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Perruso LL, Velloso E, Rocha V, Rego EM, Silva WF. Patterns and prognostic impact of CNS infiltration in adults with newly diagnosed acute lymphoblastic leukemia. Ann Hematol 2024; 103:2033-2039. [PMID: 38180535 DOI: 10.1007/s00277-023-05609-4] [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: 10/25/2023] [Accepted: 12/22/2023] [Indexed: 01/06/2024]
Abstract
Acute lymphoblastic leukemia (ALL) is highly associated with central nervous system (CNS) infiltration and can be associated with higher risk of relapse. Conventional cytology (CC) is the traditional method for diagnosing CNS infiltration, although the use of immunophenotyping by flow cytometry (FC) has gained prominence in recent years due to its higher sensitivity. Also, some authors have proposed that CSF contamination by a traumatic lumbar puncture (TLP) could have a clinical impact. This retrospective study accessed the impact of CNS infiltration by CC or FC on overall survival, event-free survival, and relapse rate. In a cohort of 105 newly diagnosed ALL patients, CNS1, CNS2, and CNS3 status were found in 84%, 14%, and 2%, respectively. We found that extramedullary disease at the diagnosis, higher leukocyte counts, and higher blast percentage were associated with a positive CC. Sensitivity and specificity of CC were 53% and 98%, respectively. Three-year overall survival was 42.5%. Conversely, TLP was not associated with a positive CC nor had an impact on relapse rates. In multivariate analysis, a positive CC was associated with an increased relapse rate (HR 2.074, p = 0.037), while its detection by FC did not associate with this endpoint. Survival rates seem to be increasing over the last years by the adoption of a stratified CNS prophylaxis risk strategy. CSF contamination does not represent a major concern according to our report, as it did not increase CNS involvement or relapse rates.
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Affiliation(s)
- Luiza Lapolla Perruso
- Laboratory of Medical Investigation in Pathogenesis and Directed Therapy in Onco-Immuno-Hematology (LIM-31), Division of Hematology and Cell Therapy, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, 01246-000, Brazil
- Instituto Do Cancer Do Estado de São Paulo, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, 251, Cerqueira César, São Paulo, SP, CEP 01246-000, Brazil
| | - Elvira Velloso
- Laboratory of Medical Investigation in Pathogenesis and Directed Therapy in Onco-Immuno-Hematology (LIM-31), Division of Hematology and Cell Therapy, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, 01246-000, Brazil
- Instituto Do Cancer Do Estado de São Paulo, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, 251, Cerqueira César, São Paulo, SP, CEP 01246-000, Brazil
| | - Vanderson Rocha
- Laboratory of Medical Investigation in Pathogenesis and Directed Therapy in Onco-Immuno-Hematology (LIM-31), Division of Hematology and Cell Therapy, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, 01246-000, Brazil
- Instituto Do Cancer Do Estado de São Paulo, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, 251, Cerqueira César, São Paulo, SP, CEP 01246-000, Brazil
| | - Eduardo Magalhaes Rego
- Laboratory of Medical Investigation in Pathogenesis and Directed Therapy in Onco-Immuno-Hematology (LIM-31), Division of Hematology and Cell Therapy, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, 01246-000, Brazil
- Instituto Do Cancer Do Estado de São Paulo, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, 251, Cerqueira César, São Paulo, SP, CEP 01246-000, Brazil
| | - Wellington Fernandes Silva
- Laboratory of Medical Investigation in Pathogenesis and Directed Therapy in Onco-Immuno-Hematology (LIM-31), Division of Hematology and Cell Therapy, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, 01246-000, Brazil.
- Instituto Do Cancer Do Estado de São Paulo, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, Av. Dr. Arnaldo, 251, Cerqueira César, São Paulo, SP, CEP 01246-000, Brazil.
