RESUMO
Relapse and graft failure after autologous (auto) or allogeneic (allo) hematopoietic stem cell transplantation (HSCT) are serious and frequently fatal events. A second HSCT can be a life-saving alternative, however, information on the results of such intervention in an outpatient setting is limited. Outpatient second hematoprogenitors transplant after reduced-intensity conditioning (RIC) at a single academic center was analyzed. Twenty-seven consecutive adults who received an allo-HSCT after an initial auto- or allo-HSCT from 2006 to 2019 were included. Data were compared using the χ2 -test. Survival analysis using Kaplan-Meier and Cox proportional hazard models was performed; cumulative incidence estimation of transplant-related mortality (TRM) was assessed. Hodgkin lymphoma was the most frequent diagnosis for the group with a first auto-HSCT with 5/12 (41.7%) cases, and acute myeloid leukemia for those with a first allo-HSCT with 6/15 (40%). One-year overall survival and disease-free survival (DFS) was 66.7% (95% CI 27.2-88.2) and 59% (95% CI 16-86) for 12 patients with a first auto-HSCT; and for 15 patients with a first allo-HSCT, it was 43.3% (95% CI 17.9-66.5) and 36% (95% CI 13.2-59.9), respectively. Eight (29.6%) patients died of TRM and the cumulative incidence of TRM at 1 year was 22% (95% CI 8.6-39.27). Chronic graft-versus-host disease and late (>10 months) second transplantation were protective factors for longer survival. Neutropenic fever was more common in the group with a first allo-HSCT (p = 0.01). In conclusion, outpatient second allo-HSCT using RIC after auto- or allografting failure or relapse is feasible and offers a reasonable alternative for patients with severe life-threatening hematological diseases.
Assuntos
Assistência Ambulatorial , Transplante de Células-Tronco Hematopoéticas , Condicionamento Pré-Transplante , Adulto , Aloenxertos , Autoenxertos , Doença Crônica , Intervalo Livre de Doença , Feminino , Doença Enxerto-Hospedeiro/etiologia , Doença Enxerto-Hospedeiro/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Neutropenia/etiologia , Neutropenia/mortalidade , Estudos Retrospectivos , Taxa de SobrevidaRESUMO
BACKGROUND AND OBJECTIVE: Hematopoietic stem cell transplantation (HSCT) in developing countries is cost-limited. Our primary goal was to determine the cost structure for the HSCT program model developed over the last decade at our public university hospital and to assess its clinical outcomes. MATERIALS AND METHODS: Adults and children receiving an allogeneic hematopoietic stem cell transplant from January 2010 to February 2011 at our hematology regional reference center were included. Laboratory tests, medical procedures, chemotherapy drugs, other drugs, and hospitalization costs were scrutinized to calculate the total cost for each patient and the median cost for the procedure. Data regarding clinical evolution were incorporated into the analysis. Physician fees are not charged at the institution and therefore were not included. RESULTS: Fifty patients were evaluated over a 1-year period. The total estimated cost for an allogeneic HSCT was $12,504. The two most expensive diseases to allograft were non-Hodgkin lymphoma ($11,760 ± $2,236) for the malignant group and thalassemia ($12,915 ± $5,170) for the nonmalignant group. Acute lymphoblastic leukemia ($11,053 ± 2,817) and acute myeloblastic leukemia ($10,251 ± $1,538) were the most frequent indications for HSCT, with 11 cases each. Median out-of-pocket expenses were $1,605, and 1-year follow-up costs amounted to $1,640, adding up to a total cost of $15,749 for the first year. The most expensive components were drugs and laboratory tests. CONCLUSION: Applying the cost structure described, HSCT is an affordable option for hematological patients living in a developing country.
Assuntos
Transplante de Células-Tronco Hematopoéticas/economia , Custos e Análise de Custo , Países em Desenvolvimento , Feminino , Humanos , Leucemia Mieloide Aguda/terapia , Linfoma não Hodgkin/terapia , Masculino , México , Talassemia/terapia , Transplante Homólogo/economia , Resultado do TratamentoRESUMO
The relationship between treatment for hematologic malignancies and risk of developing metabolic syndrome (MS) is controversial; in addition, metabolic changes following hematopoietic stem cell transplantation (HSCT) is an area of growing interest. We documented the presence of MS in patients with hematological malignancies treated with chemotherapy and HSCT. Nutritional status, anthropometrics, and pertinent laboratory parameters were used to evaluate the presence of MS using the Adult Treatment Panel (ATP III) criteria. In the study, 115 patients were included. Using ATP III criteria, MS was identified in 42 (44.7%) patients treated only with chemotherapy and in 8 (33.3%) patients with an HSCT. There was an important but not significant difference in the mean fasting glucose, which was higher in the chemotherapy group (108.32 ± 54.28 vs. 94.48 ± 18.25, P = 0.300). Mean values of biochemical markers and blood pressure were not different between the groups. An increase in central obesity in men with hematological diseases in comparison to the rest of the population was also found (46.7% vs 32.4%). There was no difference in the prevalence of MS between patients with hematologic malignancies receiving an HSCT and those treated with chemotherapy alone.
