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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; 19:175-185. [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] [MESH Headings] [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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2
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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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3
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Shimony S, Flamand Y, Valtis YK, Place AE, Silverman LB, Vrooman LM, Brunner AM, Sallan SE, Stone RM, Wadleigh M, Neuberg DS, DeAngelo DJ, Luskin MR. Effect of BMI on toxicities and survival among adolescents and young adults treated on DFCI Consortium ALL trials. Blood Adv 2023; 7:5234-5245. [PMID: 37432068 PMCID: PMC10500474 DOI: 10.1182/bloodadvances.2023009976] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/24/2023] [Accepted: 05/16/2023] [Indexed: 07/12/2023] Open
Abstract
Adolescent and young adults (AYAs) with acute lymphoblastic leukemia (ALL) treated with asparaginase-containing pediatric regimens are commonly overweight or obese. We studied the association of body mass index (BMI) on outcomes of 388 AYAs aged 15 to 50 years treated on Dana-Farber Cancer Institute (DFCI) consortium regimens (2008-2021). BMI was normal in 207 (53.3%) and overweight/obese in 181 (46.7%). Patients who were overweight or obese experienced higher nonrelapse mortality (NRM; 4-year, 11.7% vs 2.8%, P = .006), worse event-free survival (4-year, 63% vs 77%, P = .003), and worse overall survival (OS; 4-year, 64% vs 83%, P = .0001). Because younger (aged 15-29 years) AYAs more frequently had a normal BMI (79% vs 20%, P < .0001), we conducted separate analyses in each BMI group. We found excellent OS among younger and older (30-50 years) AYAs with normal BMI (4-year OS, 83% vs 85%, P = .89). Conversely, in AYAs who were overweight/obese, worse outcomes were seen in older AYAs (4-year OS, 55% vs 73%, P = .023). Regarding toxicity, AYAs who were overweight/obese experienced higher rates of grade 3/4 hepatotoxicity and hyperglycemia (60.7% vs 42.2%, P = .0005, and 36.4% vs 24.4%, P = .014, respectively) but had comparable rates of hypertriglyceridemia (29.5% vs 24.4%, P = .29). In a multivariable analysis, higher BMI was associated with worse OS, hypertriglyceridemia was associated with improved OS, and age was not associated with OS. In conclusion, among AYAs treated on DFCI Consortium ALL regimens, elevated BMI was associated with increased toxicity, increased NRM, and decreased OS. The deleterious effect of elevated BMI was more pronounced in older AYAs.
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Affiliation(s)
- Shai Shimony
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Hematology Department, Rabin Medical Center and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Flamand
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
| | - Yannis K. Valtis
- Department of Medicine, Memorial Sloan Kettering Cancer Institute, New York, NY
| | - Andrew E. Place
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Boston Children’s Hospital, Boston, MA
| | - Lewis B. Silverman
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Boston Children’s Hospital, Boston, MA
| | - Lynda M. Vrooman
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Boston Children’s Hospital, Boston, MA
| | - Andrew M. Brunner
- Leukemia Department, Hematology/Oncology, Massachusetts General Hospital, Boston, MA
| | - Stephen E. Sallan
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Boston Children’s Hospital, Boston, MA
| | - Richard M. Stone
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Martha Wadleigh
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Donna S. Neuberg
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
| | - Daniel J. DeAngelo
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Marlise R. Luskin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
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Zeckanovic A, Fuchs P, Heesen P, Bodmer N, Otth M, Scheinemann K. Pediatric-Inspired Regimens in the Treatment of Acute Lymphoblastic Leukemia in Adolescents and Young Adults: A Systematic Review. Curr Oncol 2023; 30:8612-8632. [PMID: 37754540 PMCID: PMC10528122 DOI: 10.3390/curroncol30090625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 08/19/2023] [Accepted: 08/29/2023] [Indexed: 09/28/2023] Open
Abstract
Adolescents and young adults (AYA) with acute lymphoblastic leukemia (ALL) have significantly worse outcomes than their younger counterparts. Current treatment guidelines rely mostly on non-randomized retrospective studies. We performed a systematic review of studies published within the last 15 years comparing pediatric-inspired regimens (PIR) versus adult-type regimens or performing an age-stratified analysis of outcomes in the AYA population. Due to the heterogeneity of data, a meta-analysis was not possible. However, the gathered data show a trend toward improvement in outcomes and an acceptable toxicity profile in patients treated with PIRs compared to conventional adult-type regimens. There is still room for further improvement, as older patients within the AYA population tend to perform poorly with PIR or conventional adult-type chemotherapy. Further randomized studies are needed to develop an optimal treatment strategy for AYA with ALL.
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Affiliation(s)
- Aida Zeckanovic
- Department of Oncology, University Children’s Hospital Zurich, 8032 Zurich, Switzerland; (P.F.); (N.B.); (M.O.)
- Children’s Research Center, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
| | - Philipp Fuchs
- Department of Oncology, University Children’s Hospital Zurich, 8032 Zurich, Switzerland; (P.F.); (N.B.); (M.O.)
- Children’s Research Center, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
| | - Philip Heesen
- Faculty of Medicine, University of Zurich, 8006 Zurich, Switzerland;
| | - Nicole Bodmer
- Department of Oncology, University Children’s Hospital Zurich, 8032 Zurich, Switzerland; (P.F.); (N.B.); (M.O.)