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Alves C, Pereira J, Rego EM, Rocha V, Silva WF. Outpatient administration of high-dose methotrexate in adults without drug monitoring - a case-control study of risk factors for acute kidney injury. Hematol Transfus Cell Ther 2023:S2531-1379(23)02599-3. [PMID: 38233304 DOI: 10.1016/j.htct.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 10/21/2023] [Indexed: 01/19/2024] Open
Abstract
INTRODUCTION High-dose methotrexate (HDMTX) is an essential part of chemotherapy regimens for hematologic neoplasms. The incidence of acute kidney injury (AKI) after HDMTX in unmonitored outpatient infusion had not been reported in adults yet. In this study, we evaluated toxicity data after outpatient administration of HDMTX without drug monitoring. METHODS Patients 16 years old or over with acute lymphoblastic leukemia and non-Hodgkin lymphoma who received at least one outpatient infusion of HDMTX without drug level monitoring were included. This is a retrospective, nested case-control study, in which the cases comprised patients who developed AKI after HDMTX. RESULTS Overall, 302 patients were included, encompassing 840 infusions. Hospitalization occurred in 8.6 %. A total of 25 patients presented AKI after HDMTX administration, corresponding to 3 % of the methotrexate (MTX) infusions and 8.3 % of the patients. HIV-associated Burkitt lymphoma was more common in patients who presented AKI (18 vs. 6.8 %, p = 0.03). Baseline factors related to AKI after HDMTX were age > 44 y, body surface area ≥ 1.76 m2, body mass index (BMI) ≥ 23.8 kg/m2, glomerular filtration rate, and thrombocytopenia (< 150×109/L). Multivariable analysis for adjusting such factors found that BMI was independently related to AKI after HDMTX (OR 3.8). Death after AKI occurred in 56 %. CONCLUSION Our data showed a similar rate of AKI after HDMTX to that reported in the literature, even without drug monitoring. However, patients who developed AKI in our cohort fared worse than expected, with more hospitalizations and death. A higher BMI was associated with the MTX-induced AKI in our cohort, suggesting a differential drug clearance and the need for specific guidelines for obese patients.
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Affiliation(s)
- Camila Alves
- Instituto do Cancer do Estado de São Paulo, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 01246-000, Brazil
| | - Juliana Pereira
- Laboratory of Medical Investigation in Pathogenesis and Directed Therapy in Onco-Immuno-Hematology (LIM-31), Division of Hematology and Cell Therapy, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 01246-000, Brazil; Instituto do Cancer do Estado de São Paulo, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 01246-000, Brazil
| | - Eduardo M Rego
- Laboratory of Medical Investigation in Pathogenesis and Directed Therapy in Onco-Immuno-Hematology (LIM-31), Division of Hematology and Cell Therapy, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 01246-000, Brazil; Instituto do Cancer do Estado de São Paulo, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 01246-000, Brazil
| | - Vanderson Rocha
- Laboratory of Medical Investigation in Pathogenesis and Directed Therapy in Onco-Immuno-Hematology (LIM-31), Division of Hematology and Cell Therapy, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 01246-000, Brazil; Instituto do Cancer do Estado de São Paulo, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 01246-000, Brazil
| | - Wellington F Silva
- Laboratory of Medical Investigation in Pathogenesis and Directed Therapy in Onco-Immuno-Hematology (LIM-31), Division of Hematology and Cell Therapy, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 01246-000, Brazil; Instituto do Cancer do Estado de São Paulo, Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 01246-000, Brazil.
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Silva W, Rego E. How to Manage Philadelphia-Positive Acute Lymphoblastic Leukemia in Resource-Constrained Settings. Cancers (Basel) 2023; 15:5783. [PMID: 38136329 PMCID: PMC10741425 DOI: 10.3390/cancers15245783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 10/17/2023] [Accepted: 10/20/2023] [Indexed: 12/24/2023] Open
Abstract
Recent studies have indicated that more than half of adult patients newly diagnosed with Ph+ ALL can now achieve a cure. However, determining the most suitable protocol for less-resourced settings can be challenging. In these situations, we must consider the potential for treatment toxicity and limited access to newer agents and alloSCT facilities. Currently, it is advisable to use less intensive induction regimens for Ph+ ALL. These regimens can achieve high rates of complete remission while causing fewer induction deaths. For consolidation therapy, chemotherapy should remain relatively intensive, with careful monitoring of the BCR-ABL1 molecular transcript and minimal residual disease. AlloSCT may be considered, especially for patients who do not achieve complete molecular remission or have high-risk genetic abnormalities, such as IKZF1-plus. If there is a loss of molecular response, it is essential to screen patients for ABL mutations and, ideally, change the TKI therapy. The T315I mutation is the most common mechanism for disease resistance, being targetable to ponatinib. Blinatumomab, a bispecific antibody, has shown significant synergy with TKIs in treating this disease. It serves as an excellent salvage therapy, aside from achieving outstanding results when incorporated into the frontline.
