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Juluri KR, Siu C, Cassaday RD. Asparaginase in the Treatment of Acute Lymphoblastic Leukemia in Adults: Current Evidence and Place in Therapy. Blood Lymphat Cancer 2022; 12:55-79. [PMID: 35669980 PMCID: PMC9166408 DOI: 10.2147/blctt.s342052] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 05/16/2022] [Indexed: 01/19/2023] Open
Abstract
Acute lymphoblastic leukemia (ALL) is a rare hematologic malignancy resulting in the production of abnormal lymphoid precursor cells. Occurring in B-cell and T-cell subtypes, ALL is more common in children, comprising nearly 30% of pediatric malignancies, but also constitutes 1% of adult cancer diagnoses. Outcomes are age-dependent, with five-year overall survival of greater than 90% in children and less than 20% in older adults. L-asparaginase, an enzyme not found in humans, depletes serum levels of L-asparagine. As leukemic cells are unable to synthesize this amino acid, its deprivation results in cell death. The success of asparaginase-containing regimens in the treatment of pediatric ALL, and poor outcomes with conventional cytotoxic regimens in adults, have led to trials of pediatric or pediatric-inspired regimens incorporating asparaginase in the adolescent and young adult (AYA) and adult populations. Initially purified from Escherichia coli, newer formulations of asparaginase have been developed to address short half-life, high immunogenic potential, and manufacturing difficulties. Unfamiliarity with asparaginase use and management of its unique toxicities may result in treatment-decisions that negatively impact outcomes. In this review, we address the current use of asparaginase in the treatment of ALL, with an emphasis on its role in the treatment of adults, key clinical trials, recognition and management of toxicities, and ongoing directions of study.
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Affiliation(s)
- Krishna R Juluri
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Chloe Siu
- Seattle Cancer Care Alliance, Seattle, WA, USA
- Department of Pharmacy, University of Washington School of Pharmacy, Seattle, WA, USA
| | - Ryan D Cassaday
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- Seattle Cancer Care Alliance, Seattle, WA, USA
- Correspondence: Ryan D Cassaday, Email
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Sindhu R, Manonmani HK. L-asparaginase mediated therapy in L-asparagine auxotrophic cancers: A review. Anticancer Agents Med Chem 2022; 22:2393-2410. [PMID: 34994334 DOI: 10.2174/1871520622666220106103336] [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: 04/22/2021] [Revised: 09/28/2021] [Accepted: 11/15/2021] [Indexed: 11/22/2022]
Abstract
Microbial L-asparaginase is the most effective first-line therapeutic used in the treatment protocols of paediatric and adult leukemia. Leukemic cell's auxotrophy for L-asparagine is exploited as a therapeutic strategy to mediate cell death through metabolic blockade of L-asparagine using L-asparaginase. Escherichia coli and Erwinia chrysanthemi serve as the major enzyme deriving sources accepted in clinical practise and the enzyme has bestowed improvements in patient outcomes over the last 40 years. However, an array of side effects generated by the native enzymes due to glutamine co-catalysis and short serum stays augmenting frequent dosages, intended a therapeutic switch towards the development of biobetter alternatives for the enzyme including the formulations resulting in sustained local depletion of L-asparagine. In addition, the treatment with L-asparaginase in few cancer types has proven to elicit drug-induced cytoprotective autophagy mechanisms and therefore warrants concern. Although the off-target glutamine hydrolysis has been viewed in contributing the drug-induced secondary responses in cells deficient with asparagine synthetase machinery, the beneficial role of glutaminase-asparaginase in proliferative regulation of asparagine prototrophic cells has been looked forward. The current review provides an overview on the enzyme's clinical applications in leukemia and possible therapeutic implications in other solid tumours, recent advancements in drug formulations, and discusses the aspects of two-sided roles of glutaminase-asparaginases and drug-induced cytoprotective autophagy mechanisms.
