Central nervous system involvement at presentation in childhood acute lymphoblastic leukemia: management experience and lessons

Neurological manifestations in dogs with acute leukemia

Canine acute leukemia is a rare hematopoietic neoplasm. Neurological abnormalities have been frequently reported in dogs with acute leukemia (AL). However, the description of the presentation and findings are limited. This study aimed to describe the clinical findings in dogs with acute leukemia presenting with neurological signs as their primary complaint. The database of a private referral hospital was searched for cases that presented to the neurological department with neurological deficits and were subsequently diagnosed with acute leukemia. Six cases were included; all had neurological clinical signs and an abnormal neurological examination. All cases had a focal neuroanatomical localisation on neurological examination (brain n = 4; spinal = 2). Out of the four dogs with a complete magnetic resonance imaging (MRI) study, there was an ill-defined infiltrative pattern with abnormal signal intensity in the central nervous system (CNS) in three dogs and the loss of grey and white matter differentiation in the brain (n = 2) and/or spinal cord (n = 2). Other MRI findings included abnormal meningeal enhancement (n = 3), changes affecting spinal nerves and epaxial muscles (n = 2), and lymphadenopathy in the field of view (n = 2). The bone marrow assessment on MRI showed evidence of signal change (n = 3), characterized by a loss of normal fat opacity and an abnormal degree of contrast enhancement. The cerebrospinal fluid (CSF) analysis of the four dogs showed an increased protein level with non-specific pleocytosis and without evidence of malignant cells. Treatment with cytotoxic medication was implemented in two dogs. The dogs diagnosed with acute leukemia had focal neuroanatomical localisation, an infiltrative CNS pattern, and bone marrow remodulation on MRI with an increase in CSF protein and negative cytology analysis.

Treatment outcomes of pediatrics acute myeloid leukemia (AML) and associated factors in the country's tertiary referral hospital, Ethiopia

BACKGROUND

Pediatric Acute Myeloid Leukemia (AML) is a major cause of morbidity and mortality in children with cancer in Africa and other developing continents. Systemic chemotherapy and effective supportive care have significantly contributed to increased survival rates of pediatric AML in developed countries reaching approximately 70%. There is a paucity of contextual data regarding overall and event-free survival outcomes in children with acute myeloid leukemia in developing countries and most centers in Africa provide palliative care. The objective of this study was to assess the overall survival, event-free survival, and associated factors in pediatric AML patients treated in Ethiopia.

METHODS

This retrospective study was conducted on Pediatric AML patients treated at Tikur Anbessa Hospital between January 1, 2015, and May 30, 2022. The socio-demographic profile of patients, the clinical characteristics, the biochemical and morphological subtypes of AML were analyzed using SPSS version 25. The Kaplan-Meier survival curve was used to estimate the probabilities of overall and event-free survival. Statistical significance was set at p < 0.05.

RESULTS

A total of 92 children with AML were included in this study. The median age at diagnosis was 7 years (interquartile range: 5-10 years) with a slight male predominance. The median duration of symptoms was one month. Neutropenic fever (56, 86.2%) was the most common complication during treatment. About 29.3% of the patients succumbed to early death. The corresponding 1-year and 3-year OS probabilities were 28.2% and 23% respectively. The median event-free survival time for all pediatric AML patients was one-month (95% CI: 0.77-1.23). The determinants of poorer survival outcomes were FAB subtype, type of protocol used, and signs of CNS involvement (p < 0.05).

CONCLUSION

The survival rates of children from AML were low in the study setting. More than 25% of AML patients succumbed to early death, and febrile neutropenia was the most common complication. Effective supportive and therapeutic measures should be taken to manage febrile neutropenia and to prevent early death in AML patients.

