1
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DelRocco NJ, Loh ML, Borowitz MJ, Gupta S, Rabin KR, Zweidler-McKay P, Maloney KW, Mattano LA, Larsen E, Angiolillo A, Schore RJ, Burke MJ, Salzer WL, Wood BL, Carroll AJ, Heerema NA, Reshmi SC, Gastier-Foster JM, Harvey R, Chen IM, Roberts KG, Mullighan CG, Willman C, Winick N, Carroll WL, Rau RE, Teachey DT, Hunger SP, Raetz EA, Devidas M, Kairalla JA. Enhanced Risk Stratification for Children and Young Adults with B-Cell Acute Lymphoblastic Leukemia: A Children's Oncology Group Report. Leukemia 2024; 38:720-728. [PMID: 38360863 PMCID: PMC10997503 DOI: 10.1038/s41375-024-02166-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 01/15/2024] [Accepted: 01/23/2024] [Indexed: 02/17/2024]
Abstract
Current strategies to treat pediatric acute lymphoblastic leukemia rely on risk stratification algorithms using categorical data. We investigated whether using continuous variables assigned different weights would improve risk stratification. We developed and validated a multivariable Cox model for relapse-free survival (RFS) using information from 21199 patients. We constructed risk groups by identifying cutoffs of the COG Prognostic Index (PICOG) that maximized discrimination of the predictive model. Patients with higher PICOG have higher predicted relapse risk. The PICOG reliably discriminates patients with low vs. high relapse risk. For those with moderate relapse risk using current COG risk classification, the PICOG identifies subgroups with varying 5-year RFS. Among current COG standard-risk average patients, PICOG identifies low and intermediate risk groups with 96% and 90% RFS, respectively. Similarly, amongst current COG high-risk patients, PICOG identifies four groups ranging from 96% to 66% RFS, providing additional discrimination for future treatment stratification. When coupled with traditional algorithms, the novel PICOG can more accurately risk stratify patients, identifying groups with better outcomes who may benefit from less intensive therapy, and those who have high relapse risk needing innovative approaches for cure.
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Affiliation(s)
- N J DelRocco
- Department of Biostatistics, Colleges of Medicine, Public Health and Health Professions, University of Florida, Gainesville, FL, USA.
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles, CA, USA.
| | - M L Loh
- Department of Pediatrics and the Ben Towne Center for Childhood Cancer Research, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - M J Borowitz
- Department of Pathology, Johns Hopkins University, Baltimore, MD, USA
| | - S Gupta
- Division of Haematology/Oncology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - K R Rabin
- Division of Pediatric Hematology/Oncology, Texas Children's Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | | | - K W Maloney
- Department of Pediatrics, University of Colorado and Children's Hospital Colorado, Aurora, CO, USA
| | | | - E Larsen
- Department of Pediatrics, Maine Children's Cancer Program, Scarborough, ME, USA
| | | | - R J Schore
- Division of Pediatric Oncology, Children's National Hospital, Washington, DC and the George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - M J Burke
- Division of Pediatric Hematology-Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - W L Salzer
- Uniformed Services University, F. Edward Hebert School of Medicine, Bethesda, MD, USA
| | - B L Wood
- Children's Hospital Los Angeles, Pathology and Laboratory Medicine, Los Angeles, CA, USA
| | - A J Carroll
- Department of Genetics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - N A Heerema
- Department of Pathology, The Ohio State University Wexner School of Medicine, Columbus, OH, USA
| | - S C Reshmi
- Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital and Departments of Pathology and Pediatrics, Ohio State University College of Medicine, Columbus, OH, USA
| | - J M Gastier-Foster
- Department of Pathology, The Ohio State University Wexner School of Medicine, Columbus, OH, USA
- Department of Pediatrics, Texas Children's Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | - R Harvey
- University of New Mexico Cancer Center, Albuquerque, NM, USA
| | - I M Chen
- University of New Mexico Cancer Center, Albuquerque, NM, USA
| | - K G Roberts
- Department of Pathology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - C G Mullighan
- Department of Pathology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - C Willman
- Mayo Clinic, Cancer Center/Laboratory Medicine and Pathology, Rochester, NY, USA
| | - N Winick
- UTSouthwestern, Simmons Cancer Center, Dallas, TX, USA
| | - W L Carroll
- Perlmutter Cancer Center and Department of Pediatrics, NYU Langone Health, New York, NY, USA
| | - R E Rau
- Department of Pediatrics and the Ben Towne Center for Childhood Cancer Research, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - D T Teachey
- Department of Pediatrics and The Center for Childhood Cancer Research, Children's Hospital of Philadelphia and the Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA
| | - S P Hunger
- Department of Pediatrics and The Center for Childhood Cancer Research, Children's Hospital of Philadelphia and the Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA
| | - E A Raetz
- Perlmutter Cancer Center and Department of Pediatrics, NYU Langone Health, New York, NY, USA
| | - M Devidas
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - J A Kairalla
- Department of Biostatistics, Colleges of Medicine, Public Health and Health Professions, University of Florida, Gainesville, FL, USA
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2
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Newman H, Li Y, Huang YV, Elgarten CW, Myers RM, Ruiz J, Zheng DJ, Leahy AB, Aftandilian C, Arnold SD, Bona K, Gramatges MM, Heneghan MB, Maloney KW, Modi AJ, Mody RJ, Morgan E, Rubnitz J, Winick N, Wilkes JJ, Seif AE, Fisher BT, Aplenc R, Getz KD. Household income and health-related quality of life in children receiving treatment for acute myeloid leukemia: Potential impact of selection bias in health equity research. Cancer Med 2024; 13:e6966. [PMID: 38572962 PMCID: PMC10993703 DOI: 10.1002/cam4.6966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 12/28/2023] [Accepted: 01/15/2024] [Indexed: 04/05/2024] Open
Abstract
OBJECTIVE Examine the influence of household income on health-related quality of life (HRQOL) among children with newly diagnosed acute myeloid leukemia (AML). DESIGN Secondary analysis of data prospectively collected from pediatric patients receiving treatment for AML at 14 hospitals across the United States. EXPOSURE Household income was self-reported on a demographic survey. The examined mediators included the acuity of presentation and treatment toxicity. OUTCOME Caregiver proxy reported assessment of patient HRQOL from the Peds QL 4.0 survey. RESULT Children with AML (n = 131) and caregivers were prospectively enrolled to complete PedsQL assessments. HRQOL scores were better for patients in the lowest versus highest income category (mean ± SD: 76.0 ± 14 household income <$25,000 vs. 59.9 ± 17 income ≥$75,000; adjusted mean difference: 11.2, 95% CI: 2.2-20.2). Seven percent of enrolled patients presented with high acuity (ICU-level care in the first 72 h), and 16% had high toxicity (any ICU-level care); there were no identifiable differences by income, refuting mediating roles in the association between income and HRQOL. Enrolled patients were less likely to be Black/African American (9.9% vs. 22.2%), more likely to be privately insured (50.4% vs. 40.7%), and more likely to have been treated on a clinical trial (26.7% vs. 18.5%) compared to eligible unenrolled patients not enrolled. Evaluations of potential selection bias on the association between income and HRQOL suggested differences in HRQOL may be smaller than observed or even in the opposing direction. CONCLUSIONS While primary analyses suggested lower household income was associated with superior HRQOL, differential participation may have biased these results. Future studies should partner with patients/families to identify strategies for equitable participation in clinical research.
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Affiliation(s)
- Haley Newman
- Division of Oncology, Department of PediatricsChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
- Department of PediatricsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Yimei Li
- Department of PediatricsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of Biostatistics, Epidemiology, and InformaticsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Yuan‐Shung V. Huang
- Department of Biomedical and Health InformaticsChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Caitlin W. Elgarten
- Division of Oncology, Department of PediatricsChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
- Department of PediatricsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Regina M. Myers
- Division of Oncology, Department of PediatricsChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
- Department of PediatricsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Jenny Ruiz
- Division of Hematology‐Oncology, Department of PediatricsUPMC Children's Hospital of PittsburghPittsburghPennsylvaniaUSA
| | - Daniel J. Zheng
- Division of Oncology, Department of PediatricsChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Alison Barz Leahy
- Division of Oncology, Department of PediatricsChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
- Department of PediatricsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Catherine Aftandilian
- Division of Pediatric Hematology‐Oncology, Stem Cell Transplant and Regenerative Medicine, Department of PediatricsStanford UniversityStanfordCaliforniaUSA
| | - Staci D. Arnold
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of AtlantaEmory University School of MedicineAtlantaGeorgiaUSA
| | - Kira Bona
- Division of Population Sciences, Department of Pediatric OncologyDana‐Farber Cancer InstituteBostonMassachusettsUSA
| | - M. Monica Gramatges
- Division of Pediatric Hematology‐Oncology, Department of PediatricsTexas Children's Hospital, Baylor College of MedicineHoustonTexasUSA
| | - Mallorie B. Heneghan
- Division of Pediatric Hematology‐Oncology, Department of PediatricsUniversity of UtahSalt Lake CityUtahUSA
| | - Kelly W. Maloney
- Department of Pediatrics‐Hematology/Oncology and Bone Marrow Transplant, University of Colorado Cancer CenterChildren's Hospital ColoradoAuroraColoradoUSA
| | - Arunkumar J. Modi
- Division of Hematology Oncology, Department of PediatricsUniversity of Arkansas for Medical Sciences, Arkansas Children's HospitalLittle RockArkansasUSA
| | - Rajen J. Mody
- Department of PediatricsUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
| | - Elaine Morgan
- Department of PediatricsAnn & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Jeffrey Rubnitz
- Department of OncologySt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Naomi Winick
- Department of Pediatric Hematology OncologyUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - Jennifer J. Wilkes
- Division of Cancer and Blood Disorders, Department of PediatricsUniversity of Washington School of MedicineSeattleWashingtonUSA
| | - Alix E. Seif
- Division of Oncology, Department of PediatricsChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
- Department of PediatricsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Center for Childhood Cancer ResearchChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Brian T. Fisher
- Center for Childhood Cancer ResearchChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
- Division of Infectious Disease, Department of PediatricsChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Richard Aplenc
- Division of Oncology, Department of PediatricsChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
- Department of PediatricsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Center for Childhood Cancer ResearchChildren's Hospital of PhiladelphiaPhiladelphiaPennsylvaniaUSA
| | - Kelly D. Getz
- Department of PediatricsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of Biostatistics, Epidemiology, and InformaticsUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
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3
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Rabin KR, Devidas M, Chen Z, Ji L, Kairalla J, Hitzler JK, Yang JJ, Carroll AJ, Heerema NA, Borowitz MJ, Wood BL, Roberts KG, Mullighan CG, Harvey RC, Chen IM, Willman CL, Reshmi SC, Gastier-Foster JM, Bhojwani D, Rheingold SR, Maloney KW, Mattano LA, Larsen EC, Schore RJ, Burke MJ, Salzer WL, Winick NJ, Carroll WL, Raetz EA, Loh ML, Hunger SP, Angiolillo AL. Outcomes in Children, Adolescents, and Young Adults With Down Syndrome and ALL: A Report From the Children's Oncology Group. J Clin Oncol 2024; 42:218-227. [PMID: 37890117 PMCID: PMC10824380 DOI: 10.1200/jco.23.00389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 07/05/2023] [Accepted: 08/29/2023] [Indexed: 10/29/2023] Open
Abstract
PURPOSE Patients with Down syndrome (DS) and B-ALL experience increased rates of relapse, toxicity, and death. We report results for patients with DS B-ALL enrolled on Children's Oncology Group trials between 2003 and 2019. METHODS We analyzed data for DS (n = 743) and non-DS (n = 20,067) patients age 1-30 years on four B-ALL standard-risk (SR) and high-risk trials. RESULTS Patients with DS exhibited more frequent minimal residual disease (MRD) ≥0.01% at end induction (30.8% v 21.5%; P < .001). This difference persisted at end consolidation only in National Cancer Institute (NCI) high-risk patients (34.0% v 11.7%; P < .0001). Five-year event-free survival (EFS) and overall survival (OS) were significantly poorer for DS versus non-DS patients overall (EFS, 79.2% ± 1.6% v 87.5% ± 0.3%; P < .0001; OS, 86.8% ± 1.4% v 93.6% ± 0.2%; P < .0001), and within NCI SR and high-risk subgroups. Multivariable Cox regression analysis of the DS cohort for risk factors associated with inferior EFS identified age >10 years, white blood count >50 × 103/μL, and end-induction MRD ≥0.01%, but not cytogenetics or CRLF2 overexpression. Patients with DS demonstrated higher 5-year cumulative incidence of relapse (11.5% ± 1.2% v 9.1% ± 0.2%; P = .0008), death in remission (4.9% ± 0.8% v 1.7% ± 0.1%; P < .0001), and induction death (3.4% v 0.8%; P < .0001). Mucositis, infections, and hyperglycemia were significantly more frequent in all patients with DS, while seizures were more frequent in patients with DS on high-risk trials (4.1% v 1.8%; P = .005). CONCLUSION Patients with DS-ALL exhibit an increased rate of relapse and particularly of treatment-related mortality. Novel, less-toxic therapeutic strategies are needed to improve outcomes.
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Affiliation(s)
| | | | | | - Lingyun Ji
- University of Southern California, Los Angeles, CA
| | | | | | - Jun J. Yang
- St Jude Children's Research Hospital, Memphis, TN
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Wanda L. Salzer
- US Army Medical Research and Materiel Command, Fort Detrick, MD
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4
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Gupta S, Dai Y, Chen Z, Winestone LE, Teachey DT, Bona K, Aplenc R, Rabin KR, Zweidler-McKay P, Carroll AJ, Heerema NA, Gastier-Foster J, Borowitz MJ, Wood BL, Maloney KW, Mattano LA, Larsen EC, Angiolillo AL, Burke MJ, Salzer WL, Winter SS, Brown PA, Guest EM, Dunsmore KP, Kairalla JA, Winick NJ, Carroll WL, Raetz EA, Hunger SP, Loh ML, Devidas M. Racial and ethnic disparities in childhood and young adult acute lymphocytic leukaemia: secondary analyses of eight Children's Oncology Group cohort trials. Lancet Haematol 2023; 10:e129-e141. [PMID: 36725118 PMCID: PMC9951049 DOI: 10.1016/s2352-3026(22)00371-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 11/11/2022] [Accepted: 11/14/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Previous studies have identified racial and ethnic disparities in childhood acute lymphocytic leukaemia survival. We aimed to establish whether disparities persist in contemporaneous cohorts and, if present, are attributable to differences in leukaemia biology or insurance status. METHODS Patients with newly diagnosed acute lymphocytic leukaemia in inpatient and outpatient centres in the USA, Canada, Australia, and New Zealand, aged 0-30 years, who had race or ethnicity data available, enrolled on eight completed Children's Oncology Group trials (NCT00103285, NCT00075725, NCT00408005, NCT01190930, NCT02883049, NCT02112916, NCT02828358, and NCT00557193) were included in this secondary analysis. Race and ethnicity were categorised as non-Hispanic White, Hispanic, non-Hispanic Black, non-Hispanic Asian, and non-Hispanic other. Event-free survival and overall survival were compared across race and ethnicity groups. The relative contribution of clinical and biological disease prognosticators and insurance status was examined through multivariable regression models, both among the entire cohort and among those with B-cell lineage versus T-cell lineage disease. FINDINGS Between Jan 1, 2004, and Dec 31, 2019, 24 979 eligible children, adolescents, and young adults with acute lymphocytic leukaemia were enrolled, of which 21 152 had race or ethnicity data available. 11 849 (56·0%) were male and 9303 (44·0%) were female. Non-Hispanic White patients comprised the largest racial or ethnic group (13 872 [65·6%]), followed by Hispanic patients (4354 [20·6%]), non-Hispanic Black patients (1517 [7·2%]), non-Hispanic Asian (n=1071 [5·1%]), and non-Hispanic other (n=338 [1·6%]). 5-year event-free survival was 87·4% (95% CI 86·7-88·0%) among non-Hispanic White patients compared with 82·8% (81·4-84·1%; hazard ratio [HR] 1·37, 95% CI 1·26-1·49; p<0·0001) among Hispanic patients and 81·8% (79·3-84·0; HR 1·45, 1·28-1·65; p<0·0001) among non-Hispanic Black patients. Non-hispanic Asian patients had a 5-year event-free survival of 88·1% (95% CI 85·5-90·3%) and non-Hispanic other patients had a survival of 82·8% (76·4-87·6%). Inferior event-free survival among Hispanic patients was substantially attenuated by disease prognosticators and insurance status (HR decreased from 1·37 [1·26-1·49; p<0·0001] to 1·11 [1·00-1·22; p=0·045]). The increased risk among non-Hispanic Black patients was minimally attenuated (HR 1·45 [1·28-1·65; p<0·0001] to 1·32 [1·14-1·52; p<0·0001]). 5-year overall survival was 93·6% (91·5-95·1%) in non-Hispanic Asian patients, 93·3% (92·8-93·7%) in non-Hispanic White patients, 89·9% (88·7-90·9%) in Hispanic, 89·7% (87·6-91·4%) in non-Hispanic Black patients, 88·9% (83·2-92·7%) in non-Hispanic other patients. Disparities in overall survival were wider than event-free survival (eg, among non-Hispanic other patients, the HR for event-free survival was 1·43 [1·10-1·85] compared with 1·74 [1·27-2·40] for overall survival). Disparities were restricted to patients with B-cell acute lymphocytic leukaemia, no differences in event-free survival or overall survival were seen in the T-cell acute lymphocytic leukaemia group. INTERPRETATION Substantial disparities in outcome for B-cell acute lymphocytic leukaemia persist by race and ethnicity, but are not observed in T-cell acute lymphocytic leukaemia. Future studies of relapsed patients, access to and quality of care, and other potential aspects of structural racism are warranted to inform interventions aimed at dismantling racial and ethnic disparities. FUNDING National Cancer Institute and St Baldrick's Foundation.
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Affiliation(s)
- Sumit Gupta
- Cancer Research Program, ICES, Toronto, ON, Canada; Institute for Health Policy, Evaluation and Management and Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada.
| | - Yunfeng Dai
- Biostatistics, University of Florida, Gainesville, FL, USA
| | - Zhiguo Chen
- Biostatistics, University of Florida, Gainesville, FL, USA
| | - Lena E Winestone
- Department of Pediatrics, Benioff Children's Hospital and the Helen Diller Comprehensive Cancer Centre, University of California, San Francisco, San Francisco, CA, USA
| | - David T Teachey
- Cellular Therapy and Transplant Section and Cancer Immunotherapy Program, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Division of Oncology, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kira Bona
- Division of Population Sciences, Department of Pediatric Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Richard Aplenc
- Cellular Therapy and Transplant Section and Cancer Immunotherapy Program, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Division of Oncology, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Karen R Rabin
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Patrick Zweidler-McKay
- Department of Pediatrics Research, The University of Texas MD Anderson Cancer Centre, Houston, TX, USA; University of Texas MD Anderson UT Health Graduate School of Biomedical Sciences, Houston, TX, USA; ImmunoGen, Waltham, MA, USA
| | - Andrew J Carroll
- Department of Genetics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Nyla A Heerema
- Department of Pathology, The Ohio State University Wexner School of Medicine, Columbus, OH, USA
| | - Julie Gastier-Foster
- Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, OH, USA; Department of Pediatrics, Ohio State University School of Medicine, Columbus, OH, USA
| | | | - Brent L Wood
- Department of Laboratory Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Kelly W Maloney
- Department of Pediatrics, University of Colorado and Children's Hospital Colorado, Aurora, CO, USA
| | | | - Eric C Larsen
- Department of Pediatrics, Maine Children's Cancer Program, Scarborough, ME, USA
| | - Anne L Angiolillo
- Division of Oncology, Centre for Cancer and Blood Disorders, Children's National Hospital, Washington, DC, USA
| | - Michael J Burke
- Division of Pediatric Hematology-Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Wanda L Salzer
- US Army Medical Research and Materiel Command, Fort Detrick, Frederick, MD, USA
| | - Stuart S Winter
- Children's Hospitals and Clinics of Minnesota, Minneapolis, MN, USA
| | | | - Erin M Guest
- Genomic Medicine Centre, Children's Mercy Hospital, Kansas City, MO, USA
| | - Kimberley P Dunsmore
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA
| | | | - Naomi J Winick
- Simmons Cancer Center and Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - William L Carroll
- Department of Pediatrics, NYU Langone Health, New York City, NY, USA
| | - Elizabeth A Raetz
- Department of Pediatrics, NYU Langone Health, New York City, NY, USA
| | - Stephen P Hunger
- Division of Oncology, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Mignon L Loh
- Department of Pediatrics, Benioff Children's Hospital and the Helen Diller Comprehensive Cancer Centre, University of California, San Francisco, San Francisco, CA, USA
| | - Meenakshi Devidas
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN, USA
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5
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Barth M, Xavier AC, Armenian S, Audino AN, Blazin L, Bloom D, Chung J, Davies K, Ding H, Ford JB, Galardy PJ, Hanna R, Hayashi R, Lee-Miller C, Machnitz AJ, Maloney KW, Marks L, Martin PL, McCall D, Pacheco M, Reilly AF, Roshal M, Song S, Weinstein J, Zarnegar-Lumley S, McMillian N, Schonfeld R, Sundar H. Pediatric Aggressive Mature B-Cell Lymphomas, Version 3.2022, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2022; 20:1267-1275. [PMID: 36351334 DOI: 10.6004/jnccn.2022.0057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Pediatric Aggressive Mature B-Cell Lymphomas include recommendations for the diagnosis and management of pediatric patients with primary mediastinal large B-cell lymphoma (PMBL) and sporadic variants of Burkitt lymphoma and diffuse large B-cell lymphoma. PMBL is now considered as a distinct entity arising from mature thymic B-cells accounting for 2% of mature B-cell lymphomas in children and adolescents. This discussion section includes the recommendations outlined in the NCCN Guidelines for the diagnosis and management of pediatric patients with PMBL.
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Affiliation(s)
| | - Ana C Xavier
- 2Children's of Alabama/O'Neal Comprehensive Cancer Center at UAB
| | | | - Anthony N Audino
- 4The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | - Lindsay Blazin
- 5Indiana University Melvin and Bren Simon Comprehensive Cancer Center
| | | | | | - Kimberly Davies
- 8Dana-Farber/Boston Children's Cancer and Blood Disorders Center
| | - Hilda Ding
- 9UCSD Rady Children's Hospital/UC San Diego Moores Cancer Center
| | | | | | - Rabi Hanna
- 12Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | - Robert Hayashi
- 13Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | | | | | - Kelly W Maloney
- 16Children's Hospital of Colorado/University of Colorado Cancer Center
| | | | | | - David McCall
- 19The University of Texas MD Anderson Cancer Center
| | | | - Anne F Reilly
- 21Abramson Cancer Center at the University of Pennsylvania
| | | | | | - Joanna Weinstein
- 24Robert H. Lurie Comprehensive Cancer Center of Northwestern University
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6
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Brady SW, Roberts KG, Gu Z, Shi L, Pounds S, Pei D, Cheng C, Dai Y, Devidas M, Qu C, Hill AN, Payne-Turner D, Ma X, Iacobucci I, Baviskar P, Wei L, Arunachalam S, Hagiwara K, Liu Y, Flasch DA, Liu Y, Parker M, Chen X, Elsayed AH, Pathak O, Li Y, Fan Y, Michael JR, Rusch M, Wilkinson MR, Foy S, Hedges D, Newman S, Zhou X, Wang J, Reilly C, Sioson E, Rice SV, Loyola VP, Wu G, Rampersaud E, Reshmi SC, Gastier-Foster J, Guidry-Auvil JM, Gesuwan P, Smith MA, Winick N, Carroll AJ, Heerema NA, Harvey RC, Willman CL, Larsen E, Raetz EA, Borowitz MJ, Wood BL, Carroll WL, Zweidler-McKay PA, Rabin KR, Mattano LA, Maloney KW, Winter SS, Burke MJ, Salzer W, Dunsmore KP, Angiolillo AL, Crews KR, Downing JR, Jeha S, Pui CH, Evans WE, Yang JJ, Relling MV, Gerhard DS, Loh ML, Hunger SP, Zhang J, Mullighan C. The genomic landscape of pediatric acute lymphoblastic leukemia. Nat Genet 2022; 54:1376-1389. [PMID: 36050548 PMCID: PMC9700506 DOI: 10.1038/s41588-022-01159-z] [Citation(s) in RCA: 83] [Impact Index Per Article: 41.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 07/13/2022] [Indexed: 12/13/2022]
Abstract
Acute lymphoblastic leukemia (ALL) is the most common childhood cancer. Here, using whole-genome, exome and transcriptome sequencing of 2,754 childhood patients with ALL, we find that, despite a generally low mutation burden, ALL cases harbor a median of four putative somatic driver alterations per sample, with 376 putative driver genes identified varying in prevalence across ALL subtypes. Most samples harbor at least one rare gene alteration, including 70 putative cancer driver genes associated with ubiquitination, SUMOylation, noncoding transcripts and other functions. In hyperdiploid B-ALL, chromosomal gains are acquired early and synchronously before ultraviolet-induced mutation. By contrast, ultraviolet-induced mutations precede chromosomal gains in B-ALL cases with intrachromosomal amplification of chromosome 21. We also demonstrate the prognostic significance of genetic alterations within subtypes. Intriguingly, DUX4- and KMT2A-rearranged subtypes separate into CEBPA/FLT3- or NFATC4-expressing subgroups with potential clinical implications. Together, these results deepen understanding of the ALL genomic landscape and associated outcomes.
