1
|
Winestone LE, Bhojwani D, Ghorashian S, Muffly L, Leahy AB, Chao K, Steineck A, Rössig C, Lamble A, Maude SL, Myers R, Rheingold SR. INSPIRED Symposium Part 4A: Access to CAR T Cell Therapy in Unique Populations with B Cell Acute Lymphoblastic Leukemia. Transplant Cell Ther 2024; 30:56-70. [PMID: 37821078 DOI: 10.1016/j.jtct.2023.10.005] [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: 08/28/2023] [Revised: 10/06/2023] [Accepted: 10/06/2023] [Indexed: 10/13/2023]
Abstract
The approval of tisagenlecleucel (tisa-cel) for use in children with B cell acute lymphoblastic leukemia (B-ALL) was based on the phase 2 ELIANA trial, a global registration study. However, the ELIANA trial excluded specific subsets of patients facing unique challenges and did not include a sufficient number of patients to adequately evaluate outcomes in rare subpopulations. Since the commercialization of tisa-cel, data have become available that support therapeutic indications beyond the specific cohorts previously eligible for chimeric antigen receptor (CAR) T cells targeted to CD19 (CD19 CAR-T) therapy on the registration clinical trial. Substantial real-world data and aggregate clinical trial data have addressed gaps in our understanding of response rates, longer-term efficacy, and toxicities associated with CD19 CAR-T in special populations and rare clinical scenarios. These include patients with central nervous system relapsed disease, who were excluded from ELIANA and other early CAR-T trials owing to concerns about risk of neurotoxicity that have not been born out. There is also interest in the use of CD19 CAR-T for very-high-risk patients earlier in the course of therapy, such as patients with persistent minimal residual disease after 2 cycles of upfront chemotherapy and patients with first relapse of B-ALL. However, these indications are not specified on the label for tisa-cel and historically were not included in eligibility criteria for most clinical trials; data addressing these populations are needed. Populations at high risk of relapse, including patients with high-risk cytogenetic lesions, infants with B-ALL, patients with trisomy 21, and young adults with B-ALL, also may benefit from earlier treatment with CD19 CAR-T. It is important to prospectively study patient-reported outcomes given the differential toxicity expected between CD19 CAR-T and the historic standard of care, hematopoietic cell transplantation. Now that CD19 CAR-T therapy is commercially available, studies evaluating potential access disparities created by this very expensive novel therapy are increasingly pressing.
Collapse
Affiliation(s)
- Lena E Winestone
- Division of Allergy, Immunology, and BMT, Department of Pediatrics, UCSF Benioff Children's Hospitals, UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California.
| | - Deepa Bhojwani
- Division of Pediatric Hematology-Oncology, Children's Hospital Los Angeles, Norris Comprehensive Cancer Center and Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Sara Ghorashian
- Haematology Department, Great Ormond Street Hospital, London UK, Developmental Biology and Cancer, UCL-Great Ormond Street Institute of Child Health, University College London, London United Kingdom
| | - Lori Muffly
- Division of Blood and Marrow Transplantation and Cellular Therapy, Stanford University, Stanford, California
| | - Allison Barz Leahy
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Karen Chao
- Division of Hematology, Oncology, Stem Cell Transplantation and Regenerative Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Angela Steineck
- MACC Fund Center for Cancer and Blood Disorders, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Claudia Rössig
- University Children's Hospital Muenster, Pediatric Hematology and Oncology, Muenster, Germany; Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Adam Lamble
- Division of Hematology and Oncology, Seattle Children's Hospital, Department of Pediatrics, University of Washington, Seattle, Washington
| | - Shannon L Maude
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Regina Myers
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Susan R Rheingold
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
2
|
Aoshima M, Yagasaki H, Shimozawa K, Kanezawa K, Ueno M, Morioka I. Six Years of Disease-free Survival After a Second Cord Blood Transplantation for Recurrent Acute Lymphocytic Leukemia in a Child With Down Syndrome. J Pediatr Hematol Oncol 2024; 46:e100-e102. [PMID: 38063382 DOI: 10.1097/mph.0000000000002794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 11/05/2023] [Indexed: 01/04/2024]
Abstract
Outcomes are extremely poor in Down syndrome-associated acute lymphocytic leukemia, particularly in recurrent cases. A 2-year-old boy with Down syndrome-associated acute lymphocytic leukemia achieved complete remission after standard chemotherapy. However, he experienced recurrence twice in the bone marrow and central nervous system. Salvage treatments included whole-brain/whole-spine irradiation. Thereafter, the patient received a second cord blood transplantation after the reduced-intensity conditioning. The graft was characterized by killer cell immunoglobulin-like receptor ligands mismatch. The patient has subsequently survived for 6.5 years without recurrence. We speculate that killer cell immunoglobulin-like receptor ligand-mismatched cord blood transplantation enhanced the graft-versus-leukemia effect through natural killer cells, and conferred long-term remission.
Collapse
Affiliation(s)
- Momoka Aoshima
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | | | | | | | | | | |
Collapse
|
3
|
Page EC, Heatley SL, Rehn J, Thomas PQ, Yeung DT, White DL. Gain of chromosome 21 increases the propensity for P2RY8::CRLF2 acute lymphoblastic leukemia via increased HMGN1 expression. Front Oncol 2023; 13:1177871. [PMID: 37483494 PMCID: PMC10358767 DOI: 10.3389/fonc.2023.1177871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 06/15/2023] [Indexed: 07/25/2023] Open
Abstract
Acute lymphoblastic leukemia (ALL) patients with a gain of chromosome 21, intrachromosomal amplification of chromosome 21 (iAMP21), or Down syndrome (DS), have increased expression of genes in the DS critical region (DSCR) of chromosome 21, including the high-mobility group nucleosome-binding protein 1, HMGN1. Children with DS are predisposed to develop hematologic malignancies, providing insight into the role of chromosome 21 in the development of leukemias. A 320-kb deletion in the pseudoautosomal region of the X/Y chromosome in leukemic cells, resulting in a gene fusion between the purinergic receptor and cytokine receptor-like factor-2 (P2Y Receptor Family Member 8 (P2RY8)::CRLF2), is a common feature in ~60% of DS-ALL and ~40% of iAMP21 patients, suggesting a link between chromosome 21 and P2RY8::CRLF2. In an Australian cohort of pediatric B-ALL patients with P2RY8::CRLF2 (n = 38), eight patients harbored gain of chromosome 21 (+21), and two patients had iAMP21, resulting in a significantly increased HMGN1 expression. An inducible CRISPR/Cas9 system was used to model P2RY8::CRLF2 and investigate its cooperation with HMGN1. This model was then used to validate HMGN1 as an influencing factor for P2RY8::CRLF2 development. Using Cas9 to cleave the DNA at the pseudoautosomal region without directed repair, cells expressing HMGN1 favored repair, resulting in P2RY8::CRLF2 generation, compared with cells without HMGN1. CRISPR/Cas9 P2RY8::CRLF2 cells expressing HMGN1 exhibit increased proliferation, thymic stromal lymphopoietin receptor (TSLPR) expression, and JAK/STAT signaling, consistent with cells from patients with P2RY8::CRLF2. Our patient expression data and unique CRISPR/Cas9 modeling, when taken together, suggest that HMGN1 increases the propensity for P2RY8::CRLF2 development. This has important implications for patients with DS, +21, or iAMP21.
