1
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Haddad FG, Sasaki K, Senapati J, Xiao L, Park G, Abuasab T, Venugopal S, Rivera D, Bazinet A, Babakhanlou R, Kim K, Ong F, Desikan S, Pemmaraju N, Loghavi S, Borthakur G, DiNardo C, Abbas HA, Short NJ, Daver N, Jabbour E, Garcia-Manero G, Ravandi F, Kantarjian H, Kadia T. Outcomes of Patients With Newly Diagnosed AML and Hyperleukocytosis. JCO Oncol Pract 2024:OP2400027. [PMID: 39013130 DOI: 10.1200/op.24.00027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 05/03/2024] [Accepted: 06/07/2024] [Indexed: 07/18/2024] Open
Abstract
PURPOSE AML presenting with hyperleukocytosis is associated with poor outcomes. We aim to understand the factors associated with early mortality and overall survival (OS) to help guide management and improve early mortality. METHODS We retrospectively reviewed data from 129 consecutive patients with newly diagnosed AML and a WBC count ≥100 × 109/L between January 2010 and April 2020. Logistic regression models estimated odds ratios for 4-week mortality. Cox proportional hazard models estimated hazard ratios for OS. RESULTS The median age was 65 years (range, 23-86); the median WBC was 146 × 109/L (range, 100-687). Seventy-five (58%) patients had clinical leukostasis (CL). FLT3, NPM1, and RAS pathway mutations were detected in 63%, 45%, and 27% of patients, respectively. Cytoreduction consisted of hydroxyurea in 124 (96%) patients, cytarabine in 69 (54%), and leukapheresis in 31 (24%). The cumulative 4-week and 8-week mortality rates were 9% and 13%, respectively, all in patients age 65 years and older. By multivariate analysis, older age, CL, and thrombocytopenia <40 × 109/L were independently associated with a higher 4-week mortality rate. After a median follow-up of 49.4 months, the median OS was 14.3 months (95% CI, 7 to 21.6), with 4-year OS of 29%. Age 65 years and older, CL, tumor lysis syndrome, elevated LDH ≥2,000 U/L, elevated lactate ≥2.2 mmol/L, and poor-risk cytogenetics were independent factors associated with worse OS. CONCLUSION Hyperleukocytosis is a life-threatening hematologic emergency. Early recognition and intervention including cytoreduction, blood product support, antibiotics, and renal replacement therapy may help mitigate the risk of morbidity and early mortality.
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Affiliation(s)
- Fadi G Haddad
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Koji Sasaki
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jayastu Senapati
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lianchun Xiao
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Grace Park
- Department of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Tareq Abuasab
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sangeetha Venugopal
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Daniel Rivera
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Alexandre Bazinet
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Rodrick Babakhanlou
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kunhwa Kim
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Faustine Ong
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sai Desikan
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sanam Loghavi
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Gautam Borthakur
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Courtney DiNardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Hussein A Abbas
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Naval Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Tapan Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
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2
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Lafarge A, Chean D, Whiting L, Clere-Jehl R. Management of hematological patients requiring emergency chemotherapy in the intensive care unit. Intensive Care Med 2024; 50:849-860. [PMID: 38748265 PMCID: PMC11164740 DOI: 10.1007/s00134-024-07454-z] [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: 02/27/2024] [Accepted: 04/18/2024] [Indexed: 05/30/2024]
Abstract
Hematological malignancies may require rapid-onset treatment because of their short doubling time, notably observed in acute leukemias and specific high-grade lymphomas. Furthermore, in targeted onco-hematological scenarios, chemotherapy is deemed necessary as an emergency measure when facing short-term, life-threatening complications associated with highly chemosensitive hematological malignancies. The risks inherent in the disease itself, or in the initiation of treatment, may then require admission to the intensive care unit (ICU) to optimize monitoring and initial management protocols. Hyperleukocytosis and leukostasis in acute leukemias, tumor lysis syndrome, and disseminated intravascular coagulation are the most frequent onco-hematological complications requiring the implementation of emergency chemotherapy in the ICU. Chemotherapy must also be started urgently in secondary hemophagocytic lymphohistiocytosis. Tumor-induced microangiopathic hemolytic anemia and plasma hyperviscosity due to malignant monoclonal gammopathy represent infrequent yet substantial indications for emergency chemotherapy. In all cases, the administration of emergency chemotherapy in the ICU requires close collaboration between intensivists and hematology specialists. In this review, we provide valuable insights that aid in the identification and treatment of patients requiring emergency chemotherapy in the ICU, offering diagnostic tools and guidance for their overall initial management.
