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Hu Z, Persaud Y, Ahuja S. A systematic review and meta-analysis of the effectiveness of primary thromboprophylaxis in acute lymphoblastic leukemia during early-phase therapy including asparaginase or its prolonged form. Crit Rev Oncol Hematol 2024; 197:104347. [PMID: 38583546 DOI: 10.1016/j.critrevonc.2024.104347] [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: 11/04/2023] [Revised: 03/31/2024] [Accepted: 04/04/2024] [Indexed: 04/09/2024] Open
Abstract
Asparaginase is essential in the initial management of acute lymphoblastic leukemia (ALL) but frequently leads to venous thromboembolism (VTE). Using anticoagulants for primary VTE prevention has been studied with no consensus. We conducted a systematic literature search in PubMed, Scopus, and Web of science and performed random-effect meta-analysis using Mantel-Haenszel method in RevMan 5.4 to analyze primary pharmacological thromboprophylaxis during asparaginase treatment in early-phase (induction, consolidation, or intensification phase) therapy in patients with ALL with all ages and followed with subgroup analysis by age. Meta-analysis of 13 articles describing the effect of antithrombin supplementation in 1375 patients showed that antithrombin prophylaxis decreases the risk of VTE by 43% (RR, 0.57; 95% CI, 0.38 - 0.83; p=0.004), with mild heterogeneity (I2=35%, p=0.10) and moderate certainty by GRADE. 8 articles included for meta-analysis of low-molecular weight heparin (LMWH) treatment in 612 patients showed that it decreased the risk of VTE by nearly 40% (RR, 0.61; 95% CI, 0.45 - 0.81; p=0.00081), with minimal heterogeneity (I2=14%, p=0.31) but low certainty. Subgroup analysis showed that only prophylaxis with antithrombin supplementation significantly decreased the VTE rate in adult patients with moderate certainty. In pediatric patients, one nonrandomized prospective study showed that LMWH combined with antithrombin has a better thromboprophylaxis effect than antithrombin alone. In the PREVAPIX-ALL trial, prophylaxis with direct factor Xa inhibitor Apixaban did not benefit children younger than 18 years except for cases of obesity. We concluded that thromboprophylaxis with antithrombin is effective in ALL patients older than 18 years during the early phase of therapy, and LMWH combined with antithrombin supplementation might be effective for pediatric patients with ALL. Apixaban is effective in pediatric ALL patients with obesity and needs further study in other high-risk patients.
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Affiliation(s)
- Zhongbo Hu
- Hospitalist Medicine Program, Department of Oncology, St. Jude Children's Research Hospital, 262 Danny Thomas Place Mail Stop 278, Memphis, TN 38105, USA.
| | - Yogindra Persaud
- Department of Hematology, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105, USA
| | - Sanjay Ahuja
- Department of Pediatric Hematology & Oncology, University Hospitals Rainbow Babies and Children's Hospital, 11100 Euclid Ave, Cleveland, OH 44106, USA
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Pelland-Marcotte MC, Kulkarni K, Tran TH, Stammers D, Gupta S, Sung L, Athale UH. Risk factors and clinical impact of thrombosis during induction chemotherapy for pediatric acute lymphoblastic leukemia: A report from CYP-C. Am J Hematol 2024; 99:274-283. [PMID: 38164978 DOI: 10.1002/ajh.27171] [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: 11/02/2023] [Accepted: 11/08/2023] [Indexed: 01/03/2024]
Abstract
Thromboembolism (TE) is associated with reduced survival in pediatric acute lymphoblastic leukemia (ALL). It has been hypothesized that TE might signal leukemic aggressiveness. The objective was to determine risk factors for TE during ALL induction (TEind ) therapy and whether TEind is associated with treatment refractoriness. This retrospective cohort study using the population-based Cancer in Young People Canada (CYP-C) registry included children <15 years of age diagnosed with ALL (2000-2019) and treated at one of 12 Canadian pediatric centers outside of Ontario. Univariate and multivariable logistic regression models were used to determine risk factors for TEind and whether TEind predicted induction failure and ALL treatment intensification. The impact of TEind on overall and event-free survival was estimated using Cox proportional hazard regression models. The study included 2589 children, of which 45 (1.7%) developed a TEind . Age (<1 year and ≥10 years vs. 1-<10 years), T-cell phenotype, high-risk ALL, and central nervous system involvement were all associated with TEind in univariate analysis. Age and T-cell phenotype remained independent predictors of TEind in multivariable analysis. Induction failure occurred in 53 patients (2.1%). TEind was not associated with induction failure (OR: not estimable) or treatment intensification (adjusted OR [95% CI]: 0.66 [0.26-1.69]). TEind was independently associated with overall survival (adjusted HR [95% CI]: 2.54 [1.20-5.03]) but not event-free survival (adjusted HR [95% CI] 1.86 [0.98-3.51]). In this population-based study of children treated with contemporary chemotherapy protocols, TEind was associated with age and T-cell phenotype and mortality but did not predict induction failure.