Collapse
Affiliation(s)
- Elyse C. Page
- Blood Cancer Program, Precision Cancer Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
- School of Biological Sciences, Faculty of Sciences, Engineering, and Technology, University of Adelaide, Adelaide, SA, Australia
- Adelaide Medical School, Faculty of Health and Medical Science, University of Adelaide, Adelaide, SA, Australia
| | - Susan L. Heatley
- Blood Cancer Program, Precision Cancer Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
- Adelaide Medical School, Faculty of Health and Medical Science, University of Adelaide, Adelaide, SA, Australia
| | - Jacqueline Rehn
- Blood Cancer Program, Precision Cancer Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
- Adelaide Medical School, Faculty of Health and Medical Science, University of Adelaide, Adelaide, SA, Australia
| | - Paul Q. Thomas
- Adelaide Medical School, Faculty of Health and Medical Science, University of Adelaide, Adelaide, SA, Australia
- SA Gene Editing Program, Lifelong Health Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
| | - David T. Yeung
- Blood Cancer Program, Precision Cancer Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
- Adelaide Medical School, Faculty of Health and Medical Science, University of Adelaide, Adelaide, SA, Australia
- Australasian Leukaemia and Lymphoma Group, Melbourne, VIC, Australia
- Department of Hematology, Royal Adelaide Hospital and SA Pathology, Adelaide, SA, Australia
- School of Pharmacy and Medical Science, University of South Australia, Adelaide, SA, Australia
| | - Deborah L. White
- Blood Cancer Program, Precision Cancer Medicine Theme, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
- School of Biological Sciences, Faculty of Sciences, Engineering, and Technology, University of Adelaide, Adelaide, SA, Australia
- Adelaide Medical School, Faculty of Health and Medical Science, University of Adelaide, Adelaide, SA, Australia
- Australasian Leukaemia and Lymphoma Group, Melbourne, VIC, Australia
- Australian and New Zealand Children’s Hematology/Oncology Group (ANZCHOG), Clayton, VIC, Australia
| |
Collapse
|
4
|
Myers RM, Shah NN, Pulsipher MA. How I use risk factors for success or failure of CD19 CAR T cells to guide management of children and AYA with B-cell ALL. Blood 2023; 141:1251-1264. [PMID: 36416729 PMCID: PMC10082355 DOI: 10.1182/blood.2022016937] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 11/17/2022] [Accepted: 11/20/2022] [Indexed: 11/24/2022] Open
Abstract
By overcoming chemotherapeutic resistance, chimeric antigen receptor (CAR) T cells facilitate deep, complete remissions and offer the potential for long-term cure in a substantial fraction of patients with chemotherapy refractory disease. However, that success is tempered with 10% to 30% of patients not achieving remission and over half of patients treated eventually experiencing relapse. With over a decade of experience using CAR T cells in children, adolescents, and young adults (AYA) to treat relapsed/refractory B-cell acute lymphoblastic leukemia (B-ALL) and 5 years since the first US Food and Drug Administration approval, data defining the nuances of patient-specific risk factors are emerging. With the commercial availability of 2 unique CD19 CAR T-cell constructs for B-ALL, in this article, we review the current literature, outline our approach to patients, and discuss how individual factors inform strategies to optimize outcomes in children and AYA receiving CD19 CAR T cells. We include data from both prospective and recent large retrospective studies that offer insight into understanding when the risks of CAR T-cell therapy failure are high and offer perspectives suggesting when consolidative hematopoietic cell transplantation or experimental CAR T-cell and/or alternative immunotherapy should be considered. We also propose areas where prospective trials addressing the optimal use of CAR T-cell therapy are needed.
Collapse
Affiliation(s)
- Regina M. Myers
- Division of Oncology, Cell Therapy and Transplant Section, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Nirali N. Shah
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Michael A. Pulsipher
- Division of Hematology and Oncology, Intermountain Primary Children’s Hospital, Huntsman Cancer Institute, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, UT
| |
Collapse
|
5
|
Patients with Down syndrome can be included in early phase clinical trials- a report from the T2016-003 Therapeutic Advances in Childhood Leukemia and Lymphoma (TACL) study. Leukemia 2023; 37:1138-1140. [PMID: 36813993 DOI: 10.1038/s41375-023-01856-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 02/05/2023] [Accepted: 02/15/2023] [Indexed: 02/24/2023]
|
6
|
Tisagenlecleucel in pediatric and young adult patients with Down syndrome-associated relapsed/refractory acute lymphoblastic leukemia. Leukemia 2022; 36:1508-1515. [DOI: 10.1038/s41375-022-01550-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 03/03/2022] [Accepted: 03/16/2022] [Indexed: 01/05/2023]
|
7
|
Page EC, Heatley SL, Eadie LN, McClure BJ, de Bock CE, Omari S, Yeung DT, Hughes TP, Thomas PQ, White DL. HMGN1 plays a significant role in CRLF2 driven Down Syndrome leukemia and provides a potential therapeutic target in this high-risk cohort. Oncogene 2022; 41:797-808. [PMID: 34857887 DOI: 10.1038/s41388-021-02126-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 11/10/2021] [Accepted: 11/17/2021] [Indexed: 12/12/2022]
Abstract
The genetic basis of the predisposition for Down Syndrome (DS) patients to develop cytokine receptor-like factor 2 rearranged (CRLF2r) acute lymphoblastic leukemia (ALL) is currently unknown. Genes located on chromosome 21 and expressed in hematopoietic cells are likely candidates for investigation of CRLF2r DS-ALL pathogenesis. We explored the high-mobility group nucleosome-binding protein 1 (HMGN1), located in the DS critical region, in an inducible CRISPR/Cas9 knockout (KO) xenograft model to assess the effect of HMGN1 loss of function on the leukemic burden. We demonstrated HMGN1 KO-mitigated leukemic phenotypes including hepatosplenomegaly, thrombocytopenia, and anemia, commonly observed in leukemia patients, and significantly increased survival in vivo. HMGN1 overexpression in murine stem cells and Ba/F3 cells in vitro, in combination with P2RY8-CRLF2, resulted in cytokine-independent transformation and upregulation of cell signaling pathways associated with leukemic development. Finally, in vitro screening demonstrated successful targeting of P2RY8-CRLF2 and HMGN1 co-expressing cell lines and patient samples with fedratinib (JAK2 inhibitor), and GSK-J4 (demethylase inhibitor) in combination. Together, these data provide critical insight into the development and persistence of CRLF2r DS-ALL and identify HMGN1 as a potential therapeutic target to improve outcomes and reduce toxicity in this high-risk cohort of young patients.
