|LETTER TO EDITOR
|Year : 2020 | Volume
| Issue : 3 | Page : 647-648
Management of acute leukemias: New tools validated by old treatments
Aditi Jain1, Sumeet P Mirgh2
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 Submission||12-Jul-2020|
|Date of Decision||16-Jul-2020|
|Date of Acceptance||19-Jul-2020|
|Date of Web Publication||19-Sep-2020|
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
Source of Support: None, Conflict of Interest: None
|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
Acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL) have a prolonged treatment course, complicated by multiple medical, social, and financial issues. 3+7 remains the standard induction regimen for fit patients with AML. In their first study, Pandey et al. 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, and that infections constitute one-fourth of the AML induction mortality 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. Thus, FISH should be performed only if cytogenetics are inadequate. 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. However, we agree that OMT could be a bridge to definitive therapy during the coronavirus disease 2019 pandemic.
In their second study, Pandey et al. 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. 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, 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
Conflicts of interest
There are no conflicts of interest.
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