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Affiliation(s)
- Sindhu R
- Department of Microbiology, Faculty of Life Sciences, JSS-AHER, Mysuru-570015, Karnataka, India
| | - H K Manonmani
- Food Protectants and Infestation Control Department, CSIR-Central Food Technological Research Institute, Mysuru-570020, Karnataka, India
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Gupta S, Sutradhar R, Li Q, Athale U, Bassal M, Breakey V, Gibson PJ, Patel S, Silva M, Zabih V, Pechlivanoglou P, Pole JD, Mittmann N. Health care utilisation and costs associated with different treatment protocols for newly diagnosed childhood acute lymphoblastic leukaemia: A population-based study in Ontario, Canada. Eur J Cancer 2021; 151:126-135. [PMID: 33979728 DOI: 10.1016/j.ejca.2021.04.006] [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] [Received: 01/20/2021] [Revised: 03/09/2021] [Accepted: 04/06/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Although different treatment protocols for childhood acute lymphoblastic leukaemia (ALL) all achieve high cure rates, their health care utilisation and costs have not been rigorously compared. METHODS Disease, treatment, and outcome data were chart abstracted for all children with ALL in Ontario, Canada, diagnosed 2002-2012. Linkage to population-based databases identified health care utilisation. Utilisation-associated costs were determined through validated algorithms. Chemotherapy-associated costs were calculated separately. Health care utilisation and costs were compared between patients receiving Children's Oncology Group (COG) versus Dana-Farber Cancer Institute (DFCI)-based treatment. FINDINGS Of 802 patients, 146 (18.2%) were treated on DFCI-based protocols. COG patients experienced significantly higher rates of emergency department (ED) visits (adjusted rate ratio [aRR]: 1.3, 95% confidence interval [CI]: 1.1-1.5; p = 0·01), whereas outpatient visit rates were 60% higher among DFCI patients (aRR: 1.6, 95% CI: 1.5-1.7, p < 0.0001). In adjusted analyses, DFCI-associated cost intensity was 70% higher (aRR: 1.7, 95% CI: 1.5-1.9; p < 0.0001), mainly attributable to outpatient visit costs. Total chemotherapy costs were higher among COG-treated patients ($39,400 ± $1100 versus $33,400 ± $2800; p = 0.02). Among PEG-ASNase-treated patients, total chemotherapy costs were highest among DFCI patients (median $54,200 ± $7400; p = 0.003 versus COG patients). INTERPRETATION COG and DFCI treatments were associated with higher ED visit rates and higher outpatient visit rates, respectively. Overall utilisation-associated costs were increased in DFCI-treated patients. Administration of some intravenous chemotherapy at home and decreases in PEG-ASNase cost would decrease health care utilisation and costs for all patients and mitigate differences between COG and DFCI protocols. FUNDING C17 Research Network.
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Affiliation(s)
- Sumit Gupta
- Division of Haematology/Oncology, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada; Faculty of Medicine, University of Toronto, 27 King's College Cir, Toronto, ON, M5S 1A8, Canada; Cancer Research Program, Institute for Clinical Evaluative Sciences, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada; Institute for Health Policy, Evaluation and Management, University of Toronto, 155 College St, Toronto, ON, M5T 3MG, Canada.
| | - Rinku Sutradhar
- Cancer Research Program, Institute for Clinical Evaluative Sciences, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada; Institute for Health Policy, Evaluation and Management, University of Toronto, 155 College St, Toronto, ON, M5T 3MG, Canada; Dalla Lana School of Public Health, University of Toronto, 155 College St, Toronto, ON, M5T 3MG, Canada
| | - Qing Li
- Cancer Research Program, Institute for Clinical Evaluative Sciences, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada
| | - Uma Athale
- Division of Haematology/Oncology, McMaster Children's Hospital, 1200 Main St W, Hamilton, L8N 3Z5, Canada
| | - Mylene Bassal
- Division of Haematology/Oncology, Children's Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, K1H 8L1, Canada
| | - Vicky Breakey
- Division of Haematology/Oncology, McMaster Children's Hospital, 1200 Main St W, Hamilton, L8N 3Z5, Canada
| | - Paul J Gibson
- Division of Haematology/Oncology, McMaster Children's Hospital, 1200 Main St W, Hamilton, L8N 3Z5, Canada
| | - Serina Patel
- Division of Haematology/Oncology, London Health Sciences Centre, 800 Commissioners Rd, London, N6A 5W9, Canada
| | - Mariana Silva
- Department of Pediatrics, Kingston General Hospital, 76 Stuart St, Kingston, K7L 2V7, Canada
| | - Veda Zabih
- Division of Haematology/Oncology, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G 1X8, Canada; Sickkids Research Institute, The Hospital for Sick Children, 86 Bay St, Toronto, M5G 0A4, Canada
| | - Petros Pechlivanoglou
- Institute for Health Policy, Evaluation and Management, University of Toronto, 155 College St, Toronto, ON, M5T 3MG, Canada; Sickkids Research Institute, The Hospital for Sick Children, 86 Bay St, Toronto, M5G 0A4, Canada
| | - Jason D Pole
- Cancer Research Program, Institute for Clinical Evaluative Sciences, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada; Center for Health Services Research, University of Queensland, 34 Cornwall St, Woolloongabba QLD 4102, Australia; Dalla Lana School of Public Health, University of Toronto, 155 College St, Toronto, ON, M5T 3MG, Canada
| | - Nicole Mittmann
- Institute for Health Policy, Evaluation and Management, University of Toronto, 155 College St, Toronto, ON, M5T 3MG, Canada; Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, M4N 3M5, Canada; Department of Pharmacology and Toxicology, University of Toronto, 1 King's College Cir, Toronto, ON, M5S 1A8, Canada
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