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Rujkijyanont P, Inaba H. Diagnostic and treatment strategies for pediatric acute lymphoblastic leukemia in low- and middle-income countries. Leukemia 2024:10.1038/s41375-024-02277-9. [PMID: 38762553 DOI: 10.1038/s41375-024-02277-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 04/30/2024] [Accepted: 05/02/2024] [Indexed: 05/20/2024]
Abstract
The survival rate of children and adolescents with acute lymphoblastic leukemia (ALL), the most common pediatric cancer, has improved significantly in high-income countries (HICs), serving as an excellent example of how humans can overcome catastrophic diseases. However, the outcomes in children with ALL in low- and middle-income countries (LMICs), where approximately 80% of the global population live, are suboptimal because of limited access to diagnostic procedures, chemotherapeutic agents, supportive care, and financial assistance. Although the implementation of therapeutic strategies in resource-limited countries could theoretically follow the same path of improvement as modeled in HICs, intensification of chemotherapy may simply result in increased toxicities. With the advent of genetic diagnosis, molecular targeted therapy, and immunotherapy, the management of ALL is changing dramatically in HICs. Multidisciplinary collaborations between institutions in LMICs and HICs will provide access to strategies that are suitable for institutions in LMICs, enabling them to minimize toxicities while improving outcomes. This article summarizes important aspects of the diagnosis and treatment of pediatric ALL that were mostly developed in HICs but that can be realistically implemented by institutions in countries with limited resources through resource-adapted multidisciplinary collaborations.
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Affiliation(s)
- Piya Rujkijyanont
- Division of Hematology-Oncology, Department of Pediatrics, Phramongkutklao Hospital and Phramongkutklao College of Medicine, Bangkok, Thailand
| | - Hiroto Inaba
- Leukemia/Lymphoma Division, Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA.
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA.
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2
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Chen J, Gale RP, Hu Y, Yan W, Wang T, Zhang W. Measurable residual disease (MRD)-testing in haematological and solid cancers. Leukemia 2024:10.1038/s41375-024-02252-4. [PMID: 38637690 DOI: 10.1038/s41375-024-02252-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 04/06/2024] [Accepted: 04/09/2024] [Indexed: 04/20/2024]
Affiliation(s)
- Junren Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.
- Tianjin Institutes of Health Science, Tianjin, China.
| | - Robert Peter Gale
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College of Science, Technology and Medicine, London, UK
| | - Yu Hu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Wen Yan
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Tiantian Wang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Wei Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
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3
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Gong X, Hu T, Shen Q, Zhang L, Zhang W, Liu X, Zong S, Li X, Wang T, Yan W, Hu Y, Chen X, Zheng J, Zhang A, Wang J, Feng Y, Li C, Ma J, Gao X, Song Z, Zhang Y, Gale RP, Zhu X, Chen J. Gene expression prognostic of early relapse risk in low-risk B-cell acute lymphoblastic leukaemia in children. EJHaem 2024; 5:333-345. [PMID: 38633121 PMCID: PMC11020147 DOI: 10.1002/jha2.872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 02/21/2024] [Indexed: 04/19/2024]
Abstract
ETV6::RUNX1 is the most common fusion gene in childhood acute lymphoblastic leukaemia (ALL) and is associated with favorable outcomes, especially in low-risk children. However, as many as 10% of children relapse within 3 years, and such early relapses have poor survival. Identifying children at risk for early relapse is an important challenge. We interrogated data from 87 children with low-risk ETV6::RUNX1-positive B-cell ALL and with available preserved bone marrow samples (discovery cohort). We profiled somatic point mutations in a panel of 559 genes and genome-wide transcriptome and single-nucleotide variants. We found high TIMD4 expression (> 85th-percentile value) at diagnosis was the most important independent prognostic factor of early relapse (hazard ratio [HR] = 5.07 [1.76, 14.62]; p = 0.03). In an independent validation cohort of low-risk ETV6::RUNX1-positive B-cell ALL (N = 68) high TIMD4 expression at diagnosis had an HR = 4.78 [1.07, 21.36] (p = 0.04) for early relapse. In another validation cohort including 78 children with low-risk ETV6::RUNX1-negative B-cell ALL, high TIMD4 expression at diagnosis had an HR = 3.93 [1.31, 11.79] (p = 0.01). Our results suggest high TIMD4 expression at diagnosis in low-risk B-cell ALL in children might be associated with high risk for early relapse.
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Dam M, Centanni M, Friberg LE, Centanni D, Karlsson MO, Stensig Lynggaard L, Johannsdottir IM, Wik HS, Malmros J, Vaitkeviciene GE, Griskevicius L, Hallböök H, Jónsson ÓG, Overgaard U, Schmiegelow K, Hansen SN, Heyman M, Albertsen BK. Increase in peg-asparaginase clearance as a predictor for inactivation in patients with acute lymphoblastic leukemia. Leukemia 2024; 38:712-719. [PMID: 38287133 PMCID: PMC10997509 DOI: 10.1038/s41375-024-02153-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 01/05/2024] [Accepted: 01/10/2024] [Indexed: 01/31/2024]
Abstract
Asparaginase is an essential component of acute lymphoblastic leukemia (ALL) therapy, yet its associated toxicities often lead to treatment discontinuation, increasing the risk of relapse. Hypersensitivity reactions include clinical allergies, silent inactivation, or allergy-like responses. We hypothesized that even moderate increases in asparaginase clearance are related to later inactivation. We therefore explored mandatory monitoring of asparaginase enzyme activity (AEA) in patients with ALL aged 1-45 years treated according to the ALLTogether pilot protocol in the Nordic and Baltic countries to relate mean AEA to inactivation, to build a pharmacokinetic model to better characterize the pharmacokinetics of peg-asparaginase and assess whether an increased clearance relates to subsequent inactivation. The study analyzed 1631 real-time AEA samples from 253 patients, identifying inactivation in 18.2% of the patients. This inactivation presented as mild allergy (28.3%), severe allergy (50.0%), or silent inactivation (21.7%). A pharmacokinetic transit compartment model was used to describe AEA-time profiles, revealing that 93% of patients with inactivation exhibited prior increased clearance, whereas 86% of patients without hypersensitivity maintained stable clearance throughout asparaginase treatment. These findings enable prediction of inactivation and options for either dose increments or a shift to alternative asparaginase formulations to optimize ALL treatment strategies.
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Affiliation(s)
- Merete Dam
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Lena E Friberg
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | | | | | - Line Stensig Lynggaard
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | | | - Johan Malmros
- Astrid Lindgren Children's Hospital, Karolinska University Hospital and Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | | | | | - Helene Hallböök
- Dept Of Medical Sciences, Haematology, Uppsala University, Uppsala, Sweden
| | | | - Ulrik Overgaard
- Department of Haematology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Kjeld Schmiegelow
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - Mats Heyman
- Astrid Lindgren Children's Hospital, Karolinska University Hospital and Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Birgitte Klug Albertsen
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark.
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
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Brigitha LJ, Mondelaers V, Liu Y, Albertsen BK, Zalewska-Szewczyk B, Rizzari C, Kotecha RS, Pieters R, Huitema ADR, van der Sluis IM. Pharmacokinetics of PEGasparaginase in Infants with Acute Lymphoblastic Leukemia. Pharm Res 2024; 41:711-720. [PMID: 38538970 DOI: 10.1007/s11095-024-03693-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 03/14/2024] [Indexed: 04/18/2024]
Abstract
BACKGROUND PEGasparaginase is known to be a critical drug for treating pediatric acute lymphoblastic leukemia (ALL), however, there is insufficient evidence to determine the optimal dose for infants who are less than one year of age at diagnosis. This international study was conducted to identify the pharmacokinetics of PEGasparaginase in infants with newly diagnosed ALL and gather insight into the clearance and dosing of this population. METHODS Infants with ALL who received treatment with PEGasparaginase were included in our population pharmacokinetic assessment employing non-linear mixed effects modelling (NONMEM). RESULTS 68 infants with ALL, with a total of 388 asparaginase activity samples, were included. PEGasparaginase doses ranging from 400 to 3,663 IU/m2 were administered either intravenously or intramuscularly. A one-compartment model with time-dependent clearance, modeled using a transit model, provided the best fit to the data. Body weight was significantly correlated with clearance and volume of distribution. The final model estimated a half-life of 11.7 days just after administration, which decreased to 1.8 days 14 days after administration. Clearance was 19.5% lower during the post-induction treatment phase compared to induction. CONCLUSION The pharmacokinetics of PEGasparaginase in infants diagnosed under one year of age with ALL is comparable to that of older children (1-18 years). We recommend a PEGasparaginase dosing at 1,500 IU/m2 for infants without dose adaptations according to age, and implementing therapeutic drug monitoring as standard practice.
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Affiliation(s)
- Leiah J Brigitha
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, Netherlands
- Pediatric Oncology and Hematology, Erasmus MC-Sophia Children's Hospital, Dr. Molewaterplein 40, 3015 GD, Rotterdam, Netherlands
| | - Veerle Mondelaers
- Department of Pediatric Hematology-Oncology and Stem Cell Transplantation, Ghent University Hospital, Ghent University, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Yiwei Liu
- Department of Bioinformatics and Computational Biology, the University of Texas MD Anderson Cancer Center, Houston, USA
| | - Birgitte K Albertsen
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200, Aarhus, Denmark
| | - Beata Zalewska-Szewczyk
- Department of Pediatrics, Medical University of Lodz, Oncology & Hematology, 91-738, Lodz, Poland
| | - Carmelo Rizzari
- Department of Pediatrics, University of Milano-Bicocca, Piazza Dell'Ateneo Nuovo, 1, Milano, Italy
- Fondazione IRCCS San Gerardo Dei Tintori, Via G.B. Pergolesi 33, Monza, Italy
| | - Rishi S Kotecha
- Department of Clinical Haematology, Oncology, Blood and Marrow Transplantation, Perth Children's Hospital, Perth, Australia
- Leukaemia Translational Research Laboratory, Telethon Kids Cancer Centre, Telethon Kids Institute, University of Western Australia, Perth, Australia
- Curtin Medical School, Curtin University, Perth, Australia
| | - Rob Pieters
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, Netherlands
| | - Alwin D R Huitema
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, Netherlands
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
- Department of Pharmacy & Pharmacology, Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
| | - Inge M van der Sluis
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584 CS, Utrecht, Netherlands.
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Liu HC, Huang YJ, Jaing TH, Wu KH, Chen SH, Wang SC, Yeh TC, Hsiao CC, Chang TK, Yen HJ, Huang FL, Lin PC, Hou JY, Sheen JM, Liao YM, Chang TY, Chen YC, Chiou SS, Yang CP, Pui CH, Liang DC, Shih LY. Refining risk stratification in paediatric B-acute lymphoblastic leukaemia: Combining IKZF1 plus and Day 15 MRD positivity. Br J Haematol 2024; 204:1344-1353. [PMID: 38479427 DOI: 10.1111/bjh.19338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 01/29/2024] [Accepted: 02/01/2024] [Indexed: 04/11/2024]
Abstract
This study investigates the potential utility of IKZF1 deletion as an additional high-risk marker for paediatric acute lymphoblastic leukaemia (ALL). The prognostic impact of IKZF1 status, in conjunction with minimal/measurable residual disease (MRD), was evaluated within the MRD-guided TPOG-ALL-2013 protocol using 412 newly diagnosed B-ALL patients aged 1-18. IKZF1 status was determined using multiplex ligation-dependent probe amplification. IKZF1 deletions, when co-occurring with CDKN2A, CDKN2B, PAX5 or PAR1 region deletions in the absence of ERG deletions, were termed IKZF1plus. Both IKZF1 deletion (14.6%) and IKZF1plus (7.8%) independently predicted poorer outcomes in B-ALL. IKZF1plus was observed in 4.1% of Philadelphia-negative ALL, with a significantly lower 5-year event-free survival (53.9%) compared to IKZF1 deletion alone (83.8%) and wild-type IKZF1 (91.3%) (p < 0.0001). Among patients with Day 15 MRD ≥0.01%, provisional high-risk patients with IKZF1plus exhibited the worst outcomes in event-free survival (42.0%), relapse-free survival (48.0%) and overall survival (72.7%) compared to other groups (p < 0.0001). Integration of IKZF1plus and positive Day 15 MRD identified a subgroup of Philadelphia-negative B-ALL with a 50% risk of relapse. This study highlights the importance of assessing IKZF1plus alongside Day 15 MRD positivity to identify patients at increased risk of adverse outcomes, potentially minimizing overtreatment.
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Affiliation(s)
- Hsi-Che Liu
- Department of Hematology-Oncology, MacKay Children's Hospital and MacKay Medical College, Taipei, Taiwan
| | - Ying-Jung Huang
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Tang-Her Jaing
- Department of Hematology-Oncology, Chang Gung Children's Hospital at Linkou, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Kang-Hsi Wu
- Department of Pediatrics, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Shih-Hsiang Chen
- Department of Hematology-Oncology, Chang Gung Children's Hospital at Linkou, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shih-Chung Wang
- Division of Pediatric Hematology-Oncology, Changhua Christian Children's Hospital, Changhua, Taiwan
| | - Ting-Chi Yeh
- Department of Hematology-Oncology, MacKay Children's Hospital and MacKay Medical College, Taipei, Taiwan
| | - Chih-Cheng Hsiao
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Pediatrics, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan
| | - Te-Kau Chang
- Division of Pediatric Hematology and Oncology, China Medical University Children's Hospital, Taichung, Taiwan
| | - Hsiu-Ju Yen
- Department of Pediatrics, Taipei Veterans General Hospital and School of Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
| | - Fang-Liang Huang
- Department of Pediatrics, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Pei-Chin Lin
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Jen-Yin Hou
- Department of Hematology-Oncology, MacKay Children's Hospital and MacKay Medical College, Taipei, Taiwan
| | - Jiunn-Ming Sheen
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Pediatrics, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan
- Department of Pediatrics, Chang Gung Memorial Hospital at Chiayi, Chiayi, Taiwan
| | - Yu-Mei Liao
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Tsung-Yen Chang
- Department of Hematology-Oncology, Chang Gung Children's Hospital at Linkou, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yu-Chieh Chen
- Department of Pediatrics, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan
| | - Shyh-Shin Chiou
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Chao-Ping Yang
- Department of Hematology-Oncology, Chang Gung Children's Hospital at Linkou, Taoyuan, Taiwan
| | - Ching-Hon Pui
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
- University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Der-Cherng Liang
- Department of Hematology-Oncology, MacKay Children's Hospital and MacKay Medical College, Taipei, Taiwan
| | - Lee-Yung Shih
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
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Egset KS, Stubberud J, Ruud E, Hjort MA, Eilertsen MEB, Sund AM, Hjemdal O, Weider S, Reinfjell T. Neurocognitive outcome and associated factors in long-term, adult survivors of childhood acute lymphoblastic leukemia, treated without cranial radiation therapy. J Int Neuropsychol Soc 2024:1-10. [PMID: 38465668 DOI: 10.1017/s1355617724000080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
OBJECTIVE There is limited research on neurocognitive outcome and associated risk factors in long-term, adult survivors of childhood acute lymphoblastic leukemia (ALL), without treatment of cranial radiation therapy. Moreover, the impact of fatigue severity and pain interference on neurocognition has received little attention. In this cross-sectional study, we examined neurocognitive outcome and associated factors in this population. METHOD Intellectual abilities, verbal learning/memory, processing speed, attention, and executive functions were compared to normative means/medians with one sample t tests or Wilcoxon signed-rank tests. Associations with risk factors, fatigue severity, and pain interference were analyzed with linear regressions. RESULTS Long-term, adult survivors of childhood ALL (N = 53, 51% females, mean age = 24.4 years, SD = 4.4, mean = 14.7 years post-diagnosis, SD = 3.4) demonstrated above average intellectual abilities, but performed below average in attention, inhibition, processing speed, and shifting (p < 0.001). Executive functioning complaints were significantly higher than normative means, and positively associated with fatigue (p < 0.001). There was no interaction between sex and fatigue and no neurocognitive impairments were associated with pain interference, risk group, age at diagnosis, or sex. CONCLUSIONS Long-term, adult survivors of ALL treated without cranial radiation therapy, demonstrate domain-specific performance-based neurocognitive impairments. However, continued research on the neurocognitive outcome in this population as they age will be important in the coming years. Executive functioning complaints were frequently in the clinical range, and often accompanied by fatigue. This suggests a need for cognitive rehabilitation programs.
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Affiliation(s)
- Kaja Solland Egset
- Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway
| | - Jan Stubberud
- Department of Psychology, University of Oslo, Oslo, Norway
- Department of Research, Lovisenberg Diaconal Hospital, Oslo, Norway
| | - Ellen Ruud
- Division for Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Magnus Aassved Hjort
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Children's Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Mary-Elizabeth Bradley Eilertsen
- Department of Public Health and Nursing, Center for Health Promotion Research, Norwegian University of Science and Technology, Trondheim, Norway
| | - Anne Mari Sund
- Regional Centre for Child and Youth Mental Health and Child Welfare, Norwegian University of Science and Technology, Trondheim, Norway
| | - Odin Hjemdal
- Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway
| | - Siri Weider
- Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway
| | - Trude Reinfjell
- Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway
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Hayashi H, Makimoto A, Yuza Y. Treatment of Pediatric Acute Lymphoblastic Leukemia: A Historical Perspective. Cancers (Basel) 2024; 16:723. [PMID: 38398113 PMCID: PMC10887299 DOI: 10.3390/cancers16040723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 02/06/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
Acute lymphoblastic leukemia (ALL) is the most common disease in pediatric oncology. The history of developmental therapeutics for ALL began in the 1960s with the repetition of "unreliable" medical interventions against this lethal disease. By the 1990s, the development of multi-agent chemotherapy and various types of supportive care rendered ALL treatable. Highly sophisticated, molecular, diagnostic techniques have enabled highly accurate prediction of the relapse risk, and the application of risk-adapted treatments has increased the survival rate in the standard-risk group to nearly 100% in most European nations and North America. Incorporation of state-of-the-art, molecularly targeted agents and novel treatments, including cell and immunotherapy, is further improving outcomes even in the high-risk group. On the other hand, the financial burden of treating children with ALL has increased, imperiling the availability of these diagnostic and treatment strategies to patients in low- and middle-income countries (LMICs). The fundamental treatment strategy, consisting of corticosteroid and classical cytotoxic therapy, has achieved fairly good outcomes and should be feasible in LMICs as well. The present review will discuss the history of developmental therapeutics for childhood ALL in various countries through an extensive literature review with the aim of proposing a model for a treatment backbone for pediatric ALL. The discussion will hopefully benefit LMICs and be useful as a base for future clinical trials of novel treatments.
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Affiliation(s)
- Hiroshi Hayashi
- Department of Hematology/Oncology, Tokyo Metropolitan Children’s Medical Center, 2-8-29 Musashidai, Fuchu 183-8561, Tokyo, Japan; (A.M.); (Y.Y.)
| | - Atsushi Makimoto
- Department of Hematology/Oncology, Tokyo Metropolitan Children’s Medical Center, 2-8-29 Musashidai, Fuchu 183-8561, Tokyo, Japan; (A.M.); (Y.Y.)
- Department of Laboratory Medicine, Tokyo Metropolitan Children’s Medical Center, 2-8-29 Musashidai, Fuchu 183-8561, Tokyo, Japan
| | - Yuki Yuza
- Department of Hematology/Oncology, Tokyo Metropolitan Children’s Medical Center, 2-8-29 Musashidai, Fuchu 183-8561, Tokyo, Japan; (A.M.); (Y.Y.)
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9
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Onerup A, Mirzaei S S, Wogksch MD, Goodenough CG, Lambert G, Sapkota Y, Mulrooney DA, Hudson MM, Jacola LM, Ness KK. Movement efficiency in survivors of childhood acute lymphoblastic leukemia: a report from the St. Jude lifetime cohort study. J Cancer Surviv 2024:10.1007/s11764-024-01550-1. [PMID: 38308806 DOI: 10.1007/s11764-024-01550-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 01/30/2024] [Indexed: 02/05/2024]
Abstract
PURPOSE Movement efficiency, a measure of neuromuscular biomechanics, may be modified by physical activity. We aimed to assess the risk of and risk factors for low movement efficiency in survivors of childhood acute lymphoblastic leukemia (ALL). METHODS Participants underwent an assessment of activity energy expenditure (AEE) with actigraphy, and the gold standard doubly labeled water, where the differences between elimination rates of oxygen and hydrogen from body water are evaluated over a week. Movement efficiency was assessed using the raw residuals of a linear regression between AEEs from accelerometers and doubly labeled water. Elastic-net logistic regressions were used to identify demographic, treatment, and functional variables associated with movement efficiency. RESULTS The study cohort included 256 non-cancer controls and 302 ALL survivors (48% female), categorized as efficient (N = 24), normal (N = 245), or inefficient (N = 33) based on their movement efficiency. There was no difference in the odds for poor movement efficiency between survivors (n = 33, 10.9%) compared to controls (n = 23, 9.0%, odds ratio [OR]: 1.19, 95% confidence interval [CI]: 0.67, 2.10; p = 0.55). In survivors, neuropathy was associated with a higher risk of being inefficient compared to efficient (OR 4.30, 95% CI 1.03-17.96), while obesity (≥ 30 kg/m2) had a protective association (OR 0.18, 95% CI 0.04-0.87). CONCLUSIONS Neuropathy was associated with a higher risk of poor movement efficiency in survivors of childhood ALL. IMPLICATIONS FOR CANCER SURVIVORS These results further highlight impairments associated with treatment-induced neuropathy in survivors of childhood ALL.
