Improving acute promyelocytic leukemia (APL) outcome in developing countries through networking, results of the International Consortium on APL.

Thanks to modern treatment with all-trans retinoic acid and chemotherapy, acute promyelocytic leukemia (APL) is now the most curable type of leukemia. However, this progress has not yielded equivalent benefit in developing countries. The International Consortium on Acute Promyelocytic Leukemia (IC-APL) was established to create a network of institutions in developing countries that would exchange experience and data and receive support from well-established US and European cooperative groups. The IC-APL formulated expeditious diagnostic, treatment, and supportive guidelines that were adapted to local circumstances. APL was chosen as a model disease because of the potential impact on improved diagnosis and treatment. The project included 4 national coordinators and reference laboratories, common clinical record forms, 5 subcommittees, and laboratory and data management training programs. In addition, participating institutions held regular virtual and face-to-face meetings. Complete hematological remission was achieved in 153/180 (85%) patients and 27 (15%) died during induction. After a median follow-up of 28 months, the 2-year cumulative incidence of relapse, overall survival (OS), and disease-free survival (DFS) were 4.5%, 80%, and 91%, respectively. The establishment of the IC-APL network resulted in a decrease of almost 50% in early mortality and an improvement in OS of almost 30% compared with historical controls, resulting in OS and DFS similar to those reported in developed countries.

The impact of medical education and networking on the outcome of leukemia treatment in developing countries. The experience of International Consortium on Acute Promyelocytic Leukemia (IC-APL).

OBJECTIVES: Several clinical trials conducted in Europe and US reported favorable outcomes of patients with APL treated with the combination of all trans retinoic acid (ATRA) and anthracyclines. Nevertheless, the results observed in developing countries with the same regimen was poorer, mainly due to high early mortality mainly due bleeding. The International Consortium on Acute Promyelocytic Leukemia (IC-APL) is an initiative of the International Members Committee of the ASH and the project aims to reduce this gap through the establishment of international network, which was launched in Brazil, Mexico and Uruguay. METHODS: The IC-APL treatment protocol is similar to the PETHEMA 2005, but changing idarubicin to daunorubicin. All patients with a suspected diagnosis of APL were immediately started on ATRA, while bone marrow samples were shipped to a national central lab where genetic verification of the diagnosis was performed. The immunofluorescence using an anti-PML antibody allowed a rapid confirmation of the diagnosis and, the importance of supportive measures was reinforced. RESULTS: The interim analysis of 97 patients enrolled in the IC-APL protocol showed that complete remission (CR) rate was 83% and the 2-year overall survival and disease-free survival were 80% and 90%, respectively. Of note, the early mortality rate was reduced to 7.5%. DISCUSSION: The results of IC-APL demonstrate the impact of educational programs and networking on the improvement of the leukemia treatment outcome in developing countries.

Caracterización genotípica de 80 cepas del género Mycobacterium en Uruguay / Genotype characterization of 80 strains of Mycobacterium in Uruguay

Los métodos tradicionales de identificación fenotípica del género Mycobacterium son lentos y poco sensibles, requiriéndose cuatro a seis semanas para lograr un diagnóstico apropiado a partir de un cultivo positivo. Los procedimientos moleculares han permitido acortar este período, obteniéndose resultados entre las 36 a 72 horas. En nuestro país la incidencia de M. tuberculosis es baja y no existen datos acerca de con qué frecuencia los casos diagnosticados como tuberculosis pulmonar son en realidad causados por Mycobacterium no tuberculosis (MNT), normalmente saprofitas. Desde el punto de vista terapéutico, el diagnóstico etiológico a través de la identificación precisa de la especie de Mycobacterium infectante resulta un aporte significativo, dado que el tratamiento y el manejo de sus contactos son diferentes según sea la especie involucrada. Por estas razones se introdujo en nuestro laboratorio el diagnóstico de Mycobacterium a través de su identificación genotípica. Para ello se eligieron dos marcadores moleculares de ADN: la secuencia de inserción IS6110, característica de los genomas del complejo M. tuberculosis, y la secuencia del gen ribosomal 16s (ADNr 16s) para estudiar la identidad específica dentro del género Mycobacterium. Una vez puestas a punto las técnicas moleculares seleccionadas, se procedió al estudio retrospectivo de una colección de 80 aislamientos, identificados como Mycobacterium por métodos fenotípicos. La mayoría de los aislamientos (75/80) resultaron cepas del complejo M. tuberculosis. Los restantes cinco fueron identificados como cepas MNT, tres de ellas causantes de infecciones pulmonares.

Summary Traditional methods to determine phenotype identification for mycobacterium are longer as compared with cellular procedures (4 to 6 weeks and 36 to 72 hours respectively). In Uruguay, the incidence of tuberculosis Mycobacterium is low and data on pulmonary tuberculosis cases but caused by non-tuberculosis Mycobacterium (MNT) -normally saprophytes- is lacking. From a therapeutic point of view, diagnosis based on an accurate identification of Mycobacterium infectant may be significant since treatment and management differ according to the strain found. Two DNA molecular markers were chosen in our laboratory to diagnose Mycobacterium through genotype identification: IS6110 insertion element and ribosomal DNA sequences 16s (DNAr 16s) to determine specific identity within Mycobacterium. Once selected molecular techniques were updated, we undertook a retrospective study of 80 isolates identified as Mycobacterium by phenotype methods. Most of the isolates (75/80) were tuberculosis Mycobacterium strains. The remained five were identified as MNT strains, of which three caused pulmonary infections.

Résumé Les méthodes traditionnelles d'identification phénotypi-que du genre Mycobacterium sont lentes et peu sensibles, quatre à six semaines étant nécessaires pour avoir un diagnostic approprié à partir d'une culture positive. Les procédés moléculaires ont permis de raccourcir cette période: on obtient des résultants au bout de 36-72 heures. Dans notre pays, l'incidence de M. tuberculosis est basse et il n'y a pas de registres pour savoir la fréquence avec laquelle les cas diagnostiqués comme tuberculose pulmonaire sont en réalité causés par Mycobacterium non tuberculose (MNT), normalement saprophytes. Du point de vue thérapeutique, le diagnostic étiolo-gique à travers l'identification précise de l'espèce de mycobacterium infectante est un apport important, étant donné que le traitement varie selon l'espèce en question. Voilà pourquoi on a introduit dans notre laboratoire le diagnostic de Mycobacterium à travers son identification génotypique. Pour ce faire, on a choisi deux marqueurs moléculaires d'ADN: la séquence d'insertion IS6110, caractéristique des génomes du complexe M.tuberculose, et la séquence du gène ribosome 16s (ADN 16s) pour étudier l'identité spécifique dans le genre Mycobacterium. Une fois mises à point les techniques moléculaires sélectionnées, on fait une étude rétrospective d'une collec-tion de 80 isolements, identifiés comme Mycobacterium par des méthodes phénotypiques. La plupart des isolements (75/80) étaient des cèpes du complexe M. tuberculose. Les autres cinq ont été identifiés comme des cèpes MNT, dont trois étant la cause d'infections pulmonaires.