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Brigitha LJ, Zaky K, Pieters R, van der Sluis IM. A Refined Population Pharmacokinetic Model-Based Guideline for Individualized PEGasparaginase Dosing in Pediatric Acute Lymphoblastic Leukemia. Ther Drug Monit 2024:00007691-990000000-00258. [PMID: 39137448 DOI: 10.1097/ftd.0000000000001252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 06/20/2024] [Indexed: 08/15/2024]
Abstract
BACKGROUND In the Dutch Childhood Oncology Group ALL11 protocol, PEGasparaginase dosing was individualized for standard-risk and medium-risk patients with acute lymphoblastic leukemia. After using our pragmatic old guideline, we aimed to improve individualized PEGasparaginase dosing by developing a population pharmacokinetic model-based dosing guideline. METHOD After the 3 doses of 1500 IU/m2 administered in induction, standard-risk patients received 1 individualized dose and medium-risk patients 14, targeting trough activity levels between 100 and 250 IU/L. The effectiveness, adherence, and toxicity of our new dosing guideline was assessed and compared with the old guideline. RESULTS In total, 92 patients (714 samples) were included in the new dosing group and 509 patients (4539 samples) were included in the old dosing group. Comparing the effectiveness, we found that 32% (22/67) of patients in the new and 13% (47/354) of patients in the old dosing group were within the target range after the first individualized dose (P < 0.001). Among medium-risk patients, a median of 3 dose reductions was needed to reach and maintain levels within the target range in the new dosing group compared with 5 in the old dosing group (P < 0.001). With a continuous PEGasparaginase dosing schedule, target trough activity levels were reached after 2 dose reductions in the new group versus 4 in the old dosing group. The adherence to the new guideline was >99%, with 6/714 recommended doses deviating from the guideline. With exception of a lower proportion of patients with increased (≥grade 3) serum alanine transaminase (34% new vs 64% old, P < 0.05) in the new dosing group, toxicity was comparable between guidelines. CONCLUSIONS With the new dosing guideline, fewer dose-reduction steps are necessary to reach and remain within the target. The high adherence rate emphasized its simplicity and practicality, confirming that it can be easily integrated into clinical practice.
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Affiliation(s)
- Leiah J Brigitha
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; and
- Pediatric Oncology and Hematology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Karen Zaky
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; and
| | - Rob Pieters
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands; and
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2
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Chen C, Li J, Chen Y, Gao Q, Li N, Le S. The correlation of asparaginase enzyme activity levels after PEG-asparaginase administration with clinical characteristics and adverse effects in Chinese paediatric patients with acute lymphoblastic leukaemia. Br J Haematol 2024; 205:624-633. [PMID: 38934331 DOI: 10.1111/bjh.19605] [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: 04/01/2024] [Accepted: 06/10/2024] [Indexed: 06/28/2024]
Abstract
Studies on asparaginase enzyme activity (AEA) monitoring in Chinese patients receiving PEG-asparaginase remain limited. We monitored AEA in paediatric patients diagnosed with acute lymphoblastic leukaemia (ALL) and treated according to the Chinese Children's Cancer Group study protocols, CCCG-ALL-2015/CCCG-ALL-2020 protocols. We measured the AEA at days 7 ± 1 and 14 ± 1 and analysed their association with patient characteristics and PEG-asparaginase-related adverse effects (AEs). We measured 2147 samples from 329 patients. Mean AEA levels (interquartile range) were 931 iu/L (654-1174 iu/L) at day 7 ± 1 and 664 iu/L (463-860 iu/L) at day 14 ± 1. The AEA levels were higher in younger children and increased with the cumulative dose numbers. PEG-asparaginase inactivation rate was 19.1%, and the silent inactivation (SI) rate was 12.5%. Nine patients were identified with allergic-like reactions. Hypofibrinogenaemia, hypertriglyceridaemia, pancreatitis and thrombosis were associated with older age, whereas hypoglycaemia was associated with younger age. The risk of hypertriglyceridaemia and hypoglycaemia increased with cumulative dose numbers of PEG-asparaginase. Except for hypofibrinogenaemia, elevated AEA levels did not increase the risk of PEG-asparaginase-related AEs. Drug monitoring can be utilized as guidance for treatment decision-making. Individualizing asparaginase doses do not reduce toxicities. The treatment target of PEG-asparaginase remains to achieve sustained and adequate activity.
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Affiliation(s)
- Cai Chen
- Department of Pediatric Hematology, Fujian Medical University, Union Hospital, Fuzhou, China
| | - Jian Li
- Department of Pediatric Hematology, Fujian Medical University, Union Hospital, Fuzhou, China
| | - Yiqiao Chen
- Department of Pediatric Hematology, Fujian Medical University, Union Hospital, Fuzhou, China
| | - Qinli Gao
- Department of Pediatric Hematology, Fujian Medical University, Union Hospital, Fuzhou, China
| | - Nainong Li
- Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Shaohua Le
- Department of Pediatric Hematology, Fujian Medical University, Union Hospital, Fuzhou, China
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3
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Østergaard A, Fiocco M, de Groot-Kruseman H, Moorman AV, Vora A, Zimmermann M, Schrappe M, Biondi A, Escherich G, Stary J, Imai C, Imamura T, Heyman M, Schmiegelow K, Pieters R. ETV6::RUNX1 Acute Lymphoblastic Leukemia: how much therapy is needed for cure? Leukemia 2024; 38:1477-1487. [PMID: 38844578 PMCID: PMC11216990 DOI: 10.1038/s41375-024-02287-7] [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: 01/23/2023] [Revised: 05/11/2024] [Accepted: 05/14/2024] [Indexed: 07/03/2024]
Abstract
Recent trials show 5-year survival rates >95% for ETV6::RUNX1 Acute Lymphoblastic Leukemia (ALL). Since treatment has many side effects, an overview of cumulative drug doses and intensities between eight international trials is presented to characterize therapy needed for cure. A meta-analysis was performed as a comprehensive summary of survival outcomes at 5 and 10 years. For drug dose comparison in non-high risk trial arms, risk group distribution was applied to split the trials into two groups: trial group A with ~70% (range: 63.5-75%) of patients in low risk (LR) (CCLSG ALL2004, CoALL 07-03, NOPHO ALL2008, UKALL2003) and trial group B with ~45% (range: 38.7-52.7%) in LR (AIEOP-BFM ALL 2000, ALL-IC BFM ALL 2002, DCOG ALL10, JACLS ALL-02). Meta-analysis did not show evidence of heterogeneity between studies in trial group A LR and medium risk (MR) despite differences in treatment intensity. Statistical heterogeneity was present in trial group B LR and MR. Trials using higher cumulative dose and intensity of asparaginase and pulses of glucocorticoids and vincristine showed better 5-year event-free survival but similar overall survival. Based on similar outcomes between trials despite differences in therapy intensity, future trials should investigate, to what extent de-escalation is feasible for ETV6::RUNX1 ALL.
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Affiliation(s)
- Anna Østergaard
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Marta Fiocco
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Mathematical Institute, Leiden University, Leiden, The Netherlands
- Department of Biomedical Science, Section Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands
| | - Hester de Groot-Kruseman
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
- Dutch Childhood Oncology Group (DCOG), Utrecht, The Netherlands
| | - Anthony V Moorman
- Leukaemia Research Cytogenetics Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- United Kingdom Acute Lymphoblastic Leukaemia (UKALL) study group, Liverpool, UK
| | - Ajay Vora
- United Kingdom Acute Lymphoblastic Leukaemia (UKALL) study group, Liverpool, UK
- Department of Haematology, Great Ormond Street Hospital, London, UK
| | - Martin Zimmermann
- Department of Paediatric Haematology and Oncology, Hannover Medical School, 30625, Hannover, Germany
- Berlin-Frankfurt-Münster Study Group (BFM), Frankfurt, Germany
| | - Martin Schrappe
- Berlin-Frankfurt-Münster Study Group (BFM), Frankfurt, Germany
- Department of Paediatrics, University Medical Centre Schleswig-Holstein, Kiel, Germany
| | - Andrea Biondi
- Department of Pediatrics, University of Milano-Bicocca, Monza, Italy
- Associazione Italiana di Ematologia e Oncologia Pediatrica (AIEOP), Bologna, Italy
| | - Gabriele Escherich
- Department of Pediatric Hematology and Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Childhood Acute Lymphoblastic Leukemia study group (CoALL), Hamburg, Germany
| | - Jan Stary
- Department of Pediatric Hematology and Oncology, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Chihaya Imai
- Department of Pediatrics, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
- Children's Cancer and Leukemia Study Group (CCLSG), Nagoya, Japan
| | - Toshihiko Imamura
- Department of Pediatrics, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
- Japan Childhood Leukemia Study Group (JACLS), Nagoya, Japan
| | - Mats Heyman
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Department of Paediatric Oncology, Karolinska University Hospital, Stockholm, Sweden
- Nordic Society of Paediatric Haematology and Oncology (NOPHO), Nordic Countries, Uppsala, Sweden
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
- Nordic Society of Paediatric Haematology and Oncology (NOPHO), Nordic and Baltic Countries, Uppsala, Sweden
| | - Rob Pieters
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands.
- Dutch Childhood Oncology Group (DCOG), Utrecht, The Netherlands.
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Ishida H, Imamura T, Kobayashi R, Hashii Y, Deguchi T, Miyamura T, Oda M, Yamamoto M, Okada K, Sano H, Koh K, Yuza Y, Watanabe K, Nishimura N, Takimoto T, Moriya‐Saito A, Sekimizu M, Suenobu S, Sunami S, Horibe K. Differential impact of asparaginase discontinuation on outcomes of children with T-cell acute lymphoblastic leukemia and T-cell lymphoblastic lymphoma. Cancer Med 2024; 13:e7246. [PMID: 38888368 PMCID: PMC11184648 DOI: 10.1002/cam4.7246] [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: 12/09/2023] [Revised: 04/09/2024] [Accepted: 04/27/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND Asparaginase is essential for treating T-cell acute lymphoblastic leukemia (T-ALL). Despite the ongoing debate on whether T-ALL and T-cell lymphoblastic lymphoma (T-LBL) are the same disease entity or two distinct diseases, patients with T-LBL often receive the same or similar treatment protocols as those with T-ALL. METHODS The outcomes of patients with or without L-asparaginase discontinuation were retrospectively analyzed among four national protocols: Japan Association of Childhood Leukemia Study (JACLS) ALL-02 and ALL-97 for T-ALL and Japanese Pediatric Leukemia/Lymphoma Study Group ALB-NHL03 and JACLS NHL-98 for T-LBL. The hazard ratio (HR) was calculated with the Cox regression model by considering L-asparaginase discontinuation as a time-dependent variable. RESULTS In total, 199 patients with T-ALL, and 133 patients with T-LBL were included. L-asparaginase discontinuation compromised event-free survival (EFS) of T-ALL patients (ALL-02: HR 3.32, 95% confidence interval [CI] 1.40-7.90; ALL-97: HR 3.39, 95%CI 1.19-9.67). Conversely, EFS compromise was not detected among T-LBL patients (ALB-NHL03: HR 1.39, 95%CI 0.41-4.68; NHL-98: HR 0.92, 95%CI 0.11-7.60). CONCLUSION The effects of L-asparaginase discontinuation differed between T-ALL and T-LBL. We assume that the differential impact results from (1) the inherent differential response to L-asparaginase between them and/or (2) a less stringent assessment of early treatment response in T-LBL than in T-ALL. Given the poor salvage rate of refractory or relapsed T-ALL and T-LBL, optimization of the frontline therapy is critical, and the current study provides a new suggestion for further treatment modifications. However, larger studies in contemporary intensified treatment protocols are required.
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Affiliation(s)
- Hisashi Ishida
- Department of PediatricsOkayama University HospitalOkayamaJapan
| | - Toshihiko Imamura
- Department of PediatricsKyoto Prefectural University of Medicine, Graduate School of Medical ScienceKyotoJapan
| | - Ryoji Kobayashi
- Department of Hematology/Oncology for Children and AdolescentsSapporo Hokuyu HospitalSapporoJapan
| | - Yoshiko Hashii
- Department of PediatricsOsaka International Cancer InstituteOsakaJapan
| | - Takao Deguchi
- Division of Cancer Immunodiagnostics, Children's Cancer CenterNational Center for Child Health and DevelopmentTokyoJapan
| | - Takako Miyamura
- Department of PediatricsOsaka University Graduate School of MedicineSuitaJapan
| | - Megumi Oda
- Department of PediatricsOkayama University HospitalOkayamaJapan
| | - Masaki Yamamoto
- Department of PediatricsSapporo Medical University School of MedicineSapporoJapan
| | - Keiko Okada
- Department of Pediatric Hematology/OncologyOsaka City General HospitalOsakaJapan
| | - Hideki Sano
- Department of Pediatric OncologyFukushima Medical University HospitalFukushimaJapan
| | - Katsuyoshi Koh
- Department of Hematology/OncologySaitama Children's Medical CenterSaitamaJapan
| | - Yuki Yuza
- Department of Hematology and OncologyTokyo Metropolitan Children's Medical CenterTokyoJapan
| | - Kenichiro Watanabe
- Department of Hematology and OncologyShizuoka Children's HospitalShizuokaJapan
| | - Noriyuki Nishimura
- Department of Public HealthKobe University Graduate School of Health ScienceKobeJapan
| | - Tetsuya Takimoto
- Department of Childhood Cancer Data ManagementNational Center for Child Health and DevelopmentTokyoJapan
| | - Akiko Moriya‐Saito
- Clinical Research CenterNational Hospital Organization Nagoya Medical CenterNagoyaJapan
| | - Masahiro Sekimizu
- Department of PediatricsNational Hospital Organization Nagoya Medical CenterNagoyaJapan
| | | | - Shosuke Sunami
- Department of Pediatrics, Japanese Red Cross Narita HospitalNaritaJapan
| | - Keizo Horibe
- Clinical Research CenterNational Hospital Organization Nagoya Medical CenterNagoyaJapan
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5
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van der Sluis IM, Brigitha LJ, Fiocco M, de Groot-Kruseman HA, Bierings M, van den Bos C, de Haas V, Hoogerbrugge PM, Tissing WJ, Veening MA, Pieters R. Continuous PEGasparaginase Dosing Reduces Hypersensitivity Reactions in Pediatric ALL: A Dutch Childhood Oncology Group ALL11 Randomized Trial. J Clin Oncol 2024; 42:1676-1686. [PMID: 38306592 PMCID: PMC11095866 DOI: 10.1200/jco.23.01797] [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: 08/18/2023] [Revised: 10/24/2023] [Accepted: 12/04/2023] [Indexed: 02/04/2024] Open
Abstract
PURPOSE The primary objective of this randomized study was to determine whether a continuous dosing schedule (without the asparaginase-free interval) would result in less hypersensitivity reactions to PEGasparaginase (PEGasp) compared with the standard noncontinuous dosing schedule. METHODS Eight hundred eighteen patients (age 1-18 years) with ALL were enrolled in the Dutch Childhood Oncology Group-ALL11 protocol and received PEGasp. Three hundred twelve patients stratified in the medium-risk arm were randomly assigned to receive 14 individualized PEGasp doses once every two weeks in either a noncontinuous or continuous schedule after the first three doses in induction (EudraCT: 2012-000067-25). Hypersensitivity reactions were defined as allergies, allergic-like reactions, and silent inactivation. Secondary end points were other asparaginase-related toxicities, asparaginase activity and antibody levels, and outcome. RESULTS During induction, 27 of 818 patients (3.3%) experienced hypersensitivity reactions. After random assignment, 4 of 155 (2.6%) in the continuous treatment arm versus 17 of 157 (10.8%) patients in the noncontinuous treatment arm had hypersensitivity reactions (P < .01), of which two (1.3%) versus 13 (8.3%) were inactivating reactions (P < .01). The occurrence of inactivating hypersensitivity reactions was seven times lower in the continuous arm (odds ratio, 0.15 [0.032-0.653]). In addition, antibody levels were significantly lower in the continuous arm (P < .01). With exception of a lower incidence of increased amylase in the continuous arm, there were no significant differences in total number of asparaginase-associated toxicities between arms. However, the timing of the toxicities was associated with the timing of the asparaginase administrations. No difference in 5-year cumulative incidence of relapse, death, or disease-free survival was found between both treatment arms. CONCLUSION A continuous dosing schedule of PEGasp is an effective approach to prevent antibody formation and inactivating hypersensitivity reactions. The continuous PEGasp schedule did not increase toxicity and did not affect the efficacy of the therapy.
