Prognostic factors affecting remission, remission duration, and survival in adult acute nonlymphocytic leukemia

Prognostic factors and treatment effects on survival in acute myeloid leukemia of M6 subtype: a retrospective study of 54 cases

classification system of acute myeloid leukemia (AML) which designates it as M6 AML. This report describes the data of 54 patients with newly diagnosed M6 AML, consecutively seen in our hospital between May 1976 and May 1999.

PATIENTS AND METHODS

There were 40 males and 14 females. Median age was 59 years. Pancytopenia was the most common feature at diagnosis. Twenty-six percent of cases presented with secondary AML. Karyotype was successfully performed in 35 cases. Eleven patients presented with normal karyotype, nine with simple karyotypic abnormalities, and fifteen with major karyotypic abnormalities. Fifty of the fifty-four patients received one or two courses of induction chemotherapy combining anthracyclines with cytarabine according to different successive protocols. One elderly patient only received low-dose cytarabine, and three patients died before any chemotherapy could be given.

RESULTS

Complete remission (CR) was achieved in 29 cases (54%, 95% confidence interval (CI): 40%-67%). As post-remission therapy, four patients could be allografted, and two underwent autologous transplantation. All other treated patients received continuation chemotherapy. Twenty-one patients have relapsed (72%). Median time to relapse was six months. Among those patients, only eight achieved a second CR (38%). The median disease-free survival (DFS) was eight months (95% CI: 4-10 months) with a five-year survival rate of 17%. Median overall survival (OS) was nine months (95% CI: 5-12 months) with a five-year survival rate of 13%. In univariate analysis, poor prognostic factors for DFS were secondary AML (P = 0.05) and initial platelet count <50 x 109/l (P = 0.02). Poor prognostic factors for OS were age > or = 60 years (P = 0.005), secondary AML (P = 0.05), initial 'blastic' fever (P = 0.0004), and initial haemoglobin level < 90 g/l (P = 0.03). All factors, but haemoglobin level, remained significant in the multivariate analysis. Although it was not statistically significant, there was a trent for a better prognosis of M6 patients presenting with normal karyotype as compared to those displaying chromosomal abnormality.

CONCLUSIONS

This retrospective analysis points to a somewhat heterogenous group of AML in terms of clinical and biological features, and outcome. Distinctive subgroups can be identified according to prognostic factors related to survival. A larger multicenter study with well-defined diagnostic criteria is warranted to further clarify treatment effects.

Adverse prognostic features in 251 children treated for acute myeloid leukemia

Potential predictors of event-free survival (EFS) were assessed in 251 consecutively diagnosed children treated for acute myeloid leukemia (AML) on three successive clinical trials. The lack of significant differences in 4-year EFS for these studies (20% +/- 4%, 29% +/- 4%, and 20% +/- 7%) permitted combined analysis of presenting features. Splenomegaly (P = .002), coagulation abnormalities (P = .001), leukocyte count > or = 10 x 10(9)/L (P = .002), and age > 14 years (P = .01) were statistically significant predictors of a poorer EFS by univariate analysis and retained significance in multivariate analysis. Age < 2 years and monocytic leukemias (often cited as adverse factors in AML) showed no prognostic influence in this study. The estimated relative risk of failure for a child with a single adverse feature at diagnosis was at least 1.4 times greater than that for a patient with no adverse features. For children with two or more adverse features, the relative risk increased by more than threefold. These clinical variables, alone or in combination, may identify important subgroups of patients with AML at high risk for failure and for whom improved or alternative therapies are especially important.