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Affiliation(s)
- Samuel W. Brady
- Department of Computational Biology, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Kathryn G. Roberts
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Zhaohui Gu
- Department of Computational and Quantitative Medicine & Systems Biology, Beckman Research Institute of City of Hope, Duarte CA, USA
| | - Lei Shi
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Stanley Pounds
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Deqing Pei
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Cheng Cheng
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Yunfeng Dai
- Department of Biostatistics, University of Florida, Gainesville FL, USA
| | - Meenakshi Devidas
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Chunxu Qu
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Ashley N. Hill
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Debbie Payne-Turner
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Xiaotu Ma
- Department of Computational Biology, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Ilaria Iacobucci
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Pradyuamna Baviskar
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Lei Wei
- Department of Computational Biology, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Sasi Arunachalam
- Department of Computational Biology, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Kohei Hagiwara
- Department of Computational Biology, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Yanling Liu
- Department of Computational Biology, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Diane A. Flasch
- Department of Computational Biology, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Yu Liu
- Department of Computational Biology, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Matthew Parker
- Department of Computational Biology, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Xiaolong Chen
- Department of Computational Biology, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Abdelrahman H. Elsayed
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis TN, USA,Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Omkar Pathak
- Department of Computational Biology, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Yongjin Li
- Department of Computational Biology, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Yiping Fan
- Department of Computational Biology, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - J. Robert Michael
- Department of Computational Biology, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Michael Rusch
- Department of Computational Biology, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Mark R. Wilkinson
- Department of Computational Biology, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Scott Foy
- Department of Computational Biology, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Dale Hedges
- Department of Computational Biology, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Scott Newman
- Department of Computational Biology, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Xin Zhou
- Department of Computational Biology, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Jian Wang
- Department of Computational Biology, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Colleen Reilly
- Department of Computational Biology, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Edgar Sioson
- Department of Computational Biology, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Stephen V. Rice
- Department of Computational Biology, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Victor Pastor Loyola
- Department of Computational Biology, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Gang Wu
- Center for Applied Bioinformatics, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Evadnie Rampersaud
- Center for Applied Bioinformatics, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Shalini C. Reshmi
- Institute for Genomic Medicine, Nationwide Children’s Hospital, Columbus OH, USA
| | | | - Jaime M. Guidry-Auvil
- Office of Cancer Genomics, National Cancer Institute, National Institutes of Health, Bethesda MD, USA
| | - Patee Gesuwan
- Office of Cancer Genomics, National Cancer Institute, National Institutes of Health, Bethesda MD, USA
| | - Malcolm A. Smith
- Cancer Therapeutics Evaluation Program, National Cancer Institute, National Institutes of Health, Bethesda MD, USA
| | - Naomi Winick
- Department of Pediatric Hematology Oncology and Simmons Cancer Center, University of Texas Southwestern Medical Center, Dallas TX, USA
| | - Andrew J. Carroll
- Department of Genetics, University of Alabama at Birmingham, Birmingham AL, USA
| | | | - Richard C. Harvey
- Department of Pathology, University of New Mexico Cancer Center, Albuquerque NM, USA
| | | | - Eric Larsen
- Department of Pediatrics, Maine Children’s Cancer Program, Scarborough ME, USA
| | - Elizabeth A. Raetz
- Department of Pediatrics and Perlmutter Cancer Center, New York University Langone Medical Center, New York NY, USA
| | - Michael J. Borowitz
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore MD, USA
| | - Brent L. Wood
- Department of Pathology and Laboratory Medicine, Children’s Hospital Los Angeles, University of Southern California, CA, USA
| | - William L. Carroll
- Department of Pediatrics and Perlmutter Cancer Center, New York University Langone Medical Center, New York NY, USA
| | | | - Karen R. Rabin
- Department of Pediatrics, Baylor College of Medicine, Houston TX, USA
| | | | - Kelly W. Maloney
- Department of Pediatrics and Children’s Hospital Colorado, University of Colorado, Aurora CO, USA
| | - Stuart S. Winter
- Children’s Minnesota Research Institute and Cancer and Blood Disorders Program, Minneapolis MN, USA
| | - Michael J. Burke
- Division of Pediatric Hematology-Oncology, Medical College of Wisconsin, Milwaukee WI, USA
| | - Wanda Salzer
- Uniformed Services University, School of Medicine, Bethesda, MD, USA
| | | | | | - Kristine R. Crews
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - James R. Downing
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Sima Jeha
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Ching-Hon Pui
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - William E. Evans
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Jun J. Yang
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Mary V. Relling
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis TN, USA
| | - Daniela S. Gerhard
- Office of Cancer Genomics, National Cancer Institute, National Institutes of Health, Bethesda MD, USA
| | - Mignon L. Loh
- Department of Pediatrics, Benioff Children’s Hospital and Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco CA, USA
| | - Stephen P. Hunger
- Department of Pediatrics and the Center for Childhood Cancer Research, Children’s Hospital of Philadelphia, and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA, USA
| | - Jinghui Zhang
- Department of Computational Biology, St. Jude Children's Research Hospital, Memphis, TN, USA.
| | - Charles Mullighan
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis TN, USA
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7
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Gupta S, Teachey DT, Chen Z, Rabin KR, Dunsmore KP, Larsen EC, Maloney KW, Mattano LA, Winter SS, Carroll AJ, Heerema NA, Borowitz MJ, Wood BL, Carroll WL, Raetz EA, Winick NJ, Loh ML, Hunger SP, Devidas M. Sex-based disparities in outcome in pediatric acute lymphoblastic leukemia: a Children's Oncology Group report. Cancer 2022; 128:1863-1870. [PMID: 35201611 PMCID: PMC9007837 DOI: 10.1002/cncr.34150] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 10/15/2021] [Accepted: 11/22/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Boys with acute lymphoblastic leukemia (ALL) have historically experienced inferior survival compared to girls. This study determined whether sex-based disparities persist with contemporary therapy and whether patterns of treatment failure vary by sex. METHODS Patients 1 to 30.99 years old were enrolled on frontline Children's Oncology Group trials between 2004 and 2014. Boys received an additional year of maintenance therapy. Sex-based differences in the distribution of various prognosticators, event-free survival (EFS) and overall survival (OS), and subcategories of relapse by site were explored. RESULTS A total of 8202 (54.4% male) B-cell ALL (B-ALL) and 1562 (74.3% male) T-cell ALL (T-ALL) patients were included. There was no sex-based difference in central nervous system (CNS) status. Boys experienced inferior 5-year EFS and OS (EFS, 84.6% ± 0.5% vs 86.0% ± 0.6%, P = .009; OS, 91.3% ± 0.4% vs 92.5% ± 0.4%, P = .02). This was attributable to boys with B-ALL, who experienced inferior EFS (hazard ratio [HR], 1.2; 95% confidence interval [95% CI], 1.1-1.3; P = .004) and OS (HR, 1.2; 95% CI, 1.0-1.4; P = .046) after adjustment for prognosticators. Inferior B-ALL outcomes in boys were attributable to more relapses (5-year cumulative incidence 11.2% ± 0.5% vs 9.6% ± 0.5%; P = .001), particularly involving the CNS (4.2% ± 0.3% vs 2.5% ± 0.3%; P < .0001). There was no difference in isolated bone marrow relapses (5.4% ± 0.4% vs 6.2% ± 0.4%; P = .49). There were no sex-based differences in EFS or OS in T-ALL. CONCLUSIONS Sex-based disparities in ALL persist, attributable to increased CNS relapses in boys with B-ALL. Studies of potential mechanisms are warranted. Improved strategies to identify and modify treatment for patients at highest risk of CNS relapse may have particular benefit for boys.
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Affiliation(s)
- Sumit Gupta
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
| | - David T. Teachey
- Department of Pediatrics, Department of Pediatrics and The Center for Childhood Cancer Research, Children’s Hospital of Philadelphia and the Perelman School of Medicine at The University of Philadelphia, Philadelphia, PA
| | - Zhiguo Chen
- Department of Biostatistics, Colleges of Medicine, Public Health, and Health Professions, University of Florida, Gainesville FL
| | - Karen R. Rabin
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Kimberly P. Dunsmore
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA
| | - Eric C. Larsen
- Department of Pediatrics, Maine Children’s Cancer Program, Scarborough, ME
| | - Kelly W. Maloney
- Department of Pediatrics, University of Colorado and Children’s Hospital Colorado, Aurora CO
| | | | | | - Andrew J. Carroll
- Department of Genetics, University of Alabama at Birmingham, Birmingham AL
| | - Nyla A. Heerema
- Department of Pathology, The Ohio State University Wexner School of Medicine, Columbus, OH
| | | | - Brent L. Wood
- Department of Laboratory Medicine, Children’s Hospital Los Angeles, Los Angeles, CA
| | | | | | - Naomi J. Winick
- UT Southwestern, Simmons Cancer Center, and Department of Pediatrics, Dallas, TX
| | - Mignon L. Loh
- Benioff Children’s Hospital and the Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA
| | - Stephen P. Hunger
- Department of Pediatrics, Department of Pediatrics and The Center for Childhood Cancer Research, Children’s Hospital of Philadelphia and the Perelman School of Medicine at The University of Philadelphia, Philadelphia, PA
| | - Meenakshi Devidas
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN
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8
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Mattano LA, Devidas M, Maloney KW, Wang C, Friedmann AM, Buckley P, Borowitz MJ, Carroll AJ, Gastier-Foster JM, Heerema NA, Kadan-Lottick NS, Matloub YH, Marshall DT, Stork LC, Loh ML, Raetz EA, Wood BL, Hunger SP, Carroll WL, Winick NJ. Favorable Trisomies and ETV6-RUNX1 Predict Cure in Low-Risk B-Cell Acute Lymphoblastic Leukemia: Results From Children's Oncology Group Trial AALL0331. J Clin Oncol 2021; 39:1540-1552. [PMID: 33739852 DOI: 10.1200/jco.20.02370] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
PURPOSE Children's Oncology Group (COG) AALL0331 tested whether pegaspargase intensification on a low-intensity chemotherapy backbone would improve the continuous complete remission (CCR) rate in a low-risk subset of children with standard-risk B-acute lymphoblastic leukemia (ALL). METHODS AALL0331 enrolled 5,377 patients with National Cancer Institute standard-risk B-ALL (age 1-9 years, WBC < 50,000/μL) between 2005 and 2010. Following a common three-drug induction, a cohort of 1,857 eligible patients participated in the low-risk ALL random assignment. Low-risk criteria included no extramedullary disease, < 5% marrow blasts by day 15, end-induction marrow minimal residual disease < 0.1%, and favorable cytogenetics (ETV6-RUNX1 fusion or simultaneous trisomies of chromosomes 4, 10, and 17). Random assignment was to standard COG low-intensity therapy (including two pegaspargase doses, one each during induction and delayed intensification) with or without four additional pegaspargase doses at 3-week intervals during consolidation and interim maintenance. The study was powered to detect a 4% improvement in 6-year CCR rate from 92% to 96%. RESULTS The 6-year CCR and overall survival (OS) rates for the entire low-risk cohort were 94.7% ± 0.6% and 98.7% ± 0.3%, respectively. The CCR rates were similar between arms (intensified pegaspargase 95.3% ± 0.8% v standard 94.0% ± 0.8%; P = .13) with no difference in OS (98.1% ± 0.5% v 99.2% ± 0.3%; P = .99). Compared to a subset of standard-risk study patients given identical therapy who had the same early response characteristics but did not have favorable or unfavorable cytogenetics, outcomes were significantly superior for low-risk patients (CCR hazard ratio 1.95; P = .0004; OS hazard ratio 5.42; P < .0001). CONCLUSION Standard COG therapy without intensified pegaspargase, which can easily be given as an outpatient with limited toxicity, cures nearly all children with B-ALL identified as low-risk by clinical, early response, and favorable cytogenetic criteria.
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Affiliation(s)
| | - Meenakshi Devidas
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - Kelly W Maloney
- Department of Pediatrics, University of Colorado and Children's Hospital Colorado, Aurora, CO
| | - Cindy Wang
- Department of Biostatistics, Colleges of Medicine, Public Health, and Health Professions, University of Florida, Gainesville, FL
| | - Alison M Friedmann
- Department of Pediatrics, Massachusetts General Hospital Cancer Center, Boston, MA
| | - Patrick Buckley
- Department of Pathology, Duke University Medical Center, Durham, NC
| | | | - Andrew J Carroll
- Department of Genetics, Children's Hospital of Alabama, Birmingham, AL
| | - Julie M Gastier-Foster
- Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus, OH.,Departments of Pathology and Pediatrics, Ohio State University College of Medicine, Columbus, OH
| | - Nyla A Heerema
- Department of Pathology, Wexner Medical Center, Ohio State University, Columbus, OH
| | | | - Yousif H Matloub
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - David T Marshall
- Department of Radiation Oncology, Medical University of South Carolina, Charleston, SC
| | - Linda C Stork
- Department of Pediatrics, Oregon Health and Science University, Portland, OR
| | - Mignon L Loh
- Department of Pediatrics, Benioff Children's Hospital and the Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA
| | - Elizabeth A Raetz
- Perlmutter Cancer Center and Department of Pediatrics, NYU Langone Medical Center, New York, NY
| | - Brent L Wood
- Departments of Pathology and Medicine, University of Washington, Seattle, WA
| | - Stephen P Hunger
- Department of Pediatrics and The Center for Childhood Cancer Research, Children's Hospital of Philadelphia and the Perelman School of Medicine at The University of Philadelphia, Philadelphia, PA
| | - William L Carroll
- Perlmutter Cancer Center and Department of Pediatrics, NYU Langone Medical Center, New York, NY
| | - Naomi J Winick
- Department of Pediatrics, UT Southwestern, Simmons Cancer Center, Dallas, TX
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9
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Pikman Y, Tasian SK, Sulis ML, Stevenson K, Blonquist TM, Apsel Winger B, Cooper TM, Pauly M, Maloney KW, Burke MJ, Brown PA, Gossai N, McNeer JL, Shukla NN, Cole PD, Kahn JM, Chen J, Barth MJ, Magee JA, Gennarini L, Adhav AA, Clinton CM, Ocasio-Martinez N, Gotti G, Li Y, Lin S, Imamovic A, Tognon CE, Patel T, Faust HL, Contreras CF, Cremer A, Cortopassi WA, Garrido Ruiz D, Jacobson MP, Dharia NV, Su A, Robichaud AL, Saur Conway A, Tarlock K, Stieglitz E, Place AE, Puissant A, Hunger SP, Kim AS, Lindeman NI, Gore L, Janeway KA, Silverman LB, Tyner JW, Harris MH, Loh ML, Stegmaier K. Matched Targeted Therapy for Pediatric Patients with Relapsed, Refractory, or High-Risk Leukemias: A Report from the LEAP Consortium. Cancer Discov 2021; 11:1424-1439. [PMID: 33563661 DOI: 10.1158/2159-8290.cd-20-0564] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 11/25/2020] [Accepted: 01/14/2021] [Indexed: 11/16/2022]
Abstract
Despite a remarkable increase in the genomic profiling of cancer, integration of genomic discoveries into clinical care has lagged behind. We report the feasibility of rapid identification of targetable mutations in 153 pediatric patients with relapsed/refractory or high-risk leukemias enrolled on a prospective clinical trial conducted by the LEAP Consortium. Eighteen percent of patients had a high confidence Tier 1 or 2 recommendation. We describe clinical responses in the 14% of patients with relapsed/refractory leukemia who received the matched targeted therapy. Further, in order to inform future targeted therapy for patients, we validated variants of uncertain significance, performed ex vivo drug-sensitivity testing in patient leukemia samples, and identified new combinations of targeted therapies in cell lines and patient-derived xenograft models. These data and our collaborative approach should inform the design of future precision medicine trials. SIGNIFICANCE: Patients with relapsed/refractory leukemias face limited treatment options. Systematic integration of precision medicine efforts can inform therapy. We report the feasibility of identifying targetable mutations in children with leukemia and describe correlative biology studies validating therapeutic hypotheses and novel mutations.See related commentary by Bornhauser and Bourquin, p. 1322.This article is highlighted in the In This Issue feature, p. 1307.
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Affiliation(s)
- Yana Pikman
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.
- Division of Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts
| | - Sarah K Tasian
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics and Abramson Cancer Center at the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Maria Luisa Sulis
- Division of Pediatric Hematology/Oncology/Stem Cell Transplantation, Columbia University Irving Medical Center, New York, New York
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kristen Stevenson
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Traci M Blonquist
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Beth Apsel Winger
- Department of Pediatrics, Division of Hematology/Oncology, Benioff Children's Hospital and the Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, California
| | - Todd M Cooper
- Seattle Children's Hospital, Cancer and Blood Disorders Center, Seattle, Washington
| | - Melinda Pauly
- Division of Hematology/Oncology, Emory University, Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Kelly W Maloney
- Children's Hospital Colorado, University of Colorado Cancer Center, Aurora, Colorado
| | - Michael J Burke
- Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | | | - Nathan Gossai
- Center for Cancer and Blood Disorders, Children's Minnesota, Minneapolis, Minnesota
| | | | - Neerav N Shukla
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Peter D Cole
- Children's Hospital at Montefiore, Bronx, New York
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Justine M Kahn
- Division of Pediatric Hematology/Oncology/Stem Cell Transplantation, Columbia University Irving Medical Center, New York, New York
| | - Jing Chen
- Division of Pediatric Hematology/Oncology/Stem Cell Transplantation, Columbia University Irving Medical Center, New York, New York
- Children's Cancer Institute, Joseph M. Sanzari Children's Hospital, Hackensack University Medical Center, Hackensack, New Jersey
| | | | - Jeffrey A Magee
- Division of Pediatric Hematology/Oncology, Washington University/St. Louis Children's Hospital, St. Louis, Missouri
| | | | - Asmani A Adhav
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Catherine M Clinton
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Giacomo Gotti
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Yuting Li
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Shan Lin
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Alma Imamovic
- Broad Institute of Massachusetts Institute of Technology and Harvard University, Cambridge, Massachusetts
| | - Cristina E Tognon
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Tasleema Patel
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Haley L Faust
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Cristina F Contreras
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Anjali Cremer
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- University Hospital Frankfurt, Department of Hematology/Oncology, Frankfurt/Main, Germany
| | - Wilian A Cortopassi
- Department of Pharmaceutical Chemistry, University of California, San Francisco, San Francisco, California
| | - Diego Garrido Ruiz
- Department of Pharmaceutical Chemistry, University of California, San Francisco, San Francisco, California
| | - Matthew P Jacobson
- Department of Pharmaceutical Chemistry, University of California, San Francisco, San Francisco, California
| | - Neekesh V Dharia
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts
- Broad Institute of Massachusetts Institute of Technology and Harvard University, Cambridge, Massachusetts
| | - Angela Su
- INSERM UMR 944, IRSL, St Louis Hospital, Paris, France
| | - Amanda L Robichaud
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Amy Saur Conway
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Katherine Tarlock
- Seattle Children's Hospital, Cancer and Blood Disorders Center, Seattle, Washington
| | - Elliot Stieglitz
- Department of Pediatrics, Division of Hematology/Oncology, Benioff Children's Hospital and the Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, California
| | - Andrew E Place
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts
| | | | - Stephen P Hunger
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics and Abramson Cancer Center at the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Annette S Kim
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Neal I Lindeman
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Lia Gore
- Children's Hospital Colorado, University of Colorado Cancer Center, Aurora, Colorado
| | - Katherine A Janeway
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts
| | - Lewis B Silverman
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts
| | - Jeffrey W Tyner
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, Oregon
| | - Marian H Harris
- Department of Pathology, Boston Children's Hospital, Boston, Massachusetts
| | - Mignon L Loh
- Department of Pediatrics, Division of Hematology/Oncology, Benioff Children's Hospital and the Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, California
| | - Kimberly Stegmaier
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.
- Division of Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts
- Broad Institute of Massachusetts Institute of Technology and Harvard University, Cambridge, Massachusetts
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10
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Angiolillo AL, Schore RJ, Kairalla JA, Devidas M, Rabin KR, Zweidler-McKay P, Borowitz MJ, Wood B, Carroll AJ, Heerema NA, Relling MV, Hitzler J, Lane AR, Maloney KW, Wang C, Bassal M, Carroll WL, Winick NJ, Raetz EA, Loh ML, Hunger SP. Excellent Outcomes With Reduced Frequency of Vincristine and Dexamethasone Pulses in Standard-Risk B-Lymphoblastic Leukemia: Results From Children's Oncology Group AALL0932. J Clin Oncol 2021; 39:1437-1447. [PMID: 33411585 DOI: 10.1200/jco.20.00494] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
PURPOSE AALL0932 evaluated two randomized maintenance interventions to optimize disease-free survival (DFS) while reducing the burden of therapy in children with newly diagnosed NCI standard-risk (SR) B-acute lymphoblastic leukemia (B-ALL). METHODS AALL0932 enrolled 9,229 patients with B-ALL; 2,364 average-risk (AR) patients were randomly assigned (2 × 2 factorial design) at the start of maintenance therapy to vincristine/dexamethasone pulses every 4 (VCR/DEX4) or every 12 (VCR/DEX12) weeks, and a starting dose of weekly oral methotrexate of 20 mg/m2 (MTX20) or 40 mg/m2 (MTX40). RESULTS Five-year event-free survival and overall survival (OS) from enrollment (with 95% CIs), for all eligible and evaluable SR B-ALL patients (n = 9,226), were 92.0% (91.1% and 92.8%) and 96.8% (96.2% and 97.3%), respectively. The 5-year DFS and OS from the start of maintenance for randomly assigned AR patients were 94.6% (93.3% and 95.9%) and 98.5% (97.7% and 99.2%), respectively. The 5-year DFS and OS for patients randomly assigned to receive VCR/DEX4 (n = 1,186) versus VCR/DEX12 (n = 1,178) were 94.1% (92.2% and 96.0%) and 98.3% (97.2% and 99.4%) v 95.1% (93.3% and 96.9%) and 98.6% (97.7% and 99.6%), respectively (P = .86 and .69). The 5-year DFS and OS for AR patients randomly assigned to receive MTX20 versus MTX40 were 95.1% (93.3% and 96.8%) and 98.8% (97.9% and 99.7%) v 94.2% (92.2% and 96.1%) and 98.1% (97.0% and 99.2%), respectively (P = .92 and .89). CONCLUSIONS The 0NCI-SR AR B-ALL who received VCR/DEX12 had outstanding outcomes despite receiving one third of the vincristine/dexamethasone pulses previously used as standard of care on Children's Oncology Group (COG) trials. The higher starting dose of MTX of 40 mg/m2/week did not improve outcomes when compared with 20 mg/m2/week. The decreased frequency of vincristine/dexamethasone pulses has been incorporated into frontline COG B-ALL trials to decrease the burden of therapy for patients and their families.
