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Mason NR, Cahill H, Diamond Y, McCleary K, Kotecha RS, Marshall GM, Mateos MK. Down syndrome-associated leukaemias: current evidence and challenges. Ther Adv Hematol 2024; 15:20406207241257901. [PMID: 39050114 PMCID: PMC11268035 DOI: 10.1177/20406207241257901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 05/13/2024] [Indexed: 07/27/2024] Open
Abstract
Children with Down syndrome (DS) are at increased risk of developing haematological malignancies, in particular acute megakaryoblastic leukaemia and acute lymphoblastic leukaemia. The microenvironment established by abnormal haematopoiesis driven by trisomy 21 is compounded by additional genetic and epigenetic changes that can drive leukaemogenesis in patients with DS. GATA-binding protein 1 (GATA1) somatic mutations are implicated in the development of transient abnormal myelopoiesis and the progression to myeloid leukaemia of DS (ML-DS) and provide a model of the multi-step process of leukaemogenesis in DS. This review summarises key genetic drivers for the development of leukaemia in patients with DS, the biology and treatment of ML-DS and DS-associated acute lymphoblastic leukaemia, late effects of treatments for DS-leukaemias and the focus for future targeted therapy.
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Affiliation(s)
- Nicola R. Mason
- Kids Cancer Centre, Sydney Children’s Hospital, Randwick, NSW, Australia
| | - Hilary Cahill
- Kids Cancer Centre, Sydney Children’s Hospital, Randwick, NSW, Australia
| | - Yonatan Diamond
- Kids Cancer Centre, Sydney Children’s Hospital, Randwick, NSW, Australia
| | - Karen McCleary
- Kids Cancer Centre, Sydney Children’s Hospital, Randwick, NSW, Australia
- School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Kensington, NSW, Australia
| | - Rishi S. Kotecha
- Department of Clinical Haematology, Oncology, Blood and Bone Marrow Transplantation, Perth Children’s Hospital, Perth, WA, Australia
- Leukaemia Translational Research Laboratory, Telethon Kids Cancer Centre, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
- Curtin Medical School, Curtin University, Perth, WA, Australia
| | - Glenn M. Marshall
- Kids Cancer Centre, Sydney Children’s Hospital, Randwick, Randwick, NSW, Australia School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Kensington, NSW, Australia Children’s Cancer Institute, Lowy Cancer Centre, UNSW Sydney, Kensington, NSW, Australia
| | - Marion K. Mateos
- Kids Cancer Centre, Sydney Children’s Hospital, Level 1 South Wing, High Street, Randwick, NSW 2031, Australia
- School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Kensington, NSW, Australia
- Children’s Cancer Institute, Lowy Cancer Centre, UNSW Sydney, Kensington, NSW, Australia
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2
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Jiang MR, Ahmet A, Lawrence S, Bassal M, Speckert M, Geraghty MT, Somerville S. Hypoglycemia Associated With PEG-asparaginase and 6-MP Therapy During Treatment of Acute Lymphoblastic Leukemia in Pediatric Patients: A Case Series. J Pediatr Hematol Oncol 2024; 46:e121-e126. [PMID: 38411659 DOI: 10.1097/mph.0000000000002818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 12/23/2023] [Indexed: 02/28/2024]
Abstract
BACKGROUND Asparaginases are a mainstay treatment for pediatric acute lymphoblastic leukemia (ALL). Recent reports identified hypoglycemia associated with asparaginases. Other reports describe hypoglycemia associated with 6-mercaptopurine (6-MP), another fundamental ALL therapy. Little is known about the risk of hypoglycemia associated with ALL therapy, an adverse event that puts children at risk of decreased level of consciousness, seizures, and possibly negative neurocognitive sequelae. METHODS We performed a retrospective chart review of 6 children with hypoglycemia during ALL treatment in our institution from May 2016 to August 2019. Timing and duration of hypoglycemia relative to polyethylene glycol (PEG)-asparaginase, 6-MP, and corticosteroids were determined. Laboratory values of the critical sample were collected. RESULTS The median age was 2.75 (interquartile range: 1.88 to 3.63) years. Three patients had trisomy 21. The onset of hypoglycemia was 5 to 19 days after the most recent PEG-asparaginase administration or 6 to 7 months after initiating daily 6-MP. Sixteen hypoglycemic events were documented, and 9/16 had a critical sample drawn. Six events were hypoketotic, associated with PEG-asparaginase. Three were ketotic, associated with 6-MP. Two patients required treatment with diazoxide and cornstarch. CONCLUSIONS Hypoglycemia associated with PEG-asparaginase occurred later and lasted longer than previous reports with l-asparaginase, with the likely mechanism being hyperinsulinism. 6-MP was associated with ketotic hypoglycemia.
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Affiliation(s)
- Mary R Jiang
- Department of Pediatrics, Division of Endocrinology
| | | | | | - Mylene Bassal
- Department of Pediatrics, Division of Hematology/Oncology
| | | | - Michael T Geraghty
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
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3
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Barwe SP, Kolb EA, Gopalakrishnapillai A. Down syndrome and leukemia: An insight into the disease biology and current treatment options. Blood Rev 2024; 64:101154. [PMID: 38016838 DOI: 10.1016/j.blre.2023.101154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 10/31/2023] [Accepted: 11/19/2023] [Indexed: 11/30/2023]
Abstract
Children with Down syndrome (DS) have a 10- to 20-fold greater predisposition to develop acute leukemia compared to the general population, with a skew towards myeloid leukemia (ML-DS). While ML-DS is known to be a subtype with good outcome, patients who relapse face a dismal prognosis. Acute lymphocytic leukemia in DS (DS-ALL) is considered to have poor prognosis. The relapse rate is high in DS-ALL compared to their non-DS counterparts. We have a better understanding about the mutational spectrum of DS leukemia. Studies using animal, embryonic stem cell- and induced pluripotent stem cell-based models have shed light on the mechanism by which these mutations contribute to disease initiation and progression. In this review, we list the currently available treatment strategies for DS-leukemias along with their outcome with emphasis on challenges with chemotherapy-related toxicities in children with DS. We focus on the mechanisms of initiation and progression of leukemia in children with DS and highlight the novel molecular targets with greater success in preclinical trials that have the potential to progress to the clinic.
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Affiliation(s)
- Sonali P Barwe
- Lisa Dean Moseley Institute for Cancer and Blood Disorders, Nemours Children's Health, Wilmington, Delaware, 19803, USA
| | - E Anders Kolb
- Lisa Dean Moseley Institute for Cancer and Blood Disorders, Nemours Children's Health, Wilmington, Delaware, 19803, USA
| | - Anilkumar Gopalakrishnapillai
- Lisa Dean Moseley Institute for Cancer and Blood Disorders, Nemours Children's Health, Wilmington, Delaware, 19803, USA.
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4
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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] [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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5
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Bohnstedt C, Stenmarker M, Olersbacken L, Schmidt L, Larsen HB, Schmiegelow K, Hansson H. Participation, challenges and needs in children with down syndrome during cancer treatment at hospital: a qualitative study of parents' experiences. FRONTIERS IN REHABILITATION SCIENCES 2023; 4:1099516. [PMID: 37180572 PMCID: PMC10172473 DOI: 10.3389/fresc.2023.1099516] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 04/10/2023] [Indexed: 05/16/2023]
Abstract
Background Studies report that it can be challenging to assess and treat side-effects and symptoms among children who have impairments and difficulties in expressing their needs. Children with Down syndrome have an increased vulnerability and an increased risk for contracting leukaemia. There is sparse knowledge about the parental experience of how treatment and side-effects affect children with Down syndrome with leukaemia, as well as the role of participation during treatment. Purpose This study aimed to explore the perceptions of parents of children with Down syndrome and leukaemia regarding their child's treatment, side effects and participation during hospital care. Methods A qualitative study design was used, and interviews were conducted with a semi-structured interview-guide. Fourteen parents of 10 children with Down syndrome and acute lymphoblastic leukaemia from Sweden and Denmark, 1-18 years of age, participated. All children had completed therapy or had a few months left before the end of treatment. Data was analysed according to qualitative content analysis. Results Four sub-themes were identified: (1) Continuously dealing with the child's potential susceptibility; (2) Confidence and worries regarding decisions related to treatment regulation; (3) Challenges in communication, interpretation, and participation; and (4) Facilitating participation by adapting to the child's behavioural and cognitive needs. The sub-themes were bound together in an overarching theme, which expressed the core perception "Being the child's spokesperson to facilitate the child's participation during treatment". The parents expressed this role as self-evident to facilitate communication regarding the needs of the child, but also regarding how the cytotoxic treatment affected the vulnerable child. Parents conveyed the struggle to ensure the child's right to receive optimal treatment. Conclusion The study results highlight parental challenges regarding childhood disabilities and severe health conditions, as well as communication and ethical aspects regarding to act in the best interests of the child. Parents played a vital role in interpreting their child with Down syndrome. Involving parents during treatment enables a more accurate interpretation of symptoms and eases communication and participation. Still, the results raise questions regarding issues related to building trust in healthcare professionals in a context where medical, psychosocial and ethical dilemmas are present.