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Affiliation(s)
- Inge M. van der Sluis
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Dutch Childhood Oncology Group, Utrecht, the Netherlands
| | - Leiah J. Brigitha
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Pediatric Oncology and Hematology, Erasmus MC–Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Marta Fiocco
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Department of Biomedical Data Sciences, Medical Statistics, Leiden University Medical Center, Leiden, the Netherlands
- Mathematical Institute, Leiden University, the Netherlands
| | | | - Marc Bierings
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Cor van den Bos
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Valerie de Haas
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Dutch Childhood Oncology Group, Utrecht, the Netherlands
| | | | - Wim J.E. Tissing
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | | | - Rob Pieters
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
- Dutch Childhood Oncology Group, Utrecht, the Netherlands
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6
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Dam M, Centanni M, Friberg LE, Centanni D, Karlsson MO, Stensig Lynggaard L, Johannsdottir IM, Wik HS, Malmros J, Vaitkeviciene GE, Griskevicius L, Hallböök H, Jónsson ÓG, Overgaard U, Schmiegelow K, Hansen SN, Heyman M, Albertsen BK. Increase in peg-asparaginase clearance as a predictor for inactivation in patients with acute lymphoblastic leukemia. Leukemia 2024; 38:712-719. [PMID: 38287133 PMCID: PMC10997509 DOI: 10.1038/s41375-024-02153-6] [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: 11/15/2023] [Revised: 01/05/2024] [Accepted: 01/10/2024] [Indexed: 01/31/2024]
Abstract
Asparaginase is an essential component of acute lymphoblastic leukemia (ALL) therapy, yet its associated toxicities often lead to treatment discontinuation, increasing the risk of relapse. Hypersensitivity reactions include clinical allergies, silent inactivation, or allergy-like responses. We hypothesized that even moderate increases in asparaginase clearance are related to later inactivation. We therefore explored mandatory monitoring of asparaginase enzyme activity (AEA) in patients with ALL aged 1-45 years treated according to the ALLTogether pilot protocol in the Nordic and Baltic countries to relate mean AEA to inactivation, to build a pharmacokinetic model to better characterize the pharmacokinetics of peg-asparaginase and assess whether an increased clearance relates to subsequent inactivation. The study analyzed 1631 real-time AEA samples from 253 patients, identifying inactivation in 18.2% of the patients. This inactivation presented as mild allergy (28.3%), severe allergy (50.0%), or silent inactivation (21.7%). A pharmacokinetic transit compartment model was used to describe AEA-time profiles, revealing that 93% of patients with inactivation exhibited prior increased clearance, whereas 86% of patients without hypersensitivity maintained stable clearance throughout asparaginase treatment. These findings enable prediction of inactivation and options for either dose increments or a shift to alternative asparaginase formulations to optimize ALL treatment strategies.
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Affiliation(s)
- Merete Dam
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Lena E Friberg
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | | | | | - Line Stensig Lynggaard
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | | | - Johan Malmros
- Astrid Lindgren Children's Hospital, Karolinska University Hospital and Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | | | | | - Helene Hallböök
- Dept Of Medical Sciences, Haematology, Uppsala University, Uppsala, Sweden
| | | | - Ulrik Overgaard
- Department of Haematology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - Mats Heyman
- Astrid Lindgren Children's Hospital, Karolinska University Hospital and Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Birgitte Klug Albertsen
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark.
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
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7
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Brigitha LJ, Mondelaers V, Liu Y, Albertsen BK, Zalewska-Szewczyk B, Rizzari C, Kotecha RS, Pieters R, Huitema ADR, van der Sluis IM. Pharmacokinetics of PEGasparaginase in Infants with Acute Lymphoblastic Leukemia. Pharm Res 2024; 41:711-720. [PMID: 38538970 DOI: 10.1007/s11095-024-03693-3] [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: 11/10/2023] [Accepted: 03/14/2024] [Indexed: 04/18/2024]
Abstract
BACKGROUND PEGasparaginase is known to be a critical drug for treating pediatric acute lymphoblastic leukemia (ALL), however, there is insufficient evidence to determine the optimal dose for infants who are less than one year of age at diagnosis. This international study was conducted to identify the pharmacokinetics of PEGasparaginase in infants with newly diagnosed ALL and gather insight into the clearance and dosing of this population. METHODS Infants with ALL who received treatment with PEGasparaginase were included in our population pharmacokinetic assessment employing non-linear mixed effects modelling (NONMEM). RESULTS 68 infants with ALL, with a total of 388 asparaginase activity samples, were included. PEGasparaginase doses ranging from 400 to 3,663 IU/m2 were administered either intravenously or intramuscularly. A one-compartment model with time-dependent clearance, modeled using a transit model, provided the best fit to the data. Body weight was significantly correlated with clearance and volume of distribution. The final model estimated a half-life of 11.7 days just after administration, which decreased to 1.8 days 14 days after administration. Clearance was 19.5% lower during the post-induction treatment phase compared to induction. CONCLUSION The pharmacokinetics of PEGasparaginase in infants diagnosed under one year of age with ALL is comparable to that of older children (1-18 years). We recommend a PEGasparaginase dosing at 1,500 IU/m2 for infants without dose adaptations according to age, and implementing therapeutic drug monitoring as standard practice.
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Affiliation(s)
- Leiah J Brigitha
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, Netherlands
- Pediatric Oncology and Hematology, Erasmus MC-Sophia Children's Hospital, Dr. Molewaterplein 40, 3015 GD, Rotterdam, Netherlands
| | - Veerle Mondelaers
- Department of Pediatric Hematology-Oncology and Stem Cell Transplantation, Ghent University Hospital, Ghent University, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Yiwei Liu
- Department of Bioinformatics and Computational Biology, the University of Texas MD Anderson Cancer Center, Houston, USA
| | - Birgitte K Albertsen
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200, Aarhus, Denmark
| | - Beata Zalewska-Szewczyk
- Department of Pediatrics, Medical University of Lodz, Oncology & Hematology, 91-738, Lodz, Poland
| | - Carmelo Rizzari
- Department of Pediatrics, University of Milano-Bicocca, Piazza Dell'Ateneo Nuovo, 1, Milano, Italy
- Fondazione IRCCS San Gerardo Dei Tintori, Via G.B. Pergolesi 33, Monza, Italy
| | - Rishi S Kotecha
- Department of Clinical Haematology, Oncology, Blood and Marrow Transplantation, Perth Children's Hospital, Perth, Australia
- Leukaemia Translational Research Laboratory, Telethon Kids Cancer Centre, Telethon Kids Institute, University of Western Australia, Perth, Australia
- Curtin Medical School, Curtin University, Perth, Australia
| | - Rob Pieters
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, Netherlands
| | - Alwin D R Huitema
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, Netherlands
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
- Department of Pharmacy & Pharmacology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
| | - Inge M van der Sluis
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, Netherlands.
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8
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Feldman K, Aaronson K, Gu T, Ige K, Southworth E, Sanchez L, Stieglitz E. Desensitization using pegaspargase in the era of commercially available Erwinia: A single-institution report on efficacy, cost, and resource utilization. Pediatr Blood Cancer 2024; 71:e30891. [PMID: 38311802 DOI: 10.1002/pbc.30891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 12/23/2023] [Accepted: 01/15/2024] [Indexed: 02/06/2024]
Abstract
BACKGROUND Pegaspargase is a therapeutic enzyme that is utilized in treatment regimens targeting pediatric acute lymphoblastic leukemia. However, many patients experience hypersensitivity reactions, requiring discontinuation of the therapy. Historically, this necessitated switching to an alternative form of the drug, most commonly asparaginase Erwinia chrysanthemi; however, in recent years this was difficult due to drug shortages and eventually commercial discontinuation. We report here our experience performing pegaspargase desensitizations in patients with prior hypersensitivity reactions. PROCEDURE Patients with a clinical hypersensitivity reaction to pegaspargase were identified. When due for their next dose, patients were admitted to the pediatric intensive care unit, bone marrow transplant unit, or oncology unit, and underwent desensitization utilizing a rigorous premedication and multistep dilution-based protocol. Serum asparaginase activity levels were drawn after desensitization to assess for therapeutic levels of enzyme activity. RESULTS We identified 11 patients who underwent a total of 33 desensitizations to pegaspargase and calaspargase pegol-mknl. No patients experienced clinically significant hypersensitivity reactions necessitating stopping the infusion, nor administration of rescue medications. All serum asparaginase activity levels collected demonstrated enzyme activity levels above predefined therapeutic thresholds. Cost analysis revealed substantial savings when patients received asparaginase desensitization over the now commercially available asparaginase E. chrysanthemi (recombinant) rywn. CONCLUSIONS Performing desensitization to pegaspargase in the pediatric acute lymphoblastic leukemia population is feasible, safe, and effective. It is financially advantageous over available alternative approaches, and requires fewer injections and presentations to care.
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Affiliation(s)
- Kira Feldman
- San Francisco Department of Pediatrics, University of California, San Francisco, California, USA
| | - Kathryn Aaronson
- Division of Pediatric Oncology, University of California, San Francisco Benioff Children's Hospital, San Francisco, California, USA
| | - Tina Gu
- Department of Pharmacy, University of California, San Francisco, California, USA
| | - Kelsey Ige
- Division of Pediatric Immunology, University of California, San Francisco Benioff Children's Hospital, San Francisco, California, USA
| | - Erica Southworth
- Division of Pediatric Oncology, University of California, San Francisco Benioff Children's Hospital, San Francisco, California, USA
| | - Lauren Sanchez
- Division of Pediatric Immunology, University of California, San Francisco Benioff Children's Hospital, San Francisco, California, USA
| | - Elliot Stieglitz
- Division of Pediatric Oncology, University of California, San Francisco Benioff Children's Hospital, San Francisco, California, USA
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9
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Valtis YK, Flamand Y, Shimony S, Place AE, Silverman LB, Vrooman LM, Brunner AM, Sallan SE, Wadleigh M, Stone RM, DeAngelo DJ, Luskin MR. Treatment completion, asparaginase completion, and oncologic outcomes among children, adolescents and young adults with acute lymphoblastic leukemia treated with DFCI Consortium Protocols. Leukemia 2024; 38:482-490. [PMID: 38177437 DOI: 10.1038/s41375-023-02115-4] [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: 06/05/2023] [Revised: 12/04/2023] [Accepted: 12/07/2023] [Indexed: 01/06/2024]
Abstract
Adolescents and young adult (AYA) patients with acute lymphoblastic leukemia (ALL) face worse outcomes than children. While pediatric-inspired protocols have improved outcomes, the ability of patients to complete these intensive regimens and the reasons for discontinuation are unknown. We analyzed a cohort of 332 AYA patients (aged 15-49 years) and 1159 children (aged 1-14 years) with Ph-negative ALL treated on DFCI consortium protocols. We found that AYA patients completed treatment at lower rates than children (60.8% vs. 89.7%, p < 0.001), primarily due to higher rates of early treatment failure (14.5% vs. 2.4%, p < 0.001). Withdrawal from treatment for toxicity, social/personal, or unknown reasons was uncommon, but higher among AYA patients (9.3% vs 4.7%, p = 0.001). Patients who remained on assigned therapy for one year had favorable overall survival (AYA 5-year OS 88.9%; children 5-year OS 96.4%; p < 0.001). Among patients who continued treatment for 1 year, AYA patients completed asparaginase (defined as receiving 26+ weeks) at lower rates than children (79.1% vs. 89.6%, p < 0.001). Patients who received more weeks of consolidation asparaginase had higher overall and event-free survival. Efforts should focus on identifying patients at risk for early treatment failure and optimizing asparaginase delivery.
