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Egnell C, Hallböök H, Heyman M, Wartiovaara-Kautto U, Quist-Paulsen P, Schmiegelow K, Griskevicius L, Palk K, Toft N, Overgaard UM, Harila A, Ranta S. Impact of body mass index on outcome and treatment-related toxicity in young adults with acute lymphoblastic leukemia. Acta Oncol 2023; 62:1723-1731. [PMID: 37725524 DOI: 10.1080/0284186x.2023.2258450] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 09/08/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Data on outcome for patients in different body mass index (BMI) categories in young adults with acute lymphoblastic leukemia (ALL) are scarce. We explored survival and toxicities in different BMI categories in young adults with ALL. MATERIAL AND METHODS Patients aged 18-45 years, diagnosed with ALL between July 2008 and June 2022 in the Nordic countries, Estonia, or Lithuania, and treated according to the NOPHO ALL2008 protocol, were retrospectively enrolled and classified into different BMI categories. Endpoints were overall survival (OS), event-free survival (EFS) and cumulative incidence of relapse as well as incidence rate ratio (IRR) of severe predefined toxic events, and treatment delays. RESULTS The group comprised 416 patients, of whom 234 (56%) were stratified to non-high-risk (non-HR) treatment. In the non-HR group, patients with severe obesity, BMI ≥35 kg/m2 had worse EFS due to relapses but there was no effect on toxicity or treatment delays compared with the healthy-weight patients. There was no association between BMI category and OS, overall toxicity, or treatment delays in the patients with high-risk treatment. CONCLUSION Severe obesity is associated with worse EFS in young adults treated according to the non-HR arms of the NOPHO ALL2008 protocol. Poorer outcome is explained with a higher risk of relapse, possibly due to under treatment, and not caused by excess therapy-related mortality.
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Affiliation(s)
- Christina Egnell
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Helene Hallböök
- Department of Medical Sciences, Haematology, Uppsala University, Uppsala, Sweden
| | - Mats Heyman
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | | | - Petter Quist-Paulsen
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | - Katrin Palk
- Haematology Centre, North Estonia Medical Centre, Tallinn, Estonia
| | - Nina Toft
- Department of Haematology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Ulrik Malthe Overgaard
- Department of Haematology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Arja Harila
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Susanna Ranta
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
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2
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Alqahtani A, Alhousari D, Ali A, Yaghmour G, Orgel E, Curran E, Stock W, Bhojwani D, Alachkar H. Asparaginase toxicity in Hispanic adult and pediatric patients with acute lymphoblastic leukemia: current understanding. Expert Opin Drug Metab Toxicol 2023; 19:357-366. [PMID: 37410014 DOI: 10.1080/17425255.2023.2233412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 07/03/2023] [Indexed: 07/07/2023]
Abstract
INTRODUCTION Asparaginase is essential to chemotherapy regimens for acute lymphoblastic leukemia (ALL). Survival of patients with ALL has improved since incorporating asparaginase into chemotherapy backbones. Hispanic patients have a higher incidence of ALL than other ethnicities and suffer inferior outcomes. The inferior outcome of Hispanics is due to several factors, including the increased incidence of high-risk genetic subtypes and susceptibility to treatment-related toxicity. AREAS COVERED We summarize the current knowledge of asparaginase-related toxicity by comparing their incidence between Hispanic and non-Hispanic patients. These toxicities include hypersensitivity, hepatotoxicity, pancreatitis, thrombosis, and hypertriglyceridemia. The PubMed database and Google Scholar were used to search for this review from October 2022 to June 2023. EXPERT OPINION Except for hepatotoxicity and hypertriglyceridemia secondary to asparaginase-based treatments, which may develop more frequently among Hispanic patients with ALL, other toxicities were comparable between Hispanic and non-Hispanic patients. Nevertheless, studies with larger cohorts and more accurate capturing of Hispanic ethnicity should be conducted to fill the gaps in the current knowledge.