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Affiliation(s)
- Cathrine Bohnstedt
- Paediatric Oncology Research Laboratory, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Paediatrics and Adolescent Medicine, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Margaretha Stenmarker
- Department of Paediatrics, Region Jönköping County, Jönköping, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Institute of Clinical Sciences, Department of Paediatrics, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Linn Olersbacken
- Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Lone Schmidt
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Hanne B. Larsen
- Paediatric Oncology Research Laboratory, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kjeld Schmiegelow
- Paediatric Oncology Research Laboratory, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Helena Hansson
- Paediatric Oncology Research Laboratory, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
- Correspondence: Helena Hansson
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6
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Athale U, Sutradhar R, Breakey VR, Li Q, Bassal M, Gibson P, Patel S, Wheaton L, Pole JD, Mittman N, Pechlivanoglou P, Gupta S. Healthcare utilization and costs associated with acute lymphoblastic leukemia in children with and without Down syndrome. Pediatr Blood Cancer 2022; 69:e29829. [PMID: 35674471 DOI: 10.1002/pbc.29829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 05/06/2022] [Accepted: 05/16/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Children with Down syndrome (DS) and acute lymphoblastic leukemia (ALL) are at increased risk of treatment-related morbidity and mortality compared to non-DS-ALL, requiring increased supportive care. We examined the healthcare utilization and costs in DS-ALL patients to inform future evaluations of novel therapies. METHODS A provincial registry identified all children (1-17 years) diagnosed with B-lineage ALL in Ontario, Canada between 2002 and 2012. Detailed demographic, disease, treatment, and outcome data were abstracted. Linkage to population-based health services databases identified all outpatient and emergency department (ED) visits, hospitalizations, and physician billings. Healthcare utilization costs were available for patients diagnosed during 2006-2012 using validated algorithms (2018 Canadian dollars). Healthcare utilization rates and costs were compared between DS and non-DS patients using regression models, adjusting for all covariates. RESULTS Of 711 patients, 28 (3.9%) had DS. Adjusting for all covariates, children with DS-ALL experienced substantially higher rates of ED visits (rate ratio [RR] 1.5, 95% confidence interval [95% CI]: 1.2-2.0; p = .001) and inpatient days (RR 2.5, 95% CI: 1.4-4.5; p = .002) compared to non-DS children. Outpatient visit rates were similar (RR 1.1, 95% CI: 0.9-1.3; p = .41). Among patients with available cost data (N = 533, DS = 19), median 5-year healthcare utilization cost was $247,700 among DS patients (interquartile range [IQR]: 200,900-354,500) and $196,200 among non-DS patients (IQR: 148,900-280,300; p = .02). In adjusted analyses, DS-associated costs were 50% higher (RR 1.5, 95% CI: 1.2-1.9; p < .002). CONCLUSIONS Healthcare utilization and treatment costs of DS-ALL patients are substantially higher than those of non-DS-ALL. Our data provide a baseline for future DS-specific cost-effectiveness studies.
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Affiliation(s)
- Uma Athale
- McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Rinku Sutradhar
- Cancer Research Program, ICES, Toronto, Ontario, Canada.,Institute for Health Policy, Evaluation and Management, University of Toronto, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | | | - Qing Li
- Cancer Research Program, ICES, Toronto, Ontario, Canada
| | - Mylene Bassal
- Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Paul Gibson
- McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Serina Patel
- London Health Sciences Centre, London, Ontario, Canada
| | - Laura Wheaton
- Kingston General Hospital, Kingston, Ontario, Canada
| | - Jason D Pole
- Cancer Research Program, ICES, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Center for Health Services Research, University of Queensland, Brisbane, Queensland, Australia
| | - Nicole Mittman
- Institute for Health Policy, Evaluation and Management, University of Toronto, Toronto, Ontario, Canada.,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Petros Pechlivanoglou
- Institute for Health Policy, Evaluation and Management, University of Toronto, Toronto, Ontario, Canada.,Sickkids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Sumit Gupta
- Cancer Research Program, ICES, Toronto, Ontario, Canada.,Institute for Health Policy, Evaluation and Management, University of Toronto, Toronto, Ontario, Canada.,Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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7
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Wood NM, Davis S, Lewing K, Noel-MacDonnell J, Glynn EF, Caragea D, Hoffman MA. Aligning EHR Data for Pediatric Leukemia With Standard Protocol Therapy. JCO Clin Cancer Inform 2021; 5:239-251. [PMID: 33656914 PMCID: PMC8140784 DOI: 10.1200/cci.20.00144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Children with acute lymphoblastic leukemia (ALL) are treated according to risk-based protocols defined by the Children's Oncology Group (COG). Alignment between real-world clinical practice and protocol milestones is not widely understood. Aggregate deidentified electronic health record (EHR) data offer a useful resource to evaluate real-world clinical practice.
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Affiliation(s)
- Nicole M Wood
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO.,Children's Mercy Research Institute, Kansas City, MO.,Department of Pediatrics, University of Missouri, Kansas City, MO
| | - Sierra Davis
- Children's Mercy Research Institute, Kansas City, MO
| | - Karen Lewing
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO.,Department of Pediatrics, University of Missouri, Kansas City, MO
| | - Janelle Noel-MacDonnell
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO.,Children's Mercy Research Institute, Kansas City, MO.,Department of Pediatrics, University of Missouri, Kansas City, MO
| | - Earl F Glynn
- Children's Mercy Research Institute, Kansas City, MO
| | | | - Mark A Hoffman
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO.,Children's Mercy Research Institute, Kansas City, MO.,Department of Pediatrics, University of Missouri, Kansas City, MO.,Department of Biomedical and Health Informatics, University of Missouri, Kansas City, MO
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8
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Liao W, Liu Y. Treatment outcomes in children with Acute lymphoblastic leukemia with versus without coexisting Down's syndrome: A systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e21015. [PMID: 32702842 PMCID: PMC7373598 DOI: 10.1097/md.0000000000021015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Down syndrome (DS) also known as Trisomy 21, is a chromosomal disorder affecting approximately 1 in 732newborns annually in the United States. Children with DS are more likely to develop acute lymphoblastic leukemia (ALL). For the management of pediatric ALL, different treatment protocols have been set up since years. However, ALL children with coexisting DS have shown to have increased therapy-related toxicities compared to those without DS. Therefore, in this study, we aimed to systematically analyze the treatment outcomes in acute ALL children with versus without coexisting DS. METHODS Electronic databases including the Web of Science, EMBASE, Cochrane Central, MEDLINE, http://www.ClinicalTrials.gov, and Google scholar were searched for publications reporting treatment related outcomes in ALL children with versus without co-existing DS. Several treatment protocols were used accordingly. This study had a long-term follow-up time period ranging from 5 to 10 years. The RevMan 5.3 software was used to carry out this analysis. Odds ratios (OR) with 95% confidence intervals (CI) were used to represent the results post analysis. RESULTS A total number of 31,476 children with ALL enrolled between the years 1981 and 2011 were included. Among the total number of children with ALL, 1303 had coexisting DS. Our results showed that event-free survival was similar in ALL children with versus without DS (odds ratio [OR]: 1.34, 95% confidence interval [CI]: 0.51-3.50; P = .55). Overall mortality (OR: 1.63, 95% CI: 0.86-3.10; P = .13) and participants who achieved clinical remission (OR: 1.04, 95% CI: 0.12-9.29; P = .97) were also similarly manifested. However, treatment-related mortality (OR: 4.29, 95% CI: 2.90-6.36; P = .00001) and induction failure (OR: 2.77, 95% CI: 1.08-7.07; P = .03) were significantly higher in the DS group. Also, total (OR: 1.38, 95% CI: 1.02-1.88; P = .04) and bone marrow relapses (OR: 1.29, 95% CI: 1.00-1.67; P = .05) were significantly higher in ALL children with DS. Nevertheless, central nervous system relapse (OR: 1.15, 95% CI: 0.60-2.20; P = .67), testicular relapse (OR: 0.84, 95% CI: 0.38-1.85; P = .87), and other relapses (OR: 1.12, 95% CI: 0.27-4.62; P = .88) were not significantly different when these outcomes were separately analyzed. CONCLUSION Based on this analysis of the treatment outcomes in ALL children with versus without DS, event-free survival, overall mortality, and patients who achieved clinical remission were similar during this long-term follow-up time period. However, due to the significantly higher treatment-related mortality, induction failure, and certain relapses in ALL children with DS, new guidelines might have to focus on reconsidering or modifying treatment regimens for ALL children with DS.
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Affiliation(s)
| | - Ying Liu
- Department of Oncology, Jingmen No.1 People's Hospital, Jingmen, Hubei, P.R. China
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9
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Excellent long-term survival of children with Down syndrome and standard-risk ALL: a report from the Children's Oncology Group. Blood Adv 2020; 3:1647-1656. [PMID: 31160295 DOI: 10.1182/bloodadvances.2019032094] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 03/25/2019] [Indexed: 11/20/2022] Open
Abstract
The Children's Cancer Group 1991 study was a clinical trial for children with National Cancer Institute standard-risk acute lymphoblastic leukemia (ALL). This trial demonstrated that 5 doses of vincristine and escalating IV methotrexate (MTX) without leucovorin rescue in the interim maintenance (IM) phases resulted in superior event-free survival (EFS) when compared with 2 doses of vincristine, oral (PO) MTX, PO mercaptopurine, and dexamethasone. This report describes a favorable outcome of this regimen in patients with Down syndrome (DS). Forty-four patients with DS were randomized to the arms containing PO MTX during IM, and 31 to those containing IV MTX. Ten-year EFS rates for patients with DS randomized to IV MTX vs PO MTX were 94.4% ± 5.4% vs 81.5% ± 6.6%, respectively. IV methotrexate with strict escalation parameters, as given in this study, was well tolerated, although the mean total tolerated dose received was lower in patients with DS than in those without DS. There was no increase in hepatic toxicity, systemic infections, or treatment-related deaths in patients with DS during IM on either the IV or PO MTX arms, as compared with those without DS. The incidence of mucositis was increased in patients with DS as compared with patients without DS, particularly among patients who received IV MTX. This trial was registered at www.clinicaltrials.gov as #NCT00005945.
