Treatment of Frail Older Adults and Elderly Patients With Philadelphia Chromosome-negative Acute Lymphoblastic Leukemia: Results of a Prospective Trial With Minimal Chemotherapy

BACKGROUND

The treatment of acute lymphoblastic leukemia (ALL) in older adults and elderly patients is a challenge, and modern protocols include targeted therapy and immunotherapy in combination with attenuated or minimal chemotherapy. However, frail patients are excluded from these trials, and reports on the outcome of this subgroup of patients are scarce. Our objective was to analyze the outcome of unfit older adults and elderly patients with Philadelphia chromosome-negative ALL included in a prospective trial (ALL-07FRAIL).

PATIENTS AND METHODS

Older adults and elderly patients with Charlson Comorbidity Index (CCI) ≥ 4 were included. Induction therapy consisted of vincristine and dexamethasone, and maintenance therapy with mercaptopurine and methotrexate for 2 years.

RESULTS

Seventy-two patients with a median age of 67 years (range, 57-89 years) and a median CCI of 5 (range, 4-12) were included. The rates of early withdrawal, early death, resistance, and complete response (CR) were 5%, 10%, 31%, and 54%, respectively. Six patients with CR abandoned the study, 5 died in CR, and 23 relapsed (cumulative relapse incidence 75%). The medians of disease-free and overall survival (OS) were 6.9 months (95% confidence interval [CI], 0.3-13.5 months) and 7.6 months (95% CI, 6.3-8.9 months), respectively. The most frequent toxic events were hematologic (neutropenia 77% and thrombocytopenia 54%, of grade III-IV in all cases). Eastern Cooperative Oncology Group score but not the CCI had significant impact on OS.

CONCLUSION

Complete remission with very attenuated chemotherapy can be attained in one-half of older or elderly infirm patients with ALL. These results suggest that some of these patients could benefit from the concomitant or subsequent use of immunotherapy and/or targeted therapy.

Frequency and clinical impact of CDKN2A/ARF/CDKN2B gene deletions as assessed by in-depth genetic analyses in adult T cell acute lymphoblastic leukemia

Recurrent deletions of the CDKN2A/ARF/CDKN2B genes encoded at chromosome 9p21 have been described in both pediatric and adult acute lymphoblastic leukemia (ALL), but their prognostic value remains controversial, with limited data on adult T-ALL. Here, we investigated the presence of homozygous and heterozygous deletions of the CDKN2A/ARF and CDKN2B genes in 64 adult T-ALL patients enrolled in two consecutive trials from the Spanish PETHEMA group. Alterations in CDKN2A/ARF/CDKN2B were detected in 35/64 patients (55%). Most of them consisted of 9p21 losses involving homozygous deletions of the CDKNA/ARF gene (26/64), as confirmed by single nucleotide polymorphism (SNP) arrays and interphase fluorescence in situ hybridization (iFISH). Deletions involving the CDKN2A/ARF/CDKN2B locus correlated with a higher frequency of cortical T cell phenotype and a better clearance of minimal residual disease (MRD) after induction therapy. Moreover, the combination of an altered copy-number-value (CNV) involving the CDKN2A/ARF/CDKN2B gene locus and undetectable MRD (≤ 0.01%) values allowed the identification of a subset of T-ALL with better overall survival in the absence of hematopoietic stem cell transplantation.

Flow techniques in water analysis

In the present work the main flow techniques for the analysis and monitoring of several parameters of interest in the quality control of different types of waters are reviewed. Firstly, a review involving the advantages and disadvantages of flow techniques, from those currently out-dated, such as segmented flow analysis (SFA), to the most modern techniques, such as flow injection analysis (FIA), sequential injection analysis (SIA) and multi-commutation techniques (MCFA), is carried out. On the other hand, a new technique, the multi-syringe flow analysis (MSFA) is hereby described for the first time as both a fast and robust alternative. Its possibilities, limitations and potential advantages when using this technique either on its own or coupled to SIA, which carries out a previous sample handling, are outlined.

[Peptostreptococcus endocarditis: presentation of two cases and literature review]

We describe two new cases of Peptostreptococcus endocarditis, one case of Peptostreptococcus micros prosthetic valve endocarditis and the other of Peptostreptococcus assaccharolyticus tricuspid native valve endocarditis in an intravenous drug user (IDU) patient and review nine cases previously reported.