Collapse
Affiliation(s)
- Elyse C Page
- Cancer Program, Precision Medicine Theme, South Australian Health & Medical Research Institute, Adelaide, SA, Australia
- Faculty of Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Susan L Heatley
- Cancer Program, Precision Medicine Theme, South Australian Health & Medical Research Institute, Adelaide, SA, Australia
- Discipline of Medicine, University of Adelaide, Adelaide, SA, Australia
- Australian and New Zealand Children's Haematology/Oncology Group (ANZCHOG), Sydney, NSW, Australia
| | - Laura N Eadie
- Cancer Program, Precision Medicine Theme, South Australian Health & Medical Research Institute, Adelaide, SA, Australia
- Discipline of Medicine, University of Adelaide, Adelaide, SA, Australia
| | - Barbara J McClure
- Cancer Program, Precision Medicine Theme, South Australian Health & Medical Research Institute, Adelaide, SA, Australia
- Discipline of Medicine, University of Adelaide, Adelaide, SA, Australia
| | - Charles E de Bock
- Children's Cancer Institute, UNSW Sydney, Lowy Cancer Research Centre, Sydney, NSW, Australia
- School of Women's and Children's Health, UNSW Sydney, Sydney, NSW, Australia
| | - Sofia Omari
- Children's Cancer Institute, UNSW Sydney, Lowy Cancer Research Centre, Sydney, NSW, Australia
- School of Women's and Children's Health, UNSW Sydney, Sydney, NSW, Australia
| | - David T Yeung
- Cancer Program, Precision Medicine Theme, South Australian Health & Medical Research Institute, Adelaide, SA, Australia
- Discipline of Medicine, University of Adelaide, Adelaide, SA, Australia
- Australasian Leukaemia and Lymphoma Group, Melbourne, VIC, Australia
- Department of Haematology, Royal Adelaide Hospital and SA Pathology, Adelaide, SA, Australia
- School of Pharmacy and Medical Science, University of South Australia, Adelaide, SA, Australia
| | - Timothy P Hughes
- Cancer Program, Precision Medicine Theme, South Australian Health & Medical Research Institute, Adelaide, SA, Australia
- Discipline of Medicine, University of Adelaide, Adelaide, SA, Australia
- Australasian Leukaemia and Lymphoma Group, Melbourne, VIC, Australia
- Department of Haematology, Royal Adelaide Hospital and SA Pathology, Adelaide, SA, Australia
| | - Paul Q Thomas
- Discipline of Medicine, University of Adelaide, Adelaide, SA, Australia
- Gene Editing Program, Precision Medicine Theme, South Australian Health & Medical Research Institute, Adelaide, SA, Australia
| | - Deborah L White
- Cancer Program, Precision Medicine Theme, South Australian Health & Medical Research Institute, Adelaide, SA, Australia.
- Faculty of Sciences, University of Adelaide, Adelaide, SA, Australia.
- Discipline of Medicine, University of Adelaide, Adelaide, SA, Australia.
- Australian and New Zealand Children's Haematology/Oncology Group (ANZCHOG), Sydney, NSW, Australia.
- Australasian Leukaemia and Lymphoma Group, Melbourne, VIC, Australia.
- Australian Genomic Health Alliance (AGHA), Sydney, NSW, Australia.
| |
Collapse
|
8
|
Truong TH, Jinca C, Mann G, Arghirescu S, Buechner J, Merli P, Whitlock JA. Allogeneic Hematopoietic Stem Cell Transplantation for Children With Acute Lymphoblastic Leukemia: Shifting Indications in the Era of Immunotherapy. Front Pediatr 2021; 9:782785. [PMID: 35004545 PMCID: PMC8733383 DOI: 10.3389/fped.2021.782785] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 11/08/2021] [Indexed: 12/26/2022] Open
Abstract
Pediatric acute lymphoblastic leukemia generally carries a good prognosis, and most children will be cured and become long-term survivors. However, a portion of children will harbor high-risk features at the time of diagnosis, have a poor response to upfront therapy, or suffer relapse necessitating more intensive therapy, which may include allogeneic hematopoietic stem cell transplant (HSCT). Recent advances in risk stratification, improved detection and incorporation of minimal residual disease (MRD), and intensification of upfront treatment have changed the indications for HSCT over time. For children in first complete remission, HSCT is generally reserved for those with the highest risk of relapse. These include patients with unfavorable features/cytogenetics who also have a poor response to induction and consolidation chemotherapy, usually reflected by residual blasts after prednisone or by detectable MRD at pre-defined time points. In the relapsed setting, children with first relapse of B-cell ALL are further stratified for HSCT depending on the time and site of relapse, while all patients with T-cell ALL are generally consolidated with HSCT. Alternatives to HSCT have also emerged over the last decade including immunotherapy and chimeric antigen receptor (CAR) T-cell therapy. These novel agents may spare toxicity while attempting to achieve MRD-negative remission in the most refractory cases and serve as a bridge to HSCT. In some situations, these emerging therapies can indeed be curative for some children with relapsed or resistant disease, thus, obviating the need for HSCT. In this review, we seek to summarize the role of HSCT in the current era of immunotherapy.