- Children’s Research Center, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
| | - Maria Otth
- Department of Oncology, University Children’s Hospital Zurich, 8032 Zurich, Switzerland; (P.F.); (N.B.); (M.O.)
- Children’s Research Center, University Children’s Hospital Zurich, 8032 Zurich, Switzerland
- Division of Hematology/Oncology, Children’s Hospital of Eastern Switzerland, 9006 St. Gallen, Switzerland;
- Faculty of Health Sciences and Medicine, University of Lucerne, 6000 Lucerne, Switzerland
| | - Katrin Scheinemann
- Division of Hematology/Oncology, Children’s Hospital of Eastern Switzerland, 9006 St. Gallen, Switzerland;
- Faculty of Health Sciences and Medicine, University of Lucerne, 6000 Lucerne, Switzerland
- Department of Pediatrics, McMaster Children’s Hospital and McMaster University, Hamilton, ON L8S 4L8, Canada
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5
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Mootoosamy C, Kondyli M, Serfaty SA, Tremblay DÉ, Gagné V, Ribère M, Laverdière C, Leclerc JM, Sinnett D, Tran TH, Krajinovic M. IL16 and factor V gene variations are associated with asparaginase-related thrombosis in childhood acute lymphoblastic leukemia patients. Pharmacogenomics 2023; 24:199-206. [PMID: 36946317 DOI: 10.2217/pgs-2022-0164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
Aim: We previously conducted exome-wide association study in acute lymphoblastic leukemia patients and identified association of five SNPs with asparaginase-related thrombosis. Here we aimed to replicate these findings in an independent patient cohort and through analyses in vitro. Patients & methods: SNPs located in IL16, MYBBP1A, PKD2L1, RIN3 and MPEG1 genes were analyzed in patients receiving Dana-Farber Cancer Institute acute lymphoblastic leukemia treatment protocols 05-001 and 11-001. Thrombophilia-related variations were also analysed. Results: IL16 rs11556218 conferred higher risk of thrombosis and higher in vitro sensitivity to asparaginase. The association was modulated by the treatment protocol, risk group and immunophenotype. A crosstalk between factor V Leiden, non-O blood groups and higher risk of thrombosis was also seen. Conclusion: IL16 and factor V Leiden variations are implicated in asparaginase-related thrombosis.
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Affiliation(s)
- Covida Mootoosamy
- Charles-Bruneau Cancer Center, CHU Sainte-Justine Research Center, Montreal, QC, H3T 1C5, Canada
- Department of Pharmacology & Physiology, Faculty of Medicine, University of Montreal, Montreal, QC, H3T 1J4, Canada
| | - Maria Kondyli
- Charles-Bruneau Cancer Center, CHU Sainte-Justine Research Center, Montreal, QC, H3T 1C5, Canada
| | - Sophie Annaelle Serfaty
- Charles-Bruneau Cancer Center, CHU Sainte-Justine Research Center, Montreal, QC, H3T 1C5, Canada
- Department of Pharmacology & Physiology, Faculty of Medicine, University of Montreal, Montreal, QC, H3T 1J4, Canada
| | - David-Étienne Tremblay
- Charles-Bruneau Cancer Center, CHU Sainte-Justine Research Center, Montreal, QC, H3T 1C5, Canada
| | - Vincent Gagné
- Charles-Bruneau Cancer Center, CHU Sainte-Justine Research Center, Montreal, QC, H3T 1C5, Canada
| | - Maïté Ribère
- Department of Biological Sciences, Faculty of Art & Science, University of Montreal, Montreal, QC, H3T 1J4, Canada
| | - Caroline Laverdière
- Charles-Bruneau Cancer Center, CHU Sainte-Justine Research Center, Montreal, QC, H3T 1C5, Canada
- Department of Pediatrics, Faculty of Medicine, University of Montreal, Montreal, QC, H3T 1J4, Canada
| | - Jean-Marie Leclerc
- Charles-Bruneau Cancer Center, CHU Sainte-Justine Research Center, Montreal, QC, H3T 1C5, Canada
- Department of Pediatrics, Faculty of Medicine, University of Montreal, Montreal, QC, H3T 1J4, Canada
| | - Daniel Sinnett
- Charles-Bruneau Cancer Center, CHU Sainte-Justine Research Center, Montreal, QC, H3T 1C5, Canada
- Department of Pediatrics, Faculty of Medicine, University of Montreal, Montreal, QC, H3T 1J4, Canada
| | - Thai Hoa Tran
- Charles-Bruneau Cancer Center, CHU Sainte-Justine Research Center, Montreal, QC, H3T 1C5, Canada
- Department of Pediatrics, Faculty of Medicine, University of Montreal, Montreal, QC, H3T 1J4, Canada
| | - Maja Krajinovic
- Charles-Bruneau Cancer Center, CHU Sainte-Justine Research Center, Montreal, QC, H3T 1C5, Canada
- Department of Pediatrics, Faculty of Medicine, University of Montreal, Montreal, QC, H3T 1J4, Canada
- Department of Pharmacology & Physiology, Faculty of Medicine, University of Montreal, Montreal, QC, H3T 1J4, Canada
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6
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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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7
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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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