Randomized controlled study of chemoimmunotherapy with bestatin of acute nonlymphocytic leukemia in adults

A new immunomodulating agent, bestatin (INN: Ubenimex has low toxicity even after long-term oral administration and has significant modifications in immunological response. A cooperative randomized controlled study of bestatin immunotherapy in combination with remission maintenance chemotherapy for adult acute nonlymphocytic leukemia (ANLL) was performed. After induction of complete remission, patients were randomized to the bestatin group (30 mg/bw per os (po) daily) and the control group. The 101 eligible cases (bestatin: 48, control: 53) were analyzed; the bestatin group achieved longer remission than the control group and a statistically significant longer survival. Though this prolongation of remission was not significant in the bestatin group compared to the control group in the 15-49 yr age group, in the 50-65 yr age group it was significantly longer. Bestatin is shown to be a clinically useful drug for immunotherapy of adult ANLL, since it has prolonged survival and remission especially in elderly patients, with few side-effects.

Prognostic significance of blood and marrow findings in acute myelogenous leukemia in remission. A Southeastern Cancer Study Group report

Bone marrow and peripheral blood findings at the time of complete remission were analyzed in 333 patients with acute myelogenous leukemia to determine if any variables were predictive for remission duration and survival. Patients were categorized as to percentage of blasts, promyelocytes, erythroid precursors and lymphocytes in the marrow and hemoglobin concentration, leukocyte and platelet counts, and percentage of granulocytes and blasts in the blood. Additionally, the degree of cellularity in the marrow aspirate and biopsy were analyzed. Patients with less than 1% blasts in the marrow had significantly longer remission durations than those with blasts greater than or equal to 1% (P less than 0.01). Those with hypercellular marrows had significantly shorter remission (P less than 0.05) and survival (P less than 0.01). The transient presence of more than 3% blasts in the blood also was suggestive of a shorter remission duration and survival. The presence of less than 1% blasts in the marrow, normal or decreased biopsy cellularity, and no anemia at the time of remission defined a "good" prognostic group. The quality of remission should be assessed in evaluating the results of therapy and assigning further treatment.

Treatment of acute myeloid leukemia in elderly patients. A retrospective study

In an attempt to rationalize the use of therapy in acute myeloblastic leukemia (AML) in elderly patients, 69 cases of primary AML in patients older than 60 years of age were reviewed retrospectively. Therapy was empirical and 12 patients received supportive care (SC) only, 35 received aggressive chemotherapy (AC), and 22 received low-dose cytosine arabinoside (LD-araC). Patients receiving SC only often had a poor Karnofski index and their median survival was 17 days. Aggressive chemotherapy yielded complete remissions (CR) in 48% of the patients, whereas 23% of the patients had resistant disease (RD) and 29% had other failures (OF). Low-dose araC, which was administered to patients significantly older than those receiving AC, yielded 23% CR, 68% RD, and 9% OF, with important hematologic toxicity in most patients. Median survival was 211 days in patients receiving AC and 235 days in patients treated with LD-araC. Survival beyond 2 years from diagnosis was noted in the AC group only. A low Karnofski index was the strongest factor in poor prognosis, while age was not a prognostic factor. The initial characteristics of the patients did not allow us to define groups of patients who should be treated by either AC or LD-araC. We concluded that the decision to treat patients actively should rely more on the patient's general condition and socio-economical criteria than on age.

Immunotherapy with bestatin for acute nonlymphocytic leukemia in adults

In a cooperative randomized control study of immunotherapy with bestatin in combination with chemotherapy in adults with acute nonlymphocytic leukemia (ANLL), 101 patients (48 in the bestatin group and 53 in the control group) out of 115 patients registered were evaluated as eligible. The bestatin group achieved a statistically significant prolongation of survival compared with the control group in overall ANLL and acute myelogenous leukemia. In the analysis of patient age, the bestatin group achieved a statistically significant prolongation of both the remission duration and survival in patients aged 50 to 65 years, while the differences were not significant in the 15 to 49 age group. The bestatin group tended to achieve a higher rate of reinduction of remission in patients who had recurrence of leukemia. Side effects developed in only 5 (9.6%) of 52 patients treated with bestatin. None of these side effects were particularly serious in nature. It is concluded that bestatin is useful for prolongation of survival of adult patients with ANLL, making for a longer remission duration especially in elderly patients and with few side effects.