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Affiliation(s)
- Aron Onerup
- Department of Epidemiology and Cancer Control, St. Jude Children´s Research Hospital, Memphis, TN, USA.
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Sedigheh Mirzaei S
- Department of Biostatistics, St Jude Children´s Research Hospital, Memphis, TN, USA
| | - Matthew D Wogksch
- Department of Epidemiology and Cancer Control, St. Jude Children´s Research Hospital, Memphis, TN, USA
| | - Chelsea G Goodenough
- Department of Epidemiology and Cancer Control, St. Jude Children´s Research Hospital, Memphis, TN, USA
| | - Genevieve Lambert
- Department of Epidemiology and Cancer Control, St. Jude Children´s Research Hospital, Memphis, TN, USA
| | - Yadav Sapkota
- Department of Epidemiology and Cancer Control, St. Jude Children´s Research Hospital, Memphis, TN, USA
| | - Daniel A Mulrooney
- Department of Epidemiology and Cancer Control, St. Jude Children´s Research Hospital, Memphis, TN, USA
- Department of Oncology, St Jude Children´s Research Hospital, Memphis, TN, USA
| | - Melissa M Hudson
- Department of Epidemiology and Cancer Control, St. Jude Children´s Research Hospital, Memphis, TN, USA
- Department of Oncology, St Jude Children´s Research Hospital, Memphis, TN, USA
| | - Lisa M Jacola
- Department of Psychology, St Jude Children´s Research Hospital, Memphis, TN, USA
| | - Kirsten K Ness
- Department of Epidemiology and Cancer Control, St. Jude Children´s Research Hospital, Memphis, TN, USA
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10
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Chen J. Response to comment on Have we been qualifying measurable residual disease correctly? Leukemia 2024; 38:219-220. [PMID: 37989880 PMCID: PMC10776409 DOI: 10.1038/s41375-023-02088-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 10/31/2023] [Accepted: 11/10/2023] [Indexed: 11/23/2023]
Affiliation(s)
- Junren Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.
- Tianjin Institutes of Health Science, Tianjin, China.
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11
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Liao C, Nie J, Xu XJ, Zhang JY, Xu WQ, Song H, Shen HP, Shen DY, Zhao FY, Liang J, Miao J, Tang YM. The effect of the plasma methotrexate concentration during high-dose methotrexate therapy in childhood acute lymphoblastic leukemia. Leuk Lymphoma 2024; 65:91-99. [PMID: 37820046 DOI: 10.1080/10428194.2023.2266075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 09/27/2023] [Indexed: 10/13/2023]
Abstract
Two hundred and thirty-one acute lymphoblastic leukemia (ALL) children with 1376 high-dose methotrexate (HD-MTX) courses (3-5 g/m2) were enrolled to analyze the influence of the plasma MTX concentration (CMTX) in ALL. The 24-h target peak CMTX (C24h) was set at 33 μmol/l for low-risk (LR) and 65 μmol/l for intermediate/high-risk (IR/HR) groups. The median C24h was 42.0 μmol/l and 69.7 μmol/l for LR and IR/HR groups, respectively. MTX excretion delay was observed in 14.6% of courses, which was more frequent in IR/HR groups (56.9% vs. LR group 40.2%, p = .014) and T-ALL patients (82.6% vs. B-ALL 47.1%, p = .001). MTX-related toxicities were more common in courses with MTX excretion delay. However, survival between the patients who failed to reach the target C24h or not, with or without MTX excretion delay, was comparable. These findings suggest that, owing to the effectiveness of risk stratification chemotherapy, CMTX does not exert an independent influence on the prognosis of childhood ALL.
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Affiliation(s)
- Chan Liao
- Department of Pediatric Hematology-Oncology, Children's Hospital, Zhejiang University School of Medicine, The Pediatric Leukemia Diagnostic and Therapeutic Technology Research Center of Zhejiang Province, National Clinical Research Center for Child Health, Hangzhou, China
| | - Jing Nie
- Department of Pharmacy, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
- Research Center for Clinical Pharmacy, Zhejiang University, Hangzhou, China
| | - Xiao-Jun Xu
- Department of Pediatric Hematology-Oncology, Children's Hospital, Zhejiang University School of Medicine, The Pediatric Leukemia Diagnostic and Therapeutic Technology Research Center of Zhejiang Province, National Clinical Research Center for Child Health, Hangzhou, China
| | - Jing-Ying Zhang
- Department of Pediatric Hematology-Oncology, Children's Hospital, Zhejiang University School of Medicine, The Pediatric Leukemia Diagnostic and Therapeutic Technology Research Center of Zhejiang Province, National Clinical Research Center for Child Health, Hangzhou, China
| | - Wei-Qun Xu
- Department of Pediatric Hematology-Oncology, Children's Hospital, Zhejiang University School of Medicine, The Pediatric Leukemia Diagnostic and Therapeutic Technology Research Center of Zhejiang Province, National Clinical Research Center for Child Health, Hangzhou, China
| | - Hua Song
- Department of Pediatric Hematology-Oncology, Children's Hospital, Zhejiang University School of Medicine, The Pediatric Leukemia Diagnostic and Therapeutic Technology Research Center of Zhejiang Province, National Clinical Research Center for Child Health, Hangzhou, China
| | - He-Ping Shen
- Department of Pediatric Hematology-Oncology, Children's Hospital, Zhejiang University School of Medicine, The Pediatric Leukemia Diagnostic and Therapeutic Technology Research Center of Zhejiang Province, National Clinical Research Center for Child Health, Hangzhou, China
| | - Di-Ying Shen
- Department of Pediatric Hematology-Oncology, Children's Hospital, Zhejiang University School of Medicine, The Pediatric Leukemia Diagnostic and Therapeutic Technology Research Center of Zhejiang Province, National Clinical Research Center for Child Health, Hangzhou, China
| | - Fen-Ying Zhao
- Department of Pediatric Hematology-Oncology, Children's Hospital, Zhejiang University School of Medicine, The Pediatric Leukemia Diagnostic and Therapeutic Technology Research Center of Zhejiang Province, National Clinical Research Center for Child Health, Hangzhou, China
| | - Juan Liang
- Department of Pediatric Hematology-Oncology, Children's Hospital, Zhejiang University School of Medicine, The Pediatric Leukemia Diagnostic and Therapeutic Technology Research Center of Zhejiang Province, National Clinical Research Center for Child Health, Hangzhou, China
| | - Jing Miao
- Department of Pharmacy, Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
- Research Center for Clinical Pharmacy, Zhejiang University, Hangzhou, China
| | - Yong-Min Tang
- Department of Pediatric Hematology-Oncology, Children's Hospital, Zhejiang University School of Medicine, The Pediatric Leukemia Diagnostic and Therapeutic Technology Research Center of Zhejiang Province, National Clinical Research Center for Child Health, Hangzhou, China
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12
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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13
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Suryaprakash S, Inaba H. Acute Lymphoblastic Leukemia with Central Nervous System Involvement-Challenges in Management. Indian J Pediatr 2024; 91:59-66. [PMID: 37507619 DOI: 10.1007/s12098-023-04731-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 06/09/2023] [Indexed: 07/30/2023]
Abstract
The survival of patients with acute lymphoblastic leukemia (ALL) has dramatically improved during the last six decades. This improvement is secondary to improved diagnostics, risk stratification of treatment by biological features and response to treatment, improved supportive care, and the introduction of new treatment modalities such as immunotherapy and molecular targeted therapy. However, many questions remain concerning the involvement of the central nervous system (CNS) in leukemia, including ones pertaining to the risk factors for CNS involvement and relapse, the optimal treatment strategy to prevent relapse, and the role of newer therapies. This review discusses these questions by addressing the diagnosis of CNS leukemia, the current clinical trial data for treatment regimens with CNS activity, and issues specific to treatment in low- and middle-income countries (LMICs).
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Affiliation(s)
- Shruthi Suryaprakash
- Department of Oncology, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Mail Stop 260, Memphis, TN, 38105, USA
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Hiroto Inaba
- Department of Oncology, St. Jude Children's Research Hospital, 262 Danny Thomas Place, Mail Stop 260, Memphis, TN, 38105, USA.
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA.
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14
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Pieters R, Mullighan CG, Hunger SP. Advancing Diagnostics and Therapy to Reach Universal Cure in Childhood ALL. J Clin Oncol 2023; 41:5579-5591. [PMID: 37820294 PMCID: PMC10730082 DOI: 10.1200/jco.23.01286] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 07/24/2023] [Accepted: 08/10/2023] [Indexed: 10/13/2023] Open
Abstract
Systemic combination chemotherapy and intrathecal chemotherapy markedly increased the survival rate of children with ALL. In the past two decades, the use of minimal (measurable) residual disease (MRD) measurements early in therapy improved risk group stratification with subsequent treatment intensifications for patients at high risk of relapse, and enabled a reduction of treatment for low-risk patients. The recent development of more sensitive MRD technologies may further affect risk stratification. Molecular genetic profiling has led to the discovery of many new subtypes and their driver genetic alterations. This increased our understanding of the biological basis of ALL, improved risk classification, and enabled implementation of precision medicine. In the past decade, immunotherapies, including bispecific antibodies, antibody-drug conjugates, and cellular therapies directed against surface proteins, led to more effective and less toxic therapies, replacing intensive chemotherapy courses and allogeneic stem-cell transplantation in patients with relapsed and refractory ALL, and are now being tested in newly diagnosed patients. It has taken 50-60 years to increase the cure rate in childhood ALL from 0% to 90% by stepwise improvements in chemotherapy. This review provides an overview of how the developments over the past 10-15 years mentioned above have significantly changed the diagnostic and treatment approach in ALL, and discusses how the integrated use of molecular and immunotherapeutic insights will very likely direct efforts to cure those children with ALL who are not cured today, and improve the quality of life for survivors who should have decades of life ahead. Future efforts must focus on making effective, yet very expensive, new technologies and therapies available to children with ALL worldwide.
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Affiliation(s)
- Rob Pieters
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Charles G. Mullighan
- Department of Pathology and Hematological Malignancies Program, Comprehensive Cancer Center, St Jude Children's Research Hospital, Memphis, TN
| | - Stephen P. Hunger
- Division of Oncology, Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, PA
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15
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O’Connor D, Joy M, Enshaei A, Kirkwood A, Kearns PR, Samarasinghe S, Moppett J, Moorman AV, Vora A. Cranial radiotherapy has minimal benefit in children with central nervous system involvement in T-ALL. Blood Adv 2023; 7:7231-7234. [PMID: 37824845 PMCID: PMC10698522 DOI: 10.1182/bloodadvances.2023011267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/15/2023] [Accepted: 09/28/2023] [Indexed: 10/14/2023] Open
Affiliation(s)
- David O’Connor
- UCL Cancer Institute, University College London, London, United Kingdom
- Department of Haematology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Melvin Joy
- Wolfson Childhood Cancer Centre, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Amir Enshaei
- Wolfson Childhood Cancer Centre, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Amy Kirkwood
- Cancer Research UK & University College London Cancer Trials Centre, UCL Cancer Institute, University College London, London, United Kingdom
| | - Pamela R. Kearns
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Sujith Samarasinghe
- Department of Haematology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - John Moppett
- Department of Paediatric Oncology, Bristol Royal Hospital for Children, Bristol, United Kingdom
| | - Anthony V. Moorman
- Wolfson Childhood Cancer Centre, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Ajay Vora
- Department of Haematology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
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16
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Lee SH, Ashcraft E, Yang W, Roberts KG, Gocho Y, Rowland L, Inaba H, Karol SE, Jeha S, Crews KR, Mullighan CG, Relling MV, Evans WE, Cheng C, Yang JJ, Pui CH. Prognostic and Pharmacotypic Heterogeneity of Hyperdiploidy in Childhood ALL. J Clin Oncol 2023; 41:5422-5432. [PMID: 37729596 PMCID: PMC10852380 DOI: 10.1200/jco.23.00880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 06/29/2023] [Accepted: 07/26/2023] [Indexed: 09/22/2023] Open
Abstract
PURPOSE High hyperdiploidy, the largest and favorable subtype of childhood ALL, exhibits significant biological and prognostic heterogeneity. However, factors contributing to the varied treatment response and the optimal definition of hyperdiploidy remain uncertain. METHODS We analyzed outcomes of patients treated on two consecutive frontline ALL protocols, using six different definitions of hyperdiploidy: chromosome number 51-67 (Chr51-67); DNA index (DI; DI1.16-1.6); United Kingdom ALL study group low-risk hyperdiploid, either trisomy of chromosomes 17 and 18 or +17 or +18 in the absence of +5 and +20; single trisomy of chromosome 18; double trisomy of chromosomes 4 and 10; and triple trisomy (TT) of chromosomes 4, 10, and 17. Additionally, we characterized ALL ex vivo pharmacotypes across eight main cytotoxic drugs. RESULTS Among 1,096 patients analyzed, 915 had B-ALL and 634 had pharmacotyping performed. In univariate analysis, TT emerged as the most favorable criterion for event-free survival (EFS; 10-year EFS, 97.3% v 86.8%; P = .0003) and cumulative incidence of relapse (CIR; 10-year CIR, 1.4% v 8.8%; P = .002) compared with the remaining B-ALL. In multivariable analysis, accounting for patient numbers using the akaike information criterion (AIC), DI1.16-1.6 was the most favorable criterion, exhibiting the best AIC for both EFS (hazard ratio [HR], 0.45; 95% CI, 0.23 to 0.88) and CIR (HR, 0.45; 95% CI, 0.21 to 0.99). Hyperdiploidy and subgroups with favorable prognoses exhibited notable sensitivities to asparaginase and mercaptopurine. Specifically, asparaginase sensitivity was associated with trisomy of chromosomes 16 and 17, whereas mercaptopurine sensitivity was linked to gains of chromosomes 14 and 17. CONCLUSION Among different definitions of hyperdiploid ALL, DI is optimal based on independent prognostic impact and also the large proportion of low-risk patients identified. Hyperdiploid ALL exhibited particular sensitivities to asparaginase and mercaptopurine, with chromosome-specific associations.
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Affiliation(s)
- Shawn H.R. Lee
- Department of Pharmacy and Pharmaceutical Sciences, St Jude Children's Research Hospital, Memphis, TN
- Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Khoo Teck Puat-National University Children's Medical Institute, National University Health System, Singapore, Singapore
| | - Emily Ashcraft
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, TN
| | - Wenjian Yang
- Department of Pharmacy and Pharmaceutical Sciences, St Jude Children's Research Hospital, Memphis, TN
| | - Kathryn G. Roberts
- Department of Pathology, St Jude Children's Research Hospital, Memphis, TN
| | - Yoshihiro Gocho
- Department of Pharmacy and Pharmaceutical Sciences, St Jude Children's Research Hospital, Memphis, TN
| | - Lauren Rowland
- Department of Pharmacy and Pharmaceutical Sciences, St Jude Children's Research Hospital, Memphis, TN
| | - Hiroto Inaba
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Seth E. Karol
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Sima Jeha
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Kristine R. Crews
- Department of Pharmacy and Pharmaceutical Sciences, St Jude Children's Research Hospital, Memphis, TN
| | | | - Mary V. Relling
- Department of Pharmacy and Pharmaceutical Sciences, St Jude Children's Research Hospital, Memphis, TN
| | - William E. Evans
- Department of Pharmacy and Pharmaceutical Sciences, St Jude Children's Research Hospital, Memphis, TN
| | - Cheng Cheng
- Department of Biostatistics, St Jude Children's Research Hospital, Memphis, TN
| | - Jun J. Yang
- Department of Pharmacy and Pharmaceutical Sciences, St Jude Children's Research Hospital, Memphis, TN
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
| | - Ching-Hon Pui
- Department of Pathology, St Jude Children's Research Hospital, Memphis, TN
- Department of Oncology, St Jude Children's Research Hospital, Memphis, TN
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
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17
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Nigro SE, Hall LP, Harman J, Willard VW, Conklin HM, Pui CH, Jeha S, Jacola LM. The association of environmental factors with neurocognitive outcomes in survivors of childhood acute lymphoblastic leukemia (ALL). Support Care Cancer 2023; 32:1. [PMID: 38047975 PMCID: PMC10762952 DOI: 10.1007/s00520-023-08212-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 11/27/2023] [Indexed: 12/05/2023]
Abstract
PURPOSE To investigate the association of environmental factors, rehabilitation services during therapy and socioeconomic status (SES - insurance type), with neurocognitive outcomes at the end of therapy for survivors of childhood acute lymphoblastic leukemia (ALL). METHODS Survivors (n = 236) treated on the St. Jude Total Therapy Study 16 completed end of therapy testing with performance measures (IQ, attention, processing speed, fine motor skills, academics) and caregiver ratings (attention, executive function, adaptive skills). Environmental factors were abstracted from the medical record. RESULTS Distribution of sex (47.3% female, p = 0.399), treatment arm (45.5% low risk, 54.5% standard/high risk p = 0.929), insurance type (47.7% private, 52.3% public/none, p = 0.117), and mean age at diagnosis (7.7 vs. 6.8 years, p = 0.143) were similar for groups with (n = 110; 46.6%) and without (n = 126; 53.6%) rehabilitation services during therapy. Compared to those without rehabilitation, the rehabilitation group (n = 110; 46.4%) had more caregiver reported problems with attention (Z = -0.28 vs. 0.43, p = 0.022), executive function (Z = -0.50 vs. -0.08, p = 0.003), and adaptive skills (Z = -0.41 vs.-0.13, p = 0.031). Among the rehabilitation group, there was no difference in outcomes by insurance status. Among those without rehabilitation, those with public insurance had worse neurocognitive outcomes than those with private insurance in IQ (Z = -0.04 vs. -0.45, p = 0.0115), processing speed (Z = -0.10 vs. -0.75, p = 0.0030), reading (Z = 0.18 vs. -0.59, p < 0.0001), and math (Z = -0.04 vs. -0.50, p = 0.0021). CONCLUSION Participation in rehabilitation services during early intensive therapy is associated with end of therapy caregiver-reported neurocognitive outcomes in daily life.
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Affiliation(s)
- S E Nigro
- Department of Psychology and Biobehavioral Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - L P Hall
- Department of Psychology and Biobehavioral Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - J Harman
- Department of Psychology and Biobehavioral Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - V W Willard
- Department of Psychology and Biobehavioral Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - H M Conklin
- Department of Psychology and Biobehavioral Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - C-H Pui
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - S Jeha
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - L M Jacola
- Department of Psychology and Biobehavioral Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA.
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18
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Rives S. Central nervous system therapy in acute lymphoblastic leukemia: no more, no less. Haematologica 2023; 108:3193-3194. [PMID: 37317901 PMCID: PMC10690892 DOI: 10.3324/haematol.2023.283275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 06/07/2023] [Indexed: 06/16/2023] Open
Abstract
Not available.
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Affiliation(s)
- Susana Rives
- Hospital Sant Joan de Déu de Barcelona, Barcelona, Spain; Institut de Recerca Sant Joan de Déu, Barcelona.
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19
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Liu K, Shao J, Cai J, Tang J, Shen S, Xu F, Ren Y, Zhang A, Tian X, Lu X, Hu S, Hu Q, Jiang H, Zhou F, Liang C, Leung AWK, Zhai X, Li C, Fang Y, Wang Z, Wen L, Yang H, Wang N, Jiang H. Causes of death and treatment-related mortality in newly diagnosed childhood acute lymphoblastic leukemia treatment with Chinese Children's Cancer Group study ALL-2015. Ann Hematol 2023; 102:3431-3444. [PMID: 37550503 DOI: 10.1007/s00277-023-05389-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 07/26/2023] [Indexed: 08/09/2023]
Abstract
To investigate the possible risk factors for death at post-treatment in children with acute lymphoblastic leukemia (ALL). A multivariate competing risk analysis was performed to retrospectively analyze the data of children with ALL who died after treatment with CCCG-ALL-2015 in China and to determine the possible risk factors for death at post-treatment in children with ALL. Age at the first diagnosis of ≥10 years; final risk level of high-risk; D19 minimal residual disease (MRD) (≥0.01%) and D46 MRD (≥0.01%); genetic abnormalities, such as KMT2A-rearrangement, c-Myc rearrangement, and PDGFRB rearrangement; and the presence of CNS3 (all P values, <0.05) were identified as independent risk factors, whereas the risk level at the first diagnosis of low-risk (LR) and ETV6::RUNX1 positivity was considered as independent protective factors of death in children with ALL. Among the 471 cases of death, 45 cases were treated with CCCG-ALL-2015 only, and 163 (34.61%) were treatment-related, with 62.42% due to severe infections. 55.83% of treatment-related mortality (TRM) occurred in the early phase of treatment (induction phase). TRM has a significant impact on the overall survival of pediatric patients with ALL. Moreover, the CCCG-ALL-2015 regimen has a better safety profile for treating children with ALL, with rates close to those in developed countries (registration number: ChiCTR-IPR-14005706; date of registration: June 4, 2014).
