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Pourhassan H, Murphy L, Aldoss I. Glucocorticoid Therapy in Acute Lymphoblastic Leukemia: Navigating Short-Term and Long-Term Effects and Optimal Regimen Selection. Curr Hematol Malig Rep 2024:10.1007/s11899-024-00735-w. [PMID: 38867099 DOI: 10.1007/s11899-024-00735-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2024] [Indexed: 06/14/2024]
Abstract
PURPOSE OF REVIEW Glucocorticoids are a mainstay in acute lymphoblastic leukemia treatment and lack of early response is predictive for overall disease prognosis. Given the vital position of glucocorticoids and well known long and short-term side effects associated with differing glucocorticoids, we aim to highlight the wide breadth of historical and more contemporary data to describe the current landscape of glucocorticoid use in this arena. RECENT FINDINGS Emerging studies aim to overcome issues such as steroid resistance and to optimize the antileukemic effects of glucocorticoids while aiming to mitigate the risks and side effects associated with their exposure. Glucocorticoids have and likely always will be a fundamental component of acute lymphoblastic leukemia treatment and understanding how to navigate short- and long-term effects and how to optimize regimens is at the heart of continued treatment success.
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Affiliation(s)
- Hoda Pourhassan
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California, USA
| | - Lindsey Murphy
- Department of Pediatrics, City of Hope National Medical Center, Duarte, California, USA
| | - Ibrahim Aldoss
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California, USA.
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Wanderley AV, de Moraes FCA, da Costa Nunes GG, Pereira EEB, Leitão LPC, de Oliveira MB, Tavares ÁTM, da Costa Pantoja L, Khayat BCM, Fernandes MR, de Assumpção PP, Dos Santos ÂKR, Burbano RMR, Dos Santos SEB, Ribeiro R, Khayat AS, Dos Santos NPC. Effect of American genomic ancestry on severe toxicities in children with acute lymphoblastic leukemia in the Amazon region. Discov Oncol 2024; 15:171. [PMID: 38761320 PMCID: PMC11102409 DOI: 10.1007/s12672-024-01014-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 05/04/2024] [Indexed: 05/20/2024] Open
Abstract
BACKGROUND Acute Lymphoblastic Leukemia (ALL) is a neoplasm of the hematopoietic system characterized by a clonal expansion of abnormal lymphocyte precursor cells. ALL is the most common form of cancer in children, but despite advances in treatment, it can still be fatal. Ethnic differences influence survival rates, and genomic ancestry plays an important role, especially in mixed-race populations such as Latin America. This study aims to analyze the influence of genomic ancestry on toxicity in children with ALL in the Amazon region. METHODS The study included 171 patients (protocol number 119,649/2012-Ethics Committee) with ALL treated at a pediatric treatment center in Belém do Pará, in the Brazilian Amazon. The patients were submitted to the BFM protocol of induction therapy for ALL. Toxicity was assessed based on laboratory tests and adverse events, classified according to the CTC-NCI guide. Genomic ancestry was determined using autosomal informative markers. RESULTS The majority of children (94.74%) developed some type of toxicity during treatment, 87.04% of which were severe. Infectious toxicity was the most common, present in 84.8% of cases, 77.24% of which were severe. Amerindian ancestry showed an association with the risk of severe general toxicity and severe infectious toxicity, with a contribution of 35.0% demonstrating a significant increase in risk. In addition, post-induction refractoriness and relapse were also associated with an increased risk of death. CONCLUSION This study highlights the influence of Amerindian genomic ancestry on response to therapy and toxicity in children with ALL in the Amazon region. Understanding these associations can contribute to personalizing treatment and improving clinical outcomes.
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Affiliation(s)
| | - Francisco Cezar Aquino de Moraes
- Oncology Research Center, Federal University of Pará, University Hospital João de Barros de Barreto. , Rua Dos Mundurucus, no 4487, Belem, PA, 66073-005, Brazil.
