Lipidomic profiles associated with treatment related hepatotoxicity in children with acute lymphoblastic leukemia

6-Thioguanine treatment in childhood acute lymphoblastic leukaemia (ALL) has been shown to cause hepatic veno-occlusive disease, but this usually resolved with drug withdrawal. Recent reports suggested that treatment of ALL with 6-thioguanine can lead to chronic hepatotoxicity and portal hypertension. We describe our experience from 2 UK centres of chronic hepatotoxicity in children receiving maintenance 6-thioguanine for ALL in the national leukaemia protocol ALL 97/99. Retrospective review of children who were referred with liver disease secondary to 6-thioguanine treatment of ALL was performed. A paediatric pathologist blinded to the clinical features reviewed liver histology slides. Ten of 75 children (13%) treated with 6-thioguanine in both centres were referred at a median of 6 months (range, 2-29) after discontinuation of chemotherapy. In 8 cases, referral was due to persistent thrombocytopenia and splenomegaly. Two children presented with acute variceal bleeding. All had thrombocytopenia at referral, and ultrasonography showed coarse hepatic echo texture and splenomegaly in all. Endoscopy showed oesophageal varices in 7 and gastric varices in 1. Nine underwent liver biopsy that showed features compatible with nodular regenerative hyperplasia in 5 cases. After a median follow-up of 36 months, a further child has had a variceal haemorrhage and all but 2 children remain thrombocytopenic. 6-Thioguanine-induced chronic hepatotoxicity is a significant complication in children treated with this agent for ALL. Children may present several months to years after discontinuation of 6-thioguanine. All children given maintenance treatment of ALL with this agent should be screened, and affected children require long-term surveillance.

Optimizing antimetabolite-based chemotherapy for the treatment of childhood acute lymphoblastic leukaemia.

Are Adolescents and Young Adults (AYA) with Acute Lymphoblastic Leukemia (ALL) Receiving Pediatric or Adult ALL Regimens: A Population-Based Statewide Evaluation of the Approach to AYA ALL across Pediatric and Adult Cancer Centers

Improved outcomes of liver disease in childhood and young adulthood have resulted in an increasing number of young adults (YA) entering adult liver services. The adult hepatologist therefore requires a working knowledge in diseases that arise almost exclusively in children and their complications in adulthood. To provide adult hepatologists with succinct guidelines on aspects of transitional care in YA relevant to key disease aetiologies encountered in clinical practice. A systematic literature search was undertaken using the Pubmed, Medline, Web of Knowledge and Cochrane database from 1980 to 2023. MeSH search terms relating to liver diseases ('cholestatic liver diseases', 'biliary atresia', 'metabolic', 'paediatric liver diseases', 'autoimmune liver diseases'), transition to adult care ('transition services', 'young adult services') and adolescent care were used. The quality of evidence and the grading of recommendations were appraised using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. These guidelines deal with the transition of YA and address key aetiologies for the adult hepatologist under the following headings: (1) Models and provision of care; (2) screening and management of mental health disorders; (3) aetiologies; (4) timing and role of liver transplantation; and (5) sexual health and fertility. These are the first nationally developed guidelines on the transition and management of childhood liver diseases in adulthood. They provide a framework upon which to base clinical care, which we envisage will lead to improved outcomes for YA with chronic liver disease.

Minimal Residual Disease Negative Status At the End of Induction Therapy Is a Potent Prognostic Marker in Adult Non-Ph Acute Lymphoblastic Leukemia: Results of the ALL MRD2002 Study

Mitochondrial genome variants in non-remitting ALL of childhood

Ramp-up Treatment Strategy in Philadelphia Positive Acute Lymphoblastic Leukemia Is Associated with Deep Molecular Remissions and Favorable Outcomes

Role of birthplace in chronic disease in adults and very old individuals: national cohorts in the UK and USA, 2009–2010

