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De Sa H, Deloughery T, Kaempf A, Lachowiez C, Leonard J, Mathews R, Rakshe S, Shatzel JJ, Swords R, Traer E, Hayes-Lattin B. Thromboprophylaxis with intermediate dose enoxaparin during asparaginase containing induction for young adults with acute lymphoblastic leukemia. Leuk Lymphoma 2024:1-10. [PMID: 39291957 DOI: 10.1080/10428194.2024.2405874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Revised: 09/12/2024] [Accepted: 09/13/2024] [Indexed: 09/19/2024]
Abstract
Thrombosis rates among young adults receiving asparaginase (ASP) for acute lymphoblastic leukemia (ALL) can reach 34%, with highest risk during induction. Our institution implemented a standard practice of 1 mg/kg/day enoxaparin administered to young adults with ALL who are treated with ASP during induction. We performed a retrospective analysis of patients who received thromboprophylaxis with enoxaparin 1 mg/kg/day during ASP-containing induction for ALL at Oregon Health & Science University from 2012 to 2023. The primary outcome was the cumulative incidence of thrombosis during induction. Bleeding events were assessed. Sixty-two patients were included in our analysis. Four patients (6.5%; 95% CI 1.8%-15.7%) experienced a thrombotic event. Three events were catheter-associated and 1 event was a distal lower extremity deep vein thrombosis related to myositis. No cerebral sinus thromboses, thrombosis-related deaths or major bleeding events occurred. Intermediate-dose enoxaparin is a promising thromboprophylaxis strategy and warrants further prospective research.
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Affiliation(s)
- Hong De Sa
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, USA
| | - Thomas Deloughery
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, USA
| | - Andy Kaempf
- Biostatistics Shared Resource, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, USA
| | - Curtis Lachowiez
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, USA
| | - Jessica Leonard
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, USA
| | - Rick Mathews
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
| | - Shauna Rakshe
- Biostatistics Shared Resource, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, USA
| | - Joseph J Shatzel
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, USA
| | - Ronan Swords
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, USA
| | - Elie Traer
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, USA
| | - Brandon Hayes-Lattin
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, USA
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2
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Bhat RV, Young G, Sharathkumar AA. How I treat pediatric venous thromboembolism in the DOAC era. Blood 2024; 143:389-403. [PMID: 37390311 PMCID: PMC10862368 DOI: 10.1182/blood.2022018966] [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: 02/14/2023] [Revised: 06/06/2023] [Accepted: 06/06/2023] [Indexed: 07/02/2023] Open
Abstract
ABSTRACT The direct oral anticoagulants (DOACs) rivaroxaban and dabigatran are newly licensed for the treatment and prevention of venous thromboembolism (VTE) in children and mark a renaissance in pediatric anticoagulation management. They provide a convenient option over standard-of-care anticoagulants (heparins, fondaparinux, and vitamin K antagonists) because of their oral route of administration, child-friendly formulations, and significant reduction in monitoring. However, limitations related to therapeutic monitoring when needed and the lack of approved reversal agents for DOACs in children raise some safety concerns. There is accumulating experience of safety and efficacy of DOACs in adults for a broad scope of indications; however, the cumulative experience of using DOACs in pediatrics, specifically for those with coexisting chronic illnesses, is sparse. Consequently, clinicians must often rely on their experience for treating VTE and extrapolate from data in adults while using DOACs in children. In this article, the authors share their experience of managing 4 scenarios that hematologists are likely to encounter in their day-to-day practice. Topics addressed include (1) appropriateness of indication; (2) use for special populations of children; (3) considerations for laboratory monitoring; (4) transition between anticoagulants; (5) major drug interactions; (6) perioperative management; and (7) anticoagulation reversal.
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Affiliation(s)
- Rukhmi V. Bhat
- Center for Cancer and Blood Disorders, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Guy Young
- Cancer and Blood Disorders Institute, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Anjali A. Sharathkumar
- Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA
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3
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Zhou Y, Jiang H, Wei H, Xiao X, Liu L, Ji X, Zhou C. Cerebral venous thrombosis in patients with autoimmune disease, hematonosis or coronavirus disease 2019: Many familiar faces and some strangers. CNS Neurosci Ther 2023; 29:2760-2774. [PMID: 37365966 PMCID: PMC10493677 DOI: 10.1111/cns.14321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 05/24/2023] [Accepted: 06/09/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND Cerebral venous thrombosis, a rare stroke, is characterized by neurological dysfunction caused by bleeding and/or infarction resulting from venous sinus thrombosis, the so-called venous stroke. Current guidelines recommend anticoagulants as first-line therapy in the treatment of venous stroke. With complicated causes of cerebral venous thrombosis, treatment is difficult, especially when combined with autoimmune diseases, blood diseases, and even COVID-19. AIMS This review summarizes the pathophysiological mechanisms, epidemiology, diagnosis, treatment, and clinical prognosis of cerebral venous thrombosis combined with autoimmune diseases, blood diseases, or infectious diseases such as COVID-19. CONCLUSION A systematic understanding of particular risk factors that should not be neglected when unconventional cerebral venous thrombosis occurs and for a scientific understanding of pathophysiological mechanisms, clinical diagnosis, and treatment, thus contributing to knowledge on special types of venous stroke.
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Affiliation(s)
- Yifan Zhou
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Beijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data‐based Precision MedicineCapital Medical UniversityBeijingChina
| | - Huimin Jiang
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Beijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data‐based Precision MedicineCapital Medical UniversityBeijingChina
| | - Huimin Wei
- Beijing Advanced Innovation Center for Big Data‐Based Precision Medicine, School of Engineering MedicineBeihang UniversityBeijingChina
| | - Xuechun Xiao
- Beijing Advanced Innovation Center for Big Data‐Based Precision Medicine, School of Engineering MedicineBeihang UniversityBeijingChina
| | - Lu Liu
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Xunming Ji
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Beijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data‐based Precision MedicineCapital Medical UniversityBeijingChina
- Department of Neurosurgery, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Chen Zhou
- Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Beijing Institute of Brain Disorders, Beijing Advanced Innovation Center for Big Data‐based Precision MedicineCapital Medical UniversityBeijingChina
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4
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Sandley M, Angus J. Asparaginase therapy in patients with acute lymphoblastic leukemia: expert opinion on use and toxicity management. Leuk Lymphoma 2023; 64:776-787. [PMID: 36781296 DOI: 10.1080/10428194.2023.2171267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
The addition of asparaginase to acute lymphoblastic leukemia (ALL) and lymphoblastic lymphoma (LBL) treatment regimens provides significant patient benefits. Asparaginase therapies vary in origin (Escherichia coli- or Erwinia-derived) and preparation (native or pegylated), conferring distinct pharmacokinetic and immunogenic profiles. Clinical hypersensitivity reactions (HSRs) are commonly reported in patients and range from localized erythema to systemic anaphylaxis. Due to its favorable pharmacokinetic profile and reduced immunogenicity compared to native E. coli preparations, pegaspargase is the first-line asparaginase therapeutic option. Switching to an Erwinia-derived asparaginase is recommended for patients who experience HSRs or antibody-mediated inactivation to achieve the significant clinical benefit observed in patients who complete asparaginase treatment. Previous global shortages of asparaginase Erwinia chrysanthemi necessitated conversion mitigation strategies such as premedication protocols, desensitization, and asparaginase activity level monitoring. Here, we discuss the efficacy, safety, pharmacokinetics, current use, and administration of asparaginase therapies for pediatric and adolescent patients with ALL/LBL.
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Affiliation(s)
- Melissa Sandley
- Department of Pharmacy, Oregon Health and Science University, Portland, OR, USA
| | - Jonathan Angus
- Department of Pharmacy, Cancer and Blood Disorders Center, Seattle Children's Hospital, Seattle, WA, USA
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5
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Dhariwal N, Gollamudi VRM, Sangeetha KP, Parambil BC, Moulik NR, Dhamne C, Prasad M, Vora T, Chinnaswamy G, Kembhavi S, Subramanian PG, Gujral S, Banavali SD, Narula G. Pediatric cancer-associated thrombosis: Analysis from a tertiary care cancer center in India. Pediatr Blood Cancer 2023; 70:e30096. [PMID: 36401555 DOI: 10.1002/pbc.30096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 10/08/2022] [Accepted: 10/22/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND AIMS Thrombotic events (TEs) have been extensively studied in adult cancer patients, but data in children are limited. We prospectively analyzed pediatric cancer-associated thrombosis (PCAT) in children with malignancies. METHODS Children below 15 years of age with confirmed malignancies, treated at a large tertiary cancer center in India from July 2015 to March 2020 developing any TE were eligible. A standardized approach for detection and management was followed. Data were collected after informed consent. RESULTS Of 6132 eligible children, 150 (2.44%) had 152 TEs, with median age 8.5 years and male:female of 1.83:1. Most TEs occurred on chemotherapy: 111 (74.0%). The most common site was central nervous system (CNS) 59 (39.3%), followed by upper-limb venous system 37 (24.7%). Hemato-lymphoid (HL) malignancies were more prone to PCAT than solid tumors (ST) (incidence 3.23% vs. 1.58%; odds ratio [OR] = 2.06, 95% confidence interval [CI] [1.36-2.88]; p < .001). Malignancies associated with PCAT were acute lymphoblastic leukemia (ALL) 2.94%, acute myeloid leukemia (AML) 6.66%, and non-Hodgkin lymphomas 5.35%. Response imaging done in 106 (70.7%) children showed complete to partial resolution in almost 90% children. Death was attributable to TE in seven (4.66%) children. Age above 10 years (OR 2.33, 95% CI [1.59-3.41]; p < .001), AML (OR 4.62, 95% CI [1.98-10.74]; p = .0062), and non-Hodgkin lymphoma (OR 4.01, 95% CI [1.15-14.04]; p = .029) were significantly associated with TEs. In ALL, age more than 10 years (OR 1.86, 95% CI [1.06-3.24]; p < .03), T-ALL (OR 3.32, 95% CI [1.69-6.54]; p = .001), and intermediate-risk group (OR 4.97, 95% CI [1.12-22.02]; p = .035) were significantly associated with thrombosis. The 2-year event-free survival (EFS) for HL malignancies with PCAT was 55.3% versus 72.1% in those without PCAT (p = .05), overall survival (OS) being 84.6% versus 80.0% (p = .32). CONCLUSION Incidence of PCAT was 2.4%, and occurred predominantly in older children with hematolymphoid malignancies early in treatment. Most resolved completely with low molecular weight heparin (LMWH) and mortality was low. In hematolymphoid malignancies, PCAT reduce EFS, highlighting the need for prevention.