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Affiliation(s)
- Yannis K Valtis
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yael Flamand
- Department of Data Science, Dana Farber Cancer Institute, Boston, MA, USA
| | - Shai Shimony
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Andrew E Place
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Division of Pediatric Hematology Oncology, Boston Children's Hospital, Boston, MA, USA
| | - Lewis B Silverman
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Division of Pediatric Hematology Oncology, Boston Children's Hospital, Boston, MA, USA
| | - Lynda M Vrooman
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Division of Pediatric Hematology Oncology, Boston Children's Hospital, Boston, MA, USA
| | - Andrew M Brunner
- Department of Hematology/Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Stephen E Sallan
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Division of Pediatric Hematology Oncology, Boston Children's Hospital, Boston, MA, USA
| | - Martha Wadleigh
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Richard M Stone
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Daniel J DeAngelo
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Marlise R Luskin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
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10
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Pieters R, Mullighan CG, Hunger SP. Advancing Diagnostics and Therapy to Reach Universal Cure in Childhood ALL. J Clin Oncol 2023; 41:5579-5591. [PMID: 37820294 PMCID: PMC10730082 DOI: 10.1200/jco.23.01286] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 07/24/2023] [Accepted: 08/10/2023] [Indexed: 10/13/2023] Open
Abstract
Systemic combination chemotherapy and intrathecal chemotherapy markedly increased the survival rate of children with ALL. In the past two decades, the use of minimal (measurable) residual disease (MRD) measurements early in therapy improved risk group stratification with subsequent treatment intensifications for patients at high risk of relapse, and enabled a reduction of treatment for low-risk patients. The recent development of more sensitive MRD technologies may further affect risk stratification. Molecular genetic profiling has led to the discovery of many new subtypes and their driver genetic alterations. This increased our understanding of the biological basis of ALL, improved risk classification, and enabled implementation of precision medicine. In the past decade, immunotherapies, including bispecific antibodies, antibody-drug conjugates, and cellular therapies directed against surface proteins, led to more effective and less toxic therapies, replacing intensive chemotherapy courses and allogeneic stem-cell transplantation in patients with relapsed and refractory ALL, and are now being tested in newly diagnosed patients. It has taken 50-60 years to increase the cure rate in childhood ALL from 0% to 90% by stepwise improvements in chemotherapy. This review provides an overview of how the developments over the past 10-15 years mentioned above have significantly changed the diagnostic and treatment approach in ALL, and discusses how the integrated use of molecular and immunotherapeutic insights will very likely direct efforts to cure those children with ALL who are not cured today, and improve the quality of life for survivors who should have decades of life ahead. Future efforts must focus on making effective, yet very expensive, new technologies and therapies available to children with ALL worldwide.
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Affiliation(s)
- Rob Pieters
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Charles G. Mullighan
- Department of Pathology and Hematological Malignancies Program, Comprehensive Cancer Center, St Jude Children's Research Hospital, Memphis, TN
| | - Stephen P. Hunger
- Division of Oncology, Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, PA
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11
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Zeng Q, Ren H, Liu C, Liu T, Xie Y, Tang X. Polymorphisms of inflammation-related genes and susceptibility to childhood leukemia: evidence from a meta-analysis of 16 published studies. Hematology 2023; 28:2210905. [PMID: 37183941 DOI: 10.1080/16078454.2023.2210905] [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: 05/16/2023] Open
Abstract
OBJECTIVE This study was to comprehensively clarify the associations between single nucleotide polymorphisms (SNPs) in inflammatory genes and the susceptibility to childhood leukemia. METHODS Eligible articles were collected from the databases of PubMed, EMBASE, Cochrane Library, CNKI and Wan Fang. The pooled odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated to estimate the association strength by using the STATA 15.0 software. RESULTS Sixteen studies were enrolled. These studies mainly evaluated SNPs in 13 genes, including C-X-C motif chemokine ligand 12 (CXCL12), toll-like receptor (TLR)-4, TLR6, TLR9, CD14, interleukin (IL)-1β, NLR family pyrin domain containing 3, IL-4, interleukin 4 receptor, IL-10, IL-13, macrophage migration inhibitory factor (MIF) and tumor necrosis factor-α. The meta-analysis indicated that CXCL12 rs1801157 (AG vs GG: OR = 1.99; 95%CI = 1.20-3.30; p = 0.008; AA + AG vs GG: OR = 1.92; 95%CI = 1.18-3.12; p = 0.009), TLR6 rs5743810 (TC vs TT: OR = 0.58; 95%CI = 0.39-0.85; p = 0.005), IL-10 rs1800871 (TC vs CC: OR = 1.19; 95%CI = 1.01-1.41; p = 0.044), rs1800872 (AC vs AA: OR = 1.53; 95%CI = 1.22-1.92; p < 0.001) and MIF rs755622 (CG versus GG: OR = 1.33; 95%CI = 1.07-1.67; p = 0.012) polymorphisms were associated with the risk of childhood leukemia. No significant correlations were found between SNPs in other genes and the childhood leukemia risk. Subgroup analyses of rs1800871 and rs1800872 confirmed the conclusions obtained in their overall meta-analytical processes. CONCLUSION CXCL12 rs1801157, TLR6 rs5743810, IL-10 rs1800871, rs1800872 and MIF rs755622 polymorphisms may represent candidate biomarkers for the risk prediction of childhood leukemia.
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Affiliation(s)
- Qiuping Zeng
- Department of Pediatric Hematology and Rheumatology, Zhuhai Center for Maternal and Child Health Care, Zhuhai, People's Republic of China
| | - Haoyan Ren
- Department of Pediatric Hematology and Rheumatology, Zhuhai Center for Maternal and Child Health Care, Zhuhai, People's Republic of China
| | - Cui Liu
- Department of Pediatrics, Qingdao Huangdao District Central Hospital, Qingdao, People's Republic of China
| | - Ting Liu
- Department of Pediatric Hematology and Rheumatology, Zhuhai Center for Maternal and Child Health Care, Zhuhai, People's Republic of China
| | - Yongwu Xie
- Department of Pediatric Hematology and Rheumatology, Zhuhai Center for Maternal and Child Health Care, Zhuhai, People's Republic of China
| | - Xiufu Tang
- Department of Pediatric Hematology and Rheumatology, Zhuhai Center for Maternal and Child Health Care, Zhuhai, People's Republic of China
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12
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Wang J, Jia WG, Yang LH, Kuang WY, Huang LB, Chen HQ, Wang LN, Zhou DH, Liao N. Clinical summary of pediatric acute lymphoblastic leukemia patients complicated with asparaginase-associated pancreatitis in SCCLG-ALL-2016 protocol. HEMATOLOGY (AMSTERDAM, NETHERLANDS) 2023; 28:2171723. [PMID: 36752506 DOI: 10.1080/16078454.2023.2171723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Asparaginase-associated pancreatitis (AAP) is a common and fatal complication after ASNase treatment in acute lymphoblastic leukemia(ALL). Here, a total of 1063 pediatric ALL patients treated with SCCLG-ALL-2016 regimen were collected since October 2016 to June 2020, including 35 patients with AAP. The clinical characteristics of AAP and non-AAP patients were compared. In AAP patients, the possible factors that affected the recurrence of AAP were analyzed, and the possible risk factors related to ALL-relapse were discussed. The results showed that age was a risk factor (P = .017) that affect the occurrence of AAP. In AAP patients, AAP tended to develop after the second use of PEG-ASNase (25.71%). In the follow-up chemotherapy, 17 patients re-exposed to ASNase and 7 cases developed AAP again with a percentage was 41.2%. There were no special factors that related with the recurrence of AAP. This study also found no association between the occurrence of AAP and prognosis of ALL, with the 4-year incidence of ALL relapse in AAP and non-AAP patients were 15.9% v.s.11.7% (HR: 1.009, 95% CI:0.370-2.752, P = .986), and there were no special factors that related with the ALL relapse among AAP patients. Based on the above results, the occurrence of AAP is related to age and should be vigilant after the second use of PEG-ASNase after use in pediatric ALL patients. Moreover, AAP is not associated with ALL relapse, but there is a high AAP recurrence rate when re-exposure to ASNase.
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Affiliation(s)
- Jian Wang
- Children's Medical Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat Sen University, Guangzhou, People's Republic of China
| | - Wen-Guang Jia
- Department of Paediatrics, First Affiliated Hospital of Guangxi Medical University, Nanning, People's Republic of China
| | - Li-Hua Yang
- Department of Paediatrics, Zhujiang Hospital of Southern Medical University, Guangzhou, People's Republic of China
| | - Wen-Yong Kuang
- Department of Hematology, Hunan Children's Hospital, Changsha, People's Republic of China
| | - Li-Bin Huang
- Department of Paediatrics, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Hui-Qin Chen
- Department of Paediatrics, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Li-Na Wang
- Department of Paediatrics, Guangzhou First People's Hospital, Guangzhou, People's Republic of China
| | - Dun-Hua Zhou
- Children's Medical Center, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, People's Republic of China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat Sen University, Guangzhou, People's Republic of China
| | - Ning Liao
- Department of Paediatrics, First Affiliated Hospital of Guangxi Medical University, Nanning, People's Republic of China
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13
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Egnell C, Hallböök H, Heyman M, Wartiovaara-Kautto U, Quist-Paulsen P, Schmiegelow K, Griskevicius L, Palk K, Toft N, Overgaard UM, Harila A, Ranta S. Impact of body mass index on outcome and treatment-related toxicity in young adults with acute lymphoblastic leukemia. Acta Oncol 2023; 62:1723-1731. [PMID: 37725524 DOI: 10.1080/0284186x.2023.2258450] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 09/08/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Data on outcome for patients in different body mass index (BMI) categories in young adults with acute lymphoblastic leukemia (ALL) are scarce. We explored survival and toxicities in different BMI categories in young adults with ALL. MATERIAL AND METHODS Patients aged 18-45 years, diagnosed with ALL between July 2008 and June 2022 in the Nordic countries, Estonia, or Lithuania, and treated according to the NOPHO ALL2008 protocol, were retrospectively enrolled and classified into different BMI categories. Endpoints were overall survival (OS), event-free survival (EFS) and cumulative incidence of relapse as well as incidence rate ratio (IRR) of severe predefined toxic events, and treatment delays. RESULTS The group comprised 416 patients, of whom 234 (56%) were stratified to non-high-risk (non-HR) treatment. In the non-HR group, patients with severe obesity, BMI ≥35 kg/m2 had worse EFS due to relapses but there was no effect on toxicity or treatment delays compared with the healthy-weight patients. There was no association between BMI category and OS, overall toxicity, or treatment delays in the patients with high-risk treatment. CONCLUSION Severe obesity is associated with worse EFS in young adults treated according to the non-HR arms of the NOPHO ALL2008 protocol. Poorer outcome is explained with a higher risk of relapse, possibly due to under treatment, and not caused by excess therapy-related mortality.
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Affiliation(s)
- Christina Egnell
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Helene Hallböök
- Department of Medical Sciences, Haematology, Uppsala University, Uppsala, Sweden
| | - Mats Heyman
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | | | - Petter Quist-Paulsen
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | - Katrin Palk
- Haematology Centre, North Estonia Medical Centre, Tallinn, Estonia
| | - Nina Toft
- Department of Haematology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Ulrik Malthe Overgaard
- Department of Haematology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Arja Harila
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Susanna Ranta
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
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14
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Ali AM, Adam H, Hailu D, Howe R, Abula T, Coenen MJH. Evaluating the Frequencies of CNOT3, GRIA1, NFATC2, and PNPLA3 Variant Alleles and Their Association with L-Asparaginase Hypersensitivity in Pediatric Acute Lymphoblastic Leukemia in Addis Ababa, Ethiopia. Appl Clin Genet 2023; 16:131-137. [PMID: 37551203 PMCID: PMC10404408 DOI: 10.2147/tacg.s404695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 06/13/2023] [Indexed: 08/09/2023] Open
Abstract
Introduction L-asparaginase is a vital component for the treatment of childhood acute lymphoblastic leukemia (ALL); however, hypersensitivity reactions and hepatotoxicity hinder its anti-neoplastic efficacy. Previous reports indicated that genetic variants in CNOT3, GRIA1, and NFATC2 genes might be associated with hypersensitivity reactions and PNPLA3 with liver function. Objective In this study, it was investigated whether this association also exists in a pediatric ALL cohort from Ethiopia. Methods Three variants GRIA1 rs4958351, CNOT3 rs73062673, and NFATC2 rs6021191 were genotyped in a cohort of 160 patients. Association analysis to investigate the association with hypersensitivity reactions was performed using logistic regression analyses. Besides these variants, a variant in PNPLA3 (rs738409) was genotyped to assess the association with liver function. Results Genotype frequencies of GRIA1 rs4958351, CNOT3 rs73062673, and NFATC2 rs6021191 were higher/lower than previously reported. One hundred and forty-four patients were included in the association analysis of which, 18 (12.5%) developed L-ASP hypersensitivity. Though the frequency of hypersensitivity was higher in patients that carried the risk alleles of the three investigated genes, no statistically significant differences were observed. Association analysis between PNPLA3 rs738409 and liver function could not be investigated due to a lack of clinical information. Conclusion In conclusion, none of the tested genes did predict L-asparaginase hypersensitivity in an Ethiopian pediatric ALL patients.
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Affiliation(s)
- Awol Mekonnen Ali
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Haileyesus Adam
- Department of Pediatrics and Child Health, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Daniel Hailu
- Department of Pediatrics and Child Health, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Rawleigh Howe
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Teferra Abula
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Marieke J H Coenen
- Department of Human Genetics, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
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15
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Müller J, Egyed P, Erdelyi D, Kovacs K, Mudra K, Szabo S, Egyed B, Gabor K. Our Experiences with Asparaginase Activity Measurements in Children with Lymphoblastic Diseases. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1160. [PMID: 37508657 PMCID: PMC10378469 DOI: 10.3390/children10071160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 06/25/2023] [Accepted: 06/27/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND Asparaginase is a key component of chemotherapy protocols for the treatment of lymphoblastic malignancies among children. Adequate asparagine depletion is an important factor to achieve optimal therapeutic outcomes. METHODS Over a 3.5 year period, 106 patients were monitored for asparaginase activity (329 samples) in a single center of the Hungarian Pediatric Oncology-Hematology Group. In Hungary, three asparaginase products are available: native E. coli ASNase (Kidrolase), a pegylated form of this enzyme (Pegaspargase) and another native product from Erwinia chrysanthemi (Erwinase). A retrospective data analysis was performed. RESULTS In 81% (268/329) of our patients, AEA levels were in the optimal therapeutic range of over 100 IU/L. Of 106 patients, 13 (12%) were diagnosed with 'silent inactivation'. CONCLUSIONS Monitoring of AEA can help to identify patients with 'silent inactivation' and their asparaginase therapy can thus be optimized.