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Affiliation(s)
| | - Ketan Kulkarni
- Division of Hematology-Oncology, Department of Pediatrics, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Thai Hoa Tran
- Division of Pediatric Hematology-Oncology, Charles-Bruneau Cancer Center, CHU Sainte-Justine, Montréal, Quebec, Canada
- Axis of Immune Diseases and Cancer, CHU Sainte-Justine Research Center, Montréal, Quebec, Canada
| | - David Stammers
- Division of Immunology, Hematology, Oncology& Palliative Care, Stollery's Children Hospital, Edmonton, Alberta, Canada
| | - Sumit Gupta
- Division of Hematology-Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Program in Child Health Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, Toronto, Ontario, Canada
| | - Lillian Sung
- Division of Hematology-Oncology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Program in Child Health Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, Toronto, Ontario, Canada
| | - Uma H Athale
- Division of Haematology/Oncology, McMaster Children's Hospital, and Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
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Costa J, Araújo A. The Contribution of Inherited Thrombophilia to Venous Thromboembolism in Cancer Patients. Clin Appl Thromb Hemost 2024; 30:10760296241232864. [PMID: 38442893 PMCID: PMC10916497 DOI: 10.1177/10760296241232864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 01/21/2024] [Accepted: 01/31/2024] [Indexed: 03/07/2024] Open
Abstract
Although the relationship between venous thromboembolism (VTE) and cancer has been a subject of study, knowledge of the contribution of thrombophilia to thrombosis in patients with cancer is still very limited. The aim of this article is to collect present knowledge on the contribution of inherited thrombophilia to VTE in cancer patients. We performed a search in Google Scholar and PubMed and selected 21 from 76 returned articles. Then we made a narrative review of the selected articles. We describe 11 studies on the contribution of inherited thrombophilia to VTE in cancer patients in general and 10 on that contribution in specific types of cancer: 1 in colorectal cancer, 4 in breast cancer, 1 in gynecologic cancer and 4 in hematopoietic malignancies. All studies investigate the relation of factor V Leiden (FVL) to VTE, 13 that of the prothrombin G20210A mutation (PTG20210A) and 7 studies also investigate other inherited thrombophilias, such methylenetetrahydrofolate reductase gene mutations, although only 2 investigate the contribution of deficiencies of the natural anticoagulants. Studies are very heterogeneous, in design and sample size and conclusions differ considerably. There is no consensus on the contribution of inherited thrombophilia to VTE in cancer patients except for acute lymphoblastic leukemia in children. Probably, that contribution is not the same for all types of cancer and more studies are needed to bring more knowledge on this subject.