Collapse
Affiliation(s)
- Tony H. Truong
- Division of Pediatric Oncology, Blood and Marrow Transplant/Cellular Therapy, Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada
| | - Cristian Jinca
- Department of Pediatrics, Victor Babeş University of Medicine and Pharmacy, Timişoara, Romania
| | - Georg Mann
- Children's Cancer Research Institute, St. Anna Children's Hospital, Vienna, Austria
| | - Smaranda Arghirescu
- Department of Pediatrics, Victor Babeş University of Medicine and Pharmacy, Timişoara, Romania
| | - Jochen Buechner
- Department of Pediatric Hematology and Oncology, Oslo University Hospital, Oslo, Norway
| | - Pietro Merli
- Department of Pediatric Hematology/Oncology, Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - James A. Whitlock
- Department of Paediatrics, Hospital for Sick Children/University of Toronto, Toronto, ON, Canada
| |
Collapse
|
9
|
Other (Non-CNS/Testicular) Extramedullary Localizations of Childhood Relapsed Acute Lymphoblastic Leukemia and Lymphoblastic Lymphoma-A Report from the ALL-REZ Study Group. J Clin Med 2021; 10:jcm10225292. [PMID: 34830574 PMCID: PMC8621955 DOI: 10.3390/jcm10225292] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 11/08/2021] [Accepted: 11/09/2021] [Indexed: 11/16/2022] Open
Abstract
Children with other extramedullary relapse of acute lymphoblastic leukemia are currently poorly characterized. We aim to assess the prevalence and the clinical, therapeutic and prognostic features of extramedullary localizations other than central nervous system or testis in children with relapse of acute lymphoblastic leukemia (ALL) and lymphoblastic lymphoma (LBL) treated on a relapsed ALL protocol. PATIENTS AND METHODS Patients with relapse of ALL and LBL, treated according to the multicentric ALL-REZ BFM trials between 1983 and 2015, were analyzed for other extramedullary relapse (OEMR) of the disease regarding clinical features, treatment and outcome. Local treatment/irradiation has been recommended on an individual basis and performed only in a minority of patients. RESULTS A total of 132 out of 2323 (5.6%) patients with ALL relapse presented with an OEMR (combined bone marrow relapse n = 78; isolated extramedullary relapse n = 54). Compared to the non-OEMR group, patients with OEMR had a higher rate of T-immunophenotype (p < 0.001), a higher rate of LBL (p < 0.001) and a significantly different distribution of time to relapse, i.e., more very early and late relapses compared to the non-OEMR group (p = 0.01). Ten-year probabilities of event-free survival (pEFS) and overall survival (pOS) in non-OEMR vs. OEMR were 0.38 ± 0.01 and 0.32 ± 0.04 (p = 0.0204) vs. 0.45 ± 0.01 and 0.37 ± 0.04 (p = 0.0112), respectively. OEMRs have been classified into five subgroups according to the main affected compartment: lymphatic organs (n = 32, 10y-pEFS 0.50 ± 0.09), mediastinum (n = 35, 10y-pEFS 0.11 ± 0.05), bone (n = 12, 0.17 ± 0.11), skin and glands (n = 21, 0.32 ± 0.11) and other localizations (n = 32, 0.41 ± 0.09). Patients with OEMR and T-lineage ALL/LBL showed a significantly worse 10y-pEFS (0.15 ± 0.04) than those with B-Precursor-ALL (0.49 ± 0.06, p < 0.001). Stratified into standard risk (SR) and high risk (HR) groups, pEFS and pOS of OEMR subgroups were in the expected range whereas the mediastinal subgroup had a significantly worse outcome. Subsequent relapses involved more frequently the bone marrow (58.4%) than isolated extramedullary compartments (41.7%). In multivariate Cox regression, OEMR confers an independent prognostic factor for inferior pEFS and pOS. CONCLUSION OEMR is adversely related to prognosis. However, the established risk classification can be applied for all subgroups except mediastinal relapses requiring treatment intensification. Generally, isolated OEMR of T-cell-origin needs an intensified treatment including allogeneic stem cell transplantation (HSCT) as a curative approach independent from time to relapse. Local therapy such as surgery and irradiation may be of benefit in selected cases. The indication needs to be clarified in further investigations.
Collapse
|
10
|
Shimada A. Profile of down syndrome–associated malignancies: Epidemiology, clinical features and therapeutic aspects. PEDIATRIC HEMATOLOGY ONCOLOGY JOURNAL 2021. [DOI: 10.1016/j.phoj.2021.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
|
11
|
Hu Z, VanHeyst KA, Dalal J, Hackney L. Patient with Down syndrome and relapsed acute lymphoblastic leukemia with sustained remission despite only partial R3 chemotherapy. Clin Case Rep 2021; 9:1118-1122. [PMID: 33768794 PMCID: PMC7981660 DOI: 10.1002/ccr3.3678] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 11/13/2020] [Accepted: 11/27/2020] [Indexed: 11/29/2022] Open
Abstract
DS-ALL has a higher rate of relapse and treatment-related mortality. The newer immunotherapies are potentially better options. Relapsed ALL with positive MRD has a poor prognosis. Transient long-term remission after ALL relapse due to partial chemotherapy combined severe infection is rare.
Collapse
Affiliation(s)
- Zhongbo Hu
- Department of PediatricsDivision of Pediatric Hematology OncologyRainbow Babies and Children’s Hospital at University Hospitals Cleveland Medical CenterClevelandOHUSA
| | - Kristen A. VanHeyst
- Department of PediatricsDivision of Pediatric Hematology OncologyRainbow Babies and Children’s Hospital at University Hospitals Cleveland Medical CenterClevelandOHUSA
| | - Jignesh Dalal
- Department of PediatricsDivision of Pediatric Hematology OncologyRainbow Babies and Children’s Hospital at University Hospitals Cleveland Medical CenterClevelandOHUSA
| | - Lisa Hackney
- Department of PediatricsDivision of Pediatric Hematology OncologyRainbow Babies and Children’s Hospital at University Hospitals Cleveland Medical CenterClevelandOHUSA
| |
Collapse
|
12
|
Jasinski S, De Los Reyes FA, Yametti GC, Pierro J, Raetz E, Carroll WL. Immunotherapy in Pediatric B-Cell Acute Lymphoblastic Leukemia: Advances and Ongoing Challenges. Paediatr Drugs 2020; 22:485-499. [PMID: 32860590 PMCID: PMC7537790 DOI: 10.1007/s40272-020-00413-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Leukemia, most commonly B-cell acute lymphoblastic leukemia (B-ALL), accounts for about 30% of childhood cancer diagnoses. While there have been dramatic improvements in childhood ALL outcomes, certain subgroups-particularly those who relapse-fare poorly. In addition, cure is associated with significant short- and long-term side effects. Given these challenges, there is great interest in novel, targeted approaches to therapy. A number of new immunotherapeutic agents have proven to be efficacious in relapsed or refractory disease and are now being investigated in frontline treatment regimens. Blinatumomab (a bispecific T-cell engager that targets cluster of differentiation [CD]-19) and inotuzumab ozogamicin (a humanized antibody-drug conjugate to CD22) have shown the most promise. Chimeric antigen receptor T (CAR-T) cells, a form of adoptive immunotherapy, rely on the transfer of genetically modified effector T cells that have the potential to persist in vivo for years, providing ongoing long-term disease control. In this article, we discuss the clinical biology and treatment of B-ALL with an emphasis on the role of immunotherapy in overcoming the challenges of conventional cytotoxic therapy. As immunotherapy continues to move into the frontline of pediatric B-ALL therapy, we also discuss strategies to address unique side effects associated with these agents and efforts to overcome mechanisms of resistance to immunotherapy.