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Affiliation(s)
- Anne L Angiolillo
- Children's National Medical Center, Washington, DC.,George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Reuven J Schore
- Children's National Medical Center, Washington, DC.,George Washington University School of Medicine and Health Sciences, Washington, DC
| | - John A Kairalla
- Department of Biostatistics, Colleges of Medicine and Public Health & Health Professions, University of Florida, Gainesville, FL
| | - Meenakshi Devidas
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - Karen R Rabin
- Texas Children's Cancer Center, Baylor College of Medicine, Houston, TX
| | | | - Michael J Borowitz
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Brent Wood
- Department of Laboratory Medicine, University of Washington, Seattle, WA
| | | | - Nyla A Heerema
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH
| | | | | | | | - Kelly W Maloney
- Children's Hospital Colorado and the Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Cindy Wang
- Department of Biostatistics, Colleges of Medicine and Public Health & Health Professions, University of Florida, Gainesville, FL
| | - Mylène Bassal
- Division of Pediatric Hematology/Oncology, Children's Hospital of Eastern Ontario, Ottawa, ON
| | - William L Carroll
- Department of Pediatrics and Perlmutter Cancer Center, New York University Langone Medical Center, New York, NY
| | - Naomi J Winick
- University of Texas Southwestern Medical Center, Dallas, TX
| | - Elizabeth A Raetz
- Department of Pediatrics and Perlmutter Cancer Center, New York University Langone Medical Center, New York, NY
| | - Mignon L Loh
- Department of Pediatrics, Benioff Children's Hospital, and the Helen Diller Family Comprehensive Cancer Institute, University of California, San Francisco, San Francisco, CA
| | - Stephen P Hunger
- Department of Pediatrics and the Center for Childhood Cancer Research, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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11
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Hecht A, Meyer JA, Behnert A, Wong E, Chehab F, Olshen A, Hechmer A, Aftandilian C, Bhat R, Choi SW, Chonat S, Farrar JE, Fluchel M, Frangoul H, Han JH, Kolb EA, Kuo DJ, MacMillan ML, Maese L, Maloney KW, Narendran A, Oshrine B, Schultz KR, Sulis ML, Van Mater D, Tasian SK, Hofmann WK, Loh ML, Stieglitz E. Molecular and phenotypic diversity of CBL-mutated juvenile myelomonocytic leukemia. Haematologica 2020; 107:178-186. [PMID: 33375775 PMCID: PMC8719097 DOI: 10.3324/haematol.2020.270595] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Indexed: 11/22/2022] Open
Abstract
Mutations in the CBL gene were first identified in adults with various myeloid malignancies. Some patients with juvenile myelomonocytic leukemia (JMML) were also noted to harbor mutations in CBL, but were found to have generally less aggressive disease courses compared to patients with other forms of Ras pathway-mutant JMML. Importantly, and in contrast to most reports in adults, the majority of CBL mutations in JMML patients are germline with acquired uniparental disomy occurring in affected marrow cells. Here, we systematically studied a large cohort of 33 JMML patients with CBL mutations and found that this disease is highly diverse in presentation and overall outcome. Moreover, we discovered somatically acquired CBL mutations in 15% of pediatric patients who presented with more aggressive disease. Neither clinical features nor methylation profiling were able to distinguish patients with somatic CBL mutations from those with germline CBL mutations, highlighting the need for germline testing. Overall, we demonstrate that disease courses are quite heterogeneous even among patients with germline CBL mutations. Prospective clinical trials are warranted to find ideal treatment strategies for this diverse cohort of patients.
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Affiliation(s)
- Anna Hecht
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA; Department of Hematology/Oncology, University Hospital Mannheim, Heidelberg University
| | - Julia A Meyer
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco
| | - Astrid Behnert
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco
| | - Eric Wong
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco
| | - Farid Chehab
- Department of Laboratory Medicine, University of California, San Francisco, San Francisco
| | - Adam Olshen
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA; Department of Epidemiology and Biostatistics, University of California
| | - Aaron Hechmer
- Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco
| | | | - Rukhmi Bhat
- Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Sung Won Choi
- Blood and Marrow Transplantation Program, University of Michigan, Ann Arbor, MI
| | - Satheesh Chonat
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA; Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Jason E Farrar
- Arkansas Children's Research Institute, Little Rock, AR; Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Mark Fluchel
- University of Utah, Department of Pediatrics, Division of Pediatric Hematology-Oncology, Salt Lake City, UT
| | - Haydar Frangoul
- The Children's Hospital at TriStar Centennial and Sarah Cannon Research Institute, Nashville, TN
| | - Jennifer H Han
- Division of Pediatric Hematology-Oncology, University of California, San Diego/ Rady Children's Hospital San Diego
| | - Edward A Kolb
- Nemours Center for Cancer and Blood Disorders/Alfred I. DuPont Hospital for Children, Wilmington, DE
| | - Dennis J Kuo
- Division of Pediatric Hematology-Oncology, University of California, San Diego/ Rady Children's Hospital San Diego
| | - Margaret L MacMillan
- Blood and Marrow Transplant Program, Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN
| | - Luke Maese
- Department of Pediatrics and Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | | | - Aru Narendran
- Pediatric Hematology and Oncology, Alberta Children's Hospital, Calgary, Alberta
| | | | - Kirk R Schultz
- British Columbia Children's Hospital and Research Institute, Vancouver, British Columbia
| | - Maria L Sulis
- Department of Pediatrics, Memorial Sloan Kettering Cancer Center. 1275 York Avenue. 10065 New York, NY
| | - David Van Mater
- Department of Pediatrics, Duke University Medical Center, Durham, NC
| | - Sarah K Tasian
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia; Department of Pediatrics and Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Wolf-Karsten Hofmann
- Department of Hematology/Oncology, University Hospital Mannheim, Heidelberg University
| | - Mignon L Loh
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA; Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco
| | - Elliot Stieglitz
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA; Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco.
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12
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Winters AC, Maloney KW, Treece AL, Gore L, Franklin AK. Single-center pediatric experience with venetoclax and azacitidine as treatment for myelodysplastic syndrome and acute myeloid leukemia. Pediatr Blood Cancer 2020; 67:e28398. [PMID: 32735397 DOI: 10.1002/pbc.28398] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The BCL-2 inhibitor venetoclax (ven) has revolutionized the treatment of acute myeloid leukemia (AML) in elderly adults, leading to its recent FDA approval for this population in combination regimens. Although extensive data exist for adult myeloid malignancies, there are limited preclinical data on the efficacy and/or dosing of venetoclax for pediatric myelodysplastic syndrome (MDS) or AML and thus little information to guide use of this regimen in pediatric patients. Our objective was to describe our single-center experience with venetoclax in combination with the hypomethylating agent 5-azacitidine (aza) in pediatric patients with MDS or AML. PROCEDURE We conducted a retrospective chart review of patients treated at Children's Hospital Colorado prior to March 2020 with at least one cycle of ven/aza. Patients were included if between the ages of 1 and 25 years with a diagnosis of high-grade MDS or AML. AML patients had relapsed or primary refractory disease or were deemed poor candidates for standard chemotherapy. RESULTS Eight patients received ven/aza, two for high-grade MDS and six for AML. Ven/aza was well tolerated by all patients. The most common adverse events seen with this regimen were gastrointestinal and hematologic. Morphologic responses were seen in six patients including both patients with MDS. All four AML responders became minimal residual disease negative. Three responders have thus far proceeded to allogeneic hematopoietic stem cell transplant following ven/aza. CONCLUSIONS Our clinical experience suggests that ven/aza is a safe and promising regimen that should be further explored with late-phase clinical trials.
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Affiliation(s)
- Amanda C Winters
- Center for Cancer and Blood Disorders, Children's Hospital Colorado, Aurora, Colorado
| | - Kelly W Maloney
- Center for Cancer and Blood Disorders, Children's Hospital Colorado, Aurora, Colorado
| | - Amy L Treece
- Department of Pathology, Children's Hospital Colorado, Aurora, Colorado
| | - Lia Gore
- Center for Cancer and Blood Disorders, Children's Hospital Colorado, Aurora, Colorado
| | - Anna K Franklin
- Center for Cancer and Blood Disorders, Children's Hospital Colorado, Aurora, Colorado
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13
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Davies K, Barth M, Armenian S, Audino AN, Barnette P, Cuglievan B, Ding H, Ford JB, Galardy PJ, Gardner R, Hanna R, Hayashi R, Kovach AE, Machnitz AJ, Maloney KW, Marks L, Page K, Reilly AF, Weinstein JL, Xavier AC, McMillian NR, Freedman-Cass DA. Pediatric Aggressive Mature B-Cell Lymphomas, Version 2.2020, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2020; 18:1105-1123. [PMID: 32755986 DOI: 10.6004/jnccn.2020.0036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pediatric aggressive mature B-cell lymphomas are the most common types of non-Hodgkin lymphoma in children, and they include Burkitt lymphoma (BL) and diffuse large B-cell lymphoma (DLBCL). These diseases are highly aggressive but curable, the treatment is complex, and patients may have many complicated supportive care issues. The NCCN Guidelines for Pediatric Aggressive Mature B-Cell Lymphomas provide guidance regarding pathology and diagnosis, staging, initial treatment, disease reassessment, surveillance, therapy for relapsed/refractory disease, and supportive care for clinicians who treat sporadic pediatric BL and DLBCL.
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Affiliation(s)
- Kimberly Davies
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center
| | | | | | - Anthony N Audino
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | | | - Hilda Ding
- UCSD Rady Children's Hospital/UC San Diego Moores Cancer Center
| | | | | | - Rebecca Gardner
- Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
| | - Rabi Hanna
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | - Robert Hayashi
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | | | | | - Kelly W Maloney
- Children's Hospital of Colorado/University of Colorado Cancer Center
| | | | | | - Anne F Reilly
- Abramson Cancer Center at the University of Pennsylvania
| | | | - Ana C Xavier
- Children's of Alabama/O'Neal Comprehensive Cancer Center at UAB; and
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14
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Rabin KR, Chen Z, Devidas M, Hitzler J, Larsen E, Burke M, Salzer WL, Schore RJ, Carroll AJ, Heerema NA, Borowitz MJ, Wood BL, Carroll WL, Winick NJ, Raetz EA, Hunger S, Loh ML, Maloney KW, Angiolillo AL. Outcomes in children with Down syndrome (DS) and B-lymphoblastic leukemia (B-ALL): A Children’s Oncology Group (COG) report. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.10510] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
10510 Background: Patients with DS and B-ALL experience increased rates of relapse and toxicities. Here, we report results from 4 COG trials (2003-2018). Methods: We analyzed clinical, and outcome data for DS (n = 743) and non-DS (n = 21,703) patients age 1-30 enrolled on standard-risk (SR) trials AALL0331 and AALL0932 and high-risk (HR) trials AALL0232 and AALL1131. Initially, DS-ALL patients on AALL0232/AALL0331 experienced excess mortality, prompting enhanced supportive care and omission of induction anthracycline except for slow responders on AALL1131. Other modifications included: non-random assignment to treatment strata without investigational agents; leucovorin rescue after intrathecal methotrexate (MTX); equal maintenance length for boys and girls; every 12-week maintenance vincristine/steroid pulses; and reduced anthracycline and intravenous MTX for HR patients. Results: Across all 4 trials, DS and non-DS patients did not differ significantly in age, sex, initial WBC, or CNS status. DS-ALL patients had significantly higher end of induction (EOI) minimal residual disease (MRD) vs non-DS patients on both AALL0932 and AALL1131, but the difference persisted at end of consolidation (EOC) only on AALL1131, with fewer EOI MRD+ DS patients achieving EOC MRD < 0.01% (76.1 vs 88.0%, p = 0.001). 5-year EFS and OS were significantly poorer for DS vs non-DS across all trials (EFS 79.6+2.1% vs 86.3+0.3%, p < 0.0001; OS 86.5+1.8% vs 93.1+0.2%, p < 0.0001), as well as on each individual trial. In Cox regression analysis for all DS patients, inferior EFS was associated with several known risk factors (age > 10, EOI MRD >0.01%) but not with cytogenetics or CRLF2 status Induction death was more frequent in DS patients (3.4% vs 0.8%, p < 0.0001) as was death in remission (4.8+0.8% vs 1.8+0.1%, p < 0.0001). For death in remission, the increased frequency occurred pre-maintenance and in patients taken off protocol therapy, but not during maintenance, in contrast to prior reports. Grade >3 mucositis, infections, and hyperglycemia were significantly more frequent in DS patients on all trials. Grade >3 seizures were significantly more frequent in DS patients on HR but not SR trials (4.1% vs 1.7%. p = 0.001) and occurred in all phases pre-maintenance. Conclusions: Patients with DS and B-ALL continue to have inferior outcomes compared to non-DS, with increased relapse and toxicities. Less toxic approaches such as immunotherapies and targeted therapies hold promise to improve outcomes in both these areas.
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Affiliation(s)
| | | | | | | | - Eric Larsen
- Maine Childrens Cancer Program, Scarborough, ME
| | | | | | - Reuven J. Schore
- Children's National Health System and George Washington University School of Medicine and Health Sciences, Washington, DC
| | | | - Nyla A. Heerema
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | | | - Brent L. Wood
- Department of Laboratory Medicine, University of Washington, Seattle, WA
| | | | - Naomi J. Winick
- The University of Texas Southwestern Medical Center, Dallas, TX
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15
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Schore RJ, Angiolillo AJ, Kairalla JA, Devidas M, Rabin KR, Zweidler-McKay PA, Borowitz MJ, Wood BL, Carroll AJ, Heerema NA, Relling MV, Hitzler J, Lane AR, Maloney KW, Wang C, Carroll WL, Winick NJ, Raetz EA, Loh ML, Hunger S. Outcomes with reduced intensity therapy in a low-risk subset of children with National Cancer Institute (NCI) standard-risk (SR) B-lymphoblastic leukemia (B-ALL): A report from Children’s Oncology Group (COG) AALL0932. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.10509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
10509 Background: Post-hoc analysis of COG P9904 identified a low risk (LR) group of SR B-ALL patients aged 1-9.99 years with WBC < 50,000/µL, no CNS3, and either ETV6/RUNX1 or double trisomies (DT) of chromosomes 4 and 10 with day 8 peripheral blood (PB) and day 29 marrow (BM) minimal residual disease (MRD) < 0.01% who had a 5-year event-free survival (EFS) of 97±2% and overall survival (OS) 98.8±0.8%. Outstanding results were also obtained for LR patients on COG AALL0331 using CCG-based ALL therapy. AALL0932 tested prospectively whether LR B-ALL patients could attain a 5-year EFS ≥95% with these regimens. Methods: Following a 3-drug induction, eligible AALL0932 LR patients had NCI SR B-ALL (no testicular leukemia, unfavorable genetics or Down syndrome) with DT or ETV6/RUNX1 fusion, CNS1, no steroid pre-treatment, with Day 8 PB and Day 29 BM MRD < 0.01%. Between 2010-16, 603 LR patients were randomized to P9904-based regimen LR-M (n = 301) or CCG 1991/COG AALL0331-based regimen LR-C (n = 302). LR-M included 6 24-hour infusions of 1 gm/m2 of methotrexate (MTX) with leucovorin rescue, but no anthracyclines or alkylating agents. Maintenance followed with daily 6-mercaptopurine (6-MP) and weekly oral MTX, and every 16 week 7-day pulses of dexamethasone (DEX) with vincristine (VCR) on days 1 and 8. Boys and girls were treated for 2.5 years from diagnosis. LR-C had no 24-hour MTX infusions, but included 2 Interim Maintenance (IM) phases with VCR and escalating IV MTX without leucovorin rescue given every 10 days for 5 doses, flanking an 8-week Delayed Intensification (DI) phase that included DEX, VCR, pegasparagase, doxorubicin (75 mg/m2), cyclophosphamide (1 gm/m2) and 8 doses of low-dose cytarabine (75 mg/m2/dose). LR-C Maintenance included daily 6-MP and weekly oral MTX with 5-day pulses of DEX and 1 dose of VCR given every 12 weeks. Girls received 2 years and boys 3 years of therapy from the start of IM I. Results: Both regimens achieved outstanding outcomes: 5-yr disease-free survival (±SE) 98.8%±0.8% for LR-M and 98.5%±0.9% for LR-C (p = 0.67). Both had 5-yr OS 100%. Therapies were well tolerated with higher rates of mucositis (12.9 vs 6.3%; p = 0.008) and allergic reactions (2.3% vs 0%; p = 0.02) on LR-C. Conclusions: AALL0932 demonstrated that application of stringent risk criteria can identify a favorable B-ALL subgroup almost certain to be cured with either LR-M or LR-C, allowing physicians and families to select the optimal treatment approach in the future. Clinical trial information: NCT01190930.
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Affiliation(s)
- Reuven J. Schore
- Children's National Health System and George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Anne J. Angiolillo
- Children's National Health System and George Washington University School of Medicine and Health Sciences, Washington, DC
| | | | | | | | | | | | - Brent L. Wood
- Department of Laboratory Medicine, University of Washington, Seattle, WA
| | | | - Nyla A. Heerema
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | | | | | | | | | | | | | - Naomi J. Winick
- The University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Mignon L. Loh
- Department of Pediatrics, Benioff Children’s Hospital and the Helen Diller Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA
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16
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Gupta S, Wang C, Raetz EA, Schore R, Salzer WL, Larsen EC, Maloney KW, Mattano LA, Carroll WL, Winick NJ, Hunger SP, Loh ML, Devidas M. Impact of Asparaginase Discontinuation on Outcome in Childhood Acute Lymphoblastic Leukemia: A Report From the Children's Oncology Group. J Clin Oncol 2020; 38:1897-1905. [PMID: 32275469 DOI: 10.1200/jco.19.03024] [Citation(s) in RCA: 107] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Asparaginase (ASNase) is an important component of acute lymphoblastic leukemia (ALL) treatment, but is often discontinued because of toxicity. Erwinia chrysanthemi ASNase (Erwinia) substitution was approved in 2011 for allergic reactions. Erwinia has, however, been intermittently unavailable because of drug supply issues. The impact of Erwinia substitution or complete ASNase discontinuation is unknown. METHODS Patients aged 1-30.99 years in frontline Children's Oncology Group trials for B-cell acute lymphoblastic leukemia between 2004 and 2011 (National Cancer Institute [NCI] standard risk [SR]: AALL0331; NCI high risk: AALL0232) were included. The number of prescribed pegaspargase (PEG-ASNase) doses varied by trial and strata. Maintenance therapy did not contain ASNase. Landmark analyses at maintenance compared disease-free survival (DFS) among those receiving all prescribed PEG-ASNase doses versus switching to Erwinia but receiving all doses versus not receiving all ASNase doses. RESULTS We included 5,195 AALL0331 and 3,001 AALL0232 patients. The cumulative incidence of PEG-ASNase discontinuation was 12.2% ± 4.6% in AALL0331 and 25.4% ± 0.8% in AALL0232. In multivariable analyses, NCI high-risk patients not receiving all prescribed ASNase doses had inferior DFS (hazard ratio [HR], 1.5; 95% CI, 1.2 to 1.9; P = .002) compared with those receiving all prescribed PEG-ASNase doses. Patients with Erwinia substitution who completed subsequent courses were not at increased risk (HR, 1.1; 95% CI, 0.7 to 1.6; P = .69). NCI SR patients who discontinued ASNase were not at elevated risk (HR, 1.2; 95% CI, 0.9 to 1.6; P = .23), except when restricted to those with slow early response, who were prescribed more ASNase because of therapy intensification (HR, 1.7; 95% CI, 1.1 to 2.7; P = .03). CONCLUSION Discontinuation of ASNase doses is associated with inferior DFS in higher-risk patients. Our results illustrate the severe consequences of Erwinia shortages.
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Affiliation(s)
- Sumit Gupta
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Cindy Wang
- Department of Biostatistics, University of Florida, Gainesville, FL
| | | | | | - Wanda L Salzer
- US Army Medical Research and Materiel Command, Fort Detrick, MD
| | - Eric C Larsen
- Department of Pediatrics, Maine Children's Cancer Program, Scarborough, ME
| | | | | | - William L Carroll
- Department of Pediatrics and Perlmutter Cancer Center, New York University Langone Health, New York, NY
| | - Naomi J Winick
- University of Texas Southwestern/Simmons Cancer Center, Dallas, TX
| | - Stephen P Hunger
- Department of Pediatrics and the Center for Childhood Cancer Research, Children's Hospital of Philadelphia, and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Mignon L Loh
- Department of Pediatrics, UCSF Benoiff Childen's Hospital and Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA
| | - Meenakshi Devidas
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
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17
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Maloney KW, Devidas M, Wang C, Mattano LA, Friedmann AM, Buckley P, Borowitz MJ, Carroll AJ, Gastier-Foster JM, Heerema NA, Kadan-Lottick N, Loh ML, Matloub YH, Marshall DT, Stork LC, Raetz EA, Wood B, Hunger SP, Carroll WL, Winick NJ. Outcome in Children With Standard-Risk B-Cell Acute Lymphoblastic Leukemia: Results of Children's Oncology Group Trial AALL0331. J Clin Oncol 2019; 38:602-612. [PMID: 31825704 DOI: 10.1200/jco.19.01086] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
PURPOSE Children's Oncology Group (COG) AALL0331 tested whether intensified postinduction therapy that improves survival in children with high-risk B-cell acute lymphoblastic leukemia (ALL) would also improve outcomes for those with standard-risk (SR) ALL. PATIENTS AND METHODS AALL0331 enrolled 5,377 patients between 2005 and 2010. All patients received a 3-drug induction with dexamethasone, vincristine, and pegaspargase (PEG) and were then classified as SR low, SR average, or SR high. Patients with SR-average disease were randomly assigned to receive either standard 4-week consolidation (SC) or 8-week intensified augmented Berlin-Frankfurt-Münster (BFM) consolidation (IC). Those with SR-high disease were nonrandomly assigned to the full COG-augmented BFM regimen, including 2 interim maintenance and delayed intensification phases. RESULTS The 6-year event-free survival (EFS) rate for all patients enrolled in AALL0331 was 88.96% ± 0.46%, and overall survival (OS) was 95.54% ± 0.31%. For patients with SR-average disease, the 6-year continuous complete remission (CCR) and OS rates for SC versus IC were 87.8% ± 1.3% versus 89.1% ± 1.2% (P = .52) and 95.8% ± 0.8% versus 95.2% ± 0.8% (P = 1.0), respectively. Those with SR-average disease with end-induction minimal residual disease (MRD) of 0.01% to < 0.1% had an inferior outcome compared with those with lower MRD and no improvement with IC (6-year CCR: SC, 77.5% ± 4.8%; IC, 77.1% ± 4.8%; P = .71). At 6 years, the CCR and OS rates among 635 nonrandomly treated patients with SR-high disease were 85.55% ± 1.49% and 92.97% ± 1.08%, respectively. CONCLUSION The 6-year OS rate for > 5,000 children with SR ALL enrolled in AALL0331 exceeded 95%. The addition of IC to treatment for patients with SR-average disease did not improve CCR or OS, even in patients with higher MRD, in whom it might have been predicted to provide more value. The EFS and OS rates are excellent for this group of patients with SR ALL, with particularly good outcomes for those with SR-high disease.
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Affiliation(s)
- Kelly W Maloney
- Department of Pediatrics, University of Colorado, Aurora, CO.,Children's Hospital Colorado, Aurora, CO
| | - Meenakshi Devidas
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - Cindy Wang
- Department of Biostatistics, Colleges of Medicine, Public Health and Health Professions, University of Florida, Gainesville, FL
| | | | - Alison M Friedmann
- Department of Pediatrics, Massachusetts General Hospital Cancer Center, Boston, MA
| | - Patrick Buckley
- Department of Pathology, Duke University Medical Center, Durham, NC
| | | | - Andrew J Carroll
- Department of Genetics, University of Alabama at Birmingham, Birmingham, AL
| | - Julie M Gastier-Foster
- Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, OH.,Department of Pediatrics, Ohio State University College of Medicine, Columbus, OH
| | - Nyla A Heerema
- Department of Pathology, Wexner Medical Center, Ohio State University, Columbus, OH
| | | | - Mignon L Loh
- Department of Pediatrics, Benioff Children's Hospital, San Francisco, CA.,Helen Diller Family Comprehensive Cancer, University of California, San Francisco, CA
| | - Yousif H Matloub
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - David T Marshall
- Department of Radiation Oncology, Medical University of South Carolina, Charleston, SC
| | - Linda C Stork
- Department of Pediatrics, Oregon Health & Science University, Portland, OR
| | - Elizabeth A Raetz
- Perlmutter Cancer Center, New York University (NYU) Langone Medical Center, New York, NY.,Department of Pediatrics, NYU Langone Medical Center, New York, NY
| | - Brent Wood
- Department of Pathology, University of Washington, Seattle, WA.,Department of Medicine, University of Washington, Seattle, WA
| | - Stephen P Hunger
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA.,Perelman School of Medicine at University of Philadelphia, Philadelphia, PA
| | - William L Carroll
- Perlmutter Cancer Center, New York University (NYU) Langone Medical Center, New York, NY.,Department of Pediatrics, NYU Langone Medical Center, New York, NY
| | - Naomi J Winick
- Department of Pediatrics, University of Texas (UT) Southwestern, Dallas, TX.,Simmons Cancer Center, UT Southwestern, Dallas, TX
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18
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Carroll AJ, Shago M, Mikhail FM, Raimondi SC, Hirsch BA, Loh ML, Raetz EA, Borowitz MJ, Wood BL, Maloney KW, Mattano LA, Larsen EC, Gastier-Foster J, Stonerock E, Ell D, Kahwash S, Devidas M, Harvey RC, Chen IML, Willman CL, Hunger SP, Winick NJ, Carroll WL, Rao KW, Heerema NA. Masked hypodiploidy: Hypodiploid acute lymphoblastic leukemia (ALL) mimicking hyperdiploid ALL in children: A report from the Children's Oncology Group. Cancer Genet 2019; 238:62-68. [PMID: 31425927 DOI: 10.1016/j.cancergen.2019.07.009] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 06/28/2019] [Accepted: 07/27/2019] [Indexed: 10/26/2022]
Abstract
Hyperdiploidy with greater than 50 chromosomes is usually associated with favorable prognosis in pediatric acute lymphoblastic leukemia (ALL), whereas hypodiploidy with ≤43 chromosomes is associated with extremely poor prognosis. Sometimes, hypodiploidy is "masked" and patients do not have a karyotypically visible clone with ≤43 chromosomes. Instead, their abnormal karyotypes contain 50-78 or more chromosomes from doubling of previously hypodiploid cells. When the hypodiploid and doubled hyperdiploid clones are both present, patients can be identified by traditional test methods [karyotype, DNA Index (DI), fluorescence in situ hybridization (FISH)], but the incidence of masked hypodiploid cases in which only the doubled clone is visible is unknown. We analyzed 7013 patients with B-ALL enrolled in COG AALL03B1 (2003-2011) for whom chromosome studies were available. Of 115 patients with hypodiploidy (25-39 chromosomes), karyotypes of 40 showed only the hypodiploid clone, 47 showed mosaicism with both hypodiploid and hyperdiploid (doubled) karyotypes, and 28 with masked hypodiploidy showed only a hyperdiploid (doubled) clone. Unique karyotypic signatures were identified, and widespread loss of heterozygosity (LOH) was seen in the microsatellite panel for all patients with masked hypodiploidy. An increased awareness of the unusual karyotypic profile associated with a doubled hypodiploid clone and coordinated use of DI, FISH, and LOH studies when indicated can identify patients with masked hypodiploidy and allow appropriate treatment selection.