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Affiliation(s)
- Amani Alqahtani
- School of Pharmacy, University of Southern California, Los Angeles, CA, USA
- Department of Clinical Pharmacy, School of Pharmacy, Najran University, Najran, Saudi Arabia
| | - Diala Alhousari
- School of Pharmacy, University of Southern California, Los Angeles, CA, USA
| | - Amir Ali
- USC Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, USA
| | - George Yaghmour
- USC Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, USA
| | - Etan Orgel
- USC Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, USA
- Cancer and Blood Disease Institute, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Emily Curran
- The Department of Medicine, Section of Hematology & Oncology at the University of Cincinnati College of Medicine
| | - Wendy Stock
- Section of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Deepa Bhojwani
- USC Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, USA
- Cancer and Blood Disease Institute, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Houda Alachkar
- School of Pharmacy, University of Southern California, Los Angeles, CA, USA
- USC Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, USA
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3
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Dharia P, Swartz MD, Bernhardt MB, Chen H, Gramatges MM, Lupo PJ, Brown AL, Scheurer ME. Clinical and demographic factors contributing to asparaginase-associated toxicities in children with acute lymphoblastic leukemia. Leuk Lymphoma 2022; 63:2948-2954. [PMID: 35895075 PMCID: PMC9745725 DOI: 10.1080/10428194.2022.2102621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 06/21/2022] [Accepted: 07/11/2022] [Indexed: 12/15/2022]
Abstract
A total of 548 patients (age range: 1-22 years, 60.4% Hispanic, 55.8% male) diagnosed with acute lymphoblastic leukemia were reviewed for pegaspargase-associated hypersensitivity (14.8%), hyperbilirubinemia (9.7%), venous thromboembolism (VTE, 9.7%), and pancreatitis (5.3%). Odds ratios (OR) and 95% confidence intervals (CI) evaluated associations between clinical factors and each toxicity, cumulative number of toxicities, and toxicity clusters identified using k-mode analysis. Most (68.9%) did not experience any toxicity, 24.6% experienced one toxicity, and 6.3% two or more. Age >10 years was associated with hyperbilirubinemia (OR = 3.83; 95% CI: 1.64-8.95), pancreatitis (OR = 3.72; 95% CI: 1.29-10.68), VTE (OR = 4.65; 95% CI: 1.96-11.02), and cumulative toxicity burden (OR = 3.28, 95% CI: 1.97-5.47); high-risk therapy with hypersensitivity (OR 2.25; 95% CI 1.25-4.05); and overweight with cumulative toxicity burden (OR = 1.76, 95% CI: 1.20-2.57). Eight unique toxicity profiles were identified. Older age, overweight, and treatment intensity contribute to pegaspargase-associated toxicities.
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Affiliation(s)
- Priyadarshani Dharia
- University of Texas Health Science Center at Houston, School of Public Health, Houston, TX
| | - Michael D. Swartz
- University of Texas Health Science Center at Houston, School of Public Health, Houston, TX
| | | | - Han Chen
- University of Texas Health Science Center at Houston, School of Public Health, Houston, TX
| | | | - Philip J. Lupo
- Baylor College of Medicine, Department of Pediatrics, Houston, TX
| | - Austin L. Brown
- Baylor College of Medicine, Department of Pediatrics, Houston, TX
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4
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Maese L, Rau RE. Current Use of Asparaginase in Acute Lymphoblastic Leukemia/Lymphoblastic Lymphoma. Front Pediatr 2022; 10:902117. [PMID: 35844739 PMCID: PMC9279693 DOI: 10.3389/fped.2022.902117] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 06/06/2022] [Indexed: 01/19/2023] Open
Abstract
Pediatric Acute Lymphoblastic Leukemia (ALL) cure rates have improved exponentially over the past five decades with now over 90% of children achieving long-term survival. A direct contributor to this remarkable feat is the development and expanded understanding of combination chemotherapy. Asparaginase is the most recent addition to the ALL chemotherapy backbone and has now become a hallmark of therapy. It is generally accepted that the therapeutic effects of asparaginase is due to depletion of the essential amino acid asparagine, thus occupying a unique space within the therapeutic landscape of ALL. Pharmacokinetic and pharmacodynamic profiling have allowed a detailed and accessible insight into the biochemical effects of asparaginase resulting in regular clinical use of therapeutic drug monitoring (TDM). Asparaginase's derivation from bacteria, and in some cases conjugation with a polyethylene glycol (PEG) moiety, have contributed to a unique toxicity profile with hypersensitivity reactions being the most salient. Hypersensitivity, along with several other toxicities, has limited the use of asparaginase in some populations of ALL patients. Both TDM and toxicities have contributed to the variety of approaches to the incorporation of asparaginase into the treatment of ALL. Regardless of the approach to asparagine depletion, it has continually demonstrated to be among the most important components of ALL therapy. Despite regular use over the past 50 years, and its incorporation into the standard of care treatment for ALL, there remains much yet to be discovered and ample room for improvement within the utilization of asparaginase therapy.