| | - Giovanna Gilioli da Costa Nunes
- Oncology Research Center, Federal University of Pará, University Hospital João de Barros de Barreto. , Rua Dos Mundurucus, no 4487, Belem, PA, 66073-005, Brazil
| | - Esdras Edgar Batista Pereira
- Oncology Research Center, Federal University of Pará, University Hospital João de Barros de Barreto. , Rua Dos Mundurucus, no 4487, Belem, PA, 66073-005, Brazil
| | | | - Marcelo Braga de Oliveira
- Oncology Research Center, Federal University of Pará, University Hospital João de Barros de Barreto. , Rua Dos Mundurucus, no 4487, Belem, PA, 66073-005, Brazil
| | - Ágatha Tereza Miranda Tavares
- Oncology Research Center, Federal University of Pará, University Hospital João de Barros de Barreto. , Rua Dos Mundurucus, no 4487, Belem, PA, 66073-005, Brazil
| | - Laudreisa da Costa Pantoja
- Oncology Research Center, Federal University of Pará, University Hospital João de Barros de Barreto. , Rua Dos Mundurucus, no 4487, Belem, PA, 66073-005, Brazil
| | - Bruna Cláudia Meireles Khayat
- Oncology Research Center, Federal University of Pará, University Hospital João de Barros de Barreto. , Rua Dos Mundurucus, no 4487, Belem, PA, 66073-005, Brazil
| | - Marianne Rodrigues Fernandes
- Oncology Research Center, Federal University of Pará, University Hospital João de Barros de Barreto. , Rua Dos Mundurucus, no 4487, Belem, PA, 66073-005, Brazil
| | - Paulo Pimentel de Assumpção
- Oncology Research Center, Federal University of Pará, University Hospital João de Barros de Barreto. , Rua Dos Mundurucus, no 4487, Belem, PA, 66073-005, Brazil
| | - Ândrea Kely Ribeiro Dos Santos
- Laboratory of Human and Medical Genetics, Institute of Biological Science, Federal University of Pará, Belem, 66077-830, Brazil
| | | | | | - Raul Ribeiro
- St. Jude Children's Research Hospital, Memphis, USA
| | - André Salim Khayat
- Oncology Research Center, Federal University of Pará, University Hospital João de Barros de Barreto. , Rua Dos Mundurucus, no 4487, Belem, PA, 66073-005, Brazil
| | - Ney Pereira Carneiro Dos Santos
- Oncology Research Center, Federal University of Pará, University Hospital João de Barros de Barreto. , Rua Dos Mundurucus, no 4487, Belem, PA, 66073-005, Brazil
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Mattano LA, Devidas M, Loh ML, Raetz EA, Chen Z, Winick NJ, Hunger SP, Carroll WL, Larsen EC. Development of osteonecrosis and improved survival in B-ALL: results of Children's Oncology Group Trial AALL0232. Leukemia 2024; 38:258-265. [PMID: 38062123 PMCID: PMC11235418 DOI: 10.1038/s41375-023-02099-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 11/06/2023] [Accepted: 11/21/2023] [Indexed: 01/14/2024]
Abstract
Osteonecrosis is a significant toxicity of acute lymphoblastic leukemia (ALL) therapy. In retrospective analyses, superior event-free survival was noted among affected adolescents in an earlier trial. We prospectively assessed osteonecrosis incidence, characteristics, and risk factors in patients 1-30 years with newly diagnosed high-risk B-ALL on COG AALL0232. Patients were randomized to induction dexamethasone vs prednisone, and interim maintenance high-dose methotrexate vs escalating-dose Capizzi methotrexate/pegaspargase. Event-free and overall survival were compared between patients with/without imaging-confirmed osteonecrosis. Osteonecrosis developed in 322/2730 eligible, evaluable patients. The 5-year cumulative incidence was 12.2%. Risk was greater in patients ≥10 years (hazard ratio [HR], 7.23; P < 0.0001), particularly females (HR, 1.37; P = 0.0057), but lower in those with asparaginase allergy (HR, 0.60; P = 0.0077). Among rapid early responders ≥10 years, risk was greater with dexamethasone (HR, 1.84; P = 0.0003) and with prednisone/Capizzi (HR, 1.45; P = 0.044), even though neither therapy was independently associated with improved survival. Patients with osteonecrosis had higher 5-year event-free (HR, 0.51; P < 0.0001) and overall survival (HR, 0.42; P < 0.0001), and this was directly attributable to reduced relapse rates (HR, 0.57; P = 0.0014). Osteonecrosis in high-risk B-ALL patients is associated with improved survival, suggesting an important role for host factors in mediating both toxicity and enhanced efficacy of specific therapies.