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Affiliation(s)
- Antoine Lafarge
- Médecine Intensive et Réanimation, APHP, Saint-Louis Hospital and Paris University, Paris, France.
| | - Dara Chean
- Médecine Intensive et Réanimation, APHP, Saint-Louis Hospital and Paris University, Paris, France
| | - Livia Whiting
- Médecine Intensive et Réanimation, APHP, Saint-Louis Hospital and Paris University, Paris, France
| | - Raphaël Clere-Jehl
- Médecine Intensive et Réanimation, Hôpital de Hautepierre, University Hospital of Strasbourg, Strasbourg, France
- Laboratoire d'ImmunoRhumatologie Moléculaire, INSERM (French National Institute of Health and Medical Research), UMR_S1109, Centre de Recherche d'Immunologie et d'Hématologie, University of Strasbourg, Strasbourg, France
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3
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Mack EA, Dougher MC, Ginda AM, Cahill C, Murter M, Schell K, Tanhehco YC, Bhoj VG, Fesnak AD, Siegel DL, Kambayashi T, Aqui NA, O'Doherty U. Red cell exchange for rapid leukoreduction in adults with hyperleukocytosis and leukostasis. Blood 2024; 143:1049-1054. [PMID: 38052031 DOI: 10.1182/blood.2023021895] [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: 07/21/2023] [Revised: 11/16/2023] [Accepted: 11/22/2023] [Indexed: 12/07/2023] Open
Abstract
ABSTRACT We show that red cell exchange (RCE) treats hyperleukocytosis in acute leukemia. RCE provided similar leukoreduction to standard therapeutic leukoreduction and could be superior in patients with severe anemia or monocytic leukemias or when requiring rapid treatment.
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Affiliation(s)
- Ethan A Mack
- Division of Transfusion Medicine and Therapeutic Pathology, Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Meaghan C Dougher
- Division of Transfusion Medicine and Therapeutic Pathology, Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Ashley M Ginda
- Division of Transfusion Medicine and Therapeutic Pathology, Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Caitlin Cahill
- Division of Transfusion Medicine and Therapeutic Pathology, Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Melissa Murter
- Division of Transfusion Medicine and Therapeutic Pathology, Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Kevin Schell
- Division of Transfusion Medicine and Therapeutic Pathology, Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Yvette C Tanhehco
- Division of Transfusion Medicine and Cellular Therapy, Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, NY
| | - Vijay G Bhoj
- Division of Transfusion Medicine and Therapeutic Pathology, Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Andrew D Fesnak
- Division of Transfusion Medicine and Therapeutic Pathology, Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Don L Siegel
- Division of Transfusion Medicine and Therapeutic Pathology, Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Taku Kambayashi
- Division of Transfusion Medicine and Therapeutic Pathology, Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Nicole A Aqui
- Division of Transfusion Medicine and Therapeutic Pathology, Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Una O'Doherty
- Division of Transfusion Medicine and Therapeutic Pathology, Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
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4
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Shah CV, Badra S, Farhadfar N. Role of leukapheresis in the management of acute kidney injury associated with hyperleukocytosis of acute myeloid leukemia. Clin Kidney J 2024; 17:sfad284. [PMID: 38213497 PMCID: PMC10783240 DOI: 10.1093/ckj/sfad284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Indexed: 01/13/2024] Open
Affiliation(s)
- Chintan V Shah
- Division of Nephrology, Hypertension, and Renal Transplantation, University of Florida College of Medicine, Gainesville, FL, USA
| | - Sherif Badra
- Division of Nephrology, Hypertension, and Renal Transplantation, University of Florida College of Medicine, Gainesville, FL, USA
| | - Nosha Farhadfar
- Division of Hematology & Oncology, University of Florida College of Medicine, Gainesville, FL, USA
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5
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Corbingi A, Putzulu R, Massini G, Colangelo M, Minnella G, Chiusolo P, Sica S, Piccirillo N. Genetic mutations and leukapheresis in acute myeloid leukemia: is there a link? Ann Hematol 2023; 102:2735-2740. [PMID: 37592090 DOI: 10.1007/s00277-023-05414-z] [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: 03/08/2023] [Accepted: 08/10/2023] [Indexed: 08/19/2023]
Abstract