Assuntos
Doenças Hematológicas/terapia , Neoplasias Hematológicas/terapia , Síndrome Metabólica/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Feminino , Doenças Hematológicas/epidemiologia , Neoplasias Hematológicas/epidemiologia , Transplante de Células-Tronco Hematopoéticas , Humanos , Masculino , Pessoa de Meia-Idade , Adulto JovemRESUMO
BACKGROUND/OBJECTIVE: Acute myeloid leukemia (AML) is the most common acute leukemia in adults. We documented the characteristics and results of treatment of patients with AML at a single reference center. METHODS: Patients diagnosed with AML between June 2003 and July 2011 at a university hospital in northeast Mexico were studied. Overall survival (OS) and event-free survival (EFS) were determined, and risk factors were analyzed with respect to their influence on prognosis. RESULTS: A total of 132 AML patients were included. Median age was 32 years. Complete remission (CR) was achieved by 55% of patients. CR was achieved by 65.1% of patients <60 years (n = 109), compared to 8.7% of those >60 years (n = 23; p < 0.001). In all, 39% of patients >60 years suffered an early death, compared to 14.7% of those <60 years (p < 0.001). OS for patients with AML was 35%, whereas EFS was 32%. On multivariate analysis, patients >60 years had a lower OS and EFS (p < 0.001). A total of 28% of patients received a transplant, and they had high er OS and EFS. Conclusions: Our patients were considerably younger and had remarkably lower survival rates than reported for other populations; those >60 years had a higher early death rate, and fewer of these patients achieved CR.
Assuntos
Leucemia Mieloide Aguda/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Anti-Infecciosos/uso terapêutico , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Transfusão de Componentes Sanguíneos , Criança , Pré-Escolar , Terapia Combinada , Citarabina/administração & dosagem , Dexametasona/administração & dosagem , Intervalo Livre de Doença , Doxorrubicina/administração & dosagem , Etoposídeo/administração & dosagem , Feminino , Transplante de Células-Tronco Hematopoéticas , Hospitais Universitários , Humanos , Lactente , Infusões Intravenosas , Injeções Espinhais , Estimativa de Kaplan-Meier , Leucemia Mieloide Aguda/terapia , Leucemia Mielomonocítica Aguda/epidemiologia , Leucemia Mielomonocítica Aguda/terapia , Masculino , Metotrexato/administração & dosagem , México/epidemiologia , Pessoa de Meia-Idade , Mitoxantrona/administração & dosagem , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: The impact of obesity on hematopoietic stem cell transplantation (HSCT) outcome remains controversial and has been considered a relative contraindication for the procedure. We investigated the influence of Body Mass Index (BMI) on the clinical course of adults undergoing an ambulatory HSCT after a non-myeloablative conditioning regimen. METHODS: Adults with hematologic diseases undergoing an autologous or allogeneic HSCT after reduced intensity conditioning (RIC) and supported exclusively with enteral nutrition (EN) were studied. BMI and body fat were sequentially determined. Patients were divided into three BMI subgroups: underweight; normal, and overweight/obese. RESULTS: Seventy-seven patients with a median follow-up of 21months were evaluated. Fourteen (18.2%) were underweight, 21 (27.3%) had a normal weight, and 42 (54.5%) were overweight/obese. A significant weight loss was observed among all three weight groups after HSCT (P=0.014). No correlation was found between time to engraftment and BMI (P=0.91), serum albumin (P=0.387), and fasting glucose (P=0.64), nor between BMI and acute (P=0.456) or chronic (P=0.209) graft versus host disease (GVHD). On multivariate analysis a higher overall survival (OS) was documented for obese patients (P=0.037). DISCUSSION: A BMI >30/kg/m(2) was independently associated with a higher survival rate after HSCT. Obese patients should not be excluded as transplant candidates based only on this parameter.