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Affiliation(s)
- Luke Maese
- Huntsman Cancer Institute, University of Utah, Primary Children's Hospital, Salt Lake City, UT, United States
| | - Rachel E. Rau
- Department of Pediatrics, Baylor College of Medicine Texas Children's Hospital, Houston, TX, United States
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5
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Egnell C, Heyman M, Jónsson ÓG, Raja RA, Niinimäki R, Albertsen BK, Schmiegelow K, Stabell N, Vaitkeviciene G, Lepik K, Harila-Saari A, Ranta S. Obesity as a predictor of treatment-related toxicity in children with acute lymphoblastic leukaemia. Br J Haematol 2021; 196:1239-1247. [PMID: 34726257 DOI: 10.1111/bjh.17936] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 10/20/2021] [Indexed: 02/04/2023]
Abstract
Obesity is associated with poor outcomes in childhood acute lymphoblastic leukaemia (ALL). We explored whether severe treatment-related toxicity and treatment delays could explain this observation. This study included 1 443 children aged 2·0-17·9 years with ALL treated with the Nordic Society of Pediatric Haematology and Oncology (NOPHO) ALL2008 non-high-risk protocol. Prospective treatment-related toxicities registered every three-month interval were used. Patients were classified according to sex- and age-adjusted international childhood cut-off values, corresponding to adult body mass index: underweight, <17 kg/m2 ; healthy weight, 17 to <25 kg/m2 ; overweight, 25 to <30 kg/m2 ; and obese, ≥30 kg/m2 . Obese children had a higher incidence rate ratio (IRR) for severe toxic events {IRR: 1·55 [95% confidence interval (CI) 1·07-2·50]}, liver and kidney failures, bleeding, abdominal complication, suspected unexpected severe adverse reactions and hyperlipidaemia compared with healthy-weight children. Obese children aged ≥10 years had increased IRRs for asparaginase-related toxicities compared with healthy-weight older children: thromboses [IRR 2·87 (95% CI 1·00-8·21)] and anaphylactic reactions [IRR 7·95 (95% CI 2·15-29·37)] as well as higher risk for truncation of asparaginase [IRR 3·54 (95% CI 1·67-7·50)]. The high prevalence of toxicity and a higher risk of truncation of asparaginase may play a role in the poor prognosis of obese children aged ≥10 years with ALL.
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Affiliation(s)
- Christina Egnell
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden.,Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Mats Heyman
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | | | - Raheel A Raja
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark.,Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Denmark
| | - Riitta Niinimäki
- PEDEGO Research Unit, Medical Research Center Oulu and Department of Children and Adolescents, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Birgitte Klug Albertsen
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark.,Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Denmark
| | - Niklas Stabell
- Department of Paediatrics, University Hospital of North Norway, Tromsø, Norway
| | - Goda Vaitkeviciene
- Children's Hospital, Affiliate of Vilnius University Hospital Santaros Klinikos and Vilnius University, Vilnius, Lithuania
| | - Kristi Lepik
- Department of Haematology and Oncology, Children's hospital, Tallinn, Estonia
| | - Arja Harila-Saari
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Susanna Ranta
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden.,Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
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Schulte R, Hinson A, Huynh V, Breese EH, Pierro J, Rotz S, Mixon BA, McNeer JL, Burke MJ, Orgel E. Levocarnitine for pegaspargase-induced hepatotoxicity in older children and young adults with acute lymphoblastic leukemia. Cancer Med 2021; 10:7551-7560. [PMID: 34528411 PMCID: PMC8559504 DOI: 10.1002/cam4.4281] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 08/11/2021] [Accepted: 08/17/2021] [Indexed: 12/19/2022] Open
Abstract
Background Pegaspargase (PEG‐ASP) is an integral component of therapy for acute lymphoblastic leukemia (ALL) but is associated with hepatotoxicity that may delay or limit future therapy. Obese and adolescent and young adult (AYA) patients are at high risk. Levocarnitine has been described as potentially beneficial for the treatment or prevention of PEG‐ASP‐associated hepatotoxicity. Methods We collected data for patients age ≥10 years who received levocarnitine during induction therapy for ALL, compared to a similar patient cohort who did not receive levocarnitine. The primary endpoint was conjugated bilirubin (c.bili) >3 mg/dl. Secondary endpoints were transaminases >10× the upper limit of normal and any Grade ≥3 hepatotoxicity. Results Fifty‐two patients received levocarnitine for prophylaxis (n = 29) or rescue (n = 32) of hepatotoxicity. Compared to 109 patients without levocarnitine, more patients receiving levocarnitine were obese and/or older and had significantly higher values for some hepatotoxicity markers at diagnosis and after PEG‐ASP. Levocarnitine regimens varied widely; no adverse effects of levocarnitine were identified. Obesity and AYA status were associated with an increased risk of conjugated hyperbilirubinemia and severe transaminitis. Multivariable analysis identified a protective effect of levocarnitine on the development of c.bili >3 mg/dl (OR 0.12, p = 0.029). There was no difference between groups in CTCAE Grade ≥3 hepatotoxicity. C.bili >3 mg/dl during induction was associated with lower event‐free survival. Conclusions This real‐world data on levocarnitine supplementation during ALL induction highlights the risk of PEG‐ASP‐associated hepatotoxicity in obese and AYA patients, and hepatotoxicity's potential impact on survival. Levocarnitine supplementation may be protective, but prospective studies are needed to confirm these findings.