Success and complications in lumbar punctures of pediatric patients with leukemia: a study protocol for a randomized clinical crossover trial of a bioimpedance needle system versus conventional procedure

BACKGROUND

Acute lymphoblastic leukemia (ALL) is the most common malignancy diagnosed in children. At present, the long-term survival from pediatric ALL is well over 90%. However, the probability of event-free survival is reduced if the lumbar puncture (LP) procedures at the beginning of the patient's intrathecal therapy cause blood leakage into the spinal canal and blast cells contaminate the cerebrospinal fluid. According to the literature, such traumatic LP procedures concern one out of five pediatric patients with ALL. Recently, a novel medical device measuring the tissue bioimpedance at the tip of a spinal needle was found feasible in pediatric patients with ALL. The LP procedure was successful at the first attempt in 80% of procedures, and the incidence of traumatic LPs was then 11%. The purpose of the present study is to compare the bioimpedance spinal needle system with the standard clinical practice resting on a conventional spinal needle and investigate its efficacy in clinical practice.

METHODS

The study is a multicenter, randomized, two-arm crossover noninferiority trial of pediatric hemato-oncology patients that will be conducted within the usual clinical workflow. Patients' LP procedures will be performed alternately either with the IQ-Tip system (study arm A) or a conventional Quincke-type 22G spinal needle (study arm B). For each enrolled patient, the order of procedures is randomly assigned either as ABAB or BABA. The total number of LP procedures will be at least 300, and the number of procedures per patient between two and four. After each study LP procedure, the performance will be recorded immediately, and 1-week diary-based and 4-week record-based follow-ups on symptoms, complications, and adverse events will be conducted thereafter. The main outcomes are the incidence of traumatic LP, first puncture success rate, and incidence of post-dural puncture headache.

DISCUSSION

The present study will provide sound scientific evidence on the clinical benefit, performance, and safety of the novel bioimpedance spinal needle compared with the standard clinical practice of using conventional spinal needles in the LP procedures of pediatric patients with leukemia.

TRIAL REGISTRATION

ISRCTN ISRCTN16161453. Registered on 8 July 2022.

Bioimpedance spinal needle provides high success and low complication rate in lumbar punctures of pediatric patients with acute lymphoblastic leukemia

In this prospective single-arm study of 50 pediatric patients with acute lymphoblastic leukemia (ALL), we evaluated the clinical performance of a novel bioimpedance spinal needle system in 152 intrathecal treatment lumbar punctures (LP) of these patients. The system detects in real-time when the needle tip reaches the cerebrospinal fluid (CSF) in the spinal canal. The success was defined as getting a CSF sample and/or administering the intrathecal treatment with one needle insertion. Incidence of traumatic LP (TLP) was defined as ≥ 10 erythrocytes/µL of CSF. Post-procedural complications were monitored with a one-week diary and one-month register follow-up. The success of the first attempt was 79.5%, with the CSF detection sensitivity of 86.1%. The incidence of TLP was 17.3%. A successful first attempt was associated with a significantly lower incidence of TLP (10% vs 40%, p = 0.0015). During the week after the procedure, the incidence of post-dural puncture headache was 6%. During the follow-up, no major complications were observed. In conclusion, the novel bioimpedance spinal needle system achieved a high success rate and low incidence of TLP and other complications in pediatric patients with ALL in a real-world clinical setting, indicating clinical utility for this system in pediatric hemato-oncology.

A Nomogram for Predicting Event-Free Survival in Childhood Acute Lymphoblastic Leukemia: A Multicenter Retrospective Study

OBJECTIVE

Even though childhood acute lymphoblastic leukemia (ALL) has an encouraging survival rate in recent years, some patients are still at risk of relapse or even death. Therefore, we aimed to construct a nomogram to predict event-free survival (EFS) in patients with ALL.

METHOD

Children with newly diagnosed ALL between October 2016 and July 2021 from 18 hospitals participating in the South China children's leukemia Group (SCCLG) were recruited and randomly classified into two subsets in a 7:3 ratio (training set, n=1187; validation set, n=506). Least absolute shrinkage and selection operator (LASSO) and multivariate Cox regression analysis were adopted to screen independent prognostic factors. Then, a nomogram can be build based on these prognostic factors to predict 1-, 2-, and 3-year EFS. Concordance index (C-index), area under the curve (AUC), calibration curve, and decision curve analysis (DCA) were used to evaluate the performance and clinical utility of nomogram.