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Affiliation(s)
| | - Meenakshi Devidas
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Mignon L Loh
- Division of Pediatric Hematology, Oncology, Bone Marrow Transplantation, and Cellular Therapy, Seattle Children's Hospital, Seattle, WA, USA
- The Ben Towne Center for Childhood Cancer Research, University of Washington, Seattle, WA, USA
| | - Elizabeth A Raetz
- Department of Pediatrics, New York University Langone Medical Center, New York, NY, USA
- Perlmutter Cancer Center at New York University Langone Health, New York, NY, USA
| | - Zhiguo Chen
- Department of Biostatistics, University of Florida, Gainesville, FL, USA
| | - Naomi J Winick
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Stephen P Hunger
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA
| | - William L Carroll
- Department of Pediatrics, New York University Langone Medical Center, New York, NY, USA
- Perlmutter Cancer Center at New York University Langone Health, New York, NY, USA
| | - Eric C Larsen
- Maine Children's Cancer Program, Scarborough, ME, USA
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Barr RD, Antillon-Klussmann F. Cancer and nutrition among children and adolescents in low- and middle-income countries. HEMATOLOGY (AMSTERDAM, NETHERLANDS) 2022; 27:987-993. [PMID: 36094475 DOI: 10.1080/16078454.2022.2115437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE : The primary purpose of this review is to investigate the relationships between cancer and nutrition in children and adolescents living in resource-poor, low- and middle-income countries (LMICs) in order to explore potential opportunities for interventions which could improve clinical outcomes in this population. METHOD : The implications of overlapping age groups of children and adolescents with cancer are examined, as are the adverse influences of under-nutrition and socio-economic deprivation on the efficacy of treatment and cancer survival. Evidence suggestive of novel avenues to enhance prospects for cure, based on increased understanding of the dynamic of nutrition and cancer, is evaluated. RESULT : Cancer adds to the burden of under-nutrition in disadvantaged populations which is reflective, in large measure, on inadequate governmental expenditure on health which demands public-private partnerships and the use of hospital-based foundations. Structured approaches to the measurement of nutritional status and the design of effective programmes of nutritional supplementation are of proven benefit. Initial results from studies of the perturbed gut microbiome hold considerable promise for further gains. CONCLUSION A large minority of children with cancer in LMICs are never diagnosed and the same may be true of adolescents. Investing in the training of nutritionists will have substantial returns as will increasing access to essential medicines. Recognition of these challenges has stimulated WHO and other entities to devise major strategies for comprehensive changes in the care of children and adolescents with cancer in LMICs, offering realistic prospects for improved clinical outcomes.
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Affiliation(s)
- Ronald D Barr
- Departments of Pediatrics and Medicine, McMaster University, Hamilton, Canada
| | - Federico Antillon-Klussmann
- Unidad Nacional de Oncología Pediátrica, and School of Medicine, Francisco Marroquín University, Guatemala, Guatemala
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Fernandes SDSM, Leitão LPC, Cohen-Paes ADN, Gellen LPA, Pastana LF, de Carvalho DC, Modesto AAC, da Costa ACA, Wanderley AV, de Lima CHV, Pereira EEB, Fernandes MR, Burbano RMR, de Assumpção PP, dos Santos SEB, dos Santos NPC. The Role of SLC22A1 and Genomic Ancestry on Toxicity during Treatment in Children with Acute Lymphoblastic Leukemia of the Amazon Region. Genes (Basel) 2022; 13:genes13040610. [PMID: 35456416 PMCID: PMC9026289 DOI: 10.3390/genes13040610] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 02/08/2022] [Accepted: 02/14/2022] [Indexed: 12/31/2022] Open
Abstract
In Brazil, Acute lymphoid leukemia (ALL) is the leading cause of cancer deaths in children and adolescents. Treatment toxicity is one of the reasons for stopping chemotherapy. Amerindian genomic ancestry is an important factor for this event due to fluctuations in frequencies of genetic variants, as in the NUDT15 and SLC22A1 genes, which make up the pharmacokinetic and pharmacodynamic pathways of chemotherapy. This study aimed to investigate possible associations between NUDT15 (rs1272632214) and SLC22A1 (rs202220802) gene polymorphism and genomic ancestry as a risk of treatment toxicities in patients with childhood ALL in the Amazon region of Brazil. The studied population consisted of 51 patients with a recent diagnosis of ALL when experiencing induction therapy relative to the BFM 2009 protocol. Our results evidenced a significant association of risk of severe infectious toxicity for the variant of the SLC22A1 gene (OR: 3.18, p = 0.031). Genetic ancestry analyses demonstrated that patients who had a high contribution of African ancestry had a significant protective effect for the development of toxicity (OR: 0.174; p = 0.010), possibly due to risk effects of the Amerindian contribution. Our results indicate that mixed populations with a high degree of African ancestry have a lower risk of developing general toxicity during induction therapy for ALL. In addition, individuals with the SLC22A1 variant have a higher risk of developing severe infectious toxicity while undergoing the same therapy.