Collapse
Affiliation(s)
- Sylwia Jasinski
- Perlmutter Cancer Center, Smilow 1211, Division of Pediatric Hematology/Oncology, Department of Pediatrics, NYU Langone Health, 560 First Avenue, New York, NY, 10016, USA
| | | | - Gloria Contreras Yametti
- Perlmutter Cancer Center, Smilow 1211, Division of Pediatric Hematology/Oncology, Department of Pediatrics, NYU Langone Health, 560 First Avenue, New York, NY, 10016, USA
| | - Joanna Pierro
- Perlmutter Cancer Center, Smilow 1211, Division of Pediatric Hematology/Oncology, Department of Pediatrics, NYU Langone Health, 560 First Avenue, New York, NY, 10016, USA
| | - Elizabeth Raetz
- Perlmutter Cancer Center, Smilow 1211, Division of Pediatric Hematology/Oncology, Department of Pediatrics, NYU Langone Health, 560 First Avenue, New York, NY, 10016, USA
| | - William L Carroll
- Perlmutter Cancer Center, Smilow 1211, Division of Pediatric Hematology/Oncology, Department of Pediatrics, NYU Langone Health, 560 First Avenue, New York, NY, 10016, USA.
| |
Collapse
|
13
|
Laurent AP, Kotecha RS, Malinge S. Gain of chromosome 21 in hematological malignancies: lessons from studying leukemia in children with Down syndrome. Leukemia 2020; 34:1984-1999. [PMID: 32433508 PMCID: PMC7387246 DOI: 10.1038/s41375-020-0854-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 04/22/2020] [Accepted: 04/28/2020] [Indexed: 12/31/2022]
Abstract
Structural and numerical alterations of chromosome 21 are extremely common in hematological malignancies. While the functional impact of chimeric transcripts from fused chromosome 21 genes such as TEL-AML1, AML1-ETO, or FUS-ERG have been extensively studied, the role of gain of chromosome 21 remains largely unknown. Gain of chromosome 21 is a frequently occurring aberration in several types of acute leukemia and can be found in up to 35% of cases. Children with Down syndrome (DS), who harbor constitutive trisomy 21, highlight the link between gain of chromosome 21 and leukemogenesis, with an increased risk of developing acute leukemia compared with other children. Clinical outcomes for DS-associated leukemia have improved over the years through the development of uniform treatment protocols facilitated by international cooperative groups. The genetic landscape has also recently been characterized, providing an insight into the molecular pathogenesis underlying DS-associated leukemia. These studies emphasize the key role of trisomy 21 in priming a developmental stage and cellular context susceptible to transformation, and have unveiled its cooperative function with additional genetic events that occur during leukemia progression. Here, using DS-leukemia as a paradigm, we aim to integrate our current understanding of the role of trisomy 21, of critical dosage-sensitive chromosome 21 genes, and of associated mechanisms underlying the development of hematological malignancies. This review will pave the way for future investigations on the broad impact of gain of chromosome 21 in hematological cancer, with a view to discovering new vulnerabilities and develop novel targeted therapies to improve long term outcomes for DS and non-DS patients.
Collapse
Affiliation(s)
- Anouchka P Laurent
- INSERM U1170, Gustave Roussy Institute, Université Paris Saclay, Villejuif, France
- Université Paris Diderot, Paris, France
| | - Rishi S Kotecha
- School of Pharmacy and Biomedical Sciences, Curtin University, Perth, Western Australia, Australia
- Department of Clinical Haematology, Oncology and Bone Marrow Transplantation, Perth Children's Hospital, Perth, Western Australia, Australia
- Telethon Kids Cancer Centre, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia
| | - Sébastien Malinge
- INSERM U1170, Gustave Roussy Institute, Université Paris Saclay, Villejuif, France.
- Telethon Kids Cancer Centre, Telethon Kids Institute, University of Western Australia, Perth, Western Australia, Australia.
| |
Collapse
|
14
|
McNeer JL, Rau RE, Gupta S, Maude SL, O'Brien MM. Cutting to the Front of the Line: Immunotherapy for Childhood Acute Lymphoblastic Leukemia. Am Soc Clin Oncol Educ Book 2020; 40:1-12. [PMID: 32320280 DOI: 10.1200/edbk_278171] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Although many children and young adults with B-cell acute lymphoblastic leukemia (B-ALL) are cured with modern, risk-adapted chemotherapy regimens, 10% to 15% of patients will experience relapse or have refractory disease. Recent efforts to further intensify cytotoxic chemotherapy regimens in the frontline setting have failed as a result of excessive toxicity or lack of improvement in efficacy. As a result, novel approaches will be required to achieve cures in more newly diagnosed patients. Multiple immune-based therapies have demonstrated considerable efficacy in the setting of relapsed or refractory (R/R) disease, including CD19 targeting with blinatumomab and tisagenlecleucel and CD22 targeting with inotuzumab ozogamicin. These agents are now under investigation by the Children's Oncology Group (COG) in clinical trials for newly diagnosed B-ALL, with integration into standard chemotherapy regimens based on clinically and biology-based risk stratification as well as disease response.
Collapse
Affiliation(s)
| | - Rachel E Rau
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Sumit Gupta
- The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Shannon L Maude
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Maureen M O'Brien
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| |
Collapse
|
15
|
Rabin K, Izraeli S, Hijiya N, Hitzler J. Need for new thinking: Treatment of relapsed leukemia in children with Down syndrome. Pediatr Blood Cancer 2019; 66:e27644. [PMID: 30724029 DOI: 10.1002/pbc.27644] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 12/10/2018] [Accepted: 01/16/2019] [Indexed: 12/14/2022]
Affiliation(s)
- Karen Rabin
- Texas Children's Cancer Center Division of Pediatric Hematology/Oncology, Baylor College of Medicine, Houston, Texas
| | - Shai Izraeli
- Rina Zaizov Pediatric Hematology Oncology Division, Schneider Children's Medical Center of Israel, Petach Tiqva and Dept. of Human Molecular Genetics and Biochemistry, Sackler School of Medicine, Tel Aviv University, Israel
| | - Nobuko Hijiya
- Division of Hematology/Oncology/Transplant, Ann and Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Johann Hitzler
- Division of Hematology/Oncology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
16
|
Precision medicine approaches may be the future for CRLF2 rearranged Down Syndrome Acute Lymphoblastic Leukaemia patients. Cancer Lett 2018; 432:69-74. [PMID: 29879498 DOI: 10.1016/j.canlet.2018.05.045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 05/16/2018] [Accepted: 05/28/2018] [Indexed: 02/08/2023]
Abstract
Breakthrough studies over the past decade have uncovered unique gene fusions implicated in acute lymphoblastic leukaemia (ALL). The critical gene, cytokine receptor-like factor 2 (CRLF2), is rearranged in 5-16% of B-ALL, comprising 50% of Philadelphia-like ALL and cooperates with genomic lesions in the Jak, Mapk and Ras signalling pathways. Children with Down Syndrome (DS) have a predisposition to developing CRLF2 rearranged-ALL which is observed in 60% of DS-ALL patients. These patients experience a poor survival outcome. Mutations of genes involved in epigenetic regulation are more prevalent in DS-ALL patients than non-DS ALL patients, highlighting the potential for alternative treatment strategies. DS-ALL patients also suffer greater treatment-related toxicity from current ALL treatment regimens compared to non-DS-ALL patients. An increased gene dosage of critical genes on chromosome 21 which have roles in purine synthesis and folate transport may contribute. As the genomic landscape of DS-ALL patients is different to non-DS-ALL patients, targeted therapies for individual lesions may improve outcomes. Therapeutically targeting each rearrangement with targeted or combination therapy that will perturb the transforming signalling pathways will likely improve the poor survival rates of this subset of patients.