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Affiliation(s)
- Nidhi Dhariwal
- Division of Pediatric Oncology, Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India.,Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Venkata Rama Mohan Gollamudi
- Division of Pediatric Oncology, Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India.,Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - K P Sangeetha
- Department of Medical Oncology, ESIC Bangalore, Bangalore, Karnataka, India
| | - Badira Cheriyalinkal Parambil
- Division of Pediatric Oncology, Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India.,Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Nirmalya Roy Moulik
- Division of Pediatric Oncology, Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India.,Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Chetan Dhamne
- Division of Pediatric Oncology, Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India.,Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Maya Prasad
- Division of Pediatric Oncology, Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India.,Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Tushar Vora
- Division of Pediatric Oncology, Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India.,Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Girish Chinnaswamy
- Division of Pediatric Oncology, Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India.,Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Seema Kembhavi
- Homi Bhabha National Institute, Mumbai, Maharashtra, India.,Department of Radiology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Papagudi G Subramanian
- Homi Bhabha National Institute, Mumbai, Maharashtra, India.,Hematopathology Laboratory, Department of Pathology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Sumeet Gujral
- Homi Bhabha National Institute, Mumbai, Maharashtra, India.,Hematopathology Laboratory, Department of Pathology, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - S D Banavali
- Homi Bhabha National Institute, Mumbai, Maharashtra, India.,Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Gaurav Narula
- Division of Pediatric Oncology, Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India.,Homi Bhabha National Institute, Mumbai, Maharashtra, India
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6
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Greenmyer JR, Wyatt KD, Rodriguez V, Ashrani AA, Warad D. Management Practices for Asparaginase-associated Coagulopathy: A Survey of Pediatric Oncologists. J Pediatr Hematol Oncol 2022; 44:e1023-e1028. [PMID: 35001056 DOI: 10.1097/mph.0000000000002396] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 12/08/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Coagulopathy and thrombosis are well-described complications of asparaginase therapy. However, treatment practices in pediatric hematology/oncology (PHO) patients vary widely as evidence-based guidelines for clinical management of these complications in this population are lacking. OBJECTIVE The objective of this study was to assess management practices of asparaginase-related coagulopathy by pediatric hematologist/oncologist attending physicians. DESIGN/METHOD Email survey sent to 2327 PHO physicians primarily practicing in the United States. RESULTS Two hundred eighty-five (12.2%) attending physicians completed the survey. Only 4.6% (n=13/285) routinely prescribe prophylactic anticoagulation during induction chemotherapy for leukemia. Slightly more than half (n=145/250, 50.9%) of all providers perform baseline coagulation studies. Most providers that were surveyed (n=185/285, 64.9%) only replete coagulant factors if the patient experiences bleeding or bruising. One hundred thirty (n=130/285, 45.6%) physicians replace low fibrinogen. The median fibrinogen replacement was 100 mg/dL (range: 40 to 200 mg/dL) with the median target of at least 100 mg/dL (range: 50 to 200 mg/dL). A minority of physicians (n=39/250, 13.7%) replace low antithrombin. The median antithrombin cutoff activity level was 60% (range: 40% to 100%) with a median target of 75% (range: 40% to 125%). CONCLUSIONS There is a significant variation in PHO physician practices for monitoring and management of asparaginase-associated hemostatic derangements. Evidence-based guidelines have the potential to standardize practices.
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Affiliation(s)
| | - Kirk D Wyatt
- Department of Pediatric Hematology and Oncology, Sanford Health, Fargo, ND
| | - Vilmarie Rodriguez
- Department of Pediatric Hematology and Oncology, Nationwide Children's, Columbus, OH
| | | | - Deepti Warad
- Pediatric Hematology and Oncology, Mayo Clinic, Rochester, MN
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7
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Chen Y, Buhlinger K, Perissinotti AJ, Schepers AJ, Benitez L, Auten J, Chen SL, Bixby DL, Burke PW, Pettit KM, Marini BL. Solving coagulation conundrums: comparing prophylaxis strategies in adult patients receiving PEG-asparaginase. Leuk Lymphoma 2022; 63:2663-2670. [DOI: 10.1080/10428194.2022.2087066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- YeeAnn Chen
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA
| | - Kaitlyn Buhlinger
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Anthony J. Perissinotti
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA
| | - Allison J. Schepers
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA
| | - Lydia Benitez
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA
| | - Jessica Auten
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Sheh-Li Chen
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Dale L. Bixby
- Division of Hematology/Oncology, Adult BMT and Leukemia Programs, Department of Internal Medicine, University of Michigan Medical School, Michigan Medicine, Ann Arbor, MI, USA
| | - Patrick W. Burke
- Division of Hematology/Oncology, Adult BMT and Leukemia Programs, Department of Internal Medicine, University of Michigan Medical School, Michigan Medicine, Ann Arbor, MI, USA
| | - Kristen M. Pettit
- Division of Hematology/Oncology, Adult BMT and Leukemia Programs, Department of Internal Medicine, University of Michigan Medical School, Michigan Medicine, Ann Arbor, MI, USA
| | - Bernard L. Marini
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA
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8
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Rodriguez V. Thrombosis Complications in Pediatric Acute Lymphoblastic Leukemia: Risk Factors, Management, and Prevention: Is There Any Role for Pharmacologic Prophylaxis? Front Pediatr 2022; 10:828702. [PMID: 35359904 PMCID: PMC8960248 DOI: 10.3389/fped.2022.828702] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 01/26/2022] [Indexed: 01/19/2023] Open
Abstract
Pediatric acute lymphoblastic leukemia (ALL) has achieved close to 90% cure rates through extensive collaborative and integrative molecular research, clinical studies, and advances in supportive care. Despite this high achievement, venous thromboembolic complications (VTE) remain one of the most common and potentially preventable therapy-associated adverse events in ALL. The majority of thromboses events involve the upper central venous system which is related to the use and location of central venous catheters (CVC). The reported rates of symptomatic and asymptomatic CVC-related VTE range from 2.6 to 36.7% and 5.9 to 43%, respectively. Thrombosis can negatively impact not only disease-free survival [e.g., therapy delays and/or interruption, omission of chemotherapy agents (e.g., asparaginase therapy)] but also can result in long-term adverse effects that can impair the quality of life of ALL survivors (e.g., post-thrombotic syndrome, central nervous system (CNS)-thrombosis related complications: seizures, neurocognitive deficits). In this review, will discuss thrombosis pathophysiology in pediatric ALL, risk factors, treatment, and prevention strategies. In addition, the recently published clinical efficacy and safety of direct oral anticoagulants (DOACs) use in thrombosis treatment, and their potential role in primary/secondary thrombosis prevention in pediatric patients with ALL will be discussed. Future clinical trials involving the use of these novel oral anticoagulants should be studied in ALL not only for primary thrombosis prevention but also in the treatment of thrombosis and its secondary prevention. These future research findings could potentially extrapolate to VTE prevention strategies in other pediatric cancer diagnoses and children considered at high risk for VTE.
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9
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Samji N, Bhatt MD, Kulkarni K. Challenges in Management of VTE in Children With Cancer: Risk Factors and Treatment Options. Front Pediatr 2022; 10:855162. [PMID: 35463883 PMCID: PMC9021605 DOI: 10.3389/fped.2022.855162] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 02/11/2022] [Indexed: 01/19/2023] Open
Abstract
Venous thromboembolism (VTE) occurs in 2.1 to up to 50% of children with cancer and contributes to long term morbidity as well as early mortality in this population. Pediatric patients with malignancy are predisposed to VTE due to the prothrombotic nature of cancer and its associated coagulopathies as well as chemotherapeutic agents, use of central venous catheters, surgery, radiotherapy, and concomitant thrombophilia. Management of thrombosis in this population is challenging due to concomitant thrombocytopenia, associated bleeding risks, concurrent co-morbidities, and toxicities of therapy. The aim of this paper is to highlight clinically relevant issues and management dilemmas using clinical vignettes. We review the clinical significance of asymptomatic and symptomatic thrombosis, examine the various options for asparaginase-associated thrombosis, address the role and controversies of direct oral anticoagulants, and describe our approach to managing anticoagulation therapy in the context of chemotherapy-induced thrombocytopenia.
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Affiliation(s)
- Nasrin Samji
- Department of Pediatrics, Division of Hematology Oncology, McMaster University, Hamilton, ON, Canada
| | - Mihir D Bhatt
- Department of Pediatrics, Division of Hematology Oncology, McMaster University, Hamilton, ON, Canada
| | - Ketan Kulkarni
- Department of Pediatrics, Division of Hematology Oncology, Dalhousie University and Izaak Walton Killam (IWK) Health Centre, Halifax, NS, Canada
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10
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West ZE, Castellino SM, Monroe C, Thomas AS, McCracken C, Miller TP. Quantifying the difference in risk of adverse events by induction treatment regimen in pediatric acute lymphoblastic leukemia. Leuk Lymphoma 2020; 62:899-908. [PMID: 33258395 DOI: 10.1080/10428194.2020.1852471] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The differences in overall morbidity by induction treatment regimen for pediatric acute lymphoblastic leukemia (ALL) are unknown. We examined a cohort of children with ALL who received induction chemotherapy between January 2010 and May 2018. We evaluated 20 clinically relevant adverse events (AEs) and readmission and ICU admission rates. Outcomes were compared between standard 3- and 4-drug treatment regimens in multivariate analyses using Cox proportional hazard ratios. Among 486 eligible patients, the risks of sepsis (HR = 2.16, 95% CI = 1.11-4.19), hypoxia (HR = 2.08, 95% CI = 1.03-4.18), hyperbilirubinemia (HR = 2.48, 95% CI = 1.07-5.74), hyperglycemia (HR = 2.65, 95% CI = 1.29-5.42), thromboembolic event (HR = 4.50, 95% CI = 1.30-15.6), and hyponatremia (HR = 7.88, 95% CI = 1.26-49.4) were significantly higher during 4-drug induction. Despite no differences in readmission or ICU admission rates, 4-drug induction patients had greater total inpatient days (12 vs. 4 days; p<.0001). In conclusion, pediatric patients receiving 4-drug induction for ALL experience higher morbidity. These results inform care practices and patient guidance during induction therapy.
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Affiliation(s)
- Zachary E West
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Sharon M Castellino
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Caitlin Monroe
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Amanda S Thomas
- Department of Pediatrics, Biostatistics Core, Emory University School of Medicine, Atlanta, GA, USA
| | - Courtney McCracken
- Department of Pediatrics, Biostatistics Core, Emory University School of Medicine, Atlanta, GA, USA
| | - Tamara P Miller
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, GA, USA
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11
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Baruchel A, Brown P, Rizzari C, Silverman L, van der Sluis I, Wolthers BO, Schmiegelow K. Increasing completion of asparaginase treatment in childhood acute lymphoblastic leukaemia (ALL): summary of an expert panel discussion. ESMO Open 2020; 5:e000977. [PMID: 32967920 PMCID: PMC7513670 DOI: 10.1136/esmoopen-2020-000977] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 08/10/2020] [Indexed: 02/02/2023] Open
Abstract
Insufficient exposure to asparaginase therapy is a barrier to optimal treatment and survival in childhood acute lymphoblastic leukaemia (ALL). Three important reasons for inactivity or discontinuation of asparaginase therapy are infusion related reactions (IRRs), pancreatitis and life-threatening central nervous system (CNS). For IRRs, real-time therapeutic drug monitoring (TDM) and premedication are important aspects to be considered. For pancreatitis and CNS thrombosis one key question is if patients should be re-exposed to asparaginase after their occurrence.An expert panel met during the Congress of the International Society for Paediatric Oncology in Lyon in October 2019 to discuss strategies for diminishing the impact of these three toxicities. The panel agreed that TDM is particularly useful for optimising asparaginase treatment and that when a tight pharmacological monitoring programme is established premedication could be implemented more broadly to minimise the risk of IRR. Re-exposure to asparaginase needs to be balanced against the anticipated risk of leukemic relapse. However, more prospective data are needed to give clear recommendations if to re-expose patients to asparaginase after the occurrence of severe pancreatitis and CNS thrombosis.