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Affiliation(s)
- José Costa
- Department of Hematology and Transfusion Medicine, Centro Hospitalar de Trás-os-Montes e Alto Douro
- School of Medicine and Biomedical Sciences – ICBAS, University of Porto
| | - António Araújo
- School of Medicine and Biomedical Sciences – ICBAS, University of Porto
- Department of Medical Oncology, Centro Hospitalar Universitário de Santo António
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Zheng Y, Yang W, Estepp J, Pei D, Cheng C, Takemoto CM, Inaba H, Jeha S, Pui CH, Relling MV, Karol SE. Genomic analysis of venous thrombosis in children with acute lymphoblastic leukemia from diverse ancestries. Haematologica 2024; 109:53-59. [PMID: 37408475 PMCID: PMC10772501 DOI: 10.3324/haematol.2022.281582] [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: 01/22/2023] [Accepted: 06/29/2023] [Indexed: 07/07/2023] Open
Abstract
Venous thrombosis is a common adverse effect of modern therapy for acute lymphoblastic leukemia (ALL). Prior studies to identify risks of thrombosis in pediatric ALL have been limited by genetic screens of pre-identified genetic variants or genome- wide association studies (GWAS) in ancestrally uniform populations. To address this, we performed a retrospective cohort evaluation of thrombosis risk in 1,005 children treated for newly diagnosed ALL. Genetic risk factors were comprehensively evaluated from genome-wide single nucleotide polymorphism (SNP) arrays and were evaluated using Cox regression adjusting for identified clinical risk factors and genetic ancestry. The cumulative incidence of thrombosis was 7.8%. In multivariate analysis, older age, T-lineage ALL, and non-O blood group were associated with increased thrombosis while non-low-risk treatment and higher presenting white blood cell count trended toward increased thrombosis. No SNP reached genome-wide significance. The SNP most strongly associated with thrombosis was rs2874964 near RFXAP (G risk allele; P=4x10-7; hazard ratio [HR] =2.8). In patients of non-European ancestry, rs55689276 near the α globin cluster (P=1.28x10-6; HR=27) was most strongly associated with thrombosis. Among GWAS catalogue SNP reported to be associated with thrombosis, rs2519093 (T risk allele, P=4.8x10-4; HR=2.1), an intronic variant in ABO, was most strongly associated with risk in this cohort. Classic thrombophilia risks were not associated with thrombosis. Our study confirms known clinical risk features associated with thrombosis risk in children with ALL. In this ancestrally diverse cohort, genetic risks linked to thrombosis risk aggregated in erythrocyte-related SNP, suggesting the critical role of this tissue in thrombosis risk.
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Affiliation(s)
| | | | - Jeremie Estepp
- Departments of Global Pediatric Medicine; Departments of Hematology
| | | | | | | | - Hiroto Inaba
- Departments of Oncology. St. Jude Children's Research Hospital, Memphis, TN
| | - Sima Jeha
- Departments of Global Pediatric Medicine; Departments of Oncology. St. Jude Children's Research Hospital, Memphis, TN
| | - Ching-Hon Pui
- Departments of Oncology. St. Jude Children's Research Hospital, Memphis, TN
| | | | - Seth E Karol
- Departments of Oncology. St. Jude Children's Research Hospital, Memphis, TN.