Assuntos
Transplante de Células-Tronco Hematopoéticas/mortalidade , Obesidade/complicações , Pacientes Ambulatoriais , Condicionamento Pré-Transplante , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados da Assistência ao Paciente , Fatores de Risco , Transplante Autólogo , Transplante Homólogo , Adulto JovemRESUMO
Treatment of autoimmune cytopenias remains unsatisfactory for patients refractory to first-line management. We evaluated the safety and efficacy of low-dose rituximab plus alemtuzumab in patients with steroid-refractory autoimmune hemolytic anemia and immune thrombocytopenic purpura. Nineteen of 21 included patients were assessable for response (11 with immune thrombocytopenic purpura, 8 with autoimmune hemolytic anemia). Treatment with 10 mg of alemtuzumab subcutaneously on days 1 to 3, plus 100 mg of rituximab intravenously weekly in 4 doses, was administered. The overall response rate was 100%, with complete response in 58%. The median response duration was 46 weeks (range, 16-89 weeks). Median follow-up was 70 weeks (range, 37-104 weeks). Most toxicity was grade 1 fever related to the first dose. Six patients developed infections. The combination of rituximab and alemtuzumab is feasible and has an acceptable safety profile and remarkable clinical activity in this group of patients. This study is registered at www.clinicaltrials.gov as #NCT00749112.
Assuntos
Anemia Hemolítica Autoimune/tratamento farmacológico , Anemia Hemolítica/tratamento farmacológico , Anticorpos Monoclonais Murinos/administração & dosagem , Anticorpos Monoclonais/administração & dosagem , Anticorpos Antineoplásicos/administração & dosagem , Fatores Imunológicos/administração & dosagem , Púrpura Trombocitopênica Idiopática/tratamento farmacológico , Adolescente , Adulto , Alemtuzumab , Anemia Hemolítica/mortalidade , Anemia Hemolítica Autoimune/mortalidade , Anticorpos Monoclonais Humanizados , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Púrpura Trombocitopênica Idiopática/mortalidade , RituximabRESUMO
Heart failure constantly increases its incidence and prevalence in our society, it was imperative to start a heart transplant program to improve the survival rates of patients with end stages of the disease. Legal issues made impossible to transplant patients out of Mexico City until recent years. Even with an acute hemodynamic and clinic improvement after the transplant, these patients frequently develop complications such as graft rejection or opportunistic infections due to the immunosuppressive schemes increasing the morbidity and mortality of the procedure. In the present article we report the experience acquired with 65 heart transplant patients from 4 transplant programs in Monterrey, Nuevo Leon, one of them from the socialized system and the other three from private hospitals. Our program not only has successfully transplanted patients with advanced age but, for the first time in Latin America we have transplanted patients assisted with the ambulatory Thoratec TLC II system. Even that we have faced obstacles like a newly started donation culture in our population and limited resources, our patient's survival rate push us to continue working with these very ill population.
Assuntos
Transplante de Coração/estatística & dados numéricos , Adolescente , Adulto , Idoso , Feminino , Humanos , Masculino , México , Pessoa de Meia-Idade , Adulto JovemRESUMO
The effectiveness of reduced-intensity conditioning allogeneic stem cell transplantation (allo- RIC) compared with high-dose chemotherapy followed by autologous stem cell transplantation (auto-SCT) in Hodgkin's disease (HD) and in non-Hodgkin's lymphoma (NHL) patients remains poorly defined. The purpose of the study was to demonstrate the usefulness of auto-SCT or allo-SCT, employing a RIC regimen in refractory or relapsed NHL or HD patients. We analyzed the outcome of 71 patients with advanced disease. Twenty-three NHL and 14 HD patients received an allo-RIC using fludarabine, cyclophosphamide, and low-dose busulfan as the conditioning regimen. Sixteen NHL and 18 HD patients received auto-SCT using cyclophosphamide and etoposide as conditioning regimen. All hematopoietic stem cells products were not cryopreserved and the majority of grafts were done on an outpatient basis, including conditioning and post-stem cell infusion care (auto-SCT, 62% and allo-RIC procedure, 91%). The median OS was 45.5 months for the allo-RIC recipients and 53.3 months for auto-SCT recipients. Acute/chronic GVHD incidence in NHL and HL groups was 38%/31% and 14%/7%, respectively. We found no significant difference in overall survival between allo-RIC group and auto-SCT group for NHL patients (P = 0.43) but better OS was observed for auto-SCT group than for allo-SCT group in HL patients (P < 0.001). The relapse rate was higher in autografted patients, both in NHL and HD. Both auto-SCT and allo-RIC appear to be valid treatments for poor-risk patients with relapsed or refractory lymphoma who could not otherwise be cured with conventional salvage regimens.