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Affiliation(s)
- Judit Müller
- 2nd Department of Pediatrics, Semmelweis University, 1094 Budapest, Hungary
| | - Petra Egyed
- County Hospital Fejer, Szent Gyorgy Hospital, 8000 Szekesfehervar, Hungary
| | - Daniel Erdelyi
- 2nd Department of Pediatrics, Semmelweis University, 1094 Budapest, Hungary
| | - Krisztian Kovacs
- Department of Laboratory Medicine, Semmelweis University, 1089 Budapest, Hungary
| | - Katalin Mudra
- 2nd Department of Pediatrics, Semmelweis University, 1094 Budapest, Hungary
| | - Sandor Szabo
- 2nd Department of Pediatrics, Semmelweis University, 1094 Budapest, Hungary
| | - Balint Egyed
- 2nd Department of Pediatrics, Semmelweis University, 1094 Budapest, Hungary
| | - Kovacs Gabor
- 2nd Department of Pediatrics, Semmelweis University, 1094 Budapest, Hungary
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16
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Skipper MT, Albertsen BK, Schmiegelow K, Andrés-Jensen L. Long-term effects of asparaginase-associated pancreatitis. Pediatr Blood Cancer 2023:e30528. [PMID: 37376950 DOI: 10.1002/pbc.30528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 05/19/2023] [Indexed: 06/29/2023]
Abstract
Pancreatitis is a common and severe toxicity that occurs during asparaginase treatment for acute lymphoblastic leukemia, and has received increasing attention during the last decades. However, no consensus regarding follow-up exists. In this commentary, we highlight potential long-term health-related effects following asparaginase-associated pancreatitis, thereby providing clinicians with a framework when following these patients during and after cessation of therapy.
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Affiliation(s)
- Mette Tiedemann Skipper
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Birgitte Klug Albertsen
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Liv Andrés-Jensen
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
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17
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Rizzari C, Möricke A, Valsecchi MG, Conter V, Zimmermann M, Silvestri D, Attarbaschi A, Niggli F, Barbaric D, Stary J, Elitzur S, Cario G, Vinti L, Boos J, Zucchetti M, Lanvers-Kaminsky C, von Stackelberg A, Biondi A, Schrappe M. Incidence and Characteristics of Hypersensitivity Reactions to PEG-asparaginase Observed in 6136 Children With Acute Lymphoblastic Leukemia Enrolled in the AIEOP-BFM ALL 2009 Study Protocol. Hemasphere 2023; 7:e893. [PMID: 37275740 PMCID: PMC10237686 DOI: 10.1097/hs9.0000000000000893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 04/12/2023] [Indexed: 06/07/2023] Open
Abstract
The incidence of hypersensitivity reactions (HSRs) to PEG-asparaginase (PEG-ASNase) was evaluated in 6136 children with ALL enrolled in the AIEOP-BFM ALL 2009 study. Patients with B-cell precursor-acute lymphoblastic leukemia (BCP-ALL) were stratified as standard-risk/medium-risk (MR)/high-risk (HR) and those with T-ALL as non-High/HR. PEG-ASNase was administered intravenously at 2500 IU/sqm/dose. All patients received 2 PEG-ASNase doses in induction; thereafter non-HR versus HR patients received 1 versus 6 PEG-ASNase doses, respectively. After the single regular dose of PEG-ASNase at the beginning of delayed intensification, BCP-ALL-MR patients were randomized to receive 9 additional PEG-ASNase doses every 2 weeks (experimental arm [EA]) versus none (standard arm [SA]); HR patients were randomized to receive, in consolidation, 4 weekly PEG-ASNase doses (EA) versus none (SA). The HSR cumulative incidence (CI) was estimated adjusting for competing risks. An HSR occurred in 472 of 6136 (7.7%) patients. T-non- HR/BCP-Standard-Risk, BCP-MR-SA, BCP-MR-EA, HR-SA and HR-EA patients had 1-year-CI-HSR (±SE) rates of 5.2% (0.5), 5.2% (0.5), 4.0% (0.8), 20.2% (1.2), and 6.4% (1.3), respectively. The randomized intensification of PEG-ASNase did not significantly impact on HSR incidence in BCP-MR patients (1-y-CI-HSR 3.8% [0.8] versus 3.2% [0.6] in MR-EA versus MR-SA; P = 0.55), while impacted significantly in HR patients (1-y-CI-HSR 6.4% [1.3] versus 17.9% [1.8] in HR-EA and HR-SA, respectively; P < 0.001). The CI-HSR was comparable among non-HR groups and was not increased by a substantial intensification of PEG-ASNase in the BCP-MR-EA group whilst it was markedly higher in HR-SA than in HR-EA patients, suggesting that, in such a chemotherapy context, a continuous exposure to PEG-ASNase reduces the risk of developing an HSR.
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Affiliation(s)
- Carmelo Rizzari
- Department of Pediatrics, IRCCS San Gerardo dei Tintori Foundation, Monza, Italy; Department of Medicine and Surgery, University of MIlano-Bicocca, Milano, Italy
| | - Anja Möricke
- Department of Pediatrics I, Pediatric Hematology/Oncology, ALL-BFM Study Group, Christian Albrechts University Kiel and University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Maria Grazia Valsecchi
- Department of Pediatrics, IRCCS San Gerardo dei Tintori Foundation, Monza, Italy; Department of Medicine and Surgery, University of MIlano-Bicocca, Milano, Italy
- Bicocca Center of Bioinformatics, Biostatistics and Bioimaging, School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Valentino Conter
- Department of Pediatrics, IRCCS San Gerardo dei Tintori Foundation, Monza, Italy; Department of Medicine and Surgery, University of MIlano-Bicocca, Milano, Italy
| | - Martin Zimmermann
- Department of Pediatric Hematology/Oncology, Hannover Medical School, Hannover, Germany
| | - Daniela Silvestri
- Department of Pediatrics, IRCCS San Gerardo dei Tintori Foundation, Monza, Italy; Department of Medicine and Surgery, University of MIlano-Bicocca, Milano, Italy
- Bicocca Center of Bioinformatics, Biostatistics and Bioimaging, School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Andishe Attarbaschi
- Department of Pediatric Hematology and Oncology, St. Anna Children's Hospital, Medical University of Vienna, Austria
- St. Anna Children's Cancer Research Institute (CCRI), Vienna, Austria
| | - Felix Niggli
- University Children's Hospital, Zurich, Switzerland
| | - Draga Barbaric
- Cancer Centre for Children, Sydney Children's Hospital Network, Westmead, NSW, Australia
| | - Jan Stary
- Department of Pediatric Haematology and Oncology, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Sarah Elitzur
- Pediatric Hematology-Oncology, Schneider Children's Medical Center, Petah Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Petah Tikva, Israel
| | - Gunnar Cario
- Department of Pediatrics I, Pediatric Hematology/Oncology, ALL-BFM Study Group, Christian Albrechts University Kiel and University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Luciana Vinti
- Department of Onco-Hematology and Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Joachim Boos
- Department of Pediatric Hematology and Oncology, University Childrens' Hospital of Münster, Germany
| | - Massimo Zucchetti
- Department of Oncology Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Laboratory of Cancer Pharmacology, Milano, Italy
| | - Claudia Lanvers-Kaminsky
- Department of Pediatric Hematology and Oncology, University Childrens' Hospital of Münster, Germany
| | - Arend von Stackelberg
- Department of Pediatric Hematology and Oncology, Charité and Rudolf-Virchow-Hospital, Berlin, Germany
| | - Andrea Biondi
- Department of Pediatrics, IRCCS San Gerardo dei Tintori Foundation, Monza, Italy; Department of Medicine and Surgery, University of MIlano-Bicocca, Milano, Italy
| | - Martin Schrappe
- Department of Pediatrics I, Pediatric Hematology/Oncology, ALL-BFM Study Group, Christian Albrechts University Kiel and University Hospital Schleswig-Holstein, Campus Kiel, Germany
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18
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Möricke A, Rizzari C, Alten J, Attarbaschi A, Beier R, Biondi A, Burkhardt B, Bodmer N, Boos J, Cario G, Conter V, Flotho C, Kulozik A, Lanvers-Kaminsky C, Mann G, Niggli F, Silvestri D, von Stackelberg A, Stanulla M, Valsecchi MG, Schrappe M, Zimmermann M. Hypersensitivity Reactions to Native E. coli L-asparaginase in Children With Acute Lymphoblastic Leukemia Treated in Trial ALL-BFM 2000: Impact of Treatment Schedule and Type of Glucocorticoid in Induction. Hemasphere 2023; 7:e888. [PMID: 37275738 PMCID: PMC10238044 DOI: 10.1097/hs9.0000000000000888] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 04/05/2023] [Indexed: 06/07/2023] Open
Affiliation(s)
- Anja Möricke
- Department of Pediatrics I, Pediatric Hematology/Oncology, ALL-BFM Study Group, Christian Albrechts University Kiel and University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Carmelo Rizzari
- Pediatric Hematology-Oncology Unit, Department of Pediatrics, University of Milano-Bicocca, MBBM Foundation, Monza, Italy
| | - Julia Alten
- Department of Pediatrics I, Pediatric Hematology/Oncology, ALL-BFM Study Group, Christian Albrechts University Kiel and University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Andishe Attarbaschi
- Department of Pediatric Hematology and Oncology, St. Anna Children’s Hospital, Medical University of Vienna, Austria
- St. Anna Kinderspital and Children’s Cancer Research Institute, Vienna, Austria
| | - Rita Beier
- Department of Pediatric Hematology/Oncology, Hannover Medical School, Hannover, Germany
| | - Andrea Biondi
- Pediatric Hematology-Oncology Unit, Department of Pediatrics, University of Milano-Bicocca, MBBM Foundation, Monza, Italy
| | - Birgit Burkhardt
- Department of Paediatric Hematology and Oncology, University Hospital Muenster, Germany
| | | | - Joachim Boos
- Department of Paediatric Hematology and Oncology, University Hospital Muenster, Germany
| | - Gunnar Cario
- Department of Pediatrics I, Pediatric Hematology/Oncology, ALL-BFM Study Group, Christian Albrechts University Kiel and University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Valentino Conter
- Pediatric Hematology-Oncology Unit, Department of Pediatrics, University of Milano-Bicocca, MBBM Foundation, Monza, Italy
| | - Christian Flotho
- Division of Pediatric Hematology and Oncology, Medical Center, Faculty of Medicine, University of Freiburg, Germany
| | - Andreas Kulozik
- Department of Pediatric Oncology, Hematology and Immunology, University of Heidelberg, Germany
| | | | - Georg Mann
- St. Anna Kinderspital and Children’s Cancer Research Institute, Vienna, Austria
| | - Felix Niggli
- University Children’s Hospital, Zurich, Switzerland
| | - Daniela Silvestri
- Bicocca Center of Bioinformatics, Biostatistics and Bioimaging, School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Arend von Stackelberg
- Pediatric Hematology and Oncology, Charité Medical Center, Humboldt University, Berlin, Germany
| | - Martin Stanulla
- Department of Pediatric Hematology/Oncology, Hannover Medical School, Hannover, Germany
| | - Maria-Grazia Valsecchi
- Bicocca Center of Bioinformatics, Biostatistics and Bioimaging, School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Martin Schrappe
- Department of Pediatrics I, Pediatric Hematology/Oncology, ALL-BFM Study Group, Christian Albrechts University Kiel and University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Martin Zimmermann
- Department of Pediatric Hematology/Oncology, Hannover Medical School, Hannover, Germany
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Lynggaard LS, Rank CU, Als-Nielsen B, Hoejfeldt SG, Heyman M, Schmiegelow K, Albertsen BK. PEG-asparaginase treatment regimens for acute lymphoblastic leukaemia in children: a network meta-analysis. Cochrane Database Syst Rev 2023; 5:CD014570. [PMID: 37260073 PMCID: PMC10230854 DOI: 10.1002/14651858.cd014570.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Asparaginase has played a crucial role in the improvement of survival in children with acute lymphoblastic leukaemia (ALL), which is the commonest cancer among children. Survival rates have steadily increased over decades since the introduction of asparaginase to ALL therapy, and overall survival rates reach 90% with the best contemporary protocols. Currently, polyethylene glycolated native Escherichia coli-derived L-asparaginase (PEG-asparaginase) is the preferred first-line asparaginase preparation. Besides its clinical benefits, PEG-asparaginase is well known for severe toxicities. Agreement on the optimal dose, treatment duration, and frequency of administration has never been reached among clinicians. OBJECTIVES Primary objective To assess the effect of the number of PEG-asparaginase doses on survival and relapse in children and adolescents with ALL. Secondary objectives To assess the association between the number of doses of PEG-asparaginase and asparaginase-associated toxicities (e.g. hypersensitivity, thromboembolism, pancreatitis and osteonecrosis). To undertake a network meta-analysis at dose-level in order to generate rankings of the number of doses of PEG-asparaginase used in the treatment for ALL, according to their benefits (survival and relapse) and harms (toxicity). SEARCH METHODS We searched CENTRAL, PubMed, Embase, Web of Science databases and three trials registers in November 2021, together with reference checking, citation searching and contact with study authors to identify additional studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing different PEG-asparaginase treatment regimens in children and adolescents (< 18 years of age) with first-line ALL treated with multiagent chemotherapy including PEG-asparaginase. DATA COLLECTION AND ANALYSIS Using a standardised data collection form, two review authors independently screened and selected studies, extracted data, assessed risk of bias for each outcome using a standardised tool (RoB 2.0) and assessed the certainty of evidence for each outcome using the GRADE approach. Primary outcomes included overall survival, event-free survival and leukaemic relapse. Secondary outcomes included asparaginase-associated toxicities (hypersensitivity, thromboembolism, pancreatitis, sinusoidal obstruction syndrome and osteonecrosis as well as overall asparaginase-associated toxicity). We conducted the review and performed the analyses in accordance with the guidelines of the Cochrane Handbook for Systematic Reviews of Interventions. MAIN RESULTS We included three RCTs in the review, and identified an additional four ongoing studies. We judged outcomes of two RCTs to be at low risk of bias in all the Cochrane risk of bias (RoB 2) domains. We rated the remaining study as having some concerns regarding bias. Due to concerns about imprecision, we rated all outcomes as having low- to moderate-certainty evidence. One study compared intermittent PEG-asparaginase treatment (eight doses of PEG-asparaginase, 1000 IU/m2, intramuscular (IM) administration) versus continuous PEG-asparaginase treatment (15 doses of PEG-asparaginase, 1000 IU/m2, IM) in 625 participants with non-high risk ALL aged 1.0 to 17.9 years. We found that treatment with eight doses probably results in little to no difference in event-free survival compared to treatment with 15 doses (RR 1.01, 95% CI 0.97 to 1.06; moderate-certainty evidence). Compared to treatment with 15 doses, treatment with eight doses may result in either no difference or a slight reduction in hypersensitivity (RR 0.64, 95% CI 0.21 to 1.93; low-certainty evidence), thromboembolism (RR 0.55, 95% CI 0.22 to 1.36; low-certainty evidence) or osteonecrosis (RR 0.68, 95% CI 0.35 to 1.32; low-certainty evidence). Furthermore, we found that treatment with eight doses probably reduces pancreatitis (RR 0.31, 95% CI 0.12 to 0.75; moderate-certainty evidence) and asparaginase-associated toxicity (RR 0.53, 95% CI 0.35 to 0.78; moderate-certainty evidence) compared to treatment with 15 doses. One study compared low-risk standard treatment with additional PEG-asparaginase (six doses, 2500 IU/m2, IM) versus low-risk standard treatment (two doses, 2500 IU/m2, IM) in 1857 participants aged one to nine years old with standard low-risk ALL. We found that, compared to treatment with two doses, treatment with six doses probably results in little to no difference in overall survival (RR 0.99, 95% CI 0.98 to 1.00; moderate-certainty evidence) and event-free survival (RR 1.01, 95% CI 0.99 to 1.04; moderate-certainty evidence), and may result in either no difference or a slight increase in osteonecrosis (RR 1.65, 95% CI 0.91 to 3.00; low-certainty evidence). Furthermore, we found that treatment with six doses probably increases hypersensitivity (RR 12.05, 95% CI 5.27 to 27.58; moderate-certainty evidence), pancreatitis (RR 4.84, 95% CI 2.15 to 10.85; moderate-certainty evidence) and asparaginase-associated toxicity (RR 4.49, 95% CI 3.05 to 6.59; moderate-certainty evidence) compared to treatment with two doses. One trial compared calaspargase (11 doses, 2500 IU/m2, intravenous (IV)) versus PEG-asparaginase (16 doses, 2500 IU/m2, IV) in 239 participants aged one to 21 years with standard- and high-risk ALL and lymphoblastic lymphoma. We found that treatment with 11 doses of calaspargase probably results in little to no difference in event-free survival compared to treatment with 16 doses of PEG-asparaginase (RR 1.06, 95% CI 0.97 to 1.16; moderate-certainty evidence). However, treatment with 11 doses of calaspargase probably reduces leukaemic relapse compared to treatment with 16 doses of PEG-asparaginase (RR 0.32, 95% CI 0.12 to 0.83; moderate-certainty evidence). Furthermore, we found that treatment with 11 doses of calaspargase results in either no difference or a slight reduction in hypersensitivity (RR 1.17, 95% CI 0.64 to 2.13; low-certainty evidence), pancreatitis (RR 0.85, 95% CI 0.47 to 1.52; low-certainty evidence), thromboembolism (RR 0.83, 95% CI 0.48 to 1.42; low-certainty evidence), osteonecrosis (RR 0.63, 95% CI 0.15 to 2.56; low-certainty evidence) and asparaginase-associated toxicity (RR 1.00, 95% CI 0.71 to 1.40; low-certainty evidence) compared to treatment with 16 doses of PEG-asparaginase. AUTHORS' CONCLUSIONS We were not able to conduct a network meta-analysis, and could not draw clear conclusions because it was not possible to rank the interventions. Overall, we found that different numbers of doses of PEG-asparaginase probably result in little to no difference in event-free survival across all studies. In two studies, we found that a higher number of PEG-asparaginase doses probably increases pancreatitis and asparaginase-associated toxicities.