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Đordević A, Grahovac B, Šegulja S, Bilić Zulle L, Roganović J. Inherited Thrombophilia and Risk of Thrombosis in Children with Cancer: a Single-center Experience. Acta Med Acad 2023; 52:161-168. [PMID: 38407082 PMCID: PMC10945322 DOI: 10.5644/ama2006-124.430] [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: 11/21/2023] [Accepted: 12/29/2023] [Indexed: 02/27/2024] Open
Abstract
OBJECTIVES Thrombosis is an increasingly recognized complication of childhood malignancy and its treatment. The incidence and etiology of pediatric cancer-related thrombosis is still not well understood. The aim of this study was to evaluate the prevalence of common prothrombotic genetic conditions in children with cancer, the frequency of thrombosis, and the role of inherited thrombophilia in the development of thrombosis in a pediatric oncology population. PATIENTS AND METHODS Forty-seven children (36 treated for hematological malignancies and 11 for solid tumors) with a median age of 8.8. years (range 0.4 - 19.3 years) were included in the study. Genetic polymorphisms of Factor V Leiden (G1691A), prothrombin G20210A, and methylenetetrahydrofolate reductase (MTHFR) C677T were determined by real-time polymerase chain reaction-based DNA analysis. RESULTS Four (8.5%) patients were heterozygous for Factor V Leiden, 3 (6.4%) were heterozygous for prothrombin G20210A mutation, and 3 (6.4%) were homozygous for MTHFR C677T mutation. All patients had implanted central venous catheters. Four (8.5%) children had documented thrombosis, three of which were in the upper venous system. Two of the four patients with thrombosis had Factor V Leiden heterozygosity. CONCLUSIONS Thrombosis is an important complication of childhood cancer. The risk of thrombosis may be increased in patients with Factor V Leiden. In the absence of consensus guidelines, our results support the recommendation for thrombophilia screening in children with cancer.
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Affiliation(s)
- Ana Đordević
- Department of Chemical and Pharmaceutical Sciences, University of Trieste, Trieste, Italy; Jadran-galenski laboratorij d.d., Rijeka, Croatia
| | - Blaženka Grahovac
- Department of Pathology, Faculty of Medicine, University of Rijeka, Rijeka, Croatia
| | - Silvije Šegulja
- Faculty of Health Studies, University of Rijeka, Rijeka, Croatia
| | - Lidija Bilić Zulle
- Department of Medical Informatics, Faculty of Medicine, University of Rijeka, Rijeka, Croatia; Clinical Institute for Laboratory Diagnostics, Clinical Hospital Center Rijeka, Rijeka, Croatia
| | - Jelena Roganović
- Department of Pediatrics, Faculty of Medicine, University of Rijeka, Rijeka, Croatia; Division of Hematology and Oncology, Department of Pediatrics, Clinical Hospital Center Rijeka, Rijeka, Croatia. ;
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Laumann RD, Pedersen LL, Andrés-Jensen L, Mølgaard C, Schmiegelow K, Frandsen TL, Als-Nielsen B. Hyperlipidemia in children and adolescents with acute lymphoblastic leukemia: A systematic review and meta-analysis. Pediatr Blood Cancer 2023; 70:e30683. [PMID: 37776083 DOI: 10.1002/pbc.30683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/25/2023] [Accepted: 09/07/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND The established association between acute lymphoblastic leukemia (ALL) and hyperlipidemia has, in some studies, been linked to toxicities such as pancreatitis, thrombosis, and osteonecrosis. However, a systematic review investigating the incidence, management, and clinical implications of hyperlipidemia during childhood ALL treatment is lacking. OBJECTIVES Systematically assess the incidence of hyperlipidemia during ALL treatment, explore associations with risk factors and severe toxicities (osteonecrosis, thrombosis, and pancreatitis), and review prevalent management strategies. METHODS A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Data synthesis was descriptive, and a meta-analysis of hypertriglyceridemia and risk of severe toxicities was performed. RESULTS We included 13 studies with 3,425 patients. Hyperlipidemia incidence varied widely (6.7%-85%) but with inconsistent definitions and screening strategies across studies. Evidence regarding risk factors was conflicting, but age (> 10 years) and treatment with asparaginase and glucocorticosteroids seem to be associated with hyperlipidemia. Hypertriglyceridemia (grade 3/4) increased the risk for osteonecrosis (odds ratio (OR): 4.27, 95% confidence interval (CI): 2.77-6.61). No association could be established for pancreatitis (OR: 1.60, 95% CI: 0.53-4.82) or thrombosis (OR: 2.45, 95% CI: 0.86-7.01), but larger studies are needed to confirm this. CONCLUSION The overall evidence of this systematic review is limited by the small number of studies and risk of bias. Our review suggests that hypertriglyceridemia increases the risk for osteonecrosis. However, larger studies are needed to explore the clinical implications of hyperlipidemia and randomized trials investigating hyperlipidemia management and its impact on severe toxicities.