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Affiliation(s)
- Andrew J Carroll
- Department of Genetics, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Mary Shago
- Department of Pathobiology and Laboratory Medicine, University of Toronto, Toronto, ON, Canada
| | - Fady M Mikhail
- Department of Genetics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Susana C Raimondi
- Department of Pathology, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Betsy A Hirsch
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Mignon L Loh
- Department of Pediatrics, UCSF Medical Center-Mission Bay, San Francisco, CA, USA
| | - Elizabeth A Raetz
- Department of Pediatrics, New York University Medical Center, New York, NY, USA
| | - Michael J Borowitz
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - Brent L Wood
- Department of Laboratory Medicine, University of Washington, Seattle, WA, USA
| | | | | | - Eric C Larsen
- Maine Children's Cancer Program, Scarborough, ME, USA
| | - Julie Gastier-Foster
- Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, USA; Department of Pathology, The Ohio State University, Columbus, OH, USA
| | - Eileen Stonerock
- Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Denise Ell
- Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Samir Kahwash
- Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Meenakshi Devidas
- Department of Biostatistics, University of Florida, Gainesville, FL, USA
| | | | - I-Ming L Chen
- University of New Mexico Cancer Center, Albuquerque, NM, USA
| | | | - Stephen P Hunger
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Naomi J Winick
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - William L Carroll
- Department of Pediatrics, New York University Medical Center, New York, NY, USA
| | - Kathleen W Rao
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Nyla A Heerema
- Department of Pathology, The Ohio State University, Columbus, OH, USA
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19
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Amankwah EK, Maloney KW, Larsen EC, Devidas M, Teachey DT, Rabin KR, Loh ML, Brown PA. Abstract 1576: Identification of six novel candidate miRNAs associated with early relapse in B-cell pediatric acute lymphoblastic leukemia. Cancer Res 2019. [DOI: 10.1158/1538-7445.am2019-1576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Aberrantly expressed miRNAs may contribute to treatment resistance in pediatric acute lymphoblastic leukemia relapse (ALL) and could serve as biomarkers for risk of relapse. However, few studies have evaluated the role of miRNAs in ALL relapse and a consensus clinically significant miRNA signature is yet to be identified. In this study, we identified miRNAs associated with pediatric B-ALL relapse, by profiling ~2,500 miRNAs in two independent sample sets.
Methods: We performed global miRNA profiling using Affymetrix miRNA v 4.0 on two independent samples. Profiling was initially performed on diagnostic bone marrow specimens from 6 early relapse (≤3 years after diagnosis) and 6 age and cytogenetics matched prolonged remission (≥4 years) patients treated at the Johns Hopkins School of Medicine (first set). We then performed profiling on 14 early relapse and 14 matched prolonged remission specimens from patients treated on the Children’s Oncology Group trials AALL0331 and AALL0232 (second set). Global miRNA expression was compared between early relapse and remission samples in each set. Differential expression was determined based on fold change (>1) and false discovery rate q-value (<0.05).
Results: Twelve and 39 top differentially expressed miRNAs were observed in the first (fold change=1.48-4.45, q<0.05) and second (fold change=1.12-2.19, q<0.05) sets, respectively. None of the top differentially expressed miRNAs in the two datasets overlapped. However, six miRNAs (miR-101-3p, miR-4774-5p, miR-1324, miR-631, miR-4699-5p and miR-922) were consistently upregulated in early relapse compared to remission specimens in both the first (fold change=1.13-2.19, q<0.38) and second (fold change=1.48-4.78, all q<0.05) sets; albeit these miRNAs did not meet the q-value threshold in the first set. Four (miR-631, mir-101-3p, miR-922 and miR-1324) out of the six overlapping miRNAs have been previously implicated in key functional oncogenic pathways in adult cancers, including multiple myeloma, prostate, lung, liver, breast and head and neck cancers.
Conclusion: This study provides evidence for a set of six miRNAs that are associated with early relapse in pediatric B-ALL. Although some of the differentially expressed miRNAs have been implicated in adult cancers, none of them have been previously implicated in pediatric B-ALL. Therefore, validation of these miRNAs in a larger cohort and investigation of their mechanistic role are warranted.
Citation Format: Ernest K. Amankwah, Kelly W. Maloney, Eric C. Larsen, Meenakshi Devidas, David T. Teachey, Karen R. Rabin, Mignon L. Loh, Patrick A. Brown. Identification of six novel candidate miRNAs associated with early relapse in B-cell pediatric acute lymphoblastic leukemia [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 1576.
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20
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Gupta S, Wang C, Raetz EA, Schore RJ, Salzer WL, Larsen E, Maloney KW, Mattano LA, Carroll WL, Winick NJ, Hunger S, Loh ML, Devidas M. Impact of asparaginase discontinuation on outcome in childhood ALL: A report from the Children’s Oncology Group (COG). J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.10005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
10005 Background: Asparaginase (ASP) is an important component of acute lymphoblastic leukemia (ALL) treatment, but is often discontinued due to toxicity. For allergic reactions, but not other toxicities, Erwinia Asparaginase (EA) is often substituted. The majority of treatment protocols use discrete, discontinuous periods of asparagine depletion. In the context of such protocols, the impact of EA substitution or complete ASP discontinuation is unknown. Methods: Patients age 1-30.99 years enrolled on frontline COG trials for B-ALL [standard risk (NCI SR): AALL0331; high risk (NCI HR) AALL0232] were included. The number of prescribed pegaspargase (PEG) doses varied by trial, risk strata, and randomization (Table). Maintenance therapy did not contain ASP. Landmark analyses starting at Maintenance compared event free survival (EFS) between those receiving all prescribed doses of PEG vs. those switched to EA but receiving all doses vs. those not receiving all ASP doses. Results: This study included 5,195 AALL0331 and 3,001 AALL0232 patients. The cumulative incidence of PEG discontinuation was 12.2±4.6% on AALL0331 and 25.4%±0.8% on AALL0232. In multivariable analyses adjusted for patient and disease variables, NCI HR patients who did not receive all prescribed ASP doses had inferior EFS [hazard ratio (HR) 1.5, 95% confidence interval (95CI) 1.2-1.9; p=0.002] compared to those receiving all prescribed PEG doses. Patients with EA substitution who completed their courses were not at increased risk (HR 1.1, 95CI 0.7-1.6; p=0.69). Sensitivity analyses excluding patients discontinuing ASP due to pancreatitis or thrombosis yielded similar results. NCI SR patients who discontinued ASP were not at elevated risk (HR 1.2, 95CI 0.9-1.6; p=0.23), except when analyses were restricted to NCI SR patients with slow early response (HR 1.7, 95CI 1.1-2.7; p=0.03). Conclusions: Discontinuation of ASP doses is associated with significantly inferior EFS and must be balanced against the risks of ASP re-challenge. Our results also illustrate the potentially severe consequences of EA shortages. Prescribed pegasparagase doses. [Table: see text]
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Affiliation(s)
- Sumit Gupta
- Hospital for Sick Children, Toronto, ON, Canada
| | | | | | | | | | - Eric Larsen
- Maine Childrens Cancer Program, Scarborough, ME
| | | | | | | | - Naomi J. Winick
- The University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Mignon L. Loh
- University of California, San Francisco, San Francisco, CA
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21
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McNeer JL, Devidas M, Dai Y, Carroll AJ, Heerema NA, Gastier-Foster JM, Kahwash SB, Borowitz MJ, Wood BL, Larsen E, Maloney KW, Mattano L, Winick NJ, Schultz KR, Hunger SP, Carroll WL, Loh ML, Raetz EA. Hematopoietic Stem-Cell Transplantation Does Not Improve the Poor Outcome of Children With Hypodiploid Acute Lymphoblastic Leukemia: A Report From Children's Oncology Group. J Clin Oncol 2019; 37:780-789. [PMID: 30742559 PMCID: PMC6440386 DOI: 10.1200/jco.18.00884] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2018] [Indexed: 01/06/2023] Open
Abstract
PURPOSE Children and young adults with hypodiploid B-lymphoblastic leukemia (B-ALL) fare poorly and hematopoietic stem-cell transplantation (HSCT) is often pursued in first complete remission (CR1). We retrospectively reviewed the outcomes of children and young adults with hypodiploid B-ALL who were enrolled in recent Children's Oncology Group (COG) trials to evaluate the impact of HSCT on outcome. PATIENTS AND METHODS Cytogenetic analyses and DNA index were performed at COG-approved laboratories, and hypodiploidy was defined as modal chromosome number less than 44 and/or DNA index less than 0.81. Minimal residual disease (MRD) was determined centrally using flow cytometry at two reference laboratories. Patients with hypodiploid ALL came off protocol therapy postinduction and we retrospectively collected details on their subsequent therapy and outcomes. Event-free survival (EFS) and overall survival (OS) were estimated for the cohort. RESULTS Between 2003 and 2011, 8,522 patients with National Cancer Institute standard-risk and high-risk B-ALL were enrolled in COG AALL03B1 ( ClinicalTrials.gov identifier: NCT00482352). Hypodiploidy occurred in 1.5% of patients (n = 131), 98.3% of whom achieved CR after induction therapy. Five-year EFS and OS were 52.2% ± 4.9% and 58.9% ± 4.8%, respectively. Outcomes for patients undergoing CR1 HSCT were not significantly improved: 5-year EFS and OS were 57.4% ± 7.0% and 66.2% ± 6.6% compared with 47.8% ± 7.5% and 53.8% ± 7.6%, respectively ( P = .49 and .34, respectively) for those who did not undergo transplantation. Patients with MRD of 0.01% or greater at the end of induction had 5-year EFS and OS of 26.7% ± 9.3% and 29.3% ± 10.1%, respectively, and HSCT had no significant impact on outcomes. CONCLUSION Children and young adults with hypodiploid B-ALL continue to fare poorly and do not seem to benefit from CR1 HSCT. This is especially true for patients with MRD of 0.01% or greater at the end of induction. New treatment strategies are urgently needed for these patients.
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Affiliation(s)
| | | | | | | | | | | | - Samir B. Kahwash
- Nationwide Children’s Hospital and The Ohio State University, Columbus, OH
| | | | | | - Eric Larsen
- Maine Children’s Cancer Program, Scarborough, ME
| | | | | | | | - Kirk R. Schultz
- BC Children’s Hospital and Research Institute, Vancouver, British Columbia, Canada
| | | | | | - Mignon L. Loh
- University of California, San Francisco, San Francisco, CA
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22
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Gu Z, Churchman ML, Roberts KG, Moore I, Zhou X, Nakitandwe J, Hagiwara K, Pelletier S, Gingras S, Berns H, Payne-Turner D, Hill A, Iacobucci I, Shi L, Pounds S, Cheng C, Pei D, Qu C, Newman S, Devidas M, Dai Y, Reshmi SC, Gastier-Foster J, Raetz EA, Borowitz MJ, Wood BL, Carroll WL, Zweidler-McKay PA, Rabin KR, Mattano LA, Maloney KW, Rambaldi A, Spinelli O, Radich JP, Minden MD, Rowe JM, Luger S, Litzow MR, Tallman MS, Racevskis J, Zhang Y, Bhatia R, Kohlschmidt J, Mrózek K, Bloomfield CD, Stock W, Kornblau S, Kantarjian HM, Konopleva M, Evans WE, Jeha S, Pui CH, Yang J, Paietta E, Downing JR, Relling MV, Zhang J, Loh ML, Hunger SP, Mullighan CG. PAX5-driven subtypes of B-progenitor acute lymphoblastic leukemia. Nat Genet 2019; 51:296-307. [PMID: 30643249 DOI: 10.1038/s41588-018-0315-5] [Citation(s) in RCA: 329] [Impact Index Per Article: 65.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 11/13/2018] [Indexed: 12/20/2022]
Abstract
Recent genomic studies have identified chromosomal rearrangements defining new subtypes of B-progenitor acute lymphoblastic leukemia (B-ALL), however many cases lack a known initiating genetic alteration. Using integrated genomic analysis of 1,988 childhood and adult cases, we describe a revised taxonomy of B-ALL incorporating 23 subtypes defined by chromosomal rearrangements, sequence mutations or heterogeneous genomic alterations, many of which show marked variation in prevalence according to age. Two subtypes have frequent alterations of the B lymphoid transcription-factor gene PAX5. One, PAX5alt (7.4%), has diverse PAX5 alterations (rearrangements, intragenic amplifications or mutations); a second subtype is defined by PAX5 p.Pro80Arg and biallelic PAX5 alterations. We show that p.Pro80Arg impairs B lymphoid development and promotes the development of B-ALL with biallelic Pax5 alteration in vivo. These results demonstrate the utility of transcriptome sequencing to classify B-ALL and reinforce the central role of PAX5 as a checkpoint in B lymphoid maturation and leukemogenesis.
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Affiliation(s)
- Zhaohui Gu
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Michelle L Churchman
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Kathryn G Roberts
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Ian Moore
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Xin Zhou
- Department of Computational Biology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Joy Nakitandwe
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Kohei Hagiwara
- Department of Computational Biology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Stephane Pelletier
- Department of Immunology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Sebastien Gingras
- Department of Immunology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Hartmut Berns
- Department of Transgenic/Gene Knockout Shared Resource, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Debbie Payne-Turner
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Ashley Hill
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Ilaria Iacobucci
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Lei Shi
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Stanley Pounds
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Cheng Cheng
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Deqing Pei
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Chunxu Qu
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Scott Newman
- Department of Computational Biology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Meenakshi Devidas
- Department of Biostatistics, University of Florida, Gainesville, FL, USA
| | - Yunfeng Dai
- Department of Biostatistics, University of Florida, Gainesville, FL, USA
| | - Shalini C Reshmi
- Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Julie Gastier-Foster
- Institute for Genomic Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Elizabeth A Raetz
- Division of Pediatric Hematology-Oncology, New York University, New York, NY, USA
| | - Michael J Borowitz
- Division of Hematologic Pathology, Johns Hopkins University, Baltimore, MD, USA
| | - Brent L Wood
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
| | | | | | | | | | - Kelly W Maloney
- University of Colorado School of Medicine and Children's Hospital, Aurora, CO, USA
| | - Alessandro Rambaldi
- Hematology and Bone Marrow Transplant Unit, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Orietta Spinelli
- Hematology and Bone Marrow Transplant Unit, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | | | - Mark D Minden
- Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Jacob M Rowe
- Hematology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Selina Luger
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Mark R Litzow
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Janis Racevskis
- Cancer Center, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Yanming Zhang
- Cytogenetics Laboratory, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ravi Bhatia
- Division of Hematology-Oncology, University of Birmingham, Birmingham, AL, USA
| | | | - Krzysztof Mrózek
- Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Clara D Bloomfield
- Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Wendy Stock
- University of Chicago Medical Center, Chicago, IL, USA
| | - Steven Kornblau
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hagop M Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Marina Konopleva
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Williams E Evans
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Sima Jeha
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Ching-Hon Pui
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Jun Yang
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Elisabeth Paietta
- Cancer Center, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - James R Downing
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Mary V Relling
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Jinghui Zhang
- Department of Computational Biology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Mignon L Loh
- Department of Pediatrics, UCSF Benioff Children's Hospital and the Helen Diller Family, San Francisco, CA, USA
| | - Stephen P Hunger
- Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Charles G Mullighan
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN, USA.
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23
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Gupta S, Devidas M, Loh ML, Raetz EA, Chen S, Wang C, Brown P, Carroll AJ, Heerema NA, Gastier-Foster JM, Dunsmore KP, Larsen EC, Maloney KW, Mattano LA, Winter SS, Winick NJ, Carroll WL, Hunger SP, Borowitz MJ, Wood BL. Flow-cytometric vs. -morphologic assessment of remission in childhood acute lymphoblastic leukemia: a report from the Children's Oncology Group (COG). Leukemia 2018; 32:1370-1379. [PMID: 29472723 PMCID: PMC5992047 DOI: 10.1038/s41375-018-0039-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 10/30/2017] [Accepted: 11/10/2017] [Indexed: 12/30/2022]
Abstract
Minimal residual disease (MRD) after initial therapy is integral to risk stratification in B-precursor and T-precursor acute lymphoblastic leukemia (B-ALL, T-ALL). Although MRD determines depth of remission, remission remains defined by morphology. We determined the outcomes of children with discordant assessments of remission by morphology vs. flow cytometry using patients age 1-30.99 years enrolled on Children's Oncology Group ALL trials who underwent bone marrow assessment at the end of induction (N = 9350). Morphologic response was assessed locally as M1 (<5% lymphoblasts; remission), M2 (5-25%), or M3 (>25%). MRD was centrally measured by flow cytometry. Overall, 19.8% of patients with M2/M3 morphology had MRD < 5%. M1 with MRD ≥ 5% was less common in B-ALL (0.9%) than T-ALL (6.9%; p < 0.0001). In B-ALL, M1/MRD ≥ 5% was associated with superior 5-year event-free survival (EFS) than M2/MRD ≥ 5% (59.1% ± 6.5% vs. 39.1% ± 7.9%; p = 0.009), but was inferior to M1/MRD < 5% (87.1% ± 0.4%; p < 0.0001). MRD levels were higher in M2/MRD ≥ 5% than M1/MRD ≥ 5% patients. In T-ALL, EFS was not significantly different between M1/MRD ≥ 5% and M2/MRD ≥ 5%. Patients with morphologic remission but MRD ≥ 5% have outcomes similar to those who fail to achieve morphological remission, and significantly inferior to those with M1 marrows and concordant MRD, suggesting that flow cytometry should augment the definition of remission in ALL.
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Affiliation(s)
- Sumit Gupta
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada.
| | - Meenakshi Devidas
- Department of Biostatistics, University of Florida, Gainesville, FL, USA
| | - Mignon L Loh
- Division of Hematology Oncology, University of California at San Francisco, San Francisco, CA, USA
| | - Elizabeth A Raetz
- Division of Pediatric Hematology-Oncology, Primary Children's Hospital, Salt Lake City, UT, USA
| | - Si Chen
- Department of Biostatistics, University of Florida, Gainesville, FL, USA
| | - Cindy Wang
- Department of Biostatistics, University of Florida, Gainesville, FL, USA
| | - Patrick Brown
- Johns Hopkins University/Sidney Kimmel Cancer Center, Baltimore, MD, USA
| | - Andrew J Carroll
- Department of Genetics, Children's Hospital of Alabama, Birmingham, AL, USA
| | - Nyla A Heerema
- Department of Pathology, The Ohio State University, Columbus, OH, USA
| | | | - Kimberly P Dunsmore
- Department of Pediatrics, University of Virginia Cancer Center, Norton, VA, USA
| | - Eric C Larsen
- Maine Children's Cancer Program, Scarborough, ME, USA
| | | | | | - Stuart S Winter
- University of New Mexico Cancer Center, Albuquerque, NM, USA
| | - Naomi J Winick
- Department of Pediatrics, University of Texas Southwestern/Simmons Cancer Center, Dallas, TX, USA
| | | | - Stephen P Hunger
- Department of Genetics, Children's Hospital of Alabama, Birmingham, AL, USA
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michael J Borowitz
- Division of Hematologic Pathology, John Hopkins University, Baltimore, MD, USA
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24
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Pikman Y, Tasian SK, Sulis ML, Blonquist TM, Maloney KW, McNeer JL, Pauly MG, Shukla NN, Tyner J, Cole PD, Burke MJ, Gossai N, Brown PA, Gore L, Hunger S, Cooper TM, Silverman LB, Harris MH, Loh ML, Stegmaier K. Matched targeted therapy for pediatric patients with relapsed, refractory or high-risk leukemias: A report from the LEAP consortium. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.10518] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | - Traci M. Blonquist
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | | | | | | | | | | | | | | | | | | | - Lia Gore
- University of Colorado Comprehensive Cancer Center, Aurora, CO
| | | | | | | | | | - Mignon L. Loh
- University of California, San Francisco, San Francisco, CA
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25
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Abstract
Acute lymphoblastic leukemia (ALL) is the most common cancer in childhood. Standard chemotherapy has afforded outstanding outcomes for many patients; however, there remain some sub-groups with high-risk features, refractory disease, and patients that relapse who have a poor prognosis with conventional treatments. Over the past decade, there have been significant advances in newer treatment options, including improved monoclonal antibody therapies, T cell engagers, and chimeric antigen T-cell receptor products, all of which have changed the landscape for patients who relapse. These are now being introduced more frequently and at earlier stages of therapy. We present a brief overview of the biology and etiology of childhood ALL, treatment strategies currently in use, and discuss some newer strategies and their possible role in the future of ALL therapy for children.
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Affiliation(s)
- Kelly W Maloney
- Center for Cancer and Blood Disorders, Children's Hospital Colorado, Pediatric Hematology/Oncology/Bone Marrow Transplant, University of Colorado School of Medicine, 13123 East 16th Av, Box B115, Aurora, CO, 80045, USA
| | - Lia Gore
- Center for Cancer and Blood Disorders, Children's Hospital Colorado, Pediatric Hematology/Oncology/Bone Marrow Transplant, University of Colorado School of Medicine, 13123 East 16th Av, Box B115, Aurora, CO, 80045, USA.
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26
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Hoppmann AL, Hill T, Chen Y, Landier W, Hageman L, Evans WE, Angiolillo AL, Bostrom BC, Casillas JN, Lew G, Maloney KW, Mascarenhas L, Ritchey AK, Termuhlen AM, Carroll WL, Wong FL, Relling MV, Bhatia S. Measuring mercaptopurine (6MP) adherence using red cell 6MP metabolite levels in children with acute lymphoblastic leukemia (ALL): A COG AALL03N1 study. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.10514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
10514 Background: Non-adherence to 6MP (monitored with medication event monitoring system [MEMs]) is associated with an increased risk of relapse in children with ALL.(JAMA Oncol, 2015) Self-report over-estimates true medication intake, particularly in non-adherent patients.(Blood, 2017) However, monitoring adherence using MEMs is logistically difficult. We investigated whether red cell 6MP metabolite levels (thioguanine nucleotide [TGN] and methylated mercaptopurine [MMP]) taken together, could identify non-adherent patients. Methods: The analysis included children with ALL in maintenance. To minimize variability in TGN and MMP levels due to pharmacogenetics, we excluded TPMT heterozygotes and homozygote mutants. We also excluded Asians to remove variability due to NUDT15. TGN and MMP levels were drawn at 6 consecutive monthly time points for each patient and averaged. TGN and MMP levels (pmol/8 x 108red cells) were standardized, adjusted for 6MP dose intensity, and then analyzed using cluster analysis (Spath, H. [1980]). Results: The 373 patients eligible for analysis yielded 5 clusters. Cluster #1 (n = 119; mean MMP: 15,656; mean TGN: 158); Cluster #2 (n = 211; MMP: 6,042; TGN: 135); and 3 very small outlying clusters (total N = 43). Adjusting for age, sex, race/ethnicity, cytogenetics and NCI risk, we found that patients in Cluster #2 were 2.6 times as likely to be non-adherent (MEMs-based adherence < 95%) compared to Cluster #1 (95% CI 1.5-4.4; P= 0.0007). Mean MEMs-based adherence was significantly higher for patients in Cluster #1 (94.3%) when compared to those in Cluster #2 (87.8%, p = 0.0002). Using Fine-Gray proportional subdistribution hazards models for competing risks and adjusting for clinical and sociodemographic factors, we found that patients in Cluster #2 were at a 2.3-fold higher risk of relapse compared with those in Cluster #1 (95%CI, 1.0-6.4, p = 0.058). Conclusions: These findings illustrate the potential for using a combination of red cell TGN and MMP levels in identifying non-adherent patients. We propose to use these and clinical and demographic factors associated with non-adherence in creating an adherence calculator.