Acute myeloid leukemia is the most common acute leukemia in adults and up to 20% of patients present with hyperleukocytosis at the onset of the disease. The therapeutic approach involves medical support, cytoreductive treatment, and/or leukapheresis. Despite WBC count greater than 100.000/μL, not all patients develop symptoms. To clarify the role of leukapheresis in the setting of hyperleukocytotic AML, we aimed to find associations between AML morphologic subtypes and molecular alterations on presence or absence of leukostasis symptoms (and hence therapeutic vs prophylactic leukapheresis) and clinical outcomes in the cohort of 41 patients at our single center who underwent leukapheresis for hyperleukocytotic AML. There was a trend for increased WBC count, 30-day mortality, M4-M5 AML subtypes, and number of leukapheresis procedures performed in symptomatic hyperleukocytotic pts. No molecular marker was significantly associated with presence or absence of leukostasis symptoms due to small sample size, though there was a trend for increased NPM1-mutated and NPM1 + FLT3-mutated AML in asymptomatic patients and a greater proportion of symptomatic patients who were negative for all assessed molecular alterations. In conclusion, leukapheresis combined with cytoreductive treatment represents a synergic and efficient approach in the management of hyperleukocytosis especially in symptomatic patients considering the higher mortality independently from the presence of specific clonal markers whose distribution among the two groups may result more considerable with a higher number of patients.
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Affiliation(s)
- Andrea Corbingi
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, L.go A.Gemelli, 8, 00168, Rome, Italy.
| | - Rossana Putzulu
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, L.go A.Gemelli, 8, 00168, Rome, Italy
| | - Giuseppina Massini
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, L.go A.Gemelli, 8, 00168, Rome, Italy
| | - Maria Colangelo
- UOC Genetica Medica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Gessica Minnella
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, L.go A.Gemelli, 8, 00168, Rome, Italy
| | - Patrizia Chiusolo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, L.go A.Gemelli, 8, 00168, Rome, Italy
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Simona Sica
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, L.go A.Gemelli, 8, 00168, Rome, Italy
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Nicola Piccirillo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, L.go A.Gemelli, 8, 00168, Rome, Italy
- Sezione di Ematologia, Dipartimento di Scienze Radiologiche ed Ematologiche, Università Cattolica del Sacro Cuore, Rome, Italy
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6
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Heger JM, Böll B, Naendrup JH, Simon F, Gräf CM, Hallek M, Shimabukuro-Vornhagen A, Kochanek M, Eichenauer DA, Garcia Borrega J. Hyperleukocytosis in patients with acute myeloid leukemia admitted to the intensive care unit: a single-center retrospective analysis. Leuk Res 2023; 132:107352. [PMID: 37423072 DOI: 10.1016/j.leukres.2023.107352] [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: 03/24/2023] [Revised: 06/30/2023] [Accepted: 07/03/2023] [Indexed: 07/11/2023]
Abstract
A relevant proportion of patients with acute myeloid leukemia (AML) presenting with hyperleukocytosis are admitted to the intensive care unit (ICU). However, data on characteristics and outcomes of these patients are limited. We therefore conducted a single-center retrospective analysis including 69 consecutive AML patients with a white blood cell (WBC) count > 100.000/µl who had been treated on the ICU between 2011 and 2020. The median age was 63 years (range: 14-87 years). Males accounted for the majority of cases (n = 43; 62.3%). Mechanical ventilation (MV), renal replacement therapy and the use of vasopressors were necessary in 34.8%, 8.7% and 40.6% of patients, respectively. Cardiopulmonary resuscitation was performed in 15.9% of patients. The ICU, hospital, 90-day and 1-year survival rates were 53.6%, 43.5%, 42% and 30.4%, respectively. Age (p = 0.002), SOFA score (p < 0.001) and MV (p < 0.001) were independently associated with a reduced survival probability. A score comprising the factors age > 70 years, lactate dehydrogenase level > 1500 U/l, WBC count > 150.000/µl, elevated lactate level and SOFA score > 7 allowed the discrimination of 3 distinct risk groups (low-risk: 0-1 points, intermediate-risk: 2 points, high-risk: 3-5 points) with regard to survival (p < 0.0001). Taken together, the present analysis indicates that more than two-thirds of AML patients with hyperleukocytosis treated on the ICU die within 1 year. However, outcomes vary considerably depending on the presence of risk factors.
