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Barwe SP, Kolb EA, Gopalakrishnapillai A. Down syndrome and leukemia: An insight into the disease biology and current treatment options. Blood Rev 2024; 64:101154. [PMID: 38016838 DOI: 10.1016/j.blre.2023.101154] [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: 09/15/2023] [Revised: 10/31/2023] [Accepted: 11/19/2023] [Indexed: 11/30/2023]
Abstract
Children with Down syndrome (DS) have a 10- to 20-fold greater predisposition to develop acute leukemia compared to the general population, with a skew towards myeloid leukemia (ML-DS). While ML-DS is known to be a subtype with good outcome, patients who relapse face a dismal prognosis. Acute lymphocytic leukemia in DS (DS-ALL) is considered to have poor prognosis. The relapse rate is high in DS-ALL compared to their non-DS counterparts. We have a better understanding about the mutational spectrum of DS leukemia. Studies using animal, embryonic stem cell- and induced pluripotent stem cell-based models have shed light on the mechanism by which these mutations contribute to disease initiation and progression. In this review, we list the currently available treatment strategies for DS-leukemias along with their outcome with emphasis on challenges with chemotherapy-related toxicities in children with DS. We focus on the mechanisms of initiation and progression of leukemia in children with DS and highlight the novel molecular targets with greater success in preclinical trials that have the potential to progress to the clinic.
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Affiliation(s)
- Sonali P Barwe
- Lisa Dean Moseley Institute for Cancer and Blood Disorders, Nemours Children's Health, Wilmington, Delaware, 19803, USA
| | - E Anders Kolb
- Lisa Dean Moseley Institute for Cancer and Blood Disorders, Nemours Children's Health, Wilmington, Delaware, 19803, USA
| | - Anilkumar Gopalakrishnapillai
- Lisa Dean Moseley Institute for Cancer and Blood Disorders, Nemours Children's Health, Wilmington, Delaware, 19803, USA.
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Rabin KR, Devidas M, Chen Z, Ji L, Kairalla J, Hitzler JK, Yang JJ, Carroll AJ, Heerema NA, Borowitz MJ, Wood BL, Roberts KG, Mullighan CG, Harvey RC, Chen IM, Willman CL, Reshmi SC, Gastier-Foster JM, Bhojwani D, Rheingold SR, Maloney KW, Mattano LA, Larsen EC, Schore RJ, Burke MJ, Salzer WL, Winick NJ, Carroll WL, Raetz EA, Loh ML, Hunger SP, Angiolillo AL. Outcomes in Children, Adolescents, and Young Adults With Down Syndrome and ALL: A Report From the Children's Oncology Group. J Clin Oncol 2024; 42:218-227. [PMID: 37890117 PMCID: PMC10824380 DOI: 10.1200/jco.23.00389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 07/05/2023] [Accepted: 08/29/2023] [Indexed: 10/29/2023] Open
Abstract
PURPOSE Patients with Down syndrome (DS) and B-ALL experience increased rates of relapse, toxicity, and death. We report results for patients with DS B-ALL enrolled on Children's Oncology Group trials between 2003 and 2019. METHODS We analyzed data for DS (n = 743) and non-DS (n = 20,067) patients age 1-30 years on four B-ALL standard-risk (SR) and high-risk trials. RESULTS Patients with DS exhibited more frequent minimal residual disease (MRD) ≥0.01% at end induction (30.8% v 21.5%; P < .001). This difference persisted at end consolidation only in National Cancer Institute (NCI) high-risk patients (34.0% v 11.7%; P < .0001). Five-year event-free survival (EFS) and overall survival (OS) were significantly poorer for DS versus non-DS patients overall (EFS, 79.2% ± 1.6% v 87.5% ± 0.3%; P < .0001; OS, 86.8% ± 1.4% v 93.6% ± 0.2%; P < .0001), and within NCI SR and high-risk subgroups. Multivariable Cox regression analysis of the DS cohort for risk factors associated with inferior EFS identified age >10 years, white blood count >50 × 103/μL, and end-induction MRD ≥0.01%, but not cytogenetics or CRLF2 overexpression. Patients with DS demonstrated higher 5-year cumulative incidence of relapse (11.5% ± 1.2% v 9.1% ± 0.2%; P = .0008), death in remission (4.9% ± 0.8% v 1.7% ± 0.1%; P < .0001), and induction death (3.4% v 0.8%; P < .0001). Mucositis, infections, and hyperglycemia were significantly more frequent in all patients with DS, while seizures were more frequent in patients with DS on high-risk trials (4.1% v 1.8%; P = .005). CONCLUSION Patients with DS-ALL exhibit an increased rate of relapse and particularly of treatment-related mortality. Novel, less-toxic therapeutic strategies are needed to improve outcomes.