RESULT

The parameters that predicted EFS were age at diagnosis, white blood cell at diagnosis, immunophenotype, ETV6-RUNX1/TEL-AML1 gene fusion, bone marrow remission at day 15, and minimal residual disease at day 15. The nomogram incorporated the six factors and provided C-index values of 0.811 [95% confidence interval (CI) = 0.792-0.830] and 0.797 (95% CI = 0.769-0.825) in the training and validation set, respectively. The calibration curve and AUC revealed that the nomogram had good ability to predict 1-, 2-, and 3-year EFS. DCA also indicated that our nomogram had good clinical utility. Kaplan-Meier analysis showed that EFS in the different risk groups stratified by the nomogram scores was significant differentiated.

CONCLUSION

The nomogram for predicting EFS of children with ALL has good performance and clinical utility. The model could help clinical decision-making.

Comparison of outcomes of children with acute lymphoblastic leukemia treated with BMF protocol across 2 decades

Acute lymphoblastic leukemia is the most common malignancy of childhood. The aim of this study is to compare the outcome of children with acute lymphoblastic leukemia treated with BFM protocol over two decades at our center. We retrospectively examined the files of 421 patients by dividing them into two groups by decade of treatment, 1995-2005 and 2006-2015. After excluding 117 patients, overall, 304 patients were included in the analysis. From the first to the second decade, the proportion of patients over 12 years of age increased from 7.1% to 16.8% (p < 0.04), the high-risk group increased from 15.5% to 19.5% and patients with central nervous system leukemia increased from 5.2% to 11.4%. The relapse rate remained relatively unchanged during this period (from 12.9% to 12.7%), while the mortality rate decreased from 18.7% to 15.4% (p > 0.05) and the death rate during remission induction treatment decreased from 3.9% to 0.7%. The mortality rate of high-risk and standard-risk patients decreased from 62.5% to 34.5% (p < 0.05) and 11.1% to 3.0% (p > 0.05), respectively. The 5-year overall survival and event-free survival rates for standard-, medium- and high-risk patients were 92.7% ± 6.0%, 87.9% ± 4.7%, and 54.7% ± 13.3% and 92.5% ± 6.3%, 83.2% ± 5.5%, and 48.7% ± 14.7%, respectively. For the cohort, the 5-year overall survival rate was 83.2% ± 4.1% and the event-free survival rate was 79.9% ± 4.7%. These results demonstrate the impact of a standard protocol, experience of staff, achieving better risk stratification on treatment success.

Safety and Efficacy of Chimeric Antigen Receptor T-Cell Therapy in Children With Central Nervous System Leukemia

BACKGROUND

chimeric antigen receptor-modified T cell (CAR-T) therapy is an effective and promising treatment for refractory and multiply relapsed B-cell acute lymphoblastic leukemia (B-ALL). Because of its side effects and poor responses such as neurotoxicity and cytokine release syndrome, patients with central nervous system leukemia were excluded in most previous clinical trials of CAR-T treatment.

PATIENTS AND METHODS

We enrolled 3 B-ALL patients with central nervous system leukemia relapse. They were infused with CD19-specific CAR-Ts, and their clinical responses were evaluated by bone marrow smear, flow cytometry, and cytogenetic alterations detected by quantitative PCR, interleukin-6, and the expansion and persistence of circulating CAR-Ts in peripheral blood and cerebrospinal fluid.

RESULTS

After CAR-T infusion, 2 of the 3 patients experienced bone marrow minimal residual disease-negative complete remission, and all patients tested negative for residual leukemia cells in cerebrospinal fluid tested by flow cytometry. These 3 patients experienced grade 2 or 3 cytokine release syndrome, which resolved completely after symptomatic treatment. None experienced neurotoxicity or needed further intensive care.

CONCLUSION

CAR-T infusion is a potentially effective treatment for relapsed/refractory B-ALL patients with central nervous system involvement.