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Affiliation(s)
- Jan-Michel Heger
- University of Cologne, First Department of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, Cologne, Germany
| | - Boris Böll
- University of Cologne, First Department of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, Cologne, Germany
| | - Jan-Hendrik Naendrup
- University of Cologne, First Department of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, Cologne, Germany
| | - Florian Simon
- University of Cologne, First Department of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, Cologne, Germany
| | - Claus Moritz Gräf
- University of Cologne, First Department of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, Cologne, Germany
| | - Michael Hallek
- University of Cologne, First Department of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, Cologne, Germany
| | - Alexander Shimabukuro-Vornhagen
- University of Cologne, First Department of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, Cologne, Germany
| | - Matthias Kochanek
- University of Cologne, First Department of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, Cologne, Germany
| | - Dennis A Eichenauer
- University of Cologne, First Department of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, Cologne, Germany.
| | - Jorge Garcia Borrega
- University of Cologne, First Department of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf, Cologne, Germany
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7
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Ai J. Take a spin: Apheresis in the care of adult leukaemia patients. Best Pract Res Clin Haematol 2023; 36:101467. [PMID: 37353291 DOI: 10.1016/j.beha.2023.101467] [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: 04/09/2023] [Accepted: 04/11/2023] [Indexed: 06/25/2023]
Abstract
Apheresis is an automated process to separate the whole blood of a patient or a donor, collect or remove specific blood components, and return the remaining back to the individual. Apheresis is an integral part of blood and marrow transplantation and has been increasingly utilized in novel cellular therapies for a variety of blood disorders. This review uses clinical cases to highlight the multiple roles of apheresis in the care of adult leukaemia patients, including therapeutic leukapheresis in hyperleukocytosis, mobilized peripheral blood hematopoietic progenitor cell collection in donors, mononucleated cell collection in preparation of donor lymphocyte infusion or chimeric antigen receptor T cells manufacture, and extracorporeal photopheresis in the treatment of graft versus host diseases.
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Affiliation(s)
- Jing Ai
- Transplant and Cellular Therapy Program, Levine Cancer Institute, Atrium Health, 1021 Morehead Medical Drive, LCI 2, Charlotte, NC, 28204, USA.
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8
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Wolf J, Thomas I, Stanworth S, Knapper S, Griffin J. Leukocytapheresis in the management of adults with acute myeloid leukaemia: A survey of AML treating centres highlighting variability in practice. Transfus Med 2023; 33:181-187. [PMID: 36260030 DOI: 10.1111/tme.12929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 09/01/2022] [Accepted: 10/03/2022] [Indexed: 12/01/2022]
Affiliation(s)
| | - Ian Thomas
- Centre for Trials Research, School of Medicine, Cardiff University, Cardiff, UK
| | - Simon Stanworth
- Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- University of Oxford, Oxford, UK
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9
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Macaron W, Sargsyan Z, Short NJ. Hyperleukocytosis and leukostasis in acute and chronic leukemias. Leuk Lymphoma 2022; 63:1780-1791. [DOI: 10.1080/10428194.2022.2056178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Walid Macaron
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zaven Sargsyan
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Nicholas J. Short
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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10
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Kim K, Konopleva M, DiNardo CD, Borthakur G, Loghavi S, Tang G, Daver N, Pemmaraju N, Jabbour E, Rausch CR, Yilmaz M, Sasaki K, Short NJ, Jain N, Brandt M, Pierce S, Garcia‐Manero G, Ravandi F, Kantarjian H, Kadia TM. Urgent cytoreduction for newly diagnosed acute myeloid leukemia patients allows acquisition of pretreatment genomic data and enrollment on investigational clinical trials. Am J Hematol 2022; 97:885-894. [PMID: 35413152 DOI: 10.1002/ajh.26572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/15/2022] [Accepted: 04/11/2022] [Indexed: 11/11/2022]
Abstract
Newly diagnosed acute myeloid leukemia is often deemed a medical emergency, requiring urgent treatment. This is in contradiction with the need for accurate cytogenetic and molecular data, which is not immediately available, to select optimal therapy. We hypothesized that cytoreduction with hydroxyurea or cytarabine would enable urgent disease control and provide a bridge to clinical trial enrollment. We analyzed three prospective frontline clinical trials that allowed the use of cytoreduction before treatment initiation. Among 274 patients with a median age of 62 (range, 18-89), there was no significant difference in short- and long-term outcome and safety among patients who did (CytoRed) or did not receive (NoCytoRed) cytoreduction. The overall response rate in CytoRed group was 91%, compared with 86% in NoCytoRed group (p = .264). The 30- and 60-day mortality rates were 2% and 7% in CytoRed group, compared with 2% (p = .978) and 6% (p = .652) in NoCytoRed group, respectively. There was no significant difference in overall survival (OS) between in CytoRed group compared with NoCytoRed group (Hazard ratio 0.97, 95% CI 0.70-1.37, p = .879). Results were unchanged after stratification by age (< or ≥65 years) or after multivariate analyses for OS. Our data suggests that urgent cytoreduction using hydroxyurea or cytarabine is a feasible and safe approach to facilitate acquisition of complete diagnostic information prior to treatment initiation on a clinical trial.