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Affiliation(s)
- Rachael Schulte
- Division of Pediatric Hematology and Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ashley Hinson
- Division of Pediatric Hematology and Oncology, Levine Children's Atrium Health, Charlotte, North Carolina, USA
| | - Van Huynh
- Division of Pediatric Oncology, University of California Irvine College of Medicine, CHOC Children's Hospital, Orange, California, USA
| | - Erin H Breese
- Division of Oncology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center/University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Joanna Pierro
- Division of Pediatric Hematology/Oncology, NYU Grossman School of Medicine, Perlmutter Cancer Center, Hassenfeld Children's Hospital at NYU Langone Health, New York, New York, USA
| | - Seth Rotz
- Department of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Pediatric Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Benjamin A Mixon
- Department of Pediatrics, University of Tennessee College of Medicine Chattanooga and Children's Hospital at Erlanger, Chattanooga, Tennessee, USA
| | - Jennifer L McNeer
- Section of Pediatric Hematology, Oncology, and Stem Cell Transplant, University of Chicago Comer Children's Hospital, Chicago, Illinois, USA
| | - Michael J Burke
- Division of Pediatric Hematology/Oncology and Blood and Marrow Transplantation, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Etan Orgel
- Cancer and Blood Disease Institute, Children's Hospital Los Angeles/University of Southern California, Los Angeles, California, USA
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7
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Gupta A, Damania RC, Talati R, O'Riordan MA, Matloub YH, Ahuja SP. Increased Toxicity Among Adolescents and Young Adults Compared with Children Hospitalized with Acute Lymphoblastic Leukemia at Children's Hospitals in the United States. J Adolesc Young Adult Oncol 2021; 10:645-653. [PMID: 33512257 DOI: 10.1089/jayao.2020.0154] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Purpose: Adolescent and young adult (AYA) patients (15-39 years old) with acute lymphoblastic leukemia (ALL) have less favorable outcomes and higher treatment-related mortality as compared with older children with ALL. Minimal data exist regarding how well AYA patients tolerate the intensity of chemotherapy at doses and regimens designed for children, and the toxicities suffered by this population at children's hospitals have not been thoroughly characterized. Methods: Pediatric Health Information Systems database was queried to analyze health care outcomes in pediatric (ages 10-14) and AYA patients (ages 15-39) with ALL hospitalized between January 1999 and December 2014. We extracted relevant ICD-9 data for each patient related to grades 3 or 4 toxicities as outlined by the NCI. Results: A total of 5345 hospital admissions met inclusion criteria, representing 4046 unique patients. Of these admissions, 2195 (41.1%) were in the AYA age group, and the remainder were in the 10-14-year-old group. AYA patients had a significantly higher incidence of intensive care unit stay but no difference in median hospital stay nor mortality. AYA patients had increased toxicities in almost every organ system as compared with older children. Conclusions: In this large multicenter US database study, we found an overall increased number of toxicities among AYA patients with ALL in children's hospitals. Compared with children between the ages of 10 and 15, AYA patients developed disproportionately higher toxicities from drugs commonly used in pediatric protocols for ALL. Prospective studies are needed to assess whether dose modifications for certain chemotherapeutics may improve the toxicity profile and health care burden of AYA patients with ALL treated in children's hospitals.
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Affiliation(s)
- Ajay Gupta
- Department of Pediatric Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Rahul C Damania
- Division of Pediatric Critical Care Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Ravi Talati
- Division of Hematology, Oncology, and Blood and Marrow Transplant, Cleveland Clinic Children's Hospital, Cleveland, Ohio, USA
| | - Mary Ann O'Riordan
- Women's & Children's Services, University Hospitals Rainbow Babies & Children's Hospital, Cleveland, Ohio, USA
| | - Yousif H Matloub
- Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio, USA
| | - Sanjay P Ahuja
- Division of Pediatric Hematology/Oncology, Rainbow Babies & Children's Hospital, Cleveland, Ohio, USA
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