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Affiliation(s)
| | - Torrey Hill
- University of Alabama at Birmingham, Birmingham, AL
| | - Yanjun Chen
- University of Alabama at Birmingham, Birmingham, AL
| | | | | | | | | | | | | | - Glen Lew
- Children's Healthcare of Atlanta/Emory University, Atlanta, GA
| | | | - Leo Mascarenhas
- Children’s Center for Cancer and Blood Diseases, Children’s Hospital Los Angeles, University of Southern California, Los Angeles, CA
| | | | | | | | | | | | - Smita Bhatia
- University of Alabama at Birmingham, Birmingham, AL
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27
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Landier W, Hageman L, Chen Y, Kornegay N, Evans WE, Bostrom BC, Casillas J, Dickens DS, Angiolillo AL, Lew G, Maloney KW, Mascarenhas L, Ritchey AK, Termuhlen AM, Carroll WL, Relling MV, Wong FL, Bhatia S. Mercaptopurine Ingestion Habits, Red Cell Thioguanine Nucleotide Levels, and Relapse Risk in Children With Acute Lymphoblastic Leukemia: A Report From the Children's Oncology Group Study AALL03N1. J Clin Oncol 2017; 35:1730-1736. [PMID: 28339328 DOI: 10.1200/jco.2016.71.7579] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Purpose Children with acute lymphoblastic leukemia (ALL) are generally instructed to take mercaptopurine (6-MP) in the evening and without food or dairy products. This study examines the association between 6-MP ingestion habits and 6-MP adherence, red cell thioguanine nucleotide (TGN) levels, and risk of relapse in children with TMPT wild-type genotype. Methods Participants included 441 children with ALL receiving oral 6-MP for maintenance. Adherence was monitored over 48,086 patient-days using the Medication Event Monitoring System; nonadherence was defined as adherence rate < 95%. 6-MP ingestion habits examined included: takes 6-MP with versus never with food, takes 6-MP with versus never with dairy, and takes 6-MP in the evening versus morning versus varying times. Results Median age at study was 6 years (range, 2 to 20 years); 43.8% were nonadherent. Certain 6-MP ingestion habits were associated with nonadherence (taking 6-MP with dairy [odds ratio (OR), 1.9; 95% CI, 1.3 to 2.9; P = .003] and at varying times [OR, 3.4; 95% CI, 1.8 to 6.3; P = .0001]). After adjusting for adherence and other prognosticators, there was no association between 6-MP ingestion habits and relapse risk (6-MP with food: hazard ratio [HR], 0.7; 95% CI, 0.3 to 1.9; P = .5; with dairy: HR, 0.3; 95% CI, 0.07 to 1.5; P = .2; taken in evening/night: HR, 1.1; 95% CI, 0.2 to 7.8; P = .9; at varying times: HR, 0.3; 95% CI, 0.04 to 2.7; P = .3). Among adherent patients, there was no association between red cell TGN levels and taking 6-MP with food versus without (206.1 ± 107.1 v 220.6 ± 121.6; P = .5), with dairy versus without (220.1 ± 87.8 v 216.3 ± 121.3; P =.7), or in the evening/night versus morning/midday versus varying times (218.8 ± 119.7 v 195.5 ± 82.3 v 174.8 ± 93.4; P = .6). Conclusion Commonly practiced restrictions surrounding 6-MP ingestion might not influence outcome but may hinder adherence. Future recommendations regarding 6-MP intake during maintenance therapy for childhood ALL should aim to simplify administration.
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Affiliation(s)
- Wendy Landier
- Wendy Landier, Lindsey Hageman, Yanjun Chen, and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL; Nancy Kornegay, William E. Evans, and Mary V. Relling, St. Jude Children's Research Hospital, Memphis, TN; Bruce C. Bostrom, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN; Jacqueline Casillas, David Geffen School of Medicine at University of California Los Angeles, Los Angeles; Leo Mascarenhas and Amanda M. Termuhlen, Children's Hospital Los Angeles, Los Angeles; F. Lennie Wong, City of Hope, Duarte, CA; David S. Dickens, Helen DeVos Children's Hospital at Spectrum Health/Spectrum Health at Butterworth Campus, Grand Rapids, MI; Anne L. Angiolillo, The George Washington School of Medicine, Washington, DC; Glen Lew, Children's Healthcare of Atlanta, Emory University, Atlanta, GA; Kelly W. Maloney, University of Colorado School of Medicine, Aurora, CO; A. Kim Ritchey, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA; and William L. Carroll, Perlmutter Cancer Center, New York University-Langone Medical Center, New York, NY
| | - Lindsey Hageman
- Wendy Landier, Lindsey Hageman, Yanjun Chen, and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL; Nancy Kornegay, William E. Evans, and Mary V. Relling, St. Jude Children's Research Hospital, Memphis, TN; Bruce C. Bostrom, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN; Jacqueline Casillas, David Geffen School of Medicine at University of California Los Angeles, Los Angeles; Leo Mascarenhas and Amanda M. Termuhlen, Children's Hospital Los Angeles, Los Angeles; F. Lennie Wong, City of Hope, Duarte, CA; David S. Dickens, Helen DeVos Children's Hospital at Spectrum Health/Spectrum Health at Butterworth Campus, Grand Rapids, MI; Anne L. Angiolillo, The George Washington School of Medicine, Washington, DC; Glen Lew, Children's Healthcare of Atlanta, Emory University, Atlanta, GA; Kelly W. Maloney, University of Colorado School of Medicine, Aurora, CO; A. Kim Ritchey, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA; and William L. Carroll, Perlmutter Cancer Center, New York University-Langone Medical Center, New York, NY
| | - Yanjun Chen
- Wendy Landier, Lindsey Hageman, Yanjun Chen, and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL; Nancy Kornegay, William E. Evans, and Mary V. Relling, St. Jude Children's Research Hospital, Memphis, TN; Bruce C. Bostrom, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN; Jacqueline Casillas, David Geffen School of Medicine at University of California Los Angeles, Los Angeles; Leo Mascarenhas and Amanda M. Termuhlen, Children's Hospital Los Angeles, Los Angeles; F. Lennie Wong, City of Hope, Duarte, CA; David S. Dickens, Helen DeVos Children's Hospital at Spectrum Health/Spectrum Health at Butterworth Campus, Grand Rapids, MI; Anne L. Angiolillo, The George Washington School of Medicine, Washington, DC; Glen Lew, Children's Healthcare of Atlanta, Emory University, Atlanta, GA; Kelly W. Maloney, University of Colorado School of Medicine, Aurora, CO; A. Kim Ritchey, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA; and William L. Carroll, Perlmutter Cancer Center, New York University-Langone Medical Center, New York, NY
| | - Nancy Kornegay
- Wendy Landier, Lindsey Hageman, Yanjun Chen, and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL; Nancy Kornegay, William E. Evans, and Mary V. Relling, St. Jude Children's Research Hospital, Memphis, TN; Bruce C. Bostrom, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN; Jacqueline Casillas, David Geffen School of Medicine at University of California Los Angeles, Los Angeles; Leo Mascarenhas and Amanda M. Termuhlen, Children's Hospital Los Angeles, Los Angeles; F. Lennie Wong, City of Hope, Duarte, CA; David S. Dickens, Helen DeVos Children's Hospital at Spectrum Health/Spectrum Health at Butterworth Campus, Grand Rapids, MI; Anne L. Angiolillo, The George Washington School of Medicine, Washington, DC; Glen Lew, Children's Healthcare of Atlanta, Emory University, Atlanta, GA; Kelly W. Maloney, University of Colorado School of Medicine, Aurora, CO; A. Kim Ritchey, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA; and William L. Carroll, Perlmutter Cancer Center, New York University-Langone Medical Center, New York, NY
| | - William E Evans
- Wendy Landier, Lindsey Hageman, Yanjun Chen, and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL; Nancy Kornegay, William E. Evans, and Mary V. Relling, St. Jude Children's Research Hospital, Memphis, TN; Bruce C. Bostrom, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN; Jacqueline Casillas, David Geffen School of Medicine at University of California Los Angeles, Los Angeles; Leo Mascarenhas and Amanda M. Termuhlen, Children's Hospital Los Angeles, Los Angeles; F. Lennie Wong, City of Hope, Duarte, CA; David S. Dickens, Helen DeVos Children's Hospital at Spectrum Health/Spectrum Health at Butterworth Campus, Grand Rapids, MI; Anne L. Angiolillo, The George Washington School of Medicine, Washington, DC; Glen Lew, Children's Healthcare of Atlanta, Emory University, Atlanta, GA; Kelly W. Maloney, University of Colorado School of Medicine, Aurora, CO; A. Kim Ritchey, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA; and William L. Carroll, Perlmutter Cancer Center, New York University-Langone Medical Center, New York, NY
| | - Bruce C Bostrom
- Wendy Landier, Lindsey Hageman, Yanjun Chen, and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL; Nancy Kornegay, William E. Evans, and Mary V. Relling, St. Jude Children's Research Hospital, Memphis, TN; Bruce C. Bostrom, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN; Jacqueline Casillas, David Geffen School of Medicine at University of California Los Angeles, Los Angeles; Leo Mascarenhas and Amanda M. Termuhlen, Children's Hospital Los Angeles, Los Angeles; F. Lennie Wong, City of Hope, Duarte, CA; David S. Dickens, Helen DeVos Children's Hospital at Spectrum Health/Spectrum Health at Butterworth Campus, Grand Rapids, MI; Anne L. Angiolillo, The George Washington School of Medicine, Washington, DC; Glen Lew, Children's Healthcare of Atlanta, Emory University, Atlanta, GA; Kelly W. Maloney, University of Colorado School of Medicine, Aurora, CO; A. Kim Ritchey, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA; and William L. Carroll, Perlmutter Cancer Center, New York University-Langone Medical Center, New York, NY
| | - Jacqueline Casillas
- Wendy Landier, Lindsey Hageman, Yanjun Chen, and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL; Nancy Kornegay, William E. Evans, and Mary V. Relling, St. Jude Children's Research Hospital, Memphis, TN; Bruce C. Bostrom, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN; Jacqueline Casillas, David Geffen School of Medicine at University of California Los Angeles, Los Angeles; Leo Mascarenhas and Amanda M. Termuhlen, Children's Hospital Los Angeles, Los Angeles; F. Lennie Wong, City of Hope, Duarte, CA; David S. Dickens, Helen DeVos Children's Hospital at Spectrum Health/Spectrum Health at Butterworth Campus, Grand Rapids, MI; Anne L. Angiolillo, The George Washington School of Medicine, Washington, DC; Glen Lew, Children's Healthcare of Atlanta, Emory University, Atlanta, GA; Kelly W. Maloney, University of Colorado School of Medicine, Aurora, CO; A. Kim Ritchey, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA; and William L. Carroll, Perlmutter Cancer Center, New York University-Langone Medical Center, New York, NY
| | - David S Dickens
- Wendy Landier, Lindsey Hageman, Yanjun Chen, and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL; Nancy Kornegay, William E. Evans, and Mary V. Relling, St. Jude Children's Research Hospital, Memphis, TN; Bruce C. Bostrom, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN; Jacqueline Casillas, David Geffen School of Medicine at University of California Los Angeles, Los Angeles; Leo Mascarenhas and Amanda M. Termuhlen, Children's Hospital Los Angeles, Los Angeles; F. Lennie Wong, City of Hope, Duarte, CA; David S. Dickens, Helen DeVos Children's Hospital at Spectrum Health/Spectrum Health at Butterworth Campus, Grand Rapids, MI; Anne L. Angiolillo, The George Washington School of Medicine, Washington, DC; Glen Lew, Children's Healthcare of Atlanta, Emory University, Atlanta, GA; Kelly W. Maloney, University of Colorado School of Medicine, Aurora, CO; A. Kim Ritchey, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA; and William L. Carroll, Perlmutter Cancer Center, New York University-Langone Medical Center, New York, NY
| | - Anne L Angiolillo
- Wendy Landier, Lindsey Hageman, Yanjun Chen, and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL; Nancy Kornegay, William E. Evans, and Mary V. Relling, St. Jude Children's Research Hospital, Memphis, TN; Bruce C. Bostrom, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN; Jacqueline Casillas, David Geffen School of Medicine at University of California Los Angeles, Los Angeles; Leo Mascarenhas and Amanda M. Termuhlen, Children's Hospital Los Angeles, Los Angeles; F. Lennie Wong, City of Hope, Duarte, CA; David S. Dickens, Helen DeVos Children's Hospital at Spectrum Health/Spectrum Health at Butterworth Campus, Grand Rapids, MI; Anne L. Angiolillo, The George Washington School of Medicine, Washington, DC; Glen Lew, Children's Healthcare of Atlanta, Emory University, Atlanta, GA; Kelly W. Maloney, University of Colorado School of Medicine, Aurora, CO; A. Kim Ritchey, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA; and William L. Carroll, Perlmutter Cancer Center, New York University-Langone Medical Center, New York, NY
| | - Glen Lew
- Wendy Landier, Lindsey Hageman, Yanjun Chen, and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL; Nancy Kornegay, William E. Evans, and Mary V. Relling, St. Jude Children's Research Hospital, Memphis, TN; Bruce C. Bostrom, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN; Jacqueline Casillas, David Geffen School of Medicine at University of California Los Angeles, Los Angeles; Leo Mascarenhas and Amanda M. Termuhlen, Children's Hospital Los Angeles, Los Angeles; F. Lennie Wong, City of Hope, Duarte, CA; David S. Dickens, Helen DeVos Children's Hospital at Spectrum Health/Spectrum Health at Butterworth Campus, Grand Rapids, MI; Anne L. Angiolillo, The George Washington School of Medicine, Washington, DC; Glen Lew, Children's Healthcare of Atlanta, Emory University, Atlanta, GA; Kelly W. Maloney, University of Colorado School of Medicine, Aurora, CO; A. Kim Ritchey, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA; and William L. Carroll, Perlmutter Cancer Center, New York University-Langone Medical Center, New York, NY
| | - Kelly W Maloney
- Wendy Landier, Lindsey Hageman, Yanjun Chen, and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL; Nancy Kornegay, William E. Evans, and Mary V. Relling, St. Jude Children's Research Hospital, Memphis, TN; Bruce C. Bostrom, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN; Jacqueline Casillas, David Geffen School of Medicine at University of California Los Angeles, Los Angeles; Leo Mascarenhas and Amanda M. Termuhlen, Children's Hospital Los Angeles, Los Angeles; F. Lennie Wong, City of Hope, Duarte, CA; David S. Dickens, Helen DeVos Children's Hospital at Spectrum Health/Spectrum Health at Butterworth Campus, Grand Rapids, MI; Anne L. Angiolillo, The George Washington School of Medicine, Washington, DC; Glen Lew, Children's Healthcare of Atlanta, Emory University, Atlanta, GA; Kelly W. Maloney, University of Colorado School of Medicine, Aurora, CO; A. Kim Ritchey, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA; and William L. Carroll, Perlmutter Cancer Center, New York University-Langone Medical Center, New York, NY
| | - Leo Mascarenhas
- Wendy Landier, Lindsey Hageman, Yanjun Chen, and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL; Nancy Kornegay, William E. Evans, and Mary V. Relling, St. Jude Children's Research Hospital, Memphis, TN; Bruce C. Bostrom, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN; Jacqueline Casillas, David Geffen School of Medicine at University of California Los Angeles, Los Angeles; Leo Mascarenhas and Amanda M. Termuhlen, Children's Hospital Los Angeles, Los Angeles; F. Lennie Wong, City of Hope, Duarte, CA; David S. Dickens, Helen DeVos Children's Hospital at Spectrum Health/Spectrum Health at Butterworth Campus, Grand Rapids, MI; Anne L. Angiolillo, The George Washington School of Medicine, Washington, DC; Glen Lew, Children's Healthcare of Atlanta, Emory University, Atlanta, GA; Kelly W. Maloney, University of Colorado School of Medicine, Aurora, CO; A. Kim Ritchey, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA; and William L. Carroll, Perlmutter Cancer Center, New York University-Langone Medical Center, New York, NY
| | - A Kim Ritchey
- Wendy Landier, Lindsey Hageman, Yanjun Chen, and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL; Nancy Kornegay, William E. Evans, and Mary V. Relling, St. Jude Children's Research Hospital, Memphis, TN; Bruce C. Bostrom, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN; Jacqueline Casillas, David Geffen School of Medicine at University of California Los Angeles, Los Angeles; Leo Mascarenhas and Amanda M. Termuhlen, Children's Hospital Los Angeles, Los Angeles; F. Lennie Wong, City of Hope, Duarte, CA; David S. Dickens, Helen DeVos Children's Hospital at Spectrum Health/Spectrum Health at Butterworth Campus, Grand Rapids, MI; Anne L. Angiolillo, The George Washington School of Medicine, Washington, DC; Glen Lew, Children's Healthcare of Atlanta, Emory University, Atlanta, GA; Kelly W. Maloney, University of Colorado School of Medicine, Aurora, CO; A. Kim Ritchey, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA; and William L. Carroll, Perlmutter Cancer Center, New York University-Langone Medical Center, New York, NY
| | - Amanda M Termuhlen
- Wendy Landier, Lindsey Hageman, Yanjun Chen, and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL; Nancy Kornegay, William E. Evans, and Mary V. Relling, St. Jude Children's Research Hospital, Memphis, TN; Bruce C. Bostrom, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN; Jacqueline Casillas, David Geffen School of Medicine at University of California Los Angeles, Los Angeles; Leo Mascarenhas and Amanda M. Termuhlen, Children's Hospital Los Angeles, Los Angeles; F. Lennie Wong, City of Hope, Duarte, CA; David S. Dickens, Helen DeVos Children's Hospital at Spectrum Health/Spectrum Health at Butterworth Campus, Grand Rapids, MI; Anne L. Angiolillo, The George Washington School of Medicine, Washington, DC; Glen Lew, Children's Healthcare of Atlanta, Emory University, Atlanta, GA; Kelly W. Maloney, University of Colorado School of Medicine, Aurora, CO; A. Kim Ritchey, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA; and William L. Carroll, Perlmutter Cancer Center, New York University-Langone Medical Center, New York, NY
| | - William L Carroll
- Wendy Landier, Lindsey Hageman, Yanjun Chen, and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL; Nancy Kornegay, William E. Evans, and Mary V. Relling, St. Jude Children's Research Hospital, Memphis, TN; Bruce C. Bostrom, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN; Jacqueline Casillas, David Geffen School of Medicine at University of California Los Angeles, Los Angeles; Leo Mascarenhas and Amanda M. Termuhlen, Children's Hospital Los Angeles, Los Angeles; F. Lennie Wong, City of Hope, Duarte, CA; David S. Dickens, Helen DeVos Children's Hospital at Spectrum Health/Spectrum Health at Butterworth Campus, Grand Rapids, MI; Anne L. Angiolillo, The George Washington School of Medicine, Washington, DC; Glen Lew, Children's Healthcare of Atlanta, Emory University, Atlanta, GA; Kelly W. Maloney, University of Colorado School of Medicine, Aurora, CO; A. Kim Ritchey, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA; and William L. Carroll, Perlmutter Cancer Center, New York University-Langone Medical Center, New York, NY
| | - Mary V Relling
- Wendy Landier, Lindsey Hageman, Yanjun Chen, and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL; Nancy Kornegay, William E. Evans, and Mary V. Relling, St. Jude Children's Research Hospital, Memphis, TN; Bruce C. Bostrom, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN; Jacqueline Casillas, David Geffen School of Medicine at University of California Los Angeles, Los Angeles; Leo Mascarenhas and Amanda M. Termuhlen, Children's Hospital Los Angeles, Los Angeles; F. Lennie Wong, City of Hope, Duarte, CA; David S. Dickens, Helen DeVos Children's Hospital at Spectrum Health/Spectrum Health at Butterworth Campus, Grand Rapids, MI; Anne L. Angiolillo, The George Washington School of Medicine, Washington, DC; Glen Lew, Children's Healthcare of Atlanta, Emory University, Atlanta, GA; Kelly W. Maloney, University of Colorado School of Medicine, Aurora, CO; A. Kim Ritchey, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA; and William L. Carroll, Perlmutter Cancer Center, New York University-Langone Medical Center, New York, NY
| | - F Lennie Wong
- Wendy Landier, Lindsey Hageman, Yanjun Chen, and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL; Nancy Kornegay, William E. Evans, and Mary V. Relling, St. Jude Children's Research Hospital, Memphis, TN; Bruce C. Bostrom, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN; Jacqueline Casillas, David Geffen School of Medicine at University of California Los Angeles, Los Angeles; Leo Mascarenhas and Amanda M. Termuhlen, Children's Hospital Los Angeles, Los Angeles; F. Lennie Wong, City of Hope, Duarte, CA; David S. Dickens, Helen DeVos Children's Hospital at Spectrum Health/Spectrum Health at Butterworth Campus, Grand Rapids, MI; Anne L. Angiolillo, The George Washington School of Medicine, Washington, DC; Glen Lew, Children's Healthcare of Atlanta, Emory University, Atlanta, GA; Kelly W. Maloney, University of Colorado School of Medicine, Aurora, CO; A. Kim Ritchey, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA; and William L. Carroll, Perlmutter Cancer Center, New York University-Langone Medical Center, New York, NY
| | - Smita Bhatia
- Wendy Landier, Lindsey Hageman, Yanjun Chen, and Smita Bhatia, University of Alabama at Birmingham, Birmingham, AL; Nancy Kornegay, William E. Evans, and Mary V. Relling, St. Jude Children's Research Hospital, Memphis, TN; Bruce C. Bostrom, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN; Jacqueline Casillas, David Geffen School of Medicine at University of California Los Angeles, Los Angeles; Leo Mascarenhas and Amanda M. Termuhlen, Children's Hospital Los Angeles, Los Angeles; F. Lennie Wong, City of Hope, Duarte, CA; David S. Dickens, Helen DeVos Children's Hospital at Spectrum Health/Spectrum Health at Butterworth Campus, Grand Rapids, MI; Anne L. Angiolillo, The George Washington School of Medicine, Washington, DC; Glen Lew, Children's Healthcare of Atlanta, Emory University, Atlanta, GA; Kelly W. Maloney, University of Colorado School of Medicine, Aurora, CO; A. Kim Ritchey, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA; and William L. Carroll, Perlmutter Cancer Center, New York University-Langone Medical Center, New York, NY
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Maloney JP, Branchford BR, Brodsky GL, Cosmic MS, Calabrese DW, Aquilante CL, Maloney KW, Gonzalez JR, Zhang W, Moreau KL, Wiggins KL, Smith NL, Broeckel U, Di Paola J. The ENTPD1 promoter polymorphism -860 A > G (rs3814159) is associated with increased gene transcription, protein expression, CD39/NTPDase1 enzymatic activity, and thromboembolism risk. FASEB J 2017; 31:2771-2784. [PMID: 28302652 DOI: 10.1096/fj.201600344r] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 02/26/2017] [Indexed: 11/11/2022]
Abstract
Ectonucleoside triphosphate diphosphohydrolase 1 (NTPDase1) degrades the purines ATP and ADP that are key regulators of inflammation and clotting. We hypothesized that NTPDase1 polymorphisms exist and that they regulate this pathway. We sequenced the ENTPD1 gene (encoding NTPDase1) in 216 subjects then assessed genotypes in 2 cohorts comprising 2213 humans to identify ENTPD1 polymorphisms associated with venous thromboembolism (VTE). The G allele of the intron 1 polymorphism rs3176891 was more common in VTE vs. controls (odds ratio 1.26-1.9); it did not affect RNA splicing, but it was in strong linkage disequilibrium with the G allele of the promoter polymorphism rs3814159, which increased transcriptional activity by 8-fold. Oligonucleotides containing the G allele of this promoter region bound nuclear extracts more avidly. Carriers of rs3176891 G had endothelial cells with increased NTPDase1 activity and protein expression, and had platelets with enhanced aggregation. Thus, the G allele of rs3176891 marks a haplotype associated with increased clotting and platelet aggregation attributable to a promoter variant associated with increased transcription, expression, and activity of NTPDase1. We term this gain-of-function phenotype observed with rs3814159 G "CD39 Denver."-Maloney, J. P., Branchford, B. R., Brodsky, G. L., Cosmic, M. S., Calabrese, D. W., Aquilante, C. L., Maloney, K. W., Gonzalez, J. R., Zhang, W., Moreau, K. L., Wiggins, K. L., Smith, N. L., Broeckel, U., Di Paola, J. The ENTPD1 promoter polymorphism -860 A > G (rs3814159) is associated with increased gene transcription, protein expression, CD39/NTPDase1 enzymatic activity, and thromboembolism risk.