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10
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Murphy BR, Roth M, Kolb EA, Alonzo T, Gerbing R, Wells RJ. Development of acute lymphoblastic leukemia following treatment for acute myeloid leukemia in children with Down syndrome: A case report and retrospective review of Children's Oncology Group acute myeloid leukemia trials. Pediatr Blood Cancer 2019; 66:e27700. [PMID: 30908863 PMCID: PMC6941434 DOI: 10.1002/pbc.27700] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 02/05/2019] [Accepted: 02/22/2019] [Indexed: 11/09/2022]
Abstract
Children with Down syndrome have a 150-fold increased risk of developing acute myeloid leukemia (AML) and 20-fold increased risk of developing acute lymphoblastic leukemia (ALL). Although the risk of developing AML and ALL is significantly increased in children with Down syndrome, the development of both malignancies in the same patient is very rare. We describe a patient with Down syndrome who developed ALL 6 years after being diagnosed with AML. We performed a literature review and Children's Oncology Group query and discovered eight published cases and five cases of ALL following AML in pediatric patients with Down syndrome, as well as six cases of ALL following AML in non-Down syndrome patients. There was a similar cumulative incidence of ALL after treatment for AML in the Down syndrome and non-Down syndrome populations. Overall survival in patients with Down syndrome who developed ALL after treatment for AML was comparable to overall survival for patients with Down syndrome with de novo ALL with an average follow-up of 7 years after ALL diagnosis. Clinical data collected were used to discuss whether this phenomenon represents a secondary leukemia, second primary cancer, or mixed-lineage leukemia.
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Affiliation(s)
- Brianna R. Murphy
- University of Texas M. D. Anderson Children’s Cancer Hospital, Houston, Texas
| | - Michael Roth
- University of Texas M. D. Anderson Children’s Cancer Hospital, Houston, Texas
| | - E. Anders Kolb
- Nemours/Alfred I DuPont Hospital for Children, Wilmington, Delaware
| | - Todd Alonzo
- University of Southern California Keck School of Medicine, Los Angeles, California
| | | | - Robert J. Wells
- University of Texas M. D. Anderson Children’s Cancer Hospital, Houston, Texas
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11
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Athale UH, Puligandla M, Stevenson KE, Asselin B, Clavell LA, Cole PD, Kelly KM, Laverdiere C, Leclerc JM, Michon B, Schorin MA, Sulis ML, Welch JJG, Harris MH, Neuberg DS, Sallan SE, Silverman LB. Outcome of children and adolescents with Down syndrome treated on Dana-Farber Cancer Institute Acute Lymphoblastic Leukemia Consortium protocols 00-001 and 05-001. Pediatr Blood Cancer 2018; 65:e27256. [PMID: 29878490 DOI: 10.1002/pbc.27256] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 04/10/2018] [Accepted: 04/20/2018] [Indexed: 11/06/2022]
Abstract
BACKGROUND Children and adolescents with Down syndrome (DS) and acute lymphoblastic leukemia (ALL) are reported to have increased relapse rates and therapy-related mortality (TRM). Treatment regimens for DS-ALL patients often include therapy modifications. Dana-Farber Cancer Institute (DFCI) ALL Consortium protocols have used same risk-stratified treatment for patients with and without DS. PROCEDURES We compared clinical and outcome data of DS (n = 38) and non-DS (n = 1,248) patients enrolled on two consecutive DFCI ALL trials 00-001 (2000-2004) and 05-001 (2005-2011) with similar risk adapted therapy regardless of DS status. RESULTS There was no difference in demographic or presenting clinical features between two groups except absence of T-cell phenotype and lower frequency of hyperdiploidy in DS-ALL group. All DS-ALL patients achieved complete remission; four relapsed and one subsequently died. There was no TRM in DS-ALL patients. DS-ALL patients had significantly higher rates of mucositis (52% vs. 12%, p < 0.001), non-CNS thrombosis (18% vs. 8%; p = 0.036), and seizure (16% vs. 5%, p = 0.010). Compared to non-DS-ALL patients, DS-ALL patients had a higher incidence of infections during all therapy phases. The 5-year event-free and overall survival rates of DS-ALL patients were similar to non-DS-ALL patients (91% [95% confidence interval (CI), 81-100] vs. 84% [95% CI, 82-86]; 97% [95% CI, 92-100] vs. 91% [95% CI, 90-93]). CONCLUSION The low rates of relapse and TRM indicate that uniform risk-stratified therapy for DS-ALL and non-DS-ALL patients on DFCI ALL Consortium protocols was safe and effective, although the increased rate of toxicity in the DS-ALL patients highlights the importance of supportive care during therapy.
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Affiliation(s)
- Uma H Athale
- Division of Hematology/Oncology, McMaster Children's Hospital, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Maneka Puligandla
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Kristen E Stevenson
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Barbara Asselin
- Department of Pediatrics, University of Rochester Medical Center and School of Medicine, Rochester, NY, USA
| | - Luis A Clavell
- Department of Pediatrics, San Jorge Children's Hospital, San Juan, Puerto Rico
| | - Peter D Cole
- Pediatrics, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Kara M Kelly
- Department of Pediatric Oncology, Roswell Park Comprehensive Cancer Center, Division of Pediatric Hematology/Oncology, Jacob's School of Medicine and Biomedical Sciences, University of Buffalo, NY, USA
| | - Caroline Laverdiere
- Hematology-Oncology Division, Charles Bruneau Cancer Center, Sainte-Justine University Hospital, University of Montreal, Montreal, QC, Canada
| | - Jean-Marie Leclerc
- Hematology-Oncology Division, Charles Bruneau Cancer Center, Sainte-Justine University Hospital, University of Montreal, Montreal, QC, Canada
| | - Bruno Michon
- Pediatrics, Centre Hospitalier Universitaire de Quebec, Sainte-Foy, QC, Canada
| | | | - Maria Luisa Sulis
- Division of Pediatric Hematology/Oncology/Stem Cell Transplantation, Columbia University Medical Center, New York, USA
| | - Jennifer J G Welch
- Pediatric Hematology Oncology, Hasbro Children's Hospital/Brown University, Providence, RI, USA
| | - Marian H Harris
- Department of Pathology, Boston Children's Hospital, Boston, MA, USA
| | - Donna S Neuberg
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Stephen E Sallan
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Division of Pediatric Hematology-Oncology, Boston Children's Hospital, Boston, MA, USA
| | - Lewis B Silverman
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Division of Pediatric Hematology-Oncology, Boston Children's Hospital, Boston, MA, USA
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12
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Goldsby RE, Stratton KL, Raber S, Ablin A, Strong LC, Oeffinger K, Sklar CA, Armstrong GT, Robison LL, Bhatia S, Leisenring WM. Long-term sequelae in survivors of childhood leukemia with Down syndrome: A childhood cancer survivor study report. Cancer 2017; 124:617-625. [PMID: 29105081 DOI: 10.1002/cncr.31065] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 09/11/2017] [Accepted: 09/13/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Children with Down syndrome (DS) are at increased risk of developing acute leukemia and are more prone to acute toxicities. We studied the incidence and severity of chronic health conditions among survivors of childhood leukemia with DS compared with those without DS. METHODS Chronic health conditions reported by questionnaire were compared between 154 pediatric leukemia survivors with DS and 581 without DS, matched by leukemia, age at diagnosis, race/ethnicity, sex, radiation location and chemotherapy exposure using Cox models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). Subjects were selected from 7139 5-year survivors of leukemia in the Childhood Cancer Survivor Study. RESULTS Risk of at least 1 late onset chronic health condition (grade 1-5) was similar in the DS population compared with the non-DS group (HR, 1.1; 95% CI, 0.7-1.5). Serious chronic health conditions (grade 3-5) were more common in DS survivors (HR, 1.7; 95% CI, 1.1-2.6), as were ≥ 3 chronic health conditions (grades 1-5) (HR, 1.7; 95% CI, 1.2-2.4). The 25-year cumulative incidence of any condition (grades 1-5) was 83% for DS survivors and 69% for non-DS survivors. CONCLUSION Leukemia survivors with DS have therapy-related chronic health conditions comparable to those of similarly treated survivors without DS, with a few notable exceptions: 1) an increased risk of cataracts, hearing loss, and thyroid dysfunction compared with survivors without DS (though these are known risks in the DS population), 2) decreased risk of second cancers, and 3) increased risk of severe or multiple conditions. Practitioners should be aware of these risks during and after therapy. Cancer 2018;124:617-25. © 2017 American Cancer Society.
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Affiliation(s)
- Robert E Goldsby
- Pediatric Hematology/Oncology, University of California-San Francisco Benioff Children's Hospital, San Francisco, California
| | - Kayla L Stratton
- Clinical Biostatistics and Cancer Prevention, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Shannon Raber
- Pediatric Hematology/Oncology, University of California-San Francisco Benioff Children's Hospital, San Francisco, California
| | - Arthur Ablin
- Pediatric Hematology/Oncology, University of California-San Francisco Benioff Children's Hospital, San Francisco, California
| | - Louise C Strong
- Division of Pediatrics, MD Anderson Cancer Center, Houston, Texas
| | - Kevin Oeffinger
- Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Charles A Sklar
- Pediatrics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Gregory T Armstrong
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Leslie L Robison
- Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Smita Bhatia
- Pediatric Hematology/Oncology, Children's Hospital of Alabama, Birmingham, Alabama
| | - Wendy M Leisenring
- Clinical Biostatistics and Cancer Prevention, Fred Hutchinson Cancer Research Center, Seattle, Washington
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13
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Ceppi F, Stephens D, den Hollander BS, Krueger J, Whitlock J, Sung L, Hitzler J. Clinical presentation and risk factors of serious infections in children with Down syndrome treated for acute lymphoblastic leukemia. Pediatr Blood Cancer 2016; 63:1949-53. [PMID: 27399585 DOI: 10.1002/pbc.26127] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 06/09/2016] [Accepted: 06/11/2016] [Indexed: 01/19/2023]
Abstract
BACKGROUND Treatment of acute lymphoblastic leukemia (ALL) in children with Down syndrome (DS) is associated with a higher incidence of life-threatening infections compared to the overall pediatric population. The objective of this study was to describe infections and identify risk factors of microbiologically documented infections at a sterile site in children with DS during chemotherapy for ALL. PROCEDURE We conducted a single-institution retrospective review of infectious episodes encountered by patients with DS during primary treatment for ALL. Correlations between features of clinical presentation and severity of microbiologically proven infections were investigated. RESULTS Among 237 suspected infectious episodes encountered by 35 patients with DS and ALL (DS-ALL), a total of 40 episodes (16.9%) had the clinical presentation of a severe infection (SI). Seventeen patients had 33 (13.9%) microbiologically proven infections from a sterile site. Fever was not part of the clinical presentation in 27% of microbiologically documented infectious episodes. The odds ratio of a microbiologically proven infection at a sterile site was significantly increased during a 7-day interval after treatment with glucocorticoids (2.18; 95% CI: 1.02-4.66; P = 0.04). Neither administration of anthracyclines in the preceding 14 days nor neutropenia correlated with infections. CONCLUSIONS Serious infections in DS-ALL may present without typical signs such as fever. The immediate time period following administration of glucocorticoids is particularly associated with the risk of SIs.
