Outcome of Adults with Precursor B-Cell and Mature B-Cell (Burkitt-Cell) ALL/Lymphoma in a Large Inner City Hospital.

Abstract

Acute lymphoblastic leukemia is the most common acute leukemia in children, but accounts for only about 20% of adult acute leukemias. In children overall survival at 5 years is about 70% as a result of intensive treatment regimens. Application of such treatment regimens to adults has improved the 5 year survival to about 30–35% in large studies. We report here a retrospective analysis of all 18 cases which presented to our hospital during the last 2 1/2 years. All patients were treated with intensive chemotherapy regimens (primarily Hyper CVAD alternating with MTX/AraC) including maintenance therapy for patients with precursor B-cell ALL. The mean age of all patients was 39.6 ± 15.2 years., 11 patients were male and 7 female. Thirteen patients presented with precursor B-cell ALL (8 male/5 female); the mean age of these patients was 36.3 ± 16.1 years. Five patients presented with Burkitt-cell leukemia (3 male/2 female), the mean age of these patients was 48 ± 8.9 years; 4 patients were HIV positive. Overall, 7 of 18 patients are alive, 5 are in remission, 1 did not achieve remission and is being evaluated for stem cell transplant, and 1 is completing the first cycle of chemotherapy. The 7 surviving patients include 5 with precursor B-cell ALL (4 male/1 female) and 2 Burkitt-cell patients (both female, both HIV+, both with CD4 count > 400). An analysis of high risk features in pre B-cell ALL patients showed only one patient older than 60, 1 with adverse cytogenetics (9:22 translocation), one with WBC count >50,000/ml at presentation, and 2 who required more than 1 course to achieve CR. Positivity for CD20 has been reported by some to be an adverse prognostic factor in pre B ALL. In our study 8 of 13 pre B ALL patients were CD20 positive, 3 of these patients survive as compared to 2 of 5 CD20 negative patients. Women with pre B ALL had significantly poorer outcomes than men with only 1 of 5 surviving; all women with CD20 positive disease succumbed. Among the Burkitt-cell patients, the 2 survivors were HIV positive women with the highest CD4 counts. Three of 18 patients (16.6%) died during induction; 1 presented to our hospital in first relapse 3 years after first CR, 1 developed overwhelming fungal infection, and 1 suffered probable anaphylactic reaction. More than 75% of patients with pre B ALL were Hispanic, and while 3 are still living, only one has completed induction and consolidation and is still in remission. The reasons behind the poor survival of the Hispanic subgroup are not clear, however, it should be noted that all patients who were CD20 positive in this group have either died or failed to achieve remission. In this series 27% of patients had mature B-cell disease, which is much higher than the 5% estimated incidence in adults overall. Despite the preponderance of HIV positive patients, the survival of these patients compares favorably with that reported in the literature.