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Affiliation(s)
- James P Maloney
- Division of Pulmonary and Critical Care Medicine, University of Colorado at Denver, Aurora, Colorado, USA; .,Denver Veterans Affairs Medical Center, Denver, Colorado, USA
| | - Brian R Branchford
- Center for Cancer and Blood Disorders, University of Colorado at Denver, Aurora, Colorado, USA
| | - Gary L Brodsky
- Center for Cancer and Blood Disorders, University of Colorado at Denver, Aurora, Colorado, USA
| | - Maxwell S Cosmic
- Chest, Infectious Disease, and Critical Care Associates, Des Moines, Iowa, USA
| | - David W Calabrese
- Division of Pulmonary and Critical Care Medicine, University of Colorado at Denver, Aurora, Colorado, USA.,Denver Veterans Affairs Medical Center, Denver, Colorado, USA
| | - Christina L Aquilante
- Pharmaceutical Sciences/School of Pharmacy, University of Colorado at Denver, Aurora, Colorado, USA
| | - Kelly W Maloney
- Center for Cancer and Blood Disorders, University of Colorado at Denver, Aurora, Colorado, USA
| | - Joseph R Gonzalez
- Otolaryngology-Head and Neck Surgery, University of Colorado at Denver, Aurora, Colorado, USA
| | - Weiming Zhang
- Biostatistics and Informatics/Colorado School of Public Health, University of Colorado at Denver, Aurora, Colorado, USA
| | - Kerrie L Moreau
- Division of Geriatric Medicine, University of Colorado at Denver, Aurora, Colorado, USA
| | - Kerri L Wiggins
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Nicholas L Smith
- Department of Epidemiology, University of Washington, Seattle, Washington, USA.,Seattle Epidemiologic Research and Information Center, Seattle, Washington, USA.,Veterans Affairs Office of Research and Development, Seattle, Washington, USA.,Group Health Research Institutes, Group Health Cooperative, Seattle, Washington, USA
| | - Ulrich Broeckel
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Human and Molecular Genetics Center, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jorge Di Paola
- Center for Cancer and Blood Disorders, University of Colorado at Denver, Aurora, Colorado, USA
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Rogers AEJ, Eisenman KM, Dolan SA, Belderson KM, Zauche JR, Tong S, Gralla J, Hilden JM, Wang M, Maloney KW, Dominguez SR. Risk factors for bacteremia and central line-associated blood stream infections in children with acute myelogenous leukemia: A single-institution report. Pediatr Blood Cancer 2017; 64. [PMID: 27616655 DOI: 10.1002/pbc.26254] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 08/10/2016] [Indexed: 11/05/2022]
Abstract
BACKGROUND Central line-associated blood stream infections (CLABSIs) are a source of high morbidity and mortality in children with acute myelogenous leukemia (AML). PROCEDURE To understand the epidemiology and risk factors associated with the development of CLABSI in children with AML. METHODS We retrospectively reviewed all patients with AML over a 5-year period between 2007 and 2011 at the Children's Hospital Colorado. Cases and controls were classified on the basis of the presence of a CLABSI as defined by the National Healthcare Safety Network. RESULTS Of 40 patients in the study, 25 (62.5%) developed at least one CLABSI during therapy. The majority of CLABSIs were due to oral or gastrointestinal organisms (83.0%). Skin organisms accounted for 8.5%. In a multivariable analysis, the strongest risk factors associated with CLABSI were diarrhea (odds ratio [OR] 6.7, 95% confidence interval [CI] 1.6-28.7), receipt of blood products in the preceding 4-7 days (OR 10.0, 95%CI 3.2-31.0), not receiving antibiotics (OR 8.3, 95%CI 2.8-25.0), and chemotherapy cycle (OR 3.5, 95%CI 1.4-8.9). CLABSIs led to increased morbidity, with 13 cases (32.5%) versus two controls (1.9%) requiring transfer to the pediatric intensive care unit (P < 0.001). Three (7.5%) of 40 CLABSI events resulted in or contributed to death. CONCLUSIONS Intensified line care efforts cannot eliminate all CLABSIs in the patients with AML. Exploring the role of mucosal barrier breakdown and/or the use of antibiotic prophylaxis may be effective strategies for further prevention of CLABSIs, supporting ongoing trials in this patient population.
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Affiliation(s)
- Ashley E J Rogers
- Department of Pediatric Oncology, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Kristen M Eisenman
- Department of Pediatric Oncology, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Susan A Dolan
- Department of Epidemiology, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Kristin M Belderson
- Department of Pediatric Oncology, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Jocelyn R Zauche
- Department of Pediatric Oncology, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Suhong Tong
- Department of Pediatrics, Biostatistics and Informatics, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Jane Gralla
- Department of Pediatrics, Biostatistics and Informatics, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Joanne M Hilden
- Department of Pediatric Oncology, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Michael Wang
- Department of Pediatric Oncology, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Kelly W Maloney
- Department of Pediatric Oncology, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Samuel R Dominguez
- Department of Epidemiology, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado.,Department of Infectious Disease, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado
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30
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Liu C, Yang W, Devidas M, Cheng C, Pei D, Smith C, Carroll WL, Raetz EA, Bowman WP, Larsen EC, Maloney KW, Martin PL, Mattano LA, Winick NJ, Mardis ER, Fulton RS, Bhojwani D, Howard SC, Jeha S, Pui CH, Hunger SP, Evans WE, Loh ML, Relling MV. Clinical and Genetic Risk Factors for Acute Pancreatitis in Patients With Acute Lymphoblastic Leukemia. J Clin Oncol 2016; 34:2133-40. [PMID: 27114598 DOI: 10.1200/jco.2015.64.5812] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
PURPOSE Acute pancreatitis is one of the common causes of asparaginase intolerance. The mechanism is unknown, and genetic predisposition to asparaginase-induced pancreatitis has not been previously identified. METHODS To determine clinical risk factors for asparaginase-induced pancreatitis, we studied a cohort of 5,185 children and young adults with acute lymphoblastic leukemia, including 117 (2.3%) who were diagnosed with at least one episode of acute pancreatitis during therapy. A genome-wide association study was performed in the cohort and in an independent case-control group of 213 patients to identify genetic risk factors. RESULTS Risk factors associated with pancreatitis included genetically defined Native American ancestry (P < .001), older age (P < .001), and higher cumulative dose of asparaginase (P < .001). No common variants reached genome-wide significance in the genome-wide association study, but a rare nonsense variant rs199695765 in CPA2, encoding carboxypeptidase A2, was highly associated with pancreatitis (hazard ratio, 587; 95% CI, 66.8 to 5166; P = 9.0 × 10(-9)). A gene-level analysis showed an excess of additional CPA2 variants in patients who did versus those who did not develop pancreatitis (P = .001). Sixteen CPA2 single-nucleotide polymorphisms were associated (P < .05) with pancreatitis, and 13 of 24 patients who carried at least one of these variants developed pancreatitis. Biologic functions that were overrepresented by common variants modestly associated with pancreatitis included purine metabolism and cytoskeleton regulation. CONCLUSION Older age, higher exposure to asparaginase, and higher Native American ancestry were independent risk factors for pancreatitis in patients with acute lymphoblastic leukemia. Those who inherit a nonsense rare variant in the CPA2 gene had a markedly increased risk of asparaginase-induced pancreatitis.
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Affiliation(s)
- Chengcheng Liu
- Chengcheng Liu, Wenjian Yang, Cheng Cheng, Deqing Pei, Colton Smith, Sima Jeha, Ching-Hon Pui, William E. Evans, and Mary V. Relling, St Jude Children's Research Hospital; Scott C. Howard, University of Memphis, Memphis, TN; Meenakshi Devidas, University of Florida, Gainesville, FL; William L. Carroll, New York University Langone Medical Center, New York, NY; Elizabeth A. Raetz, University of Utah, Salt Lake City, UT; W. Paul Bowman, Cook Children's Hospital, Ft Worth; Naomi J. Winick, University of Texas Southwestern Medical Center, Dallas, TX; Eric C. Larsen, Maine Children's Cancer Program, Scarborough, ME; Kelly W. Maloney, University of Colorado Denver, Aurora, CO; Paul L. Martin, Duke University, Durham, NC; Leonard A. Mattano Jr, HARP Pharma Consulting, Mystic, CT; Elaine R. Mardis and Robert S. Fulton, The McDonnell Genome Institute, Washington University School of Medicine, St. Louis, MO; Deepa Bhojwani, Children's Hospital of Los Angeles, Los Angeles; Mignon L. Loh, University of California San Francisco Medical Center-Parnassus, San Francisco, CA; and Stephen P. Hunger, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Wenjian Yang
- Chengcheng Liu, Wenjian Yang, Cheng Cheng, Deqing Pei, Colton Smith, Sima Jeha, Ching-Hon Pui, William E. Evans, and Mary V. Relling, St Jude Children's Research Hospital; Scott C. Howard, University of Memphis, Memphis, TN; Meenakshi Devidas, University of Florida, Gainesville, FL; William L. Carroll, New York University Langone Medical Center, New York, NY; Elizabeth A. Raetz, University of Utah, Salt Lake City, UT; W. Paul Bowman, Cook Children's Hospital, Ft Worth; Naomi J. Winick, University of Texas Southwestern Medical Center, Dallas, TX; Eric C. Larsen, Maine Children's Cancer Program, Scarborough, ME; Kelly W. Maloney, University of Colorado Denver, Aurora, CO; Paul L. Martin, Duke University, Durham, NC; Leonard A. Mattano Jr, HARP Pharma Consulting, Mystic, CT; Elaine R. Mardis and Robert S. Fulton, The McDonnell Genome Institute, Washington University School of Medicine, St. Louis, MO; Deepa Bhojwani, Children's Hospital of Los Angeles, Los Angeles; Mignon L. Loh, University of California San Francisco Medical Center-Parnassus, San Francisco, CA; and Stephen P. Hunger, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Meenakshi Devidas
- Chengcheng Liu, Wenjian Yang, Cheng Cheng, Deqing Pei, Colton Smith, Sima Jeha, Ching-Hon Pui, William E. Evans, and Mary V. Relling, St Jude Children's Research Hospital; Scott C. Howard, University of Memphis, Memphis, TN; Meenakshi Devidas, University of Florida, Gainesville, FL; William L. Carroll, New York University Langone Medical Center, New York, NY; Elizabeth A. Raetz, University of Utah, Salt Lake City, UT; W. Paul Bowman, Cook Children's Hospital, Ft Worth; Naomi J. Winick, University of Texas Southwestern Medical Center, Dallas, TX; Eric C. Larsen, Maine Children's Cancer Program, Scarborough, ME; Kelly W. Maloney, University of Colorado Denver, Aurora, CO; Paul L. Martin, Duke University, Durham, NC; Leonard A. Mattano Jr, HARP Pharma Consulting, Mystic, CT; Elaine R. Mardis and Robert S. Fulton, The McDonnell Genome Institute, Washington University School of Medicine, St. Louis, MO; Deepa Bhojwani, Children's Hospital of Los Angeles, Los Angeles; Mignon L. Loh, University of California San Francisco Medical Center-Parnassus, San Francisco, CA; and Stephen P. Hunger, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Cheng Cheng
- Chengcheng Liu, Wenjian Yang, Cheng Cheng, Deqing Pei, Colton Smith, Sima Jeha, Ching-Hon Pui, William E. Evans, and Mary V. Relling, St Jude Children's Research Hospital; Scott C. Howard, University of Memphis, Memphis, TN; Meenakshi Devidas, University of Florida, Gainesville, FL; William L. Carroll, New York University Langone Medical Center, New York, NY; Elizabeth A. Raetz, University of Utah, Salt Lake City, UT; W. Paul Bowman, Cook Children's Hospital, Ft Worth; Naomi J. Winick, University of Texas Southwestern Medical Center, Dallas, TX; Eric C. Larsen, Maine Children's Cancer Program, Scarborough, ME; Kelly W. Maloney, University of Colorado Denver, Aurora, CO; Paul L. Martin, Duke University, Durham, NC; Leonard A. Mattano Jr, HARP Pharma Consulting, Mystic, CT; Elaine R. Mardis and Robert S. Fulton, The McDonnell Genome Institute, Washington University School of Medicine, St. Louis, MO; Deepa Bhojwani, Children's Hospital of Los Angeles, Los Angeles; Mignon L. Loh, University of California San Francisco Medical Center-Parnassus, San Francisco, CA; and Stephen P. Hunger, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Deqing Pei
- Chengcheng Liu, Wenjian Yang, Cheng Cheng, Deqing Pei, Colton Smith, Sima Jeha, Ching-Hon Pui, William E. Evans, and Mary V. Relling, St Jude Children's Research Hospital; Scott C. Howard, University of Memphis, Memphis, TN; Meenakshi Devidas, University of Florida, Gainesville, FL; William L. Carroll, New York University Langone Medical Center, New York, NY; Elizabeth A. Raetz, University of Utah, Salt Lake City, UT; W. Paul Bowman, Cook Children's Hospital, Ft Worth; Naomi J. Winick, University of Texas Southwestern Medical Center, Dallas, TX; Eric C. Larsen, Maine Children's Cancer Program, Scarborough, ME; Kelly W. Maloney, University of Colorado Denver, Aurora, CO; Paul L. Martin, Duke University, Durham, NC; Leonard A. Mattano Jr, HARP Pharma Consulting, Mystic, CT; Elaine R. Mardis and Robert S. Fulton, The McDonnell Genome Institute, Washington University School of Medicine, St. Louis, MO; Deepa Bhojwani, Children's Hospital of Los Angeles, Los Angeles; Mignon L. Loh, University of California San Francisco Medical Center-Parnassus, San Francisco, CA; and Stephen P. Hunger, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Colton Smith
- Chengcheng Liu, Wenjian Yang, Cheng Cheng, Deqing Pei, Colton Smith, Sima Jeha, Ching-Hon Pui, William E. Evans, and Mary V. Relling, St Jude Children's Research Hospital; Scott C. Howard, University of Memphis, Memphis, TN; Meenakshi Devidas, University of Florida, Gainesville, FL; William L. Carroll, New York University Langone Medical Center, New York, NY; Elizabeth A. Raetz, University of Utah, Salt Lake City, UT; W. Paul Bowman, Cook Children's Hospital, Ft Worth; Naomi J. Winick, University of Texas Southwestern Medical Center, Dallas, TX; Eric C. Larsen, Maine Children's Cancer Program, Scarborough, ME; Kelly W. Maloney, University of Colorado Denver, Aurora, CO; Paul L. Martin, Duke University, Durham, NC; Leonard A. Mattano Jr, HARP Pharma Consulting, Mystic, CT; Elaine R. Mardis and Robert S. Fulton, The McDonnell Genome Institute, Washington University School of Medicine, St. Louis, MO; Deepa Bhojwani, Children's Hospital of Los Angeles, Los Angeles; Mignon L. Loh, University of California San Francisco Medical Center-Parnassus, San Francisco, CA; and Stephen P. Hunger, Children's Hospital of Philadelphia, Philadelphia, PA
| | - William L Carroll
- Chengcheng Liu, Wenjian Yang, Cheng Cheng, Deqing Pei, Colton Smith, Sima Jeha, Ching-Hon Pui, William E. Evans, and Mary V. Relling, St Jude Children's Research Hospital; Scott C. Howard, University of Memphis, Memphis, TN; Meenakshi Devidas, University of Florida, Gainesville, FL; William L. Carroll, New York University Langone Medical Center, New York, NY; Elizabeth A. Raetz, University of Utah, Salt Lake City, UT; W. Paul Bowman, Cook Children's Hospital, Ft Worth; Naomi J. Winick, University of Texas Southwestern Medical Center, Dallas, TX; Eric C. Larsen, Maine Children's Cancer Program, Scarborough, ME; Kelly W. Maloney, University of Colorado Denver, Aurora, CO; Paul L. Martin, Duke University, Durham, NC; Leonard A. Mattano Jr, HARP Pharma Consulting, Mystic, CT; Elaine R. Mardis and Robert S. Fulton, The McDonnell Genome Institute, Washington University School of Medicine, St. Louis, MO; Deepa Bhojwani, Children's Hospital of Los Angeles, Los Angeles; Mignon L. Loh, University of California San Francisco Medical Center-Parnassus, San Francisco, CA; and Stephen P. Hunger, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Elizabeth A Raetz
- Chengcheng Liu, Wenjian Yang, Cheng Cheng, Deqing Pei, Colton Smith, Sima Jeha, Ching-Hon Pui, William E. Evans, and Mary V. Relling, St Jude Children's Research Hospital; Scott C. Howard, University of Memphis, Memphis, TN; Meenakshi Devidas, University of Florida, Gainesville, FL; William L. Carroll, New York University Langone Medical Center, New York, NY; Elizabeth A. Raetz, University of Utah, Salt Lake City, UT; W. Paul Bowman, Cook Children's Hospital, Ft Worth; Naomi J. Winick, University of Texas Southwestern Medical Center, Dallas, TX; Eric C. Larsen, Maine Children's Cancer Program, Scarborough, ME; Kelly W. Maloney, University of Colorado Denver, Aurora, CO; Paul L. Martin, Duke University, Durham, NC; Leonard A. Mattano Jr, HARP Pharma Consulting, Mystic, CT; Elaine R. Mardis and Robert S. Fulton, The McDonnell Genome Institute, Washington University School of Medicine, St. Louis, MO; Deepa Bhojwani, Children's Hospital of Los Angeles, Los Angeles; Mignon L. Loh, University of California San Francisco Medical Center-Parnassus, San Francisco, CA; and Stephen P. Hunger, Children's Hospital of Philadelphia, Philadelphia, PA
| | - W Paul Bowman
- Chengcheng Liu, Wenjian Yang, Cheng Cheng, Deqing Pei, Colton Smith, Sima Jeha, Ching-Hon Pui, William E. Evans, and Mary V. Relling, St Jude Children's Research Hospital; Scott C. Howard, University of Memphis, Memphis, TN; Meenakshi Devidas, University of Florida, Gainesville, FL; William L. Carroll, New York University Langone Medical Center, New York, NY; Elizabeth A. Raetz, University of Utah, Salt Lake City, UT; W. Paul Bowman, Cook Children's Hospital, Ft Worth; Naomi J. Winick, University of Texas Southwestern Medical Center, Dallas, TX; Eric C. Larsen, Maine Children's Cancer Program, Scarborough, ME; Kelly W. Maloney, University of Colorado Denver, Aurora, CO; Paul L. Martin, Duke University, Durham, NC; Leonard A. Mattano Jr, HARP Pharma Consulting, Mystic, CT; Elaine R. Mardis and Robert S. Fulton, The McDonnell Genome Institute, Washington University School of Medicine, St. Louis, MO; Deepa Bhojwani, Children's Hospital of Los Angeles, Los Angeles; Mignon L. Loh, University of California San Francisco Medical Center-Parnassus, San Francisco, CA; and Stephen P. Hunger, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Eric C Larsen
- Chengcheng Liu, Wenjian Yang, Cheng Cheng, Deqing Pei, Colton Smith, Sima Jeha, Ching-Hon Pui, William E. Evans, and Mary V. Relling, St Jude Children's Research Hospital; Scott C. Howard, University of Memphis, Memphis, TN; Meenakshi Devidas, University of Florida, Gainesville, FL; William L. Carroll, New York University Langone Medical Center, New York, NY; Elizabeth A. Raetz, University of Utah, Salt Lake City, UT; W. Paul Bowman, Cook Children's Hospital, Ft Worth; Naomi J. Winick, University of Texas Southwestern Medical Center, Dallas, TX; Eric C. Larsen, Maine Children's Cancer Program, Scarborough, ME; Kelly W. Maloney, University of Colorado Denver, Aurora, CO; Paul L. Martin, Duke University, Durham, NC; Leonard A. Mattano Jr, HARP Pharma Consulting, Mystic, CT; Elaine R. Mardis and Robert S. Fulton, The McDonnell Genome Institute, Washington University School of Medicine, St. Louis, MO; Deepa Bhojwani, Children's Hospital of Los Angeles, Los Angeles; Mignon L. Loh, University of California San Francisco Medical Center-Parnassus, San Francisco, CA; and Stephen P. Hunger, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Kelly W Maloney
- Chengcheng Liu, Wenjian Yang, Cheng Cheng, Deqing Pei, Colton Smith, Sima Jeha, Ching-Hon Pui, William E. Evans, and Mary V. Relling, St Jude Children's Research Hospital; Scott C. Howard, University of Memphis, Memphis, TN; Meenakshi Devidas, University of Florida, Gainesville, FL; William L. Carroll, New York University Langone Medical Center, New York, NY; Elizabeth A. Raetz, University of Utah, Salt Lake City, UT; W. Paul Bowman, Cook Children's Hospital, Ft Worth; Naomi J. Winick, University of Texas Southwestern Medical Center, Dallas, TX; Eric C. Larsen, Maine Children's Cancer Program, Scarborough, ME; Kelly W. Maloney, University of Colorado Denver, Aurora, CO; Paul L. Martin, Duke University, Durham, NC; Leonard A. Mattano Jr, HARP Pharma Consulting, Mystic, CT; Elaine R. Mardis and Robert S. Fulton, The McDonnell Genome Institute, Washington University School of Medicine, St. Louis, MO; Deepa Bhojwani, Children's Hospital of Los Angeles, Los Angeles; Mignon L. Loh, University of California San Francisco Medical Center-Parnassus, San Francisco, CA; and Stephen P. Hunger, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Paul L Martin
- Chengcheng Liu, Wenjian Yang, Cheng Cheng, Deqing Pei, Colton Smith, Sima Jeha, Ching-Hon Pui, William E. Evans, and Mary V. Relling, St Jude Children's Research Hospital; Scott C. Howard, University of Memphis, Memphis, TN; Meenakshi Devidas, University of Florida, Gainesville, FL; William L. Carroll, New York University Langone Medical Center, New York, NY; Elizabeth A. Raetz, University of Utah, Salt Lake City, UT; W. Paul Bowman, Cook Children's Hospital, Ft Worth; Naomi J. Winick, University of Texas Southwestern Medical Center, Dallas, TX; Eric C. Larsen, Maine Children's Cancer Program, Scarborough, ME; Kelly W. Maloney, University of Colorado Denver, Aurora, CO; Paul L. Martin, Duke University, Durham, NC; Leonard A. Mattano Jr, HARP Pharma Consulting, Mystic, CT; Elaine R. Mardis and Robert S. Fulton, The McDonnell Genome Institute, Washington University School of Medicine, St. Louis, MO; Deepa Bhojwani, Children's Hospital of Los Angeles, Los Angeles; Mignon L. Loh, University of California San Francisco Medical Center-Parnassus, San Francisco, CA; and Stephen P. Hunger, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Leonard A Mattano
- Chengcheng Liu, Wenjian Yang, Cheng Cheng, Deqing Pei, Colton Smith, Sima Jeha, Ching-Hon Pui, William E. Evans, and Mary V. Relling, St Jude Children's Research Hospital; Scott C. Howard, University of Memphis, Memphis, TN; Meenakshi Devidas, University of Florida, Gainesville, FL; William L. Carroll, New York University Langone Medical Center, New York, NY; Elizabeth A. Raetz, University of Utah, Salt Lake City, UT; W. Paul Bowman, Cook Children's Hospital, Ft Worth; Naomi J. Winick, University of Texas Southwestern Medical Center, Dallas, TX; Eric C. Larsen, Maine Children's Cancer Program, Scarborough, ME; Kelly W. Maloney, University of Colorado Denver, Aurora, CO; Paul L. Martin, Duke University, Durham, NC; Leonard A. Mattano Jr, HARP Pharma Consulting, Mystic, CT; Elaine R. Mardis and Robert S. Fulton, The McDonnell Genome Institute, Washington University School of Medicine, St. Louis, MO; Deepa Bhojwani, Children's Hospital of Los Angeles, Los Angeles; Mignon L. Loh, University of California San Francisco Medical Center-Parnassus, San Francisco, CA; and Stephen P. Hunger, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Naomi J Winick
- Chengcheng Liu, Wenjian Yang, Cheng Cheng, Deqing Pei, Colton Smith, Sima Jeha, Ching-Hon Pui, William E. Evans, and Mary V. Relling, St Jude Children's Research Hospital; Scott C. Howard, University of Memphis, Memphis, TN; Meenakshi Devidas, University of Florida, Gainesville, FL; William L. Carroll, New York University Langone Medical Center, New York, NY; Elizabeth A. Raetz, University of Utah, Salt Lake City, UT; W. Paul Bowman, Cook Children's Hospital, Ft Worth; Naomi J. Winick, University of Texas Southwestern Medical Center, Dallas, TX; Eric C. Larsen, Maine Children's Cancer Program, Scarborough, ME; Kelly W. Maloney, University of Colorado Denver, Aurora, CO; Paul L. Martin, Duke University, Durham, NC; Leonard A. Mattano Jr, HARP Pharma Consulting, Mystic, CT; Elaine R. Mardis and Robert S. Fulton, The McDonnell Genome Institute, Washington University School of Medicine, St. Louis, MO; Deepa Bhojwani, Children's Hospital of Los Angeles, Los Angeles; Mignon L. Loh, University of California San Francisco Medical Center-Parnassus, San Francisco, CA; and Stephen P. Hunger, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Elaine R Mardis