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Affiliation(s)
- Renate Dagsdottir Laumann
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Louise Lindkvist Pedersen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Liv Andrés-Jensen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Christian Mølgaard
- Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
- Pediatric Nutrition Unit, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Leth Frandsen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Bodil Als-Nielsen
- Department of Pediatrics and Adolescent Medicine, University Hospital Rigshospitalet, Copenhagen, Denmark
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Athale UH, Flamand Y, Blonquist T, Stevenson KE, Spira M, Asselin BL, Clavell LA, Cole PD, Kelly KM, Laverdiere C, Leclerc JM, Michon B, Schorin MA, Welch JJG, Harris MH, Neuberg DS, Sallan SE, Silverman LB. Predictors of thrombosis in children receiving therapy for acute lymphoblastic leukemia: Results from Dana-Farber Cancer Institute ALL Consortium trial 05-001. Pediatr Blood Cancer 2022; 69:e29581. [PMID: 35316569 DOI: 10.1002/pbc.29581] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 12/20/2021] [Accepted: 01/06/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND/OBJECTIVES Although thromboembolism (TE) is a serious complication in patients with acute lymphoblastic leukemia (ALL), thromboprophylaxis is not commonly used due to the inherent bleeding risk in this population. Identifying prothrombotic risk factors will help target thromboprophylaxis to those at highest thrombotic risk. We aimed to define predictors and the impact of TE on ALL outcome in children (1-18 years) treated on the Dana-Farber Cancer Institute ALL 05-001 trial. METHODS Clinical and laboratory data including TE events were prospectively collected. PCR-based allelic discrimination assay identified single-nucleotide polymorphisms (SNP) for prothrombin G20210A (rs1799963) and Factor V G1691A (rs6025). Univariate and multivariable competing risk regression models evaluated the effect of diagnostic clinical (age, sex, body mass index, ALL-immunophenotype, risk group) and laboratory variables (presenting leukocyte count, blood group, SNPs) on the cumulative incidence of TE. Cox regression modeling explored the impact of TE on survival. RESULTS Of 794 patients [median age 4.97 (range, 1.04-17.96) years; males 441], 100 developed TE; 25-month cumulative incidence 13.0% (95% CI, 10.7%-15.5%). Univariate analyses identified older age (≥10 years), presenting leucocyte count, T-ALL, high-risk ALL, and non-O blood group as risk factors. Age and non-O blood group were independent predictors of TE on multivariable regression; the blood group impact being most evident in patients 1-5 years of age (P = 0.011). TE did not impact survival. Induction TE was independently associated with induction failure (OR 6.45; 95% CI, 1.64-25.47; P = 0.008). CONCLUSION We recommend further evaluation of these risk factors and consideration of thromboprophylaxis for patients ≥10 years (especially those ≥15 years) when receiving asparaginase.