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Affiliation(s)
- Francesco Ceppi
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Derek Stephens
- Department of Public Health Sciences, University of Toronto, Toronto, ON, Canada
| | - Barbara S den Hollander
- Department of Pediatric Oncology/Haematology, Erasmus MC-Sophia Children's Hospital, University of Rotterdam, Rotterdam, The Netherlands
| | - Joerg Krueger
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - James Whitlock
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, Canada.,Child Health Evaluative Sciences Program, The Hospital for Sick Children Research Institute, Toronto, ON, Canada
| | - Lillian Sung
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, Canada.,Child Health Evaluative Sciences Program, The Hospital for Sick Children Research Institute, Toronto, ON, Canada
| | - Johann Hitzler
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, Canada. .,Developmental and Stem Cell Biology Program, The Hospital for Sick Children Research Institute, Toronto, ON, Canada.
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14
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Salazar EG, Li Y, Fisher BT, Rheingold SR, Fitzgerald J, Seif AE, Huang YS, Bagatell R, Aplenc R. Supportive care utilization and treatment toxicity in children with Down syndrome and acute lymphoid leukaemia at free-standing paediatric hospitals in the United States. Br J Haematol 2016; 174:591-9. [PMID: 27161549 DOI: 10.1111/bjh.14085] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 01/26/2016] [Indexed: 12/22/2022]
Abstract
Although inferior outcomes of children with Down syndrome (DS) and acute lymphoid leukaemia (ALL) are established, national supportive care patterns for these patients are unknown. A validated retrospective cohort of paediatric patients diagnosed with ALL from 1999 to 2011 was assembled from the US Pediatric Health Information System (PHIS) database to examine organ toxicity, sepsis, and resource utilization in children with and without DS. Among 10699 ALL patients, 298 had DS-ALL (2·8%). In a multivariate model, DS was associated with increased risk of cardiovascular (odds ratio [OR] 2·0, 95% confidence interval [CI] 1·6-2·7), respiratory (OR 2·1, 95% CI: 1·6-2·9), neurologic (OR 3·4, 95% CI 1·9-6·2), and hepatic (OR 1·4, 95% CI 1·0-1·9) dysfunction and sepsis (OR 1·8, 95% CI: 1·4-2·4). Children with DS-ALL used significantly more respiratory support, insulin, and anti-infectives, including broad-spectrum Gram-positive agents, quinolones, and azoles. They used significantly fewer analgesics and antiemetics compared to non-DS-ALL children. Ultimately, this study confirms the increased risk of infectious and end-organ toxicity in children with DS-ALL and quantifies important differences in resource utilization between children with DS and non-DS ALL. These findings highlight the importance of investigating the impact of these care variations and developing specific supportive care guidelines for this population.
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Affiliation(s)
- Elizabeth G Salazar
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Yimei Li
- Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,The Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Brian T Fisher
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,The Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Division of Infectious Diseases, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Susan R Rheingold
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Anesthesia and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Julie Fitzgerald
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Anesthesia and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alix E Seif
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Yuan-Shung Huang
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Rochelle Bagatell
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Richard Aplenc
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Division of Oncology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,The Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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15
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Hefti E, Blanco JG. Anthracycline-Related Cardiotoxicity in Patients with Acute Myeloid Leukemia and Down Syndrome: A Literature Review. Cardiovasc Toxicol 2016; 16:5-13. [PMID: 25616318 PMCID: PMC4514565 DOI: 10.1007/s12012-015-9307-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Pediatric patients with Down syndrome (DS) are at an increased risk of developing certain cancers. Specifically, patients with DS have a reported 10-20-fold increased risk of developing acute myeloid leukemia (AML). Anthracycline-based treatment regimens achieve good results in patients with DS and AML. It has been proposed that DS status constitutes a risk factor for the cardiotoxicity associated with the use of anthracyclines in the pediatric setting. However, published evidence pointing toward an increased risk of cardiotoxicity in patients with DS is relatively scarce and conflictive. This concise review compiles literature relating to the incidence of anthracycline-related cardiotoxicity in pediatric patients with DS. In general, reports from trials using anthracyclines at the maximum recommended dose showed increases in the incidence of anthracycline-related cardiotoxicity in patients with DS in comparison with trials that used anthracyclines at reduced doses. Evidence from the literature suggests that patients with DS can achieve favorable therapeutic outcomes after receiving treatment with reduced doses of anthracyclines to minimize the potential for cardiotoxicity. Further prospective trials, along with the available evidence, would assist the design of treatment protocols for patients with pediatric leukemias and DS.
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Affiliation(s)
- Erik Hefti
- Department of Pharmaceutical Sciences, The School of Pharmacy and Pharmaceutical Sciences, The State University of New York at Buffalo, 470 Kapoor Hall, Buffalo, NY, 14214, USA
| | - Javier G Blanco
- Department of Pharmaceutical Sciences, The School of Pharmacy and Pharmaceutical Sciences, The State University of New York at Buffalo, 470 Kapoor Hall, Buffalo, NY, 14214, USA.
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16
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Roncadin C, Hitzler J, Downie A, Montour-Proulx I, Alyman C, Cairney E, Spiegler BJ. Neuropsychological late effects of treatment for acute leukemia in children with Down syndrome. Pediatr Blood Cancer 2015; 62:854-8. [PMID: 25545182 DOI: 10.1002/pbc.25362] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 10/22/2014] [Indexed: 11/08/2022]
Abstract
BACKGROUND Children with Down syndrome (DS) have an elevated risk of developing acute leukemia, but little is known about treatment-related neuropsychological morbidity because they are systematically excluded from research in this area. The current study investigated neuropsychological outcomes in children with DS treated for acute lymphoblastic leukemia (ALL) or acute myeloid leukemia (AML) compared to children with DS with no history of cancer. PROCEDURE Participants were 4 to 17 years of age at testing and were administered measures of intelligence, academic achievement, language, visual-motor and fine-motor skills, and adaptive function. Patients had been off treatment for at least 2 years. RESULTS The AML group (N = 12) had significantly lower verbal intelligence and receptive vocabulary compared to controls (N = 21). By contrast, the ALL group (N = 14) performed significantly worse than controls on measures of verbal intelligence, spelling, receptive and expressive vocabulary, visual-motor skills, and adaptive function. CONCLUSIONS Patients with DS treated for AML may have specific post-treatment morbidity in verbal function, whereas those treated for ALL have broader morbidity affecting multiple neuropsychological domains and overall adaptive function. We hypothesize that the broader impairment profile of ALL survivors may be related to a combination of the longer duration of central nervous system-directed treatment for ALL compared to AML and the concomitant limited access to intervention opportunities during active treatment.
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17
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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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18
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Child and adolescent Down syndrome-associated leukaemia: the Irish experience. Ir J Med Sci 2014; 184:877-82. [PMID: 25344131 DOI: 10.1007/s11845-014-1212-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Accepted: 10/14/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Down syndrome (DS), the most common syndromic chromosomal abnormality is associated with a unique susceptibility to develop both acute myeloid (ML) and lymphoblastic leukaemia (ALL). These leukaemias differ from the non-DS-related types of leukaemia and are thought to be distinct biological entities. AIMS To perform a retrospective review of our experience of treating DS-related leukaemia at Our Lady's Children's Hospital. METHODS Data were extracted from a database established in 2000 to prospectively gather data on DS-associated leukaemias and their outcomes following polychemotherapy. Kaplan-Meier survival curves were constructed. RESULTS Nineteen patients with DS-ML were treated and 19 with DS-ALL. Sixteen (84%) patients with DS-ML are alive and in complete remission with a median follow-up of 7 years. All deaths in this cohort were due to treatment-related mortality (TRM). Of the DS-ALL patients, 12 (63%) remain alive with a median follow-up of 3.6 years. TRM accounted for five of the six deaths. One death was due to leukaemic relapse. CONCLUSION High cure rates are seen in DS-ML using contemporary polychemotherapy protocols, however, there is significant TRM in this cohort. DS-ALL does not have the same high cure rate as non-DS-ALL (>90%) and again this is mainly due to an excess of TRM.