Determining the Significant Prognostic Factors for the Recurrence of Pediatric Acute Lymphoblastic Leukemia Using a Competing Risks Approach

Acute lymphoblastic leukemia (ALL) is the most common cause of cancer-related fatality among children. This study aimed to identify the significant prognostic factors for the incidence of pediatric ALL. This retrospective study, conducted from 2007 to 2016 in the Iranian city of Mashhad, enrolled 417 patients with ALL. The diagnosis was confirmed by Giemsa staining of bone marrow smears. The first recurrence was regarded as the event of interest and non-relapse mortality as the competing event through a three-parameter Gompertz model. The level of statistical significance for univariate and multivariate analyses was set at 0.2 and 0.05, respectively. The first recurrence occurred in 44 (10.6%) survivors. Disease-free survival and 5-year overall survival rates were 85.9% and 74%, correspondingly. The five-year incidence rate for the first recurrence was 11.5% in the presence of non-relapse mortality. Briefly, the characteristics of the Gompertz model conferred more effective prognostic factors. Age above 10 years (P=0.010), involvement of the central nervous system (P=0.050), a high white blood cell count (P=0.020), and tumor lysis syndrome (P=0.010) were the significant prognostic factors for the recurrence and mortality of ALL. Accordingly, careful monitoring in the administration of treatment protocols is suggested to reduce the risk of recurrence and death in these patients.

New attempts for central nervous infiltration of pediatric acute lymphoblastic leukemia

The cure rate of acute lymphoblastic leukemia (ALL), the commonest childhood cancer, has been sharply improved and reached almost 90% ever since the central nervous system (CNS)-directed therapy proposed in the 1960s. However, relapse, particularly in the central nervous system (CNS), is still a common cause of treatment failure. Up to now, the classic CNS-directed treatment for CNS leukemia (CNSL) has been aslant from cranial radiation to high-dose system chemotherapy plus intrathecal (IT) chemotherapy for the serious side effects of cranial radiation. The neurotoxic effects of chemotherapy and IT chemotherapy have been reported in recent years as well. For better prevention and treatment of CNSL, plenty of studies have tried to improve the detection sensitivity for CNSL and prevent CNSL from happening by targeting cytokines and chemokines which could be key factors for the traveling of ALL cells into the CNS. Other studies also have aimed to completely kill ALL cells (including dormant cells) in the CNS by promoting the entering of chemotherapy drugs into the CNS or targeting the components of the CNS niche which could be in favor of the survival of ALL cells in CNS. The aim of this review is to discuss the imperfection of current diagnostic methods and treatments for CNSL, as well as new attempts which could be significant for better elimination of CNSL.

Altered CSF Proteomic Profiling of Paediatric Acute Lymphocytic Leukemia Patients with CNS Infiltration

Background

For childhood acute lymphocytic leukemia (ALL), central nervous system leukemia (CNSL) is still the main reason of treatment failure. Changes of cerebrospinal fluid (CSF) proteome are deemed to occur after intrathecal chemotherapy.

Objective

To find critical CSF biomarkers, which could be utilized to increase diagnostic and prognostic accuracy of CNSL.

Methods

We performed proteomic profiling of CSF before and after the treatment of six sporadic paediatric patients diagnosed as ALL with central nervous system (CNS) involvement. CSF samples were properly processed and analyzed through the use of label-free liquid chromatography-tandem mass spectrometry (LC-MS/MS).

Results

Among identified 428 unique proteins in all CSF samples, we quantified 10 altered proteins with diverse biological functions after induction chemotherapy.

Conclusions

The levels of those 10 proteins change during the treatment of CNSL. Some of the proteins are likely to play a vital biological role as biomarkers for the development of ALL. In addition, our results indicated the feasible and reproducible utility of CSF for diagnosis and prognosis of patients with CNSL.

Higher rate of central nervous system involvement by flow cytometry than morphology in acute lymphoblastic leukemia

INTRODUCTION

Central nervous system (CNS) involvement in acute lymphoblastic leukemia (ALL) is diagnosed traditionally by cytopathology (CP) of the cerebrospinal fluid (CSF). Role of flow cytometry (FC) to diagnose CNS involvement has not been extensively investigated.