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Affiliation(s)
- Kangkang Liu
- Department of Pediatrics, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Jingbo Shao
- Department of Hematology/Oncology, Children's Hospital Affiliated to Shanghai Jiaotong University, Shanghai, China
| | - Jiaoyang Cai
- Department of Hematology/Oncology, Shanghai Children's Medical Center, Shanghai Jiaotong University of School of Medicine, Shanghai, China
| | - Jingyan Tang
- Department of Hematology/Oncology, Shanghai Children's Medical Center, Shanghai Jiaotong University of School of Medicine, Shanghai, China
| | - Shuhong Shen
- Department of Hematology/Oncology, Shanghai Children's Medical Center, Shanghai Jiaotong University of School of Medicine, Shanghai, China
| | - Fengling Xu
- Department of Hematology/Oncology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yuanyuan Ren
- Department of Pediatrics, Institute of Hematology and Blood Disease Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Aijun Zhang
- Department of Pediatrics, Qilu Hospital of Shandong University, Jinan, China
| | - Xin Tian
- Department of Hematology/Oncology, Kunming Children's Hospital, Kunming, China
| | - Xiaoqian Lu
- Department of Hematology/Oncology, West China Second Hospital of Sichuan University, Chengdu, China
| | - Shaoyan Hu
- Department of Hematology/Oncology, Children's Hospital of Soochow University, Suzhou, China
| | - Qun Hu
- Department of Pediatrics, Huazhong University of Science and Technology Tongji Medical College Tongji Hospital, Wuhan, China
| | - Hua Jiang
- Department of Hematology/Oncology, Guangzhou Women and Children Health Care Center, Guangzhou, China
| | - Fen Zhou
- Department of Pediatrics, Huazhong University of Science and Technology Tongji Medical College Union Hospital, Wuhan, China
| | - Changda Liang
- Department of Hematology/Oncology, Jiangxi Provincial Children's Hospital, Nanchang, China
| | - Alex Wing Kwan Leung
- Department of Pediatrics, The Chinese University of Hong Kong, Hong Kong Children's Hospital, Hong Kong, China
| | - Xiaowen Zhai
- Department of Hematology/Oncology, Children's Hospital of Fudan University, Shanghai, China
| | - Chunfu Li
- Department of Pediatrics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yongjun Fang
- Department of Hematology/Oncology, Nanjing Children's Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Zhenling Wang
- Department of Pediatrics, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Lu Wen
- Department of Hematology/Oncology, Northwest Women's and Children's Hospital, Xi'an, China
| | - Hui Yang
- Department of Pediatrics, Xiangya Hospital Central South University, Changsha, Hunan, China
| | - Ningling Wang
- Department of Pediatrics, The Second Affiliated Hospital of Anhui Medical University, Hefei, China.
| | - Hui Jiang
- Department of Hematology/Oncology, Children's Hospital Affiliated to Shanghai Jiaotong University, Shanghai, China.
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Orvain C, Chantepie S, Thomas X, Escofrre-Barbe M, Huguet F, Desbrosses Y, Guillerm G, Uzunov M, Leguay T, Barbieux S, Vey N, Chevallier P, Malfuson JV, Lepretre S, Baumann M, Aykut M, Chaib A, Joris M, Zerazhi H, Stussi G, Chapiro J, Berthon C, Bonmati C, Jourdan E, Carp D, Marcais AR, Gallego-Hernanz MP, Vaida I, Bilger K, Villate A, Pasquier F, Chalandon Y, Maury S, Lheritier V, Ifrah N, Dombret H, Boissel N, Hunault-Berger M. Impact of central nervous system involvement in adult patients with Philadelphia-negative acute lymphoblastic leukemia: a GRAALL-2005 study. Haematologica 2023; 108:3287-3297. [PMID: 36891751 PMCID: PMC10690907 DOI: 10.3324/haematol.2022.282332] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 02/28/2023] [Indexed: 03/10/2023] Open
Abstract
Whereas the prognosis of adult patients with Philadelphia-negative acute lymphoblastic leukemia (ALL) has greatly improved since the advent of pediatric-inspired regimens, the impact of initial central nervous system (CNS) involvement has not been formerly re-evaluated. We report here the outcome of patients with initial CNS involvement included in the pediatric-inspired prospective randomized GRAALL-2005 study. Between 2006 and 2014, 784 adult patients (aged 18-59 years) with newly diagnosed Philadelphia-negative ALL were included, of whom 55 (7%) had CNS involvement. In CNSpositive patients, overall survival was shorter (median 1.9 years vs. not reached, HR=1.8 [1.3-2.6], P<0.001). While there was no statistical difference in cumulative incidence of relapse between CNS+ and CNS- patients (HR=1.5 [0.9-2.5], P=0.11), non-relapse mortality was significantly higher in those with initial CNS disease (HR=2.1 [1.2-3.5], P=0.01). This increase in toxicity was mostly observed in patients randomized to the high-dose cyclophosphamide arm and in those who received allogeneic stem cell transplantation. Exploratory landmark analyses did not show any association between either cranial irradiation or allogeneic stem cell transplantation and outcome. Despite improved outcome in young adult ALL patients with pediatric-inspired protocols, CNS involvement is associated with a worse outcome mainly due to excess toxicity, without improved outcome with allogeneic SCT.
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Affiliation(s)
- Corentin Orvain
- Maladies du Sang, CHU d'Angers, Angers, France; Federation Hospitalo-Universitaire Grand-Ouest Acute Leukemia, FHU-GOAL; Universite d'Angers, Inserm UMR 1307, CNRS UMR 6075, Nantes Universite, CRCI2NA, F-49000 Angers
| | | | - Xavier Thomas
- Hematologie Clinique, HCL, Centre Hospitalier Lyon Sud, Pierre Benite
| | | | - Francoise Huguet
- Hematologie, Centre Hospitalo-Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse-Oncopole
| | | | | | | | - Thibaut Leguay
- Hematologie Clinique, Hopital du Haut-Leveque, CHU de Bordeaux, Pessac
| | - Sarah Barbieux
- Hematologie Clinique, Centre Hospitalier de Dunkerque, Dunkerque
| | - Norbert Vey
- Hematologie Clinique, Institut Paoli-Calmettes, Marseille
| | | | | | | | - Michael Baumann
- Klinik fur Med. Onkologie und Hamatologie, Kantonsspital St. Gallen, St. Gallen, Switzerland; Swiss Group for Clinical Cancer Research (SAKK), Bern
| | - Murat Aykut
- Swiss Group for Clinical Cancer Research (SAKK), Bern, Switzerland; Klinik fur Medizinische Onkologie und Hamatologie, Universitatsspital Zurich, Zurich
| | - Abdelaziz Chaib
- Hemato-Oncologie et Medecine Interne, Centre Hospitalier du Pays d'Aix, Aix-en-Provence
| | | | - Hacene Zerazhi
- Hematologie Clinique, Centre Hospitalier Henri Duffaut, Avignon
| | - Georg Stussi
- Swiss Group for Clinical Cancer Research (SAKK), Bern, Switzerland; Clinica di Ematologia, Istituto oncologico della Svizzera Italiana, Bellinzona
| | | | | | | | | | - Diana Carp
- Oncologie Medicale, Centre Hospitalier d'Orleans, Orleans
| | | | | | - Iona Vaida
- Onco-Hematologie, Centre Hospitalier Rene-Dubos, Pontoise
| | - Karin Bilger
- Oncologie et Hematologie, Institut de Cancerologie Strasbourg Europe (ICANS), Strasbourg
| | - Alban Villate
- Hematologie et Therapie Cellulaire, CHRU de Tours, Tours
| | - Florence Pasquier
- Departement d'Hematologie, Gustave Roussy, Universite Paris-Saclay, Villejuif
| | - Yves Chalandon
- Swiss Group for Clinical Cancer Research (SAKK), Bern, Switzerland; Department of Oncology, Hematology Division, University Hospital of Geneva and Faculty of Medicine of Geneva, Geneva
| | - Sebastien Maury
- Departement d'Hematologie, Assistance Publique-Hopitaux de Paris (AP-HP), Hopital Henri Mondor, Creteil
| | | | - Norbert Ifrah
- Maladies du Sang, CHU d'Angers, Angers, France; Federation Hospitalo-Universitaire Grand-Ouest Acute Leukemia, FHU-GOAL; Universite d'Angers, Inserm UMR 1307, CNRS UMR 6075, Nantes Universite, CRCI2NA, F-49000 Angers
| | - Herve Dombret
- Hematologie Adulte, Hopital Saint-Louis, AP-HP, Paris
| | | | - Mathilde Hunault-Berger
- Maladies du Sang, CHU d'Angers, Angers, France; Federation Hospitalo-Universitaire Grand-Ouest Acute Leukemia, FHU-GOAL; Universite d'Angers, Inserm UMR 1307, CNRS UMR 6075, Nantes Universite, CRCI2NA, F-49000 Angers.
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21
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Heilmann J, Vieth S, Möricke A, Attarbaschi A, Barbaric D, Bodmer N, Colombini A, Dalla-Pozza L, Elitzur S, Izraeli S, Mann G, Niggli F, Silvestri D, Stary J, Rizzari C, Valsecchi MG, Zapotocka E, Zimmermann M, Cario G, Schrappe M, Conter V. Effect of two additional doses of intrathecal methotrexate during induction therapy on serious infectious toxicity in pediatric patients with acute lymphoblastic leukemia. Haematologica 2023; 108:3278-3286. [PMID: 37021527 PMCID: PMC10690925 DOI: 10.3324/haematol.2022.281788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 03/30/2023] [Indexed: 04/07/2023] Open
Abstract
Although initial central nervous system (CNS) involvement is rarely detected in childhood acute lymphoblastic leukemia (ALL), risk-adapted CNS-directed therapy is essential for all patients. Treatment intensity depends on the initial CNS status. In the AIEOP-BFM ALL 2009 trial, patients with cytomorphologic detection of leukemic blasts in initial cerebrospinal fluid were classified as CNS2 or CNS3 and received five intrathecal doses of methotrexate (MTX) in induction therapy compared to patients with CNS1 status (no blasts detected) who received three doses. The impact of additional intrathecal (IT) MTX on systemic toxicity in induction therapy is unknown. Between June 1st 2010 and February 28th 2017, a total of 6,136 ALL patients aged 1-17 years were enrolled onto the AIEOP-BFM ALL 2009 trial. The effect of three versus five doses of IT MTX during induction therapy on the incidence of severe infectious complications was analyzed. Among 4,706 patients treated with three IT MTX doses, 77 (1.6%) had a life-threatening infection during induction as compared to 59 of 1,350 (4.4%) patients treated with five doses (P<0.001; Odds Ratio 2.86 [95% Confidence Interval 1.99-4.13]). In a multivariate regression model, treatment with additional IT MTX proved to be the strongest risk factor for life-threatening infections (Odds Ratio 2.85 [1.96-4.14]). Fatal infections occurred in 16 (0.3%) and 38 (1.6%) patients treated with three or five IT MTX doses, respectively (P<0.001). As the relevance of additional intrathecal MTX in induction for relapse prevention in CNS2 patients is unclear, doses of intrathecal therapy have been reduced for these patients. (Clinicaltrials.gov identifiers: NCT01117441 and NCT00613457).
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Affiliation(s)
- Janina Heilmann
- Department of Pediatrics, Christian-Albrechts-University Kiel and University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Simon Vieth
- Department of Pediatrics, Christian-Albrechts-University Kiel and University Medical Center Schleswig-Holstein, Kiel, Germany.
| | - Anja Möricke
- Department of Pediatrics, Christian-Albrechts-University Kiel and University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Andishe Attarbaschi
- Department of Pediatrics, St. Anna Children's Cancer Research Institute and St. Anna Children's Hospital, Medical University School, Vienna
| | - Draga Barbaric
- Children's Cancer Institute Australia, University of New South Wales, Lowy Cancer Centre, Randwick, Australia; Kids Cancer Centre, Sydney Children's Hospital, Randwick, Australia
| | - Nicole Bodmer
- Department of Pediatric Oncology, University Children's Hospital, Zuerich, Switzerland
| | - Antonella Colombini
- Pediatric Clinic, University Milano-Bicocca-Fondazione MBBM/ San Gerardo Hospital, Monza, Italy
| | - Luciano Dalla-Pozza
- The Children's Hospital at Westmead, Department of Oncology, Westmead, Australia
| | - Sarah Elitzur
- Pediatric Hematology-Oncology, Schneider Children's Medical Center and Sackler Faculty of Medicine, Aviv University, Aviv, Israel
| | - Shai Izraeli
- Pediatric Hematology-Oncology, Schneider Children's Medical Center and Sackler Faculty of Medicine, Aviv University, Aviv, Israel
| | - Georg Mann
- Department of Pediatrics, St. Anna Children's Cancer Research Institute and St. Anna Children's Hospital, Medical University School, Vienna
| | - Felix Niggli
- Department of Pediatric Oncology, University Children's Hospital, Zuerich, Switzerland
| | - Daniela Silvestri
- Pediatric Clinic, University Milano-Bicocca-Fondazione MBBM/ San Gerardo Hospital, Monza, Italy; University of Milano-Bicocca, Center of Biostatistics for Clinical Epidemiology, Department of Health Science, Milan, Italy
| | - Jan Stary
- University Hospital Motol, Department of Pediatric Hematology/Oncology, Prague, Czech Republic
| | - Carmelo Rizzari
- Pediatric Clinic, University Milano-Bicocca-Fondazione MBBM/ San Gerardo Hospital, Monza, Italy
| | - Maria Grazia Valsecchi
- University of Milano-Bicocca, Center of Biostatistics for Clinical Epidemiology, Department of Health Science, Milan, Italy
| | - Ester Zapotocka
- University Hospital Motol, Department of Pediatric Hematology/Oncology, Prague, Czech Republic
| | - Martin Zimmermann
- Hannover Medical School, Pediatric Hematology and Oncology, Hannover, Germany
| | - Gunnar Cario
- Department of Pediatrics, Christian-Albrechts-University Kiel and University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Martin Schrappe
- Department of Pediatrics, Christian-Albrechts-University Kiel and University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Valentino Conter
- Pediatric Clinic, University Milano-Bicocca-Fondazione MBBM/ San Gerardo Hospital, Monza, Italy
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22
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Canavera K, Ghafoor S, Fan K, Cheng C, Jeha S, Pui CH, Elliott A, Morrison RR, Jacola LM. Post-PICU Cognitive and Psychological Outcomes in Children Receiving Treatments for Acute Lymphoblastic Leukemia. Pediatr Crit Care Med 2023; 24:e584-e591. [PMID: 38055007 DOI: 10.1097/pcc.0000000000003340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
OBJECTIVES To examine neurocognitive and psychological outcomes associated with post-PICU admissions in children treated for childhood acute lymphoblastic leukemia (ALL). DESIGN Observational study from October 2007 to March 2017. SETTING Pediatric onco-critical care unit. PATIENTS All patients in this study (n = 296; ages 3-21) were treated for ALL on the St. Jude Total Therapy 16 clinical trial (NCT00549848) from 2007 to 2017. Of these, 104 patients were admitted to the PICU during protocol-directed therapy. All patients completed protocol-directed neurocognitive monitoring prospectively, at the end of cancer-directed therapy. Data on PICU stays were abstracted retrospectively from the medical record. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Demographic and critical illness variables were abstracted from institutional databases and medical records. Neurocognitive and psychosocial outcomes were prospectively obtained at the end of treatment. Children who had a PICU admission experienced significantly lower functioning compared to normative samples in several areas of cognitive functioning (working memory, processing speed, executive functions, inattention, math achievement, fine motor dexterity, and speed), daily living skills, and internalizing problems (all ps < 0.05). Compared with those without PICU admissions, patients with PICU admissions had worse performance on a measure of sustained attention (p = 0.017). The frequency of patients at risk for problems with learning and memory was significantly higher in the PICU group compared with the non-PICU group (25% vs 12%, p = 0.006). Critical illness symptom severity was not associated with neurocognitive or psychological outcomes. CONCLUSIONS Children with ALL, with or without a PICU admission, experienced lower cognitive and psychological outcomes following treatment. Future research is needed to continue identifying risk factors for post-intensive care syndrome (PICS-p) and post-PICU cognitive and psychological impairments in pediatric patients.
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Affiliation(s)
- Kristin Canavera
- Department of Pediatrics, Ochsner Hospital for Children, New Orleans, LA
| | - Saad Ghafoor
- Division of Critical Care Medicine, St. Jude Children's Research Hospital, Memphis, TN
| | - Kimberly Fan
- Division of Critical Care Medicine, St. Jude Children's Research Hospital, Memphis, TN
| | - Cheng Cheng
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN
| | - Sima Jeha
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN
| | - Ching-Hon Pui
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN
| | - Andrew Elliott
- Department of Pediatrics, St. Jude Children's Research Hospital, Memphis, TN
| | - R Ray Morrison
- Division of Critical Care Medicine, St. Jude Children's Research Hospital, Memphis, TN
| | - Lisa M Jacola
- Department of Psychology, St. Jude Children's Research Hospital, Memphis, TN
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23
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Jeha S, Goto H, Baruchel A, Boëlle-Le Corfec E, Geffriaud-Ricouard C, Pieters R, Shin HY. Patient-Level Meta-analysis of Clofarabine in Acute Lymphoblastic Leukemia. Adv Ther 2023; 40:5447-5463. [PMID: 37819554 PMCID: PMC10611855 DOI: 10.1007/s12325-023-02696-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 09/22/2023] [Indexed: 10/13/2023]
Abstract
INTRODUCTION Clofarabine monotherapy at a dose of 52 mg/m2 per day was approved in the USA in 2004 for the treatment of relapsed or refractory acute lymphoblastic leukemia (R/R ALL) in patients aged 1-21 years after at least two prior regimens. To address a post-marketing requirement for additional evidence of the clinical benefit of clofarabine in its approved indication, a meta-analysis of patient-level data was conducted. METHODS A systematic literature review was conducted, using the Dr.Evidence software platform, DOC Search, and Embase, to identify clinical trials with patients with R/R ALL who received clofarabine monotherapy at 52 mg/m2. The primary endpoint was complete remission (CR). Secondary endpoints were overall remission (OR, defined by CR or CR with either incomplete platelet recovery or incomplete neutrophil and platelet recovery), duration of response, overall survival (OS), and safety. RESULTS A total of 754 patients in 12 clinical studies were analyzed including 682 patients with R/R ALL treated with clofarabine monotherapy at 52 mg/m2; of them, 374 were aged < 22 years (pediatric population). Rates of CR and OR were 16% (95% confidence interval [CI] 7, 26) and 28% (95% CI 20, 37), respectively, in the pediatric population and 12% (95% CI 5, 21) and 21% (95% CI 13, 31) in the overall population. Median OS (evaluable in three studies in pediatric patients) was 3.7 months (95% CI 0.1, 31.4), reaching 10.1 months (95% CI 0.3, 68.9) for those achieving OR. Sensitivity analyses supported these findings. The most frequent grade 3-4 adverse events were liver abnormalities, anemia, diarrhea, and febrile neutropenia. CONCLUSION In this meta-analysis, CR duration and median OS in pediatric patients with R/R ALL appeared to be slightly longer than in the phase II study. No new safety signals were identified. Results support the use of clofarabine monotherapy in its approved indication.
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Affiliation(s)
- Sima Jeha
- St Jude Children's Hospital Research, 262 Danny Thomas Place, Memphis, TN, 38105-3678, USA.
| | - Hiroaki Goto
- Division of Hematology/Oncology, Kanagawa Children's Medical Center, Minami-ku, Yokohama, Kanagawa, Japan
| | - André Baruchel
- Department of Pediatric Hemato-Immunology, Hôpital Universitaire Robert Debré (APHP and Université Paris Cité), Paris, France
| | | | | | - Rob Pieters
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Hee Young Shin
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
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24
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Antić Ž, Lentes J, Bergmann AK. Cytogenetics and genomics in pediatric acute lymphoblastic leukaemia. Best Pract Res Clin Haematol 2023; 36:101511. [PMID: 38092485 DOI: 10.1016/j.beha.2023.101511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 07/24/2023] [Accepted: 08/15/2023] [Indexed: 12/18/2023]
Abstract
The last five decades have witnessed significant improvement in diagnostics, treatment and management of children with acute lymphoblastic leukaemia (ALL). These advancements have become possible through progress in our understanding of the genetic and biological background of ALL, resulting in the introduction of risk-adapted treatment and novel therapeutic targets, e.g., tyrosine kinase inhibitors for BCR::ABL1-positive ALL. Further advances in the taxonomy of ALL and the discovery of new genetic biomarkers and therapeutic targets, as well as the introduction of targeted and immunotherapies into the frontline treatment protocols, may improve management and outcome of children with ALL. In this review we describe the current developments in the (cyto)genetic diagnostics and management of children with ALL, and provide an overview of the most important advances in the genetic classification of ALL. Furthermore, we discuss perspectives resulting from the development of new techniques, including artificial intelligence (AI).
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Affiliation(s)
- Željko Antić
- Department of Human Genetics, Hannover Medical School (MHH), Hannover, Germany
| | - Jana Lentes
- Department of Human Genetics, Hannover Medical School (MHH), Hannover, Germany
| | - Anke K Bergmann
- Department of Human Genetics, Hannover Medical School (MHH), Hannover, Germany.