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19
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Hoa Tran T, Lee M, Alexander S, Gibson P, Bartels U, Johnston DL, Portwine C, Silva M, Pole JD, Sung L. Lack of treatment-related mortality definitions in clinical trials of children, adolescents and young adults with lymphomas, solid tumors and brain tumors: a systematic review. BMC Cancer 2014; 14:612. [PMID: 25155014 PMCID: PMC4152582 DOI: 10.1186/1471-2407-14-612] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 08/20/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is a lack of standardized definition for treatment-related mortality (TRM), which represents an important endpoint in cancer. Our objective was to describe TRM definitions used in studies of children, adolescents and young adults with lymphomas, solid tumors and brain tumors. METHODS We conducted a systematic review of studies enrolling children, adolescents and young adults with lymphomas, solid tumors and brain tumors in which an anti-cancer intervention was randomized, or all study designs in which TRM was a primary or secondary outcome. We searched Ovid MEDLINE, EMBASE and Evidence-Based Medicine Reviews from 1980 to June 2013. Two reviewers evaluated study eligibility and abstracted data. RESULTS In total, 67 studies were included and consisted of 62 randomized therapeutic trials and 5 TRM studies. None of the studies (0/67) provided a definition for TRM. Only one randomized trial of rhabdomyosarcoma provided a definition of early death. CONCLUSIONS We were unable to identify any TRM definitions used in studies of children, adolescents and young adults with lymphomas, solid tumors and brain tumors. Given that a proportion of this patient population may receive intensive treatment, there is an urgent need for consensus-based definitions of TRM for use across clinical trials.
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Affiliation(s)
- Thai Hoa Tran
- />Division of Haematology/Oncology, The Hospital for Sick Children, 555 University Ave, Toronto, Ontario M5G 1X8 Canada
| | - Michelle Lee
- />Child Health Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, 686 Bay St, Toronto, Ontario M5G 0A4 Canada
| | - Sarah Alexander
- />Division of Haematology/Oncology, The Hospital for Sick Children, 555 University Ave, Toronto, Ontario M5G 1X8 Canada
| | - Paul Gibson
- />Haematology/Oncology, Department of Pediatrics, London Health Sciences Centre, PO Box 5010800, Commissioners Rd E, London, N6A 5W9 Canada
| | - Ute Bartels
- />Division of Haematology/Oncology, The Hospital for Sick Children, 555 University Ave, Toronto, Ontario M5G 1X8 Canada
| | - Donna L Johnston
- />Division of Hematology/Oncology, Children’s Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, Ontario K1H 8L1 Canada
| | - Carol Portwine
- />Hematology/Oncology, McMaster Children’s Hospital, 1200 Main St W, Hamilton, Ontario L8N 3Z5 Canada
| | - Marianna Silva
- />Hematology/Oncology, Cancer Centre of Southeastern Ontario, 25 King St W, Kingston, Ontario K7L 5P9 Canada
| | - Jason D Pole
- />Pediatric Oncology Group of Ontario, Dalla Lana School of Public Health, University of Toronto, 155 College St, Toronto, Ontario M5T 3M7 Canada
| | - Lillian Sung
- />Division of Haematology/Oncology, The Hospital for Sick Children, 555 University Ave, Toronto, Ontario M5G 1X8 Canada
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20
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Seif AE, Fisher BT, Li Y, Torp K, Rheam DP, Huang YSV, Harris T, Shah A, Hall M, Fieldston ES, Kavcic M, Vujkovic M, Bailey LC, Kersun LS, Reilly AF, Rheingold SR, Walker DM, Aplenc R. Patient and hospital factors associated with induction mortality in acute lymphoblastic leukemia. Pediatr Blood Cancer 2014; 61:846-52. [PMID: 24249480 PMCID: PMC3951664 DOI: 10.1002/pbc.24855] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Accepted: 10/18/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND Deaths during induction chemotherapy for pediatric acute lymphoblastic leukemia (ALL) account for one-tenth of ALL-associated mortality and half of ALL treatment-related mortality. We sought to ascertain patient- and hospital-level factors associated with induction mortality. PROCEDURE We performed a retrospective cohort analysis of 8,516 children ages 0 to <19 years with newly diagnosed ALL admitted to freestanding US children's hospitals from 1999 to 2009 using the Pediatric Health Information System database. Induction mortality risk was modeled accounting for demographics, intensive care unit-level interventions, and socioeconomic status (SES) using Cox regression. The association of ALL induction mortality with hospital-level factors including volume, hospital-wide mortality and payer mix was analyzed with multiple linear regression. RESULTS ALL induction mortality was 1.12%. Race and patient-level SES factors were not associated with induction mortality. Patients receiving both mechanical ventilation and vasoactive infusions experienced nearly 50% mortality (hazard ratio 122.30, 95% CI 66.56-224.80). Institutions in the highest induction mortality quartile contributed 27% of all patients but nearly half of all deaths (47 of 95). Hospital payer mix was associated with ALL induction mortality after adjustment for other hospital-level factors (P = 0.046). CONCLUSIONS The overall risk of induction death is low but substantially increased in patients with cardio-respiratory and other organ failures. Induction mortality varies up to three-fold across hospitals and is correlated with hospital payer mix. Further work is needed to improve induction outcomes in hospitals with higher mortality. These data suggest an induction mortality rate of less than 1% may be an attainable national benchmark.
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Affiliation(s)
- Alix E. Seif
- Division of Oncology, the Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Brian T. Fisher
- Division of Infectious Diseases, the Children’s Hospital of Philadelphia, Philadelphia, PA,Center for Pediatric Clinical Effectiveness, the Children’s Hospital of Philadelphia, Philadelphia, PA,Department of Biostatistics and Epidemiology, the Perelman School of Medicine, the University of Pennsylvania, Philadelphia, PA
| | - Yimei Li
- Division of Oncology, the Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Kari Torp
- Division of Oncology, the Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Douglas P. Rheam
- Division of Oncology, the Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Yuan-Shung V. Huang
- Center for Pediatric Clinical Effectiveness, the Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Tracey Harris
- Division of Oncology, the Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Ami Shah
- Division of Oncology, the Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Matthew Hall
- Children’s Hospital Association, Overland Park, KS
| | - Evan S. Fieldston
- Center for Pediatric Clinical Effectiveness, the Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Marko Kavcic
- Division of Oncology, the Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Marijana Vujkovic
- Division of Oncology, the Children’s Hospital of Philadelphia, Philadelphia, PA
| | - L. Charles Bailey
- Division of Oncology, the Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Leslie S. Kersun
- Division of Oncology, the Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Anne F. Reilly
- Division of Oncology, the Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Susan R. Rheingold
- Division of Oncology, the Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | - Richard Aplenc
- Division of Oncology, the Children’s Hospital of Philadelphia, Philadelphia, PA,Center for Pediatric Clinical Effectiveness, the Children’s Hospital of Philadelphia, Philadelphia, PA,Department of Biostatistics and Epidemiology, the Perelman School of Medicine, the University of Pennsylvania, Philadelphia, PA
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Patrick K, Wade R, Goulden N, Rowntree C, Hough R, Moorman AV, Mitchell CD, Vora A. Outcome of Down syndrome associated acute lymphoblastic leukaemia treated on a contemporary protocol. Br J Haematol 2014; 165:552-5. [PMID: 24428704 DOI: 10.1111/bjh.12739] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 12/06/2013] [Indexed: 11/26/2022]
Abstract
We report the outcome for children and young people with Down syndrome-associated acute lymphoblastic leukaemia (DS-ALL) treated on a contemporary protocol. Compared with non-DS ALL, patients with DS-ALL had an inferior event-free survival (65·6% vs. 87·7% at 5 years; P < 0·00005) and overall survival (70·0% vs. 92·2%; P < 0·00005). Excess treatment-related mortality - was primarily responsible for the worse outcomes for DS-ALL (21·6% at 5 years, vs. 3·3%, P < 0·00005). Minimal residual disease (MRD) risk status was highly discriminant for relapse in DS patients with 0/28 relapses in the MRD low risk group.
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Xavier AC, Ge Y, Taub J. Unique clinical and biological features of leukemia in Down syndrome children. Expert Rev Hematol 2014; 3:175-86. [DOI: 10.1586/ehm.10.14] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Abstract
Abstract
Children with Down syndrome are at high risk for developing B-cell precursor acute lymphoblastic leukemia (DS-ALL) associated with poor outcome due to both a high relapse rate and increased treatment-related mortality (TRM) from infections. Biologically, these heterogeneous leukemias are characterized by under-representation of the common cytogenetic subgroups of childhood ALL and overrepresentation of CRLF2-IL7R-JAK-STAT activating genetic aberrations. Although relapse is the major determinant of poor outcomes in this population, de-escalation of chemotherapy intensity might be feasible in the 10% to 15% DS-ALL patients with ETV6-RUNX1 or high hyperdipoidy in whom TRM is the major limiting event. As infection-associated TRM occurs during all treatment phases, including the maintenance period, increased surveillance and supportive care is required throughout therapy. Improvement in outcome will require better understanding of the causes of treatment failure and TRM, incorporation of new therapies targeting the unique biological properties of DS-ALL, and enhanced supportive care measures to reduce the risk of infection-related TRM. To facilitate these goals, an international collaboration plans to establish a prospective DS-ALL registry and develop specific supportive care recommendations for this at-risk population.