Minimal Residual Disease (MRD) Status after Induction Therapy Is a Strong Prognostic Factor in the Treatment of Adult Ph (-) Acute Lymphoblastic Leukemia (ALL): Results of a Prospective Study (ALL MRD2008 Study)

Background: Acute Lymphoblastic Leukemia (ALL) is the most common childhood malignancies representing about one third of all pediatric cancers. Adding methotrexate to leukemia treatment protocols has been associated with an increased survival rate in children with ALL. The efficacy of this agent is often limited by its toxicity which can be reduced if supplemented with anti-oxidants. Nigella sativa has antioxidant property through different mechanisms. Objective: The aim of this work was to study the role of Nigella sativa oil in the protection against hepatotoxicity induced by methotrexate therapy in children with ALL and the impact on the treatment outcome. Patients and methods: The present study was conducted in the period between July 2010 and July 2013 on 40 children with newly diagnosed ALL including 28 males and 12 females, with mean age value of 9.17 ± 3.81 years and they were divided into 20 patients of ALL under methotrexate therapy included in ALL treatment protocol, delayed leukovorin rescue (10 mg/m2 orally or IV every 6 hours for five doses beginning 48 hours after start of methotrexate infusion and Nigella sativa oil in form of soft gelatin capsule 450 mg in dose of 80 mg/kg/day on three divided doses for one week after each methotrexate dose (Group II) and 20 patients of ALL under methotrexate therapy included in ALL treatment protocol, delayed leukovorin rescue (10 mg/m2 orally or IV every 6 hours for five doses beginning 48 hours after start of methotrexate infusion and placebo for one week after each methotrexate dose (Group III). This study also included 20 healthy children as a control group (11 males and 9 females) with their mean age value of 9.1+ 2.9 (Group I). All patients included in the study were subjected to the following investigations: Complete blood picture, bone marrow aspiration, cytochemistry, immunophenotyping and liver function testes. Results: There were no significant difference in serum bilirubin, alanine aminotransferase, aspartate aminotransferase, alkaline phosphase levels and prothrombin time between group II and group III but there was significant difference between group II and group III compared to controls. There was no significant difference in total protein, albumin, globulin levels, and albumin globulin ratio between studied groups. There were non-significant increase in total, direct and indirect serum bilirubin, serum ALT, AST, and alkaline phosphatase levels and prothrombin time in group II after methotrexate and Nigella sativa oil therapy but there was significant increase in group III after treatment with methotrexate and placebo with significant difference between group II and III after therapy. There were significant differences in overall and disease free survival between group II and group III. Conclusion: Oral administration of Nigella sativa oil in leukemic children can prevent MTX hepatotoxicity and improved survival in patients with ALL. Recommendations: Nigella sativa oil is recommended adjuvant drug as hepatoprotective agent in patients with ALL who received methotrexate therapy.