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25
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Kimura S, Polonen P, Montefiori L, Park CS, Iacobucci I, Yeoh AE, Attarbaschi A, Moore AS, Brown A, Manabe A, Buldini B, Freeman BB, Chen C, Cheng C, Kean Hui C, Li CK, Pui CH, Qu C, Tomizawa D, Teachey DT, Varotto E, Paietta EM, Arnold ED, Locatelli F, Escherich G, Elisa Muhle H, Marquart HV, de Groot-Kruseman HA, Rowe JM, Stary J, Trka J, Choi JK, Meijerink JPP, Yang JJ, Takita J, Pawinska-Wasikowska K, Roberts KG, Han K, Caldwell KJ, Schmiegelow K, Crews KR, Eguchi M, Schrappe M, Zimmerman M, Takagi M, Maybury M, Svaton M, Reiterova M, Kicinski M, Prater MS, Kato M, Reyes N, Spinelli O, Thomas P, Mazilier P, Gao Q, Masetti R, Kotecha RS, Pieters R, Elitzur S, Luger SM, Mitchell S, Pruett-Miller SM, Shen S, Jeha S, Köhrer S, Kornblau SM, Skoczeń S, Miyamura T, Vincent TL, Imamura T, Conter V, Tang Y, Liu YC, Chang Y, Gu Z, Cheng Z, Yinmei Z, Inaba H, Mullighan CG. Biologic and clinical features of childhood gamma delta T-ALL: identification of STAG2/LMO2 γδ T-ALL as an extremely high risk leukemia in the very young. medRxiv 2023:2023.11.06.23298028. [PMID: 37986997 PMCID: PMC10659466 DOI: 10.1101/2023.11.06.23298028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
PURPOSE Gamma delta T-cell receptor-positive acute lymphoblastic leukemia (γδ T-ALL) is a high-risk but poorly characterized disease. METHODS We studied clinical features of 200 pediatric γδ T-ALL, and compared the prognosis of 93 cases to 1,067 protocol-matched non-γδ T-ALL. Genomic features were defined by transcriptome and genome sequencing. Experimental modeling was used to examine the mechanistic impacts of genomic alterations. Therapeutic vulnerabilities were identified by high throughput drug screening of cell lines and xenografts. RESULTS γδ T-ALL in children under three was extremely high-risk with 5-year event-free survival (33% v. 70% [age 3-<10] and 73% [age ≥10], P =9.5 x 10 -5 ) and 5-year overall survival (49% v. 78% [age 3-<10] and 81% [age ≥10], P =0.002), differences not observed in non-γδ T-ALL. γδ T-ALL in this age group was enriched for genomic alterations activating LMO2 activation and inactivating STAG2 inactivation ( STAG2/LMO2 ). Mechanistically, we show that inactivation of STAG2 profoundly perturbs chromatin organization by altering enhancer-promoter looping resulting in deregulation of gene expression associated with T-cell differentiation. Drug screening showed resistance to prednisolone, consistent with clinical slow treatment response, but identified a vulnerability in DNA repair pathways arising from STAG2 inactivation, which was efficaciously targeted by Poly(ADP-ribose) polymerase (PARP) inhibition, with synergism with HDAC inhibitors. Ex-vivo drug screening on PDX cells validated the efficacy of PARP inhibitors as well as other potential targets including nelarabine. CONCLUSION γδ T-ALL in children under the age of three is extremely high-risk and enriched for STAG2/LMO2 ALL. STAG2 loss perturbs chromatin conformation and differentiation, and STAG2/LMO2 ALL is sensitive to PARP inhibition. These data provide a diagnostic and therapeutic framework for pediatric γδ T-ALL. SUPPORT The authors are supported by the American and Lebanese Syrian Associated Charities of St Jude Children's Research Hospital, NCI grants R35 CA197695, P50 CA021765 (C.G.M.), the Henry Schueler 41&9 Foundation (C.G.M.), and a St. Baldrick's Foundation Robert J. Arceci Innovation Award (C.G.M.), Gabriella Miller Kids First X01HD100702 (D.T.T and C.G.M.) and R03CA256550 (D.T.T. and C.G.M.), F32 5F32CA254140 (L.M.), and a Garwood Postdoctoral Fellowship of the Hematological Malignancies Program of the St Jude Children's Research Hospital Comprehensive Cancer Center (S.K.). This project was supported by the National Cancer Institute of the National Institutes of Health under the following award numbers: U10CA180820, UG1CA189859, U24CA114766, U10CA180899, U10CA180866 and U24CA196173. DISCLAIMER The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The funding agencies were not directly involved in the design of the study, gathering, analysis and interpretation of the data, writing of the manuscript, or decision to submit the manuscript for publication.
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26
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Feng Y, Qi S, Liu X, Zhang L, Hu Y, Shen Q, Gong X, Zhang W, Wang J, Yan W, Wang T, Wang H, Song Z, Zhu X, Gale RP, Chen J. Have we been qualifying measurable residual disease correctly? Leukemia 2023; 37:2168-2172. [PMID: 37704711 PMCID: PMC10624632 DOI: 10.1038/s41375-023-02026-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 08/30/2023] [Accepted: 09/05/2023] [Indexed: 09/15/2023]
Affiliation(s)
- Yahui Feng
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Saibing Qi
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Xueou Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Li Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Yu Hu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Qiujin Shen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Xiaowen Gong
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Wei Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Junxia Wang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Wen Yan
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Tiantian Wang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Huijun Wang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Zhen Song
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Xiaofan Zhu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.
- Tianjin Institutes of Health Science, Tianjin, China.
| | - Robert Peter Gale
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College of Science, Technology and Medicine, London, UK
| | - Junren Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.
- Tianjin Institutes of Health Science, Tianjin, China.
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Duffy C, Graetz DE, Lopez AMZ, Carrillo AK, Job G, Chen Y, Devidas M, Leon SA, Bonzi SA, Flores PC, Torres LE, Broncano EH, Jaramillo SJ, Zelada MO, Novoa RR, Samudio A, Sánchez-Fernandez G, Villanueva E, Metzger ML, Friedrich P, Jeha S. Retrospective analysis of outcomes for pediatric acute lymphoblastic leukemia in South American centers. Front Oncol 2023; 13:1254233. [PMID: 38023200 PMCID: PMC10643117 DOI: 10.3389/fonc.2023.1254233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 10/09/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Acute lymphoblastic Leukemia (ALL) is the most common pediatric malignancy. While the survival rate for childhood ALL exceeds 90% in high-income countries, the estimated survival in low-and middle-income countries ranges from 22-79%, depending on the region and local resources. Methods This study retrospectively reviewed demographic, biological, and clinical parameters of children under 18 years of age with newly diagnosed ALL presenting between 2013-2017 across five pediatric centers in 4 countries in South America. Survival analyses were estimated using the Kaplan-Meier method. Results Across the five centers, 752 patients were analyzed (Bolivia [N=9], Ecuador [N=221], Paraguay [N=197], Peru [N=325]) and 92.1% (n=690) patients were diagnosed with B-cell and 7.5% (n= 56) with T-cell ALL. The median age was 5.5 years old (IQR 7.29). At diagnosis, 47.8% of patients were categorized as standard and 51.9% as high risk per their institutional regimen. Advanced diagnostics availability varied between modalities. MRD was evaluated in 69.1% of patients; molecular testing was available for ETV6-RUNX, BCR-ABL1, TCF3-PBX1, and KMT2A-rearranged ALL in 75-81% of patients; however, karyotyping and evaluation for iAMP21 were only performed in 42-61% of patients. Central nervous system (CNS) involvement was evaluated at diagnosis in 57.3% (n=429) patients; of these, 93.7% (n=402) were CNS 1, 1.6% (n=7) were CNS 2, 0.7% (n=11) were CNS3, 1.9% (n=8) had cranial nerve palsy, and 2.1% (n=9) results unavailable. Chemotherapy delays >2 weeks were reported in 56.0% (n=421) patients during treatment. Delays were attributed to infection in 63.2% (n=265), drug-related toxicities in 47.3% (n=198), and resource constraints, including lack of bed availability in 23.2% (n=97) of patients. The 3-year Abandonment-sensitive EFS and OS were 61.0±1.9% and 67.2±1.8%, respectively. The 3-year EFS and OS were 71.0±1.8% and 79.6±1.7%, respectively. Discussion This work reveals opportunities to improve survival, including addressing severe infections, treatment interruptions, and modifications due to drug shortages. In 2018, healthcare professionals across South America established the Pediatric Oncology Latin America (POLA) group in collaboration with St. Jude Children's Research Hospital. POLA collaborators developed an evidence-based, consensus-derived, adapted treatment guideline, informed by preliminary results of this evaluation, to serve as the new standard of care for pediatric ALL in participating institutions.
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Affiliation(s)
- Caitlyn Duffy
- St. Jude Children’s Research Hospital, Department of Global Pediatric Medicine, Memphis, TN, United States
| | - Dylan E. Graetz
- St. Jude Children’s Research Hospital, Department of Global Pediatric Medicine, Memphis, TN, United States
| | - Arturo M. Zapata Lopez
- Departamento de Oncología Pediátrica, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Angela K. Carrillo
- St. Jude Children’s Research Hospital, Department of Global Pediatric Medicine, Memphis, TN, United States
| | - Godwin Job
- St. Jude Children’s Research Hospital, Department of Global Pediatric Medicine, Memphis, TN, United States
| | - Yichen Chen
- St. Jude Children’s Research Hospital, Department of Global Pediatric Medicine, Memphis, TN, United States
| | - Meenakshi Devidas
- St. Jude Children’s Research Hospital, Department of Global Pediatric Medicine, Memphis, TN, United States
| | - Sandra Alarcón Leon
- Departamento de Oncología Pediátrica, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Sol Aponte Bonzi
- Departamento de Hemato Oncología Pediátrica, Hospital de Clínicas, Facultad de Ciencias Médicas, Universidad Nacional de Asunción, Asunción, Paraguay
| | - Pedro Cardona Flores
- Hospital Santa Cruz Caja Petrolera Salud (CPS), Hemato-Oncología Pediátrica, Santa Cruz, Bolivia
| | | | - Eddy Hernández Broncano
- Departamento de Oncología Pediátrica, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Soledad Jiménez Jaramillo
- La Sociedad de Lucha Contra el Cáncer (SOLCA) Núcleo de Loja, Oncohematóloga Pediatra, Loja, Ecuador
| | - Ma Ofelia Zelada
- Departamento de Hemato Oncología Pediátrica, Hospital de Clínicas, Facultad de Ciencias Médicas, Universidad Nacional de Asunción, Asunción, Paraguay
| | - Romulo Reaño Novoa
- Departamento de Oncología Pediátrica, Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru
| | - Angelica Samudio
- Departamento de Hemato Oncología Pediátrica, Hospital de Clínicas, Facultad de Ciencias Médicas, Universidad Nacional de Asunción, Asunción, Paraguay
| | | | - Erika Villanueva
- Hospital SOLCA Núcleo Quito, Hemato-Oncología Pediátrica, Quito, Ecuador
| | | | - Paola Friedrich
- St. Jude Children’s Research Hospital, Department of Global Pediatric Medicine, Memphis, TN, United States
| | - Sima Jeha
- St. Jude Children’s Research Hospital, Department of Global Pediatric Medicine, Memphis, TN, United States
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Moreira DC, González-Ramella O, Echavarría Valenzuela M, Carrillo AK, Faughnan L, Job G, Chen Y, Villegas C, Ellis Irigoyen A, Barra Urbays R, Ramírez Martinez M, Altamirano Alvarez E, León Espitia JA, López Facundo NA, Colunga Pedraza JE, Reyes Gutierrez FDM, Aguilar Román AB, Tamez Gómez EL, Portillo Zavala CS, Negroe Ocampo NDC, Pulido Sanchez SG, Cortés Alva D, Casillas Toral P, Salas Villa K, Mendoza Sánchez PJ, Pérez Alvarado C, Tamayo Pedraza G, González Zamorano M, Ávila Alba JMR, Becerril Becerril J, Ramírez Durán H, Sandoval Cabrera A, Pineda Gordillo A, de la Rosa Alonso DI, Mejía Marín LJ, Benítez Can LDLÁ, Gutiérrez Martinez I, Jiménez Osorio MI, Echeandia N, Casillas E, Guerrero-Gomez K, Devidas M, Friedrich P. Evaluation of factors leading to poor outcomes for pediatric acute lymphoblastic leukemia in Mexico: a multi-institutional report of 2,116 patients. Front Oncol 2023; 13:1255555. [PMID: 37790759 PMCID: PMC10544893 DOI: 10.3389/fonc.2023.1255555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 08/21/2023] [Indexed: 10/05/2023] Open
Abstract
Background and aims Pediatric acute lymphoblastic leukemia (ALL) survival rates in low- and middle-income countries are lower due to deficiencies in multilevel factors, including access to timely diagnosis, risk-stratified therapy, and comprehensive supportive care. This retrospective study aimed to analyze outcomes for pediatric ALL at 16 centers in Mexico. Methods Patients <18 years of age with newly diagnosed B- and T-cell ALL treated between January 2011 and December 2019 were included. Clinical and biological characteristics and their association with outcomes were examined. Results Overall, 2,116 patients with a median age of 6.3 years were included. B-cell immunophenotype was identified in 1,889 (89.3%) patients. The median white blood cells at diagnosis were 11.2.5 × 103/mm3. CNS-1 status was reported in 1,810 (85.5%), CNS-2 in 67 (3.2%), and CNS-3 in 61 (2.9%). A total of 1,488 patients (70.4%) were classified as high-risk at diagnosis. However, in 52.5% (991/1,889) of patients with B-cell ALL, the reported risk group did not match the calculated risk group allocation based on National Cancer Institute (NCI) criteria. Fluorescence in situ hybridization (FISH) and PCR tests were performed for 407 (19.2%) and 736 (34.8%) patients, respectively. Minimal residual disease (MRD) during induction was performed in 1,158 patients (54.7%). The median follow-up was 3.7 years. During induction, 191 patients died (9.1%), and 45 patients (2.1%) experienced induction failure. A total of 365 deaths (17.3%) occurred, including 174 deaths after remission. Six percent (176) of patients abandoned treatment. The 5-year event-free survival (EFS) was 58.9% ± 1.7% for B-cell ALL and 47.4% ± 5.9% for T-cell ALL, while the 5-year overall survival (OS) was 67.5% ± 1.6% for B-cell ALL and 54.3% ± 0.6% for T-cell ALL. The 5-year cumulative incidence of central nervous system (CNS) relapse was 5.5% ± 0.6%. For the whole cohort, significantly higher outcomes were seen for patients aged 1-10 years, with DNA index >0.9, with hyperdiploid ALL, and without substantial treatment modifications. In multivariable analyses, age and Day 15 MRD continued to have a significant effect on EFS. Conclusion Outcomes in this multi-institutional cohort describe poor outcomes, influenced by incomplete and inconsistent risk stratification, early toxic death, high on-treatment mortality, and high CNS relapse rate. Adopting comprehensive risk-stratification strategies, evidence-informed de-intensification for favorable-risk patients and optimized supportive care could improve outcomes.
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Affiliation(s)
- Daniel C. Moreira
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Oscar González-Ramella
- Department of Pediatric Hematology/Oncology, Hospital Civil de Guadalajara Juan I. Menchaca, Guadalajara, Mexico
| | | | - Angela K. Carrillo
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Lane Faughnan
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Godwin Job
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Yichen Chen
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Cesar Villegas
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Andrea Ellis Irigoyen
- Department of Pediatric Oncology, Hospital Infantil Teletón de Oncología, Querétaro, Mexico
| | - Rosario Barra Urbays
- Department of Pediatric Oncology, Centro Estatal de Cancerologia Dr. Miguel Dorantes Mesa, Xalapa, Mexico
| | | | - Eduardo Altamirano Alvarez
- Department of Pediatric Hematology/Oncology, Hospital General con Especialidades “Juan María Salvatierra”, La Paz, Mexico
| | | | | | | | | | | | - Edna Liliana Tamez Gómez
- Department of Pediatric Hematology/Oncology, Hospital Infantil de Tamaulipas, Ciudad Victoria, Mexico
| | | | | | | | - Deyanira Cortés Alva
- Department of Pediatric Oncology, Hospital del Niño DIF Hidalgo, Pachuca, Mexico
| | - Paola Casillas Toral
- Department of Pediatric Hematology/Oncology, Hospital Civil de Guadalajara Juan I. Menchaca, Guadalajara, Mexico
| | - Karime Salas Villa
- Department of Pediatric Oncology, Hospital Pediátrico de Sinaloa, Culiacán, Mexico
| | | | - Carlos Pérez Alvarado
- Department of Pediatric Oncology, Centro Estatal de Cancerologia Dr. Miguel Dorantes Mesa, Xalapa, Mexico
| | | | - Margarita González Zamorano
- Department of Pediatric Hematology/Oncology, Hospital General con Especialidades “Juan María Salvatierra”, La Paz, Mexico
| | | | | | - Hernán Ramírez Durán
- Department of Pediatric Hematology, Hospital Universitario “José Eleuterio González”, Monterrey, Mexico
| | | | | | | | | | | | - Itzel Gutiérrez Martinez
- Department of Pediatric Hematology, Hospital Infantil de Morelia “Eva Sámano de López Mateos”, Morelia, Mexico
| | | | - Naomi Echeandia
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | | | | | - Meenakshi Devidas
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
| | - Paola Friedrich
- Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, United States
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Correa BT, Silva GSS, Mendes WJS, Maia ADM, Aleluia ACM, Fonseca TCC, da Guarda CC, Gonçalves MDS, Aleluia MM. Association of the clinical profile and overall survival of pediatric patients with acute lymphoblastic leukemia. Front Pediatr 2023; 11:1223889. [PMID: 37744444 PMCID: PMC10513176 DOI: 10.3389/fped.2023.1223889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 08/25/2023] [Indexed: 09/26/2023] Open
Abstract
Introduction The clarification of etiopathology, the improvement of chemotherapy regimens and their risk stratifications, and the improvement in treatment support have increased the survival of children and adolescents affected by Acute Lymphoblastic Leukemia (ALL) past few years. This study aimed to estimate overall survival (OS) and event-free survival (EFS) in an onco-hematology treatment center in Brazil, reports the main clinical-laboratory characteristics of patients at diagnosis, verify the frequency of treatment-related adverse effects and the main causes of death. Material and methods Retrospective analysis involving patients diagnosed with ALL, treated with the protocol of the Brazilian Group for Treatment of Leukemias in Childhood (GBTLI), between 2010 and 2020 was carried out; the outcomes (relapse, deaths, development of new neoplasms) were analyzed SPSS® software was used for the statistical analyses, and the p-value was considered significant when less than 0.05 for all analyses. Results 109 patients were included in the study; the median age was 5 years, with a slight predominance of males. Sixty-six patients were classified as high-risk (HR) group and 43 patients were classified as low-risk (LR) group. After 5 years of diagnosis, the OS was 71.5%, and the EFS was 65%. No statistical difference was found between the HR and LR groups for OS and EFS, while leukocyte counts were statistically associated with the outcome of death (p = 0.028). Among the patients, 28 (25.6%) died due to infection accounting 46.4% of death causes. Among the 34 patients with unfavorable outcomes (death and/or relapse), 32 had no research for the minimal residual disease at the end of remission induction, and 25 were not investigated for the presence of chromosomal abnormalities. The most reported complications and treatment-related adverse effects were increased liver transaminases (85.9%), airway infection (79.4%), oral mucositis (67.2%), febrile neutropenia (64.4%), and diarrhea (36.4%). Conclusions The rates of OS and EFS obtained in this cohort are similar to those obtained in the few previous similar studies in Brazil and lower than those carried out in developed countries. The unavailability of prognostic tests may have hindered risk stratification and influenced the results obtained.