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Affiliation(s)
| | | | | | - Lingyun Ji
- University of Southern California, Los Angeles, CA
| | | | | | - Jun J. Yang
- St Jude Children's Research Hospital, Memphis, TN
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Wanda L. Salzer
- US Army Medical Research and Materiel Command, Fort Detrick, MD
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Pieters R, de Groot-Kruseman H, Fiocco M, Verwer F, Van Overveld M, Sonneveld E, van der Velden V, Beverloo HB, Bierings M, Dors N, de Haas V, Hoogerbrugge P, Van der Sluis I, Tissing W, Veening M, Boer J, Den Boer M. Improved Outcome for ALL by Prolonging Therapy for IKZF1 Deletion and Decreasing Therapy for Other Risk Groups. J Clin Oncol 2023; 41:4130-4142. [PMID: 37459571 DOI: 10.1200/jco.22.02705] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 03/30/2023] [Accepted: 05/12/2023] [Indexed: 07/20/2023] Open
Abstract
PURPOSE The ALL10 protocol improved outcomes for children with ALL by stratifying and adapting therapy into three minimal residual disease-defined risk groups: standard risk, medium risk (MR), and high risk. IKZF1-deleted (IKZF1del) ALL in the largest MR group still showed poor outcome, in line with protocols worldwide, accounting for a high number of overall relapses. ALL10 showed high toxicity in Down syndrome (DS) and excellent outcome in ETV6::RUNX1 ALL. Poor prednisone responders (PPRs) were treated as high risk in ALL10. In ALL11, we prolonged therapy for IKZF1del from 2 to 3 years. We reduced therapy for DS by omitting anthracyclines completely, for ETV6::RUNX1 in intensification, and for PPR by treatment as MR. METHODS Eight hundred nineteen patients with ALL (age, 1-18 years) were enrolled on ALL11 and stratified as in ALL10. Results were compared with those in ALL10. RESULTS The five-year overall survival (OS), event-free survival (EFS), cumulative risk of relapse (CIR), and death in complete remission on ALL11 were 94.2% (SE, 0.9%), 89.0% (1.2), 8.2% (1.1), and 2.3% (0.6), respectively. Prolonged maintenance for IKZF1del MR improved 5-year CIR by 2.2-fold (10.8% v 23.4%; P = .035) and EFS (87.1% v 72.3%; P = .019). Landmark analysis at 2 years from diagnosis showed a 2.9-fold reduction of CIR (25.6%-8.8%; P = .008) and EFS improvement (74.4%-91.2%; P = .007). Reduced therapy did not abrogate 5-year outcome for ETV6::RUNX1 (EFS, 98.3%; OS, 99.4%), DS (EFS, 87.0%; OS, 87.0%), and PPR (EFS, 81.1%; OS, 94.9%). CONCLUSION Children with IKZF1del ALL seem to benefit from prolonged maintenance therapy. Chemotherapy was successfully reduced for patients with ETV6::RUNX1, DS, and PPR ALL. It has to be noted that these results were obtained in a nonrandomized study using a historical control group.