In patients with acute leukaemia, studies of minimal (i.e. submicroscopic) residual disease (MRD) should improve measurements of treatment response and enable estimates of the residual leukaemic cell burden during clinical remission, thereby improving the selection of therapeutic strategies and, possibly, long-term clinical outcome. The most useful methods for MRD monitoring currently available are polymerase chain reaction (PCR) amplification of fusion transcripts and rearranged antigen-receptor genes, and flow cytometric detection of aberrant immunophenotypes. Several studies in patients with acute lymphoblastic leukaemia and acute myeloid leukaemia have demonstrated that MRD is a powerful and independent prognostic indicator. The strong association between MRD and risk of relapse was observed in children and adult patients irrespective of the methodology used to detect residual disease. This article discusses the relative advantages and disadvantages of each MRD assay, and reviews the reported correlations between MRD, clinical and biological features of the disease, and outcome. A multitude of factors influence treatment response in patients with acute leukaemia (Lowenberg et al, 1999; Pui et al, 2001). Cell lineage, stage of maturation, karyotype and molecular abnormalities regulate expression of genes that control drug metabolism and apoptosis, and determine the leukaemic cells' capacity to grow and their sensitivity to chemotherapy. Other important factors include size of the tumour burden, dosage of drugs and their interaction, pharmacokinetic and pharmacogenetic variables, and compliance with treatment schedule. These parameters are associated with a varying risk of relapse but their predictive power is far from absolute and their use to make treatment decisions in individual patients is inherently limited. In vivo measurements of leukaemia cytoreduction should reflect the combined effect of clinical and cellular variables; rather than predicting outcome, these measurements provide direct information on the effectiveness of treatment in each patient. However, estimates by conventional morphological techniques have limited sensitivity and accuracy: in most cases, leukaemic cells can be detected in bone marrow with certainty only when they constitute 5% or more of the total cell population. Such a high detection threshold results in the inability to measure fluctuations in the leukaemia tumour mass with accuracy, and resurgent disease can be diagnosed only at its most advanced stages. Methods for detecting MRD (i.e. submicroscopic) are at least 100-times more sensitive than conventional morphological techniques and allow a more stringent definition of 'remission' in patients with acute leukaemia, which is rapidly becoming the standard at many cancer centres (Fig 1). Factors that influence response to treatment in patients with acute leukaemia. An essential premise of MRD studies is that MRD levels provide reliable estimates of the residual leukaemia mass. This assumes that leukaemic cells are homogeneously distributed throughout the bone marrow so that measurements of MRD performed on a small aliquot of bone marrow (perhaps, equivalent to one thousandth of the total active marrow) are representative of the total leukaemia burden. However, observations in patients (Mathe et al, 1966) and in animal models of leukaemia (Martens et al, 1987) indicate that there could be considerable heterogeneity in the distribution of leukaemic cells after treatment and that individual samples may not be informative. Another caveat is that MRD signals may not correspond to viable leukaemic cells with a capacity for cell renewal. Cell viability can only be determined with methods that use intact cells (e.g. flow cytometry) but it is impossible to determine with MRD methods that examine nucleic acid material (e.g. polymerase chain reaction). Moreover, even when viable, leukaemic cells may lack sustained self-renewal capacity, a feature that is not possible to assess on a routine basis. As discussed in this article, most of these reservations have been dispelled by the results of several correlative studies of MRD and treatment outcome. It is now clear that detectable MRD implies the presence of leukaemic stem cells capable of leading to disease recurrence. The first MRD studies in patients with leukaemia were made soon after antibodies for leucocyte differentiation antigens became available. Strong expression of the common acute lymphoblastic leukaemia (ALL) antigen (CD10) and terminal deoxynucleotidyl transferase (TdT) in ALL cells, and apparent absence of these markers on normal peripheral blood cells, suggested the use of these molecules as markers of leukaemia. However, it was soon clear that a proportion of cells in the bone marrow (i.e. B-cell progenitors) expressed both CD10 and TdT (Janossy et al, 1980). The distinction between leukaemic lymphoblasts and normal lymphoid progenitors remains crucial for detecting MRD in patients with B-lineage ALL. In early studies, it was also noted that T-lineage ALL cells (and normal thymocytes) expressed TdT and T-cell markers whereas lymphoid cells in bone marrow and peripheral