Assuntos
Assistência Ambulatorial , Transplante de Células-Tronco Hematopoéticas/métodos , Linfoma/prevenção & controle , Linfoma/cirurgia , Transplante Autólogo/métodos , Transplante Homólogo/métodos , Adulto , Antineoplásicos/uso terapêutico , Progressão da Doença , Intervalo Livre de Doença , Feminino , Humanos , Linfoma/tratamento farmacológico , Linfoma/mortalidade , Masculino , Pessoa de Meia-Idade , Recidiva , Indução de Remissão , Estudos Retrospectivos , Condicionamento Pré-Transplante/métodos , Resultado do TratamentoRESUMO
Aplastic anemia (AA) is most frequently due to autoimmune attack on its own stem cells. Alemtuzumab is a monoclonal antibody which recognizes the CD52 antigen on the surface of T and B cells. It has proved useful in autoimmune diseases, lymphoproliferative conditions, and graft versus host disease. Based on its immunosuppressive properties, we treated 14 AA patients with alemtuzumab. Median age was 23 years. Ten milligrams of alemtuzumab were injected subcutaneously each day for five consecutive days. Cyclosporine A was also administered orally at a dose of 2 mg/kg every 12 h for 3 months, and then gradually tapered. Response to alemtuzumab was followed for a median of 20 months. There were eight responses (57.1%), two complete and six partial. Whereas six (42.8%) patients were non-responders. Median complete blood count values on alemtuzumab responders were Hb 13.1 mg/dL, absolute neutrophil count 2.4 x 10(9)/L, and platelets 97.5 x 10(9)/L. A good response was produced in 57% of AA patients with the administration of alemtuzumab, who lacked a stem cell donor.
Assuntos
Anemia Aplástica/tratamento farmacológico , Anticorpos Monoclonais/administração & dosagem , Anticorpos Antineoplásicos/administração & dosagem , Ciclosporina/administração & dosagem , Adolescente , Adulto , Idoso , Alemtuzumab , Anticorpos Monoclonais Humanizados , Protocolos de Quimioterapia Combinada Antineoplásica/administração & dosagem , Criança , Feminino , Seguimentos , Humanos , Imunossupressores/uso terapêutico , Masculino , Pessoa de Meia-Idade , Indução de Remissão , Análise de Sobrevida , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: Palliative care (PC) for patients with malignant hematological diseases is scarcely documented, particularly in low- and middle-income countries. This study aimed to document PC provided to patients with hematologic malignancies. METHODS: Bidirectional study conducted from July 2016 to June 2019 at the hematology and palliative care departments at a reference center in Northeast Mexico for low-income open population uninsured patients. Clinical records and electronic files of patients with malignant hematological diseases of both sexes and all ages attending an academic hematology center were reviewed. Statistical analysis was performed with the SPSS version 22 program. Acute and chronic leukemias, multiple myeloma, Hodgkin lymphoma, non-Hodgkin lymphoma, and others were included. RESULTS: Five-hundred ten patients were studied, of which 148 (29%) died. Eighty-one (15.88%) patients including 31 (20.9%) who died received PC. Median age at palliative diagnosis was 42 (2-91) years. The most common symptom was pain (69.7%). The most frequent reason for palliative referral was treatment-refractory disease (39%). During the last week of life, 19 (95%) of 20 patients had blood sampling; 17 (85%) received antibiotics; 16 (80%) had a urinalysis performed; 16 (80%) received analgesia, including paracetamol (11, 35.5%) and buprenorphine (7, 22.6%); 10 (50%) received blood products; 9 (45%) were intubated; and central venous catheters were inserted in 5 (25%) patients. CONCLUSIONS: Palliative care was provided to a minority of patients with hematologic malignancies and considerable improvement is required in its timely use and extension.