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Tran TH, Mitchell D, Dix D, Cellot S, Ethier MC, Gillmeister B, Hitzler J, Lewis V, Yanofsky R, Johnston DL, Portwine C, Price V, Zelcer S, Silva M, Michon B, Bowes L, Stobart K, Brossard J, Beyene J, Sung L. Infections in children with down syndrome and acute myeloid leukemia: a report from the Canadian infections in AML research group. Infect Agent Cancer 2013; 8:47. [PMID: 24289042 PMCID: PMC4174901 DOI: 10.1186/1750-9378-8-47] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Accepted: 10/30/2013] [Indexed: 12/02/2022] Open
Abstract
Background Children with Down syndrome (DS) are at high risk of infectious toxicity when treated with acute lymphoblastic leukemia chemotherapy protocols optimized in children without DS. Our objective was to determine if children with DS and acute myeloid leukemia (AML) have a different risk of infection when treated with chemotherapy protocols developed for children with DS compared to AML treatment protocols developed for children without DS. Methods We conducted a retrospective, population-based cohort study that included DS children ≤ 18 years of age with de novo, non-M3 AML diagnosed between January 1995 and December 2004, and treated at 15 Canadian centers. Patients were monitored for infection from initiation of AML treatment until recovery from the last cycle of chemotherapy, conditioning for hematopoietic stem cell transplantation, relapse, persistent disease or death (whichever occurred first). Trained research associates abstracted all information from each site. Results There were 31 children with DS included; median age was 1.7 (range 0.1-11.1) years. Eleven were treated according to a DS-specific protocol while 20 were treated with non-DS specific protocols. A total of 157 courses of chemotherapy were delivered. Microbiologically documented sterile site infection occurred in 11.9% and 14.3% of DS-specific and non-DS specific AML treatment courses respectively. Sepsis was rare and there were no infection-related deaths. In multiple regression, treatment with a DS-specific protocol was independently associated with a reduction in microbiologically documented sterile site infection (adjusted odds ratio (OR) 0.65, 95% confidence interval (CI) 0.42-0.99; P = 0.044), and clinically documented infection (adjusted OR 0.36, 95% CI 0.14-0.91; P = 0.031) but not bacteremia (adjusted OR 0.73, 95% CI 0.44-1.22; P = 0.231). Conclusions Our study suggests that children with DS do not experience excessive infectious toxicity during treatment for AML compared to children without DS. Incorporation of DS-specific AML treatment protocols is associated with a more favorable infection profile for children with DS-AML.
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Affiliation(s)
- Thai Hoa Tran
- Division of Haematology/Oncology, The Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada.
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Acute lymphoblastic leukemia in children with Down syndrome: a retrospective analysis from the Ponte di Legno study group. Blood 2013; 123:70-7. [PMID: 24222333 DOI: 10.1182/blood-2013-06-509463] [Citation(s) in RCA: 152] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Children with Down syndrome (DS) have an increased risk of B-cell precursor (BCP) acute lymphoblastic leukemia (ALL). The prognostic factors and outcome of DS-ALL patients treated in contemporary protocols are uncertain. We studied 653 DS-ALL patients enrolled in 16 international trials from 1995 to 2004. Non-DS BCP-ALL patients from the Dutch Child Oncology Group and Berlin-Frankfurt-Münster were reference cohorts. DS-ALL patients had a higher 8-year cumulative incidence of relapse (26% ± 2% vs 15% ± 1%, P < .001) and 2-year treatment-related mortality (TRM) (7% ± 1% vs 2.0% ± <1%, P < .0001) than non-DS patients, resulting in lower 8-year event-free survival (EFS) (64% ± 2% vs 81% ± 2%, P < .0001) and overall survival (74% ± 2% vs 89% ± 1%, P < .0001). Independent favorable prognostic factors include age <6 years (hazard ratio [HR] = 0.58, P = .002), white blood cell (WBC) count <10 × 10(9)/L (HR = 0.60, P = .005), and ETV6-RUNX1 (HR = 0.14, P = .006) for EFS and age (HR = 0.48, P < .001), ETV6-RUNX1 (HR = 0.1, P = .016) and high hyperdiploidy (HeH) (HR = 0.29, P = .04) for relapse-free survival. TRM was the major cause of death in ETV6-RUNX1 and HeH DS-ALLs. Thus, while relapse is the main contributor to poorer survival in DS-ALL, infection-associated TRM was increased in all protocol elements, unrelated to treatment phase or regimen. Future strategies to improve outcome in DS-ALL should include improved supportive care throughout therapy and reduction of therapy in newly identified good-prognosis subgroups.
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Meyr F, Escherich G, Mann G, Klingebiel T, Kulozik A, Rossig C, Schrappe M, Henze G, von Stackelberg A, Hitzler J. Outcomes of treatment for relapsed acute lymphoblastic leukaemia in children with Down syndrome. Br J Haematol 2013; 162:98-106. [PMID: 23594030 DOI: 10.1111/bjh.12348] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Accepted: 03/13/2013] [Indexed: 11/29/2022]
Abstract
Children with Down syndrome (DS) have a greater risk for developing both acute lymphoblastic leukaemia (ALL) and significant adverse effects of chemotherapy. We investigated their outcome with, and tolerance of, treatment protocols for relapsed ALL optimized in the paediatric population without DS. Probability of survival and causes of treatment failure were determined for 49 children with DS and a matched cohort of 98 children without DS among 2160 children treated for relapsed ALL in clinical trials conducted by the Berlin-Frankfurt-Münster ALL Relapse Study Group between 1983 and 2012. Despite more favourable ALL relapse characteristics, children with DS experienced lower event-free (EFS) and overall survival (OS) than the control group without DS (EFS 17 ± 08% vs. non-DS 41 ± 06%, P = 0·006; OS 17 ± 09% vs. non-DS 51 ± 06%, P < 0·001). Children with DS developed more frequently fatal complications of treatment (34 ± 07% vs. non-DS 10 ± 04%, P < 0·001). During the last decade, EFS and OS were no longer significantly different in children with and without DS (EFS 31 ± 09% vs. 36 ± 09%, P = 0·399; OS 31 ± 12% vs. 53 ± 09%, P = 0·151). DS proved an independent prognostic factor of outcome after ALL relapse. Induction deaths and treatment-related mortality but not subsequent relapse were the main barrier to successful outcomes of relapse therapy in children with DS.
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Affiliation(s)
- Franziska Meyr
- Paediatric Haematology/Oncology, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, Berlin, Germany.
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Physicians compliance during maintenance therapy in children with Down syndrome and acute lymphoblastic leukemia. Leukemia 2012; 27:866-70. [PMID: 23138181 DOI: 10.1038/leu.2012.325] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Children with Down syndrome (DS) and acute lymphoblastic leukemia (ALL) have an inferior prognosis compared with non-DS ALL patients. We reviewed methotrexate (MTX)/mercaptopurine (6MP) maintenance therapy data for children with DS treated according to the Nordic Society of Pediatric Hematology and Oncology (NOPHO) ALL92 or the NOPHO ALL2000 protocols between 1992 and 2007. The 5-year event-free survival probability (pEFS(5 yr)) for the 66 DS patients was inferior to the 2602 non-DS patients (0.50 ± 0.07 vs 0.77 ± 0.01 (P<0.001)). The 48 DS patients in first remission at the beginning of maintenance therapy had pEFS(10 yr) below that of the 522 non-DS control patients (pEFS(10 yr): 0.58 (95% confidence interval (CI) 0.43-0.77) vs 0.83 (95% CI 0.80-0.86), respectively (P<0.0001)). The DS patients received lower median doses of MTX (median: 11.8 vs 15.4 (P<0.0001)) and 6MP (median: 43.6 vs 59.4 (P<0.0001)). In Cox regression analysis, male gender, presence of DS and high median maintenance therapy white blood cell levels (mWBC) were associated with increased risk for relapse. DS-ALL patients with mWBC above or below 3.5 × 10(9)/l (protocol target) had pEFS(10 yr) of 0.31 and 0.72 (P=0.02), and the mWBC hazard ratio for DS-ALL patients was 2.0 (P<0.0005). We conclude that insufficient treatment intensity during maintenance therapy of DS-ALL patients may contribute to their poor prognosis.
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Maloney KW. Acute lymphoblastic leukaemia in children with Down syndrome: an updated review. Br J Haematol 2011; 155:420-5. [DOI: 10.1111/j.1365-2141.2011.08846.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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29
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Goto H, Inukai T, Inoue H, Ogawa C, Fukushima T, Yabe M, Kikuchi A, Koike K, Fukushima K, Isoyama K, Saito T, Ohara A, Hanada R, Iwamoto J, Hotta N, Nagatoshi Y, Okamura J, Tsuchida M. Acute lymphoblastic leukemia and Down syndrome: the collaborative study of the Tokyo Children’s Cancer Study Group and the Kyushu Yamaguchi Children’s Cancer Study Group. Int J Hematol 2011; 93:192-198. [DOI: 10.1007/s12185-011-0765-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2010] [Revised: 12/11/2010] [Accepted: 01/05/2011] [Indexed: 10/18/2022]
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Abstract
Children with Down syndrome have an increased risk for developing both acute myeloid as well as lymphoblastic leukemia. These leukemias differ in presenting characteristics and underlying biology when compared with leukemias occurring in non-Down syndrome children. Myeloid leukemia in children with Down syndrome is preceded by a preleukemic clone (transient leukemia or transient myeloproliferative disorder), which may disappear spontaneously, but may also need treatment in case of severe symptoms. Twenty percent of children with transient leukemia subsequently develop myeloid leukemia. This transition offers a unique model to study the stepwise development of leukemia and of gene dosage effects mediated by aneuploidy.
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31
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Down syndrome childhood acute lymphoblastic leukemia has a unique spectrum of sentinel cytogenetic lesions that influences treatment outcome: a report from the Children's Oncology Group. Blood 2010; 116:1045-50. [PMID: 20442364 DOI: 10.1182/blood-2009-07-235291] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Children with Down syndrome (DS) have an increased risk of acute lymphoblastic leukemia (ALL) and an inferior outcome. We reviewed data from 2811 children with ALL enrolled in Children's Oncology Group P9900, which included prospective testing for the major cytogenetic lesions in childhood ALL: ETV6-RUNX1, TCF3-PBX1, BCR-ABL1, and MLL translocations and trisomies of chromosomes 4 and 10. Eighty (3%) B-precursor ALL patients had DS. Age, sex, white blood cell count, and risk group were similar between DS-ALL and non-DS-ALL but significantly more patients with DS-ALL were white (91.2% vs 76.4%, P = .001). Children with DS-ALL had lower rates of the favorable cytogenetic lesions ETV6-RUNX1 (2.5% vs 24%, P < .001) and trisomies 4 and 10 (7.7% vs 24%, P < .001). Five-year event-free (EFS) and overall survival (OS) were inferior in children with DS-ALL: 69.9% +/- 8.6% versus 78.1% +/- 1.2% (P = .078), and 85.8% +/- 6.5% versus 90.0% +/- 0.9% (P = .033). However, when children with MLL translocations, BCR-ABL1, ETV6-RUNX1, and trisomies 4 and 10 were excluded, the EFS and OS were similar for children with and without DS (EFS 68.0 %+/- 9.3% vs 70.5% +/- 1.9%, P = .817; and OS 86.7% +/- 6.7% vs 85.4% +/- 1.5%; P = .852), both overall and adjusted for race. DS-ALL displays a unique spectrum of biologic subtypes with different frequencies of sentinel cytogenetic lesions having a large influence on outcome.