Collapse
|
17
|
Alimi A, Taytard J, Abou Taam R, Houdouin V, Forgeron A, Lubrano Lavadera M, Cros P, Gibertini I, Derelle J, Deschildre A, Thumerelle C, Epaud R, Reix P, Fayon M, Roullaud S, Troussier F, Renoux MC, de Blic J, Leyronnas S, Thouvenin G, Perisson C, Ravel A, Clement A, Corvol H, Nathan N. Pulmonary hemosiderosis in children with Down syndrome: a national experience. Orphanet J Rare Dis 2018; 13:60. [PMID: 29678139 PMCID: PMC5910623 DOI: 10.1186/s13023-018-0806-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 04/12/2018] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Pulmonary hemosiderosis is a rare and complex disease in children. A previous study from the French RespiRare® network led to two important findings: 20% of the children presented with both pulmonary hemosiderosis and Down syndrome (DS), and at least one tested autoantibody was found positive in 50%. This study investigates the relationships between pulmonary hemosiderosis and DS. METHODS Patients younger than 20 years old and followed for pulmonary hemosiderosis were retrieved from the RespiRare® database. Clinical, biological, functional, and radiological findings were collected, and DS and non-DS patients' data were compared. RESULTS A total of 34 patients (22 girls and 12 boys) were included, among whom nine (26%) presented with DS. The mean age at diagnosis was 4.1 ± 3.27 years old for non-DS and 2.9 ± 3.45 years old for DS patients. DS patients tended to present a more severe form of the disease with an earlier onset, more dyspnoea at diagnosis, more frequent secondary pulmonary hypertension, and an increased risk of fatal evolution. CONCLUSIONS DS patients have a higher risk of developing pulmonary hemosiderosis, and the disease seems to be more severe in this population. This could be due to the combination of an abnormal lung capillary bed with fragile vessels, a higher susceptibility to autoimmune lesions, and a higher risk of evolution toward pulmonary hypertension. A better screening for pulmonary hemosiderosis and a better prevention of hypoxia in DS paediatric patients may prevent a severe evolution of the disease.
Collapse
Affiliation(s)
- Aurelia Alimi
- Assistance Publique Hôpitaux de Paris (APHP), Pediatric Pulmonology department and Reference centre for rare lung diseases, RespiRare, Trousseau Hospital, 75012 Paris, France
| | - Jessica Taytard
- Assistance Publique Hôpitaux de Paris (APHP), Pediatric Pulmonology department and Reference centre for rare lung diseases, RespiRare, Trousseau Hospital, 75012 Paris, France
| | - Rola Abou Taam
- APHP, Pediatric Pulmonology department, RespiRare, Necker Enfants Malades Hospital , 75015 Paris, France
| | - Véronique Houdouin
- APHP, Pediatric Pulmonology department, RespiRare, Faculty Paris Diderot VII, Inserm U1149, Robert Debré Hospital, Paris, France
| | - Aude Forgeron
- Pediatric department, Hospital Center, Inserm U646, 72037 Le Mans, France
| | | | - Pierrick Cros
- Pediatric Pulmonology department, University Hospital, Inserm 1078, Brest, France
| | | | | | - Antoine Deschildre
- Pediatric Pulmonology department, University Hospital, UMR CNRS 8204 - Inserm U1019, Lille, France
| | - Caroline Thumerelle
- Pediatric Pulmonology department, University Hospital, UMR CNRS 8204 - Inserm U1019, Lille, France
| | - Ralph Epaud
- Pediatric Pulmonology department, RespiRare, Créteil University Hospital, Inserm U955, Créteil, France
| | - Philippe Reix
- Pediatric Pulmonology department, University Hospital, UMR CNRS 5558, Lyon, France
| | - Michael Fayon
- Pediatric Pulmonology department, University Hospital, U1219, Bordeaux, France
| | | | - Françoise Troussier
- Pediatric Pulmonology department, University Hospital, Inserm U892, Angers, France
| | - Marie-Catherine Renoux
- Pediatric Pulmonology department, University Hospital, Inserm U1046, Montpellier, France
| | - Jacques de Blic
- APHP, Pediatric Pulmonology department, RespiRare, Necker Enfants Malades Hospital , 75015 Paris, France
| | - Sophie Leyronnas
- Assistance Publique Hôpitaux de Paris (APHP), Pediatric Pulmonology department and Reference centre for rare lung diseases, RespiRare, Trousseau Hospital, 75012 Paris, France
| | - Guillaume Thouvenin
- Assistance Publique Hôpitaux de Paris (APHP), Pediatric Pulmonology department and Reference centre for rare lung diseases, RespiRare, Trousseau Hospital, 75012 Paris, France
- Sorbonne Université, Inserm UMR-S938, Paris, France
| | - Caroline Perisson
- Assistance Publique Hôpitaux de Paris (APHP), Pediatric Pulmonology department and Reference centre for rare lung diseases, RespiRare, Trousseau Hospital, 75012 Paris, France
| | | | - Annick Clement
- Assistance Publique Hôpitaux de Paris (APHP), Pediatric Pulmonology department and Reference centre for rare lung diseases, RespiRare, Trousseau Hospital, 75012 Paris, France
- Sorbonne Université, Inserm UMR-S933, Paris, France
| | - Harriet Corvol
- Assistance Publique Hôpitaux de Paris (APHP), Pediatric Pulmonology department and Reference centre for rare lung diseases, RespiRare, Trousseau Hospital, 75012 Paris, France
- Sorbonne Université, Inserm UMR-S938, Paris, France
| | - Nadia Nathan
- Assistance Publique Hôpitaux de Paris (APHP), Pediatric Pulmonology department and Reference centre for rare lung diseases, RespiRare, Trousseau Hospital, 75012 Paris, France
- Sorbonne Université, Inserm UMR-S933, Paris, France
| | - for the French RespiRare® group
- Assistance Publique Hôpitaux de Paris (APHP), Pediatric Pulmonology department and Reference centre for rare lung diseases, RespiRare, Trousseau Hospital, 75012 Paris, France
- APHP, Pediatric Pulmonology department, RespiRare, Necker Enfants Malades Hospital , 75015 Paris, France
- APHP, Pediatric Pulmonology department, RespiRare, Faculty Paris Diderot VII, Inserm U1149, Robert Debré Hospital, Paris, France
- Pediatric department, Hospital Center, Inserm U646, 72037 Le Mans, France
- Pediatric Pulmonology department, University Hospital, Rouen, France
- Pediatric Pulmonology department, University Hospital, Inserm 1078, Brest, France
- Pediatric department, University Hospital, Tours, France
- Pediatric department, University Hospital, Nancy, France
- Pediatric Pulmonology department, University Hospital, UMR CNRS 8204 - Inserm U1019, Lille, France
- Pediatric Pulmonology department, RespiRare, Créteil University Hospital, Inserm U955, Créteil, France
- Pediatric Pulmonology department, University Hospital, UMR CNRS 5558, Lyon, France
- Pediatric Pulmonology department, University Hospital, U1219, Bordeaux, France
- Pediatric department, Hospital Centre, Angouleme, France
- Pediatric Pulmonology department, University Hospital, Inserm U892, Angers, France