Assuntos
Países em Desenvolvimento , Neoplasias Hematológicas/epidemiologia , Cuidados Paliativos/organização & administração , Assistência Terminal/organização & administração , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Pessoas sem Cobertura de Seguro de Saúde , México/epidemiologia , Pessoa de Meia-Idade , Cuidados Paliativos/normas , Cuidados Paliativos/estatística & dados numéricos , Estudos Retrospectivos , Assistência Terminal/normas , Assistência Terminal/estatística & dados numéricos , Adulto JovemRESUMO
BACKGROUND: Heterogeneity regarding clinical and laboratory findings at diagnosis of acute lymphoblastic leukemia exists. The frequency of complete blood count abnormalities and its combinations, symptoms and physical findings were investigated in Hispanic children from an open population at the diagnosis of acute lymphoblastic leukemia. METHODS: The patient charts and electronic records of under 16-year-old children diagnosed with acute lymphoblastic leukemia over 10 years at a regional hematology center of a university hospital were analyzed to retrieve data concerning the complete blood count at first evaluation. Type and distribution of abnormal data, frequency of symptoms and physical findings at presentation were documented. RESULTS: The records of 203 children aged 0-15 years diagnosed with acute lymphoblastic leukemia from 2006 to 2016 were revisited. The results of the blood workup showed a median white blood cell count of 7120 × 109/L (range: 450-600,000 × 109/L), and a median hemoglobin concentration of 7.5 g/dL (range: 2.4-15.3 g/dL), whereas the median platelet count was 47,400 × 109/L (range: 4000-544,000 × 109/L). Leukocytosis and leukopenia were present in 36.6% and 36.1% of cases, respectively; anemia was diagnosed in 82.9% children. The order of frequency for major clinical symptoms was fatigue 62%, fever 60%, bone and joint pain 39%, hyporexia 33% and weight loss 21%, while main physical findings were hepatomegaly 78%, splenomegaly 63%, lymphadenopathy 57%, pallor 48%, and purpura 30%. CONCLUSION: Data differing from those classically expected at diagnosis of acute lymphoblastic leukemia in children were documented in a cohort of Hispanic children over one decade with a wide spectrum of complete blood count abnormalities, forms of presentation and frequency of physical findings.
RESUMO
Efficacy of an ambulatory hematopoietic stem cell transplant (HSCT) program with a reduced intensity conditioning regimen (RIC) in malignant hematological diseases was assessed. We analyzed 217 patients who underwent HSCT from August 2013 to July 2017. There were 78 (35.9%) HLA-identical, 56 (25.8%) haploidentical, and 83 (38.2%) autologous transplants. Two-year transplant-related mortality (TRM) for HLA-identical, haploidentical, and auto grafts were 20%, 25%, and 2.5%; relapse/progression was 44%, 60%, and 55%; overall survival (OS) was 61%, 44.8%, and 78.0%; and disease-free survival (DFS) was 36.8%, 26.5%, and 43.5%, respectively. Factors associated with a high risk of TRM were male sex (HR = 2.62, P = 0.031), fever and neutropenia (HR = 3.30, P = 0.023), and cell dose < 5 × 106 CD34 +/kg (HR = 4.24, P = 0.001); cGVHD was a protective factor for TRM (HR = 0.29, P = 0.022). Transfusion was associated with increased risk of relapse/progression in univariate and multivariate analysis (HR = 3.10, P = 0.001 and HR = 3.30, P = 0.004); cGVHD was a protective factor (HR = 0.18, P = 0.001 and HR = 0.17, P = 0.002). In a multivariate analysis for allo-HSCT, infections were associated with high risk of mortality (HR = 3.90, P = 0.016) and transfusion with reduced DFS (HR = 2.76, P = 0.029); for haplo-HSCT, CD34 + < 5 × 106/kg was a risk factor for mortality and lower DFS (HR = 5.41, P = 0.001 and HR = 3.93, P = 0.001). Outcomes of our RIC-based outpatient transplant program are comparable to excellence centers in high-income countries.
Assuntos
Transplante de Células-Tronco de Sangue Periférico/métodos , Pobreza/tendências , Condicionamento Pré-Transplante/métodos , Adolescente , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Síndrome do Lobo Médio , Adulto JovemRESUMO
Nutritional status is an important variable when planning the treatment of children with acute lymphoblastic leukemia (ALL). We determined the nutritional status of children from Northern Mexico diagnosed with ALL during a 5-year period at a public university hospital. One hundred and two children were included. Evaluation by a clinical nutritionist through a food frequency questionnaire and anthropometrical measurements was carried out. Dual energy X-ray absorptiometry (DEXA) for body composition analysis was performed. Based on their body mass index (BMI) percentile, children were classified in four groups as underweight, normal weight, at-risk for overweight and overweight. Fifty-four patients were boys (53%) and 48 (47%) girls. Median values were: age, 6.0 years; weight, 23 kg, height, 118 cm. BMI median value was 16.7. In 78 patients studied by DEXA, median body mass was 24,335 g, with 66.4% from lean tissue, 23.5% from fat. Bone mineral content was 10.6%. Bone density was 0.754 g/cm(2). The majority of children with ALL in Northern Mexico are well nourished at diagnosis and have a normal body composition. Early nutritional intervention is important to maintain this status and correct specific abnormalities.