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32
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Pieters R, Carroll WL. Biology and Treatment of Acute Lymphoblastic Leukemia. Hematol Oncol Clin North Am 2010; 24:1-18. [DOI: 10.1016/j.hoc.2009.11.014] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Xavier AC, Ge Y, Taub JW. Down syndrome and malignancies: a unique clinical relationship: a paper from the 2008 william beaumont hospital symposium on molecular pathology. J Mol Diagn 2009; 11:371-80. [PMID: 19710397 DOI: 10.2353/jmoldx.2009.080132] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
The patterns of malignancies in Down syndrome (DS) are unique and highlight the relationship between chromosome 21 and cancer. DS children have a approximately 10- to 20-fold higher risk for developing acute lymphoblastic leukemia and acute myeloid leukemia (AML), as compared with non-DS children, although they do not have a uniformly increased risk of developing solid tumors. DS children with acute lymphoblastic leukemia frequently experience higher levels of treatment-related toxicity and inferior event-free survival rates, as compared with non-DS children. DS children also develop AML with unique features and have a 500-fold increased risk of developing the AML subtype, acute megakaryocytic leukemia (AMkL; M7). Nearly 10% of DS newborns are diagnosed with a variant of AMkL, the transient myeloproliferative disorder, which can resolve spontaneously without treatment; event-free survival rates for DS patients with AMkL ranges from 80% to 100%, in comparison with <30% for non-DS children with AMkL. In addition, somatic mutations of the GATA1 gene have been detected in nearly all DS TMD and AMkL cases and not in leukemia cases in non-DS children. GATA1 mutations are key factors linked to both leukemogenesis and the high cure rates of DS AMkL patients. Identifying the mechanisms that account for the high event-free survival rates of DS AMkL patients may ultimately improve AML treatment as well. Examining leukemogenesis in DS children may identify factors linked to the general development of childhood leukemia and lead to potential new therapeutic strategies to fight this disease.
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Affiliation(s)
- Ana C Xavier
- Division of Hematology/Oncology, Children's Hospital of Michigan, Department of Pediatrics, Wayne State University School of Medicine, 3901 Beaubien Blvd., Detroit, Michigan 48201, USA
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34
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35
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Malinge S, Izraeli S, Crispino JD. Insights into the manifestations, outcomes, and mechanisms of leukemogenesis in Down syndrome. Blood 2009; 113:2619-28. [PMID: 19139078 PMCID: PMC2661853 DOI: 10.1182/blood-2008-11-163501] [Citation(s) in RCA: 164] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2008] [Accepted: 12/23/2008] [Indexed: 11/20/2022] Open
Abstract
Children with Down syndrome (DS) show a spectrum of clinical anomalies, including cognitive impairment, cardiac malformations, and craniofacial dysmorphy. Moreover, hematologists have also noted that these children commonly show macrocytosis, abnormal platelet counts, and an increased incidence of transient myeloproliferative disease (TMD), acute megakaryocytic leukemia (AMKL), and acute lymphoid leukemia (ALL). In this review, we summarize the clinical manifestations and characteristics of these leukemias, provide an update on therapeutic strategies and patient outcomes, and discuss the most recent advances in DS-leukemia research. With the increased knowledge of the way in which trisomy 21 affects hematopoiesis and the specific genetic mutations that are found in DS-associated leukemias, we are well on our way toward designing improved strategies for treating both myeloid and lymphoid malignancies in this high-risk population.
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MESH Headings
- Animals
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Cell Transformation, Neoplastic/genetics
- Chromosomes, Human, Pair 21/genetics
- Disease Models, Animal
- Disease Progression
- Down Syndrome/blood
- Down Syndrome/complications
- Down Syndrome/genetics
- GATA1 Transcription Factor/genetics
- Gene Expression Regulation, Leukemic
- Genetic Predisposition to Disease
- Hematopoiesis, Extramedullary/genetics
- Humans
- Incidence
- Janus Kinases/genetics
- Leukemia, Megakaryoblastic, Acute/drug therapy
- Leukemia, Megakaryoblastic, Acute/epidemiology
- Leukemia, Megakaryoblastic, Acute/etiology
- Leukemia, Megakaryoblastic, Acute/genetics
- Liver/embryology
- Liver/pathology
- Mice
- MicroRNAs/genetics
- Mutation
- Myeloproliferative Disorders/congenital
- Myeloproliferative Disorders/drug therapy
- Myeloproliferative Disorders/epidemiology
- Myeloproliferative Disorders/etiology
- Myeloproliferative Disorders/genetics
- Neoplasm Proteins/genetics
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/drug therapy
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/epidemiology
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/etiology
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/genetics
- Preleukemia/congenital
- Preleukemia/drug therapy
- Preleukemia/epidemiology
- Preleukemia/etiology
- Preleukemia/genetics
- RNA, Neoplasm/genetics
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Affiliation(s)
- Sébastien Malinge
- Division of Hematology/Oncology, Northwestern University, Chicago, IL 60611, USA
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36
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Abstract
Patients with Down syndrome (DS) display a unique spectrum of malignancies, with a 10- to 20-fold higher risk of acute leukemias, and a markedly lower incidence of solid tumors. This review discusses the current understanding of the basis for this distinctive pattern of cancer incidence and the clinical and biologic features of the malignant disorders most frequent in DS individuals: transient myeloproliferative disease, acute megakaryoblastic leukemia, and acute lymphoblastic leukemia. We also review distinctive pharmacogenetic issues, highlighting the differential chemosensitivity and toxicity profiles of DS patients compared with the general population, and epidemiologic studies of protective and adverse environmental risk factors for the development of leukemia.
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Shah N, Al-Ahmari A, Al-Yamani A, Dupuis L, Stephens D, Hitzler J. Outcome and toxicity of chemotherapy for acute lymphoblastic leukemia in children with Down syndrome. Pediatr Blood Cancer 2009; 52:14-9. [PMID: 18802938 DOI: 10.1002/pbc.21737] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Acute lymphoblastic leukemia (ALL) in children with Down syndrome (DS) presents with an increased incidence, higher frequency of adverse effects and inferior probability of survival. Attempts at improving outcomes face the dilemma posed by the need to avoid excessive toxicity while maintaining the efficacy of treatment. Dose reductions and avoidance of infusions of intermediate and high-dose methotrexate are common in this group. PROCEDURE In a matched pair analysis we compared adverse effects and survival after ALL chemotherapy using intermediate and high doses of methotrexate in children with and without Down syndrome. RESULTS Following intermediate and high doses of methotrexate to treat primary ALL, children with DS did not require opiate analgesia and parenteral nutrition for severe mucositis more often than children without DS. Children with DS spent more days in hospital and missed more doses of maintenance chemotherapy. Chemotherapy dose reductions were common and in this study had no detectable adverse impact. Event-free and overall survival (OS) of children with ALL was lower in the DS than the non-Down syndrome (NDS) control group. The difference, however, was no longer significant during the recent treatment era. CONCLUSIONS The feasibility of all treatment elements that are efficacious in pediatric ALL needs to be carefully considered in children with DS. In addition to survival data, the prospective collection of data on both adverse events and treatment modifications is essential to strike a balance between the avoidance of adverse effects and the need for intensive therapy that will safely improve ALL outcomes in this group.
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Affiliation(s)
- Niketa Shah
- Division of Hematology/Oncology, University of Toronto, Toronto, Ontario, Canada
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Stewart CF. Treating children with acute lymphoblastic leukemia and Down syndrome: pharmacokinetics provides insight into vincristine therapy. Pediatr Blood Cancer 2009; 52:1-2. [PMID: 18816806 PMCID: PMC2585145 DOI: 10.1002/pbc.21743] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- Clinton F. Stewart
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital (SJCRH), Memphis, TN,Department of Pharmaceutical Sciences, University of Tennessee, Memphis, TN
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40
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Carroll WL, Raetz EA. "When can I go home?"-seeking ways to lower the burden on patients and families. Pediatr Blood Cancer 2008; 51:318-9. [PMID: 18506756 DOI: 10.1002/pbc.21625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- William L Carroll
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, NYU Cancer Institute, NYU School of Medicine, New York 10016, USA.
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41
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Abstract
Children with Down syndrome have an increased risk for developing both acute myeloid as well as lymphoblastic leukemia. These leukemias differ in presenting characteristics and underlying biology when compared with leukemias occurring in non-Down syndrome children. Myeloid leukemia in children with Down syndrome is preceded by a preleukemic clone (transient leukemia or transient myeloproliferative disorder), which may disappear spontaneously, but may also need treatment in case of severe symptoms. Twenty percent of children with transient leukemia subsequently develop myeloid leukemia. This transition offers a unique model to study the stepwise development of leukemia, and of gene dosage effects mediated by aneuploidy.
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Affiliation(s)
- Michel C Zwaan
- Department of Pediatric Oncology/Hematology, Erasmus MC/Sophia Children's Hospital, Dr Molewaterplein 60, Rotterdam, The Netherlands.