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Affiliation(s)
- Kunhwa Kim
- Department of Leukemia The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Marina Konopleva
- Department of Leukemia The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Courtney D. DiNardo
- Department of Leukemia The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Gautam Borthakur
- Department of Leukemia The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Sanam Loghavi
- Department of Hematopathology The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Guilin Tang
- Department of Hematopathology The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Naval Daver
- Department of Leukemia The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Naveen Pemmaraju
- Department of Leukemia The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Elias Jabbour
- Department of Leukemia The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Caitlin R. Rausch
- Department of Leukemia The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Musa Yilmaz
- Department of Leukemia The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Koji Sasaki
- Department of Leukemia The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Nicholas J. Short
- Department of Leukemia The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Nitin Jain
- Department of Leukemia The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Mark Brandt
- Department of Leukemia The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Sherry Pierce
- Department of Leukemia The University of Texas MD Anderson Cancer Center Houston Texas USA
| | | | - Farhad Ravandi
- Department of Leukemia The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Hagop Kantarjian
- Department of Leukemia The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Tapan M. Kadia
- Department of Leukemia The University of Texas MD Anderson Cancer Center Houston Texas USA
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11
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Rinaldi I, Sutandyo N, Winston K. Comparison of early mortality between leukapheresis and non-leukapheresis in adult acute myeloid leukemia patients with hyperleukocytosis: a systematic review and meta-analysis. Hematology 2022; 27:141-149. [DOI: 10.1080/16078454.2021.2024939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Ikhwan Rinaldi
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Cipto Mangunkusumo National General Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Noorwati Sutandyo
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Dharmais National Cancer Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Kevin Winston
- Department of Internal Medicine, Cipto Mangunkusumo National General Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
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12
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Ngo RT, Webb McAdams AL, Furiato A. Acute Myeloid Leukemia Complicated by Hyperleukocytosis and Leukostasis in the Emergency Department. Cureus 2021; 13:e15392. [PMID: 34094792 PMCID: PMC8171272 DOI: 10.7759/cureus.15392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Acute myeloid leukemia (AML) and other hematologic malignancies can be complicated by hyperleukocytosis, which leads to an increased risk for other severe complications such as tumor lysis syndrome, disseminated intravascular coagulation (DIC), and leukostasis. In this report, we present a case of a 65-year-old female with newly diagnosed AML complicated by leukostasis. We briefly review the clinical significance as well as initial diagnostic and therapeutic considerations pertaining to hyperleukocytosis and its associated complications.
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Affiliation(s)
- Ryan T Ngo
- Emergency Medicine, Brandon Regional Hospital, Brandon, USA
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13
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Göçer M, Kurtoğlu E. Effect of prophylactic leukapheresis on early mortality and overall survival in acute leukemia patients with hyperleukocytosis. Ther Apher Dial 2021; 25:697-703. [PMID: 33686785 DOI: 10.1111/1744-9987.13645] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 03/02/2021] [Accepted: 03/05/2021] [Indexed: 11/30/2022]
Abstract
Hyperleukocytosis has been associated with early mortality owing to the presence of complications including leukostasis, tumor lysis syndrome (TLS), and disseminated intravascular coagulation (DIC). Leukapheresis is a fast and effective cytoreductive procedure that removes leukocytes from the peripheral circulation. This single-center, retrospective, and observational study included 32 patients diagnosed with acute leukemia who underwent leukapheresis due to hyperleukocytosis between 2014 and 2020. This study primarily aimed to investigate the effect of prophylactic leukapheresis on early mortality and overall survival (OS). In the symptomatic group, seven and two patients died in the first and second weeks, respectively. In the prophylactic leukapheresis group, two and one patients died in the first and second weeks (p = 0.792), respectively. OS was significantly longer in the prophylactic leukapheresis group (p = 0.004). The leukapheresis procedure appears to be effective on early mortality and OS. Initiation of prophylactic leukapheresis before the appearance of leukostasis symptoms is effective on OS and possibly early mortality.