- Chengcheng Liu, Wenjian Yang, Cheng Cheng, Deqing Pei, Colton Smith, Sima Jeha, Ching-Hon Pui, William E. Evans, and Mary V. Relling, St Jude Children's Research Hospital; Scott C. Howard, University of Memphis, Memphis, TN; Meenakshi Devidas, University of Florida, Gainesville, FL; William L. Carroll, New York University Langone Medical Center, New York, NY; Elizabeth A. Raetz, University of Utah, Salt Lake City, UT; W. Paul Bowman, Cook Children's Hospital, Ft Worth; Naomi J. Winick, University of Texas Southwestern Medical Center, Dallas, TX; Eric C. Larsen, Maine Children's Cancer Program, Scarborough, ME; Kelly W. Maloney, University of Colorado Denver, Aurora, CO; Paul L. Martin, Duke University, Durham, NC; Leonard A. Mattano Jr, HARP Pharma Consulting, Mystic, CT; Elaine R. Mardis and Robert S. Fulton, The McDonnell Genome Institute, Washington University School of Medicine, St. Louis, MO; Deepa Bhojwani, Children's Hospital of Los Angeles, Los Angeles; Mignon L. Loh, University of California San Francisco Medical Center-Parnassus, San Francisco, CA; and Stephen P. Hunger, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Robert S Fulton
- Chengcheng Liu, Wenjian Yang, Cheng Cheng, Deqing Pei, Colton Smith, Sima Jeha, Ching-Hon Pui, William E. Evans, and Mary V. Relling, St Jude Children's Research Hospital; Scott C. Howard, University of Memphis, Memphis, TN; Meenakshi Devidas, University of Florida, Gainesville, FL; William L. Carroll, New York University Langone Medical Center, New York, NY; Elizabeth A. Raetz, University of Utah, Salt Lake City, UT; W. Paul Bowman, Cook Children's Hospital, Ft Worth; Naomi J. Winick, University of Texas Southwestern Medical Center, Dallas, TX; Eric C. Larsen, Maine Children's Cancer Program, Scarborough, ME; Kelly W. Maloney, University of Colorado Denver, Aurora, CO; Paul L. Martin, Duke University, Durham, NC; Leonard A. Mattano Jr, HARP Pharma Consulting, Mystic, CT; Elaine R. Mardis and Robert S. Fulton, The McDonnell Genome Institute, Washington University School of Medicine, St. Louis, MO; Deepa Bhojwani, Children's Hospital of Los Angeles, Los Angeles; Mignon L. Loh, University of California San Francisco Medical Center-Parnassus, San Francisco, CA; and Stephen P. Hunger, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Deepa Bhojwani
- Chengcheng Liu, Wenjian Yang, Cheng Cheng, Deqing Pei, Colton Smith, Sima Jeha, Ching-Hon Pui, William E. Evans, and Mary V. Relling, St Jude Children's Research Hospital; Scott C. Howard, University of Memphis, Memphis, TN; Meenakshi Devidas, University of Florida, Gainesville, FL; William L. Carroll, New York University Langone Medical Center, New York, NY; Elizabeth A. Raetz, University of Utah, Salt Lake City, UT; W. Paul Bowman, Cook Children's Hospital, Ft Worth; Naomi J. Winick, University of Texas Southwestern Medical Center, Dallas, TX; Eric C. Larsen, Maine Children's Cancer Program, Scarborough, ME; Kelly W. Maloney, University of Colorado Denver, Aurora, CO; Paul L. Martin, Duke University, Durham, NC; Leonard A. Mattano Jr, HARP Pharma Consulting, Mystic, CT; Elaine R. Mardis and Robert S. Fulton, The McDonnell Genome Institute, Washington University School of Medicine, St. Louis, MO; Deepa Bhojwani, Children's Hospital of Los Angeles, Los Angeles; Mignon L. Loh, University of California San Francisco Medical Center-Parnassus, San Francisco, CA; and Stephen P. Hunger, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Scott C Howard
- Chengcheng Liu, Wenjian Yang, Cheng Cheng, Deqing Pei, Colton Smith, Sima Jeha, Ching-Hon Pui, William E. Evans, and Mary V. Relling, St Jude Children's Research Hospital; Scott C. Howard, University of Memphis, Memphis, TN; Meenakshi Devidas, University of Florida, Gainesville, FL; William L. Carroll, New York University Langone Medical Center, New York, NY; Elizabeth A. Raetz, University of Utah, Salt Lake City, UT; W. Paul Bowman, Cook Children's Hospital, Ft Worth; Naomi J. Winick, University of Texas Southwestern Medical Center, Dallas, TX; Eric C. Larsen, Maine Children's Cancer Program, Scarborough, ME; Kelly W. Maloney, University of Colorado Denver, Aurora, CO; Paul L. Martin, Duke University, Durham, NC; Leonard A. Mattano Jr, HARP Pharma Consulting, Mystic, CT; Elaine R. Mardis and Robert S. Fulton, The McDonnell Genome Institute, Washington University School of Medicine, St. Louis, MO; Deepa Bhojwani, Children's Hospital of Los Angeles, Los Angeles; Mignon L. Loh, University of California San Francisco Medical Center-Parnassus, San Francisco, CA; and Stephen P. Hunger, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Sima Jeha
- Chengcheng Liu, Wenjian Yang, Cheng Cheng, Deqing Pei, Colton Smith, Sima Jeha, Ching-Hon Pui, William E. Evans, and Mary V. Relling, St Jude Children's Research Hospital; Scott C. Howard, University of Memphis, Memphis, TN; Meenakshi Devidas, University of Florida, Gainesville, FL; William L. Carroll, New York University Langone Medical Center, New York, NY; Elizabeth A. Raetz, University of Utah, Salt Lake City, UT; W. Paul Bowman, Cook Children's Hospital, Ft Worth; Naomi J. Winick, University of Texas Southwestern Medical Center, Dallas, TX; Eric C. Larsen, Maine Children's Cancer Program, Scarborough, ME; Kelly W. Maloney, University of Colorado Denver, Aurora, CO; Paul L. Martin, Duke University, Durham, NC; Leonard A. Mattano Jr, HARP Pharma Consulting, Mystic, CT; Elaine R. Mardis and Robert S. Fulton, The McDonnell Genome Institute, Washington University School of Medicine, St. Louis, MO; Deepa Bhojwani, Children's Hospital of Los Angeles, Los Angeles; Mignon L. Loh, University of California San Francisco Medical Center-Parnassus, San Francisco, CA; and Stephen P. Hunger, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Ching-Hon Pui
- Chengcheng Liu, Wenjian Yang, Cheng Cheng, Deqing Pei, Colton Smith, Sima Jeha, Ching-Hon Pui, William E. Evans, and Mary V. Relling, St Jude Children's Research Hospital; Scott C. Howard, University of Memphis, Memphis, TN; Meenakshi Devidas, University of Florida, Gainesville, FL; William L. Carroll, New York University Langone Medical Center, New York, NY; Elizabeth A. Raetz, University of Utah, Salt Lake City, UT; W. Paul Bowman, Cook Children's Hospital, Ft Worth; Naomi J. Winick, University of Texas Southwestern Medical Center, Dallas, TX; Eric C. Larsen, Maine Children's Cancer Program, Scarborough, ME; Kelly W. Maloney, University of Colorado Denver, Aurora, CO; Paul L. Martin, Duke University, Durham, NC; Leonard A. Mattano Jr, HARP Pharma Consulting, Mystic, CT; Elaine R. Mardis and Robert S. Fulton, The McDonnell Genome Institute, Washington University School of Medicine, St. Louis, MO; Deepa Bhojwani, Children's Hospital of Los Angeles, Los Angeles; Mignon L. Loh, University of California San Francisco Medical Center-Parnassus, San Francisco, CA; and Stephen P. Hunger, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Stephen P Hunger
- Chengcheng Liu, Wenjian Yang, Cheng Cheng, Deqing Pei, Colton Smith, Sima Jeha, Ching-Hon Pui, William E. Evans, and Mary V. Relling, St Jude Children's Research Hospital; Scott C. Howard, University of Memphis, Memphis, TN; Meenakshi Devidas, University of Florida, Gainesville, FL; William L. Carroll, New York University Langone Medical Center, New York, NY; Elizabeth A. Raetz, University of Utah, Salt Lake City, UT; W. Paul Bowman, Cook Children's Hospital, Ft Worth; Naomi J. Winick, University of Texas Southwestern Medical Center, Dallas, TX; Eric C. Larsen, Maine Children's Cancer Program, Scarborough, ME; Kelly W. Maloney, University of Colorado Denver, Aurora, CO; Paul L. Martin, Duke University, Durham, NC; Leonard A. Mattano Jr, HARP Pharma Consulting, Mystic, CT; Elaine R. Mardis and Robert S. Fulton, The McDonnell Genome Institute, Washington University School of Medicine, St. Louis, MO; Deepa Bhojwani, Children's Hospital of Los Angeles, Los Angeles; Mignon L. Loh, University of California San Francisco Medical Center-Parnassus, San Francisco, CA; and Stephen P. Hunger, Children's Hospital of Philadelphia, Philadelphia, PA
| | - William E Evans
- Chengcheng Liu, Wenjian Yang, Cheng Cheng, Deqing Pei, Colton Smith, Sima Jeha, Ching-Hon Pui, William E. Evans, and Mary V. Relling, St Jude Children's Research Hospital; Scott C. Howard, University of Memphis, Memphis, TN; Meenakshi Devidas, University of Florida, Gainesville, FL; William L. Carroll, New York University Langone Medical Center, New York, NY; Elizabeth A. Raetz, University of Utah, Salt Lake City, UT; W. Paul Bowman, Cook Children's Hospital, Ft Worth; Naomi J. Winick, University of Texas Southwestern Medical Center, Dallas, TX; Eric C. Larsen, Maine Children's Cancer Program, Scarborough, ME; Kelly W. Maloney, University of Colorado Denver, Aurora, CO; Paul L. Martin, Duke University, Durham, NC; Leonard A. Mattano Jr, HARP Pharma Consulting, Mystic, CT; Elaine R. Mardis and Robert S. Fulton, The McDonnell Genome Institute, Washington University School of Medicine, St. Louis, MO; Deepa Bhojwani, Children's Hospital of Los Angeles, Los Angeles; Mignon L. Loh, University of California San Francisco Medical Center-Parnassus, San Francisco, CA; and Stephen P. Hunger, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Mignon L Loh
- Chengcheng Liu, Wenjian Yang, Cheng Cheng, Deqing Pei, Colton Smith, Sima Jeha, Ching-Hon Pui, William E. Evans, and Mary V. Relling, St Jude Children's Research Hospital; Scott C. Howard, University of Memphis, Memphis, TN; Meenakshi Devidas, University of Florida, Gainesville, FL; William L. Carroll, New York University Langone Medical Center, New York, NY; Elizabeth A. Raetz, University of Utah, Salt Lake City, UT; W. Paul Bowman, Cook Children's Hospital, Ft Worth; Naomi J. Winick, University of Texas Southwestern Medical Center, Dallas, TX; Eric C. Larsen, Maine Children's Cancer Program, Scarborough, ME; Kelly W. Maloney, University of Colorado Denver, Aurora, CO; Paul L. Martin, Duke University, Durham, NC; Leonard A. Mattano Jr, HARP Pharma Consulting, Mystic, CT; Elaine R. Mardis and Robert S. Fulton, The McDonnell Genome Institute, Washington University School of Medicine, St. Louis, MO; Deepa Bhojwani, Children's Hospital of Los Angeles, Los Angeles; Mignon L. Loh, University of California San Francisco Medical Center-Parnassus, San Francisco, CA; and Stephen P. Hunger, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Mary V Relling
- Chengcheng Liu, Wenjian Yang, Cheng Cheng, Deqing Pei, Colton Smith, Sima Jeha, Ching-Hon Pui, William E. Evans, and Mary V. Relling, St Jude Children's Research Hospital; Scott C. Howard, University of Memphis, Memphis, TN; Meenakshi Devidas, University of Florida, Gainesville, FL; William L. Carroll, New York University Langone Medical Center, New York, NY; Elizabeth A. Raetz, University of Utah, Salt Lake City, UT; W. Paul Bowman, Cook Children's Hospital, Ft Worth; Naomi J. Winick, University of Texas Southwestern Medical Center, Dallas, TX; Eric C. Larsen, Maine Children's Cancer Program, Scarborough, ME; Kelly W. Maloney, University of Colorado Denver, Aurora, CO; Paul L. Martin, Duke University, Durham, NC; Leonard A. Mattano Jr, HARP Pharma Consulting, Mystic, CT; Elaine R. Mardis and Robert S. Fulton, The McDonnell Genome Institute, Washington University School of Medicine, St. Louis, MO; Deepa Bhojwani, Children's Hospital of Los Angeles, Los Angeles; Mignon L. Loh, University of California San Francisco Medical Center-Parnassus, San Francisco, CA; and Stephen P. Hunger, Children's Hospital of Philadelphia, Philadelphia, PA.
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31
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Bhatia S, Landier W, Hageman L, Chen Y, Kim H, Sun CL, Kornegay N, Evans WE, Angiolillo AL, Bostrom B, Casillas J, Lew G, Maloney KW, Mascarenhas L, Ritchey AK, Termuhlen AM, Carroll WL, Wong FL, Relling MV. Systemic Exposure to Thiopurines and Risk of Relapse in Children With Acute Lymphoblastic Leukemia: A Children's Oncology Group Study. JAMA Oncol 2016; 1:287-95. [PMID: 26181173 DOI: 10.1001/jamaoncol.2015.0245] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
IMPORTANCE Variability in prescribed doses of 6-mercaptopurine (6MP) and lack of adherence to a 6MP treatment regimen could result in intra-individual variability in systemic exposure to 6MP (measured as erythrocyte thioguanine nucleotide [TGN] levels) in children with acute lymphoblastic leukemia (ALL). The effect on relapse risk of this variability is unknown. OBJECTIVE To determine the effect of high intra-individual variability of 6MP systemic exposure on relapse risk in children with ALL. DESIGN, SETTING, AND PARTICIPANTS We used a prospective longitudinal design (Children's Oncology Group study [COG-AALL03N1]) to monitor 6MP and disease relapse in 742 children with ALL in ambulatory care settings of 94 participating institutions from May 30, 2005, to September 9, 2011. All participants met the following eligibility criteria: (1) diagnosis of ALL at 21 years or younger; (2) first continuous remission in progress at the time of study entry; (3) receiving self-, parent-, or caregiver-administered oral 6MP during maintenance therapy; and (4) completion of at least 6 months of maintenance therapy at the time of study enrollment. The median patient age at diagnosis was 5 years; 68% were boys; and 43% had National Cancer Institute-based high-risk disease. MAIN OUTCOMES AND MEASURES Daily 6MP regimen adherence was measured over 68 716 person-days using an electronic system that recorded the date and time of each 6MP bottle opening; adherence rate was defined as the ratio of days that a 6MP bottle was opened to days thata 6MP bottle was prescribed. Average monthly 6MP dose intensity was measured over 120 439 person-days by dividing the number of 6MP doses actually prescribed by the number of planned protocol doses (75 mg/m2/d). Monthly erythrocyte TGN levels (pmol/8 × 108 erythrocytes) were measured over 6 consecutive months per patient (n = 3944 measurements). Using intra-individual coefficients of variation (CV%), patients were classified as having stable (CV% <85th percentile) vs varying (CV% ≥85th percentile) indices. Median follow-up time was 6.7 years from the time of diagnosis. RESULTS Adjusting for clinical prognosticators, we found that patients with 6MP nonadherence (mean adherence rate <95%) were at a 2.7-fold increased risk of relapse (95% CI, 1.3-5.6; P = .01) compared with patients with a mean adherence rate of 95% or greater. Among adherers, high intra-individual variability in TGN levels contributed to increased relapse risk (hazard ratio, 4.4; 95% CI, 1.2-15.7; P = .02). Furthermore, adherers with varying TGN levels had varying 6MP dose intensity (odds ratio [OR], 4.5; 95% CI, 1.5-13.4; P = .01) and 6MP drug interruptions (OR, 10.2; 95% CI, 2.2-48.3; P = .003). CONCLUSIONS AND RELEVANCE These findings emphasize the need to maximize 6MP regimen adherence and maintain steady thiopurine exposure to minimize relapse in children with ALL.
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Affiliation(s)
- Smita Bhatia
- City of Hope, Duarte, California2University of Alabama, Birmingham
| | - Wendy Landier
- City of Hope, Duarte, California2University of Alabama, Birmingham
| | | | | | | | | | - Nancy Kornegay
- St Jude Children's Research Hospital, Memphis, Tennessee
| | | | - Anne L Angiolillo
- Children's National Medical Center, The George Washington School of Medicine, Washington, DC
| | - Bruce Bostrom
- Children's Hospitals and Clinics of Minnesota, Minneapolis
| | | | - Glen Lew
- Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia
| | | | - Leo Mascarenhas
- Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California,Los Angeles
| | - A Kim Ritchey
- Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | | | | | - Mary V Relling
- St Jude Children's Research Hospital, Memphis, Tennessee
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Kunin-Batson AS, Lu X, Balsamo L, Graber K, Devidas M, Hunger SP, Carroll WL, Winick NJ, Mattano LA, Maloney KW, Kadan-Lottick NS. Prevalence and predictors of anxiety and depression after completion of chemotherapy for childhood acute lymphoblastic leukemia: A prospective longitudinal study. Cancer 2016; 122:1608-17. [PMID: 27028090 DOI: 10.1002/cncr.29946] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 12/08/2015] [Accepted: 01/11/2016] [Indexed: 12/12/2022]
Abstract
BACKGROUND The months immediately after the completion of treatment for childhood acute lymphoblastic leukemia (ALL) are often regarded as a stressful time for children and families. In this prospective, longitudinal study, the prevalence and predictors of anxiety and depressive symptoms after the completion of treatment were examined. METHODS Participants included 160 children aged 2 to 9 years with standard-risk ALL who were enrolled on Children's Oncology Group protocol AALL0331. Parents completed standardized rating scales of their children's emotional-behavioral functioning and measures of coping and family functioning at approximately 1 month, 6 months, and 12 months after diagnosis and again 3 months after the completion of chemotherapy. RESULTS At 3 months off therapy, approximately 24% of survivors had at-risk/clinically elevated anxiety scores and 28% had elevated depression scores, which are significantly higher than the expected 15% in the general population (P = .028 and .001, respectively). Patients with elevated anxiety 1 month after diagnosis were at greater risk of off-therapy anxiety (odds ratio, 4.1; 95% confidence interval, 1.31-12.73 [P = .022]) and those with elevated depressive symptoms 6 months after diagnosis were at greater risk of off-therapy depression (odds ratio, 7.88; 95% confidence interval, 2.61-23.81 [P = .0002]). In adjusted longitudinal analyses, unhealthy family functioning (P = .008) and less reliance on social support coping (P = .009) were found to be associated with risk of emotional distress. Children from Spanish-speaking families (P = .05) also were found to be at a greater risk of distress. CONCLUSIONS A significant percentage of children experience emotional distress during and after therapy for ALL. These data provide a compelling rationale for targeted early screening and psychosocial interventions to support family functioning and coping skills. Cancer 2016;122:1608-17. © 2015 American Cancer Society.
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Affiliation(s)
- Alicia S Kunin-Batson
- HealthPartners Institute, Minneapolis, Minnesota.,Division of Oncology, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota
| | - Xiaomin Lu
- Division of Oncology, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota.,Department of Biostatistics, Colleges of Medicine, Public Health, and Health Professions, University of Florida, Gainesville, Florida
| | - Lyn Balsamo
- Department of Pediatric Hematology/Oncology, Yale University School of Medicine, Yale Comprehensive Cancer Center, New Haven, Connecticut
| | - Kelsey Graber
- Yale University Child Study Center, New Haven, Connecticut
| | - Meenakshi Devidas
- Department of Biostatistics, Colleges of Medicine, Public Health, and Health Professions, University of Florida, Gainesville, Florida
| | - Stephen P Hunger
- Center for Childhood Cancer Research, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - William L Carroll
- Department of Pediatrics, New York University Langone Medical Center, Stephen D. Hassenfeld Children's Center for Cancer and Blood Disorders, New York, New York
| | - Naomi J Winick
- Department of Pediatric Hematology/Oncology, University of Texas Southwestern School of Medicine, Dallas, Texas
| | | | - Kelly W Maloney
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado
| | - Nina S Kadan-Lottick
- Department of Pediatric Hematology/Oncology, Yale University School of Medicine, Yale Comprehensive Cancer Center, New Haven, Connecticut
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Dupuis LL, Lu X, Mitchell HR, Sung L, Devidas M, Mattano LA, Carroll WL, Winick N, Hunger SP, Maloney KW, Kadan-Lottick NS. Anxiety, pain, and nausea during the treatment of standard-risk childhood acute lymphoblastic leukemia: A prospective, longitudinal study from the Children's Oncology Group. Cancer 2016; 122:1116-25. [PMID: 26773735 DOI: 10.1002/cncr.29876] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 11/17/2015] [Accepted: 12/02/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND This prospective study describes the procedure-related anxiety, treatment-related anxiety, pain, and nausea experienced by children with standard-risk acute lymphoblastic leukemia (ALL) during the first year of treatment. METHODS This study was undertaken at 31 Children's Oncology Group (COG) sites. Eligible children who were 2 to 9.99 years old were enrolled in a COG trial for patients with newly diagnosed standard-risk ALL from 2005 to 2009. Parents completed a demographic survey at the baseline and the Pediatric Quality of Life Inventory 3.0 Cancer Module (proxy version) and the General Functioning Scale of the Family Assessment Device 1, 6, and 12 months after the diagnosis. The association between patient-related (age, sex, ethnicity, and treatment), parent-related (marital status and education), and family-related factors (functioning, income, and size) and symptom scores was evaluated. RESULTS The mean scores for procedure-related anxiety, treatment-related anxiety, and pain improved during the first year of treatment (P < .0389). The mean nausea score was poorer 6 months after the diagnosis in comparison with the other assessments (P = .0085). A younger age at diagnosis was associated with significantly worse procedure-related anxiety (P = .004). An older age (P = .0002) and assignment to the intensified consolidation study arm (P = .02) were associated with significantly worse nausea. CONCLUSIONS Children with ALL experienced decreasing treatment-related anxiety, procedure-related anxiety, and pain during the first year of treatment. In comparison with scores at 1 and 12 months, nausea was worse 6 months after the diagnosis. Minimization of procedure-related anxiety in younger children and improved nausea control in older children and those receiving more intensified treatment should be prioritized.
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Affiliation(s)
- L Lee Dupuis
- Department of Pharmacy, Research Institute, Hospital for Sick Children, Toronto, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Xiaomin Lu
- Department of Biostatistics, Public Health and Health Professions, College of Medicine, University of Florida, Gainesville, Florida
| | | | - Lillian Sung
- Division of Haematology/Oncology, Hospital for Sick Children, Toronto, Canada
| | - Meenakshi Devidas
- Department of Biostatistics, Public Health and Health Professions, College of Medicine, University of Florida, Gainesville, Florida
| | | | - William L Carroll
- Perlmutter Cancer Center, Langone Medical Center, New York University, New York, New York
| | - Naomi Winick
- Pediatric Hematology-Oncology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Stephen P Hunger
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Kelly W Maloney
- Center for Cancer and Blood Disorders, Children's Hospital Colorado, Aurora, Colorado
| | - Nina S Kadan-Lottick
- Section of Pediatric Hematology/Oncology, Yale University School of Medicine, New Haven, Connecticut
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Maloney KW, Angiolillo AL, Schore RJ, Devidas M, Lu X, Wang C, Friedmann AM, Mattano LA, Loh ML, Raetz EA, Stork LC, Winick NJ, Hunger S, Carroll WL. Association of intravenous (IV) and intramuscular (IM) pegaspargase (PEG) administration with rate of adverse events (AE) in standard risk (SR) Acute Lymphoblastic Leukemia (ALL) Children’s Oncology Group (COG) trials. J Clin Oncol 2015. [DOI: 10.1200/jco.2015.33.15_suppl.10035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Naomi J. Winick
- The University of Texas Southwestern Medical Center, Dallas, TX
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Abstract
Children with Down syndrome (DS) and acute leukemias acute have unique biological, cytogenetic, and intrinsic factors that affect their treatment and outcome. Myeloid leukemia of Down syndrome (ML-DS) is associated with high event-free survival (EFS) rates and frequently preceded by a preleukemia condition, the transient abnormal hematopoiesis (TAM) present at birth. For acute lymphoblastic leukemia (ALL), their EFS and overall survival are poorer than non-DS ALL, it is important to enroll them on therapeutic trials, including relapse trials; investigate new agents that could potentially improve their leukemia-free survival; and strive to maximize the supportive care these patients need.