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Affiliation(s)
- Sweny de S. M. Fernandes
- Oncology Research Center, Federal University of Pará, Belém 66073, PA, Brazil; (S.d.S.M.F.); (L.P.C.L.); (A.d.N.C.-P.); (L.P.A.G.); (L.F.P.); (D.C.d.C.); (A.A.C.M.); (A.C.A.d.C.); (A.V.W.); (C.H.V.d.L.); (R.M.R.B.); (P.P.d.A.); (S.E.B.d.S.); (N.P.C.d.S.)
| | - Luciana P. C. Leitão
- Oncology Research Center, Federal University of Pará, Belém 66073, PA, Brazil; (S.d.S.M.F.); (L.P.C.L.); (A.d.N.C.-P.); (L.P.A.G.); (L.F.P.); (D.C.d.C.); (A.A.C.M.); (A.C.A.d.C.); (A.V.W.); (C.H.V.d.L.); (R.M.R.B.); (P.P.d.A.); (S.E.B.d.S.); (N.P.C.d.S.)
| | - Amanda de N. Cohen-Paes
- Oncology Research Center, Federal University of Pará, Belém 66073, PA, Brazil; (S.d.S.M.F.); (L.P.C.L.); (A.d.N.C.-P.); (L.P.A.G.); (L.F.P.); (D.C.d.C.); (A.A.C.M.); (A.C.A.d.C.); (A.V.W.); (C.H.V.d.L.); (R.M.R.B.); (P.P.d.A.); (S.E.B.d.S.); (N.P.C.d.S.)
| | - Laura P. A. Gellen
- Oncology Research Center, Federal University of Pará, Belém 66073, PA, Brazil; (S.d.S.M.F.); (L.P.C.L.); (A.d.N.C.-P.); (L.P.A.G.); (L.F.P.); (D.C.d.C.); (A.A.C.M.); (A.C.A.d.C.); (A.V.W.); (C.H.V.d.L.); (R.M.R.B.); (P.P.d.A.); (S.E.B.d.S.); (N.P.C.d.S.)
| | - Lucas F. Pastana
- Oncology Research Center, Federal University of Pará, Belém 66073, PA, Brazil; (S.d.S.M.F.); (L.P.C.L.); (A.d.N.C.-P.); (L.P.A.G.); (L.F.P.); (D.C.d.C.); (A.A.C.M.); (A.C.A.d.C.); (A.V.W.); (C.H.V.d.L.); (R.M.R.B.); (P.P.d.A.); (S.E.B.d.S.); (N.P.C.d.S.)
| | - Darlen C. de Carvalho
- Oncology Research Center, Federal University of Pará, Belém 66073, PA, Brazil; (S.d.S.M.F.); (L.P.C.L.); (A.d.N.C.-P.); (L.P.A.G.); (L.F.P.); (D.C.d.C.); (A.A.C.M.); (A.C.A.d.C.); (A.V.W.); (C.H.V.d.L.); (R.M.R.B.); (P.P.d.A.); (S.E.B.d.S.); (N.P.C.d.S.)
| | - Antônio A. C. Modesto
- Oncology Research Center, Federal University of Pará, Belém 66073, PA, Brazil; (S.d.S.M.F.); (L.P.C.L.); (A.d.N.C.-P.); (L.P.A.G.); (L.F.P.); (D.C.d.C.); (A.A.C.M.); (A.C.A.d.C.); (A.V.W.); (C.H.V.d.L.); (R.M.R.B.); (P.P.d.A.); (S.E.B.d.S.); (N.P.C.d.S.)