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Affiliation(s)
- Wellington Silva
- Discipline of Hematology, Hospital das Clínicas da Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 05403-010, Brazil;
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Basquiera AL, Seiwald MC, Best Aguilera CR, Enciso L, Fernandez I, Jansen AM, Nunes E, Sanchez del Villar M, Urbalejo Ceniceros VI, Rocha V. Expert Recommendations for the Diagnosis, Treatment, and Management of Adult B-Cell Acute Lymphoblastic Leukemia in Latin America. JCO Glob Oncol 2023; 9:e2200292. [PMID: 37167576 PMCID: PMC10497277 DOI: 10.1200/go.22.00292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 01/19/2023] [Accepted: 03/13/2023] [Indexed: 05/13/2023] Open
Abstract
PURPOSE Despite strong induction chemotherapy response rates, only 30%-40% of patients with adult B-cell acute lymphoblastic leukemia (ALL) attain long-term remission. This study analyzes ALL in Latin America (LA) and recommends diagnosis, treatment, and management protocols. METHODS The Americas Health Foundation organized a panel of hematologists from Argentina, Brazil, Chile, Colombia, and Mexico to examine ALL diagnosis and therapy and produce recommendations. RESULTS Lack of regional data, unequal access to diagnosis and therapy, inadequate treatment response, and uneven health care distribution complicate adult ALL management. The panel recommended diagnosis, first-line and refractory treatment, and post-transplantation maintenance. Targeted treatments, including rituximab, blinatumomab, and inotuzumab ozogamicin, are becoming available in LA and must be equitably accessed. CONCLUSION This review adapts global information on treating ALL to LA. Governments, the medical community, society, academia, industry, and patient advocates must work together to improve policies.
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Affiliation(s)
- Ana Lisa Basquiera
- Hematology and Oncology Service, Bone Marrow Transplant Program, Hospital Privado Universitario de Cordoba, Instituto Universitario de Ciencias Biomédicas de Cordoba (IUCBC), Cordoba, Argentina
| | - Maria Cristina Seiwald
- Department of Clinical Medicine, Hematology and Hemotherapy, University of Sao Paulo (FMUSP), Sao Paulo, Brazil
| | - Carlos Roberto Best Aguilera
- Conacyt National Quality Postgraduate Program, University of Guadalajara & Western General Hospital, Guadalajara, Mexico
| | | | | | | | - Elenaide Nunes
- Hospital de Clínicas—Federal University of Parana, Parana, Brazil
| | - Matias Sanchez del Villar
- Chief Bone Marrow Transplant Service, Department of Hematology, Clinica Alemana de Santiago, Santiago, Chile
| | | | - Vanderson Rocha
- Department of Clinical Medicine, Hematology and Hemotherapy, University of Sao Paulo (FMUSP), Sao Paulo, Brazil
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Colunga-Pedraza PR, Colunga-Pedraza JE, Peña-Lozano SP, Gómez-De León A, Ruiz-Delgado GJ, Ribeiro RC. Diagnosis and treatment of acute lymphoblastic leukemia in Latin America. HEMATOLOGY (AMSTERDAM, NETHERLANDS) 2022; 27:971-976. [PMID: 36040187 DOI: 10.1080/16078454.2022.2117119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE to discuss the status and challenges associated with the management of acute lymphoblastic leukemia (ALL) in Latin America. METHODS This review summarizes various insights gained from information regarding diagnostic approaches and treatment strategies in adult patients with ALL in Latin American Countries. RESULTS Information regarding ALL in Latin America is scarce; however, many efforts have been made to overcomes these barriers. Nevertheless, major obstacles to successful treatment in Latin America and LMIC remain poor adherence, abandonment of treatment, and lack of supportive therapy and new therapeutic agents. CONCLUSION Further improvements in survival should be pursued by developing more Latin American registries, forming cooperative groups, developing educational models to facilitate earlier diagnosis and prevention of complications, better support therapy and management of infections, and adapting treatment strategies.
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Affiliation(s)
- Perla R Colunga-Pedraza
- Universidad Autónoma de Nuevo León, Facultad de Medicina, Servicio de Hematología, Hospital Universitario "Dr. José E. González", Monterrey, Mexico
| | - Julia E Colunga-Pedraza
- Universidad Autónoma de Nuevo León, Facultad de Medicina, Servicio de Hematología, Hospital Universitario "Dr. José E. González", Monterrey, Mexico
| | - Samantha P Peña-Lozano
- Universidad Autónoma de Nuevo León, Facultad de Medicina, Servicio de Hematología, Hospital Universitario "Dr. José E. González", Monterrey, Mexico
| | - Andrés Gómez-De León
- Universidad Autónoma de Nuevo León, Facultad de Medicina, Servicio de Hematología, Hospital Universitario "Dr. José E. González", Monterrey, Mexico
| | - Guillermo J Ruiz-Delgado
- Centro de Hematología y Medicina Interna, Clínica RUIZ, Puebla, Mexico.,Universidad Popular Autónoma del Estado de Puebla, Puebla, México
| | - Raul C Ribeiro
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
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