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Table of Contents
LETTER TO EDITOR
Year : 2020  |  Volume : 3  |  Issue : 3  |  Page : 647-648

Management of acute leukemias: New tools validated by old treatments


1 Department of Hematology, Safdarjung and VMMC Hospital, New Delhi, India
2 Department of Medical Oncology, Tata Memorial Hospital, Advanced Centre for Treatment, Research and Education in Cancer, Homi Bhabha National Institute, Mumbai, Maharashtra, India

Date of Submission12-Jul-2020
Date of Decision16-Jul-2020
Date of Acceptance19-Jul-2020
Date of Web Publication19-Sep-2020

Correspondence Address:
Sumeet P Mirgh
211, Hematolymphoid OPD, Pay Master Shodhika, Tata Memorial Centre, Advanced Centre for Treatment, Research and Education in Cancer, Sector-22, Kharghar, Navi Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CRST.CRST_240_20

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How to cite this article:
Jain A, Mirgh SP. Management of acute leukemias: New tools validated by old treatments. Cancer Res Stat Treat 2020;3:647-8

How to cite this URL:
Jain A, Mirgh SP. Management of acute leukemias: New tools validated by old treatments. Cancer Res Stat Treat [serial online] 2020 [cited 2020 Oct 22];3:647-8. Available from: https://www.crstonline.com/text.asp?2020/3/3/647/295495



Acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL) have a prolonged treatment course, complicated by multiple medical, social, and financial issues.[1] 3+7 remains the standard induction regimen for fit patients with AML. In their first study, Pandey et al.[2] analyzed the efficacy of oral metronomic therapy (OMT) with prednisolone, etoposide, and 6-mercaptopurine for AML. However, the rationale for using this drug combination was not mentioned. Moreover, only patients with de novo AML with a median age of 40 years were included in this study. Of these, 80% (12/15) had an Eastern Cooperative Oncology Group-performance status (ECOG-PS) of 0–1. Furthermore, patients with active fungal infections, major bleeding, and prior chemotherapy/radiotherapy were excluded. It is well known that young patients with AML have a longer duration of complete remission (CR) and overall survival,[3] and that infections constitute one-fourth of the AML induction mortality[4] with the standard 3 + 7 induction chemotherapy. Thus, including older patients with poor ECOG-PS or those with baseline infections or relapsed/refractory disease, where OMT could be more useful, would have unveiled the true potential of this treatment.

We disagree with the statement that fluorescence in situ hybridization (FISH) in AML is a part of every baseline diagnostic workup. Clinically significant discordance between karyotyping and FISH is highly uncommon, and hence FISH can be safely omitted.[5] Thus, FISH should be performed only if cytogenetics are inadequate.[6] In our view, a well-performed karyotype with 20 metaphases is adequate. Analysis of minimal residual disease (MRD) appears to have been a futile exercise in patient 5 (Group A) as the marrow aspirate showed 24% blasts. On the other hand, in Group B, the added benefit of OMT in patients who had already achieved CR may be questionable.[2] However, we agree that OMT could be a bridge to definitive therapy during the coronavirus disease 2019 pandemic.[7]

In their second study, Pandey et al.[8] performed a retrospective analysis of the effect of MRD on the survival of 130 patients with ALL treated with the MCP-841 protocol in Bihar, India. This protocol is still used in resource-limited settings as it requires minimum supportive care and is cost-effective. We would like to compliment the author on being able to provide a standard effective protocol as a stand-alone oncologist, despite the lack of supportive staff, institutional facilities, and the low socioeconomic status of the population.[9] It is commendable that they were able to use a combination of leukocyte-associated immunophenotype and different-from-normal approach by sending samples to national accredited labs with financial aid.

Limiting the BCR-ABL (Breakpoint cluster region-Abelson leukemia virus) testing only to patients with a total leukocyte count >15,000/mm3 is a gross lacuna,[10] especially because baseline cytogenetics and molecular tests were also omitted for cost-effectiveness. Furthermore, the authors also failed to mention how the Ph-positive patients were treated and whether any tyrosine kinase inhibitor was added. It is unclear whether the survival data presented in the study are for the total number of patients enrolled at the beginning or for those who completed induction or achieved CR at the end of induction, because of the conflicting statements in the study. Survival data need to be calculated with the latter as the denominator for determining the effect of MRD on survival. Toxicity-related deaths after induction were also included in the survival analysis and are likely to be a confounding factor for the true effect of MRD on relapse rates. The short duration of this study (median follow-up of 21 months) could also underrepresent this aspect.

We applaud the authors' attempts to improve the treatment for acute leukemias in resource-constrained settings with minimal chemotoxicity. Further studies down the road may benefit a large number of patients in this group.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Philip CC, Mathew A, John MJ. Cancer care: Challenges in the developing world. Cancer Res Stat Treat 2018;1:58-62.  Back to cited text no. 1
  [Full text]  
2.
Pandey A, Deshpande P, Singh A, Singh S, Murari K, Aryan R. Oral Prednisolone, Etoposide, 6- Mercaptopurine (PREM) metronomic chemotherapy in treatment naïve and partially treated acute myeloid leukemia in a resource constrained setting. Cancer Res Stat Treat 2020;3:172-82.  Back to cited text no. 2
  [Full text]  
3.
Pemmaraju N, Kantarjian H, Ravandi F, Nogueras-Gonzalez GM, Huang X, O'Brien S, et al. Patient characteristics and outcomes in adolescents and young adults (AYA) with acute myeloid leukemia (AML). Clin Lymphoma Myeloma Leuk 2016;16:213-22.  Back to cited text no. 3
    
4.
Philip C, George B, Ganapule A, Korula A, Jain P, Alex AA, et al. Acute myeloid leukaemia: Challenges and real world data from India. Br J Haematol 2015;170:110-7.  Back to cited text no. 4
    
5.
Wheeler FC, Kim AS, Mosse CA, Shaver AC, Yenamandra A, Seegmiller AC. Limited utility of fluorescence in situ hybridization for recurrent abnormalities in acute myeloid leukemia at diagnosis and follow-up. Am J Clin Pathol 2018;149:418-24.  Back to cited text no. 5
    
6.
Döhner H, Estey E, Grimwade D, Amadori S, Appelbaum FR, Büchner T, et al. Diagnosis and management of AML in adults: 2017 ELN recommendations from an international expert panel. Blood 2017;129:424-47.  Back to cited text no. 6
    
7.
Karpe A, Nagvekar-Karpe S. Management of hematological malignancies during the COVID-19 pandemic. Cancer Res Stat Treat 2020;3 Suppl 1:54-8.  Back to cited text no. 7
    
8.
Pandey A, Ahlawat S, Singh A, Singh S, Krishna M, Aryan R. Outcomes and impact of minimal residual disease in pediatric, adolescent, and young adults with acute lymphoblastic leukemia treated with modified MCP 841 protoco. Cancer Res Stat Treat 2020;3:183-91.  Back to cited text no. 8
  [Full text]  
9.
Nayak L. Optimizing acute leukemia treatment in resource-constrained settings. Cancer Res Stat Treat 2020;3:287-9.  Back to cited text no. 9
  [Full text]  
10.
National comprehensive care network. Pediatric Acute Lymphoblastic Leukemia (Version 2.2020). Available from: https://www.nccn.org/professionals/physician_gls/pdf/ped_all.pdf. [Last accessed on 2020 July 08].  Back to cited text no. 10
    




 

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