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Affiliation(s)
- Bruno Terra Correa
- Departamento de Ciências Biológicas, Laboratório de Patologia Aplicada e Genética, Universidade Estadual de Santa Cruz, Ilhéus, Bahia, Brasil
| | - Gabriela Sales Serra Silva
- Departamento de Ciências Biológicas, Laboratório de Patologia Aplicada e Genética, Universidade Estadual de Santa Cruz, Ilhéus, Bahia, Brasil
| | - Webert Joaquim Silva Mendes
- Departamento de Ciências Biológicas, Laboratório de Patologia Aplicada e Genética, Universidade Estadual de Santa Cruz, Ilhéus, Bahia, Brasil
| | | | - Augusto Cezar Magalhães Aleluia
- Departamento de Ciências Naturais, Universidade Estadual do Sudoeste da Bahia-Campus de Vitória da Conquista, Vitória da Conquista, Bahia, Brasil
| | | | - Caroline Conceição da Guarda
- Departamento de Ciências Biológicas, Laboratório de Patologia Aplicada e Genética, Universidade Estadual de Santa Cruz, Ilhéus, Bahia, Brasil
| | - Marilda de Souza Gonçalves
- Laboratório de Investigação Genética e Hematologia Translacional, Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Bahia, Brasil
| | - Milena Magalhães Aleluia
- Departamento de Ciências Biológicas, Laboratório de Patologia Aplicada e Genética, Universidade Estadual de Santa Cruz, Ilhéus, Bahia, Brasil
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Lyseight FLS, Dupont COC, Cherubini GB. Intrathecal chemotherapy for the management of lymphoblastic lymphoma in a 4-year-old dog: a case report. Front Vet Sci 2023; 10:1209935. [PMID: 37732143 PMCID: PMC10507905 DOI: 10.3389/fvets.2023.1209935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 07/25/2023] [Indexed: 09/22/2023] Open
Abstract
Intrathecal chemotherapy is used in human medicine for the treatment or prophylaxis of CNS hematopoietic neoplasia. However, the clinical benefits in veterinary medicine have been scarcely documented. A 4-year-old male entire cross-breed dog presented with a 24-h history of severe lethargy, pelvic limb weakness, and urinary retention. Examination revealed generalized peripheral lymphadenomegaly, and the neurological findings were suggestive of a myelopathy in the region of T3-L3. Following the diagnosis of multicentric lymphoblastic B-cell lymphoma (stage Vb), a modified L-LOP with cytosine arabinoside was started, and complete clinical remission was achieved. After 4 weeks, there was acute neurological deterioration (spinal pain and proprioceptive deficits) without peripheral lymphadenomegaly. MRI findings and CSF analysis were consistent with meningeal and spinal cord lymphoma infiltration at the level of L3. Intrathecal chemotherapy (cytosine arabinoside and methotrexate) were administered in the cisterna magna with systemic dexamethasone and analgesia. Clinical signs were resolved within 24 h, and the patient remained asymptomatic for 3.5 weeks. After this period, CNS relapse (proprioceptive deficits and severe thoracolumbar pain) was suspected, and repeat intrathecal chemotherapy was declined. The patient was humanely euthanized 9 weeks after the initial diagnosis. This is the first report on the clinical benefit of intrathecal chemotherapy with a combination of methotrexate and cytarabine for the management of CNS lymphoma in dogs. Based on our case, intrathecal chemotherapy with methotrexate and cytarabine can induce a short-lasting CNS clinical remission (3 weeks).
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Affiliation(s)
| | | | - Giunio Bruto Cherubini
- Neurology and Neurosurgery Service, Dick White Referrals, Part of Linnaeus Veterinary Limited, Cambridgeshire, United Kingdom
- Department of Veterinary Sciences, University of Pisa, Pisa, Italy
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Cai J, Liu H, Chen Y, Yu J, Gao J, Jiang H, Zhai X, Ju X, Wu X, Wang N, Tian X, Liang C, Fang Y, Zhou F, Li H, Sun L, Yang L, Guo J, Liu A, Li CK, Zhu Y, Tang J, Yang JJ, Shen S, Cheng C, Pui CH. Effect of the tyrosine kinase inhibitors on the growth in children with Philadelphia chromosome-positive acute lymphoblastic leukemia: a case-control study. Lancet Reg Health West Pac 2023; 38:100818. [PMID: 37790080 PMCID: PMC10544282 DOI: 10.1016/j.lanwpc.2023.100818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/10/2023] [Accepted: 05/24/2023] [Indexed: 10/05/2023]
Abstract
Background First-generation ABL-targeted tyrosine kinase inhibitor (TKI) imatinib is known to retard growth in children but it is not known if the second-generation ABL-targeted TKI dasatinib has the same effect. We aimed to determine the impact of the first- or second-generation TKI on the growth of children treated for Philadelphia chromosome-positive (Ph+) childhood acute lymphoblastic leukemia (ALL). Methods We evaluated the longitudinal growth changes in 140 children with Ph+ ALL treated with imatinib or dasatinib in additional to intensive cytotoxic chemotherapy and 280 matched controls treated with the same intensity of cytotoxic chemotherapy without TKI on Chinese Children's Cancer Group ALL-2015 protocol between 2015 and 2019. We retrospectively reviewed the height data obtained during routine clinic visits at 4 time points: at diagnosis, the end of therapy, 1 year and 2 years off therapy. Height z Scores were derived with the aid of WHO Anthro version 3.2.2 and WHO AnthroPlus version 1.0.4, global growth monitoring tool. Findings This study consisted only patients who have completed all treatment in continuous complete remission without major events, including 33 patients randomized to receive imatinib, 43 randomized to receive dasatinib, and 64 assigned to receive dasatinib. Similar degree of loss of height z scores from diagnosis to the end of therapy was observed for the 33 imatinib- and the 107 dasatinib-treated patients (median △ = -0.84 vs. -0.88, P = 0.41). Adjusting for height z score at diagnosis, puberty status, and sex, there was no significant difference in the longitudinal mean height z scores between patients treated with imatinib and those with dasatinib (0.08, 95% CI, -0.22 to 0.38, P = 0.60). The degree of loss of height z scores from diagnosis to end of therapy was significantly greater in the 140 TKI-treated patients than the 280 controls (median △ = -0.88 vs. -0.18, P < 0.001). The longitudinal mean height z scores in the TKI-treated patients were significantly lower than those of the controls (-0.84, 95% CI, -0.98 to -0.69; P < 0.001). Interpretation These data suggest that dasatinib and imatinib have the similar adverse impact on the growth of children with Ph+ ALL. Funding This study was supported by the National Natural Science Foundation of China (grant 81670136 [JCai and JT]), the fourth round of Three-Year Public Health Action Plan (2015-2017; GWIV-25 [SS]), Shanghai Health Commission Clinical Research Project (202140161 [JCai]), the US National Cancer institute (CA21765 [C-H Pui]), and the American Lebanese Syrian Associated Charities (CC, JJY, and C-HP). The content of this paper is solely the responsibility of the authors and does not necessarily represent the official views of the US National Institutes of Health.
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Affiliation(s)
- Jiaoyang Cai
- Department of Hematology/Oncology, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Key Laboratory of Pediatric Hematology & Oncology of China Ministry of Health, and National Children’s Medical Center, Shanghai, China
| | - Hu Liu
- Department of Hematology/Oncology, Children's Hospital of Soochow University, Suzhou, China
| | - Yumei Chen
- Department of Pediatrics, State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Jie Yu
- Department of Hematology/Oncology, Chongqing Medical University Affiliated Children's Hospital, Chongqing, China
| | - Ju Gao
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Key Laboratory of Birth Defects and Related Disease of Women and Children, Ministry of Education, Chengdu, China
| | - Hua Jiang
- Department of Hematology/Oncology, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Xiaowen Zhai
- Department of Hematology/Oncology, Children's Hospital of Fudan University, Shanghai, China
| | - Xiuli Ju
- Department of Pediatrics, Qilu Hospital of Shandong University, Jinan, China
| | - Xuedong Wu
- Department of Pediatrics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ningling Wang
- Department of Pediatrics, Anhui Medical University Second Affiliated Hospital, Anhui, China
| | - Xin Tian
- Department of Hematology/Oncology, KunMing Children’s Hospital, Kunming, China
| | - Changda Liang
- Department of Hematology/Oncology, Jiangxi Provincial Children's Hospital, Nanchang, China
| | - Yongjun Fang
- Department of Hematology/Oncology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Fen Zhou
- Department of Pediatrics, Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hong Li
- Department of Hematology/Oncology, Shanghai Children's Hospital, Shanghai, China
| | - Lirong Sun
- Department of Pediatrics, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Liangchun Yang
- Department of Pediatrics, Xiangya Hospital Central South University, Changsha, China
| | - Jing Guo
- Department of Hematology/Oncology, Xi 'an Northwest Women's and Children's Hospital, Xi 'an, China
| | - Aiguo Liu
- Department of Pediatrics, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chi-kong Li
- Department of Pediatrics, Hong Kong Children’s Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Yiping Zhu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Key Laboratory of Birth Defects and Related Disease of Women and Children, Ministry of Education, Chengdu, China
| | - Jingyan Tang
- Department of Hematology/Oncology, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Key Laboratory of Pediatric Hematology & Oncology of China Ministry of Health, and National Children’s Medical Center, Shanghai, China
| | - Jun J. Yang
- Departments of Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Shuhong Shen
- Department of Hematology/Oncology, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Key Laboratory of Pediatric Hematology & Oncology of China Ministry of Health, and National Children’s Medical Center, Shanghai, China
| | - Cheng Cheng
- Departments of Biostatistics, St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Ching-Hon Pui
- Departments of Oncology, Pathology, and Global Pediatric Medicine, St. Jude Children’s Research Hospital, Memphis, TN, USA
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Hoshitsuki K, Zhou Y, Miller AM, Choi JK, Swanson HD, Bhakta NH, Jeha S, Karol SE, Ribeiro RC, Rubnitz JE, Mullighan CG, Cheng C, Yang JJ, Relling MV, Pui CH, Inaba H. Rituximab administration in pediatric patients with newly diagnosed acute lymphoblastic leukemia. Leukemia 2023; 37:1782-1791. [PMID: 37543655 PMCID: PMC10666913 DOI: 10.1038/s41375-023-01992-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 07/18/2023] [Accepted: 07/27/2023] [Indexed: 08/07/2023]
Abstract
Polyethylene glycol (PEG)-asparaginase (pegaspargase) is a key agent in chemotherapy for acute lymphoblastic leukemia (ALL), but recipients frequently experience allergic reactions. We hypothesized that by decreasing antibody-producing CD20-positive B cells, rituximab may reduce these reactions. Children and adolescents (aged 1-18 years) with newly diagnosed B-ALL treated on the St. Jude Total XVII study were randomized to induction therapy with or without rituximab on day 3 (cohort 1) or on days 6 and 24 (cohort 2). Patient clinical demographics, CD20 expression, minimal residual disease (MRD), rituximab reactions, pegaspargase allergy, anti-pegaspargase antibodies, and pancreatitis were evaluated. Thirty-five patients received rituximab and 37 did not. Among the 35 recipients, 16 (45.7%) experienced a grade 2 or higher reaction to rituximab. There were no differences between recipients and non-recipients in the incidence of pegaspargase reactions (P > 0.999), anti-pegaspargase antibodies (P = 0.327), or pancreatitis (P = 0.480). CD20 expression on day 8 was significantly lower in rituximab recipients (P < 0.001), but there were no differences in MRD levels on day 8, 15, or at the end of induction. Rituximab administration during induction in pediatric patients with B-ALL was associated with a high incidence of infusion reactions with no significant decrease in pegaspargase allergies, anti-pegaspargase antibodies, or MRD.
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Affiliation(s)
- Keito Hoshitsuki
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Yinmei Zhou
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - April M Miller
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - John K Choi
- Department of Pathology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Hope D Swanson
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Nickhill H Bhakta
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Sima Jeha
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Seth E Karol
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Raul C Ribeiro
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Jeffrey E Rubnitz
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Charles G Mullighan
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Cheng Cheng
- Department of Biostatistics, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Jun J Yang
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Mary V Relling
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Ching-Hon Pui
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Hiroto Inaba
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA.
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Kourti M, Aivaliotis M, Hatzipantelis E. Proteomics in Childhood Acute Lymphoblastic Leukemia: Challenges and Opportunities. Diagnostics (Basel) 2023; 13:2748. [PMID: 37685286 PMCID: PMC10487225 DOI: 10.3390/diagnostics13172748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/20/2023] [Accepted: 08/21/2023] [Indexed: 09/10/2023] Open
Abstract
Acute lymphoblastic leukemia (ALL) is the most common cancer in children and one of the success stories in cancer therapeutics. Risk-directed therapy based on clinical, biologic and genetic features has played a significant role in this accomplishment. Despite the observed improvement in survival rates, leukemia remains one of the leading causes of cancer-related deaths. Implementation of next-generation genomic and transcriptomic sequencing tools has illustrated the genomic landscape of ALL. However, the underlying dynamic changes at protein level still remain a challenge. Proteomics is a cutting-edge technology aimed at deciphering the mechanisms, pathways, and the degree to which the proteome impacts leukemia subtypes. Advances in mass spectrometry enable high-throughput collection of global proteomic profiles, representing an opportunity to unveil new biological markers and druggable targets. The purpose of this narrative review article is to provide a comprehensive overview of studies that have utilized applications of proteomics in an attempt to gain insight into the pathogenesis and identification of biomarkers in childhood ALL.
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Affiliation(s)
- Maria Kourti
- Third Department of Pediatrics, School of Medicine, Aristotle University and Hippokration General Hospital, 54642 Thessaloniki, Greece
| | - Michalis Aivaliotis
- Laboratory of Biological Chemistry, School of Medicine, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece;
| | - Emmanouel Hatzipantelis
- Children & Adolescent Hematology-Oncology Unit, Second Department of Pediatrics, School of Medicine, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece;
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Ariffin H, Chiew EKH, Oh BLZ, Lee SHR, Lim EH, Kham SKY, Abdullah WA, Chan LL, Foo KM, Lam JCM, Chan YH, Lin HP, Quah TC, Tan AM, Yeoh AEJ. Anthracycline-Free Protocol for Favorable-Risk Childhood ALL: A Noninferiority Comparison Between Malaysia-Singapore ALL 2003 and ALL 2010 Studies. J Clin Oncol 2023:JCO2202347. [PMID: 37276496 DOI: 10.1200/jco.22.02347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 03/10/2023] [Accepted: 04/17/2023] [Indexed: 06/07/2023] Open
Abstract
PURPOSE To investigate whether, for children with favorable-risk B-cell precursor ALL (BCP-ALL), an anthracycline-free protocol is noninferior to a modified Berlin-Frankfurt-Muenster ALL-IC2002 protocol, which includes 120 mg/m2 of anthracyclines. PATIENTS AND METHODS Three hundred sixty-nine children with favorable-risk BCP-ALL (age 1-9 years, no extramedullary disease, and no high-risk genetics) who cleared minimal residual disease (≤0.01%) at the end of remission induction were enrolled into Ma-Spore (MS) ALL trials. One hundred sixty-seven standard-risk (SR) patients (34% of Malaysia-Singapore ALL 2003 study [MS2003]) were treated with the MS2003-SR protocol and received 120 mg/m2 of anthracyclines during delayed intensification while 202 patients (42% of MS2010) received an anthracycline-free successor protocol. The primary outcome was a noninferiority margin of 1.15 in 6-year event-free survival (EFS) between the MS2003-SR and MS2010-SR cohorts. RESULTS The 6-year EFS of MS2003-SR and MS2010-SR (anthracycline-free) cohorts was 95.2% ± 1.7% and 96.5% ± 1.5%, respectively (P = .46). The corresponding 6-year overall survival was 97.6% and 99.0% ± 0.7% (P = .81), respectively. The cumulative incidence of relapse was 3.6% and 2.6%, respectively (P = .42). After adjustment for race, sex, age, presenting WBC, day 8 prednisolone response, and favorable genetic subgroups, the hazard ratio for MS2010-SR EFS was 0.98 (95% CI, 0.84 to 1.14; P = .79), confirming noninferiority. Compared with MS2003-SR, MS2010-SR had significantly lower episodes of bacteremia (30% v 45.6%; P = .04) and intensive care unit admissions (1.5% v 9.5%; P = .004). CONCLUSION In comparison with MS2003-SR, the anthracycline-free MS2010-SR protocol is not inferior and was less toxic as treatment for favorable-risk childhood BCP-ALL.
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Affiliation(s)
| | | | - Bernice Ling Zhi Oh
- National University of Singapore, Singapore, Singapore
- National University Hospital, Singapore, Singapore
| | - Shawn Hsien Ren Lee
- National University of Singapore, Singapore, Singapore
- National University Hospital, Singapore, Singapore
| | | | | | | | - Lee Lee Chan
- Subang Jaya Medical Centre, Subang Jaya, Malaysia
| | - Koon Mian Foo
- KK Women's and Children's Hospital, Singapore, Singapore
| | | | | | - Hai Peng Lin
- Subang Jaya Medical Centre, Subang Jaya, Malaysia
| | - Thuan Chong Quah
- National University of Singapore, Singapore, Singapore
- National University Hospital, Singapore, Singapore
| | - Ah Moy Tan
- KK Women's and Children's Hospital, Singapore, Singapore
| | - Allen Eng Juh Yeoh
- National University of Singapore, Singapore, Singapore
- National University Hospital, Singapore, Singapore
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Talleur AC, Pui CH, Karol SE. What is Next in Pediatric B-cell Precursor Acute Lymphoblastic Leukemia. Lymphatics 2023; 1:34-44. [PMID: 38269058 PMCID: PMC10804398 DOI: 10.3390/lymphatics1010005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
Cure rates now exceed 90% in many contemporary trials for children with B-cell acute lymphoblastic leukemia (ALL). However, treatment remains suboptimal and therapy is toxic for all patients. New treatment options potentially offer the chance to reduce both treatment resistance and toxicity. Here, we review recent advances in ALL diagnostics, chemotherapy, and immunotherapy. In addition to describing recently published results, we also attempt to project the impact of these new developments into the future to imagine what B-ALL therapy may look like in the next few years.
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Affiliation(s)
- Aimee C Talleur
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Ching-Hon Pui
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Seth E Karol
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
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Rizzari C, Möricke A, Valsecchi MG, Conter V, Zimmermann M, Silvestri D, Attarbaschi A, Niggli F, Barbaric D, Stary J, Elitzur S, Cario G, Vinti L, Boos J, Zucchetti M, Lanvers-Kaminsky C, von Stackelberg A, Biondi A, Schrappe M. Incidence and Characteristics of Hypersensitivity Reactions to PEG-asparaginase Observed in 6136 Children With Acute Lymphoblastic Leukemia Enrolled in the AIEOP-BFM ALL 2009 Study Protocol. Hemasphere 2023; 7:e893. [PMID: 37275740 PMCID: PMC10237686 DOI: 10.1097/hs9.0000000000000893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 04/12/2023] [Indexed: 06/07/2023] Open
Abstract
The incidence of hypersensitivity reactions (HSRs) to PEG-asparaginase (PEG-ASNase) was evaluated in 6136 children with ALL enrolled in the AIEOP-BFM ALL 2009 study. Patients with B-cell precursor-acute lymphoblastic leukemia (BCP-ALL) were stratified as standard-risk/medium-risk (MR)/high-risk (HR) and those with T-ALL as non-High/HR. PEG-ASNase was administered intravenously at 2500 IU/sqm/dose. All patients received 2 PEG-ASNase doses in induction; thereafter non-HR versus HR patients received 1 versus 6 PEG-ASNase doses, respectively. After the single regular dose of PEG-ASNase at the beginning of delayed intensification, BCP-ALL-MR patients were randomized to receive 9 additional PEG-ASNase doses every 2 weeks (experimental arm [EA]) versus none (standard arm [SA]); HR patients were randomized to receive, in consolidation, 4 weekly PEG-ASNase doses (EA) versus none (SA). The HSR cumulative incidence (CI) was estimated adjusting for competing risks. An HSR occurred in 472 of 6136 (7.7%) patients. T-non- HR/BCP-Standard-Risk, BCP-MR-SA, BCP-MR-EA, HR-SA and HR-EA patients had 1-year-CI-HSR (±SE) rates of 5.2% (0.5), 5.2% (0.5), 4.0% (0.8), 20.2% (1.2), and 6.4% (1.3), respectively. The randomized intensification of PEG-ASNase did not significantly impact on HSR incidence in BCP-MR patients (1-y-CI-HSR 3.8% [0.8] versus 3.2% [0.6] in MR-EA versus MR-SA; P = 0.55), while impacted significantly in HR patients (1-y-CI-HSR 6.4% [1.3] versus 17.9% [1.8] in HR-EA and HR-SA, respectively; P < 0.001). The CI-HSR was comparable among non-HR groups and was not increased by a substantial intensification of PEG-ASNase in the BCP-MR-EA group whilst it was markedly higher in HR-SA than in HR-EA patients, suggesting that, in such a chemotherapy context, a continuous exposure to PEG-ASNase reduces the risk of developing an HSR.