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Affiliation(s)
- Line Stensig Lynggaard
- Department of Child and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Cecilie U Rank
- Department of Haematology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Bodil Als-Nielsen
- Department of Paediatric Haematology/Oncology (5054), The Child and Youth Clinic, Copenhagen, Denmark
| | - Sofie G Hoejfeldt
- Department of Child and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Mats Heyman
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Kjeld Schmiegelow
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Birgitte K Albertsen
- Department of Child and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
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20
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Ishida H, Imamura T, Tatebe Y, Ishihara T, Sakaguchi K, Suenobu S, Sato A, Hashii Y, Deguchi T, Takahashi Y, Hasegawa D, Miyamura T, Iguchi A, Kato K, Saito-Moriya A, Hara J, Horibe K. Impact of asparaginase discontinuation on outcomes of children with acute lymphoblastic leukaemia receiving the Japan Association of Childhood Leukaemia Study ALL-02 protocol. Br J Haematol 2023. [PMID: 36891758 DOI: 10.1111/bjh.18745] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 02/27/2023] [Accepted: 02/28/2023] [Indexed: 03/10/2023]
Abstract
Asparaginase is an essential drug for acute lymphoblastic leukaemia (ALL) treatment, but has several side effects, and its discontinuation often compromises patient outcomes. In the prospective Japan Association of Childhood Leukaemia Study ALL-02 protocol, two major changes were made: (1) additional chemotherapies to compensate for the reduction of treatment intensity when asparaginase was discontinued and (2) more intensive concomitant corticosteroid administration, relative to our previous ALL-97 protocol. In ALL-02 study, 1192 patients were included and L-asparaginase was discontinued for 88 (7.4%). Discontinuation due to allergy was markedly decreased relative to the ALL-97 protocol (2.3% vs 15.4%). Event-free survival (EFS) among patients with T-ALL was compromised when L-asparaginase was discontinued, as well as among patients with high-risk B-cell ALL, especially when discontinued before maintenance therapy. Moreover, multivariate analysis identified discontinuation of L-asparaginase as an independent poor prognostic factor for EFS. In the current study, additional chemotherapies failed to fully compensate for L-asparaginase discontinuation, illustrating the difficulty of replacing asparaginase with other classes of drugs, although this study was not designed to evaluate the effect of these modifications. Concomitant intensive corticosteroid treatment may help to reduce allergy to asparaginase. These results will assist in further optimization of asparaginase use.
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Affiliation(s)
- Hisashi Ishida
- Department of Pediatrics, Okayama University Hospital, Okayama, Japan
| | - Toshihiko Imamura
- Department of Pediatrics, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan
| | - Yasuhisa Tatebe
- Department of Pharmacy, Okayama University Hospital, Okayama, Japan
| | - Takashi Ishihara
- Department of Pediatrics, Nara Medical University, Kashihara, Japan
| | - Kimiyoshi Sakaguchi
- Department of Pediatrics, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Souichi Suenobu
- Division of General Pediatrics and Emergency Medicine, Oita University Faculty of Medicine, Yufu, Japan
| | - Atsushi Sato
- Department of Hematology/Oncology, Miyagi Children's Hospital, Sendai, Japan
| | - Yoshiko Hashii
- Department of Pediatrics, Osaka University Graduate School of Medicine, Suita, Japan
| | - Takao Deguchi
- Department of Pediatrics, Mie University, Tsu, Japan
| | - Yoshihiro Takahashi
- Department of Pediatrics, Aomori Prefectural Central Hospital, Aomori, Japan
| | - Daiichiro Hasegawa
- Department of Hematology/Oncology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Takako Miyamura
- Department of Pediatrics, Osaka University Graduate School of Medicine, Suita, Japan
| | - Akihiro Iguchi
- Department of Pediatrics, Hokkaido University Hospital, Sapporo, Japan
| | - Koji Kato
- Department of Hematology Oncology, Children's Medical Center, Japanese Red Cross Nagoya First Hospital, Nagoya, Japan
| | - Akiko Saito-Moriya
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Junichi Hara
- Department of Pediatric Hematology/Oncology, Osaka City General Hospital, Osaka, Japan
| | - Keizo Horibe
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
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21
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Lin T, Whigham T, Fernando I, Choi MR, Wang Q, Silverman JA. Population pharmacokinetics of intramuscular recombinant Erwinia chrysanthemi asparaginase (JZP458) in patients with acute lymphoblastic leukemia. Clin Transl Sci 2023; 16:898-909. [PMID: 36929533 PMCID: PMC10175977 DOI: 10.1111/cts.13499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 01/23/2023] [Accepted: 02/06/2023] [Indexed: 02/24/2023] Open
Abstract
JZP458 is a recombinant Erwinia chrysanthemi asparaginase for patients with acute lymphoblastic leukemia (ALL)/lymphoblastic lymphoma (LBL) who have developed hypersensitivity to Escherichia coli-derived asparaginases. A population pharmacokinetic (PopPK) model was developed for intramuscular (i.m.) JZP458 using serum asparaginase activity (SAA) data from 166 patients with ALL/LBL enrolled in a phase II/III study conducted in collaboration with the Children's Oncology Group (AALL1931; NCT04145531). The pharmacokinetics of i.m. JZP458 is best characterized by a one-compartment model with mixed-order absorption and linear elimination, with body surface area included as an allometric covariate on JZP458 SAA clearance and volume, and race (i.e., Black/African American) and disease subtype (i.e., T-cell ALL) as covariates on JZP458 SAA clearance. The PopPK model was used to simulate SAA profiles to estimate the likelihood of achieving nadir SAA (NSAA) levels greater than or equal to 0.1 IU/mL with different dosing regimens. Model-based simulations suggest when JZP458 is administered i.m. at 25/25/50 mg/m2 Monday/Wednesday/Friday (MWF), 92.1% of subjects (95% confidence interval [CI]: 90.9%, 93.3%) are expected to achieve the last 72-h (after 50 mg/m2 dose) NSAA level greater than or equal to 0.1 IU/mL, and 93.8% (95% CI: 92.7%, 94.9%) are expected to achieve the last 48-h (after 25 mg/m2 dose) NSAA level greater than or equal to 0.1 IU/mL. When JZP458 is administered 25 mg/m2 i.m. every 48 h, 93.8% (95% CI: 92.7%, 94.8%) are expected to achieve the last 48-h NSAA level greater than or equal to 0.1 IU/mL. These data supported the i.m. dose of 25 mg/m2 every 48 h or 25/25/50 mg/m2 on a MWF dosing schedule in patients with ALL/LBL.
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Affiliation(s)
- Tong Lin
- Jazz Pharmaceuticals, Inc., Palo Alto, California, USA
| | - Tajhia Whigham
- IQVIA, Overland Park, Kansas, USA.,Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Mi Rim Choi
- Jazz Pharmaceuticals, Inc., Palo Alto, California, USA
| | - Qi Wang
- Jazz Pharmaceuticals, Inc., Palo Alto, California, USA
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22
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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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23
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Aldoss I, Yin J, Wall A, Mrózek K, Liedtke M, Claxton DF, Foster MC, Appelbaum FR, Erba HP, Litzow MR, Tallman MS, Stone RM, Larson RA, Advani AS, Stock W, Luger SM. The impact of early PEG-asparaginase discontinuation in young adults with ALL: a post hoc analysis of the CALGB 10403 study. Blood Adv 2023; 7:196-204. [PMID: 36269846 PMCID: PMC9841239 DOI: 10.1182/bloodadvances.2022007791] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 08/25/2022] [Accepted: 09/12/2022] [Indexed: 01/21/2023] Open
Abstract
Asparaginase is a key component of pediatric-inspired regimens in young adults with acute lymphoblastic leukemia (ALL). Truncation of asparaginase therapy is linked to inferior outcomes in children with ALL. However, a similar correlation in adults is lacking. Here, we studied the prevalence and risk factors associated with pegylated (PEG)-asparaginase discontinuation in young adults with ALL treated on the US intergroup Cancer and Leukemia Group B (CALGB) 10403 study and examined the prognostic impact of early discontinuation (ED) (defined as <4 of 5 or 6 planned doses) on survival outcomes. The analysis included 176 patients who achieved complete remission and initiated the delayed intensification (DI) cycle. The median number of PEG-asparaginase doses administered before DI was 5 (range, 1-6), with 57 (32%) patients with ED. The ED patients were older (median, 26 vs 23 years; P = .023). Survival was apparently lower for ED patients compared with those receiving ≥4 doses, but this finding was not statistically significant (hazard ratio [HR], 1.82; 95% confidence interval [CI], 0.97-3.43; P = .06), with corresponding 5-year overall survival (OS) rates of 66% and 80%, respectively. In patients with standard-risk ALL, the ED of PEG-asparaginase adversely influenced OS (HR, 2.3; 95% CI, 1.02-5.22; P = .04) with a trend toward inferior event-free survival (EFS) (HR, 1.84; 95% CI, 0.92-3.67; P = .08). In contrast, there was no impact of early PEG-asparaginase discontinuation on OS (P = .64) or EFS (P = .32) in patients with high-risk disease based on the presence of high-risk cytogenetics, Ph-like genotype, and/or high white blood cell count at presentation. In conclusion, early PEG-asparaginase discontinuation is common in young adults with ALL and may adversely impact survival of patients with standard-risk ALL.
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Affiliation(s)
- Ibrahim Aldoss
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Jun Yin
- Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN
| | - Anna Wall
- Alliance Statistics and Data Center, Mayo Clinic, Rochester, MN
| | - Krzysztof Mrózek
- The Ohio State University Comprehensive Cancer Center, Clara D. Bloomfield Center for Leukemia Outcomes Research, Columbus, OH
| | | | - David F. Claxton
- Department of Medicine, Penn State University, State College, PA
| | - Matthew C. Foster
- Department of Medicine, University of North Carolina, Chapel Hill, NC
| | - Frederick R. Appelbaum
- Clinical Research Division, University of Washington, Fred Hutchinson Cancer Center, Seattle, WA
| | | | - Mark R. Litzow
- Division of Hematology, Mayo Clinic Rochester, Rochester, NY
| | | | | | | | - Anjali S. Advani
- Taussig Cancer Institute/Leukemia Program, Cleveland Clinic, Cleveland, OH
| | - Wendy Stock
- Department of Medicine, Section of Hematology/Oncology, University of Chicago, Chicago, IL
| | - Selina M. Luger
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
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24
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Aldoss I, Pourhassan H, Douer D. SOHO State of the Art Updates and Next Questions | Asparaginase-Understanding and Overcoming Toxicities in Adults with ALL. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:787-794. [PMID: 36114134 DOI: 10.1016/j.clml.2022.08.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/11/2022] [Accepted: 08/18/2022] [Indexed: 06/15/2023]
Abstract
The adoption of pediatric-inspired regimens in young adults with newly diagnosed acute lymphoblastic leukemia (ALL) has significantly improved their survival outcomes. Pediatric-inspired regimens in ALL rely profoundly on delivering adequate dosing of non-myelosuppressive drugs of which asparaginase, a bacterial derived agent, is a key component. Asparaginase therapy is associated with a spectrum of unique toxicities that are observed more frequently in adult patients compared to children with ALL, and this observation has contributed to the reluctance of adult oncologists to administer the drug to their patients. Understanding the breadth of asparaginase toxicity and the associated risk factors may help in preventing severe manifestations and allow safer treatment for adults with ALL. In this review, we will discuss the different formulations of asparaginase and the appropriate dosing in adults with ALL. We will further discuss the frequency and risk factors for individual toxicities of asparaginase along with strategies for their prevention and management.