- Pediatric Pulmonology department, University Hospital, Inserm U1046, Montpellier, France
- Sorbonne Université, Inserm UMR-S938, Paris, France
- Institut Jérôme Lejeune, Paris, France
- Sorbonne Université, Inserm UMR-S933, Paris, France
| |
Collapse
|
18
|
Oskarsson T, Söderhäll S, Arvidson J, Forestier E, Montgomery S, Bottai M, Lausen B, Carlsen N, Hellebostad M, Lähteenmäki P, Saarinen-Pihkala UM, Jónsson ÓG, Heyman M. Relapsed childhood acute lymphoblastic leukemia in the Nordic countries: prognostic factors, treatment and outcome. Haematologica 2015; 101:68-76. [PMID: 26494838 DOI: 10.3324/haematol.2015.131680] [Citation(s) in RCA: 100] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 10/20/2015] [Indexed: 11/09/2022] Open
Abstract
Relapse is the main reason for treatment failure in childhood acute lymphoblastic leukemia. Despite improvements in the up-front therapy, survival after relapse is still relatively poor, especially for high-risk relapses. The aims of this study were to assess outcomes following acute lymphoblastic leukemia relapse after common initial Nordic Society of Paediatric Haematology and Oncology protocol treatment; to validate currently used risk stratifications, and identify additional prognostic factors for overall survival. Altogether, 516 of 2735 patients (18.9%) relapsed between 1992 and 2011 and were included in the study. There were no statistically significant differences in outcome between the up-front protocols or between the relapse protocols used, but an improvement over time was observed. The 5-year overall survival for patients relapsing in the period 2002-2011 was 57.5±3.4%, but 44.7±3.2% (P<0.001) if relapse occurred in the period 1992-2001. Factors independently predicting mortality after relapse included short duration of first remission, bone marrow involvement, age ten years or over, unfavorable cytogenetics, and Down syndrome. T-cell immunophenotype was not an independent prognostic factor unless in combination with hyperleukocytosis at diagnosis. The outcome for early combined pre-B relapses was unexpectedly poor (5-year overall survival 38.0±10.6%), which supports the notion that these patients need further risk adjustment. Although survival outcomes have improved over time, the development of novel approaches is urgently needed to increase survival in relapsed childhood acute lymphoblastic leukemia.
Collapse
Affiliation(s)
- Trausti Oskarsson
- Department of Pediatric Oncology, Astrid Lindgren Children's Hospital, Stockholm, Sweden Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Stefan Söderhäll
- Department of Pediatric Oncology, Astrid Lindgren Children's Hospital, Stockholm, Sweden Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Johan Arvidson
- Department of Pediatric Oncology, Uppsala University Hospital, Sweden
| | - Erik Forestier
- Department of Pediatrics, Umeå University Hospital, Sweden
| | - Scott Montgomery
- Clinical Epidemiology and Biostatistics, Faculty of Medicine and Health, Örebro University, Sweden Clinical Epidemiology Unit, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden Department of Epidemiology and Public Health, University College London, UK
| | - Matteo Bottai
- Unit of Biostatistics, IMM, Karolinska Institutet, Stockholm, Sweden
| | - Birgitte Lausen
- Department of Pediatric Oncology, Rigshospitalet University Hospital, Copenhagen, Denmark
| | - Niels Carlsen
- Department of Pediatrics, Odense University Hospital, Denmark
| | | | | | - Ulla M Saarinen-Pihkala
- Children's Hospital, University of Helsinki and Helsinki University Central Hospital, Finland
| | - Ólafur G Jónsson
- Children's Hospital, Landspitali University Hospital, Reykjavik, Iceland
| | - Mats Heyman
- Department of Pediatric Oncology, Astrid Lindgren Children's Hospital, Stockholm, Sweden Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | | |
Collapse
|
19
|
Abstract
Children with Down syndrome (DS) and acute leukemias acute have unique biological, cytogenetic, and intrinsic factors that affect their treatment and outcome. Myeloid leukemia of Down syndrome (ML-DS) is associated with high event-free survival (EFS) rates and frequently preceded by a preleukemia condition, the transient abnormal hematopoiesis (TAM) present at birth. For acute lymphoblastic leukemia (ALL), their EFS and overall survival are poorer than non-DS ALL, it is important to enroll them on therapeutic trials, including relapse trials; investigate new agents that could potentially improve their leukemia-free survival; and strive to maximize the supportive care these patients need.
Collapse
Affiliation(s)
- Kelly W Maloney
- Center for Cancer & Blood Disorders, Children's Hospital Colorado, 13123 East 16th Avenue, B115, Aurora, CO 80045, USA
| | - Jeffrey W Taub
- Division of Pediatric Hematology/Oncology, Children's Hospital of Michigan, Wayne State University School of Medicine, 3901 Beaubien Boulevard, Detroit, MI 48201, USA.
| | - Yaddanapudi Ravindranath
- Division of Pediatric Hematology/Oncology, Children's Hospital of Michigan, Wayne State University School of Medicine, 3901 Beaubien Boulevard, Detroit, MI 48201, USA
| | - Irene Roberts
- Department of Paediatrics and Molecular Haematology Unit, University of Oxford and Oxford University Hospitals NHS Trust, Oxford, OX3 9DS, UK
| | - Paresh Vyas
- MRC Molecular Haematology Unit, Department of Haematology, Weatherall Institute of Molecular Medicine, Oxford University Hospitals NHS Trust, University of Oxford, Oxford OX3 9DS, UK
| |
Collapse
|
20
|
Hitzler JK, He W, Doyle J, Cairo M, Camitta BM, Chan KW, Perez MAD, Fraser C, Gross TG, Horan JT, Kennedy-Nasser AA, Kitko C, Kurtzberg J, Lehmann L, O’Brien T, Pulsipher MA, Smith FO, Zhang MJ, Eapen M, Carpenter PA. Outcome of transplantation for acute lymphoblastic leukemia in children with Down syndrome. Pediatr Blood Cancer 2014; 61:1126-8. [PMID: 24391118 PMCID: PMC4080799 DOI: 10.1002/pbc.24918] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Accepted: 12/06/2013] [Indexed: 11/06/2022]
Abstract
We report on 27 patients with Down syndrome (DS) and acute lymphoblastic leukemia (ALL) who received allogeneic hematopoietic cell transplantation (HCT) between 2000 and 2009. Seventy-eight percent of patients received myeloablative conditioning and 52% underwent transplantation in second remission. Disease-free survival (DFS) was 24% at a median of 3 years. Post-transplant leukemic relapse was more frequent than expected for children with DS-ALL (54%) than for non-DS ALL. These data suggest leukemic relapse rather than transplant toxicity is the most important cause of treatment failure. Advancements in leukemia control are especially needed for improvement in HCT outcomes for DS-ALL.