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Affiliation(s)
- Rob Pieters
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Dutch Childhood Oncology Group (DCOG), Utrecht, the Netherlands
| | - Hester de Groot-Kruseman
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Dutch Childhood Oncology Group (DCOG), Utrecht, the Netherlands
| | - Marta Fiocco
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Dutch Childhood Oncology Group (DCOG), Utrecht, the Netherlands
- Department of Biomedical Data Science, Section Medical Statistics, Leiden University Medical Center, Leiden, the Netherlands
- Mathematical Institute, Leiden University, Leiden, the Netherlands
| | - Femke Verwer
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Dutch Childhood Oncology Group (DCOG), Utrecht, the Netherlands
| | | | - Edwin Sonneveld
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Dutch Childhood Oncology Group (DCOG), Utrecht, the Netherlands
| | | | - H Berna Beverloo
- Department of Clinical Genetics, Erasmus MC, Rotterdam, the Netherlands
| | - Marc Bierings
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Dutch Childhood Oncology Group (DCOG), Utrecht, the Netherlands
| | - Natasja Dors
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Valérie de Haas
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Dutch Childhood Oncology Group (DCOG), Utrecht, the Netherlands
| | | | | | - Wim Tissing
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Margreet Veening
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Judith Boer
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Monique Den Boer
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
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Palmi C, Bresolin S, Junk S, Fazio G, Silvestri D, Zaliova M, Oikonomou A, Scharov K, Stanulla M, Moericke A, Zimmermann M, Schrappe M, Buldini B, Bhatia S, Borkhardt A, Saitta C, Galbiati M, Bardini M, Lo Nigro L, Conter V, Valsecchi MG, Biondi A, te Kronnie G, Cario G, Cazzaniga G. Definition and Prognostic Value of Ph-like and IKZF1plus Status in Children With Down Syndrome and B-cell Precursor Acute Lymphoblastic Leukemia. Hemasphere 2023; 7:e892. [PMID: 37304931 PMCID: PMC10256328 DOI: 10.1097/hs9.0000000000000892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 04/11/2023] [Indexed: 06/13/2023] Open
Abstract
Children with Down syndrome have an augmented risk for B-cell acute lymphoblastic leukemia (DS-ALL), which is associated with lower survival than in non-DS-ALL. It is known that cytogenetic abnormalities common in childhood ALL are less frequent in DS-ALL, while other genetic aberrancies (ie, CRLF2 overexpression and IKZF1 deletions) are increased. A possible cause for the lower survival of DS-ALL that we herewith evaluated for the first time was the incidence and prognostic value of the Philadelphia-like (Ph-like) profile and the IKZF1plus pattern. These features have been associated with poor outcome in non-DS ALL and therefore introduced in current therapeutic protocols. Forty-six out of 70 DS-ALL patients treated in Italy from 2000 to 2014 displayed Ph-like signature, mostly characterized by CRLF2 (n = 33) and IKZF1 (n = 16) alterations; only 2 cases were positive for ABL-class or PAX5-fusion genes. Moreover, in an Italian and German joint cohort of 134 DS-ALL patients, we observed 18% patients positive for IKZF1plus feature. Ph-like signature and IKZF1 deletion were associated with poor outcome (cumulative incidence of relapse: 27.7 ± 6.8% versus 13 ± 7%; P = 0.04 and 35.2 ± 8.6% versus 17 ± 3.9%; P = 0.007, respectively), which further worsens when IKZF1 deletion was co-occurring with P2RY8::CRLF2, qualifying for the IKZF1plus definition (13/15 patients had an event of relapse or treatment-related death). Notably, ex vivo drug screening revealed sensitivity of IKZF1plus blasts for drugs active against Ph-like ALL such as Birinapant and histone deacetylase inhibitors. We provided data in a large setting of a rare condition (DS-ALL) supporting that these patients, not associated with other high-risk features, need tailored therapeutic strategies.