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Affiliation(s)
- André Baruchel
- Université de Paris, APHP, Hôpital Universitaire Robert-Debré, Paris, France.
| | - Patrick Brown
- Johns Hopkins Medicine Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland, USA
| | | | | | - Inge van der Sluis
- Princess Maxima Center for Pediatric Oncology, Utrecht, Utrecht, Netherlands
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12
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Garg A, Kashyap R, Lal H, Mishra P. Cerebral Sinus Venous Thrombosis in Indian Pediatric Patients With Acute Lymphoblastic Leukemia: Incidence, Risk Factors, and Outcome. Indian J Med Paediatr Oncol 2020. [DOI: 10.4103/ijmpo.ijmpo_206_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
AbstractCerebral sinus venous Thrombosis (CSVT) is a rare complication of acute lymphoblastic leukemia (ALL) treatment, with an incidence rate ranging from 1.1% to 2.9%. Steroids and L-asparaginase (LASP) are the major risk factors.The aim of this study was to find the incidence rate and risk factors for CSVT in our patients. Ninety-two pediatric ALL diagnosed and treated with ALL-Berlin–Frankfurt–Munster-95 protocol over a period of 5 years (2013–2017) were the subject of the study. Six (6.5%) patients developed CSVT during their therapy and were further analyzed.Six (five males and one female) patients had a CSVT event. The mean age at presentation was 13.5 ± 4.1 years. CSVT event occurred during the induction/re-induction phase of chemotherapy. The superior sagittal sinus was the most frequent site of thrombosis. The timing of CSVT was related to using of LASP and steroids. High-risk disease was associated with an increased risk of thrombosis. Infection and dehydration were other important risk factors. No association was observed between the risk of CSVT and age, sex, immunophenotype, and white blood cell count. All the patients were treated with low-molecular-weight heparin and one patient developed heparin-induced thrombocytopenia. No death occurred due to CSVT.The Incidence of CSVT was 6.5% in our study which is significantly high but comparable with studies from other Asian countries. It is, therefore, important to be vigilant for the detection of CSVT during treatment of ALL and initiate the appropriate treatment to prevent adverse events.
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Affiliation(s)
- Akanksha Garg
- Department of Hematology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Rajesh Kashyap
- Department of Hematology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Hira Lal
- Department of Radiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Prabhakar Mishra
- Department of Biostatistics and Health Informatics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Gupta S, Wang C, Raetz EA, Schore R, Salzer WL, Larsen EC, Maloney KW, Mattano LA, Carroll WL, Winick NJ, Hunger SP, Loh ML, Devidas M. Impact of Asparaginase Discontinuation on Outcome in Childhood Acute Lymphoblastic Leukemia: A Report From the Children's Oncology Group. J Clin Oncol 2020; 38:1897-1905. [PMID: 32275469 DOI: 10.1200/jco.19.03024] [Citation(s) in RCA: 116] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Asparaginase (ASNase) is an important component of acute lymphoblastic leukemia (ALL) treatment, but is often discontinued because of toxicity. Erwinia chrysanthemi ASNase (Erwinia) substitution was approved in 2011 for allergic reactions. Erwinia has, however, been intermittently unavailable because of drug supply issues. The impact of Erwinia substitution or complete ASNase discontinuation is unknown. METHODS Patients aged 1-30.99 years in frontline Children's Oncology Group trials for B-cell acute lymphoblastic leukemia between 2004 and 2011 (National Cancer Institute [NCI] standard risk [SR]: AALL0331; NCI high risk: AALL0232) were included. The number of prescribed pegaspargase (PEG-ASNase) doses varied by trial and strata. Maintenance therapy did not contain ASNase. Landmark analyses at maintenance compared disease-free survival (DFS) among those receiving all prescribed PEG-ASNase doses versus switching to Erwinia but receiving all doses versus not receiving all ASNase doses. RESULTS We included 5,195 AALL0331 and 3,001 AALL0232 patients. The cumulative incidence of PEG-ASNase discontinuation was 12.2% ± 4.6% in AALL0331 and 25.4% ± 0.8% in AALL0232. In multivariable analyses, NCI high-risk patients not receiving all prescribed ASNase doses had inferior DFS (hazard ratio [HR], 1.5; 95% CI, 1.2 to 1.9; P = .002) compared with those receiving all prescribed PEG-ASNase doses. Patients with Erwinia substitution who completed subsequent courses were not at increased risk (HR, 1.1; 95% CI, 0.7 to 1.6; P = .69). NCI SR patients who discontinued ASNase were not at elevated risk (HR, 1.2; 95% CI, 0.9 to 1.6; P = .23), except when restricted to those with slow early response, who were prescribed more ASNase because of therapy intensification (HR, 1.7; 95% CI, 1.1 to 2.7; P = .03). CONCLUSION Discontinuation of ASNase doses is associated with inferior DFS in higher-risk patients. Our results illustrate the severe consequences of Erwinia shortages.
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Affiliation(s)
- Sumit Gupta
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Cindy Wang
- Department of Biostatistics, University of Florida, Gainesville, FL
| | | | | | - Wanda L Salzer
- US Army Medical Research and Materiel Command, Fort Detrick, MD
| | - Eric C Larsen
- Department of Pediatrics, Maine Children's Cancer Program, Scarborough, ME
| | | | | | - William L Carroll
- Department of Pediatrics and Perlmutter Cancer Center, New York University Langone Health, New York, NY
| | - Naomi J Winick
- University of Texas Southwestern/Simmons Cancer Center, Dallas, TX
| | - Stephen P Hunger
- Department of Pediatrics and the Center for Childhood Cancer Research, Children's Hospital of Philadelphia, and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Mignon L Loh
- Department of Pediatrics, UCSF Benoiff Childen's Hospital and Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA
| | - Meenakshi Devidas
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
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14
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Nasser NJ, Fox J, Agbarya A. Potential Mechanisms of Cancer-Related Hypercoagulability. Cancers (Basel) 2020; 12:cancers12030566. [PMID: 32121387 PMCID: PMC7139427 DOI: 10.3390/cancers12030566] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 02/25/2020] [Accepted: 02/26/2020] [Indexed: 11/16/2022] Open
Abstract
The association between cancer and thrombosis has been known for over a century and a half. However, the mechanisms that underlie this correlation are not fully characterized. Hypercoagulability in cancer patients can be classified into two main categories: Type I and Type II. Type I occurs when the balance of endogenous heparin production and degradation is disturbed, with increased degradation of endogenous heparin by tumor-secreted heparanase. Type II hypercoagulability includes all the other etiologies, with factors related to the patient, the tumor, and/or the treatment. Patients with poor performance status are at higher risk of venous thromboembolism (VTE). Tumors can result in VTE through direct pressure on blood vessels, resulting in stasis. Several medications for cancer are correlated with a high risk of thrombosis. These include hormonal therapy (e.g., tamoxifen), chemotherapy (e.g., cisplatin, thalidomide and asparaginase), molecular targeted therapy (e.g., lenvatinib, osimertinib), and anti-angiogenesis monoclonal antibodies (e.g., bevacizumab and ramucirumab).
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Affiliation(s)
- Nicola J. Nasser
- Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY 10467, USA;
- Correspondence:
| | - Jana Fox
- Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, NY 10467, USA;
| | - Abed Agbarya
- Institute of Oncology, Bnai Zion Medical Center, Haifa 31048, Israel;
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Zwicker JI, Wang TF, DeAngelo DJ, Lauw MN, Connors JM, Falanga A, McMasters M, Carrier M. The prevention and management of asparaginase-related venous thromboembolism in adults: Guidance from the SSC on Hemostasis and Malignancy of the ISTH. J Thromb Haemost 2020; 18:278-284. [PMID: 31999063 DOI: 10.1111/jth.14671] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 10/25/2019] [Indexed: 02/01/2023]
Abstract
Venous thromboembolism is a common complication of asparaginase-based chemotherapy regimens for the treatment of acute lymphoblastic leukemia. Thrombosis associated with asparaginase administration poses a number of specific and often clinically challenging management decisions. This review provides guidance on the prevention and treatment of thrombosis associated with asparaginase in adults including discussions on antithrombin repletion, pharmacologic thromboprophylaxis, cerebral venous thrombosis, and therapeutic anticoagulation.
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Affiliation(s)
- Jeffrey I Zwicker
- Division of Hematology and Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Tzu-Fei Wang
- Division of Hematology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Daniel J DeAngelo
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Mandy N Lauw
- Department of Hematology, Erasmus MC, Rotterdam, the Netherlands
- Department of Hematology, Amsterdam UMC, Amsterdam, the Netherlands
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Amsterdam, the Netherlands
| | - Jean M Connors
- Hematology Division, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Anna Falanga
- University of Milan Bicocca, Milan, Italy
- Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Malgorzata McMasters
- Division of Hematologic Malignancies, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, ON, Canada
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Ishihara T, Nogami K, Ochi S, Ishida T, Kosaka Y, Sawada A, Inoue M, Osone S, Imamura T, Hosoi H, Shima M. Disordered hemostasis associated with severely depressed fibrinolysis demonstrated using a simultaneous thrombin and plasmin generation assay during L-asparaginase induction therapy in pediatric acute lymphoblastic leukemia. Pediatr Blood Cancer 2020; 67:e28016. [PMID: 31556233 DOI: 10.1002/pbc.28016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 09/03/2019] [Accepted: 09/12/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND L-asparaginase (L-Asp)-associated thromboembolisms are serious complications in pediatrics patients with acute lymphoblastic leukemia (ALL), especially at ≥10.0 years old, but the pathogenesis remains to be clarified. PROCEDURE We conducted a multicenter, prospective study of 72 patients with ALL aged 1.0 to 15.2 years treated with either a Berlin-Frankfurt-Münster (BFM) 95-ALL oriented regimen or Japan Association of Childhood Leukemia Study ALL-02 protocol. We divided patients into each treatment protocol and investigated the dynamic changes in coagulation and fibrinolysis using simultaneous thrombin and plasmin generation assay. Patients' plasma samples were collected at the prephase (T0), intermittent phase (T1), and postphase of L-Asp therapy (T2), and postinduction phase (T3). Measurements of endogenous thrombin potential (T-EP) and plasmin peak height (P-Peak) were compared to normal plasma. RESULTS None of the cases developed thromboembolisms. Median ratios of T-EP and P-Peak for the controls in the JACLS group were 1.06 and 0.87 (T0), 1.04 and 0.71 (T1), 1.02 and 0.69 (T2), and 1.20 and 0.92 (T3), respectively, while those in the BFM group were 1.06 and 1.00 (T0), 1.04 and 0.64 (T1), 1.16 and 0.58 (T2), and 1.16 and 0.85 (T3), respectively. In particular, P-Peak ratios were depressed at T1 and T2 compared to T0 in the BFM group (P < .01). Moreover, P-Peak ratios in patients ≥10.0 years old were lower at T1 in the BFM group (P = .02). CONCLUSIONS The results demonstrated that hemostatic dynamics appeared to shift to a hypercoagulable state with marked hypofibrinolysis associated with L-Asp therapy, especially in patients ≥10.0 years old following the BFM regimen.