blood did not (Bradstock et al, 1981). This finding enabled the first productive MRD studies in patients with acute leukaemia, and remains the basis of MRD studies by immunological techniques in T-lineage ALL. Over the following two decades, many methods to study MRD have been tested (Campana & Pui, 1995; Szczepanski et al, 2001). In ALL, the most reliable methods include flow cytometric profiling of aberrant immunophenotypes, polymerase chain reaction (PCR) amplification of fusion transcripts and chromosomal breakpoints, and PCR amplification of antigen-receptor genes. In acute myeloid leukaemia (AML), only the first two of these methods can be applied, as most patients lack antigen-receptor gene rearrangements. Owing to limited sensitivity (approximately 1–5%), conventional karyotyping and fluorescence in situ hybridization (FISH) are occasionally useful for clarifying the nature of morphologically suspicious blast cells, but cannot reliably detect submicroscopic leukaemia (Mancini et al, 2000). However, improvements in image analysis technology, allowing simultaneous visualization of morphological, immunophenotypic and FISH features, may enhance the usefulness of this approach (Bielorai et al, 2002). The success of methods based on differential properties of normal and leukaemic cells in culture has been limited to a few laboratories (Estrov et al, 1986; Uckun et al, 1993). Many comprehensive reviews have addressed in detail the methodological aspects of MRD detection (Campana & Pui, 1995; van Dongen et al, 1999; Foroni et al, 1999; Lo Coco et al, 1999a; Szczepanski et al, 2001; Campana & Coustan-Smith, 2002; Liu & Grimwade, 2002). Table I and the following sections summarize the applicability and the main specific advantages and disadvantages of each technique. Breakpoint fusion regions of chromosomal aberrations, and rearranged immunoglobulin (IG) and T-cell receptor (TCR) genes are leukaemia-specific sequences that have been used with consistent success in molecular studies of MRD. The value of another target, WT-1, is supported by some studies (Cilloni et al, 2002; Ogawa et al, 2003). However, WT-1 is also expressed by normal haematopoietic progenitors (Hosen et al, 2002) and has not been found to be reliable by some investigators (Elmaagacli et al, 2000). Internal tandem duplications (ITD) of the FLT3 gene occur in approximately 20–30% of AML patients and, in principle, could be used as targets for PCR-based MRD studies (Stirewalt et al, 2001). However, FLT3/ITD detected at diagnosis appear to be unstable, often becoming undetectable at relapse (Kottaridis et al, 2002; Shih et al, 2002). With the exception of the TAL1 gene abnormalities, the genomic breakpoints of the most common known leukaemia fusion genes are spread over large distances within each gene locus. PCR analysis starting from DNA would require determination of the exact breakpoint in each patient, which is not practical (van Dongen et al, 1999). As the resulting mRNA is similar in many patients, RNA is the typical starting material for PCR-mediated amplification of breakpoint fusion sequences. After reverse transcription (RT) into cDNA, PCR amplification is applied using primers at opposite sites of the breakpoint fusion region (van Dongen et al, 1999). An advantage of using the breakpoint-fusion regions for MRD studies is their stability during the disease course. However, only 50% or less of ALL and AML cases in children and adults have specific chromosomal aberrations with well-defined breakpoint fusion regions (Look, 1997; Liu & Grimwade, 2002). Therefore, the applicability of this approach is restricted to certain subgroups of leukaemias. The uniqueness of each immunoglobulin (Ig) and TCR molecule depends on the rearrangement and joining of the multiple variable (V), diversity (D) and joining (J) gene segments of the IG and TCR gene loci, on the deletion of nucleotides from the germline sequences of the rearranging gene segments, and on the random insertion of nucleotides at the junctional sites (Foroni et al, 1999; Pongers-Willemse et al, 1999). Thus, the sequences of the junctional regions of rearranged IG and TCR genes are signatures of each lymphoid cell clone, normal or malignant. For MRD studies, the various IG and TCR gene rearrangements must be identified in each patient at diagnosis. The sequence information enables the design of junctional region-specific oligonucleotides, which can be used as primers in the PCR procedure to specifically amplify the rearrangements of the malignant clone (Pongers-Willemse et al, 1999) or as probes to distinguish PCR products derived from leukaemic cells among those that are derived from normal lymphoid cells (Yokota et al, 1991). Virtually all B-lineage ALL patients have rearranged IGH genes (van Dongen & Wolvers-Tettero, 1991). In addition, rearrangements of the IGK deleting element (Kde) occur at a relatively high frequency (approximately 60%) (Beishuizen et al, 1997). Most T-ALL patients have rearranged TCRB, TCRG and/or TCRD genes (van Dongen & Wolvers-Tettero, 1991), and cross-lineage TCR rearrangements are found in many patients with B-lineage ALL (Szczepanski et al, 1999). In the majority (approximately 90%) of B-lineage ALL patients, MRD can be revealed by junctional regions of IGH, IGK-Kde, TCRG and/or TCRD gene rearrangements (Pongers-Willemse et al, 1999), and in most (> 95%) T-ALL patients by TCRB, TCRG and/or TCRD (Kneba et al, 1995; Pongers-Willemse et al, 1999). The need to develop individual probes or primers is one of the main limiting factors in the widespread application of MRD studies by PCR amplification of IG and TCR genes. Some investigators have attempted to bypass this need by identifying the leukaemic DNA on the basis of size and signal intensity after separation by high-resolution gel electrophoresis (Deane & Norton, 1990; Sykes et al, 1997). Polyclonal background levels vary but usually limit the sensitivity of this approach to the detection of one leukaemic cell among 103 normal cells. IG and TCR gene rearrangements in B- and T-lineage ALL are prone to subclone formation and multiple IGH gene rearrangements are already found at diagnosis in 30% to 40% of B-lineage ALL patients (Beishuizen et al, 1994). This creates uncertainty about the prioritization of the clones that should be monitored in some patients. In addition, the emergence of subclones that are not apparent at diagnosis may occur, carrying the risk of false-negative results during MRD monitoring (van Dongen & Wolvers-Tettero, 1991; Beishuizen et al, 1994; Pongers-Willemse et al, 1999). In a recent analysis of 94 patients with B-lineage ALL, studied at diagnosis and relapse, 71% of the potential Ig and TCR targets for MRD analysis identified at diagnosis were preserved at relapse (Szczepanski et al, 2002). The most stable were IGK-Kde rearrangements and the least stable were incomplete TCRD rearrangements. Monoclonal rearrangements were significantly more stable than oligoclonal rearrangement. For these reasons, it has been recommended that at least two PCR targets should be used. In B-lineage ALL, these are available in approximately 70% of children and 50% of adults; in T-lineage ALL, two PCR targets (including TAL1 deletions) can be identified in approximately 90% of children and 85% of adults (Pongers-Willemse et al, 1999). Notably, clonotypic rearrangements of IG and TCR genes are found in only 50% of infants with t(4;11) ALL (Peham et al, 2002). Depending on the uniqueness of the sequence targeted and the quality of the material, PCR can detect one leukaemic cell in 103−106 normal cells. High sensitivity may paradoxically become a problem as it generates a propensity to false-positive results due to contamination, particularly when the same set of primers is applied to different patients. However, investigators are well aware of this potential problem and most take measures to minimize it. A complication of MRD studies by PCR is related to the limited quantitative power of the technique. Nevertheless, under typical conditions and using appropriate techniques, the quantification of leukaemic cells by PCR amplification of single-copy genes (e.g. IGH and TCR genes) can be adequate (Sykes et al, 1992; Cave et al, 1994; Ouspenskaia et al, 1995; Pongers-Willemse et al, 1998; Neale et al, 1999). When RNA is the target molecule, additional potential pitfalls may render the correlation more imprecise. RNA is prone to degradation, and the efficiency of its initial conversion to cDNA by reverse transcriptase may vary. For example, it was reported that, using standard techniques, less than 1000 PML-RARA molecules could be obtained from 1 µg of diagnostic bone marrow RNA derived from approximately 106 acute promyelocytic leukaemia (APL) cells (Seale et al, 1996). Poor yield of PML-RARA cDNA would then lead to low sensitivity of the RT-PCR. Moreover, the number of transcripts per cell is unlikely to be homogeneous in all the leukaemic cell population and is also unlikely to remain stable in cells exposed to chemotherapy. Finally, levels of transcript expression in patients with the same disease may differ considerably (Krauter et al, 1999; Buonamici et al, 2002), which may affect the consistency of MRD measurements in a patient population. MRD is traditionally quantified by comparing the PCR product obtained in the test sample with that of the patient's leukaemic cell DNA or RNA serially diluted into DNA or RNA from normal cells. Efforts to enhance the precision of the assay by competitive PCR or limiting dilution analysis have been effective (Sykes et al, 1992; Cave et al, 1994; Ouspenskaia et al, 1995) but the increased complexity of these approaches may hinder their routine application. Real-time quantitative PCR (RQ-PCR) appears to have solved some of the complications associated with PCR quantification. A fluorescent reporter is used in the PCR, and accumulation of fluorescence during the reaction ('real-time') is measured: the increase in fluorescence is proportional to the amount of target amplicon synthesized. Results are compared with those of serial dilutions of diagnostic material. This methodology can be applied to both breakpoint fusion region (Pallisgaard et al, 1999; Chen et al, 2001; de Haas et al, 2002) and antigen-receptor genes (Pongers-Willemse et al, 1998). In the latter case, to reduce the costs