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Affiliation(s)
- Carmelo Rizzari
- Department of Pediatrics, IRCCS San Gerardo dei Tintori Foundation, Monza, Italy; Department of Medicine and Surgery, University of MIlano-Bicocca, Milano, Italy
| | - Anja Möricke
- Department of Pediatrics I, Pediatric Hematology/Oncology, ALL-BFM Study Group, Christian Albrechts University Kiel and University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Maria Grazia Valsecchi
- Department of Pediatrics, IRCCS San Gerardo dei Tintori Foundation, Monza, Italy; Department of Medicine and Surgery, University of MIlano-Bicocca, Milano, Italy
- Bicocca Center of Bioinformatics, Biostatistics and Bioimaging, School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Valentino Conter
- Department of Pediatrics, IRCCS San Gerardo dei Tintori Foundation, Monza, Italy; Department of Medicine and Surgery, University of MIlano-Bicocca, Milano, Italy
| | - Martin Zimmermann
- Department of Pediatric Hematology/Oncology, Hannover Medical School, Hannover, Germany
| | - Daniela Silvestri
- Department of Pediatrics, IRCCS San Gerardo dei Tintori Foundation, Monza, Italy; Department of Medicine and Surgery, University of MIlano-Bicocca, Milano, Italy
- Bicocca Center of Bioinformatics, Biostatistics and Bioimaging, School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Andishe Attarbaschi
- Department of Pediatric Hematology and Oncology, St. Anna Children's Hospital, Medical University of Vienna, Austria
- St. Anna Children's Cancer Research Institute (CCRI), Vienna, Austria
| | - Felix Niggli
- University Children's Hospital, Zurich, Switzerland
| | - Draga Barbaric
- Cancer Centre for Children, Sydney Children's Hospital Network, Westmead, NSW, Australia
| | - Jan Stary
- Department of Pediatric Haematology and Oncology, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Sarah Elitzur
- Pediatric Hematology-Oncology, Schneider Children's Medical Center, Petah Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Petah Tikva, Israel
| | - Gunnar Cario
- Department of Pediatrics I, Pediatric Hematology/Oncology, ALL-BFM Study Group, Christian Albrechts University Kiel and University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Luciana Vinti
- Department of Onco-Hematology and Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Joachim Boos
- Department of Pediatric Hematology and Oncology, University Childrens' Hospital of Münster, Germany
| | - Massimo Zucchetti
- Department of Oncology Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Laboratory of Cancer Pharmacology, Milano, Italy
| | - Claudia Lanvers-Kaminsky
- Department of Pediatric Hematology and Oncology, University Childrens' Hospital of Münster, Germany
| | - Arend von Stackelberg
- Department of Pediatric Hematology and Oncology, Charité and Rudolf-Virchow-Hospital, Berlin, Germany
| | - Andrea Biondi
- Department of Pediatrics, IRCCS San Gerardo dei Tintori Foundation, Monza, Italy; Department of Medicine and Surgery, University of MIlano-Bicocca, Milano, Italy
| | - Martin Schrappe
- Department of Pediatrics I, Pediatric Hematology/Oncology, ALL-BFM Study Group, Christian Albrechts University Kiel and University Hospital Schleswig-Holstein, Campus Kiel, Germany
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Lynggaard LS, Rank CU, Als-Nielsen B, Hoejfeldt SG, Heyman M, Schmiegelow K, Albertsen BK. PEG-asparaginase treatment regimens for acute lymphoblastic leukaemia in children: a network meta-analysis. Cochrane Database Syst Rev 2023; 5:CD014570. [PMID: 37260073 PMCID: PMC10230854 DOI: 10.1002/14651858.cd014570.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Asparaginase has played a crucial role in the improvement of survival in children with acute lymphoblastic leukaemia (ALL), which is the commonest cancer among children. Survival rates have steadily increased over decades since the introduction of asparaginase to ALL therapy, and overall survival rates reach 90% with the best contemporary protocols. Currently, polyethylene glycolated native Escherichia coli-derived L-asparaginase (PEG-asparaginase) is the preferred first-line asparaginase preparation. Besides its clinical benefits, PEG-asparaginase is well known for severe toxicities. Agreement on the optimal dose, treatment duration, and frequency of administration has never been reached among clinicians. OBJECTIVES Primary objective To assess the effect of the number of PEG-asparaginase doses on survival and relapse in children and adolescents with ALL. Secondary objectives To assess the association between the number of doses of PEG-asparaginase and asparaginase-associated toxicities (e.g. hypersensitivity, thromboembolism, pancreatitis and osteonecrosis). To undertake a network meta-analysis at dose-level in order to generate rankings of the number of doses of PEG-asparaginase used in the treatment for ALL, according to their benefits (survival and relapse) and harms (toxicity). SEARCH METHODS We searched CENTRAL, PubMed, Embase, Web of Science databases and three trials registers in November 2021, together with reference checking, citation searching and contact with study authors to identify additional studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing different PEG-asparaginase treatment regimens in children and adolescents (< 18 years of age) with first-line ALL treated with multiagent chemotherapy including PEG-asparaginase. DATA COLLECTION AND ANALYSIS Using a standardised data collection form, two review authors independently screened and selected studies, extracted data, assessed risk of bias for each outcome using a standardised tool (RoB 2.0) and assessed the certainty of evidence for each outcome using the GRADE approach. Primary outcomes included overall survival, event-free survival and leukaemic relapse. Secondary outcomes included asparaginase-associated toxicities (hypersensitivity, thromboembolism, pancreatitis, sinusoidal obstruction syndrome and osteonecrosis as well as overall asparaginase-associated toxicity). We conducted the review and performed the analyses in accordance with the guidelines of the Cochrane Handbook for Systematic Reviews of Interventions. MAIN RESULTS We included three RCTs in the review, and identified an additional four ongoing studies. We judged outcomes of two RCTs to be at low risk of bias in all the Cochrane risk of bias (RoB 2) domains. We rated the remaining study as having some concerns regarding bias. Due to concerns about imprecision, we rated all outcomes as having low- to moderate-certainty evidence. One study compared intermittent PEG-asparaginase treatment (eight doses of PEG-asparaginase, 1000 IU/m2, intramuscular (IM) administration) versus continuous PEG-asparaginase treatment (15 doses of PEG-asparaginase, 1000 IU/m2, IM) in 625 participants with non-high risk ALL aged 1.0 to 17.9 years. We found that treatment with eight doses probably results in little to no difference in event-free survival compared to treatment with 15 doses (RR 1.01, 95% CI 0.97 to 1.06; moderate-certainty evidence). Compared to treatment with 15 doses, treatment with eight doses may result in either no difference or a slight reduction in hypersensitivity (RR 0.64, 95% CI 0.21 to 1.93; low-certainty evidence), thromboembolism (RR 0.55, 95% CI 0.22 to 1.36; low-certainty evidence) or osteonecrosis (RR 0.68, 95% CI 0.35 to 1.32; low-certainty evidence). Furthermore, we found that treatment with eight doses probably reduces pancreatitis (RR 0.31, 95% CI 0.12 to 0.75; moderate-certainty evidence) and asparaginase-associated toxicity (RR 0.53, 95% CI 0.35 to 0.78; moderate-certainty evidence) compared to treatment with 15 doses. One study compared low-risk standard treatment with additional PEG-asparaginase (six doses, 2500 IU/m2, IM) versus low-risk standard treatment (two doses, 2500 IU/m2, IM) in 1857 participants aged one to nine years old with standard low-risk ALL. We found that, compared to treatment with two doses, treatment with six doses probably results in little to no difference in overall survival (RR 0.99, 95% CI 0.98 to 1.00; moderate-certainty evidence) and event-free survival (RR 1.01, 95% CI 0.99 to 1.04; moderate-certainty evidence), and may result in either no difference or a slight increase in osteonecrosis (RR 1.65, 95% CI 0.91 to 3.00; low-certainty evidence). Furthermore, we found that treatment with six doses probably increases hypersensitivity (RR 12.05, 95% CI 5.27 to 27.58; moderate-certainty evidence), pancreatitis (RR 4.84, 95% CI 2.15 to 10.85; moderate-certainty evidence) and asparaginase-associated toxicity (RR 4.49, 95% CI 3.05 to 6.59; moderate-certainty evidence) compared to treatment with two doses. One trial compared calaspargase (11 doses, 2500 IU/m2, intravenous (IV)) versus PEG-asparaginase (16 doses, 2500 IU/m2, IV) in 239 participants aged one to 21 years with standard- and high-risk ALL and lymphoblastic lymphoma. We found that treatment with 11 doses of calaspargase probably results in little to no difference in event-free survival compared to treatment with 16 doses of PEG-asparaginase (RR 1.06, 95% CI 0.97 to 1.16; moderate-certainty evidence). However, treatment with 11 doses of calaspargase probably reduces leukaemic relapse compared to treatment with 16 doses of PEG-asparaginase (RR 0.32, 95% CI 0.12 to 0.83; moderate-certainty evidence). Furthermore, we found that treatment with 11 doses of calaspargase results in either no difference or a slight reduction in hypersensitivity (RR 1.17, 95% CI 0.64 to 2.13; low-certainty evidence), pancreatitis (RR 0.85, 95% CI 0.47 to 1.52; low-certainty evidence), thromboembolism (RR 0.83, 95% CI 0.48 to 1.42; low-certainty evidence), osteonecrosis (RR 0.63, 95% CI 0.15 to 2.56; low-certainty evidence) and asparaginase-associated toxicity (RR 1.00, 95% CI 0.71 to 1.40; low-certainty evidence) compared to treatment with 16 doses of PEG-asparaginase. AUTHORS' CONCLUSIONS We were not able to conduct a network meta-analysis, and could not draw clear conclusions because it was not possible to rank the interventions. Overall, we found that different numbers of doses of PEG-asparaginase probably result in little to no difference in event-free survival across all studies. In two studies, we found that a higher number of PEG-asparaginase doses probably increases pancreatitis and asparaginase-associated toxicities.
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Affiliation(s)
- Line Stensig Lynggaard
- Department of Child and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Cecilie U Rank
- Department of Haematology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Bodil Als-Nielsen
- Department of Paediatric Haematology/Oncology (5054), The Child and Youth Clinic, Copenhagen, Denmark
| | - Sofie G Hoejfeldt
- Department of Child and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Mats Heyman
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Kjeld Schmiegelow
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Birgitte K Albertsen
- Department of Child and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
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Sato A, Hatta Y, Imai C, Oshima K, Okamoto Y, Deguchi T, Hashii Y, Fukushima T, Hori T, Kiyokawa N, Kato M, Saito S, Anami K, Sakamoto T, Kosaka Y, Suenobu S, Imamura T, Kada A, Saito AM, Manabe A, Kiyoi H, Matsumura I, Koh K, Watanabe A, Miyazaki Y, Horibe K. Nelarabine, intensive L-asparaginase, and protracted intrathecal therapy for newly diagnosed T-cell acute lymphoblastic leukaemia in children and young adults (ALL-T11): a nationwide, multicenter, phase 2 trial including randomisation in the very high-risk group. Lancet Haematol 2023:S2352-3026(23)00072-8. [PMID: 37167992 DOI: 10.1016/s2352-3026(23)00072-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/07/2023] [Accepted: 03/09/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND T-cell acute lymphoblastic leukaemia has distinct biological characteristics and a poorer prognosis than B-cell precursor acute lymphoblastic leukaemia. This trial aimed to reduce the rate of radiation and haematopoietic stem-cell transplantation (HSCT) while improving outcomes by adding nelarabine, intensified L-asparaginase, and protracted intrathecal therapy in the Berlin-Frankfurt-Münster (BFM)-type treatment. METHODS In this nationwide, multicenter, phase 2 trial, we enrolled patients with newly diagnosed T-cell acute lymphoblastic leukaemia (age <25 years at diagnosis) conducted by Japan Children's Cancer Group and Japan Adult Leukemia Study Group. Patients were stratified into standard-risk, high-risk, and very-high-risk groups according to prednisolone response, CNS status, and end-of-consolidation minimal residual disease. We used the Associazione Italiana di Ematologia Oncologia Pediatrica (AIEOP)-BFM-ALL 2000-backbone chemotherapy. Nelarabine (650 mg/m2 per day for 5 days) was given to high-risk and very high-risk patients. All patients received, until the measurement of end-of-consolidation minimal residual disease, an identical therapy schedule, which included the prednisolone pre-phase remission induction therapy with dexamethasone (10 mg/m2 per day, for 3 weeks [for patients <10 years] or for 2 weeks including a 7-day off interval [for patients ≥10 years]) instead of prednisolone, and consolidation therapy added with Escherichia coli-derived L-asparaginase. On the basis of the stratification, patients received different intensities of treatment; L-asparaginase-intensified standard BFM-type therapy for standard risk and nelarabine-added high risk BFM-type therapy for high risk. In the very high-risk group, patients were randomly assigned (1:1) to group A (BFM-based block therapy) and group B (another block therapy, including high-dose dexamethasone) stratified by hospital, age (≥18 years or <18 years), and end-of-induction bone marrow blast percentage of M1 (<5%) or M2 (≥5%, <25%)+M3 (≥25%). Cranial radiotherapy was limited to patients with overt CNS disease at diagnosis (CNS3; >5 white blood cells per μL with blasts) and patients with no evidence of CNS disease received protracted triple intrathecal therapy. Only very high-risk patients were scheduled to receive HSCT. The primary endpoint was 3-year event-free survival for the entire cohort and the proportion of patients with disappearance of minimal residual disease between randomly assigned groups A and B in the very high-risk group. Secondary endpoints were overall survival, remission induction rate, and occurrence of adverse events. 3 years after the completion of patient accrual, a primary efficacy analysis was performed in the full analysis set and the per-protocol set. This study is registered with the Japan Registry of Clinical Trials, jRCTs041180145. FINDINGS Between Dec 1, 2011, and Nov 30, 2017, of 349 eligible patients (median age 9 years [IQR 6-13]), 238 (68%) were male, and 28 (8%) patients had CNS3 status. 168 (48%) patients were stratified as standard risk, 103 (30%) as high risk, 39 (11%) as very high risk, and 39 (11%) as no risk (patients who had off protocol treatment before risk assessment. The composite complete remission (complete remission plus complete remission in suppression) rate after remission induction therapy was 89% (298 of 335 patients). HSCT was performed in 35 (10%) of 333 patients. With a median follow-up of 5·2 years (IQR 3·6-6·7), 3-year event-free survival was 86·4% (95% CI 82·3-89·7%) and 3-year overall survival was 91·3% (87·7-93·8%). The proportion of minimal residual disease disappearance was 0·86 (12 of 14 patients; 95% CI 0·57-0·98) in group A and 0·50 (6 of 12 patients, 0·21-0·79) in group B. Grade 3 peripheral motor neuropathy was seen in 11 (3%) of 349 patients and sensory neuropathy was seen in 6 (2%) patients. The most common grade 3 or worse adverse event was febrile neutropenia (294 [84%] of 349 patients). Treatment-related death occurred in three patients due to sepsis, gastric perforation, or intracranial haemorrhage during remission induction. INTERPRETATION The ALL-T11 protocol produced encouraging outcomes with acceptable toxicities despite limited cranial radiotherapy and HSCT use. FUNDING Ministry of Health, Labor and Welfare of Japan, and Japan Agency for Medical Research and Development. TRANSLATION For the Japanese translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Atsushi Sato
- Department of Hematology and Oncology, Miyagi Children's Hospital, Sendai, Japan.
| | - Yoshihiro Hatta
- Department of Hematology and Rheumatology, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Chihaya Imai
- Department of Pediatrics, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Koichi Oshima
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Yasuhiro Okamoto
- Department of Pediatrics, Kagoshima University Hospital, Kagoshima, Japan
| | - Takao Deguchi
- Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Yoshiko Hashii
- Department of Pediatrics, Osaka University, Osaka, Japan
| | - Takashi Fukushima
- Department of Pediatrics, University of Tsukuba Hospital, Tsukuba, Japan
| | - Toshinori Hori
- Department of Pediatrics, Aichi Medical University Hospital, Aich, Japan
| | - Nobutaka Kiyokawa
- Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Motohiro Kato
- Department of Pediatrics, The University of Tokyo, Tokyo, Japan
| | - Shoji Saito
- Department of Pediatrics, Shinshu University Hospital, Matsumoto, Japan
| | - Kenichi Anami
- Department of Medical Oncology, Hematology, and Infectious Diseases, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Tatsuhiro Sakamoto
- Department of Hematology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Yoshiyuki Kosaka
- Department of Hematology/Oncology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Souichi Suenobu
- Department of Pediatrics, Oita University Hospital, Oita, Japan
| | - Toshihiko Imamura
- Department of Pediatrics, University Hospital Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Akiko Kada
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Akiko M Saito
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Atsushi Manabe
- Department of Pediatrics, Hokkaido University Hospital, Sapporo, Japan
| | - Hitoshi Kiyoi
- Department of Hematology and Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Itaru Matsumura
- Department of Hematology and Rheumatology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Katsuyoshi Koh
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Arata Watanabe
- Department of Pediatrics, Nakadori General Hospital, Akita, Japan
| | - Yasushi Miyazaki
- Department of Hematology, Atomic Bomb Disease and Hibakusha Medicine Unit, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Keizo Horibe
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
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Yu H, Han J, Wu X, Qiu Y, Yu H, Xu J, Hao J, Peng Y, Jin R, Zhou F. Hypothyroidism in induction chemotherapy of children with acute lymphoblastic leukaemia: A single-centre study. Int J Cancer 2023. [PMID: 37144811 DOI: 10.1002/ijc.34535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 03/09/2023] [Accepted: 03/13/2023] [Indexed: 05/06/2023]
Abstract
Hypothyroidism as a long-term complication in cancer survivors has been an issue, but few studies have focused on changes in thyroid hormone levels during chemotherapy for leukaemia. This retrospective study was conducted to assess the characteristics of children with acute lymphoblastic leukaemia (ALL) and hypothyroidism during induction chemotherapy and to investigate the prognostic value of hypothyroidism in ALL. Patients with a detailed thyroid hormone profile at ALL diagnosis were enrolled. Hypothyroidism was defined as low serum levels of free tetraiodothyronine (FT4) and/or free triiodothyronine (FT3). The Kaplan-Meier method was used to create survival curves, and multivariate Cox regression analysis was used to screen prognostic factors associated with progression-free survival (PFS) and overall survival (OS). There were 276 children eligible for the study, and 184 patients (66.67%) were diagnosed with hypothyroidism, including 90 cases (48.91%) with functional central hypothyroidism and 82 cases (44.57%) with low T3 syndrome. Hypothyroidism was correlated with the dosages of L-Asparaginase (L-Asp) (P = .004) and glucocorticoids (P = .010), central nervous system (CNS) status (P = .012), number of severe infections (grade 3, 4 or 5) (P = .026) and serum albumin level (P = .032). Hypothyroidism was an independent prognostic factor for PFS in ALL children (P = .024, 95% CI: 1.1-4.1). We conclude that hypothyroidism is commonly present in ALL children during induction remission, which is related to chemotherapy drugs and severe infections. Hypothyroidism was a predictor of poor prognosis in childhood ALL.
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Affiliation(s)
- Hui Yu
- Department of Paediatrics, Union Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Juan Han
- Department of Paediatrics, Union Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Xiaoyan Wu
- Department of Paediatrics, Union Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Yining Qiu
- Department of Paediatrics, Union Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Hui Yu
- Department of Paediatrics, Union Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Jiawei Xu
- Department of Paediatrics, Union Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Jinjin Hao
- Department of Paediatrics, Union Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Yun Peng
- Department of Paediatrics, Union Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Runming Jin
- Department of Paediatrics, Union Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Fen Zhou
- Department of Paediatrics, Union Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
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Campbell M, Kiss C, Zimmermann M, Riccheri C, Kowalczyk J, Felice MS, Kuzmanovic M, Kovacs G, Kosmidis H, Gonzalez A, Bilic E, Castillo L, Kolenova A, Jazbec J, Popa A, Konstantinov D, Kappelmayer J, Szczepanski T, Dworzak M, Buldini B, Gaipa G, Marinov N, Rossi J, Nagy A, Gaspar I, Stary J, Schrappe M. Childhood Acute Lymphoblastic Leukemia: Results of the Randomized Acute Lymphoblastic Leukemia Intercontinental-Berlin-Frankfurt-Münster 2009 Trial. J Clin Oncol 2023:JCO2201760. [PMID: 37141547 DOI: 10.1200/jco.22.01760] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023] Open
Abstract
PURPOSE The International Berlin-Frankfurt-Münster (BFM) study group conducted a study on pediatric acute lymphoblastic leukemia (ALL). Minimal residual disease (MRD) was assessed using flow cytometry (FCM), and the impact of early intensification and methotrexate (MTX) dose on survival was evaluated. PATIENTS AND METHODS We included 6,187 patients younger than 19 years. MRD by FCM refined the risk group definition previously used in the ALL intercontinental-BFM 2002 study on the basis of age, WBC count, unfavorable genetic aberrations, and treatment response measured morphologically. Patients at intermediate risk (IR) and high risk (HR) were randomly assigned to protocol augmented protocol I phase B (IB) versus IB regimen. MTX doses of 2 versus 5 g/m2 every 2 weeks, four times, were evaluated in precursor B-cell-ALL (pcB-ALL) IR. RESULTS The 5-year event-free survival (EFS ± SE) and overall survival (OS ± SE) rates were 75.2% ± 0.6% and 82.6% ± 0.5%, respectively. Their values in risk groups were standard risk (n = 624), 90.7% ± 1.4% and 94.7% ± 1.1%; IR (n = 4,111), 77.9% ± 0.7% and 85.7% ± 0.6%; and HR (n = 1,452), 60.8% ± 1.5% and 68.4% ± 1.4%, respectively. MRD by FCM was available in 82.6% of cases. The 5-year EFS rates in patients randomly assigned to protocol IB (n = 1,669) and augmented IB (n = 1,620) were 73.6% ± 1.2% and 72.8% ± 1.2%, respectively (P = .55), while those in patients receiving MTX doses of 2 g/m2 (n = 1,056) and MTX 5 g/m2 (n = 1,027) were 78.8% ± 1.4% and 78.9% ± 1.4%, respectively (P = .84). CONCLUSION The MRDs were successfully assessed using FCM. An MTX dose of 2 g/m2 was effective in preventing relapse in non-HR pcB-ALL. Augmented IB showed no advantages over the standard IB.