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Affiliation(s)
- Chiara Palmi
- Tettamanti Center, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Silvia Bresolin
- Women’s and Children’s Health Department, Hematology-Oncology Clinic and Laboratory, University-Hospital of Padua, Italy
- Istituto di Ricerca Pediatrica-Città della Speranza, Padua, Italy
| | - Stefanie Junk
- Pediatric Hematology and Oncology, Hannover Medical School, Hannover, Germany
| | - Grazia Fazio
- Tettamanti Center, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Daniela Silvestri
- Tettamanti Center, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Marketa Zaliova
- Department of Paediatric Haematology and Oncology, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | | | - Katerina Scharov
- Department of Paediatric Oncology, Haematology and Clinical Immunology, Heinrich-Heine University Dusseldorf, Medical Faculty, Düsseldorf, Germany
| | - Martin Stanulla
- Pediatric Hematology and Oncology, Hannover Medical School, Hannover, Germany
| | - Anja Moericke
- Pediatrics, Christian-Albrechts-University and University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Martin Zimmermann
- Pediatric Hematology and Oncology, Hannover Medical School, Hannover, Germany
| | - Martin Schrappe
- Pediatrics, Christian-Albrechts-University and University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Barbara Buldini
- Women’s and Children’s Health Department, Hematology-Oncology Clinic and Laboratory, University-Hospital of Padua, Italy
- Istituto di Ricerca Pediatrica-Città della Speranza, Padua, Italy
| | - Sanil Bhatia
- Department of Paediatric Oncology, Haematology and Clinical Immunology, Heinrich-Heine University Dusseldorf, Medical Faculty, Düsseldorf, Germany
| | - Arndt Borkhardt
- Department of Paediatric Oncology, Haematology and Clinical Immunology, Heinrich-Heine University Dusseldorf, Medical Faculty, Düsseldorf, Germany
| | - Claudia Saitta
- Tettamanti Center, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Marta Galbiati
- Tettamanti Center, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Michela Bardini
- Tettamanti Center, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Luca Lo Nigro
- Center of Pediatric Hematology and Oncology, Azienda Policlinico-San Marco, Catania, Italy
| | - Valentino Conter
- Tettamanti Center, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Maria Grazia Valsecchi
- Statistics, University of Milan Bicocca, Monza, Italy
- Biostatistics and Clinical Epidemiology, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Andrea Biondi
- Pediatrics, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- School of Medicine and Surgery, University of Milan Bicocca, Italy
| | - Geertruy te Kronnie
- Women’s and Children’s Health Department, Hematology-Oncology Clinic and Laboratory, University-Hospital of Padua, Italy
| | - Gunnar Cario
- Pediatrics, Christian-Albrechts-University and University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Giovanni Cazzaniga
- Tettamanti Center, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- Medical Genetics, School of Medicine and Surgery, University of Milan Bicocca, Monza, Italy
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Roberts I. Leukemogenesis in infants and young children with trisomy 21. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:1-8. [PMID: 36485097 PMCID: PMC9820574 DOI: 10.1182/hematology.2022000395] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Children with Down syndrome (DS) have a greater than 100-fold increased risk of developing acute myeloid leukemia (ML) and an approximately 30-fold increased risk of acute lymphoblastic leukemia (ALL) before their fifth birthday. ML-DS originates in utero and typically presents with a self-limiting, neonatal leukemic syndrome known as transient abnormal myelopoiesis (TAM) that is caused by cooperation between trisomy 21-associated abnormalities of fetal hematopoiesis and somatic N-terminal mutations in the transcription factor GATA1. Around 10% of neonates with DS have clinical signs of TAM, although the frequency of hematologically silent GATA1 mutations in DS neonates is much higher (~25%). While most cases of TAM/silent TAM resolve without treatment within 3 to 4 months, in 10% to 20% of cases transformation to full-blown leukemia occurs within the first 4 years of life when cells harboring GATA1 mutations persist and acquire secondary mutations, most often in cohesin genes. By contrast, DS-ALL, which is almost always B-lineage, presents after the first few months of life and is characterized by a high frequency of rearrangement of the CRLF2 gene (60%), often co-occurring with activating mutations in JAK2 or RAS genes. While treatment of ML-DS achieves long-term survival in approximately 90% of children, the outcome of DS-ALL is inferior to ALL in children without DS. Ongoing studies in primary cells and model systems indicate that the role of trisomy 21 in DS leukemogenesis is complex and cell context dependent but show promise in improving management and the treatment of relapse, in which the outcome of both ML-DS and DS-ALL remains poor.