Assuntos
Avaliação Nutricional , Estado Nutricional , Leucemia-Linfoma Linfoblástico de Células Precursoras/epidemiologia , Criança , Humanos , México/epidemiologia , Leucemia-Linfoma Linfoblástico de Células Precursoras/diagnóstico , Classe Social , Fatores de TempoRESUMO
INTRODUCTION: The outcomes for adolescents and young adults (AYAs) with acute myeloid leukemia (AML) have been poorly characterized in Hispanics in low- to middle-income countries. The results are influenced by biologic and socioeconomic factors. The clinical paths for AYA patients with AML are reported. PATIENTS AND METHODS: A retrospective analysis of AYA and pediatric AML patients aged 1 to 39 years during 2003 to 2016 from a single reference center in Northeast Mexico treated with a 7+3 standard protocol was performed. The 5-year overall survival (OS) and event-free survival (EFS) were estimated using Kaplan-Meier analysis. The hazard ratios for relapse and death were estimated using a Cox regression model. The patients with promyelocytic leukemia were analyzed separately. RESULTS: The study included 110 non-PML AML patients, 39 children and 71 AYAs. No difference in complete remission was found (P = .446), although the overall response rate was greater in the children (87.2% vs. 69% in AYAs; P = .034). The 5-year EFS rate was 33% for the children versus 9.3% in the AYAs at a median follow-up of 22 and 9 months, respectively (P = .008). The 5-year OS rate was 51% in the children and 22% in the AYAs (P = .001). Of the 44 AYAs with complete remission, 29 (65%) developed a relapse. Of the 39 children and 71 AYAs, 20 children (51.3%) and 21 AYAs (29.6%) underwent transplantation (P = .024). Patients with refractory disease had a 1-year OS rate of 14.4%. Older age (hazard ratio [HR], 2.55; P = .002) and white blood cell count > 50 × 109/L (HR, 1.79; P = .023) were significant for death, and transplantation was protective (HR, 0.57; P = .023). CONCLUSION: Low EFS and OS rates were found for AML patients in the AYA group. To improve survival rates, intensified chemotherapy regimens and early hematopoietic stem cell transplantation are needed.
Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Leucemia Mieloide Aguda/mortalidade , Leucemia Mieloide Aguda/terapia , Adolescente , Adulto , Criança , Pré-Escolar , Terapia Combinada/métodos , Intervalo Livre de Doença , Feminino , Transplante de Células-Tronco Hematopoéticas , Hispânico ou Latino/estatística & dados numéricos , Humanos , Lactente , Estimativa de Kaplan-Meier , Leucemia Mieloide Aguda/etnologia , Estudos Longitudinais , Masculino , México , Indução de Remissão , Estudos Retrospectivos , Adulto JovemRESUMO
BACKGROUND: The therapeutic progress for adults with acute lymphoblastic leukemia (ALL) has been slow, with a 5-year survival of 30% to 45% in developed countries. Scarce information is available regarding the treatment and survival rates from nonindustrialized populations. In the present study, the characteristics of adults with ALL at a single institution were documented. PATIENTS AND METHODS: The clinical files of patients aged ≥ 18 years who had been diagnosed with ALL from 2005 to 2015 at a reference center in Mexico were scrutinized. Overall survival (OS) and event-free survival (EFS) were determined using the Kaplan-Meier method. The hazard ratios for death and relapse were estimated using Cox regression analysis. RESULTS: A total of 94 adults were included. Their median age was 33 years; 69 (73.4%) had high-risk and 25 (26.6%) had standard-risk ALL. Of the 94 patients, 67 (71.3%) achieved complete remission (CR), 20 (21.3%) experienced disease resistance, and 7 (7.4%) died early during induction to remission, mainly of sepsis. The 5-year EFS and OS was 23.4% and 31.1% for the whole group and 24.9% and 38.9% for patients who achieved CR, respectively. Of the 94 patients, 50 (43.9%) died of sepsis or disease progression. Relapse developed in 43 patients (45.7%). The median survival after relapse was 6.93 months. Bone marrow was the most frequent site of relapse (21 patients [48.8%]) and conferred a significantly lower 5-year OS of 16.4%. CONCLUSION: Adults with ALL in Mexico had high-risk characteristics and an increased relapse rate; however, the OS after CR was similar to the greatest achieved in developed countries, suggesting that a threshold for curing adult ALL with current therapeutic strategies has been reached.