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Affiliation(s)
- Takashi Ishihara
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
| | - Keiji Nogami
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
| | - Satoshi Ochi
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
| | - Toshiaki Ishida
- Department of Hematology and Oncology, Children's Cancer Center, Kobe Children's Hospital, Kobe, Japan
| | - Yoshiyuki Kosaka
- Department of Hematology and Oncology, Children's Cancer Center, Kobe Children's Hospital, Kobe, Japan
| | - Akihisa Sawada
- Department of Hematology/Oncology, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Masami Inoue
- Department of Hematology/Oncology, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Shinya Osone
- Department of Pediatrics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Toshihiko Imamura
- Department of Pediatrics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hajime Hosoi
- Department of Pediatrics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Midori Shima
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
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Klaassen ILM, Lauw MN, Fiocco M, van der Sluis IM, Pieters R, Middeldorp S, van de Wetering MD, de Groot‐Kruseman HA, van Ommen CH. Venous thromboembolism in a large cohort of children with acute lymphoblastic leukemia: Risk factors and effect on prognosis. Res Pract Thromb Haemost 2019; 3:234-241. [PMID: 31011707 PMCID: PMC6462738 DOI: 10.1002/rth2.12182] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 11/15/2018] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is relatively common in children with acute lymphoblastic leukemia (ALL). Thrombotic risk factors in ALL are asparaginase and steroids. However, within the ALL populations treated on the same regimen, it is less clear which other risk factors play a role. Furthermore, few data are available on the effect of VTE on ALL outcomes. METHODS In 778 children (1-18 years) with newly diagnosed precursor-B-lineage or T-lineage ALL, treated in the Dutch Childhood Oncology Group (DCOG) ALL-10 protocol in the Netherlands (October 2004 to April 2013), we conducted a nested case control study with 59 VTE cases and 118 controls to identify risk factors for VTE. RESULTS Fifty-nine of 778 ALL patients developed VTE (7.6%), with cerebral venous sinus thrombosis (CVST) in 26 of 59 patients (44.1%). VTE occurred during induction treatment in 59.3% (n = 35) and in 40.7% (n = 24) during medium risk intensification. Conditional multivariable logistic regression analysis showed that age and ALL subtype were significantly associated with VTE (age ≥7 years: OR 2.72, 95% CI 1.33-5.57; ALL subtype T-ALL: OR 2.95, 95% CI 1.02-8.57). A multivariable Cox model showed no association between the occurrence of VTE and event free survival. In CVST patients, permanent disability was present in 34.6%. CONCLUSION Within this large pediatric ALL cohort, we demonstrated a high morbidity in CVST patients. Age ≥7 years at diagnosis and T-ALL subtype were the main risk factors for VTE, and should be considered in preventive strategies.
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Affiliation(s)
- Irene L. M. Klaassen
- Department of Pediatric HematologyAcademic Medical CenterAmsterdamthe Netherlands
- Department of Vascular MedicineAcademic Medical CenterAmsterdamthe Netherlands
| | - Mandy N. Lauw
- Department of Vascular MedicineAcademic Medical CenterAmsterdamthe Netherlands
- Department of HematologyAcademic Medical CenterAmsterdamthe Netherlands
| | - Marta Fiocco
- Medical StatisticsDepartment of Biomedical Data SciencesLeiden University Medical CenterLeidenthe Netherlands
- Mathematical Institute Leiden UniversityLeidenthe Netherlands
- Dutch Childhood Oncology GroupThe Haguethe Netherlands
| | - Inge M. van der Sluis
- Department of Pediatric Oncology/HematologyErasmus MC‐Sophia Children's HospitalRotterdamthe Netherlands
- Princess Máxima Center for Pediatric OncologyUtrechtthe Netherlands
| | - Rob Pieters
- Princess Máxima Center for Pediatric OncologyUtrechtthe Netherlands
| | - Saskia Middeldorp
- Department of Vascular MedicineAcademic Medical CenterAmsterdamthe Netherlands
| | | | | | - C. Heleen van Ommen
- Department of Pediatric Oncology/HematologyErasmus MC‐Sophia Children's HospitalRotterdamthe Netherlands
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19
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Sun LR, Cooper S. Neurological Complications of the Treatment of Pediatric Neoplastic Disorders. Pediatr Neurol 2018; 85:33-42. [PMID: 30126755 DOI: 10.1016/j.pediatrneurol.2018.05.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 05/25/2018] [Indexed: 01/19/2023]
Abstract
Neurological complications resulting from childhood cancer treatments are common. Treatment for childhood neoplastic disorders is often multimodal and may include procedures, cranial irradiation, chemotherapy, transplant, and immunotherapy, each of which carries distinct neurological risks. Procedures, such as lumbar punctures, are commonly used in this population for diagnostic purposes as well as intrathecal medication administration. Surgery is associated with an array of potential neurological complications, with posterior fossa syndrome being a common cause of morbidity in pediatric brain tumor patients after neurosurgical resection. Cranial irradiation can cause late neurological sequelae such as stroke, cerebral vasculopathy, secondary malignancy, and cognitive dysfunction. Neurotoxic effects of chemotherapeutic agents are common and include neuropathy, coagulopathy causing stroke or cerebral sinovenous thrombosis, encephalopathy, seizures, cerebellar dysfunction, myelopathy, and neuropsychologic difficulties. Hematopoietic stem cell transplant has a high risk of neurological complications including central nervous system infection, seizures, and stroke. Immunotherapies, including chimeric antigen receptor-modified T-cells (CAR T-cells) and immune checkpoint inhibitors, are emerging as potentially effective strategies to treat some types of childhood cancer, but may carry with them substantial neurotoxicity which is just beginning to be recognized and studied. With evolving treatment protocols, childhood cancer survivorship is increasing, and the role of the neurologist in managing both the acute and chronic neurological consequences of treatment is becoming more important. Prevention, early recognition, and treatment of therapy-associated neurotoxicity are imperative to ensuring children can remain on the most effective therapeutic regimens and to improve the neurological function and quality of life of childhood cancer survivors.
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Affiliation(s)
- Lisa R Sun
- The Johns Hopkins University School of Medicine, Department of Neurology, Division of Pediatric Neurology, Baltimore, Maryland; The Johns Hopkins University School of Medicine, Department of Neurology, Division of Cerebrovascular Neurology, Baltimore, Maryland.
| | - Stacy Cooper
- The Johns Hopkins University School of Medicine, Department of Oncology, Division of Pediatric Oncology, Baltimore, Maryland
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20
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Sibson KR, Biss TT, Furness CL, Grainger JD, Hough RE, Macartney C, Payne JH, Chalmers EA. BSH Guideline: management of thrombotic and haemostatic issues in paediatric malignancy. Br J Haematol 2018; 180:511-525. [DOI: 10.1111/bjh.15112] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 10/28/2017] [Accepted: 11/07/2017] [Indexed: 01/19/2023]
Affiliation(s)
- Keith R. Sibson
- Department of Haematology; Great Ormond Street Hospital; London UK
| | - Tina T. Biss
- The Newcastle Upon Tyne Hospitals NHS Foundation Trust; Newcastle Upon Tyne UK
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21
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Hough R, Vora A. Crisis management in the treatment of childhood acute lymphoblastic leukemia: putting right what can go wrong (emergency complications of disease and treatment). HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:251-258. [PMID: 29222263 PMCID: PMC6142611 DOI: 10.1182/asheducation-2017.1.251] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The improvement in overall survival in children with acute lymphoblastic leukemia (ALL) over the last 5 decades has been considerable, with around 90% now surviving long term. The risk of relapse has been reduced to such an extent that the risk of treatment-related mortality is now approaching that of mortality caused by relapse. Toxicities may also lead to the suboptimal delivery of chemotherapy (treatment delays, dose reductions, dose omissions), potentially increasing relapse risk, and short- and long-term morbidity, adding to the "burden of therapy" in an increasing number of survivors. Thus, the need to reduce toxicity in pediatric ALL is becoming increasingly important. This work focuses on the risk factors, pathogenesis, clinical features, and emergency management of the life-threatening complications of ALL at presentation and during subsequent chemotherapy, including leucostasis, tumor lysis syndrome, infection, methotrexate encephalopathy, thrombosis, and pancreatitis. Potential strategies to abrogate these toxicities in the future are also discussed.
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Affiliation(s)
- Rachael Hough
- Department of Adolescent Haematology, University College London Hospitals NHS Foundation Trust, London, United Kingdom; and
| | - Ajay Vora
- Department of Haematology, Great Ormond Street Hospital for Children, London, United Kingdom
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22
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Ghanem KM, Dhayni RM, Al-Aridi C, Tarek N, Tamim H, Chan AKC, Saab R, Abboud MR, El-Solh H, Muwakkit SA. Cerebral sinus venous thrombosis during childhood acute lymphoblastic leukemia therapy: Risk factors and management. Pediatr Blood Cancer 2017; 64. [PMID: 28660695 DOI: 10.1002/pbc.26694] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 05/16/2017] [Accepted: 05/30/2017] [Indexed: 11/12/2022]
Abstract
BACKGROUND Cerebral sinus venous thrombosis (CSVT) is a rare but serious complication of childhood acute lymphoblastic leukemia (ALL) therapy. No available consensus exists regarding its risk factors and appropriate management due to the rarity of cases. PROCEDURES Out of 209 ALL patients aged 1-21 years treated at the Children's Cancer Center of Lebanon between May 2002 and May 2015, 13 developed CSVT during therapy. Patient characteristics, clinical management, and outcomes were studied. RESULTS The incidence of CSVT was 6.2% (95% confidence interval [CI]: 3.4-10.4). Using univariate analysis, increased risk of CSVT was observed with age >10 years (odds ratio [OR]: 3.56, 95% CI: 1.13-11.2), T-cell immunophenotype (OR: 4.14, 95% CI: 1.16-14.7), and intermediate/high risk disease (OR: 3.4, 95% CI: 1.03-11.7). The only statistically significant risk factor by multivariate analysis was the treatment as per the intermediate-/high-risk protocol (HR: 15.6, 95% CI: 1.43-171.3). Most cases (77%) occurred in the postinduction phases of treatment while receiving a combination of asparaginase and dexamethasone rather than prednisone. Treatment with low molecular weight heparin (LMWH) for a minimum of 3 months and until significant radiological improvement is observed resulted in 100% survival rate. All but one patient had complete neurological recovery. CONCLUSIONS CSVT is an important complication of childhood ALL therapy. Postinduction combined asparaginase and dexamethasone intensive treatment for intermediate-/high-risk patients was the most important risk factor. Treatment with LMWH for a minimum of 3 months, and until asparginase therapy is over, with major radiological improvement seems to be effective and feasible.