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Affiliation(s)
- Mesut Göçer
- Department of Internal Medicine, Division of Hematology, Antalya Training and Research Hospital, Antalya, Turkey
| | - Erdal Kurtoğlu
- Department of Internal Medicine, Division of Hematology, Antalya Training and Research Hospital, Antalya, Turkey
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14
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The factors influencing clinical outcomes after leukapheresis in acute leukaemia. Sci Rep 2021; 11:6426. [PMID: 33742034 PMCID: PMC7979875 DOI: 10.1038/s41598-021-85918-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 03/08/2021] [Indexed: 12/01/2022] Open
Abstract
Leukapheresis is used for the mechanical removal of leukaemic cells in hyperleukocytosis. However, the effectiveness of leukapheresis remains unclear due to selection and confounding factors in the cohorts. We compared the effectiveness of leukapheresis among the subgroups according to either the 2016 World Health Organization classification or the number of cytogenetic abnormalities with a retrospective, single-centre study from January 2009 to December 2018. Acute myeloid leukaemia (AML, n = 212) and acute lymphoblastic leukaemia (ALL, n = 97) were included. The 30-day survival rates (95% confidence interval, 95% CI) for AML and ALL were 86.3% (81.6–90.9%) and 94.8% (90.3–99.2%), respectively. For AML, ‘primary AML with myelodysplasia-related changes’ and ‘AML with biallelic mutation of CEBPA’ showed better 30-day survival outcomes (P = 0.026) than the other subgroups. A higher platelet count after leukapheresis was associated with better 30-day survival in AML patients (P = 0.029). A decrease in blast percentage count after leukapheresis was associated with better 30-day survival in ALL patients (P = 0.034). Our study suggested that prophylactic platelet transfusion to raise the platelet count to 50 × 109/L or greater might improve clinical outcome in AML patients undergoing leukapheresis.
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15
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Connelly-Smith L, Linenberger ML. Leukocytapheresis for AML hyperleukocytosis: Failing to make the grade. Transfusion 2021; 60:2161-2163. [PMID: 33615498 DOI: 10.1111/trf.16091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 09/08/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Laura Connelly-Smith
- Seattle Cancer Care Alliance and Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington, USA
| | - Michael L Linenberger
- Seattle Cancer Care Alliance and Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington, USA
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16
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Zhao J, Bewersdorf JP, Jaszczur S, Kowalski A, Perreault S, Schiffer M, Gore S, Podoltsev N, Prebet T, Shallis R, Zeidan AM. High dose cyclophosphamide for cytoreduction in patients with acute myeloid leukemia with hyperleukocytosis or leukostasis. Leuk Lymphoma 2020; 62:1195-1202. [PMID: 33325761 DOI: 10.1080/10428194.2020.1856835] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Hyperleukocytosis may lead to multiple medical emergencies. Hydroxyurea, intensive chemotherapy, and leukapheresis are used for cytoreduction. However, there is little data regarding the best approach. Here, we report on the efficacy and safety of high dose cyclophosphamide (HDCy; 60 mg/kg). 27 patients with acute myeloid leukemia or blast phase chronic myeloid leukemia who presented with white blood cell count (WBC) of ≥50x109/L or symptoms of leukostasis were treated with HDCy. Primary endpoint was early mortality (death within seven days of admission). Median WBC was 107 × 109/L at time of HDCy; 74% had leukostasis symptoms at presentation. Eight (29.6%) patients died within seven days of admission. Sustained WBC reduction was achieved in 18/24 (75%) evaluable patients with median nadir of 0.25 × 109/L. Adverse effects attributed to HDCy included tumor lysis syndrome (n = 7; 25.9%), disseminated intravascular coagulopathy (n = 5; 18.5%), and hemorrhagic cystitis (n = 1; 3.7%). HDCy was effective for cytoreduction and adverse effects were acceptable.