Assuntos
Pobreza/estatística & dados numéricos , Leucemia-Linfoma Linfoblástico de Células Precursoras/mortalidade , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Antineoplásicos/uso terapêutico , Medula Óssea/patologia , Intervalo Livre de Doença , Feminino , Humanos , Masculino , México , Pessoa de Meia-Idade , Leucemia-Linfoma Linfoblástico de Células Precursoras/tratamento farmacológico , Leucemia-Linfoma Linfoblástico de Células Precursoras/patologia , Prognóstico , Modelos de Riscos Proporcionais , Recidiva , Indução de Remissão/métodos , Taxa de Sobrevida , Adulto JovemRESUMO
Remission induction regimens for acute lymphoblastic leukemia (ALL) in adults induce complete remission (CR) in 60-90% and cure in 20-40%. A cohort study of newly diagnosed patients with ALL treated with mitoxantrone versus doxorubicin was conducted from 2005 to 2013. The primary endpoint was the proportion of CR. Eighty-five patients were included. Fifty-three received induction with doxorubicin and 32 with mitoxantrone. Median follow-up in the cohort was 40.2 months (range 2-95). Twenty-nine patients (90.6%) achieved CR in the mitoxantrone arm compared with 37 (69.8%) in the doxorubicin group (p = 0.032). There was no difference in death or relapse rate (p = 0.095 and 0.075), hematological recovery (p = 0.654), incidence of adverse events (p = 0.6), in-hospital days during induction (p = 0.456) or overall survival (p = 0.105). Induction toxicities were comparable. Mitoxantrone can be safely and effectively used as a frontline anthracycline in adults newly diagnosed with ALL.
Assuntos
Doxorrubicina/uso terapêutico , Mitoxantrona/uso terapêutico , Leucemia-Linfoma Linfoblástico de Células Precursoras/tratamento farmacológico , Adolescente , Adulto , Idoso , Antraciclinas/efeitos adversos , Antraciclinas/uso terapêutico , Antineoplásicos/efeitos adversos , Antineoplásicos/uso terapêutico , Estudos de Coortes , Intervalo Livre de Doença , Neutropenia Febril/induzido quimicamente , Feminino , Seguimentos , Humanos , Quimioterapia de Indução , Masculino , Pessoa de Meia-Idade , Mitoxantrona/efeitos adversos , Mucosite/induzido quimicamente , Indução de Remissão , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: Development of thromboembolytic events is a major complication during induction of remission therapy (IRT) for acute lymphoblastic leukemia (ALL) of childhood. Increased in vitro platelet aggregation in response to drugs employed at this stage has been documented. To investigate the presence of an in vivo platelet agonist effect, we studied changes in aggregation patterns of patients with ALL receiving IRT. METHODS: Platelets from 22 children with a new diagnosis of ALL were obtained during IRT once the platelet count reached >100 x 10(9)/L. Platelets were stimulated with adenosine diphosphate (ADP), collagen, ristocetin, and epinephrine. Platelet responses were evaluated by optical aggregometry. RESULTS: Percentages of platelet aggregation in ALL patients were as follows: ADP, 89+/-22; collagen, 90+/-24; ristocetin, 84+/-26, and epinephrine, 81+/-20. Percentages in healthy individuals were ADP: 98+/-12; collagen: 105+/-10; ristocetin: 100+/-15, and epinephrine, 98+/-8. CONCLUSIONS: Platelet aggregation with classical agonists was diminished during IRT for ALL of childhood, although it remained within the normal lower limit for age. Considerable heterogeneity in platelet reactivity existed, probably reflecting the presence of several pharmacologically altered platelet subpopulations. No apparent clinical correlation of aggregometric changes was documented.