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Affiliation(s)
- Kelly W Maloney
- Center for Cancer & Blood Disorders, Children's Hospital Colorado, 13123 East 16th Avenue, B115, Aurora, CO 80045, USA
| | - Jeffrey W Taub
- Division of Pediatric Hematology/Oncology, Children's Hospital of Michigan, Wayne State University School of Medicine, 3901 Beaubien Boulevard, Detroit, MI 48201, USA.
| | - Yaddanapudi Ravindranath
- Division of Pediatric Hematology/Oncology, Children's Hospital of Michigan, Wayne State University School of Medicine, 3901 Beaubien Boulevard, Detroit, MI 48201, USA
| | - Irene Roberts
- Department of Paediatrics and Molecular Haematology Unit, University of Oxford and Oxford University Hospitals NHS Trust, Oxford, OX3 9DS, UK
| | - Paresh Vyas
- MRC Molecular Haematology Unit, Department of Haematology, Weatherall Institute of Molecular Medicine, Oxford University Hospitals NHS Trust, University of Oxford, Oxford OX3 9DS, UK
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Winick NJ, Devidas M, Maloney KW, Larsen E, Mattano LA, Borowitz MJ, Carroll AJ, Gastier-Foster JM, Heerema NA, Willman CL, Wood BL, Loh ML, Raetz EA, Hunger S, Carroll WL. The impact of initial cerebrospinal fluid (CSF) findings on outcome among patients with NCI standard (SR) and high-risk (HR) B-lymphoblastic leukemia (ALL): A report from the Children’s Oncology Group (COG) Studies AALL0331 and AALL0232. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.15_suppl.10016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Naomi Joan Winick
- The University of Texas Southwestern Medical Center; Center for Cancer and Blood Disorders, Children's Medical Center Dallas, Dallas, TX
| | | | | | - Eric Larsen
- Maine Children's Cancer Program, Scarborough, ME
| | | | | | - Andrew J Carroll
- The University of Alabama at Birmingham Comprehensive Cancer Center, Birmingham, AL
| | | | | | | | | | - Mignon L. Loh
- University of California, San Francisco, San Francisco, CA
| | | | - Stephen Hunger
- University of Colorado Denver Health Science Center, Aurora, CO
| | - William L. Carroll
- NYU Cancer Institute, New York University Langone Medical Center, New York, NY
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Landier W, Chen Y, Hageman L, Kim H, Bostrom BC, Casillas JN, Dickens DS, Evans WE, Maloney KW, Mascarenhas L, Ritchey AK, Termuhlen AM, Carroll WL, Relling MV, Wong FL, Bhatia S. Factors associated with nonadherence to oral 6-mercaptopurine (6MP) in children with acute lymphoblastic leukemia (ALL): A report from Children’s Oncology Group (COG) study AALL03N1. J Clin Oncol 2014. [DOI: 10.1200/jco.2014.32.15_suppl.10013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | | | | | - Leo Mascarenhas
- Children's Hospital Los Angeles, Saban Research Insititute, Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | | | | | - William L. Carroll
- NYU Cancer Institute, New York University Langone Medical Center, New York, NY
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Myers RM, Balsamo L, Lu X, Devidas M, Hunger SP, Carroll WL, Winick NJ, Maloney KW, Kadan-Lottick NS. A prospective study of anxiety, depression, and behavioral changes in the first year after a diagnosis of childhood acute lymphoblastic leukemia: a report from the Children's Oncology Group. Cancer 2014; 120:1417-25. [PMID: 24473774 PMCID: PMC4319360 DOI: 10.1002/cncr.28578] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 10/16/2013] [Accepted: 11/18/2013] [Indexed: 11/09/2022]
Abstract
BACKGROUND The authors prospectively assessed anxiety, depression, and behavior in children with standard-risk acute lymphoblastic leukemia (SR-ALL) during the first year of therapy and identified associated risk factors. METHODS A cohort study was performed of 159 children (aged 2 years-9.99 years) with SR-ALL who were enrolled on Children's Oncology Group protocol AALL0331 at 31 sites. Parents completed the Behavior Assessment System for Children, the General Functioning Scale of the Family Assessment Device, and the Coping Health Inventory for Parents at approximately 1, 6, and 12 months after diagnosis. RESULTS Overall, mean scores for anxiety, depression, aggression, and hyperactivity were similar to population norms. However, more children scored in the at-risk/clinical range for depression than the expected 15% at 1 month (21.7%; P= .022), 6 months (28.6%; P< .001), and 12 months (21.1%; P= .032). For anxiety, more children scored in the at-risk/clinical range at 1 month (25.2% vs 15%; P= .001), but then reverted to expected levels. On adjusted analysis, unhealthy family functioning was found to be predictive of anxiety (odds ratio [OR], 2.24; P= .033) and depression (OR, 2.40; P= .008). Hispanic ethnicity was associated with anxiety (OR, 3.35; P= .009). Worse physical functioning (P= .049), unmarried parents (P= .017), and less reliance on social support (P= .004) were found to be associated with depression. Emotional distress at 1 month predicted anxiety (OR, 7.11; P= .002) and depression (OR, 3.31; P= .023) at 12 months. CONCLUSIONS Anxiety is a significant problem in a subpopulation of patients with SR-ALL immediately after diagnosis, whereas depression remains a significant problem for at least 1 year. Children of Hispanic ethnicity or those with unhealthy family functioning may be particularly vulnerable. These data suggest that clinicians should screen for anxiety and depression throughout the first year of therapy.
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Affiliation(s)
- Regina M Myers
- Section of Pediatric Hematology/Oncology, Yale University School of Medicine and Yale Comprehensive Cancer Center, New Haven, Connecticut
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Heerema NA, Carroll AJ, Devidas M, Loh ML, Borowitz MJ, Gastier-Foster JM, Larsen EC, Mattano LA, Maloney KW, Willman CL, Wood BL, Winick NJ, Carroll WL, Hunger SP, Raetz EA. Intrachromosomal amplification of chromosome 21 is associated with inferior outcomes in children with acute lymphoblastic leukemia treated in contemporary standard-risk children's oncology group studies: a report from the children's oncology group. J Clin Oncol 2013; 31:3397-402. [PMID: 23940221 DOI: 10.1200/jco.2013.49.1308] [Citation(s) in RCA: 105] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Five-year overall survival (OS) for children with B-cell precursor acute lymphoblastic leukemia (B-ALL) exceeds 90% with risk-adapted therapy. Age, initial WBC count, genetic aberrations, and minimal residual disease (MRD) are used for risk stratification. Intrachromosomal amplification of a region of chromosome 21 (iAMP21; three or more extra copies of RUNX1 on an abnormal chromosome 21) is a recently identified recurrent genomic lesion associated with inferior outcome in some studies. We investigated the impact of iAMP21 in a large cohort treated in contemporary Children's Oncology Group (COG) ALL trials. PATIENTS AND METHODS Fluorescent in situ hybridization for specific genetic aberrations was required at diagnosis. MRD was measured by flow cytometry at end induction. Outcome was measured as event-free survival (EFS) and OS. RESULTS iAMP21 was found in 158 (2%) of 7,793 patients with B-ALL age ≥ 1 year; 74 (1.5%) of 5,057 standard-risk (SR) patients, and 84 (3.1%) of 2,736 high-risk (HR) patients. iAMP21 was associated with age ≥ 10 years, WBC less than 50,000/μL, female sex, and detectable MRD at day 29. Four-year EFS and OS were significantly worse for patients with iAMP21 and SR B-ALL, but iAMP21 was not a statistically significant prognostic factor in HR patients. There was no interaction between MRD and iAMP21. Among SR patients, day 29 MRD ≥ 0.01% and iAMP21 were associated with the poorest EFS and OS; absence of both was associated with the best outcome. CONCLUSION iAMP21 is associated with inferior outcome in pediatric B-ALL, particularly SR patients who require more intensive therapy and are now treated on HR COG ALL protocols.
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Affiliation(s)
- Nyla A Heerema
- Nyla A. Heerema and Julie M. Gastier-Foster, The Ohio State University Wexner Medical Center; Julie M. Gastier-Foster, The Ohio State University College of Medicine and Nationwide Children's Hospital, Columbus, OH; Andrew J. Carroll, University of Alabama at Birmingham, Birmingham, AL; Meenakshi Devidas, University of Florida, Gainesville, FL; Mignon L. Loh, University of California at San Francisco, San Francisco, CA; Michael J. Borowitz, Johns Hopkins Medical Institutions, Baltimore, MD; Eric C. Larsen, Maine Children's Cancer Program, Scarborough, ME; Leonard A. Mattano Jr, Michigan State University College of Human Medicine, Kalamazoo, MI; Kelly W. Maloney and Stephen P. Hunger, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, CO; Cheryl L. Willman, University of New Mexico, Albuquerque, NM; Brent L. Wood, University of Washington, Seattle, WA; Naomi J. Winick, University of Texas Southwestern Medical Center, Dallas, TX; and William L. Carroll and Elizabeth A. Raetz, The New York University Cancer Institute, New York University Langone Medical Center, New York, NY
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Borowitz MJ, Wood BL, Devidas M, Loh ML, Raetz EA, Larsen E, Maloney KW, Carroll AJ, Friedmann AM, Gastier-Foster JM, Heerema NA, Mattano LA, Nachman JB, Winick NJ, Carroll WL, Hunger S. Assessment of end induction minimal residual disease (MRD) in childhood B precursor acute lymphoblastic leukemia (ALL) to eliminate the need for day 14 marrow examination: A Children’s Oncology Group study. J Clin Oncol 2013. [DOI: 10.1200/jco.2013.31.15_suppl.10001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
10001 Background: Response to initial therapy is a powerful prognostic factor in pediatric ALL. Traditionally, slow early response (SER) has been defined by marrow morphology 8 or 15 days after start of induction therapy. More recently, MRD has been identified as the most important predictor of adverse outcome. The value of morphologic assessment of response in the setting of MRD has not been established. Methods: In COG studies AALL0331 (for NCI Standard Risk (SR) B ALL patients (pts)) and AALL0232 (High Risk (HR) B ALL pts), SER was defined by morphology as either ≥5% blasts in a day 15 marrow, or by flow cytometry as ≥0.1% MRD in a d29 marrow (SER MRD). Assignment to treatment arms also depended upon cytogenetic findings and extramedullary disease; each protocol had randomized treatment questions. SER pts were non-randomly assigned to receive augmented BFM therapy (ABFM) with 2 interim maintenance and delayed intensification phases (and CNS radiation for HR SER pts only). All pt treatment groups were combined for these analyses. Rapid early responders (RER) had a better outcome than SER pts (Table). However, pts who were SER only by morphology had a 5y DFS that was not significantly different from that of RER pts, and superior to that of pts who were SER MRD, or SER by both morphology and MRD. In multivariate analysis, SER by morphology was not an adverse prognostic factor after adjusting for risk group and MRD, or separately in SR or HR pts after adjusting for MRD. However, pts with .01-.1% MRD who were SER by morphology had a better 5y DFS than the.01-.1% MRD pts who were RER (90±6%, n=91 vs 77±3%, n=592). Only the former group received ABFM, suggesting intensification based on response rescues some poor risk pts. We conclude that a day 15 marrow is not needed to assess response if MRD is measured at end induction, provided that SER MRD is defined using a .01% cutoff, the threshold for intensifying therapy in current COG ALL trials. Clinical trial information: NCT00103285, NCT00075725. [Table: see text]
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Affiliation(s)
| | | | | | - Mignon L. Loh
- University of California, San Francisco, San Francisco, CA
| | | | - Eric Larsen
- Maine Children's Cancer Program, Scarborough, ME
| | | | | | | | | | - Nyla A. Heerema
- The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute, Columbus, OH
| | | | | | - Naomi Joan Winick
- The University of Texas Southwestern Medical Center; Center for Cancer and Blood Disorders, Children's Medical Center Dallas, Dallas, TX
| | | | - Stephen Hunger
- University of Colorado Denver Health Science Center, Aurora, CO
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Mattano LA, Devidas M, Friedmann AM, Raetz EA, Hunger S, Winick NJ, Carroll WL, Maloney KW. Effect of dexamethasone (DEX) dose modification on osteonecrosis (ON) risk associated with intensified therapies for standard risk acute lymphoblastic leukemia (SR-ALL): A report from the Children’s Oncology Group (COG) study AALL0331. J Clin Oncol 2013. [DOI: 10.1200/jco.2013.31.15_suppl.10002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
10002 Background: ON is a known toxicity of childhood ALL therapy, particularly in patients (pts) >9 years (y). Intensified use of DEX, methotrexate (MTX), and asparaginase (ASNase) may increase the risk of developing ON among B-precursor NCI SR-ALL pts despite their younger age. Methods: Newly diagnosed SR-ALL pts 1-9y enrolled on AALL0331 between 4/05 and 5/10 were prospectively monitored for symptomatic ON within three treatment cohorts risk-stratified by clinical, cytogenetic, and early response criteria. ON sites were confirmed by imaging. SR-Low (SRL) pts were randomized to standard therapy +/- 4 additional doses of PEG-ASNase. SR-Average (SRA) pts were randomized (2x2) to standard therapy +/- an intensive consolidation (IC) +/- an augmented interim maintenance/delayed intensification (AIM/ADI). SR-High (SRH) pts all received IC and two AIM/ADI phases. After 6/08, alternate week DEX (AWD, days 1-7/15-21) replaced continuous DEX (days 1-21) during DI, and escalating-dose MTX replaced oral MTX during IM. All pts received DEX days 1-28 during induction and 5-day pulses every 4 weeks during maintenance. Results: Overall ON cumulative incidence (CI) at 5y was 2.7% (133/5261), correlating with sex (F 3.7%, M 1.9%, p<0.0001), age (1-2y 0.8%, 3-4y 2.0%, 5-6y 3.3%, 7-9y 7.8%, p<0.0001), and risk group (SRL 2.6%, SRA 2.9%, SRH 5.7%, p=0.0009). Before 6/08, ON CI was higher for SRA pts given intensive vs standard consolidation (5.8% vs 1.9%, p=0.002), and trended higher for SRL pts given additional PEG-ASNase (4.0 vs 2.3%, p=0.09). Use of AWD significantly reduced ON CI at 3y among SRH pts (7.4% vs 1.5%, p=0.003) and further reduced ON events in SRL/SRA pts. Conclusions: Young children receiving intensified therapy for SR-ALL therapy are at risk for ON. Extended exposure to PEG-ASNase is a likely contributing factor, possibly by potentiating DEX exposure during DI. ON risk can be significantly reduced by using AWD during DI, which is now COG standard of care. Clinical trial information: NCT00103285.
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Affiliation(s)
| | | | | | | | - Stephen Hunger
- University of Colorado Denver Health Science Center, Aurora, CO
| | - Naomi Joan Winick
- The University of Texas Southwestern Medical Center; Center for Cancer and Blood Disorders, Children's Medical Center Dallas, Dallas, TX
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Abstract
Children with Down syndrome (DS) often present with hematopoietic abnormalities, and are at increased risk of developing leukemia. Specifically, 3-10% of newborns with DS are diagnosed with transient myeloproliferative disease, and children with DS are 500 times more likely to develop acute megakaryoblastic leukemia (AMKL) and 20 times more likely to develop acute lymphoblastic leukemia (ALL) than typical children. This review examines the characteristics of these leukemias and their development in the unique genetic background of trisomy 21. A discussion is also provided for areas of future research and potential therapeutic development.
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Affiliation(s)
- Laura Seewald
- Linda Crnic Institute for Down Syndrome, University of Colorado School of Medicine, Aurora, CO, USA.
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Affiliation(s)
- Kelly W Maloney
- The Children's Hospital, The Center for Cancer and Blood Disorders, Aurora, Colorado 80045, USA.
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Friedman K, Wallis T, Maloney KW, Hendrickson RJ, Mengshol S, Cadnapaphornchai MA. An unusual cause of pediatric hypertension. J Pediatr 2007; 151:206-12. [PMID: 17643780 DOI: 10.1016/j.jpeds.2007.04.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2006] [Revised: 01/23/2007] [Accepted: 04/10/2007] [Indexed: 11/29/2022]
Affiliation(s)
- Kevin Friedman
- Department of Pediatrics, The Children's Hospital, University of Colorado Health Sciences Center, Denver, Colorado 80218, USA
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Gershan JA, Johnson BD, Weber J, Schauer DW, Natalia N, Behnke S, Burns K, Maloney KW, Warwick AB, Orentas RJ. Immediate transfection of patient-derived leukemia: a novel source for generating cell-based vaccines. Genet Vaccines Ther 2005; 3:4. [PMID: 15969754 PMCID: PMC1182385 DOI: 10.1186/1479-0556-3-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2005] [Accepted: 06/21/2005] [Indexed: 11/18/2022]
Abstract
Background The production of cell-based cancer vaccines by gene vectors encoding proteins that stimulate the immune system has advanced rapidly in model systems. We sought to develop non-viral transfection methods that could transform patient tumor cells into cancer vaccines, paving the way for rapid production of autologous cell-based vaccines. Methods As the extended culture and expansion of most patient tumor cells is not possible, we sought to first evaluate a new technology that combines electroporation and chemical transfection in order to determine if plasmid-based gene vectors could be instantaneously delivered to the nucleus, and to determine if gene expression was possible in a cell-cycle independent manner. We tested cultured cell lines, a primary murine tumor, and primary human leukemia cells from diagnostic work-up for transgene expression, using both RFP and CD137L expression vectors. Results Combined electroporation-transfection directly delivered plasmid DNA to the nucleus of transfected cells, as demonstrated by confocal microscopy and real-time PCR analysis of isolated nuclei. Expression of protein from plasmid vectors could be detected as early as two hours post transfection. However, the kinetics of gene expression from plasmid-based vectors in tumor cell lines indicated that optimal gene expression was still dependent on cell division. We then tested to see if pediatric acute lymphocytic leukemia (ALL) would also display the rapid gene expression kinetics of tumor cells lines, determining gene expression 24 hours after transfection. Six of 12 specimens showed greater than 17% transgene expression, and all samples showed at least some transgene expression. Conclusion Given that transgene expression could be detected in a majority of primary tumor samples analyzed within hours, direct electroporation-based transfection of primary leukemia holds the potential to generate patient-specific cancer vaccines. Plasmid-based gene therapy represents a simple means to generate cell-based cancer vaccines and does not require the extensive infrastructure of a virus-based vector system.
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Affiliation(s)
- Jill A Gershan
- Department of Pediatrics, Medical College of Wisconsin and the Children's Research Institute, Children's Hospital of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI 53226, USA
| | - Bryon D Johnson
- Department of Pediatrics, Medical College of Wisconsin and the Children's Research Institute, Children's Hospital of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI 53226, USA
| | - James Weber
- Department of Pediatrics, Medical College of Wisconsin and the Children's Research Institute, Children's Hospital of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI 53226, USA
| | - Dennis W Schauer
- Department of Pediatrics, Medical College of Wisconsin and the Children's Research Institute, Children's Hospital of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI 53226, USA
| | - Natalia Natalia
- Department of Pediatrics, Medical College of Wisconsin and the Children's Research Institute, Children's Hospital of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI 53226, USA
| | - Stephanie Behnke
- Department of Pediatrics, Medical College of Wisconsin and the Children's Research Institute, Children's Hospital of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI 53226, USA
| | - Karen Burns
- Department of Pediatrics, Medical College of Wisconsin and the Children's Research Institute, Children's Hospital of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI 53226, USA
| | - Kelly W Maloney
- Department of Pediatrics, Medical College of Wisconsin and the Children's Research Institute, Children's Hospital of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI 53226, USA
| | - Anne B Warwick
- Department of Pediatrics, Medical College of Wisconsin and the Children's Research Institute, Children's Hospital of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI 53226, USA
| | - Rimas J Orentas
- Department of Pediatrics, Medical College of Wisconsin and the Children's Research Institute, Children's Hospital of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI 53226, USA
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Abstract
OBJECTIVE To determine the frequency of underlying bleeding disorders in adolescents with menorrhagia. STUDY DESIGN We retrospectively reviewed the charts of all girls, aged 10 to 19 years, who presented to our children's hospital for inpatient or outpatient evaluation of menorrhagia between January 1990 and November 1998. RESULTS At presentation, 9 of the 71 girls (13%) had thrombocytopenia (platelet count <150,000/microL; range, 5000-106,000/microL). The most common causes for thrombocytopenia were immune thrombocytopenic purpura (n = 5) and myelosuppression caused by chemotherapy (n = 2). Of 14 girls who underwent a more detailed hemostatic evaluation, 8 were given a diagnosis of a hereditary coagulation disorder: 6 had platelet function defects and 2 had type 1 von Willebrand disease. Excessive menstrual bleeding commonly results in anemia. One half of the total group had anemia (hemoglobin <12.0 g/dL). Seven girls (10%) had potentially life-threatening anemia (hemoglobin <5.0 g/dL). CONCLUSIONS Acquired and congenital bleeding disorders are common causes of menorrhagia in adolescent girls. Severe anemia is a frequent complication of menorrhagia. We recommend that adolescents without thrombocytopenia who present with menorrhagia receive a comprehensive hemostatic evaluation, including testing for von Willebrand disease and platelet function defects.
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Affiliation(s)
- J A Bevan
- Department of Pediatrics, Section of Pediatric Hematology and Oncology, Medical College and Children's Hospital of Wisconsin, Milwaukee, WI 53201-2178, USA
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Maloney KW, Shuster JJ, Murphy S, Pullen J, Camitta BA. Long-term results of treatment studies for childhood acute lymphoblastic leukemia: Pediatric Oncology Group studies from 1986-1994. Leukemia 2000; 14:2276-85. [PMID: 11187919 DOI: 10.1038/sj.leu.2401965] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This paper presents the long-term results of treatment for children with acute lymphoblastic leukemia (ALL) as conducted by the Pediatric Oncology Group (POG) from 1986 to 1994. The data are presented using standard NCI/Rome risk criteria. The overall event-free survival (EFS) at 5 and 10 years were 70.9% and 67.3% for children with B-precursor ALL, 51.0% and 50.2% for patients with T cell ALL, and 22.4% and 20.9% for infants with ALL. Concomitant biologic studies found that in B-precursor ALL a DNA index (DI) of > or =1.16 and trisomies of both chromosomes 4 and 10 were good prognostic indicators for patients with B-precursor ALL. The traditional prognostic indicators (age and white count), DI and trisomies did not predict outcome in patients with T cell disease. Infants continued to do poorly overall despite more intensive therapy with rotating pairs of chemotherapy. We recommend continued reporting of study results using common risk criteria in order to facilitate comparisons both within and across study groups.
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Affiliation(s)
- K W Maloney
- Department of Pediatrics, Midwest Children's Cancer Center, Milwaukee, WI 53226, USA
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Maloney KW, McGavran L, Odom LF, Hunger SP. Acquisition of p16(INK4A) and p15(INK4B) gene abnormalities between initial diagnosis and relapse in children with acute lymphoblastic leukemia. Blood 1999; 93:2380-5. [PMID: 10090949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
Abstract
Although numerous somatic mutations that contribute to the pathogenesis of childhood acute lymphoblastic leukemia (ALL) have been identified, no specific cytogenetic or molecular abnormalities are known to be consistently associated with relapse. The p16(INK4A) (p16), which encodes for both p16(INK4A) and p19(ARF) proteins, and p15(INK4B) (p15) genes are inactivated by homozygous deletion and/or p15 promoter hypermethylation in a significant proportion of cases of childhood ALL at the time of initial diagnosis. To determine whether alterations in these genes play a role in disease progression, we analyzed a panel of 18 matched specimen pairs collected from children with ALL at the time of initial diagnosis and first bone marrow relapse for homozygous p16 and/or p15 deletions or p15 promoter hypermethylation. Four sample pairs contained homozygous p16 and p15 deletions at both diagnosis and relapse. Among the 14 pairs that were p16/p15 germline at diagnosis, three ALLs developed homozygous deletions of both p16 and p15, and two developed homozygous p16 deletions and retained p15 germline status at relapse. In two patients, p15 promoter hypermethylation developed in the interval between initial diagnosis and relapse. In total, homozygous p16 deletions were present in nine of 18 cases, homozygous p15 deletions in seven of 18 cases, and p15 promoter hypermethylation in two of eight cases at relapse. These findings indicate that loss of function of proteins encoded by p16 and/or p15 plays an important role in the biology of relapsed childhood ALL, and is associated with disease progression in a subset of cases.
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Affiliation(s)
- K W Maloney
- Section of Pediatric Hematology/Oncology, Department of Pediatrics, University of Colorado School of Medicine, Denver, USA
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