- Laboratory of Human and Medical Genetics, Institute of Biological Science, Federal University of Pará, Belém 66077-830, PA, Brazil;
| | - Ana C. A. da Costa
- Oncology Research Center, Federal University of Pará, Belém 66073, PA, Brazil; (S.d.S.M.F.); (L.P.C.L.); (A.d.N.C.-P.); (L.P.A.G.); (L.F.P.); (D.C.d.C.); (A.A.C.M.); (A.C.A.d.C.); (A.V.W.); (C.H.V.d.L.); (R.M.R.B.); (P.P.d.A.); (S.E.B.d.S.); (N.P.C.d.S.)
| | - Alayde V. Wanderley
- Oncology Research Center, Federal University of Pará, Belém 66073, PA, Brazil; (S.d.S.M.F.); (L.P.C.L.); (A.d.N.C.-P.); (L.P.A.G.); (L.F.P.); (D.C.d.C.); (A.A.C.M.); (A.C.A.d.C.); (A.V.W.); (C.H.V.d.L.); (R.M.R.B.); (P.P.d.A.); (S.E.B.d.S.); (N.P.C.d.S.)
| | - Carlos H. V. de Lima
- Oncology Research Center, Federal University of Pará, Belém 66073, PA, Brazil; (S.d.S.M.F.); (L.P.C.L.); (A.d.N.C.-P.); (L.P.A.G.); (L.F.P.); (D.C.d.C.); (A.A.C.M.); (A.C.A.d.C.); (A.V.W.); (C.H.V.d.L.); (R.M.R.B.); (P.P.d.A.); (S.E.B.d.S.); (N.P.C.d.S.)
| | - Esdras E. B. Pereira
- Laboratory of Human and Medical Genetics, Institute of Biological Science, Federal University of Pará, Belém 66077-830, PA, Brazil;
| | - Marianne R. Fernandes
- Oncology Research Center, Federal University of Pará, Belém 66073, PA, Brazil; (S.d.S.M.F.); (L.P.C.L.); (A.d.N.C.-P.); (L.P.A.G.); (L.F.P.); (D.C.d.C.); (A.A.C.M.); (A.C.A.d.C.); (A.V.W.); (C.H.V.d.L.); (R.M.R.B.); (P.P.d.A.); (S.E.B.d.S.); (N.P.C.d.S.)
- Correspondence:
| | - Rommel M. R. Burbano
- Oncology Research Center, Federal University of Pará, Belém 66073, PA, Brazil; (S.d.S.M.F.); (L.P.C.L.); (A.d.N.C.-P.); (L.P.A.G.); (L.F.P.); (D.C.d.C.); (A.A.C.M.); (A.C.A.d.C.); (A.V.W.); (C.H.V.d.L.); (R.M.R.B.); (P.P.d.A.); (S.E.B.d.S.); (N.P.C.d.S.)
- Laboratory of Human and Medical Genetics, Institute of Biological Science, Federal University of Pará, Belém 66077-830, PA, Brazil;
| | - Paulo P. de Assumpção
- Oncology Research Center, Federal University of Pará, Belém 66073, PA, Brazil; (S.d.S.M.F.); (L.P.C.L.); (A.d.N.C.-P.); (L.P.A.G.); (L.F.P.); (D.C.d.C.); (A.A.C.M.); (A.C.A.d.C.); (A.V.W.); (C.H.V.d.L.); (R.M.R.B.); (P.P.d.A.); (S.E.B.d.S.); (N.P.C.d.S.)
| | - Sidney E. B. dos Santos
- Oncology Research Center, Federal University of Pará, Belém 66073, PA, Brazil; (S.d.S.M.F.); (L.P.C.L.); (A.d.N.C.-P.); (L.P.A.G.); (L.F.P.); (D.C.d.C.); (A.A.C.M.); (A.C.A.d.C.); (A.V.W.); (C.H.V.d.L.); (R.M.R.B.); (P.P.d.A.); (S.E.B.d.S.); (N.P.C.d.S.)
- Laboratory of Human and Medical Genetics, Institute of Biological Science, Federal University of Pará, Belém 66077-830, PA, Brazil;
| | - Ney P. C. dos Santos
- Oncology Research Center, Federal University of Pará, Belém 66073, PA, Brazil; (S.d.S.M.F.); (L.P.C.L.); (A.d.N.C.-P.); (L.P.A.G.); (L.F.P.); (D.C.d.C.); (A.A.C.M.); (A.C.A.d.C.); (A.V.W.); (C.H.V.d.L.); (R.M.R.B.); (P.P.d.A.); (S.E.B.d.S.); (N.P.C.d.S.)