Immunodiagnosis and immunotherapy of childhood malignancies

Recent advances in immunologic techniques have allowed the generation of monoclonal antibodies against antigens on tumor cells and their normal counterparts. Monoclonal antibodies useful for diagnosing and defining subtypes of acute leukemias and neuroblastoma have been prepared, although the prognostic significance of the subtypes defined by such antibodies remains to be determined. The usefulness of these reagents for therapeutic purposes either ex vivo, in association with autologous bone marrow transplantation, or in vivo, as carriers of cytotoxic agents, is currently under investigation.

The epipodophyllotoxin VP16-213 in combination chemotherapy for adults with acute nonlymphoblastic leukaemia

A total of 232 previously untreated adults with acute nonlymphoblastic leukaemia were consecutively entered into four successive studies. In the first, complete remission rates and survival were inferior to a group treated on the same regimen in London, suggesting population differences, possibly on the basis of late referral and poor nutritional status. In the second study the addition of the epipodophyllotoxin VP16-213 to conventional doses of doxorubicin and cytosine arabinoside improved complete remission rate and median duration of survival. In the third study this induction programme was unchanged and short duration of intensification was compared with an extended period, but no statistically significant difference was demonstrated. In the fourth study, which is currently active, the role of the epipodophyllotoxin VP16-213 (Cape Town Regimen/CTR III) was compared with the same two agents in combination with thioguanine (DAT), but to date no difference in remission rate or survival is evident. Four conclusions are supported by data from these studies. First, the addition of VP16-213 to doxorubicin and cytosine arabinoside improves complete remission rate, prolongs median duration of complete remission and survival, with shortening of the time taken to achieve this status in our population. Second, evidence to date shows no advantage for the DAT programme containing thioguanine over CTR III in which this latter agent is replaced by the epipodophyllotoxin VP16-213. Third, there is no statistically significant difference in survival once patients have achieved complete remission following randomisation to receive 6 months in comparison with 15 months of intensification therapy. Finally, of the previously described prognostic factors, only response to initial chemotherapy has proved significant.(ABSTRACT TRUNCATED AT 250 WORDS)

Immunotherapy maintenance in acute non-lymphocytic leukaemia

Between January 1975 and December 1977, 264 adult patients with acute non-lymphocytic leukaemia entered the Australian National Leukaemia Trial. Of 251 evaluable patients, three induction regimens achieved similar complete response (CR) rates. CROP (cytosine arabinoside, daunorubicin, vincristine, prednisolone) produced CR in 41% of patients, 7 and 3 (cytosine arabinoside, daunorubicin) in 42% and 7 and 3 plus hydroxyurea in 52%. Remission duration and survival were similar when induction regimens were compared. Forty-five patients reaching maintenance therapy were randomised to either chemo-immunotherapy (BCG plus intradermal leukaemic blast cells) or chemotherapy alone. The duration of CR in these two groups was almost identical, though patients receiving chemotherapy alone had prolonged survival (median 161 weeks) when compared to the chemo-immunotherapy group (84 weeks, p = 0 . 07). Institutions with less developed supportive facilities reported lower CR rates (p = 0 . 04). Leucocytosis (greater than 100 X 10(9)/1) and older age (greater than 50 years) were associated with shortened survival. The Trial has failed to show any advantage for this form of immunotherapy.

Prediction of remission in adult acute leukemia: development and testing of predictive models

Logistic regression methods were applied to derive a set of models relating achievement of CR to prognostic characteristics in a group of 300 adult acute leukemia patients treated with cytosine arabinoside, vincristine, and prednisone combined with adriamycin (ADOAP) or rubidazone (ROAP). These models were tested prospectively in an independent group of 107 subsequent patients treated with ADOAP or ROAP therapy, by comparing observed outcomes to predictions of response based on the models. Several models were able to identify subgroups of patients with good, intermediate, and poor prognoses. A model regarded as clinically useful and which provided a good fit to both the population from which it was derived and the test population included the pretreatment factors age, history of an antecedent hematologic disorder, temperature, blood urea nitrogen, hemoglobin, and liver size.