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Affiliation(s)
| | | | - Dan Douer
- University of Southern California, Los Angeles, CA
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25
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Brigitha LJ, Pieters R, Struys EA, Bakkali A, van der Sluis IM. Depletion of d- and l-asparagine in cerebrospinal fluid in acute lymphoblastic leukemia during PEGasparaginase therapy. Pediatr Blood Cancer 2022; 69:e29865. [PMID: 35880973 DOI: 10.1002/pbc.29865] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 06/07/2022] [Accepted: 06/13/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND l-Asparaginase hydrolyzes l-asparagine and not its enantiomer d-asparagine. Unlike l-asparagine, d-asparagine is nonessential for the survival of acute lymphoblastic leukemia (ALL) cells. Studies showed that serum asparagine is depleted below 0.5 μM in ≥96% of the patients during pegylated Escherichia coli l-asparaginase (PEGasparaginase) treatment; however, cerebrospinal fluid (CSF) asparagine levels are depleted in only 20%-30% of the patients. Thus far, studies only reported the total CSF asparagine (sum of d- and l-asparagine) concentrations. Data on the pharmacological goal, which is l-asparagine depletion, are lacking. METHOD Therefore, we studied this in 30 patients (95 samples) with newly diagnosed ALL. They received two doses of PEGasparaginase on day 4 and 18 in induction. RESULTS Median age at diagnosis was 5.7 years (range 1.5-17.1 years). d-Asparagine and l-asparagine concentrations (median (range)) before PEGasparaginase treatment were 0.038 (0.0-0.103) μM and 6.1 (1.82-11.5) μM, respectively. CSF l-asparagine concentrations were reduced by 85% (76%-100%) and approximately one-third of the patients (32%) had CSF l-asparagine depletion below 0.5 μM 11 days after the second PEGasparaginase dose administration. CSF d-asparagine and l-glutamine levels remained stable before and after administration of PEGasparaginase. The percentage of d-asparagine as a fraction of total asparagine (sum of d- and l-asparagine) was 0.62% before and 4.5% after PEGasparaginase treatment. No correlation was found between higher serum PEGasparaginase activity and CSF l-asparagine concentration. CONCLUSION l-Asparagine is not a better parameter than total asparagine in CSF due to the negligible amount of d-asparagine in the CSF before and after PEGasparaginase treatment.
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Affiliation(s)
- Leiah J Brigitha
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Rob Pieters
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Eduard A Struys
- Amsterdam University Medical Centers, Clinical Chemistry, Amsterdam, The Netherlands
| | - Abdellatif Bakkali
- Amsterdam University Medical Centers, Clinical Chemistry, Amsterdam, The Netherlands
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26
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Albertsen BK, Lynggaard LS, Schmiegelow K. Asparaginase encapsulated in erythrocytes as second-line treatment in hypersensitive patients with acute lymphoblastic leukaemia. Br J Haematol 2022; 198:e84-e85. [PMID: 35917113 DOI: 10.1111/bjh.18373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 07/08/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Birgitte Klug Albertsen
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Line Stensig Lynggaard
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
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27
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Does L-asparaginase dose intensity correlate with acute pancreatitis in acute lymphoblastic leukemia patients? Pediatr Res 2022; 92:341-342. [PMID: 35681086 DOI: 10.1038/s41390-022-02146-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 03/01/2022] [Accepted: 05/26/2022] [Indexed: 11/08/2022]
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28
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Skipper MT, Rank CU, Jarvis KB, Lynggaard LS, Andrés‐Jensen L, Quist‐Paulsen P, Semaskeviciene R, Hallböök H, Waitiovaara‐Kautto U, Ranta S, Trakymiene S, Abrahamsson J, Huttunen P, Albertsen BK, Schmiegelow K, Tuckuviene R. Cerebral sinovenous thrombosis and asparaginase re‐exposure in patients aged 1–45 years with acute lymphoblastic leukaemia: A NOPHO ALL2008 study. EJHAEM 2022; 3:754-763. [PMID: 36051071 PMCID: PMC9422014 DOI: 10.1002/jha2.484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 05/06/2022] [Accepted: 05/11/2022] [Indexed: 11/22/2022]
Abstract
Cerebral sinovenous thrombosis (CSVT) is a serious complication during asparaginase therapy in patients with acute lymphoblastic leukaemia (ALL). We identified 46 patients with CSVT among 2651 patients (1‒45 years) treated according to the Nordic Society of Paediatric Haematology and Oncology (NOPHO) ALL2008 protocol between 2008 and 2018. CSVT cases were prospectively registered in the NOPHO database with retrospective updates. We examined the frequency of asparaginase re‐exposure after CSVT, potential factors associated with asparaginase truncation, and sequelae after CSVT. This work was supported by the Danish Cancer Society and the Danish Childhood Cancer Foundation. The 2.5‐year cumulative incidence of CSVT was 1.9% (95% confidence interval 1.4%–2.5%). The majority of patients (74%, n = 31) were re‐exposed to asparaginase (with low‐molecular‐weight heparin coverage), one of whom had a second CSVT, without neurological sequelae. Patients re‐exposed to asparaginase were earlier in ALL treatment and lacked more asparaginase doses than non‐re‐exposed patients at CSVT diagnosis (median 50 vs. 81 days, p = 0.03; mean 11.2 vs. 8.4 asparaginase doses, p = 0.04). No other examined factors had an impact on asparaginase re‐exposure. At the last follow‐up (median 4.5 years after CSVT), 61% of patients had normal neurological status, and 57% had complete recanalisation of CSVT, with no significant difference between patients re‐exposed and non‐re‐exposed to asparaginase. Our results indicate that re‐exposure to asparaginase is safe after CSVT during anticoagulation.
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Affiliation(s)
- Mette Tiedemann Skipper
- Department of Paediatrics and Adolescent Medicine Aarhus University Hospital Aarhus Denmark
- Department of Clinical Medicine Aarhus University Aarhus Denmark
| | - Cecilie Utke Rank
- Department of Paediatrics and Adolescent Medicine Rigshospitalet University Hospital Copenhagen Denmark
| | | | - Line Stensig Lynggaard
- Department of Paediatrics and Adolescent Medicine Aarhus University Hospital Aarhus Denmark
| | - Liv Andrés‐Jensen
- Department of Paediatrics and Adolescent Medicine Rigshospitalet University Hospital Copenhagen Denmark
| | | | - Ruta Semaskeviciene
- Oncology and Transfusion Medicine Centre Vilnius University Hospital Santaros Klinikos Vilnius Lithuania
| | - Helene Hallböök
- Department of Medical Sciences Uppsala University Uppsala Sweden
| | - Ulla Waitiovaara‐Kautto
- Department of Haematology Comprehensive Cancer Centre Helsinki University Hospital and University of Helsinki Helsinki Finland
| | - Susanna Ranta
- Astrid Lindgren Children's Hospital Karolinska University Hospital and Childhood Cancer Research Unit Department of Women's and Children's Health Karolinska Institute Stockholm Sweden
| | - Sonata Trakymiene
- Clinic of Children's Diseases Faculty of Medicine Vilnius University Vilnius University Hospital Santaros Klinikos Vilnius Lithuania
| | - Jonas Abrahamsson
- Department of Paediatrics Institution of Clinical Science Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
| | - Pasi Huttunen
- Department of Paediatric Haematology Oncology and SCT New Children's Hospital Helsinki University Hospital Helsinki Finland
| | - Birgitte Klug Albertsen
- Department of Paediatrics and Adolescent Medicine Aarhus University Hospital Aarhus Denmark
- Department of Clinical Medicine Aarhus University Aarhus Denmark
| | - Kjeld Schmiegelow
- Department of Paediatrics and Adolescent Medicine Rigshospitalet University Hospital Copenhagen Denmark
| | - Ruta Tuckuviene
- Department of Paediatrics and Adolescent Medicine Rigshospitalet University Hospital Copenhagen Denmark
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29
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Wu Q, Gao ZJ, Yu X, Wang P. Dietary regulation in health and disease. Signal Transduct Target Ther 2022; 7:252. [PMID: 35871218 PMCID: PMC9308782 DOI: 10.1038/s41392-022-01104-w] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/21/2022] [Accepted: 07/04/2022] [Indexed: 02/08/2023] Open
Abstract
Nutriments have been deemed to impact all physiopathologic processes. Recent evidences in molecular medicine and clinical trials have demonstrated that adequate nutrition treatments are the golden criterion for extending healthspan and delaying ageing in various species such as yeast, drosophila, rodent, primate and human. It emerges to develop the precision-nutrition therapeutics to slow age-related biological processes and treat diverse diseases. However, the nutritive advantages frequently diversify among individuals as well as organs and tissues, which brings challenges in this field. In this review, we summarize the different forms of dietary interventions extensively prescribed for healthspan improvement and disease treatment in pre-clinical or clinical. We discuss the nutrient-mediated mechanisms including metabolic regulators, nutritive metabolism pathways, epigenetic mechanisms and circadian clocks. Comparably, we describe diet-responsive effectors by which dietary interventions influence the endocrinic, immunological, microbial and neural states responsible for improving health and preventing multiple diseases in humans. Furthermore, we expatiate diverse patterns of dietotheroapies, including different fasting, calorie-restricted diet, ketogenic diet, high-fibre diet, plants-based diet, protein restriction diet or diet with specific reduction in amino acids or microelements, potentially affecting the health and morbid states. Altogether, we emphasize the profound nutritional therapy, and highlight the crosstalk among explored mechanisms and critical factors to develop individualized therapeutic approaches and predictors.
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Affiliation(s)
- Qi Wu
- Tongji University Cancer Center, Shanghai Tenth People's Hospital of Tongji University, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Zhi-Jie Gao
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, P. R. China
| | - Xin Yu
- Department of Breast and Thyroid Surgery, Renmin Hospital of Wuhan University, Wuhan, Hubei, P. R. China
| | - Ping Wang
- Tongji University Cancer Center, Shanghai Tenth People's Hospital of Tongji University, School of Medicine, Tongji University, Shanghai, 200092, China.
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30
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Kasonkanji E, Kimani S, Skiver B, Ellis G, Seguin R, Kaimila B, Tomoka T, Mulenga M, Montgomery N, Fedoriw Y, Gopal S, Westmorland KD, Painschab MS. Clinical Characteristics and Outcomes of Acute Lymphoblastic Leukemia in Adolescents and Young Adults in Malawi. JCO Glob Oncol 2022; 8:e2100388. [PMID: 35772043 PMCID: PMC9276115 DOI: 10.1200/go.21.00388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
There are limited data on treatment and outcomes for acute lymphoblastic leukemia (ALL) among adolescents and young adults in sub-Saharan Africa. We describe a prospective observational cohort in Malawi.
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Affiliation(s)
| | - Stephen Kimani
- University of North Carolina Project-Malawi, Lilongwe, Malawi
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | | | - Grace Ellis
- Lineberger Comprehensive Cancer, University of North Carolina, Chapel Hill, NC
| | - Ryan Seguin
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Bongani Kaimila
- University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Tamiwe Tomoka
- University of North Carolina Project-Malawi, Lilongwe, Malawi
- University of Malawi College of Medicine, Blantyre, Malawi
| | | | - Nathan Montgomery
- Lineberger Comprehensive Cancer, University of North Carolina, Chapel Hill, NC
| | - Yuri Fedoriw
- Lineberger Comprehensive Cancer, University of North Carolina, Chapel Hill, NC
| | - Satish Gopal
- Center for Global Health, National Cancer Institute, Rockville, MD
| | - Katherine D. Westmorland
- University of North Carolina Project-Malawi, Lilongwe, Malawi
- Lineberger Comprehensive Cancer, University of North Carolina, Chapel Hill, NC
| | - Matthew S. Painschab
- University of North Carolina Project-Malawi, Lilongwe, Malawi
- Lineberger Comprehensive Cancer, University of North Carolina, Chapel Hill, NC
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31
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Nielsen RL, Wolthers BO, Helenius M, Albertsen BK, Clemmensen L, Nielsen K, Kanerva J, Niinimäki R, Frandsen TL, Attarbaschi A, Barzilai S, Colombini A, Escherich G, Aytan-Aktug D, Liu HC, Möricke A, Samarasinghe S, van der Sluis IM, Stanulla M, Tulstrup M, Yadav R, Zapotocka E, Schmiegelow K, Gupta R. Can Machine Learning Models Predict Asparaginase-associated Pancreatitis in Childhood Acute Lymphoblastic Leukemia. J Pediatr Hematol Oncol 2022; 44:e628-e636. [PMID: 35226426 PMCID: PMC8946594 DOI: 10.1097/mph.0000000000002292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 06/21/2021] [Indexed: 11/26/2022]
Abstract
Asparaginase-associated pancreatitis (AAP) frequently affects children treated for acute lymphoblastic leukemia (ALL) causing severe acute and persisting complications. Known risk factors such as asparaginase dosing, older age and single nucleotide polymorphisms (SNPs) have insufficient odds ratios to allow personalized asparaginase therapy. In this study, we explored machine learning strategies for prediction of individual AAP risk. We integrated information on age, sex, and SNPs based on Illumina Omni2.5exome-8 arrays of patients with childhood ALL (N=1564, 244 with AAP 1.0 to 17.9 yo) from 10 international ALL consortia into machine learning models including regression, random forest, AdaBoost and artificial neural networks. A model with only age and sex had area under the receiver operating characteristic curve (ROC-AUC) of 0.62. Inclusion of 6 pancreatitis candidate gene SNPs or 4 validated pancreatitis SNPs boosted ROC-AUC somewhat (0.67) while 30 SNPs, identified through our AAP genome-wide association study cohort, boosted performance (0.80). Most predictive features included rs10273639 (PRSS1-PRSS2), rs10436957 (CTRC), rs13228878 (PRSS1/PRSS2), rs1505495 (GALNTL6), rs4655107 (EPHB2) and age (1 to 7 y). Second AAP following asparaginase re-exposure was predicted with ROC-AUC: 0.65. The machine learning models assist individual-level risk assessment of AAP for future prevention trials, and may legitimize asparaginase re-exposure when AAP risk is predicted to be low.