- Laboratory of Human and Medical Genetics, Institute of Biological Science, Federal University of Pará, Belém 66077-830, PA, Brazil;
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Valtis YK, Place AE, Silverman LB, Vrooman LM, DeAngelo DJ, Luskin MR. Orthopaedic adverse events among adolescents and adults treated with asparaginase for acute lymphoblastic leukaemia. Br J Haematol 2022; 198:421-430. [PMID: 35312041 DOI: 10.1111/bjh.18093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 02/01/2022] [Accepted: 02/02/2022] [Indexed: 01/19/2023]
Abstract
Osteonecrosis (ON) is a complication of acute lymphoblastic leukaemia (ALL) treatment with patient- (age, female sex, genetic polymorphisms, presence of metabolic syndrome) and treatment-specific (glucocorticoid type and schedule) risk factors described. The potential role of asparaginase in increasing risk of ON via effects on coagulation, lipid metabolism, and steroid clearance is now also recognised. Paediatric studies consistently identify age as a key risk factor for ON, with adolescents at higher risk than young children. Fewer studies comprehensively report on risk of ON in adults, but available evidence suggests that adolescents and young adults (AYAs) treated with corticosteroid and asparaginase-containing paediatric-inspired regimens are more at risk than older adults treated with paediatric-inspired or traditional adult regimens. There are few proven strategies to prevent or mitigate the severity of ON and other orthopaedic complications of ALL therapy. Future clinical trials should carefully ascertain orthopaedic adverse events in adults. Evidence-based guidelines should be developed for management of orthopaedic adverse events in adults being treated for ALL, especially high-risk AYAs being treated with paediatric-inspired regimens.
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Affiliation(s)
- Yannis K Valtis
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Andrew E Place
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Division of Pediatric Hematology Oncology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lewis B Silverman
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Division of Pediatric Hematology Oncology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lynda M Vrooman
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Division of Pediatric Hematology Oncology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Daniel J DeAngelo
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Marlise R Luskin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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7
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Orthopedic Toxicities Among Adolescents and Young Adults Treated on DFCI ALL Consortium Trials. Blood Adv 2021; 6:72-81. [PMID: 34610104 PMCID: PMC8753211 DOI: 10.1182/bloodadvances.2021005278] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 08/10/2021] [Indexed: 11/20/2022] Open
Abstract
Orthopedic toxicity was common in adolescent and young adult patients treated on DFCI Consortium ALL pediatric protocols. Younger age and exposure to pegaspargase were associated with higher risk of ON, and patients with ON had superior OS.
Adolescent and young adult patients with acute lymphoblastic leukemia (ALL) have superior outcomes when treated on pediatric regimens. Pediatric ALL regimens rely heavily on corticosteroids and asparaginase and are known to increase the risk of osteonecrosis (ON) and fractures in children, particularly adolescents. Orthopedic toxicity among young adults treated on pediatric-inspired regimens is not well described. Here, we report the symptomatic orthopedic toxicities of patients aged 15 to 50 years treated on sequential Dana-Farber Cancer Institute ALL Consortium protocols. Among 367 patients with a median age of 23 years (range, 15-50 years; 68% aged <30 years), 60 patients were diagnosed with ON (5-year cumulative incidence, 17%; 95% confidence interval [CI], 13-22), and 40 patients experienced fracture (5-year cumulative incidence, 12%; 95% CI, 8-15). Patients aged <30 years were significantly more likely to be diagnosed with ON (5-year cumulative incidence, 21% vs 8%; P = .004). Patients treated more recently on pegaspargase-based protocols were significantly more likely to be diagnosed with ON compared with those treated on earlier trials with native Escherichia coli asparaginase (5-year cumulative incidence, 24% vs 5%; P < .001). Of the 54 ON events for which adequate information was available, surgery was performed in 25 (46%). Patients with ON had superior overall survival (OS) compared with those without (multivariable OS hazard ratio, 0.15; 95% CI, 0.05-0.46; P = .001; ON included as a time-varying exposure). Increased rates of orthopedic toxicity in late-generation protocols may be driven by the pharmacokinetic drug interaction between pegaspargase and dexamethasone, leading to higher dexamethasone exposure.
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