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Affiliation(s)
- Khaled M Ghanem
- Department of Pediatrics and Adolescent Medicine, Hematology Oncology Service, Children's Cancer Center of Lebanon, American University of Beirut, Beirut, Lebanon
| | - Raghida M Dhayni
- Department of Pediatrics and Adolescent Medicine, Hematology Oncology Service, Children's Cancer Center of Lebanon, American University of Beirut, Beirut, Lebanon
| | - Carol Al-Aridi
- Department of Pediatrics and Adolescent Medicine, Hematology Oncology Service, Children's Cancer Center of Lebanon, American University of Beirut, Beirut, Lebanon
| | - Nidale Tarek
- Department of Pediatrics and Adolescent Medicine, Hematology Oncology Service, Children's Cancer Center of Lebanon, American University of Beirut, Beirut, Lebanon
| | - Hani Tamim
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Anthony K C Chan
- Department of Pediatrics, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Raya Saab
- Department of Pediatrics and Adolescent Medicine, Hematology Oncology Service, Children's Cancer Center of Lebanon, American University of Beirut, Beirut, Lebanon
| | - Miguel R Abboud
- Department of Pediatrics and Adolescent Medicine, Hematology Oncology Service, Children's Cancer Center of Lebanon, American University of Beirut, Beirut, Lebanon
| | - Hassan El-Solh
- Department of Pediatrics and Adolescent Medicine, Hematology Oncology Service, Children's Cancer Center of Lebanon, American University of Beirut, Beirut, Lebanon
| | - Samar A Muwakkit
- Department of Pediatrics and Adolescent Medicine, Hematology Oncology Service, Children's Cancer Center of Lebanon, American University of Beirut, Beirut, Lebanon
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23
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Klaassen ILM, van Els AL, van de Wetering MD, van Ommen CH. Increasing Incidence and Recurrence Rate of Venous Thromboembolism in Paediatric Oncology Patients in One Single Centre Over 25 Years. Thromb Haemost 2017; 117:2156-2162. [PMID: 28981557 DOI: 10.1160/th17-02-0109] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Venous thromboembolism (VTE) is a serious complication in paediatric oncology patients. To identify the incidence, risk factors and recurrence rate of VTE in paediatric oncology patients, an observational, retrospective cohort study of all consecutive children (≤18 years) with malignancies, treated at the Emma Children's Hospital Academic Medical Centre between January 1989 and December 2013, was done. A matched case-control study in children with lymphomas was performed, to identify thrombotic risk factors. Cumulative recurrence-free survival after first VTE was estimated by the Kaplan-Meier method. Of the 2,183 children included (male: female = 1.4:1.0; median age, 6.6 years) with cancer, 78 patients developed VTE (3.6%; 95% confidence interval [CI], 2.8-4.4). The incidence increased from 0.8% (4/478, 95% CI, 0.0-1.6) between 1989 and 1993 to 10.4% (44/423, 95% CI, 7.6-13.4) between 2009 and 2013. Independent risk factors for VTE were age ≥ 12 years, acute lymphoblastic leukaemia (ALL) and lymphoma. The case-control study in lymphoma patients showed a trend for increased VTE incidence in stage IV lymphoma. Twelve (15.4%) patients developed recurrent thrombosis, 7 patients while on therapeutic or prophylactic anticoagulation. The cumulative recurrence-free survival after first VTE was 88.5, 87.1 and 80.6% after 1, 5 and 10 years, respectively. In conclusion, we demonstrated an increasing incidence of VTE in children with malignancies, with age ≥ 12 years, ALL and lymphoma as independent risk factors. The elevated recurrence rate underlines the importance of full anticoagulant therapy and might warrant prophylactic anticoagulation after first VTE during cancer treatment.
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Affiliation(s)
- Irene L M Klaassen
- Department of Pediatric Hematology, Emma Children's Hospital Academical Medical Center, Amsterdam, The Netherlands.,Department of Vascular Medicine, Academical Medical Center, Amsterdam, The Netherlands
| | - Anne L van Els
- Department of Pediatric Hematology, Emma Children's Hospital Academical Medical Center, Amsterdam, The Netherlands.,Department of Pediatric Oncology, Emma Children's Hospital Academical Medical Center, Amsterdam, The Netherlands
| | - Marianne D van de Wetering
- Department of Pediatric Oncology, Emma Children's Hospital Academical Medical Center, Amsterdam, The Netherlands
| | - C Heleen van Ommen
- Department of Pediatric Hematology, Sophia Children's Hospital Erasmus MC, Rotterdam, The Netherlands
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Evaluation of coagulopathy before and during induction chemotherapy for acute lymphoblastic leukaemia, including assessment of global clotting tests. Blood Cancer J 2017. [PMID: 28622302 PMCID: PMC5520401 DOI: 10.1038/bcj.2017.54] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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Schmiegelow K, Müller K, Mogensen SS, Mogensen PR, Wolthers BO, Stoltze UK, Tuckuviene R, Frandsen T. Non-infectious chemotherapy-associated acute toxicities during childhood acute lymphoblastic leukemia therapy. F1000Res 2017; 6:444. [PMID: 28413626 PMCID: PMC5389408 DOI: 10.12688/f1000research.10768.1] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/04/2017] [Indexed: 01/19/2023] Open
Abstract
During chemotherapy for childhood acute lymphoblastic leukemia, all organs can be affected by severe acute side effects, the most common being opportunistic infections, mucositis, central or peripheral neuropathy (or both), bone toxicities (including osteonecrosis), thromboembolism, sinusoidal obstruction syndrome, endocrinopathies (especially steroid-induced adrenal insufficiency and hyperglycemia), high-dose methotrexate-induced nephrotoxicity, asparaginase-associated hypersensitivity, pancreatitis, and hyperlipidemia. Few of the non-infectious acute toxicities are associated with clinically useful risk factors, and across study groups there has been wide diversity in toxicity definitions, capture strategies, and reporting, thus hampering meaningful comparisons of toxicity incidences for different leukemia protocols. Since treatment of acute lymphoblastic leukemia now yields 5-year overall survival rates above 90%, there is a need for strategies for assessing the burden of toxicities in the overall evaluation of anti-leukemic therapy programs.
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Affiliation(s)
- Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Klaus Müller
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Signe Sloth Mogensen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Pernille Rudebeck Mogensen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Diabetes and Metabolism, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Benjamin Ole Wolthers
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Ulrik Kristoffer Stoltze
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Ruta Tuckuviene
- Department of Pediatrics, Aalborg University Hospital, Aalborg, Denmark
| | - Thomas Frandsen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
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Lee JH, Lee J, Yhim HY, Oh D, Bang SM. Venous thromboembolism following L-asparaginase treatment for lymphoid malignancies in Korea. J Thromb Haemost 2017; 15:655-661. [PMID: 28150907 DOI: 10.1111/jth.13636] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Indexed: 01/19/2023]
Abstract
Essentials Data on venous thromboembolism (VTE) after L-asparaginase (L-asp) in Asian lymphoma are scarce. This is a population-based study in Asian patients with lymphoid disease and L-asp-related VTE. The overall incidence of L-asp-associated VTE was similar to reports on Caucasians. This first and largest study in Asians shows that mainly adult patients are at risk of thrombosis. SUMMARY Background L-asparaginase (L-asp)-associated venous thromboembolism (VTE) is a serious adverse complication associated with acute lymphoblastic leukemia (ALL) and lymphoma treatment. The incidence rate of L-asp-related VTE in Asian cancer patients is not well known. Methods We performed a population-based study between 2009 and 2013 using claim databases, including both diagnostic and medication codes, such as anti-cancer treatment with L-asp and VTE diagnoses from the starting date until 3 months after cessation of L-asp. Results A total of 3286 patients were prescribed L-asp treatment for any type of lymphoid malignancy including ALL and lymphoma; 116 patients (3.5%) experienced VTE. The most common site of thrombosis was the upper extremities (34.5%). Cerebral vein thrombosis (1.7%) occurred in two pediatric patients; 2.4% (43/1795) of pediatric patients and 4.9% (72/1486) of adult patients suffered from VTE, respectively; 2.7% (56/2064) of ALL and 4.9% (59/1217) of lymphoma patients were diagnosed with VTE after L-asp exposure. After univariate analysis, both the diagnosis of lymphoma (vs. ALL) and being an adult patient (vs. pediatric patient) were risk factors for VTE occurrence. However, after multivariate analysis, only age > 18 remained a risk factor for VTE (odds ratio, 1.79; 95% confidence interval, 1.14-2.81). Conclusions This is the first and largest population-based study in Asian patients with lymphoid malignancies treated with L-asp demonstrating that adult patients are at elevated risk of thrombosis after L-asp exposure. The overall incidence of L-asp-related VTE amongst these patients was similar to that in Caucasian populations.
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Affiliation(s)
- J H Lee
- Department of Internal Medicine, Dong-A University College of Medicine, Busan
| | - J Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam
| | - H-Y Yhim
- Department of Internal Medicine, Chonbuk National University Medical School, Jeonju
| | - D Oh
- Department of Internal Medicine, School of Medicine, CHA University, Seongnam, South Korea
| | - S-M Bang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam
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McNeer JL, Bleyer A, Conter V, Stock W. Acute Lymphoblastic Leukemia. CANCER IN ADOLESCENTS AND YOUNG ADULTS 2017. [DOI: 10.1007/978-3-319-33679-4_7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Eden D, Hipkins R, Bradbury CA. Cerebral Thrombotic Complications Related to l-Asparaginase Treatment for Acute Lymphoblastic Leukemia. Clin Appl Thromb Hemost 2016; 22:589-93. [DOI: 10.1177/1076029615572464] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
l-Asparaginase is a potent antileukemia agent and an essential part of treatment protocols for acute lymphoblastic leukemia. However, toxicity limits dose escalation, especially in adults. This includes a significant risk of thrombosis, which remains an important source of avoidable morbidity and mortality. Here, we provide a detailed report of 10 cases of cerebral thrombotic complications that occurred over a 5-year period at 4 large tertiary referral hospitals. To our knowledge, this is the first report of this type in the published literature.
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Affiliation(s)
- D. Eden
- Department of Haematology, University Hospital Birmingham NHS Trust, Birmingham, United Kingdom
| | - R. Hipkins
- Russells Hall Hospital, Dudley, United Kingdom
| | - C. A. Bradbury
- Department of Haematology, University Hospital Bristol NHS Trust, Bristol, United Kingdom
- University of Bristol, Bristol, United Kingdom
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29
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Musgrave KM, van Delft FW, Avery PJ, Clack RM, Chalmers EA, Qureshi A, Vora AJ, Biss TT. Cerebral sinovenous thrombosis in children and young adults with acute lymphoblastic leukaemia - a cohort study from the United Kingdom. Br J Haematol 2016; 179:667-669. [PMID: 27392277 DOI: 10.1111/bjh.14231] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Kathryn M Musgrave
- Department of Haematology, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Frederik W van Delft
- Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - Peter J Avery
- School of Mathematics and Statistics, Newcastle University, Newcastle upon Tyne, UK
| | - Rachel M Clack
- Clinical Trial Service Unit, University of Oxford, Oxford, UK
| | | | - Amrana Qureshi
- Oxford Children's Hospital, Oxford University NHS Foundation Trust, Oxford, UK
| | - Ajay J Vora
- Sheffield Children's Hospital, Sheffield, UK
| | - Tina T Biss
- Department of Haematology, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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30
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Tan RMR, Ganau M, Jeelani NUO, Tahir Z, Mankad K, Kachramanoglou C, Prabhakar P, Goulden N, Samarasinghe S. Central nervous system aspergillosis resembling haemorrhagic brain infarct in a paediatric leukaemia patient. Br J Haematol 2016; 178:642-645. [DOI: 10.1111/bjh.14161] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 04/06/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Ronald M. R. Tan
- Department of Paediatric Haematology; Great Ormond Street Hospital for Children; London UK
| | - Mario Ganau
- Department of Paediatric Neurosurgery; Great Ormond Street Hospital for Children; London UK
| | - N. U. Owase Jeelani
- Department of Paediatric Neurosurgery; Great Ormond Street Hospital for Children; London UK
| | - Zubair Tahir
- Department of Paediatric Neurosurgery; Great Ormond Street Hospital for Children; London UK
| | - Kshitij Mankad
- Department of Paediatric Neuroradiology; Great Ormond Street Hospital for Children; London UK
| | - Carolina Kachramanoglou
- Department of Paediatric Neuroradiology; Great Ormond Street Hospital for Children; London UK
| | - Prab Prabhakar
- Department of Paediatric Neurology; Great Ormond Street Hospital for Children; London UK
| | - Nicholas Goulden
- Department of Paediatric Haematology; Great Ormond Street Hospital for Children; London UK
| | - Sujith Samarasinghe
- Department of Paediatric Haematology; Great Ormond Street Hospital for Children; London UK
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Farrell K, Fyfe A, Allan J, Tait RC, Leach M. An antithrombin replacement strategy during asparaginase therapy for acute lymphoblastic leukemia is associated with a reduction in thrombotic events. Leuk Lymphoma 2016; 57:2568-74. [PMID: 27078747 DOI: 10.3109/10428194.2016.1165815] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Thrombosis is a well-recognized complication of asparaginase therapy for acute lymphoblastic leukemia (ALL), associated with the depletion of antithrombin (AT). Following a high incidence of thrombotic episodes during induction therapy for ALL in our tertiary referral center, we prospectively instituted a protocol of AT replacement. Forty-five consecutive adolescents and adults with ALL treated with asparaginase-containing phase I induction protocols were included in this observational study. Fifteen received standard therapy with no replacement; the subsequent 30 were managed with the protocol described. One or more low AT levels (<70 iu/dl) were recorded in 76% of patients in the cohort managed using the protocol, resulting them in receiving an AT replacement. There was a significant reduction in the incidence of thrombosis with this strategy (0/30 vs. 5/15, p < 0.001). We suggest that such a strategy should be studied in a prospective randomized sub-study within the context of a national ALL trial.