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Affiliation(s)
- Irene Roberts
- Correspondence Irene Roberts, Department of Paediatrics, MRC Molecular Haematology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, Headington, Oxford OX3 9DS, United Kingdom; e-mail: ,
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Athale U, Sutradhar R, Breakey VR, Li Q, Bassal M, Gibson P, Patel S, Wheaton L, Pole JD, Mittman N, Pechlivanoglou P, Gupta S. Healthcare utilization and costs associated with acute lymphoblastic leukemia in children with and without Down syndrome. Pediatr Blood Cancer 2022; 69:e29829. [PMID: 35674471 DOI: 10.1002/pbc.29829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 05/06/2022] [Accepted: 05/16/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Children with Down syndrome (DS) and acute lymphoblastic leukemia (ALL) are at increased risk of treatment-related morbidity and mortality compared to non-DS-ALL, requiring increased supportive care. We examined the healthcare utilization and costs in DS-ALL patients to inform future evaluations of novel therapies. METHODS A provincial registry identified all children (1-17 years) diagnosed with B-lineage ALL in Ontario, Canada between 2002 and 2012. Detailed demographic, disease, treatment, and outcome data were abstracted. Linkage to population-based health services databases identified all outpatient and emergency department (ED) visits, hospitalizations, and physician billings. Healthcare utilization costs were available for patients diagnosed during 2006-2012 using validated algorithms (2018 Canadian dollars). Healthcare utilization rates and costs were compared between DS and non-DS patients using regression models, adjusting for all covariates. RESULTS Of 711 patients, 28 (3.9%) had DS. Adjusting for all covariates, children with DS-ALL experienced substantially higher rates of ED visits (rate ratio [RR] 1.5, 95% confidence interval [95% CI]: 1.2-2.0; p = .001) and inpatient days (RR 2.5, 95% CI: 1.4-4.5; p = .002) compared to non-DS children. Outpatient visit rates were similar (RR 1.1, 95% CI: 0.9-1.3; p = .41). Among patients with available cost data (N = 533, DS = 19), median 5-year healthcare utilization cost was $247,700 among DS patients (interquartile range [IQR]: 200,900-354,500) and $196,200 among non-DS patients (IQR: 148,900-280,300; p = .02). In adjusted analyses, DS-associated costs were 50% higher (RR 1.5, 95% CI: 1.2-1.9; p < .002). CONCLUSIONS Healthcare utilization and treatment costs of DS-ALL patients are substantially higher than those of non-DS-ALL. Our data provide a baseline for future DS-specific cost-effectiveness studies.
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Affiliation(s)
- Uma Athale
- McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Rinku Sutradhar
- Cancer Research Program, ICES, Toronto, Ontario, Canada.,Institute for Health Policy, Evaluation and Management, University of Toronto, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | | | - Qing Li
- Cancer Research Program, ICES, Toronto, Ontario, Canada
| | - Mylene Bassal
- Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Paul Gibson
- McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Serina Patel
- London Health Sciences Centre, London, Ontario, Canada
| | - Laura Wheaton
- Kingston General Hospital, Kingston, Ontario, Canada
| | - Jason D Pole
- Cancer Research Program, ICES, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Center for Health Services Research, University of Queensland, Brisbane, Queensland, Australia
| | - Nicole Mittman
- Institute for Health Policy, Evaluation and Management, University of Toronto, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Petros Pechlivanoglou
- Institute for Health Policy, Evaluation and Management, University of Toronto, Toronto, Ontario, Canada.,Sickkids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sumit Gupta
- Cancer Research Program, ICES, Toronto, Ontario, Canada.,Institute for Health Policy, Evaluation and Management, University of Toronto, Toronto, Ontario, Canada.,Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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Staab A, Gakenheimer-Smith L, Boyer M, Harris A, Afify Z. Successful administration of CD19 chimeric antigen receptor T cells in association with severe cyanotic congenital heart disease. Pediatr Blood Cancer 2022; 69:e29671. [PMID: 35293676 DOI: 10.1002/pbc.29671] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 03/02/2022] [Indexed: 01/03/2023]
Affiliation(s)
- Ambur Staab
- School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | | | - Michael Boyer
- Division of Hematology Oncology, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Andrew Harris
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Zeinab Afify
- Division of Hematology Oncology, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
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Risk stratification for Down syndrome and acute lymphocytic leukaemia: one size does not fit all. LANCET HAEMATOLOGY 2021; 8:e673-e675. [PMID: 34560009 DOI: 10.1016/s2352-3026(21)00280-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 08/30/2021] [Indexed: 11/22/2022]
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