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Affiliation(s)
- Jennifer Zhao
- Department of Pharmacy, Yale New Haven Hospital, New Haven, CT, USA
| | | | - Sara Jaszczur
- Department of Pharmacy, Yale New Haven Hospital, New Haven, CT, USA
| | - Andrew Kowalski
- Department of Pharmacy, Yale New Haven Hospital, New Haven, CT, USA
| | - Sarah Perreault
- Department of Pharmacy, Yale New Haven Hospital, New Haven, CT, USA
| | - Molly Schiffer
- Department of Pharmacy, Yale New Haven Hospital, New Haven, CT, USA
| | - Steven Gore
- Department of Internal Medicine, Section of Hematology, Yale University School of Medicine, New Haven, CT, USA
| | - Nikolai Podoltsev
- Department of Internal Medicine, Section of Hematology, Yale University School of Medicine, New Haven, CT, USA
| | - Thomas Prebet
- Department of Internal Medicine, Section of Hematology, Yale University School of Medicine, New Haven, CT, USA
| | - Rory Shallis
- Department of Internal Medicine, Section of Hematology, Yale University School of Medicine, New Haven, CT, USA
| | - Amer M Zeidan
- Department of Internal Medicine, Section of Hematology, Yale University School of Medicine, New Haven, CT, USA
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17
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Bewersdorf JP, Giri S, Tallman MS, Zeidan AM, Stahl M. Leukapheresis for the management of hyperleukocytosis in acute myeloid leukemia—A systematic review and meta‐analysis. Transfusion 2020; 60:2360-2369. [DOI: 10.1111/trf.15994] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 06/15/2020] [Indexed: 02/06/2023]
Affiliation(s)
- Jan P. Bewersdorf
- Department of Internal Medicine, Section of Hematology Yale School of Medicine New Haven Connecticut USA
| | - Smith Giri
- Division of Hematology and Oncology University of Alabama School of Medicine Birmingham Alabama USA
| | - Martin S. Tallman
- Leukemia Service Memorial Sloan Kettering Cancer Center New York New York USA
| | - Amer M. Zeidan
- Department of Internal Medicine, Section of Hematology Yale School of Medicine New Haven Connecticut USA
| | - Maximilian Stahl
- Leukemia Service Memorial Sloan Kettering Cancer Center New York New York USA
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18
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Shallis RM, Stahl M, Bewersdorf JP, Hendrickson JE, Zeidan AM. Leukocytapheresis for patients with acute myeloid leukemia presenting with hyperleukocytosis and leukostasis: a contemporary appraisal of outcomes and benefits. Expert Rev Hematol 2020; 13:489-499. [PMID: 32248712 DOI: 10.1080/17474086.2020.1751609] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Introduction: Hyperleukocytosis, defined as a total white blood cell count (WBC) >50 or more commonly >100 × 109 cells/L, is a presenting feature of acute myeloid leukemia (AML) in about 6-20% of cases and is associated with a higher risk of tumor lysis syndrome (TLS), disseminated intravascular coagulation (DIC), clinical leukostasis with end organ damage, and mortality.Areas covered: In this review, authors discuss the implications of hyperleukocytosis in AML and the current understanding of cytoreductive strategies with a focus on the use of leukocytapheresis.Expert commentary: Efforts to rapidly reduce peripheral myeloblasts have included the use of leukocytapheresis. Early studies demonstrated feasibility in reducing peripheral WBC and blast counts as well as clinically relevant patient outcomes which prompted its common use for many years. However, more recent data have directly challenged the previously touted reports of reduced TLS and DIC incidence as well as survival benefit, even in patients with clinical leukostasis. The use of leukocytapheresis remains highly controversial with wide practice variations among physicians, institutions, and countries given the lack of high-quality data, risks associated with leukocytapheresis itself, associated high costs, resource utilization, and lack of evidence-based clinical guidelines.
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Affiliation(s)
- Rory M Shallis
- Division of Hematology, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA.,Yale Cancer Center, New Haven, CT, USA
| | - Maximilian Stahl
- Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jan Philipp Bewersdorf
- Division of Hematology, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Jeanne E Hendrickson
- Departments of Laboratory Medicine and Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - Amer M Zeidan
- Division of Hematology, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA.,Yale Cancer Center, New Haven, CT, USA
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