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Affiliation(s)
| | | | | | - R Campbell Tait
- d Beatson West of Scotland Cancer Centre, Gartnavel General Hospital , Glasgow , UK
| | - Mike Leach
- c Glasgow Royal Infirmary , Glasgow , UK
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32
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Strategies to Prevent and Manage Thrombotic Complications of Acute Lymphoblastic Leukemia in Children and Young People Vary Between Centers in the United Kingdom. J Pediatr Hematol Oncol 2016; 38:221-6. [PMID: 26907659 DOI: 10.1097/mph.0000000000000538] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
There is a lack of evidence-based guidance for the prevention and management of thrombosis in children and young people treated for acute lymphoblastic leukemia. To determine current UK practice, a survey was sent to 28 centers participating in the Medical Research Council UKALL 2011 trial. Marked variation in practice was noted. In total, 43% of centers defer central venous access device insertion until end of induction for treatment of low-risk disease. Central venous access devices are removed at the end of intensive blocks in 38% and end of treatment in 42%. Duration of anticoagulation for line-associated thrombosis is 6 weeks in 43% and 3 months in 33% and for cerebral sinovenous thrombosis is 3 months in 71% and 6 months in 24%. Platelet transfusion to maintain platelet count >50×10/L, in preference to interrupting therapeutic anticoagulation, is used by 50% for line-associated thrombosis and 73% for cerebral sinovenous thrombosis. Conformity of practice was seen in some areas. In total, 70% treat thrombosis with twice-daily low-molecular weight heparin and 86% monitor antifactor Xa activity levels. In total, 91% reexpose individuals to asparaginase following a thrombotic event. Given this variation in practice, in the absence of high-quality evidence, consensus guidelines may be helpful.
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33
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Duarte X, Esteves S, Neto AM, Pereira F. Incidence and risk factors for Central Nervous System thrombosis in paediatric acute lymphoblastic leukaemia during intensive asparaginase treatment: a single-centre cohort study. Br J Haematol 2016; 174:280-91. [PMID: 27018199 DOI: 10.1111/bjh.14048] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Accepted: 01/22/2016] [Indexed: 01/19/2023]
Abstract
Central Nervous System (CNS) thrombosis is a complication of acute lymphoblastic leukaemia (ALL) treatment that is potentially associated with significant morbidity and neurological sequelae. Its presumably multifactorial aetiology is poorly characterized. We conducted a single-centre, retrospective cohort study on 346 ALL paediatric patients (1-16 years old) treated with asparaginase intensive Dana Farber Cancer Institute (DFCI) protocols from 1998 to 2011. The incidence, risk factors and outcome of CNS thrombosis were evaluated. CNS thrombosis occurred in 3·8% (13/346) of the patients (95% confidence interval 2·0-6·3%). Twelve events were diagnosed during intensification, all of which resolved within 2 weeks without neurological sequelae or significant impact in survival. Obesity (body mass index above 95th percentile) and asparaginase formulation were the only factors associated with CNS thrombosis, with an increase in the odds of event in obese patients [odds ratio (OR) = 3·37; P = 0·064] and a reduction in patients receiving Erwinia asparaginase (OR = 0·12; P = 0·018). No association could be demonstrated for age, gender, DFCI risk-group, ALL phenotype, steroid or doxorubicin use, central venous line use or CNS radiotherapy. CNS thrombosis is a rare but manageable adverse event without significant sequelae or detrimental effects in survival. Increased awareness is recommended in obese patients particularly during intensive asparaginase use.
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Affiliation(s)
- Ximo Duarte
- Paediatric Department, Instituto Português de Oncologia de Lisboa Francisco Gentil EPE, Lisbon, Portugal
| | - Susana Esteves
- Clinical Research Unit, Instituto Português de Oncologia de Lisboa Francisco Gentil EPE, Lisbon, Portugal
| | - Ana M Neto
- Paediatric Department, Instituto Português de Oncologia de Lisboa Francisco Gentil EPE, Lisbon, Portugal
| | - Filomena Pereira
- Paediatric Department, Instituto Português de Oncologia de Lisboa Francisco Gentil EPE, Lisbon, Portugal
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Jenkinson S, Kirkwood AA, Goulden N, Vora A, Linch DC, Gale RE. Impact of PTEN abnormalities on outcome in pediatric patients with T-cell acute lymphoblastic leukemia treated on the MRC UKALL2003 trial. Leukemia 2016; 30:39-47. [PMID: 26220040 PMCID: PMC4705426 DOI: 10.1038/leu.2015.206] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 06/29/2015] [Accepted: 07/22/2015] [Indexed: 12/21/2022]
Abstract
PTEN gene inactivation by mutation or deletion is common in pediatric T-cell acute lymphoblastic leukemia (T-ALL), but the impact on outcome is unclear, particularly in patients with NOTCH1/FBXW7 mutations. We screened samples from 145 patients treated on the MRC UKALL2003 trial for PTEN mutations using heteroduplex analysis and gene deletions using single nucleotide polymorphism arrays, and related genotype to response to therapy and long-term outcome. PTEN loss-of-function mutations/gene deletions were detected in 22% (PTEN(ABN)). Quantification of mutant level indicated that 67% of mutated cases harbored more than one mutant, with up to four mutants detected, consistent with the presence of multiple leukemic sub-clones. Overall, 41% of PTEN(ABN) cases were considered to have biallelic abnormalities (mutation and/or deletion) with complete loss of PTEN in a proportion of cells. In addition, 9% of cases had N- or K-RAS mutations. Neither PTEN nor RAS genotype significantly impacted on response to therapy or long-term outcome, irrespective of mutant level, and there was no evidence that they changed the highly favorable outcome of patients with double NOTCH1/FBXW7 mutations. These results indicate that, for pediatric patients treated according to current protocols, routine screening for PTEN or RAS abnormalities at diagnosis is not warranted to further refine risk stratification.
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Affiliation(s)
- S Jenkinson
- Department of Haematology, UCL Cancer Institute, London, UK
| | - A A Kirkwood
- Cancer Research UK & UCL Cancer Trials Centre, London, UK
| | - N Goulden
- Department of Haematology, Great Ormond Street Hospital, London, UK
| | - A Vora
- Department of Haematology, Sheffield Children's Hospital, Sheffield, UK
| | - D C Linch
- Department of Haematology, UCL Cancer Institute, London, UK
| | - R E Gale
- Department of Haematology, UCL Cancer Institute, London, UK
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35
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Hijiya N, van der Sluis IM. Asparaginase-associated toxicity in children with acute lymphoblastic leukemia. Leuk Lymphoma 2015; 57:748-57. [PMID: 26457414 PMCID: PMC4819847 DOI: 10.3109/10428194.2015.1101098] [Citation(s) in RCA: 149] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Asparaginase is an integral component of multiagent chemotherapy regimens for the treatment of children with acute lymphoblastic leukemia. Positive outcomes are seen in patients who are able to complete their entire prescribed course of asparaginase therapy. Toxicities associated with asparaginase use include hypersensitivity (clinical and subclinical), pancreatitis, thrombosis, encephalopathy, and liver dysfunction. Depending on the nature and severity of the toxicity, asparaginase therapy may be altered or discontinued in some patients. Clinical hypersensitivity is the most common asparaginase-associated toxicity requiring treatment discontinuation, occurring in up to 30% of patients receiving Escherichia coli-derived asparaginase. The ability to rapidly identify and manage asparaginase-associated toxicity will help ensure patients receive the maximal benefit from asparaginase therapy. This review will provide an overview of the common toxicities associated with asparaginase use and recommendations for treatment management.
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Affiliation(s)
- Nobuko Hijiya
- a Division of Hematology/Oncology/Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago and Department of Pediatrics, Feinberg School of Medicine , Northwestern University , Chicago , IL , USA
| | - Inge M van der Sluis
- b Department of Pediatric Oncology/Hematology , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands
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36
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Couturier MA, Huguet F, Chevallier P, Suarez F, Thomas X, Escoffre-Barbe M, Cacheux V, Pignon JM, Bonmati C, Sanhes L, Bories P, Daguindau E, Dorvaux V, Reman O, Frayfer J, Orvain C, Lhéritier V, Ifrah N, Dombret H, Hunault-Berger M, Tanguy-Schmidt A. Cerebral venous thrombosis in adult patients with acute lymphoblastic leukemia or lymphoblastic lymphoma during induction chemotherapy with l-asparaginase: The GRAALL experience. Am J Hematol 2015. [PMID: 26214580 DOI: 10.1002/ajh.24130] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Central nervous system (CNS) thrombotic events are a well-known complication of acute lymphoblastic leukemia (ALL) induction therapy, especially with treatments including l-asparaginase (l-ASP). Data on risk factors and clinical evolution is still lacking in adult patients. We report on the clinical evolution of 22 CNS venous thrombosis cases occurring in 708 adults treated for ALL or lymphoblastic lymphoma (LL) with the Group for Research on Adult Acute Lymphoblastic Leukemia (GRAALL)-induction protocol, which included eight L-ASP (6,000 IU/m(2) ) infusions. The prevalence of CNS thrombosis was 3.1%. CNS thrombosis occurred after a median of 18 days (range: 11-31) when patients had received a median of three l-ASP injections (range: 2-7). Patients with CNS thrombosis exhibited a median antithrombin (AT) nadir of 47.5% (range: 36-67%) at Day 17 (range: D3-D28), and 95% of them exhibited AT levels lower than 60%. There were no evident increase in hereditary thrombotic risk factors prevalence, and thrombosis occurred despite heparin prophylaxis which was performed in 90% of patients. Acquired AT deficiency was frequently detected in patients with l-ASP-based therapy, and patients with CNS thrombosis received AT prophylaxis (45%) less frequently than patients without CNS thrombosis (83%), P = 0.0002). CNS thrombosis was lethal in 5% of patients, while 20% had persistent sequelae. One patient received all planned l-ASP infusions without recurrence of CNS thrombotic whereas l-ASP injections were discontinued in 20 patients during the management of thrombosis without a significant impact on overall survival (P = 0.4).