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Affiliation(s)
- Myriam Campbell
- Department of Pediatric Hematology and Oncology, Hospital Roberto del Rio, Universidad de Chile, Chilean National Pediatric Oncology Group, PINDA, Santiago, Chile
| | - Csongor Kiss
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Martin Zimmermann
- Department of Pediatric Hematology and Oncology, Hannover Medical School, Hannover, Germany
| | - Cecilia Riccheri
- Argentine Group for the Treatment of Acute Leukemia, GATLA, Buenos Aires, Argentina
| | - Jerzy Kowalczyk
- Department of Pediatric, Hematology, Oncology, and Transplantology, Medical University of Lublin, Lublin, Poland
| | - Maria S Felice
- Hematology and Oncology Department, Hospital de Pediatría Prof. Dr Juan P. Garrahan, SAHOP, Buenos Aires, Argentina
| | - Milos Kuzmanovic
- Mother and Child Health Care Institute of Serbia "Dr Vukan Cupic", Faculty of Medicine, Belgrade, Serbia
| | - Gabor Kovacs
- 2nd Department of Pediatrics Semmelweis University, Budapest, Hungary
| | - Helen Kosmidis
- Pediatric and Adolescent Oncology Clinic, Children's Hospital MITERA, Athens, Greece
| | | | - Ernest Bilic
- School of Medicine Division of Pediatric Hematology and Oncology, University Hospital Center, University of Zagreb, Zagreb, Croatia
| | - Luis Castillo
- Pediatric Hemato-Oncology Department, Hospital Pereira Rossell, Pérez Scremini Foundation, Montevideo, Uruguay
| | - Alexandra Kolenova
- Department of Pediatric Hematology and Oncology, National Institute of Children's Diseases and Medical School, Comenius University, Bratislava, Slovakia
| | - Janez Jazbec
- University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Alexander Popa
- Pediatric Oncology and Hematology Research Institute of N.N.Blokhin National Cancer Research Center, Center, Moscow, Russia
| | - Dobrin Konstantinov
- Pediatric Hematology & Oncology Department, University Hospital "Tsaritsa Johanna-ISUL", Sofia, Bulgaria
| | - Janos Kappelmayer
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Tomasz Szczepanski
- Department of Pediatric Hematology and Oncology, Zabrze, Medical University of Silesia, Katowice, Poland
| | - Michael Dworzak
- St Anna Children's Cancer Research Institute (CCRI), Vienna, Austria
| | - Barbara Buldini
- Mother and Child's Health Department, Division of Pediatric Hematology, Oncology and Stem Cell Transplant, University of Padova, Padova, Veneto, Italy
| | - Giuseppe Gaipa
- Centro Tettamanti, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Neda Marinov
- Chilean National Pediatric Oncology Group, PINDA, Hospital Roberto del Rio/Universidad de Chile, Santiago, Chile
- Hospital del Salvador, Universidad de Chile, Santiago, Chile
| | - Jorge Rossi
- Immunology and Rheumatology Department, Hospital de Pediatría Prof. Dr Juan P. Garrahan, Buenos Aires, Argentina
| | - Attila Nagy
- Department of Interventional Epidemiology, Faculty of Public Health, University of Debrecen, Debrecen, Hungary
| | - Imre Gaspar
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Jan Stary
- Department of Pediatric Hematology and Oncology Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Martin Schrappe
- Department of Pediatric and Adolescent Medicine, University Medical Center Schleswig-Holstein, Kiel, Germany
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Jonart LM, Ostergaard J, Brooks A, Fitzpatrick G, Chen L, Gordon PM. CXCR4 antagonists disrupt leukaemia-meningeal cell adhesion and attenuate chemoresistance. Br J Haematol 2023; 201:459-469. [PMID: 36535585 PMCID: PMC10121760 DOI: 10.1111/bjh.18607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 11/28/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022]
Abstract
The effective prophylaxis and treatment of central nervous system (CNS) involvement in acute lymphoblastic leukaemia (ALL) remains a significant clinical challenge. Developing novel and more effective CNS-directed therapies has been hampered, in part, by our limited understanding of the leukaemia niche in the CNS relative to the bone marrow. Accordingly, defining the molecular and cellular components critical for the establishment and maintenance of the CNS leukaemia niche may lead to new therapeutic opportunities. In prior work we showed that direct intercellular interactions between leukaemia and meningeal cells enhance leukaemia chemoresistance in the CNS. Herein, we show that the CXCR4/CXCL12 chemokine axis contributes to leukaemia-meningeal cell adhesion. Importantly, clinically tested CXCR4 antagonists, which are likely to cross the blood-brain and blood-cerebral spinal fluid barriers and penetrate the CNS, effectively disrupted leukaemia-meningeal cell adhesion. Moreover, by disrupting these intercellular interactions, CXCR4 antagonists attenuated leukaemia chemoresistance in leukaemia-meningeal cell co-culture experiments and enhanced the efficacy of cytarabine in targeting leukaemia cells in the meninges in vivo. This work identifies the CXCR4/CXCL12 axis as an important regulator of intercellular interactions within the CNS leukaemia niche and supports further testing of the therapeutic efficacy of CXCR4 antagonists in overcoming CNS niche-mediated chemoresistance.
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Affiliation(s)
- Leslie M Jonart
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota, USA
- Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jason Ostergaard
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota, USA
- Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - Athena Brooks
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota, USA
- Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - Garrett Fitzpatrick
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Liam Chen
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Peter M Gordon
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota, USA
- Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota, USA
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Yoshimura S, Panetta JC, Hu J, Li L, Gocho Y, Du G, Umezawa A, Karol SE, Pui CH, Mullighan CG, Konopleva M, Stock W, Teachey DT, Jain N, Yang JJ. Preclinical pharmacokinetic and pharmacodynamic evaluation of dasatinib and ponatinib for the treatment of T-cell acute lymphoblastic leukemia. Leukemia 2023:10.1038/s41375-023-01900-5. [PMID: 37076694 DOI: 10.1038/s41375-023-01900-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 04/04/2023] [Accepted: 04/06/2023] [Indexed: 04/21/2023]
Abstract
LCK is a novel therapeutic target in ~40% of T-cell acute lymphoblastic leukemia (T-ALL), and dasatinib and ponatinib can act as LCK inhibitors with therapeutic effects. We herein report a comprehensive preclinical pharmacokinetic and pharmacodynamic evaluation of dasatinib and ponatinib in LCK-activated T-ALL. In 51 human T-ALL cases, these two drugs showed similar patterns of cytotoxic activity, with ponatinib being slightly more potent. Given orally in mice, ponatinib was associated with slower clearance with a longer Tmax and higher AUC0-24 h, although maximum pLCK inhibition was comparable between the two drugs. After establishing the exposure-to-response models, we simulated the steady-state pLCK inhibitory effects of each drug at currently approved dosages in humans: dasatinib at 140 mg and ponatinib at 45 mg once daily are both sufficient to achieve >50% pLCK inhibition for 13.0 and 13.9 h/day, respectively, comparable to pharmacodynamic profiles of these agents in BCR::ABL1 leukemias. Moreover, we developed a dasatinib-resistant T-ALL cell line model with LCK T316I mutation, in which ponatinib retained partial activity against LCK. In conclusion, we described the pharmacokinetic and pharmacodynamic profiles of dasatinib and ponatinib as LCK inhibitors in T-ALL, providing critical data for the development of human trials of these agents.
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Affiliation(s)
- Satoshi Yoshimura
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
- Department of Advanced Pediatric Medicine, Tohoku University School of Medicine, Tokyo, Japan
| | - John C Panetta
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Jianzhong Hu
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
- Amgen, 1 Amgen Center Drive, Thousand Oaks, CA, USA
| | - Lie Li
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Yoshihiro Gocho
- Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Guoqing Du
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Akihiro Umezawa
- Department of Advanced Pediatric Medicine, Tohoku University School of Medicine, Tokyo, Japan
| | - Seth E Karol
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Ching-Hon Pui
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Charles G Mullighan
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Marina Konopleva
- Department of Oncology and Molecular Pharmacology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Wendy Stock
- Department of Medicine Section of Hematology-Oncology, University of Chicago, Chicago, IL, USA
| | - David T Teachey
- Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA
| | - Nitin Jain
- Department of Leukemia, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jun J Yang
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN, USA.
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, TN, USA.
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Zhang H, Wan Y, Wang H, Cai J, Yu J, Hu S, Fang Y, Gao J, Jiang H, Yang M, Liang C, Jin R, Tian X, Ju X, Hu Q, Jiang H, Li Z, Wang N, Sun L, Leung AWK, Wu X, Qian X, Qian M, Li CK, Yang J, Tang J, Zhu X, Shen S, Zhang L, Pui CH, Zhai X. Prognostic factors of childhood acute lymphoblastic leukemia with TCF3::PBX1 in CCCG-ALL-2015: A multicenter study. Cancer 2023; 129:1691-1703. [PMID: 36943767 DOI: 10.1002/cncr.34741] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 01/08/2023] [Accepted: 01/24/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Contemporary risk-directed treatment has improved the outcome of patients with acute lymphoblastic leukemia (ALL) and TCF3::PBX1 fusion. In this study, the authors seek to identify prognostic factors that can be used to further improve outcome. METHODS The authors studied 384 patients with this genotype treated on Chinese Children's Cancer Group ALL-2015 protocol between January 1, 2015 and December 31, 2019. All patients provisionally received intensified chemotherapy in the intermediate-risk arm without prophylactic cranial irradiation; those with high minimal residual disease (MRD) ≥1% at day 46 (end) of remission induction were candidates for hematopoietic cell transplantation. RESULTS The overall 5-year event-free survival was 84.4% (95% confidence interval [CI], 80.6-88.3) and 5-year overall survival 88.9% (95% CI, 85.5-92.4). Independent factors associated with lower 5-year event-free survival were male sex (80.4%, [95% CI, 74.8-86.4] vs. 88.9%, [95% CI, 84.1-93.9] in female, p = .03) and positive day 46 MRD (≥0.01%) (62.1%, [95% CI, 44.2-87.4] vs. 87.1%, [95% CI, 83.4-90.9] in patients with negative MRD, p < .001). The presence of testicular leukemia at diagnosis (n = 10) was associated with particularly dismal 5-year event-free survival (33.3% [95% CI, 11.6-96.1] vs. 83.0% [95% CI, 77.5-88.9] in the other 192 male patients, p < .001) and was an independent risk factor (hazard ratio [HR], 5.7; [95% CI, 2.2-14.5], p < .001). CONCLUSIONS These data suggest that the presence of positive MRD after intensive remission induction and testicular leukemia at diagnosis are indicators for new molecular therapeutics or immunotherapy in patients with TCF3::PBX1 ALL.
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Affiliation(s)
- Honghong Zhang
- Department of Hematology/Oncology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Yang Wan
- Department of Pediatrics, State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Hongsheng Wang
- Department of Hematology/Oncology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Jiaoyang Cai
- Department of Hematology/Oncology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, National Health Committee Key Laboratory of Pediatric Hematology & Oncology, Shanghai, China
| | - Jie Yu
- Department of Hematology/Oncology, Chongqing Medical University Affiliated Children's Hospital, Chongqing, China
| | - Shaoyan Hu
- Department of Hematology/Oncology, Children's Hospital of Soochow University, Suzhou, China
| | - Yongjun Fang
- Department of Hematology/Oncology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Ju Gao
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Key Laboratory of Birth Defects and Related Disease of Women and Children, Ministry of Education, Chengdu, China
| | - Hua Jiang
- Department of Hematology/Oncology, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Minghua Yang
- Department of Pediatrics, Xiangya Hospital Central South University, Changsha, China
| | - Changda Liang
- Department of Hematology/Oncology, Jiangxi Provincial Children's Hospital, Nanchang, China
| | - Runming Jin
- Department of Pediatrics, Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xin Tian
- Department of Hematology/Oncology, KunMing Children's Hospital, Kunming, China
| | - Xiuli Ju
- Department of Pediatrics, Qilu Hospital of Shandong University, Jinan, China
| | - Qun Hu
- Department of Pediatrics, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hui Jiang
- Department of Hematology/Oncology, Children's Hospital Affiliated to Shanghai Jiao Tong University, Shanghai, China
| | - Zhifan Li
- Department of Hematology/Oncology, Xi'an Northwest Women's and Children's Hospital, Xi'an, China
| | - Ningling Wang
- Department of Pediatrics, Anhui Medical University Second Affiliated Hospital, Hefei, Anhui, China
| | - Lirong Sun
- Department of Pediatrics, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Alex W K Leung
- Department of Pediatrics, Hong Kong Children's Hospital, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Xuedong Wu
- Department of Pediatrics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xiaowen Qian
- Department of Hematology/Oncology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Maoxiang Qian
- Department of Hematology/Oncology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Chi-Kong Li
- Department of Pediatrics, Hong Kong Children's Hospital, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Jun Yang
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Jingyan Tang
- Department of Hematology/Oncology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, National Health Committee Key Laboratory of Pediatric Hematology & Oncology, Shanghai, China
| | - Xiaofan Zhu
- Department of Pediatrics, State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Shuhong Shen
- Department of Hematology/Oncology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, National Health Committee Key Laboratory of Pediatric Hematology & Oncology, Shanghai, China
| | - Li Zhang
- Department of Pediatrics, State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Ching-Hon Pui
- Department of Oncology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
- Department of Global Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
- Department of Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Xiaowen Zhai
- Department of Hematology/Oncology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
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Liu J, Yang Y, Zeng Y, Qin X, Guo L, Liu W. Exploring the mechanism of physcion-1-O-β-D-monoglucoside against acute lymphoblastic leukaemia based on network pharmacology and experimental validation. Heliyon 2023; 9:e14009. [PMID: 36923879 PMCID: PMC10008983 DOI: 10.1016/j.heliyon.2023.e14009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 02/16/2023] [Accepted: 02/17/2023] [Indexed: 02/26/2023] Open
Abstract
Objective To explore the mechanism of PG against acute lymphoblastic leukaemia (ALL) by network pharmacology and experimental verification in vitro. Methods First, the biological activity of PG against B-ALL was determined by CCK-8 and flow cytometry. Then, the potential targets of PG were obtained from the PharmMapper database. ALL-related genes were collected from the GeneCards, OMIM and PharmGkb databases. The two datasets were intersected to obtain the target genes of PG in ALL. Then, protein interaction networks were constructed using the STRING database. The key targets were obtained by topological analysis of the network with Cytoscape 3.8.0 software. In addition, the mechanism of PG in ALL was confirmed by protein‒protein interaction, gene ontology and Kyoto Encyclopedia of Genes and Genomes pathway enrichment analyses. Furthermore, molecular docking was carried out by AutoDock Vina. Finally, Western blotting was performed to confirm the effect of PG on NALM6 cells. Results PG inhibited the proliferation of NALM6 cells. A total of 174 antileukaemic targets of PG were obtained by network pharmacology. The key targets included AKT1, MAPK14, EGFR, ESR1, LCK, PTPN11, RHOA, IGF1, MDM2, HSP90AA1, HRAS, SRC and JAK2. Enrichment analysis found that PG had antileukaemic effects by regulating key targets such as MAPK signalling, and PG had good binding activity with MAPK14 protein (-8.9 kcal/mol). PG could upregulate the expression of the target protein p-P38, induce cell cycle arrest, and promote the apoptosis of leukaemia cells. Conclusion MAPK14 was confirmed to be one of the key targets and pathways of PG by network pharmacology and molecular experiments.
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Key Words
- AKT1, Protein Kinase B α
- Acute lymphoblastic leukaemia
- B-ALL, B-acute lymphoblastic leukemia
- CDK2, Cyclin-dependent kinase 2
- Cleaved PARP, Cleaved Poly ADP-Ribose Polymerase
- DMSO, Dimethyl sulfoxide
- Experimental validation
- GO, Gene Ontology
- KEGG, Kyoto Encyclopedia of Genes and Genomes
- MAPK14
- MAPK14, Mitogen-activated protein kinase
- Network pharmacology
- OMIM, Online Mendelian Inheritance in Man
- PG, Physcion-1-O-β-D-monoglucoside
- PPI, Protein-protein interaction
- Physcion-1-O-β-D-monoglucoside
- RIPA, Radio-Immunoprecipitation Assay
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Affiliation(s)
- Jing Liu
- Department of Pediatrics, Children Hematological Oncology and Birth Defects Laboratory, The Affiliated Hospital of Southwest Medical University, Sichuan Clinical Research Center for Birth Defects, Luzhou, Sichuan, 646000, China
| | - Yan Yang
- Department of Pediatrics, Children Hematological Oncology and Birth Defects Laboratory, The Affiliated Hospital of Southwest Medical University, Sichuan Clinical Research Center for Birth Defects, Luzhou, Sichuan, 646000, China
| | - Yan Zeng
- Department of Pediatrics, Children Hematological Oncology and Birth Defects Laboratory, The Affiliated Hospital of Southwest Medical University, Sichuan Clinical Research Center for Birth Defects, Luzhou, Sichuan, 646000, China
| | - Xiang Qin
- Department of Pediatrics, Children Hematological Oncology and Birth Defects Laboratory, The Affiliated Hospital of Southwest Medical University, Sichuan Clinical Research Center for Birth Defects, Luzhou, Sichuan, 646000, China
| | - Ling Guo
- Department of Pediatrics, Children Hematological Oncology and Birth Defects Laboratory, The Affiliated Hospital of Southwest Medical University, Sichuan Clinical Research Center for Birth Defects, Luzhou, Sichuan, 646000, China
| | - Wenjun Liu
- Department of Pediatrics, Children Hematological Oncology and Birth Defects Laboratory, The Affiliated Hospital of Southwest Medical University, Sichuan Clinical Research Center for Birth Defects, Luzhou, Sichuan, 646000, China
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45
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Attarbaschi A, Möricke A, Harrison CJ, Mann G, Baruchel A, De Moerloose B, Conter V, Devidas M, Elitzur S, Escherich G, Hunger SP, Horibe K, Manabe A, Loh ML, Pieters R, Schmiegelow K, Silverman LB, Stary J, Vora A, Pui CH, Schrappe M, Zimmermann M. Outcomes of Childhood Noninfant Acute Lymphoblastic Leukemia With 11q23/ KMT2A Rearrangements in a Modern Therapy Era: A Retrospective International Study. J Clin Oncol 2023; 41:1404-1422. [PMID: 36256911 PMCID: PMC9995095 DOI: 10.1200/jco.22.01297] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 08/01/2022] [Accepted: 09/07/2022] [Indexed: 11/20/2022] Open
Abstract
PURPOSE We aimed to study prognostic factors and efficacy of allogeneic hematopoietic stem-cell transplantation (allo-HSCT) in first remission of patients with noninfant childhood acute lymphoblastic leukemia (ALL) with 11q23/KMT2A rearrangements treated with chemotherapy regimens between 1995 and 2010. PATIENTS AND METHODS Data were retrospectively retrieved from 629 patients with 11q23/KMT2A-rearranged ALL from 17 members of the Ponte-di-Legno Childhood ALL Working Group. Clinical and biologic characteristics, early response assessed by minimal residual disease at the end of induction (EOI) therapy, and allo-HSCT were analyzed for their impact on outcomes. RESULTS A specific 11q23/KMT2A translocation partner gene was identified in 84.3% of patients, with the most frequent translocations being t(4;11)(q21;q23) (n = 273; 51.5%), t(11;19)(q23;p13.3) (n = 106; 20.0%), t(9;11)(p21_22;q23) (n = 76; 14.3%), t(6;11)(q27;q23) (n = 20; 3.8%), and t(10;11)(p12;q23) (n = 14; 2.6%); 41 patients (7.7%) had less frequently identified translocation partner genes. Patient characteristics and early response varied among subgroups, indicating large biologic heterogeneity and diversity in therapy sensitivity among 11q23/KMT2A-rearranged ALL. The EOI remission rate was 93.2%, and the 5-year event-free survival (EFS) for the entire cohort was 69.1% ± 1.9%, with a range from 41.7% ± 17.3% for patients with t(9;11)-positive T-ALL (n = 9) and 64.8% ± 3.0% for patients with t(4;11)-positive B-ALL (n = 266) to 91.2% ± 4.9% for patients with t(11;19)-positive T-ALL (n = 34). Low EOI minimal residual disease was associated with favorable EFS, and induction failure was particularly predictive of nonresponse to further therapy and relapse and poor EFS. In addition, EFS was not improved by allo-HSCT compared with chemotherapy only in patients with both t(4;11)-positive B-ALL (n = 64 v 51; P = .10) and 11q23/KMT2A-rearranged T-ALL (n = 16 v 10; P = .69). CONCLUSION Compared with historical data, prognosis of patients with noninfant 11q23/KMT2A-rearranged ALL has improved, but allo-HSCT failed to affect outcome. Targeted therapies are needed to reduce relapse and treatment-related mortality rates.