A robust multi-syringe system for process flow analysis. Part 3. Time based injection applied to the spectrophotometric determination of nickel(II) and iron speciation

A new software-controlled time-based system for sample or reagent introduction in process flow injection analysis was developed. By using a multi-syringe burette coupled with one multi-port selection valve, the time-based injection of precise known volumes was accomplished. Characteristics and performance of the injection system were studied by injecting an indicator in a buffered carrier. Two multi-syringe time-based injection (MS-TBI) systems were implemented: first, the injection of a sample in a multiple-channel manifold where the sample would sequentially merge and react with different reagents, and second, the sequential injection of several solutions (sample and reagents) into a particular flowing stream. The first system was applied to the spectrophotometric determination of nickel(II) in diluted samples from the acidic nickel ore leaching process, by using ammonium citrate as carrier, a saturated solution of iodine as oxidizing agent and alkaline dimethylglyoxime as chromogenic reagent. The sampling frequency attained was 57 h-1. Determinations on process samples compared well at the 95% confidence level with the reference values obtained by ICP-OES. The second time-based injection system was applied to the speciation of iron. Total iron and iron(II) concentrations were separately and sequentially determined using 1,10-phenanthroline in acetic buffer medium as reagent. The developed manifold allowed the optional use of two different carrier solutions, containing or not containing ascorbic acid, for performing the separate determinations. Also, in the sequential procedure, plugs of reducing carrier were alternatively intercalated before the sample injections used for total iron determinations. Sampling frequencies of 68 injections per hour were routinely used. Accuracy was assessed by analyzing synthetic known mixtures of Fe(III) and Fe(II) standard solutions. Recoveries of 98-100.5% with a maximum relative standard deviation of 3.6% were found. Results obtained for various samples of fertilizers agreed well with those attained by the standard batch procedure.

Fast sequential injection determination of benzo[A]pyrene using variable angle fluorescence with on-line solid-phase extraction

A methodology for the analysis of drinking water for one of the most potent carcinogenic agents known; benzo[a]pyrene (BaP), in the presence of other interfering PAHs is presented. The methodology described is based on the sequential injection analysis of the sample on to a microcolumn (containing 5 mg of C18) where extraction and preconcentration of BaP takes place, followed by elution of BaP with 1 ml of 1,4-dioxane and subsequent detection by using variable angle fluorescence. The advantages of the method include the small amount of stationary phase employed together with the possibility of re-using the phase in order to carry out a large number of injections without the need for column re-packing. Also noteworthy is the small volume of 1,4-dioxane used to elute the BaP retained on the column and the small sample volumes required (9-10 ml) for achieving detection limits at the ng l-1 level. Thus, a methodology for BaP determination is obtained which complies with the requirements of the 98/83/EC Directive which fixes a maximum admissible concentration for this pollutant in waters for public consumption of 10 ng l-1. The variable angle spectra obtained are further processed by means of the multiple linear regression technique. The detection limit for BaP is 2.5 ng l-1, and the linear range is between 7.5 and 280 ng l-1.

A robust multisyringe system for process flow analysis. Part II. A multi-commuted injection system applied to the photometric determination of free acidity and iron(III) in metallurgical solutions

A new software-controlled volume-based system for sample introduction in process flow injection analysis was developed. By using a multi-syringe burette coupled with one or two additional commutation valves, the multi-commuted injection of precise sample volumes was accomplished. Characteristics and performance of the injection system were studied by injecting an indicator in a buffered carrier. Three configurations were implemented in order to achieve two different tasks: the single injection of a sample in a two- or three-channels manifold, and the dual injection into different streams. The two channel flow system using the single injection was applied to the determination of free acidity in diluted samples containing high levels of iron(III), by employing the single point titration methodology. The precipitation of ferric hydroxide was prevented using the ammonium and sodium salts of oxalate and acetate as buffer titrant. Methyl Red was employed as indicator. The procedure allows determination of acid concentration in solutions with a Fe(III)/H+ molar ratio up to 0.2. Samples with higher Fe(III)/H+ molar ratios were spiked with a known strong acid at dilution. The three-channel configuration was applied to the determination of ferric ions, using, as reagent, a merging mixture of sulfuric acid and potassium thiocyanate. The double injection system was implemented in series in a single (three-channel) manifold in such a way that a different injection volume and a changed reagent were used for each analyte. It was applied to the separated or sequential determination of free acidity and ferric ions. In this configuration, iron(III) was determined using 0.5-0.7% (w/v) sodium salicylate solution as reagent. The systems can operate at up to 100, 84 and 78 injections per hour, respectively. Determinations on synthetic and process samples compared well with the reference values and procedures. Recoveries of 95-102% with a maximum RSD value of 5.4% were found for acidity. The respective values obtained for iron determinations were 96-105% and 4.3%.