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Affiliation(s)
- Uma H Athale
- Division of Hematology/Oncology, McMaster Children's Hospital, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Yael Flamand
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Traci Blonquist
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Kristen E Stevenson
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Menachem Spira
- Department of Pediatrics, New York-Presbyterian Hospital, New York, New York
| | - Barbara L Asselin
- Department of Pediatrics, University of Rochester Medical Center and School of Medicine, Rochester, New York
| | | | - Peter D Cole
- Division of Pediatric Hematology/Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Kara M Kelly
- Roswell Park Comprehensive Cancer Center, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York
| | - Caroline Laverdiere
- Hematology-Oncology Division, Charles Bruneau Cancer Center, Sainte-Justine University Hospital, University of Montreal, Montreal, Quebec, Canada
| | - Jean-Marie Leclerc
- Hematology-Oncology Division, Charles Bruneau Cancer Center, Sainte-Justine University Hospital, University of Montreal, Montreal, Quebec, Canada
| | - Bruno Michon
- Centre Hospitalier Universitaire de Quebec, Sainte-Foy, Quebec, Canada
| | | | - Jennifer J G Welch
- Pediatric Hematology Oncology, Hasbro Children's Hospital/Brown University, Providence, Rhode Island
| | - Marian H Harris
- Department of Pathology, Boston Children's Hospital, Boston, Massachusetts
| | - Donna S Neuberg
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Stephen E Sallan
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Division of Pediatric Hematology-Oncology, Boston Children's Hospital, Boston, Massachusetts
| | - Lewis B Silverman
- Department of Pediatric Oncology, Dana-Farber Cancer Institute and Division of Pediatric Hematology-Oncology, Boston Children's Hospital, Boston, Massachusetts
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Pelland‐Marcotte M, Kulkarni K, Athale UH, Pole JD, Brandão LR, Sung L. Thrombosis is associated with worse survival in children with acute lymphoblastic leukemia: A report from CYP-C. Am J Hematol 2021; 96:796-804. [PMID: 33848369 DOI: 10.1002/ajh.26193] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 04/09/2021] [Accepted: 04/12/2021] [Indexed: 01/19/2023]
Abstract
There are conflicting data about whether the development of cancer-associated thrombo-embolism (TE) negatively impacts survival in children. The objective was to determine whether TE during treatment was associated with overall survival (OS) and event-free survival (EFS) in children with acute lymphoblastic leukemia (ALL). We performed a population-based retrospective cohort study using the Cancer in Young People-Canada registry. Children <15 years of age were diagnosed with de novo ALL (2000-2016). The primary exposure variable was radiologically-confirmed thrombo-embolism requiring medical intervention. Multivariable Cox regression models were used to determine the impact of thrombo-embolism on survival, where TE was time-dependent. We included 2006 children (median age: 4 years, 88.5% precursor B-cell ALL). Thrombo-embolism occurred in 113 patients (5.6%), at a median time of 107 days (interquartile range: 35-184 days) after ALL diagnosis. Among standard/low-risk patients, 41/1165 (3.5%) developed TE while among high/very high-risk patients, 72/841 (8.6%) developed TE. Patients with TE had a significantly worse OS (adjusted HR [aHR] of death: 2.61, 95% CI: 1.62-4.22, p < 0.001) and EFS (aHR of an event [death, relapse, second malignancy]: 2.03, 95% CI: 1.35-3.05, p = 0.001), compared with patients without TE. No statistically significant difference was seen in standard/low risk ALL for OS and EFS, but TE was associated with a significantly lower OS and EFS in children with high/very high-risk ALL (aHR of death: 2.90, 95% CI: 1.79-4.72, p < 0.001; aHR of an event: 2.02, 95% CI: 1.30-3.12, p = 0.002). Thus, TE led to a statistically significant reduction in OS and EFS in children with high risk/very high-risk leukemia.
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Affiliation(s)
| | - Ketan Kulkarni
- Division of Hematology‐Oncology, Department of Pediatrics IWK Health Centre Halifax Nova Scotia Canada
| | - Uma H. Athale
- Division of Haematology/Oncology, McMaster Children's Hospital, and Department of Pediatrics McMaster University Hamilton Ontario Canada
| | - Jason D. Pole
- Centre for Health Services Research University of Queensland Herston Queensland Australia
| | - Leonardo R. Brandão
- Division of Haematology/Oncology, Department of Paediatrics SickKids Hospital Toronto Ontario Canada
- Program in Child Health Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning Toronto Ontario Canada
- Dalla Lana School of Public Health, University of Toronto Toronto Ontario Canada
| | - Lillian Sung
- Division of Haematology/Oncology, Department of Paediatrics SickKids Hospital Toronto Ontario Canada
- Program in Child Health Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning Toronto Ontario Canada
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