Prognostic factors and treatment effects on survival in erythroleukemia: a retrospective study of 134 cases

A total of 134 cases of erythroleukemia (119 from the literature and 15 of the authors' patients) were reviewed in an attempt to correlate survival with age, sex, hepatomegaly, splenomegaly, lymphadenopathy, infection, or hemorrhagic complications at initial presentation; hemoglobin (Hgb), white blood cell (WBC) count, and platelet count; percent myeloblasts in the marrow at diagnosis; and treatment regimens employed. Statistical methods included single classification analysis of variance, nonparametric analysis of variance (Kruskal-Wallis method), contingency table analysis, and correlation coefficient determination for numerical data. No significant correlation between survival and age, sex, hepatomegaly, lymphadenopathy, infection, or hemorrhagic phenomena was found. Improved survival was noted in patients without splenomegaly, and in daunorubicin-treated cases in contrast to those treated with other chemotherapeutic agents. A positive correlation between survival and initial Hgb and WBC was also noted. Erythroleukemia complicating a chronic myeloproliferative disorder had a worse prognosis than de novo erythroleukemia.

The prognostic significance of in vitro bone marrow growth pattern in acute non-lymphocytic leukaemia

The growth pattern of bone marrow cells in agar culture was studied in 56 patients with untreated acute non-lymphocytic leukaemia. 4 different growth patterns were recognized: (A) colony and cluster formation, (B) growth of small clusters (3-20 cells) only but less than 600/10(5) cells, (C) growth of small clusters only but more than 600/10(5) cells, and (D) no growth in vitro. Patients in group A and B had a significantly higher remission rate (23/34) than patients in group C and D (3/22). This was true also when only patients below 60 years of age were considered. The median survival time of patients in group A and B was 7.3 months and 9.4 months, and in group C and D 4.0 months and 3.3 months. Identical growth patterns were found for marrow and blood cells in 21 of 27 patients studied and the number of clusters in blood and marrow showed a significant correlation (r = +0.96, P less than 0.001). The mean 3H-labelling index (LI) of myeloblasts determined in 32 patients was 14.8 +/- 7.8% (SD). Patients with LI below 15% tended to have a higher remission rate than patients with LI above 15%. It is concluded that the in vitro growth pattern at diagnosis of bone marrow cells from patients with ANLL is of value in detecting patients with a poor response to current therapeutic protocols. Such information could possibly lead to alternative cytostatic regimes in these patients.

Characteristics of children with acute nonlymphocytic leukemia in long-term continuous remission: a report for Childrens Cancer Study Group

Children and young adults less than 18 years of age with acute nonlymphocytic leukemia who remained in long term bone marrow and extramedullary remission for two years or longer since starting maintenance were compared to the remaining responders for the following characteristics: cell type, sex, age at diagnosis, race, pretreatment, white blood count, length of time from start to induction therapy to achievement of an M1 marrow, marrow rating at day 56 of therapy, marrow rating at the start of maintenance therapy, and specific study. Forty-eight patients of a group of 333 qualified as having long term remission (14.4%). Multivariant analysis indicated that patients between the ages of 3 and 10 years (p = 0.003) as well as the length of time to achieve an M1 marrow from the start of treatment (p = 0.03) were the only characteristics associated with achievement of a long term remission. Maintenance therapy was discontinued in 15 patients from 2.5 to 4.8 years after start of maintenance and all patients remained in bone marrow remission of periods from 0+ to 3.0+ years after stopping treatment. Of the 33 who have remained on a continuous maintenance therapy 12 have had bone marrow relapses. These data confirm the prognostic value of age and length of time to achieve remission during induction in acute nonlymphocytic leukemia and suggest that there may be no significant benefit from maintenance therapy continued beyond 2 years for patients in their initial remission.