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Affiliation(s)
| | | | | | | | - Xavier Thomas
- Hématologie, HCL, Centre hospitalier Lyon Sud; France
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Boissel N, Sender LS. Best Practices in Adolescent and Young Adult Patients with Acute Lymphoblastic Leukemia: A Focus on Asparaginase. J Adolesc Young Adult Oncol 2015; 4:118-28. [PMID: 26421220 PMCID: PMC4575545 DOI: 10.1089/jayao.2015.0014] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
The inclusion of asparaginase in chemotherapy regimens to treat acute lymphoblastic leukemia (ALL) has had a positive impact on survival in pediatric patients. Historically, asparaginase has been excluded from most treatment protocols for adolescent and young adult (AYA) patients because of perceived toxicity in this population, and this is believed to have contributed to poorer outcomes in these patients. However, retrospective analyses over the past 12 years have shown that 2-, 5-, and 7-year overall survival of AYA patients is significantly improved with pediatric versus adult protocols. The addition of asparaginase to adult protocols yielded high rates of first remission and improved survival. However, long-term survival remains lower compared with what has been seen in pediatrics. The notion that asparaginase is poorly tolerated by AYA patients has been challenged in multiple studies. In some, but not all, studies, the incidences of hepatic and pancreatic toxicities were higher in AYA patients, whereas the rates of hypersensitivity reactions did not appear to differ with age. There is an increased risk of venous thromboembolic events, and management with anti-coagulation therapy is recommended. Overall, the risk of therapy-related mortality is low. Together, this suggests that high-intensity pediatric protocols offer an effective and tolerable approach to treating ALL in the AYA population.
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Affiliation(s)
- Nicolas Boissel
- Department of Adult Hematology, Saint-Louis Hospital, University of Paris, Paris, France
| | - Leonard S. Sender
- Department of Epidemiology, University of California, Irvine, Irvine, California
- Chao Family Comprehensive Cancer Center, University of California, Irvine, Irvine, California
- Hyundai Cancer Institute, CHOC Children's Hospital, Orange, California
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38
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Goyal G, Bhatt VR. L-asparaginase and venous thromboembolism in acute lymphocytic leukemia. Future Oncol 2015; 11:2459-70. [PMID: 26274336 DOI: 10.2217/fon.15.114] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
The occurrence of venous thromboembolism (VTE) in acute lymphocytic leukemia patients receiving L-asparaginase therapy may cause significant morbidity, neurological sequela and possibly worse outcomes. The prophylactic use of antithrombin infusion (to keep antithrombin activity >60%) or low molecular weight heparin (LMWH) may reduce the risk of VTE. The decision to continue L-asparaginase therapy after the development of VTE should be based on anticipated benefits, severity of VTE and the ability to continue therapeutic anticoagulation. In patients receiving asparaginase rechallenge, the use of therapeutic LMWH, monitoring of anti-Xa level and antithrombin level are important. Novel oral anticoagulants are not dependent on antithrombin level, hence offer theoretical advantages over LMWH for the prevention and therapy of asparaginase-related VTE.
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Affiliation(s)
- Gaurav Goyal
- Department of Internal Medicine, Creighton University School of Medicine, 2500 California Plaza, Omaha, NE 68178, USA
| | - Vijaya Raj Bhatt
- Department of Internal Medicine, Division of Hematology-Oncology, University of Nebraska Medical Center, 987680 Nebraska Medical Center, Omaha, NE 68198, USA
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Kim JE, Kim JY. Oral Rivaroxaban Treatment for L-asparaginase-induced Deep Thrombophlebitis in Lower Extremity. CLINICAL PEDIATRIC HEMATOLOGY-ONCOLOGY 2015. [DOI: 10.15264/cpho.2015.22.1.80] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Jung Eun Kim
- Department of Pediatrics, Kyungpook National University School of Medicine, Department of Pediatric Hematology-Oncology, Kyungpook National University Children’s Hospital, Daegu, Korea
| | - Ji Yoon Kim
- Department of Pediatrics, Kyungpook National University School of Medicine, Department of Pediatric Hematology-Oncology, Kyungpook National University Children’s Hospital, Daegu, Korea
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40
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De Stefano V, Za T, Ciminello A, Betti S, Rossi E. Haemostatic alterations induced by treatment with asparaginases and clinical consequences. Thromb Haemost 2014; 113:247-61. [PMID: 25338526 DOI: 10.1160/th14-04-0372] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 09/18/2014] [Indexed: 01/19/2023]
Abstract
The benefit of asparaginase for treating acute lymphoid leukaemia (ALL) has been well established. Native asparaginase derives from Escherichia coli (colaspase) or Erwinia chrysanthemi (crisantaspase); in a third preparation, colaspase is pegylated. Depletion of asparagine leads to decreased synthesis of procoagulant, anticoagulant, and fibrinolytic proteins, with resultant hypercoagulability and greater risk of venous thromboembolism (VTE). Colaspase and crisantaspase are not dose-equivalent, with crisantaspase displaying haemostatic toxicity only at dosages much higher and administered more frequently than those of colaspase. Cerebral venous thrombosis and pulmonary embolism are two life-endangering manifestations that occur during treatment with asparaginase particularly in children and in adults with ALL, respectively. Approximately one-third of VTEs are located in the upper extremities and are central venous line-related. Other risk factors are longer duration of asparaginase treatment and concomitant use of prednisone, anthracyclines, and oral contraceptives. The risk associated with inherited thrombophilia is uncertain but is clearly enhanced by other risk factors or by the use of prednisone. VTE prevention with fresh frozen plasma is not recommended; the efficacy of antithrombin (AT) concentrates has occasionally been reported, but these reports should be confirmed by proper studies, and AT should not be routinely employed. Therapeutic or prophylactic heparin doses are only partially effective, and direct thrombin or factor Xa inhibitors could play significant roles in the near future.
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Affiliation(s)
- Valerio De Stefano
- Valerio De Stefano, MD, Institute of Hematology, Catholic University, Largo Gemelli 8, 00168 Rome, Italy, Tel.: +39 06 30154968, Fax: +39 06 30155209, E-mail:
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41
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Ranta S, Tuckuviene R, Mäkipernaa A, Albertsen BK, Frisk T, Tedgård U, Jónsson ÓG, Pruunsild K, Gretenkort Andersson N, Winther Gunnes M, Saulyte Trakymiene S, Frandsen T, Heyman M, Ruud E, Helgestad J. Cerebral sinus venous thromboses in children with acute lymphoblastic leukaemia - a multicentre study from the Nordic Society of Paediatric Haematology and Oncology. Br J Haematol 2014; 168:547-52. [PMID: 25288392 DOI: 10.1111/bjh.13162] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2014] [Accepted: 08/29/2014] [Indexed: 11/27/2022]
Abstract
We present a prospective multicentre cohort of 20 children with acute lymphoblastic leukaemia (ALL) and cerebral sinus venous thrombosis (CSVT). The study covers a period of 5 years and comprises 1038 children treated according to the Nordic Society of Paediatric Haematology and Oncology (NOPHO) ALL 2008 protocol. The cumulative incidence of CSVT was 2%. Sixteen of the thromboses were related to asparaginase and 16 to steroids. Most CSVTs occurred in the consolidation phase. Nearly all were treated with low molecular weight heparin without bleeding complications. Mortality related to CSVT directly or indirectly was 10%, emphasizing the importance of this complication.
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Affiliation(s)
- Susanna Ranta
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
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42
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Rizzari C, Putti MC, Colombini A, Casagranda S, Ferrari GM, Papayannidis C, Iacobucci I, Abbenante MC, Sartor C, Martinelli G. Rationale for a pediatric-inspired approach in the adolescent and young adult population with acute lymphoblastic leukemia, with a focus on asparaginase treatment. Hematol Rep 2014; 6:5554. [PMID: 25317319 PMCID: PMC4194384 DOI: 10.4081/hr.2014.5554] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Revised: 08/21/2014] [Accepted: 08/25/2014] [Indexed: 01/19/2023] Open
Abstract
In the last two decades great improvements have been made in the treatment of childhood acute lymphoblastic leukemia, with 5-year overall survival rates currently approaching almost 90%. In comparison, results reported in adolescents and young adults (AYAs) are relatively poor. In adults, results have improved, but are still lagging behind those obtained in children. Possible reasons for this different pattern of results include an increased incidence of unfavorable and a decreased incidence of favorable cytogenetic abnormalities in AYAs compared with children. Furthermore, in AYAs less intensive treatments (especially lower cumulative doses of drugs such as asparaginase, corticosteroids and methotrexate) and longer gaps between courses of chemotherapy are planned compared to those in children. However, although favorable results obtained in AYAs receiving pediatric protocols have been consistently reported in several international collaborative trials, physicians must also be aware of the specific toxicity pattern associated with increased success in AYAs, since an excess of toxicity may compromise overall treatment schedule intensity. Cooperative efforts between pediatric and adult hematologists in designing specific protocols for AYAs are warranted.
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Affiliation(s)
- Carmelo Rizzari
- Pediatric Hematology-Oncology Unit Department of Pediatrics, University of Milan-Bicocca , Monza, Italy
| | | | - Antonella Colombini
- Pediatric Hematology-Oncology Unit Department of Pediatrics, University of Milan-Bicocca , Monza, Italy
| | - Sara Casagranda
- Pediatric Hematology-Oncology Unit Department of Pediatrics, University of Milan-Bicocca , Monza, Italy
| | - Giulia Maria Ferrari
- Pediatric Hematology-Oncology Unit Department of Pediatrics, University of Milan-Bicocca , Monza, Italy
| | | | | | | | - Chiara Sartor
- Institute of Hematology, University of Bologna , Italy
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Beshlawi I, Al Lamki Z, Rawas A, Abdel-Baki MS, Wali Y. Lumbar puncture in haemophilia A: controversy in the management. Haemophilia 2013; 20:e175-7. [PMID: 24372668 DOI: 10.1111/hae.12343] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2013] [Indexed: 11/28/2022]
Affiliation(s)
- I Beshlawi
- Pediatric Hematology Unit, Department of Child Health, Sultan Qaboos University Hospital, Muscat, Oman
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44
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Moorman AV, Robinson H, Schwab C, Richards SM, Hancock J, Mitchell CD, Goulden N, Vora A, Harrison CJ. Risk-directed treatment intensification significantly reduces the risk of relapse among children and adolescents with acute lymphoblastic leukemia and intrachromosomal amplification of chromosome 21: a comparison of the MRC ALL97/99 and UKALL2003 trials. J Clin Oncol 2013; 31:3389-96. [PMID: 23940220 DOI: 10.1200/jco.2013.48.9377] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
PURPOSE To evaluate the effect on outcome of intensifying therapy for patients with acute lymphoblastic leukemia (ALL) and an intrachromosomal amplification of chromosome 21 (iAMP21). PATIENTS AND METHODS We report two cohorts of patients treated on Medical Research Council ALL97 or United Kingdom (UK) ALL2003. iAMP21 was identified retrospectively in ALL97 and was not used to guide therapy. However, in UKALL2003, iAMP21 was determined prospectively, and patients were allocated to the most intensive treatment arm (regimen C), which included augmented Berlin-Frankfurt-Munster consolidation, escalating Capizzi maintenance, double delayed intensification, and an option for first remission transplantation. The presence of iAMP21 was determined by fluorescence in situ hybridization using probes specific for the RUNX1 gene. RESULTS iAMP21 was identified in 2% of patients with B-cell precursor ALL treated on UKALL2003 and ALL97. The event-free survival, relapse, and overall survival rates at 5 years for iAMP21 patients treated on ALL97 and UKALL2003 were 29% and 78%, 70% and 16%, and 67% and 89%, respectively (all P < .01). Patients treated on ALL97 had an increased risk of relapse compared with patients treated on UKALL2003 (hazard ratio, 7.2; 95% CI, 2.91 to 17.87; P < .001). CONCLUSION iAMP21 patients with ALL benefitted from receiving more intensive therapy in UKALL2003. In UKALL2011, they will continue to be treated as cytogenetic high risk, receive intensive chemotherapy (regimen C), and will only be recommended for transplantation if they do not achieve a complete remission by the end of induction therapy. This study illustrates how the discovery and characterization of disease-specific genetic aberrations can be used to tailor therapy more precisely.
