell transplantations using peripheral blood are presently preferred to marrow as the source of stem cells, but an aggressive prior in vivo purge (high-dose consolidation course(s) before cytaphereses) is then mandatory. In good-risk acute myelocytic leukemia, autografting is superior to high-dose ARA-C; in standard-risk acute myelocytic leukemia, both are supposedly equivalent. There is no prospective randomized study testing the two approaches in the good-standard-risk population. We presently test the combination of marrow and blood both purged by mafosfamide. In adult acute lymphocytic leukemia, good-risk patients get the best benefit from autografting over conventional chemotherapy. Maintenance chemotherapy after transplant is likely to bring benefit. Research in progress aims at facilitating access of the largest number of patients to autografting and at introducing posttransplant immunomodulation maneuvers such as tumor vaccination.