associated with designing fluorescent probes that match patient-specific sequences, probes matching germ line segments, such as V (Donovan et al, 2000; Verhagen et al, 2000), J (Bruggemann et al, 2000) and Kde regions (van der Velden et al, 2002a), and applicable to multiple patients can be used. Alternatively, some investigators have bypassed the requirement for fluoresceinated probes by using the DNA intercalating dye SYBR green I as a fluorescent reporter (Nakao et al, 2000; Li et al, 2002). In patients with T-lineage ALL, MRD can be monitored by searching for cells expressing TdT and CD3 or other cell markers in bone marrow or peripheral blood (Campana & Coustan-Smith, 2002) (Fig 2). In B-lineage ALL and AML, one needs to identify aberrant phenotypes that are not expressed by normal bone marrow or peripheral blood cells (Fig 2). Therefore, MRD studies in these leukaemias are complicated by variations in the cellular composition and immunophenotype of normal bone marrow that occur with age and exposure to various agents. For example, proportions of early lymphoid progenitors (or 'haematogones') are low in the bone marrow of healthy adults and especially low in patients receiving corticosteroids or chemotherapy (Paolucci et al, 1979). In contrast, these cells are found in high proportions in young children and in patients after transplantation or chemotherapy (Lucio et al, 1999; van Lochem et al, 2000; Van Wering et al, 2000; McKenna et al, 2001). These conditions may uncover normal cells expressing phenotypes that are undetectable in studies of healthy individuals. Nevertheless, immunophenotypes that clearly distinguish B-lineage ALL cells from normal lymphoid progenitors and haematogones have been identified (Campana & Coustan-Smith, 2002). Immunophenotypic differences between leukaemia cells and normal bone marrow cells. Flow cytometric dot plots shows expression of markers typically used for detecting MRD in T-lineage ALL, B-lineage ALL and AML (top row), and the expression of the same markers in bone marrow cells from healthy individuals (middle row) and from patients recovering after chemotherapy (bottom row). Dashed circles enclose areas of the dot plot corresponding to leukaemic cells in each case. Immunophenotypic analysis of T-lineage ALL cells was done on CD3+ cells, analysis of B-lineage ALL cells on CD19+ cells and analysis of AML cells on CD33+ and/or CD34+ cells (markers that were expressed in virtually all leukaemic cells at diagnosis). The analysis of the corresponding normal control subjects was done on the same cell subsets. Detection of MRD by flow cytometry in AML presents some specific difficulties. Owing to their immunophenotypic heterogeneity, AML cells usually spread across many areas of the dot plot instead of forming the tight cluster typical of ALL cells (Fig 2). Therefore, with any given marker combination, only a fraction of cells may be phenotypically abnormal. In addition, AML cells often have light scattering properties similar to those of normal cells with high autofluorescence. These features introduce complexity in the analysis, and may reduce the sensitivity of the assay. Nevertheless, sensitive MRD detection in AML is feasible. In a recent study using four-colour flow cytometry, 26 of 54 (48%) children with AML had leukaemia cells expressing immunophenotypes that allowed measurement of MRD with a sensitivity of one leukaemic cell among 104 or more normal cells; another 20 patients (37%) had immunophenotypes that enabled the detection of one leukaemic cell among 103 cells (unpublished observations). In adult AML, the proportion of patients that can be studied with a high degree of sensitivity may be larger. In one study, 46 of 53 patients had phenotypes that were found at frequencies of less than one in 104 cells in normal bone marrow, while seven had phenotypes found in normal bone marrow but at frequencies of less than one in 103 (San Miguel et al, 1997). In another study, 65 of 93 patients had a phenotype for detection of one leukaemic cell in 104 normal cells et al, 2000). The of that enable the analysis of gene expression has to identify markers of leukaemia. The results of one of studies et al, that a of the gene of normal and leukaemic cells identify applicable markers for MRD studies in both ALL and AML, and should allow the design of for reliable and monitoring of MRD. of the main of false-positive MRD results by flow cytometry is the use of markers to distinguish leukaemic cells from normal cells. The of needs to be by studies of bone marrow and peripheral blood cells not only from healthy individuals but also from patients at various of treatment (Campana & Coustan-Smith, 2002). The use of immunophenotypic that only in samples at certain during treatment a high risk of the influence of individual in and treatment compliance on normal is A of false-negative MRD results is the of immunophenotypic et al, 1998; et al, 2001). In the of this on MRD results can be by using multiple of markers in each patient. main influence MRD detection by flow the degree of morphological and between target cells and the cells, and the number of cells that can be As discussed immunophenotypes