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Affiliation(s)
- Andishe Attarbaschi
- St Anna Children's Hospital and St Anna Children's Cancer Research Institute, Medical University of Vienna, Vienna, Austria
| | - Anja Möricke
- Christian-Albrechts-University Kiel and University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Christine J. Harrison
- Leukaemia Research Cytogenetics Group, Translational and Clinical Research Institute, Newcastle University Centre for Cancer, Newcastle upon Tyne, United Kingdom
| | - Georg Mann
- St Anna Children's Hospital and St Anna Children's Cancer Research Institute, Medical University of Vienna, Vienna, Austria
| | - André Baruchel
- Robert Debré University Hospital (APHP), Université Paris Cité, Paris, France
| | | | - Valentino Conter
- University of Milano-Bicocca, MBBM Foundation/ASST Monza, Monza, Italy
| | - Meenakshi Devidas
- Department of Global Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN
| | - Sarah Elitzur
- Schneider Children's Medical Center, Tel Aviv, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - Gabriele Escherich
- Clinic of Paediatric Haematology and Oncology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | | | - Keizo Horibe
- National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Atsushi Manabe
- Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Mignon L. Loh
- Ben Towne Center for Childhood Cancer Research, Seattle Children's Research Institute, Seattle, WA
- Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA
| | - Rob Pieters
- Princess Máxima Centre for Pediatric Oncology, Utrecht, the Netherlands
| | - Kjeld Schmiegelow
- Rigshospitalet and University Hospital Copenhagen, Copenhagen, Denmark
- Faculty of Medicine, Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - Jan Stary
- University Hospital Motol and Charles University, Prague, Czech Republic
| | - Ajay Vora
- Great Ormond Street Hospital, London, United Kingdom
| | - Ching-Hon Pui
- St Jude Children's Research Hospital, Memphis, TN
- University of Tennessee, Memphis, TN
| | - Martin Schrappe
- Christian-Albrechts-University Kiel and University Medical Center Schleswig-Holstein, Kiel, Germany
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46
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Yu CH, Jou ST, Su YH, Coustan-Smith E, Wu G, Cheng CN, Lu MY, Lin KH, Wu KH, Chen SH, Huang FL, Chang HH, Wang JL, Yen HJ, Li MJ, Chou SW, Ho WL, Liu YL, Chang CC, Lin ZS, Lin CY, Chen HY, Ni YL, Lin DT, Lin SW, Yang JJ, Ni YH, Pui CH, Yu SL, Yang YL. Clinical impact of minimal residual disease and genetic subtypes on the prognosis of childhood acute lymphoblastic leukemia. Cancer 2023; 129:790-802. [PMID: 36537587 DOI: 10.1002/cncr.34606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/27/2022] [Accepted: 11/29/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND This study analyzed data from two consecutive protocols for children newly diagnosed with acute lymphoblastic leukemia (ALL) to determine the clinical impact of minimal/measurable residual disease (MRD) and recently identified tumor genetic subtypes. METHODS Genetic subtypes were determined by sequential approaches including DNA indexing, reverse transcriptase-polymerase chain reaction, multiplex ligation-dependent probe amplification, and RNA-sequencing. MRD was assessed by flow cytometry. The Taiwan Pediatric Oncology Group TPOG-ALL-2013 study enrolled patients who received MRD-directed therapy. RESULTS The 5-year event-free survival (EFS) and overall survival rates in the 2013 cohort were 77.8% and 86.9% compared to those of the 2002 cohort, which were 62.4% and 76.5%. Among patients treated with MRD-guided therapy, those with ETV6-RUNX1 fusion and high hyperdiploidy had the highest 5-year EFS (91.4% and 89.6%, respectively). The addition of dasatinib improved outcomes in patients with BCR-ABL1 ALL. Recently identified subtypes like DUX4-rearranged, ZNF384-rearranged, MEF2D-rearranged, and PAX5alt subtypes were frequently positive for MRD after remission induction, and these patients consequently received intensified chemotherapy. Treatment intensification according to the MRD improved the outcomes of patients presenting DUX4 rearrangements. In high-risk or very-high-risk subtypes, the TPOG-ALL-2013 regimen did not confer significant improvements compared to TPOG-ALL-2002, and the outcomes of BCR-ABL1-like, MEF2D-rearranged, and KMT2A-rearranged ALL subtypes (in addition to those of T-cell ALL) were not sufficiently good. Novel agents or approaches are needed to improve the outcomes for these patients. CONCLUSIONS The TPOG-ALL-2013 study yielded outcomes superior to those of patients treated in the preceding TPOG-ALL-2002 study. This study provides important data to inform the design of future clinical trials in Taiwan. PLAIN LANGUAGE SUMMARY MRD-directed therapy improved the outcomes for pediatric ALL, especially standard-risk patients. Genomic analyses and MRD might be used together for risk-directed therapy of childhood ALL. Our work provides important data to inform the design of future clinical trials in Taiwan.
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Affiliation(s)
- Chih-Hsiang Yu
- Department of Clinical Laboratory Sciences and Medical Biotechnology, College of Medicine, National Taiwan University, Taipei, Taiwan.,Institute of Statistical Science Academia Sinica, Taipei, Taiwan
| | - Shiann-Tarng Jou
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan.,Department of Pediatrics, College of Medicine, National Taiwan University, Taipei, Taiwan
| | | | - Elane Coustan-Smith
- Department of Pediatrics, Yong, Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Gang Wu
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Chao-Neng Cheng
- Department of Pediatrics, National Cheng Kung University Hospital, Tainan, Taiwan.,Department of Pediatrics, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Meng-Yao Lu
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan.,Department of Pediatrics, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Kai-Hsin Lin
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan
| | - Kang-Hsi Wu
- Department of Pediatrics, Chung Shan Medical University Hospital, Taichung, Taiwan.,School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Shu-Huey Chen
- Department of Pediatrics, Taipei Medical University-Shuang Ho Hospital, Taipei, Taiwan
| | - Fang-Liang Huang
- Department of Pediatrics, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Hsiu-Hao Chang
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan.,Department of Pediatrics, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Jinn-Li Wang
- Division of Hematology Oncology, Department of Pediatrics, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,Department of Pediatrics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Hsiu-Ju Yen
- Department of Pediatrics, Taipei Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan
| | - Meng-Ju Li
- Department of Pediatrics, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Shu-Wei Chou
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan
| | - Wan-Ling Ho
- Department of Pediatrics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Pediatrics, Taipei Medical University Hospital, Taipei, Taiwan
| | - Yen-Lin Liu
- Department of Pediatrics, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Pediatrics, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chia-Ching Chang
- Department of Clinical Laboratory Sciences and Medical Biotechnology, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ze-Shiang Lin
- Department of Clinical Laboratory Sciences and Medical Biotechnology, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chien-Yu Lin
- Institute of Statistical Science Academia Sinica, Taipei, Taiwan
| | - Hsuan-Yu Chen
- Institute of Statistical Science Academia Sinica, Taipei, Taiwan
| | - Yu-Ling Ni
- Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Dong-Tsamn Lin
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan.,Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Shu-Wha Lin
- Department of Clinical Laboratory Sciences and Medical Biotechnology, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jun J Yang
- Department of Pharmacology, St. Jude Children's Research Hospital and the University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Yen-Hsuan Ni
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan.,Department of Pediatrics, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Ching-Hon Pui
- Department of Oncology, St. Jude Children's Research Hospital and the University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Sung-Liang Yu
- Department of Clinical Laboratory Sciences and Medical Biotechnology, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Centers of Genomic and Precision Medicine, National Taiwan University, Taipei, Taiwan.,Graduate Institute of Pathology, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yung-Li Yang
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan.,Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Department of Laboratory Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
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47
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Kato M. Recent progress in pediatric lymphoblastic leukemia. Int J Hematol 2023; 117:155-161. [PMID: 36456860 DOI: 10.1007/s12185-022-03501-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 11/21/2022] [Accepted: 11/21/2022] [Indexed: 12/05/2022]
Abstract
The probability of long-term survival for children with lymphoblastic leukemia has improved dramatically over recent decades, mainly owing to advances in genomic analysis techniques, which have improved our understanding of the nature of leukemic cells and prognostic prediction based on the evaluation of precise treatment response. Risk-adjusted chemotherapy based on these advances has simultaneously reduced relapse rates and minimized complications. In addition, recent genomic analyses have deepened our understanding of the pathogenesis of leukemia and revealed the involvement of germline variations in the clinical course of leukemia treatment. Additionally, advances in minimal residual disease assays and the introduction of immunotherapy are expected to further improve therapeutic analyses. Further advances in clinical and translational research are anticipated to improve survival to 100% in a healthy state.
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Affiliation(s)
- Motohiro Kato
- Department of Pediatrics, The University of Tokyo, 7-3-1, Hongo, Bunkyo-Ku, Tokyo, 113-8655, Japan.
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48
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Dargenio M, Bonifacio M, Chiaretti S, Vitale A, Fracchiolla NS, Papayannidis C, Giglio F, Salutari P, Audisio E, Scappini B, Zappasodi P, Defina M, Forghieri F, Scattolin AM, Todisco E, Lunghi M, Guolo F, Del Principe MI, Annunziata M, Lazzarotto D, Cedrone M, Pasciolla C, Imovilli A, Tanasi I, Trappolini S, Cerrano M, La Starza R, Krampera M, Di Renzo N, Candoni A, Pizzolo G, Ferrara F, Foà R. Incidence, treatment and outcome of central nervous system relapse in adult acute lymphoblastic leukaemia patients treated front-line with paediatric-inspired regimens: A retrospective multicentre Campus ALL study. Br J Haematol 2023; 200:440-450. [PMID: 36335916 PMCID: PMC10098932 DOI: 10.1111/bjh.18537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 10/16/2022] [Accepted: 10/17/2022] [Indexed: 11/08/2022]
Abstract
Within the Campus ALL network we analyzed the incidence, characteristics, treatment and outcome of a central nervous system (CNS) relapse in 1035 consecutive adult acute lymphoblastic leukemia (ALL) patients treated frontline with pediatric-inspired protocols between 2009 and 2020. Seventy-one patients (6.8%) experienced a CNS recurrence, more frequently in T- (28/278; 10%) than in B-ALL (43/757; 5.7%) (p = 0.017). An early CNS relapse-< 12 months from diagnosis-was observed in 41 patients. In multivariate analysis, risk factors for early CNS relapse included T-cell phenotype (p = <0.001), hyperleucocytosis >100 × 109 /L (p<0.001) and male gender (p = 0.015). Treatment was heterogeneous, including chemotherapy, radiotherapy, intrathecal therapy and novel agents. A complete remission (CR) was obtained in 39 patients (55%) with no differences among strategies. After CR, 26 patients underwent an allogenic transplant, with a significant overall survival benefit compared to non-transplanted patients (p = 0.012). After a median observation of 8 months from CNS relapse, 23 patients (32%) were alive. In multivariate analysis, the time to CNS relapse was the strongest predictor of a lower 2-year post-relapse survival (p<0.001). In conclusion, in adult ALL the outcome after a CNS relapse remains very poor. Effective CNS prophylaxis remains the best approach and allogenic transplant should be pursued when possible.
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Affiliation(s)
- Michelina Dargenio
- Ospedale Vito Fazzi, Unità Operativa di Ematologia e Trapianto, Lecce, Italy
| | - Massimiliano Bonifacio
- Dipartimento di Medicina, Sezione di Ematologia, Università e Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Sabina Chiaretti
- Divisione di Ematologia, Dipartimento di Medicina Traslazionale e di Precisione, Università Sapienza, Rome, Italy
| | - Antonella Vitale
- Divisione di Ematologia, Dipartimento di Medicina Traslazionale e di Precisione, Università Sapienza, Rome, Italy
| | | | - Cristina Papayannidis
- IRCCS Azienda Ospedaliero-Universitaria, Istituto di Ematologia "Seràgnoli", Bologna, Italy
| | - Fabio Giglio
- Ospedale San Raffaele, Unità Operativa di Ematologia, Milan, Italy
| | - Prassede Salutari
- Unità Operativa Complessa di Ematologia, Ospedale Civile Spirito Santo, Pescara, Italy
| | - Ernesta Audisio
- Dipartimento di Ematologia e Oncologia, AO Città della Salute e della Scienza, Torino, Italy
| | | | - Patrizia Zappasodi
- Unità Operativa di Ematologia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Marzia Defina
- Unità Operativa Complessa di Ematologia, AOUS, Università di Siena, Siena, Italy
| | - Fabio Forghieri
- Unità Operativa Complessa di Ematologia, AOU Policlinico, Modena, Italy
| | | | - Elisabetta Todisco
- Unità Operativa Ematologia, Istituto Europeo di Oncologia (IEO), Milan, Italy
| | - Monia Lunghi
- Divisione di Ematologia, Dipartimento di Medicina Traslazionale, Università del Piemonte Orientale, Novara, Italy
| | - Fabio Guolo
- Clinica Ematologica, Dipartimento di Medicina Interna, Università degli Studi di Genova, Genoa, Italy.,Dipartimento di Oncologia e Ematologia, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | | | - Mario Annunziata
- Unità Operativa Complessa di Ematologia, AORN Cardarelli, Naples, Italy
| | - Davide Lazzarotto
- Clinica ematologica e centro trapianti, Azienda sanitaria universitaria Friuli Centrale, Udine, Italy
| | - Michele Cedrone
- Unità Operativa Complessa di Ematologia, Ospedale San Giovanni Addolorata, Rome, Italy
| | - Crescenza Pasciolla
- Unità Operativa di Ematologia, IRCCS Istituto Tumori Giovanni Paolo II, Bari, Italy
| | | | - Ilaria Tanasi
- Dipartimento di Medicina, Sezione di Ematologia, Università e Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | | | - Marco Cerrano
- Unità Operativa di Ematologia, Presidio Molinette-AOU Città della Salute e della Scienza, Torino, Italy
| | - Roberta La Starza
- Sezione di Ematologia e Trapianto, Università degli Studi di Perugia, A.O. Perugia, Italy
| | - Mauro Krampera
- Dipartimento di Medicina, Sezione di Ematologia, Università e Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Nicola Di Renzo
- Ospedale Vito Fazzi, Unità Operativa di Ematologia e Trapianto, Lecce, Italy
| | - Anna Candoni
- Unità Operativa Complessa di Ematologia, AORN Cardarelli, Naples, Italy
| | - Giovanni Pizzolo
- Dipartimento di Medicina, Sezione di Ematologia, Università e Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Felicetto Ferrara
- Dipartimento di Biomedicina e Prevenzione, Università degli studi Tor Vergata, Rome, Italy
| | - Robin Foà
- Divisione di Ematologia, Dipartimento di Medicina Traslazionale e di Precisione, Università Sapienza, Rome, Italy
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Mangum DS, Bishop JD, Zhou Y, Cheng C, Karol SE, Rubnitz JE, Ribeiro RC, Yang JJ, Mullighan CG, Jeha S, Pui CH, Inaba H. Characterisation of children and adolescents with acute lymphoblastic leukaemia who presented without peripheral blood blasts at diagnosis. Br J Haematol 2023; 200:338-343. [PMID: 36352514 PMCID: PMC9852218 DOI: 10.1111/bjh.18552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 10/21/2022] [Accepted: 10/26/2022] [Indexed: 11/11/2022]
Abstract
Of 1003 children with acute lymphoblastic leukaemia (ALL), 147 (14.7%) presented without peripheral blood blasts (PBB). While absence of PBB was not independently associated with survival outcomes when compared to those with PBB, patients without PBB had distinct genetic and clinical characteristics. Notably, we identified a novel genotype-phenotype relationship, in that the patients without PBB had a significantly higher incidence of hyperdiploid B-ALL, accounting for almost half of all patients without PBB (46.9% vs. 22.7%, p < 0.001). Further, absence of PBB was associated with decreased rates of leukaemia involvement of the central nervous system (p < 0.001).
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Affiliation(s)
- D. Spencer Mangum
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
- Division of Hematology/Oncology, Department of Pediatrics, University of Utah and Primary Children’s Hospital, Salt Lake City, UT, USA
| | - Johnathon D. Bishop
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
- Department of Pediatrics, University of Tennessee Health Science Center and Le Bonheur Children’s Hospital, Memphis, Tennessee, USA
| | - Yinmei Zhou
- Department of Bioinformatics, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Cheng Cheng
- Department of Bioinformatics, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Seth E. Karol
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Jeffrey E. Rubnitz
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Raul C. Ribeiro
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Jun J Yang
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Charles G. Mullighan
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Sima Jeha
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Ching-Hon Pui
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - Hiroto Inaba
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
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Hu W, Cheung YT, Tang Y, Hong L, Zhu Y, Chen J, Wang Z, Zhou M, Gao Y, Chen J, Li B, Xue H, Gu L, Shen S, Tang J, Pui C, Inaba H, Cai J. Association between body mass index at diagnosis and outcomes in Chinese children with newly diagnosed acute lymphoblastic leukemia. Cancer Med 2023; 12:2850-2860. [PMID: 36168702 PMCID: PMC9939171 DOI: 10.1002/cam4.5188] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 08/16/2022] [Accepted: 08/20/2022] [Indexed: 11/12/2022] Open
Abstract
PURPOSE Studies of the association between body mass index (BMI) at diagnosis and treatment outcome in children with acute lymphoblastic leukemia (ALL) have yielded inconsistent results. Hence, we conducted a retrospective study in a large cohort of Chinese children with ALL treated with contemporary protocols. PATIENTS AND METHODS A total of 1437 children (62.1% male; median age at diagnosis 5.7 years, range: 2.3-16.3 years) were enrolled in two consecutive clinical trials at the Shanghai Children's Medical Center. The rates of overall survival, event-free survival, relapse, treatment-related mortality, and adverse events were compared among patients who were underweight (BMI < 5th percentile), at a healthy weight (5th to 85th percentile), overweight (>85th to <95th percentile), and obese (≥95th percentile). RESULTS At diagnosis, 91 (6.3%) patients were underweight, 1070 (74.5%) were at a healthy weight, 91 (6.3%) were overweight, and 185 (12.9%) were obese. No significant association was found between weight status and 5-year overall survival, event-free survival, or relapse in the overall cohort. When analyzed as a continuous variable, a higher BMI Z-score was associated with treatment-related mortality (hazard ratio 1.33 (95% confidence interval [CI], 1.05-1.68%), p = 0.02). The treatment-related mortality rate was higher in the overweight (5.5%, 95% CI 0.8-10.2%) and obese (3.2%, 95% CI 0.6-5.8%) groups compared with the underweight (0.0%) and healthy-weight groups (1.9%, 95% CI 1.1-2.7%; p = 0.04). Multivariable analysis showed that children who were overweight had a higher risk of treatment-related mortality (hazard ratio 3.8, 95% CI 1.3-11.4). CONCLUSION While body weight status was not associated with event-free survival or overall survival, overweight patients were at higher risk of treatment-related mortality.
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Affiliation(s)
- Wenting Hu
- Department of Hematology/Oncology, Key Laboratory of Pediatric Hematology and Oncology of China Ministry of Health, National Children's Medical Center, Shanghai Children's Medical CenterShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Yin Ting Cheung
- School of Pharmacy, Faculty of MedicineThe Chinese University of Hong KongHong KongChina
| | - Yanjing Tang
- Department of Hematology/Oncology, Key Laboratory of Pediatric Hematology and Oncology of China Ministry of Health, National Children's Medical Center, Shanghai Children's Medical CenterShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Li Hong
- Department of Clinical Nutrition, Shanghai Children's Medical CenterShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Yuan Zhu
- Department of Clinical Nutrition, Shanghai Children's Medical CenterShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Jing Chen
- Department of Hematology/Oncology, Key Laboratory of Pediatric Hematology and Oncology of China Ministry of Health, National Children's Medical Center, Shanghai Children's Medical CenterShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Zhuo Wang
- Department of Hematology/Oncology, Key Laboratory of Pediatric Hematology and Oncology of China Ministry of Health, National Children's Medical Center, Shanghai Children's Medical CenterShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Min Zhou
- Department of Hematology/Oncology, Key Laboratory of Pediatric Hematology and Oncology of China Ministry of Health, National Children's Medical Center, Shanghai Children's Medical CenterShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Yijin Gao
- Department of Hematology/Oncology, Key Laboratory of Pediatric Hematology and Oncology of China Ministry of Health, National Children's Medical Center, Shanghai Children's Medical CenterShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Jing Chen
- Department of Hematology/Oncology, Key Laboratory of Pediatric Hematology and Oncology of China Ministry of Health, National Children's Medical Center, Shanghai Children's Medical CenterShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Benshang Li
- Department of Hematology/Oncology, Key Laboratory of Pediatric Hematology and Oncology of China Ministry of Health, National Children's Medical Center, Shanghai Children's Medical CenterShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Huiliang Xue
- Department of Hematology/Oncology, Key Laboratory of Pediatric Hematology and Oncology of China Ministry of Health, National Children's Medical Center, Shanghai Children's Medical CenterShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Longjun Gu
- Department of Hematology/Oncology, Key Laboratory of Pediatric Hematology and Oncology of China Ministry of Health, National Children's Medical Center, Shanghai Children's Medical CenterShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Shuhong Shen
- Department of Hematology/Oncology, Key Laboratory of Pediatric Hematology and Oncology of China Ministry of Health, National Children's Medical Center, Shanghai Children's Medical CenterShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Jingyan Tang
- Department of Hematology/Oncology, Key Laboratory of Pediatric Hematology and Oncology of China Ministry of Health, National Children's Medical Center, Shanghai Children's Medical CenterShanghai Jiao Tong University School of MedicineShanghaiChina
| | - Ching‐Hon Pui
- Department of OncologySt. Jude Children's Research HospitalMemphisTennesseeUSA
- Department of Global Pediatric MedicineSt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Hiroto Inaba
- Department of OncologySt. Jude Children's Research HospitalMemphisTennesseeUSA
| | - Jiaoyang Cai
- Department of Hematology/Oncology, Key Laboratory of Pediatric Hematology and Oncology of China Ministry of Health, National Children's Medical Center, Shanghai Children's Medical CenterShanghai Jiao Tong University School of MedicineShanghaiChina
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