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Affiliation(s)
- Rikke L. Nielsen
- Departments of Health Technology
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet
- Sino-Danish Center for Education and Research, University of Chinese Academy of Sciences, Huairou, China
| | - Benjamin O. Wolthers
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet
| | | | - Birgitte K. Albertsen
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Line Clemmensen
- Department of Applied Mathematics and Computer Science, Kgs. Lyngby
| | - Kasper Nielsen
- Center for Biological Sequence Analysis, Technical University of Denmark
| | - Jukka Kanerva
- Children’s Hospital, Helsinki University Central Hospital, University of Helsinki, Helsinki
| | - Riitta Niinimäki
- Oulu University Hospital, Department of Children and Adolescents, and University of Oulu, PEDEGO Research Unit, Oulu, Finland
| | - Thomas L. Frandsen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet
| | - Andishe Attarbaschi
- Department of Pediatric Hematology and Oncology, St Anna Children’s Hospital and Department of Pediatric and Adolescent Medicine, Medical University of Vienna, Wien, Austria
| | - Shlomit Barzilai
- Pediatric Hematology and Oncology, Schneider Children’s Medical Center of Israel, Petah-Tikva, Israel and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
| | - Antonella Colombini
- Department of Pediatrics, Ospedale San Gerardo, University of Milano-Bicocca, Fondazione MBBM, Monza, Italy
| | - Gabriele Escherich
- Clinic of Pediatric Hematology and Oncology, University Medical Center Eppendorf, Hamburg
| | | | - Hsi-Che Liu
- Division of Pediatric Hematology-Oncology, Mackay Memorial Hospital, Taipei, Taiwan
| | - Anja Möricke
- Department of Pediatrics, Christian-Albrechts-University Kiel and University Medical Center Schleswig-Holstein, Kiel
| | | | - Inge M. van der Sluis
- Dutch Childhood Oncology Group, The Hague and Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Martin Stanulla
- Department of Pediatric Hematology and Oncology, Hannover Medical School, Hannover, Germany
| | - Morten Tulstrup
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet
| | - Rachita Yadav
- Center for Biological Sequence Analysis, Technical University of Denmark
| | - Ester Zapotocka
- Department of Pediatric Hematology/Oncology, University Hospital Motol, Prague, Czech Republic
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet
- Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen
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32
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Sidhu J, Masurekar AN, Gogoi MP, Fong C, Ioannou T, Lodhi T, Parker C, Liu J, Kirkwood AA, Moorman AV, Das K, Goulden NJ, Vora A, Saha V, Krishnan S. Activity and toxicity of intramuscular 1000 iu/m 2 polyethylene glycol-E. coli L-asparaginase in the UKALL 2003 and UKALL 2011 clinical trials. Br J Haematol 2022; 198:142-150. [PMID: 35348200 PMCID: PMC9314843 DOI: 10.1111/bjh.18158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 03/10/2022] [Accepted: 03/11/2022] [Indexed: 11/26/2022]
Abstract
In successive UK clinical trials (UKALL 2003, UKALL 2011) for paediatric acute lymphoblastic leukaemia (ALL), polyethylene glycol‐conjugated E. coli L‐asparaginase (PEG‐EcASNase) 1000 iu/m2 was administered intramuscularly with risk‐stratified treatment. In induction, patients received two PEG‐EcASNase doses, 14 days apart. Post‐induction, non‐high‐risk patients (Regimens A, B) received 1–2 doses in delayed intensification (DI) while high‐risk Regimen C patients received 6–10 PEG‐EcASNase doses, including two in DI. Trial substudies monitored asparaginase (ASNase) activity, ASNase‐related toxicity and ASNase‐associated antibodies (total, 1112 patients). Median (interquartile range) trough plasma ASNase activity (14 ± 2 days post dose) following first and second induction doses and first DI dose was respectively 217 iu/l (144–307 iu/l), 265 iu/l (165–401 iu/l) and 292 iu/l (194–386 iu/l); 15% (138/910) samples showed subthreshold ASNase activity (<100 iu/l) at any trough time point. Older age was associated with lower (regression coefficient −9.5; p < 0.0001) and DI time point with higher ASNase activity (regression coefficient 29.9; p < 0.0001). Clinical hypersensitivity was observed in 3.8% (UKALL 2003) and 6% (UKALL 2011) of patients, and in 90% or more in Regimen C. A 7% (10/149) silent inactivation rate was observed in UKALL 2003. PEG‐EcASNase schedule in UKALL paediatric trials is associated with low toxicity but wide interpatient variability. Therapeutic drug monitoring potentially permits optimisation through individualised asparaginase dosing.
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Affiliation(s)
- Jasmeet Sidhu
- Tata Translational Cancer Research Centre, Tata Medical Center, Kolkata, India.,Department of Paediatric Haematology and Oncology, Tata Medical Center, Kolkata, India
| | - Ashish Narayan Masurekar
- Childrens Cancer Group, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Manash Pratim Gogoi
- Tata Translational Cancer Research Centre, Tata Medical Center, Kolkata, India
| | - Caroline Fong
- Childrens Cancer Group, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Tasos Ioannou
- Childrens Cancer Group, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Taha Lodhi
- Childrens Cancer Group, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Catriona Parker
- Childrens Cancer Group, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Jizhong Liu
- Childrens Cancer Group, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Amy A Kirkwood
- Cancer Research UK & UCL Cancer Trials Centre, UCL Cancer Institute, University College, London, UK
| | - Anthony V Moorman
- Wolfson Childhood Cancer Research Centre, Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, UK
| | - Kiranmoy Das
- Interdisciplinary Statistical Research Unit, Indian Statistical Institute, Kolkata, India
| | - Nicholas J Goulden
- Department of Haematology, Great Ormond Street Hospital for Children, London, UK
| | - Ajay Vora
- Department of Haematology, Great Ormond Street Hospital for Children, London, UK
| | - Vaskar Saha
- Tata Translational Cancer Research Centre, Tata Medical Center, Kolkata, India.,Department of Paediatric Haematology and Oncology, Tata Medical Center, Kolkata, India.,Childrens Cancer Group, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Shekhar Krishnan
- Tata Translational Cancer Research Centre, Tata Medical Center, Kolkata, India.,Department of Paediatric Haematology and Oncology, Tata Medical Center, Kolkata, India.,Childrens Cancer Group, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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33
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Lynggaard LS, Vaitkeviciene G, Langenskiöld C, Lehmann AK, Lähteenmäki PM, Lepik K, El Hariry I, Schmiegelow K, Albertsen BK. Asparaginase encapsulated in erythrocytes as second-line treatment in hypersensitive patients with acute lymphoblastic leukaemia. Br J Haematol 2022; 197:745-754. [PMID: 35344210 DOI: 10.1111/bjh.18152] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/06/2022] [Accepted: 03/08/2022] [Indexed: 11/30/2022]
Abstract
Asparaginase is essential in treating acute lymphoblastic leukaemia (ALL). Asparaginase-related hypersensitivity causes treatment discontinuation, which is associated with decreased event-free survival. To continue asparaginase treatment after hypersensitivity, a formulation of asparaginase encapsulated in erythrocytes (eryaspase) was developed. In NOR-GRASPALL 2016 (NCT03267030) the safety and efficacy of eryaspase was evaluated in 55 patients (aged 1-45 years; median: 6.1 years) with non-high-risk ALL and hypersensitivity to asparaginase conjugated with polyethylene glycol (PEG-asparaginase). Eryaspase (150 u/kg) was scheduled to complete the intended course of asparaginase (1-7 doses) in two Nordic/Baltic treatment protocols. Forty-nine (96.1%) patients had asparaginase enzyme activity (AEA) ≥100 iu/l 14 ± 2 days after the first eryaspase infusion [median AEA 511 iu/l; interquartile range (IQR), 291-780], whereas six of nine (66.7%) patients had AEA ≥100 iu/l 14 ± 2 days after the fourth infusion (median AEA 932 iu/l; IQR, 496-163). The mean terminal half-life of eryaspase following the first infusion was 15.3 ± 15.5 days. Few asparaginase-related adverse events were reported; five patients (9.1%) developed clinical allergy associated with enzyme inactivation. Replacement therapy was successfully completed in 50 patients (90.9%). Eryaspase was well tolerated, and most patients had AEA levels above the therapeutic target after the first infusion. The half-life of eryaspase confirmed that a 2-week schedule is appropriate.
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Affiliation(s)
- Line Stensig Lynggaard
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Goda Vaitkeviciene
- Center of Pediatric Oncology and Hematology, Vilnius University Hospital Santaros Klinikos and Vilnius University, Vilnius, Lithuania
| | | | | | - Päivi M Lähteenmäki
- Department of Pediatric and Adolescent Medicine, Turku University Hospital, Turku, Finland
| | - Kristi Lepik
- Department of Hematology and Oncology, Tallinn Children's Hospital, Tallinn, Estonia
| | | | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Birgitte Klug Albertsen
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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34
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Van Trimpont M, Peeters E, De Visser Y, Schalk AM, Mondelaers V, De Moerloose B, Lavie A, Lammens T, Goossens S, Van Vlierberghe P. Novel Insights on the Use of L-Asparaginase as an Efficient and Safe Anti-Cancer Therapy. Cancers (Basel) 2022; 14:cancers14040902. [PMID: 35205650 PMCID: PMC8870365 DOI: 10.3390/cancers14040902] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 02/05/2022] [Accepted: 02/09/2022] [Indexed: 12/14/2022] Open
Abstract
Simple Summary L-asparaginase (L-ASNase) therapy is key for achieving the very high cure rate of pediatric acute lymphoblastic leukemia (ALL), yet its use is mostly confined to this indication. One main reason preventing the expansion of today’s FDA-approved L-ASNases to solid cancers is their high toxicity and side effects, which become especially challenging in adult patients. The design of optimized L-ASNase molecules provides opportunities to overcome these unwanted toxicities. An additional challenge to broader application of L-ASNases is how cells can counter the pharmacological effect of this drug and the identification of L-ASNases resistance mechanisms. In this review, we discuss recent insights into L-ASNase adverse effects, resistance mechanisms, and how novel L-ASNase variants and drug combinations can expand its clinical applicability, with a focus on both hematological and solid tumors. Abstract L-Asparaginase (L-ASNase) is an enzyme that hydrolyses the amino acid asparagine into aspartic acid and ammonia. Systemic administration of bacterial L-ASNase is successfully used to lower the bioavailability of this non-essential amino acid and to eradicate rapidly proliferating cancer cells with a high demand for exogenous asparagine. Currently, it is a cornerstone drug in the treatment of the most common pediatric cancer, acute lymphoblastic leukemia (ALL). Since these lymphoblasts lack the expression of asparagine synthetase (ASNS), these cells depend on the uptake of extracellular asparagine for survival. Interestingly, recent reports have illustrated that L-ASNase may also have clinical potential for the treatment of other aggressive subtypes of hematological or solid cancers. However, immunogenic and other severe adverse side effects limit optimal clinical use and often lead to treatment discontinuation. The design of optimized and novel L-ASNase formulations provides opportunities to overcome these limitations. In addition, identification of multiple L-ASNase resistance mechanisms, including ASNS promoter reactivation and desensitization, has fueled research into promising novel drug combinations to overcome chemoresistance. In this review, we discuss recent insights into L-ASNase adverse effects, resistance both in hematological and solid tumors, and how novel L-ASNase variants and drug combinations can expand its clinical applicability.
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Affiliation(s)
- Maaike Van Trimpont
- Cancer Research Institute Ghent (CRIG), 9000 Ghent, Belgium; (M.V.T.); (E.P.); (Y.D.V.); (B.D.M.); (T.L.); (S.G.)
- Department of Biomolecular Medicine, Ghent University, 9000 Ghent, Belgium
- Department of Diagnostic Sciences, Ghent University, 9000 Ghent, Belgium
| | - Evelien Peeters
- Cancer Research Institute Ghent (CRIG), 9000 Ghent, Belgium; (M.V.T.); (E.P.); (Y.D.V.); (B.D.M.); (T.L.); (S.G.)
- Department of Diagnostic Sciences, Ghent University, 9000 Ghent, Belgium
- Department of Biomedical Molecular Biology, Ghent University, 9000 Ghent, Belgium
| | - Yanti De Visser
- Cancer Research Institute Ghent (CRIG), 9000 Ghent, Belgium; (M.V.T.); (E.P.); (Y.D.V.); (B.D.M.); (T.L.); (S.G.)
- Department of Biomolecular Medicine, Ghent University, 9000 Ghent, Belgium
- Department of Imaging and Pathology, KU Leuven, 3000 Leuven, Belgium
| | - Amanda M. Schalk
- Department of Biochemistry and Molecular Genetics, University of Illinois, Chicago, IL 60607, USA; (A.M.S.); (A.L.)
| | - Veerle Mondelaers
- Department of Pediatric Hemato-Oncology and Stem Cell Transplantation, Ghent University Hospital, 9000 Ghent, Belgium;
| | - Barbara De Moerloose
- Cancer Research Institute Ghent (CRIG), 9000 Ghent, Belgium; (M.V.T.); (E.P.); (Y.D.V.); (B.D.M.); (T.L.); (S.G.)
- Department of Pediatric Hemato-Oncology and Stem Cell Transplantation, Ghent University Hospital, 9000 Ghent, Belgium;
- Department of Internal Medicine and Pediatrics, Ghent University, 9000 Ghent, Belgium
| | - Arnon Lavie
- Department of Biochemistry and Molecular Genetics, University of Illinois, Chicago, IL 60607, USA; (A.M.S.); (A.L.)
- The Jesse Brown VA Medical Center, Chicago, IL 60607, USA
| | - Tim Lammens
- Cancer Research Institute Ghent (CRIG), 9000 Ghent, Belgium; (M.V.T.); (E.P.); (Y.D.V.); (B.D.M.); (T.L.); (S.G.)
- Department of Pediatric Hemato-Oncology and Stem Cell Transplantation, Ghent University Hospital, 9000 Ghent, Belgium;
- Department of Internal Medicine and Pediatrics, Ghent University, 9000 Ghent, Belgium
| | - Steven Goossens
- Cancer Research Institute Ghent (CRIG), 9000 Ghent, Belgium; (M.V.T.); (E.P.); (Y.D.V.); (B.D.M.); (T.L.); (S.G.)
- Department of Diagnostic Sciences, Ghent University, 9000 Ghent, Belgium
| | - Pieter Van Vlierberghe
- Cancer Research Institute Ghent (CRIG), 9000 Ghent, Belgium; (M.V.T.); (E.P.); (Y.D.V.); (B.D.M.); (T.L.); (S.G.)