that not with the normal of leukaemic cells must be The number of cells that can be for each set of markers in clinical samples is usually less than 1 a cluster of at least is to flow cytometric the sensitivity of the assay under these would be (Campana & Coustan-Smith, 2002). Therefore, a sensitivity of (or one leukaemic cell in 104 normal should be during routine MRD even allowing for varying of available cells and immunophenotypes that are not expressed in of leukaemic cells. are various aspects of the procedure that need and have been discussed in detail (Campana & Coustan-Smith, 2002). it to that which may have minimal during routine of leukaemia, may be a of when MRD. signals can from conditions of the sample and of antibodies or to cells (Campana & Coustan-Smith, 2002). flow cytometry and PCR amplification of IGH genes, studied serial dilutions of normal and leukaemic cells and found the two methods to be et al, 1999). then bone marrow samples from children with ALL in clinical et al, 1999). In both techniques detected MRD levels 1 in The of leukaemic cells by the two methods well the had MRD levels 1 in Results were in only two PCR detected two in 104 and in 104 leukaemic cells, whereas the flow cytometric assay was both patients were MRD by both and remain in clinical after of compared the results obtained by using a of antibodies the MRD marker with those of PCR amplification of IGH genes in samples obtained from patients at various during et al, (unpublished In 46 MRD was by PCR analysis and by flow cytometric contrast, leukaemic cells were detected by both methods in and the MRD estimates by the two methods were The two methods results in only of the one was by PCR to have leukaemic cells, but MRD was detected by flow cytometric analysis of the two other samples were by analysis to have leukaemic cells but by PCR to have less than and (unpublished observations). A study comparing the results of flow cytometry and PCR amplification of TCRG and TCRD genes to detect MRD in bone marrow samples from patients with ALL found results in were more during the early of and were to low and presence of PCR et al, 2001). A study comparing flow cytometry to detection of transcripts in bone marrow samples from patients with ALL in observed results in samples et al, 2000). In two samples the assay was while cells were detectable by flow the samples had leukaemic cells by flow cytometry but signal by RT-PCR. also compared the results of flow cytometry with the results of amplification of fusion transcripts and observations). The methods results in of bone marrow samples of children with B-lineage ALL in clinical had MRD and were MRD the two one was by flow cytometry but by the other was by flow cytometry but by PCR patient had MRD that was detectable by both methods in and A similar was performed with samples obtained from 20 children with AML during treatment (unpublished observations). The molecular abnormalities studied were and In a of residual disease of these samples also had residual cells detectable by flow cytometry, whereas one with to levels of residual disease by did leukaemic were not detected by The samples had undetectable leukaemic transcripts or signals corresponding to levels of residual disease than but seven of these with undetectable leukaemic transcripts and with residual disease by had residual disease by flow The variable of MRD detection by flow cytometry in in and by to and the limited quantitative capacity of the conventional used can the observed A correlation between flow cytometric results and PCR detection of WT-1 was in a recent et al, 2002). Several studies in ALL have the of MRD at different during treatment (Fig there are due to differences in chemotherapy these studies have demonstrated the clinical of MRD. In one study, MRD was in patients by a competitive PCR assay junctional sequences of IGH and TCR et al, 1998). The absence or presence and of residual leukaemia during the first of were significantly with the risk of early relapse at each of the with leukaemic cells after the of or those with at had a particularly high risk of Another study monitored MRD in children with ALL to of the (van Dongen et al, 1998). This study also used PCR analysis of IGH and TCR genes as well as TAL1 patients had relapse at than those were MRD at the various at MRD levels at the of treatment and treatment were associated with a relapse when compared with patients with a low degree of MRD, and with a to relapse when compared with patients. MRD information from the first two was particularly allowing the of different risk a of patients with a relapse of a of patients with a relapse of and with a relapse of of MRD during treatment in children with ALL. the of patients, to the studies areas correspond to patients with MRD in each were obtained from et and results for the studies, from Cave et for the for and of study, and from van Dongen et for the used flow cytometry to study MRD in children with diagnosed ALL in a chemotherapy et al, found that detectable MRD (i.e. leukaemic at each of of and and of was significantly associated with a relapse (Fig with high levels of MRD at the of the or at