METHODS

We aimed to detect CNS involvement in 42 ALL patients (33 B-ALL, nine T-ALL) at diagnosis by FC and comparing it with CP and to correlate it with known risk factors for CNS disease like Lactate dehydrogenase (LDH). A receiver operating characteristic curve was used to determine the cutoff of LDH to predict CSF involvement. For the analysis of categorical/quantitative variables, Fisher's exact test was used. For the analysis of continuous variables, Mann-Whitney test was used. A P value of <.05 was taken as significant.

RESULTS

CP and FC were positive in five (11.9%) and 11 patients (26.14%) respectively with FC detecting a significantly higher level of involvement (P=.001). All CP-positive cases were FC positive. A LDH value of >472 U/L had a sensitivity of 61% and specificity of 62.5% for diagnosis of CSF involvement by FC.

CONCLUSIONS

CSF FC detects CNS disease in ALL patients at diagnosis at a rate double than CP alone and is statistically associated with an elevated LDH level. It should be incorporated in the evaluation of CSF to detect CNS involvement.

Bilateral Facial Nerve Palsy in Acute B Cell Lymphoblastic Leukemia: A Case Report and Review of the Literature

Acute lymphoblastic leukemia (ALL) is a haematological malignancy that can involve the central nervous system (CNS). Less than 10 % of patients with ALL have CNS involvement at presentation. The cranial nerve most commonly affected is cranial nerve VII although bilateral involvement is rare. Management and outcomes of these patients are not well understood. Moreover bilateral Bells palsy as a presenting symptom of ALL is extremely uncommon. We report a very unusual presentation of ALL with bilateral facial nerve palsy, and discuss the management strategies and outcomes for patients with ALL that present with cranial nerve palsies.

Intracerebral metastasis in pediatric acute lymphoblastic leukemia: A rare presentation

Central nervous system leukemia may present in different ways. However, intraparenchymal mass is extremely rare in childhood leukemia. Herein, we report a boy who presented with right hemiparesis and anisocoria 1 year after the cessation of the chemotherapy protocol for acute lymphoblastic leukemia. Cranial imaging demonstrated an extensive mass located in the anterior white matter of left frontal lobe, and cerebrospinal fluid examination revealed concomitant lymphoblasts. Immunohistochemical staining of the biopsy material showed neoplastic cells with positive CD10 and TdT. Complete remission was achieved with chemotherapy alone for a duration of 2 years.

Childhood acute myeloid leukemia: an Indian perspective

Cure rates of childhood malignancies are inferior in India as compared to developed nations. There is paucity of data addressing outcome of childhood acute myeloid leukemia (AML) from India. Hence, this study was designed to assess the outcome of childhood AML in India over the last 2 decades, identify shortcomings and suggest remedial measures. A comprehensive search to identify studies addressing outcome of childhood AML from India was carried out. International Society of Paediatric Oncology annual meeting abstracts were searched to identify unpublished data. Clinicodemographic and outcome data were extracted from these abstracts. Outcomes of <500 patients have been published to date, with predominantly small single-center series from 5 cities. Several AML protocols with modifications to suit the logistics in India have been used. Administration of chemotherapy (standard as well as oral and outpatient based) with manageable toxicity has been deemed feasible. Survival outcomes are modest (23% to 53.8%) except for AML M3 (over 80%), with high early-death rates, relapse, along with abandonment. Few series have identified prognostic parameters and disease burden at diagnosis, and used cytogenetics (for risk stratification) or bone marrow transplant (BMT). There is a need for assessment of risk factors in Indian patients; administration of adequate and appropriate therapy, both upfront and after relapse; improvement in supportive care; and national data management infrastructure with updating/monitoring of registries along with better financial and social support initiatives. These multimodal and additive remedial measures could significantly improve outcome of childhood AML in India by reducing mortality, relapse, and abandonment.