Assuntos
Agregação Plaquetária , Leucemia-Linfoma Linfoblástico de Células Precursoras/sangue , Difosfato de Adenosina/farmacologia , Adolescente , Antibacterianos/farmacologia , Criança , Pré-Escolar , Colágeno/farmacologia , Epinefrina/farmacologia , Feminino , Humanos , Imunofenotipagem , Lactente , Masculino , Ativação Plaquetária , Leucemia-Linfoma Linfoblástico de Células Precursoras/tratamento farmacológico , Indução de Remissão , Ristocetina/farmacologia , Fatores de Tempo , Vasoconstritores/farmacologiaRESUMO
Clinical and experimental evidence demonstrating the effects of tumor necrosis factor-alpha (TNF-alpha) in patients with heart failure continues to accumulate. It is well established that high concentrations of TNF-alpha appear in the circulation of patients with heart failure and that these levels have a directly proportional correlation with the patient's functional class. TNF-alpha levels also show a linear relation with prognosis. These circulating levels are responsible for the decreased expression of myocardial TNF-alpha receptors observed in heart failure. As a result of extrapolation of findings from experimental animals, we assume that TNF-alpha is deleterious to myocardial function in humans because it induces a negative inotropic state in patients who have not undergone heart transplant. Supporting this assumption is the fact that the resolution or improvement of pressure overload (obstructive hypertrophic myocardiopathy, by ethanol ablation) and volume overload (terminal dilated myocardiopathy, by ventricular assistance) states is accompanied by a decrease in myocardial TNF-alpha expression. The use of specific antagonists of circulating TNF-alpha in patients with symptomatic heart failure has been demonstrated to be safe and possibly effective. At present, multicenter studies are under way to assess the efficacy of this antagonism in a larger number of patients. If the results of these studies are favorable, we will have new therapeutic elements for managing patients with advanced hear failure. The transplanted heart behaves differently from the native heart. From the early stages of HTx, myocardial TNF-alpha expression is greatly increased (much more than in patients with heart failure) and not associated with contractile dysfunction, in contrast with what occurs in the native heart. However, we know that the transplanted heart soon develops ventricular hypertrophy, fibrosis, diastolic dysfunction, and late graft failure, even in the presence of normal epicardial coronary arteries. Clinical evidence suggests that TNF-alpha may be involved in these processes.
Assuntos
Insuficiência Cardíaca/etiologia , Fator de Necrose Tumoral alfa/fisiologia , Insuficiência Cardíaca/tratamento farmacológico , Insuficiência Cardíaca/cirurgia , Transplante de Coração , Humanos , Miocárdio/metabolismo , Receptores do Fator de Necrose Tumoral/fisiologia , Fator de Necrose Tumoral alfa/antagonistas & inibidores , Fator de Necrose Tumoral alfa/biossínteseRESUMO
Abstract Background Heterogeneity regarding clinical and laboratory findings at diagnosis of acute lymphoblastic leukemia exists. The frequency of complete blood count abnormalities and its combinations, symptoms and physical findings were investigated in Hispanic children from an open population at the diagnosis of acute lymphoblastic leukemia. Methods The patient charts and electronic records of under 16-year-old children diagnosed with acute lymphoblastic leukemia over 10 years at a regional hematology center of a university hospital were analyzed to retrieve data concerning the complete blood count at first evaluation. Type and distribution of abnormal data, frequency of symptoms and physical findings at presentation were documented. Results The records of 203 children aged 0-15 years diagnosed with acute lymphoblastic leukemia from 2006 to 2016 were revisited. The results of the blood workup showed a median white blood cell count of 7120 × 109/L (range: 450-600,000 × 109/L), and a median hemoglobin concentration of 7.5 g/dL (range: 2.4-15.3 g/dL), whereas the median platelet count was 47,400 × 109/L (range: 4000-544,000 × 109/L). Leukocytosis and leukopenia were present in 36.6% and 36.1% of cases, respectively; anemia was diagnosed in 82.9% children. The order of frequency for major clinical symptoms was fatigue 62%, fever 60%, bone and joint pain 39%, hyporexia 33% and weight loss 21%, while main physical findings were hepatomegaly 78%, splenomegaly 63%, lymphadenopathy 57%, pallor 48%, and purpura 30%. Conclusion Data differing from those classically expected at diagnosis of acute lymphoblastic leukemia in children were documented in a cohort of Hispanic children over one decade with a wide spectrum of complete blood count abnormalities, forms of presentation and frequency of physical findings.
Assuntos
Humanos , Masculino , Feminino , Pré-Escolar , Criança , Esplenomegalia , Contagem de Células Sanguíneas , Leucemia-Linfoma Linfoblástico de Células Precursoras , Hepatomegalia , LeucocitoseRESUMO
Haploidentical hematopoietic stem cell transplantation (haplo-HSCT) has been developed as an alternative transplant strategy for children with hematological disorders who do not have an HLA-matched donor. We report the analysis of the outcome for 18 consecutive pediatric patients with various hematological diseases, who underwent haplo-HSCT using a reduced-intensity conditioning regimen and CD3/CD19 depletion in an outpatient setting. Twelve of the 18 patients (66.6%) engrafted either transiently or definitively (9 patients engrafted with full donor chimerism and 3 with mixed chimerism). Six patients with acute lymphoblastic leukemia were disease-free between 2 and 35 months (median 25 months) post-HSCT. The overall survival was 33.3% with a median of 25 months (range 2-35). Our results suggest that haplo-HSCT can be a feasible therapeutic alternative for children who do not have a suitable family donor or available cord blood units. These results also demonstrate that it is possible to perform this regimen on an outpatient basis.