Adult acute leukemia

High Dose Cytarabine and Mitoxantrone in Combination with Dasatinib As Active Induction Therapy in Adult Patients with Philadelphia Chromosome Positive (ph+) Acute Lymphoblastic Leukemia (ALL)

The Role of Cytotoxic Therapy with Hematopoietic Stem Cell Transplantation in the Treatment of Adult Acute Lymphoblastic Leukemia: Update of the 2006 Evidence-Based Review

Children with acute lymphocytic leukemia (ALL) are at high risk for developing hyperglycemia. Hyperglycemic adult ALL patients have shorter remissions, more infections, and increased mortality. No corresponding data are available in children. We hypothesized that children with ALL who become hyperglycemic during induction chemotherapy have an increased risk for infection during their first year of treatment. We conducted a retrospective chart review of 135 patients diagnosed with ALL during 1999-2001 at Texas Children's Hospital. Infectious outcomes during the first year of therapy were compared in three groups patients based on blood glucose concentrations during induction therapy: euglycemic (<140 mg/dl), mild hyperglycemic (MH) (140-199 mg/dl) and overt hyperglycemic (OH) (blood glucose >200 mg/dl). Seventy-five (56%) patients met criteria for either MH (21%) or OH (35%). Hyperglycemia was more prevalent in older children (P < 0.001) and those at risk for being overweight (BMI% >85%) at diagnosis (P < 0.01). Patients with MH and OH were 2.5 times (95% CI 1.0-6.2) and 2.1 times (95% CI 1.0-4.6) more likely to have documented infections, respectively. Patients with OH were 4.2 times (95% CI 1.5-12) more likely to have bacteremia/fungemia, 3.8 times (95% CI 1.2-11.6) more likely to have cellulitis, and 4.0 times (95% CI 1.7-9.3) more likely to be admitted for fever and neutropenia than the euglycemia group. Hyperglycemia, especially when overt, may be a previously unrecognized risk factor of infectious complications in children with ALL during the first year of treatment.