Collapse
Affiliation(s)
- Johann K. Hitzler
- The Hospital for Sick Children, University of Toronto, Toronto ON, Canada
| | - Wensheng He
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - John Doyle
- The Hospital for Sick Children, University of Toronto, Toronto ON, Canada
| | | | - Bruce M. Camitta
- Midwest Center for Cancer and Blood Disorders, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ka Wah Chan
- Texas Transplant Institute, San Antonio, TX, USA
| | | | | | | | - John T. Horan
- Children’s Healthcare of Atlanta at Egleston, Atlanta, GA, USA
| | | | | | | | | | | | | | | | - Mei-Jie Zhang
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mary Eapen
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | | |
Collapse
|
21
|
Lundin C, Forestier E, Klarskov Andersen M, Autio K, Barbany G, Cavelier L, Golovleva I, Heim S, Heinonen K, Hovland R, Johannsson JH, Kjeldsen E, Nordgren A, Palmqvist L, Johansson B. Clinical and genetic features of pediatric acute lymphoblastic leukemia in Down syndrome in the Nordic countries. J Hematol Oncol 2014; 7:32. [PMID: 24726034 PMCID: PMC4022076 DOI: 10.1186/1756-8722-7-32] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Accepted: 04/08/2014] [Indexed: 11/23/2022] Open
Abstract
Background Children with Down syndrome (DS) have an increased risk for acute lymphoblastic leukemia (ALL). Although previous studies have shown that DS-ALL differs clinically and genetically from non-DS-ALL, much remains to be elucidated as regards genetic and prognostic factors in DS-ALL. Methods To address clinical and genetic differences between DS-ALL and non-DS-ALL and to identify prognostic factors in DS-ALL, we ascertained and reviewed all 128 pediatric DS-ALL diagnosed in the Nordic countries between 1981 and 2010. Their clinical and genetic features were compared with those of the 4,647 B-cell precursor (BCP) ALL cases diagnosed during the same time period. Results All 128 DS-ALL were BCP ALL, comprising 2.7% of all such cases. The 5-year event-free survival (EFS) and overall survival (OS) were significantly (P = 0.026 and P = 0.003, respectively) worse for DS-ALL patients with white blood cell counts ≥50 × 109/l. The age distributions varied between the DS and non-DS cases, with age peaks at 2 and 3 years, respectively; none of the DS patients had infant ALL (P = 0.029). The platelet counts were lower in the DS-ALL group (P = 0.005). Abnormal karyotypes were more common in non-DS-ALL (P < 0.0001), and there was a significant difference in the modal number distribution, with only 2% high hyperdiploid DS-ALL cases (P < 0.0001). The 5-year EFS and 5-year OS were significantly worse for DS-ALL (0.574 and 0.691, respectively) compared with non-DS-ALL (0.783 and 0.894, respectively) in the NOPHO ALL-1992/2000 protocols (P < 0.001). Conclusions The present study adds further support for genetic and clinical differences between DS-ALL and non-DS-ALL.
Collapse
Affiliation(s)
- Catarina Lundin
- Department of Clinical Genetics, University and Regional Laboratories Region Skåne, SE-221 85 Lund, Sweden.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Abstract
Abstract
Children with Down syndrome are at high risk for developing B-cell precursor acute lymphoblastic leukemia (DS-ALL) associated with poor outcome due to both a high relapse rate and increased treatment-related mortality (TRM) from infections. Biologically, these heterogeneous leukemias are characterized by under-representation of the common cytogenetic subgroups of childhood ALL and overrepresentation of CRLF2-IL7R-JAK-STAT activating genetic aberrations. Although relapse is the major determinant of poor outcomes in this population, de-escalation of chemotherapy intensity might be feasible in the 10% to 15% DS-ALL patients with ETV6-RUNX1 or high hyperdipoidy in whom TRM is the major limiting event. As infection-associated TRM occurs during all treatment phases, including the maintenance period, increased surveillance and supportive care is required throughout therapy. Improvement in outcome will require better understanding of the causes of treatment failure and TRM, incorporation of new therapies targeting the unique biological properties of DS-ALL, and enhanced supportive care measures to reduce the risk of infection-related TRM. To facilitate these goals, an international collaboration plans to establish a prospective DS-ALL registry and develop specific supportive care recommendations for this at-risk population.
Collapse
|
23
|
Acute lymphoblastic leukemia in children with Down syndrome: a retrospective analysis from the Ponte di Legno study group. Blood 2013; 123:70-7. [PMID: 24222333 DOI: 10.1182/blood-2013-06-509463] [Citation(s) in RCA: 152] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Children with Down syndrome (DS) have an increased risk of B-cell precursor (BCP) acute lymphoblastic leukemia (ALL). The prognostic factors and outcome of DS-ALL patients treated in contemporary protocols are uncertain. We studied 653 DS-ALL patients enrolled in 16 international trials from 1995 to 2004. Non-DS BCP-ALL patients from the Dutch Child Oncology Group and Berlin-Frankfurt-Münster were reference cohorts. DS-ALL patients had a higher 8-year cumulative incidence of relapse (26% ± 2% vs 15% ± 1%, P < .001) and 2-year treatment-related mortality (TRM) (7% ± 1% vs 2.0% ± <1%, P < .0001) than non-DS patients, resulting in lower 8-year event-free survival (EFS) (64% ± 2% vs 81% ± 2%, P < .0001) and overall survival (74% ± 2% vs 89% ± 1%, P < .0001). Independent favorable prognostic factors include age <6 years (hazard ratio [HR] = 0.58, P = .002), white blood cell (WBC) count <10 × 10(9)/L (HR = 0.60, P = .005), and ETV6-RUNX1 (HR = 0.14, P = .006) for EFS and age (HR = 0.48, P < .001), ETV6-RUNX1 (HR = 0.1, P = .016) and high hyperdiploidy (HeH) (HR = 0.29, P = .04) for relapse-free survival. TRM was the major cause of death in ETV6-RUNX1 and HeH DS-ALLs. Thus, while relapse is the main contributor to poorer survival in DS-ALL, infection-associated TRM was increased in all protocol elements, unrelated to treatment phase or regimen. Future strategies to improve outcome in DS-ALL should include improved supportive care throughout therapy and reduction of therapy in newly identified good-prognosis subgroups.
Collapse
|