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42
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Cytogenetic features of acute lymphoblastic and myeloid leukemias in pediatric patients with Down syndrome: an iBFM-SG study. Blood 2008; 111:1575-83. [DOI: 10.1182/blood-2007-09-114231] [Citation(s) in RCA: 127] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Children with Down syndrome (DS) have a markedly increased risk of acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML). To identify chromosomal changes cooperating with +21 that may provide information on the pathogenesis of these leukemias, we analyzed 215 DS-ALLs and 189 DS-AMLs. Unlike previous smaller series, a significant proportion of DS-ALLs had the typical B-cell precursor ALL abnormalities high hyperdiploidy (HeH; 11%) and t(12;21)(p13;q22) (10%). The HeH DS-ALLs were characterized by gains of the same chromosomes as non–DS-HeH, suggesting the same etiology/pathogenesis. In addition, specific genetic subtypes of DS-ALL were suggested by the significant overrepresentation of cases with +X, t(8;14)(q11;q32), and del(9p). Unlike DS-ALL, the common translocations associated with non–DS-AML were rare in DS-AML, which instead were characterized by the frequent presence of dup(1q), del(6q), del(7p), dup(7q), +8, +11, del(16q), and +21. This series of DS leukemias—the largest to date—reveals that DS-ALL is a heterogeneous disorder that comprises both t(12;21) and HeH as well as DS-related abnormalities. Furthermore, this analysis confirms that DS-AML is a distinct entity, originating through other genetic pathways than do non–DS-AMLs, and suggests that unbalanced changes such as dup(1q), +8, and +21 are involved in the leukemogenic process.
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Abstract
Acute lymphoblastic leukemia (ALL), the most common type of cancer in children, is a heterogeneous disease in which many genetic lesions result in the development of multiple biologic subtypes. Today, with intensive multiagent chemotherapy, most children who have ALL are cured. The many national or institutional ALL therapy protocols in use tend to stratify patients in a multitude of different ways to tailor treatment to the rate of relapse. This article discusses the factors used in risk stratification and the treatment of pediatric ALL.
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Affiliation(s)
- Rob Pieters
- Department of Pediatric Oncology and Hematology, Erasmus MC-Sophia Children's Hospital, Dr Molewaterplein 60, Rotterdam, The Netherlands.
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Abstract
Acute lymphoblastic leukaemia in children with Down syndrome (ALL-DS) is characterised by unique clinical and biological features. Notable among these are an absence of ALL in DS patients <1 year of age; a lower incidence of favourable and unfavourable chromosomal translocations; heightened sensitivity to methotrexate; and an increased propensity to infections. Although children with ALL-DS have historically fared less well than their non-DS counterparts (ALL-NDS), recent data indicate that outcomes in ALL-DS are now comparable with ALL-NDS with risk-adapted therapies, after adjusting for biological differences between the ALL-DS and ALL-NDS populations. Given the increased risk of ALL-DS patients for treatment-related toxicities, further intensification of therapy may not yield continued improvements in survival. Future investigations in the ALL-DS population should focus on maintaining excellent outcomes while reducing treatment-related complications through novel treatment strategies, such as the integration of targeted noncytotoxic agents.
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Affiliation(s)
- James A Whitlock
- Division of Pediatric Hematology/Oncology, Vanderbilt Children's Hospital and Vanderbilt-Ingram Cancer Center, Nashville, TN 37232, USA.
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Gadner H, Masera G, Schrappe M, Eden T, Benoit Y, Harrison C, Nachman J, Pui CH. The Eighth International Childhood Acute Lymphoblastic Leukemia Workshop ('Ponte di legno meeting') report: Vienna, Austria, April 27-28, 2005. Leukemia 2006; 20:9-17. [PMID: 16281070 DOI: 10.1038/sj.leu.2404016] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The International Acute Lymphoblastic Leukemia Working Group, the so-called 'Ponte di Legno Workshop' has led to substantial progress in international collaboration in leukemia research. On April 27-28, 2005, the 8th Meeting was held in Vienna, Austria, to continue the discussions about special common treatment elements in randomized clinical trials, ethical and clinical aspects of therapy. Furthermore, collaborative projects of clinical relevance with special emphasis on rare genetic subtypes of Childhood ALL were established. The following report summarizes the achievements and aspects of possible future cooperation.
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Affiliation(s)
- H Gadner
- Berlin-Frankfurt-Münster Study Group and St Anna Children's Hospital, Vienna, Austria.
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Morrissette JJD, Halligan GE, Punnett HH, McKenzie AS, Guerrero F, de Chadarévian JP. Down syndrome with low hypodiploidy in precursor B-cell acute lymphoblastic leukemia. ACTA ACUST UNITED AC 2006; 169:58-61. [PMID: 16875938 DOI: 10.1016/j.cancergencyto.2006.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2005] [Revised: 02/09/2006] [Accepted: 02/10/2006] [Indexed: 11/25/2022]
Abstract
We describe the rare finding of a 33-month-old child neonatally diagnosed with Down syndrome, who presented with pre-B acute lymphoblastic leukemia (ALL) with a pretreatment bone marrow karyotype in which a low hypodiploid cell line (38 chromosomes) was identified in 17/19 cells studied. The abnormal cell line retained the extra constitutional chromosome 21. Hypodiploidy (loss of one or more chromosomes) is seen in approximately 5% of all childhood pre-B ALL cases and in approximately 2.2% cases of individuals with a constitutional trisomy 21. Low hypodiploidy, associated with a high risk of relapse, is rare in pediatric ALL cases in the general population, and, to our knowledge, is previously unreported in patients with trisomy 21.
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Affiliation(s)
- Jennifer J D Morrissette
- Department of Pathology and Laboratory Medicine, Section of Cytogenetics, Drexel University College of Medicine, St. Christopher's Hospital for Children, Philadelphia, PA 19134, USA.
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Abstract
Abnormal number of chromosomes, aneuploidy, is the most common abnormality in leukemia and cancer. However, the casual relationship between aneuploidy and cancer is unclear. Additional copies of chromosome 21 are frequently found in leukemic cells. Constitutional trisomy 21 that characterizes Down Syndrome is associated with markedly increased risk for childhood leukemia. In this perspective I review recent studies that suggest that constitutional trisomy 21 promotes leukemic transformation during fetal hematopoiesis. As most of childhood leukemias arise in-utero, these studies are of general relevance to sporadic childhood leukemias.
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Affiliation(s)
- Shai Izraeli
- Department of Pediatric Hemato-Oncology, Cancer Research Center, Safra's Children's Hospital, Sheba Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Israel.
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Slats AM, Egeler RM, van der Does-van den Berg A, Korbijn C, Hählen K, Kamps WA, Veerman AJP, Zwaan CM. Causes of death--other than progressive leukemia--in childhood acute lymphoblastic (ALL) and myeloid leukemia (AML): the Dutch Childhood Oncology Group experience. Leukemia 2005; 19:537-44. [PMID: 15690069 DOI: 10.1038/sj.leu.2403665] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
We analyzed causes of death, other than resistant disease or relapse, in 875 children with acute lymphoblastic leukemia (ALL) and 229 with acute myeloid leukemia (AML), treated on three different Dutch Childhood Oncology Group (DCOG) ALL and three AML protocols. Overall, 23 (2.6%) ALL and 44 (19.2%) AML patients died. Early death (ED, before remission was reached) occurred in nine ALL (1%) and thirty AML (13.1%) patients, including three and ten deaths before treatment was initiated. Chemotherapy-related mortality in remission (CRM) occurred in nine ALL (1.1%) and eight AML (4.4%) patients. For ALL, both ED and CRM declined over time, although this was not statistically significant. For AML a decrease in ED was observed (from 26% to approximately 10%), but counter-balanced by an increase in CRM (from 3 to 8%), maybe related to the scheduling of intensification blocks in AML-92/94. Including transplant-related mortality, death in CR rates in AML increased from 3 to 15% in the last study. The main cause of ED was hemorrhage, often associated with hyperleucocytosis, and infection for CRM. We conclude that mortality dropped favorably in ALL, but not in AML. Especially for AML, effective but less toxic therapy and better supportive care guidelines need to be developed.
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Affiliation(s)
- A M Slats
- Department of Pediatric Hematology/Oncology, VU University Medical Center, Amsterdam, The Netherlands
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Steiner M, Attarbaschi A, König M, Nebral K, Gadner H, Haas OA, Mann G. Equal frequency of TEL/AML1 rearrangements in children with acute lymphoblastic leukemia with and without Down syndrome. Pediatr Hematol Oncol 2005; 22:229-34. [PMID: 16020107 DOI: 10.1080/08880010590921603] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Constitutional trisomy 21 is the most prominent predisposing factor to childhood leukemia, whereas the t(12;21)(p13;q22) with its molecular genetic counterpart, the TEL/AML1 fusion gene, is the most common acquired chromosomal rearrangement in childhood B-cell precursor (BCP) acute lymphoblastic leukemia (ALL). Thus, it was somewhat surprising that according to the currently available literature the incidence of TEL/AML1+ BCP ALL is extremely low in patients with Down syndrome (DS). To further investigate this issue in a population-based fashion, the authors retrospectively assessed the number of DS patients with a TEL/AML1+ ALL in two consecutive Austrian ALL multicenter trials. Accordingly, they were able to analyze 8 of 10 individuals with DS and a BCP ALL, two of whom who suffered from a TEL/AML1+ leukemia. Based on this observation they concluded that individuals with BCP leukemia and a constitutional trisomy 21 may have similar likelihood to have a TEL/AML1 rearrangement as BCP ALL patients without this specific predisposing factor.
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Affiliation(s)
- Manuel Steiner
- St. Anna Children's Hospital, Kinderspitalgasse 6, 1090 Vienna, Austria
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