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Affiliation(s)
- Anthony V Moorman
- Anthony V. Moorman, Hazel Robinson, Claire Schwab, and Christine J. Harrison, Leukaemia Research Cytogenetics Group, Northern Institute for Cancer Research, Newcastle University, Newcastle; Sue M. Richards, University of Oxford; Christopher D. Mitchell, John Radcliffe Hospital, Oxford; Jeremy Hancock, Bristol Genetics Laboratory, North Bristol National Health Service Trust, Bristol; Nicholas Goulden, Great Ormond Street Hospital, London; and Ajay Vora, Sheffield Children's Hospital, Sheffield, United Kingdom
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Schwab CJ, Chilton L, Morrison H, Jones L, Al-Shehhi H, Erhorn A, Russell LJ, Moorman AV, Harrison CJ. Genes commonly deleted in childhood B-cell precursor acute lymphoblastic leukemia: association with cytogenetics and clinical features. Haematologica 2013; 98:1081-8. [PMID: 23508010 DOI: 10.3324/haematol.2013.085175] [Citation(s) in RCA: 115] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
In childhood B-cell precursor acute lymphoblastic leukemia, cytogenetics is important in diagnosis and as an indicator of response to therapy, thus playing a key role in risk stratification of patients for treatment. Little is known of the relationship between different cytogenetic subtypes in B-cell precursor acute lymphoblastic leukemia and the recently reported copy number abnormalities affecting significant leukemia associated genes. In a consecutive series of 1427 childhood B-cell precursor acute lymphoblastic leukemia patients, we have determined the incidence and type of copy number abnormalities using multiplex ligation-dependent probe amplification. We have shown strong links between certain deletions and cytogenetic subtypes, including the novel association between RB1 deletions and intrachromosomal amplification of chromosome 21. In this study, we characterized the different copy number abnormalities and show heterogeneity of PAX5 and IKZF1 deletions and the recurrent nature of RB1 deletions. Whole gene losses are often indicative of larger deletions, visible by conventional cytogenetics. An increased number of copy number abnormalities is associated with NCI high risk, specifically deletions of IKZF1 and CDKN2A/B, which occur more frequently among these patients. IKZF1 deletions and rearrangements of CRLF2 among patients with undefined karyotypes may point to the poor risk BCR-ABL1-like group. In conclusion, this study has demonstrated in a large representative cohort of children with B-cell precursor acute lymphoblastic leukemia that the pattern of copy number abnormalities is highly variable according to the primary genetic abnormality.
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Affiliation(s)
- Claire J Schwab
- Leukaemia Research Cytogenetics Group, Northern Institute for Cancer Research, Newcastle University, Newcastle-upon-Tyne, UK
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Tong WH, van der Sluis IM, Alleman CJM, van Litsenburg RRL, Kaspers GJL, Pieters R, Uyl-de Groot CA. Cost-analysis of treatment of childhood acute lymphoblastic leukemia with asparaginase preparations: the impact of expensive chemotherapy. Haematologica 2013; 98:753-9. [PMID: 23403311 DOI: 10.3324/haematol.2012.073510] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Asparaginase is an expensive drug, but important in childhood acute lymphoblastic leukemia. In order to compare costs of PEGasparaginase, Erwinia asparaginase and native E. coli asparaginase, we performed a cost-analysis in the Dutch Childhood Oncology Group ALL-10 medium-risk group intensification protocol. Treatment costs were calculated based on patient level data of 84 subjects, and were related to the occurrence of allergy to PEGasparaginase. Simultaneously, decision tree and sensitivity analyses were conducted. The total costs of the intensification course of 30 weeks were $57,893 in patients without PEGasparaginase allergy (n=64). The costs were significantly higher ($113,558) in case of allergy (n=20) necessitating a switch to Erwinia asparaginase. Simulated scenarios (decision tree analysis) using native E. coli asparaginase in intensification showed that the costs of PEGasparaginase were equal to those of native E. coli asparaginase. Also after sensitivity analyses, the costs for PEGasparaginase were equal to those of native E. coli asparaginase. Intensification treatment with native E. coli asparaginase, followed by a switch to PEGasparaginase, and subsequently to Erwinia asparaginase in case of allergy had similar overall costs compared to the treatment with PEGasparaginase as the first-line drug (followed by Erwinia asparaginase in the case of allergy). PEGasparaginase is preferred over native E. coli asparaginase, because it is administered less frequently, with less day care visits. PEGasparaginase is less immunogenic than native E. coli asparaginase and is not more expensive. Asparaginase costs are mainly determined by the percentage of patients who are allergic and require a switch to Erwinia asparaginase.
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Affiliation(s)
- Wing H Tong
- Department of Pediatric Oncology/Hematology, Erasmus MC-Sophia Children’s Hospital, Rotterdam, The Netherlands
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Jenkinson S, Koo K, Mansour MR, Goulden N, Vora A, Mitchell C, Wade R, Richards S, Hancock J, Moorman AV, Linch DC, Gale RE. Impact of NOTCH1/FBXW7 mutations on outcome in pediatric T-cell acute lymphoblastic leukemia patients treated on the MRC UKALL 2003 trial. Leukemia 2013; 27:41-7. [PMID: 22814294 DOI: 10.1038/leu.2012.176] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Accepted: 06/27/2012] [Indexed: 12/24/2022]
Abstract
Activating mutations in the NOTCH1 pathway are frequent in pediatric T-cell acute lymphoblastic leukemia (T-ALL) but their role in refining risk stratification is unclear. We screened 162 pediatric T-ALL patients treated on the MRC UKALL2003 trial for NOTCH1/FBXW7 gene mutations and related genotype to response to therapy and long-term outcome. Overall, 35% were wild-type (WT) for both genes (NOTCH1(WT)FBXW7(WT)), 38% single NOTCH1 mutant (NOTCH1(Single)FBXW7(WT)), 3% just FBXW7 mutant (NOTCH1(WT)FBXW7(MUT)) and 24% either double NOTCH1 mutant (NOTCH1(Double)FBXW7(WT)) or mutant in both genes (NOTCH1(MUT)FBXW7(MUT)), hereafter called as NOTCH1±FBXW7(Double). There was no difference between groups in early response to therapy, but NOTCH1±FBXW7(Double) patients were more likely to be associated with negative minimal residual disease (MRD) post-induction than NOTCH1(WT)FBXW7(WT) patients (71% versus 40%, P=0.004). Outcome improved according to the number of mutations, overall survival at 5 years 82%, 88% and 100% for NOTCH1(WT)FBXW7(WT), NOTCH1(Single)FBXW7(WT) and NOTCH1±FBXW7(Double) patients, respectively (log-rank P for trend=0.005). Although 14 NOTCH1±FBXW7(Double) patients were classified as high risk (slow response and/or MRD positive), only two had disease progression and all remain alive. Patients with double NOTCH1 and/or FBXW7 mutations have a very good outcome and should not be considered for more intensive therapy in first remission, even if slow early responders or MRD positive after induction therapy.
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Affiliation(s)
- S Jenkinson
- Department of Haematology, UCL Cancer Institute, London, UK
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Truelove E, Fielding AK, Hunt BJ. The coagulopathy and thrombotic risk associated with L-asparaginase treatment in adults with acute lymphoblastic leukaemia. Leukemia 2012; 27:553-9. [PMID: 23099335 DOI: 10.1038/leu.2012.290] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The dramatic improvements seen in the outcome of paediatric patients with acute lymphoblastic leukaemia (ALL) have led to increasing incorporation of L-asparaginase (L-Asp) in adult treatment protocols. However, its use is associated with a disruption in the physiological balance between haemostatic and anticoagulant pathways, with the predominant clinical manifestation being thrombosis. Although L-Asp therapy is known to be associated with an acquired deficiency of antithrombin (AT), the concurrent depletion of fibrinogen and other haemostatic proteins means that the precise mechanism of thrombosis remains to be defined. In vitro coagulation assays are often prolonged but thrombosis rather than haemorrhage is the primary concern. Management of thrombotic events in these patients is based around agents that rely on AT for their anticoagulant effect, even though it is usually depleted. There is currently only limited evidence supporting the use of AT concentrates in either primary prevention or management following an established event. Evidence-based guidelines for prevention and management strategies are lacking.
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Affiliation(s)
- E Truelove
- Department of Haematology, Nottingham University Hospitals, Nottingham, UK.
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Allogeneic Hematopoietic Stem Cell Transplantation for a BCR-FGFR1 Myeloproliferative Neoplasm Presenting as Acute Lymphoblastic Leukemia. Case Rep Hematol 2012; 2012:620967. [PMID: 23082258 PMCID: PMC3467796 DOI: 10.1155/2012/620967] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Accepted: 09/02/2012] [Indexed: 01/15/2023] Open
Abstract
Hematopoietic myeloproliferative neoplasms (MPNS) with rearrangements of the receptor tyrosine kinase FGFR1 gene, located on chromosome 8p11, are uncommon and associated with diverse presentations such as atypical chronic myeloid leukemia, acute myeloid leukemia, or an acute T- or B-lymphoblastic leukemia, reflecting the hematopoietic stem cell origin of the disease. A review of MPN patients with the t(8;22) translocation that results in a chimeric BCR-FGFR1 fusion gene reveals that this disease either presents or rapidly transforms into an acute leukemia that is generally unresponsive to currently available chemotherapeutic regimens including tyrosine kinase inhibitors (TKIS). The first case of a rare BCR-FGFR1 MPN presenting in a B-acute lymphoblastic phase who underwent allogeneic hematopoietic stem cell transplantation (HSCT) with a subsequent sustained complete molecular remission is described. Allogeneic HSCT is currently the only available therapy capable of achieving long-term remission in BCR-FGFR1 MPN patients.
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