- Department of Biomolecular Medicine, Ghent University, 9000 Ghent, Belgium
- Correspondence:
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35
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Sindhu R, Manonmani HK. L-asparaginase mediated therapy in L-asparagine auxotrophic cancers: A review. Anticancer Agents Med Chem 2022; 22:2393-2410. [PMID: 34994334 DOI: 10.2174/1871520622666220106103336] [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: 04/22/2021] [Revised: 09/28/2021] [Accepted: 11/15/2021] [Indexed: 11/22/2022]
Abstract
Microbial L-asparaginase is the most effective first-line therapeutic used in the treatment protocols of paediatric and adult leukemia. Leukemic cell's auxotrophy for L-asparagine is exploited as a therapeutic strategy to mediate cell death through metabolic blockade of L-asparagine using L-asparaginase. Escherichia coli and Erwinia chrysanthemi serve as the major enzyme deriving sources accepted in clinical practise and the enzyme has bestowed improvements in patient outcomes over the last 40 years. However, an array of side effects generated by the native enzymes due to glutamine co-catalysis and short serum stays augmenting frequent dosages, intended a therapeutic switch towards the development of biobetter alternatives for the enzyme including the formulations resulting in sustained local depletion of L-asparagine. In addition, the treatment with L-asparaginase in few cancer types has proven to elicit drug-induced cytoprotective autophagy mechanisms and therefore warrants concern. Although the off-target glutamine hydrolysis has been viewed in contributing the drug-induced secondary responses in cells deficient with asparagine synthetase machinery, the beneficial role of glutaminase-asparaginase in proliferative regulation of asparagine prototrophic cells has been looked forward. The current review provides an overview on the enzyme's clinical applications in leukemia and possible therapeutic implications in other solid tumours, recent advancements in drug formulations, and discusses the aspects of two-sided roles of glutaminase-asparaginases and drug-induced cytoprotective autophagy mechanisms.
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Affiliation(s)
- Sindhu R
- Department of Microbiology, Faculty of Life Sciences, JSS-AHER, Mysuru-570015, Karnataka, India
| | - H K Manonmani
- Food Protectants and Infestation Control Department, CSIR-Central Food Technological Research Institute, Mysuru-570020, Karnataka, India
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36
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Impact of Antibodies Against Polyethylene Glycol on the Pharmacokinetics of PEGylated Asparaginase in Children with Acute Lymphoblastic Leukaemia: A Population Pharmacokinetic Approach. Eur J Drug Metab Pharmacokinet 2021; 47:187-198. [PMID: 34878584 PMCID: PMC8917038 DOI: 10.1007/s13318-021-00741-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2021] [Indexed: 11/04/2022]
Abstract
Background and Objectives Besides allergic reactions, antibodies against polyethylene glycol (PEG) have been associated with reduced PEG-asparaginase (PEG-ASNase) activity. Population pharmacokinetics (popPK) allow for an in-depth investigation of the influence of anti-PEG antibodies on PEG-ASNase pharmacokinetics. Methods PEG-ASNase activity (6261 samples) and anti-PEG antibodies (2082/6412 samples prior to/post administration) in 1444 children with acute lymphoblastic leukaemia treated in the AIEOP-BFM ALL 2009 trial were evaluated. Patients received two doses of PEG-ASNase during induction (2500 U/m2, intravenous, biweekly) and a third dose during reinduction treatment. Anti-PEG IgG and IgM measured prior to and post administration were explored for their influence on the initial clearance of PEG-ASNase using a previously established popPK model. Categorical and continuous antibody data, including each isotype individually as well as in combination, were assessed. Results High pre-existing levels of anti-PEG antibodies increase the initial drug clearance. Analysed separately, both anti-PEG IgGprior and IgMprior were significant covariates; the stronger effect was observed for anti-PEG IgMprior. Hockey stick models best described the data. For anti-PEG IgMprior, each additional log unit above the estimated cut point was related to a 41.4% increase in initial clearance after the first dose in induction. Antibody levels below the cut point were not associated with an effect on clearance. The combination of both isotypes did not provide additional information compared to anti-PEG IgMprior alone. Antibody levels post administration were not associated with an effect on clearance. Conclusion Pre-existing antibodies against PEG-ASNase significantly increased the initial clearance in a subgroup of patients showing high antibody levels. (Trial registration: EU clinical trials register; EudraCT No: 2007-004270-43; first registered 23 October 2009.) Supplementary Information The online version contains supplementary material available at 10.1007/s13318-021-00741-w.
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37
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Egnell C, Heyman M, Jónsson ÓG, Raja RA, Niinimäki R, Albertsen BK, Schmiegelow K, Stabell N, Vaitkeviciene G, Lepik K, Harila-Saari A, Ranta S. Obesity as a predictor of treatment-related toxicity in children with acute lymphoblastic leukaemia. Br J Haematol 2021; 196:1239-1247. [PMID: 34726257 DOI: 10.1111/bjh.17936] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 10/20/2021] [Indexed: 02/04/2023]
Abstract
Obesity is associated with poor outcomes in childhood acute lymphoblastic leukaemia (ALL). We explored whether severe treatment-related toxicity and treatment delays could explain this observation. This study included 1 443 children aged 2·0-17·9 years with ALL treated with the Nordic Society of Pediatric Haematology and Oncology (NOPHO) ALL2008 non-high-risk protocol. Prospective treatment-related toxicities registered every three-month interval were used. Patients were classified according to sex- and age-adjusted international childhood cut-off values, corresponding to adult body mass index: underweight, <17 kg/m2 ; healthy weight, 17 to <25 kg/m2 ; overweight, 25 to <30 kg/m2 ; and obese, ≥30 kg/m2 . Obese children had a higher incidence rate ratio (IRR) for severe toxic events {IRR: 1·55 [95% confidence interval (CI) 1·07-2·50]}, liver and kidney failures, bleeding, abdominal complication, suspected unexpected severe adverse reactions and hyperlipidaemia compared with healthy-weight children. Obese children aged ≥10 years had increased IRRs for asparaginase-related toxicities compared with healthy-weight older children: thromboses [IRR 2·87 (95% CI 1·00-8·21)] and anaphylactic reactions [IRR 7·95 (95% CI 2·15-29·37)] as well as higher risk for truncation of asparaginase [IRR 3·54 (95% CI 1·67-7·50)]. The high prevalence of toxicity and a higher risk of truncation of asparaginase may play a role in the poor prognosis of obese children aged ≥10 years with ALL.
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Affiliation(s)
- Christina Egnell
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden.,Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Mats Heyman
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | | | - Raheel A Raja
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark.,Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Denmark
| | - Riitta Niinimäki
- PEDEGO Research Unit, Medical Research Center Oulu and Department of Children and Adolescents, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Birgitte Klug Albertsen
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark.,Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Denmark
| | - Niklas Stabell
- Department of Paediatrics, University Hospital of North Norway, Tromsø, Norway
| | - Goda Vaitkeviciene
- Children's Hospital, Affiliate of Vilnius University Hospital Santaros Klinikos and Vilnius University, Vilnius, Lithuania
| | - Kristi Lepik
- Department of Haematology and Oncology, Children's hospital, Tallinn, Estonia
| | - Arja Harila-Saari
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Susanna Ranta
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden.,Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
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38
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Asparaginase Enzyme Activity Levels and Toxicity in Childhood Acute Lymphoblastic Leukemia: a NOPHO ALL2008 study. Blood Adv 2021; 6:138-147. [PMID: 34625787 PMCID: PMC8753199 DOI: 10.1182/bloodadvances.2021005631] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 09/01/2021] [Indexed: 01/19/2023] Open
Abstract
Overall asparaginase-associated toxicity and relapse were not significantly associated with increased asparaginase enzyme activity levels. The risk of pancreatitis and osteonecrosis were significantly associated with increasing asparaginase enzyme activity.
Asparaginase treatment is a mainstay in contemporary treatment of acute lymphoblastic leukemia (ALL), but substantial asparaginase-related toxicity may lead to jeopardized protocol compliance and compromises survival. We investigated the association between risk of asparaginase-associated toxicities (AspTox) and asparaginase enzyme activity (AEA) levels in 1155 children aged 1.0 to 17.9 years, diagnosed with ALL between July 2008 and March 2016, and treated according to the Nordic Society of Pediatric Hematology and Oncology (NOPHO) ALL2008 protocol. Patients with ≥2 blood samples for AEA measurement drawn 14 ± 2 days after asparaginase administration were included (6944 trough values). AEA was measurable (or >0 IU/L) in 955 patients, whereas 200 patients (17.3%) had asparaginase inactivation and few AspTox recorded. A time-dependent multiple Cox model of time to any first asparaginase-associated toxicity adjusted for sex and age was used. For patients with measurable AEA, we found a hazard ratio (HR) of 1.17 per 100 IU/L increase in median AEA (95% confidence interval [CI], 0.98-1.41; P = .09). For pancreatitis, thromboembolism, and osteonecrosis, the HRs were 1.40 (95% CI, 1.12-1.75; P = .002), 0.99 (95% CI, 0.70-1.40; P = .96), and 1.36 (95% CI, 1.04-1.77; P = .02) per 100 IU/L increase in median AEA, respectively. No significant decrease in the risk of leukemic relapse was found: HR 0.88 per 100 IU/L increase in AEA (95% CI, 0.66-1.16; P = .35). In conclusion, these results emphasize that overall AspTox and relapse are not associated with AEA levels, yet the risk of pancreatitis and osteonecrosis increases with increasing AEA levels.
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39
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Schmiegelow K, Rank CU, Stock W, Dworkin E, van der Sluis I. SOHO State of the Art Updates and Next Questions: Management of Asparaginase Toxicity in Adolescents and Young Adults with Acute Lymphoblastic Leukemia. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 21:725-733. [PMID: 34511319 DOI: 10.1016/j.clml.2021.07.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 07/08/2021] [Accepted: 07/09/2021] [Indexed: 01/23/2023]
Abstract
A wider use of L-asparaginase in the treatment of children with acute lymphoblastic leukemia has improved cure rates during recent decades and hence led to introduction of pediatric-inspired treatment protocols for adolescents and young adults. In parallel, a range of burdensome, often severe and occasionally life-threatening toxicities have become frequent, including hypersensitivity, hepatotoxicity, hypertriglyceridemia, thromboembolism, pancreatitis, and osteonecrosis. This often leads to truncation of asparaginase therapy, which at least in the pediatric population has been clearly associated with a higher risk of leukemic relapse. Many of the asparaginase induced toxicities are far more common in older patients, but since their relapse rate is still unsatisfactory, the decision to discontinue asparaginase therapy should balance the risk of toxicity with continued asparaginase therapy against the risk of relapse in the individual patient. The underlying mechanisms of most of the asparaginase induced side effects are still unclear. In this review we address the individual toxicities, known risk factors, and their clinical management.
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Affiliation(s)
- Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet Copenhagen University Hospital, 2100 Copenhagen, Denmark; Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark.
| | - Cecilie Utke Rank
- Department of Hematology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Wendy Stock
- Department of Medicine, University of Chicago Medicine and Comprehensive Cancer Center, Chicago, IL
| | - Emily Dworkin
- Department of Medicine, University of Chicago Medicine and Comprehensive Cancer Center, Chicago, IL
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40
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Tong WH. Comment on "Pharmacodynamics of cerebrospinal fluid asparagine after asparaginase". Cancer Chemother Pharmacol 2021; 88:919-920. [PMID: 34468793 DOI: 10.1007/s00280-021-04345-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 08/18/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Wing H Tong
- Department of Public Health and Primary Care (PHEG), Leiden University Medical Center (LUMC), Building 3, Hippocratespad 21, PO Box 9600, 2300 RC, Leiden, The Netherlands. .,Center for Specialized Geriatric Care, Argos Zorggroep "DrieMaasStede", Schiedam, The Netherlands.
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41
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Lukes J, Wolthers BO, Altaf Raja R, Uhrinova K, Skvarova Kramarzova K, Hermanova I, Simcikova M, Kicko P, Zaliova M, Sramkova L, Stary J, Trka J, Schmiegelow K, Starkova J. Pancreatitis-associated protein as an early marker of asparaginase-associated pancreatitis. Leuk Lymphoma 2021; 62:3506-3510. [PMID: 34369235 DOI: 10.1080/10428194.2021.1961236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Julius Lukes
- CLIP - Childhood Leukaemia Investigation Prague, Prague, Czech Republic.,Department of Paediatric Haematology and Oncology, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Benjamin O Wolthers
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Raheel Altaf Raja
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Karolina Uhrinova
- Department of Paediatric Haematology and Oncology, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Karolina Skvarova Kramarzova
- CLIP - Childhood Leukaemia Investigation Prague, Prague, Czech Republic.,Department of Paediatric Haematology and Oncology, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Ivana Hermanova
- CLIP - Childhood Leukaemia Investigation Prague, Prague, Czech Republic.,Department of Paediatric Haematology and Oncology, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Marketa Simcikova
- Department of Paediatric Haematology and Oncology, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Peter Kicko
- Department of Dermatovenereology, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Marketa Zaliova
- CLIP - Childhood Leukaemia Investigation Prague, Prague, Czech Republic.,Department of Paediatric Haematology and Oncology, Second Faculty of Medicine, Charles University, Prague, Czech Republic.,University Hospital Motol, Prague, Czech Republic
| | - Lucie Sramkova
- CLIP - Childhood Leukaemia Investigation Prague, Prague, Czech Republic.,Department of Paediatric Haematology and Oncology, Second Faculty of Medicine, Charles University, Prague, Czech Republic.,University Hospital Motol, Prague, Czech Republic
| | - Jan Stary
- Department of Paediatric Haematology and Oncology, Second Faculty of Medicine, Charles University, Prague, Czech Republic.,University Hospital Motol, Prague, Czech Republic
| | - Jan Trka
- CLIP - Childhood Leukaemia Investigation Prague, Prague, Czech Republic.,Department of Paediatric Haematology and Oncology, Second Faculty of Medicine, Charles University, Prague, Czech Republic.,University Hospital Motol, Prague, Czech Republic
| | - 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
| | - Julia Starkova
- CLIP - Childhood Leukaemia Investigation Prague, Prague, Czech Republic.,Department of Paediatric Haematology and Oncology, Second Faculty of Medicine, Charles University, Prague, Czech Republic.,University Hospital Motol, Prague, Czech Republic
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