Search

Objective: To identify disparities-using recursive partitioning (RP)-in early survival for children with leukemias treated in Argentina, and to depict the main characteristics of the most vulnerable groups., Methods: This secondary data analysis evaluated 12-month survival (12-ms) in 3 987 children diagnosed between 2000 and 2008 with lymphoid leukemia (LL) and myeloid leukemia (ML) and registered in Argentina's population-based oncopediatric registry. Prognostic groups based on age at diagnosis, gender, socioeconomic index of the province of residence, and migration to a different province to receive health care were identified using the RP method., Results: Overall 12-ms for LL and ML cases was 83.7% and 59.9% respectively. RP detected major gaps in 12-ms. Among 1-10-year-old LL patients from poorer provinces, 12-ms for those who did and did not migrate was 87.0% and 78.2% respectively. Survival of ML patients < 2 years old from provinces with a low/medium socioeconomic index was 38.9% compared to 62.1% for those in the same age group from richer provinces. For 2-14-year-old ML patients living in poor provinces, patient migration was associated with a 30% increase in 12-ms., Conclusions: Major disparities in leukemia survival among Argentine children were found. Patient migration and socioeconomic index of residence province were associated with survival. The RP method was instrumental in identifying and characterizing vulnerable groups.

In the article data are presented about morbidity by oncogematologic pathology - one of the most meaningful of social-economic problems. In Ukraine annually diagnose the to 8 thousand new cases of haemoblastosis. Indexes of morbidity on a 100 thousand population are 5,2; at illness of Hodgkin's lymphoma - 2,5, at plural myeloma - 1,6; at leukemia - 8,1. Morbidity by haematological pathology in Kyiv long time remains high: annually 250 expose patients with malignant lymphnoma, 57 - with myeloma, 190 - with leukemia, from them at 55 % is a sharp form and at 40 % - chronic. The anxiety of doctors causes circumstance that the special treatment is overcome 58,1 % patients by leukemia, 68,6 % - plural myeloma and 77,8 % patients with malignant lymphoma. World experience shows that application of complex methods of therapy allows to prolong life-span 80-90 % patients with Hodgkin's malignant lymphoma on 10, and at 95 % patients by a lymphogranulomatosis - to attain nonrecurrence survival to 5 years.

Patient readmission within 30 days from discharge has been perceived by the Centers for Medicare and Medical Services as an indicator of poor healthcare quality for specific high-cost medical conditions. Patients who undergo allogeneic hematopoietic cell transplantation (allo-HCT) are often being readmitted. Our study identified the risk factors for 30-day readmission among 618 adult recipients of myeloablative allo-HCT from 1990 to 2009. Two hundred forty-two (39%) of 618 patients (median age = 42 years [range: 18-66]) were readmitted a median of 10 days (range: 1-30) from their hospital discharge. Median duration of readmission was 8 days (range: 0-103). Infections (n = 68), fever with or without identified source of infection (n = 63), gastrointestinal complications (n = 44), graft-versus-host disease (GVHD) (n = 38), and other reasons (n = 29) accounted for 28%, 26%, 18%, 16%, and 12% of readmissions, respectively. During their index admission, patients who were subsequently readmitted had more documented infections (P < .001), higher hematopoietic cell transplantation comorbidity index (HCT-CI) (P < .01), total body irridiation (TBI)-based conditioning (P < .001), unrelated donor (P < .001), and peripheral stem cell (P = .014) transplantation. In multivariable analysis, HCT-CI (odds ratio [OR] = 1.78; 95% confidence interval [CI], 1.25-2.52), TBI-based preparative regimen (OR = 2.63; 95% CI, 1.67-4.13), and infection during admission for allo-HSCT (OR = 2.00; 95% CI, 1.37-2.92) predicted 30-day readmission. Thirty-day readmission itself was an independent predictor of all-cause mortality (hazard ratio [HR](Adj) = 1.66; 95% CI, 1.36-2.10). Our data emphasize the importance of a risk-standardized approach to 30-day hospital readmission if it is used as a quality-of-care metric for bone marrow transplantation., (Copyright © 2012 American Society for Blood and Marrow Transplantation. Published by Elsevier Inc. All rights reserved.)

Purpose: To characterize the clinical and imaging features of orbital leukemic tumors in 27 patients seen and treated at St. Jude Children's Research Hospital., Methods: A retrospective review was performed on the clinical and imaging records of 27 consecutive patients with a diagnosis of orbital leukemic tumors. The following data were extracted from the patients' records: age at diagnosis of orbital leukemic tumors, sex, race, national origin, type of leukemia, temporal relationship of orbital disease to diagnosis of leukemia, survival from diagnosis of orbital leukemic tumor, laterality of the orbital disease, location of the mass within the orbit, imaging features of the mass, chemotherapeutic protocol, treatment with bone marrow transplant, and orbital radiation., Results: The median age at diagnosis of orbital leukemic tumor was 8 years (range, 1-18 years). Nineteen of the 27 patients were male, and 21 patients were born and lived in the United States. Twenty-one patients had acute myeloid leukemia, five had acute lymphoblastic leukemia, and one had chronic myelogenous leukemia. In 85% of patients (n = 23), the diagnosis of leukemia was based on the bone marrow examination findings. Orbital imaging revealed homogenous masses that molded to one or more orbital walls without bony destruction. Nine patients had bilateral orbital involvement. All patients received multiagent systemic chemotherapy, and 14 underwent bone marrow transplantation. Five patients received external beam radiation for the treatment of orbital disease. Fifteen (55.6%) of the 27 patients were alive at the time of the study. The median survival for all patients was 4.75 years (range, 0.1-24 years) after the diagnosis of orbital disease., Conclusions: Orbital leukemic tumors occur most commonly in the first decade of life, in association with acute myeloid leukemia. They appear as homogenous masses along the orbital walls. Although the overall survival rate for patients with leukemia has improved over the past 3 decades, the mortality of patients who develop orbital leukemic tumors remains high.

Over a 3-year period, 145 patients ineligible for myeloablative conditioning underwent reduced-intensity conditioning (RIC) hematopoietic stem cell transplantation (SCT) from an HLA-identical sibling in a prospective study. The median age was 54 years, 88 patients were male and 61 patients were beyond the early-intermediate phase of their disease. The 100-day probability of developing grade II-IV acute graft-versus-host disease (GVHD) was 34%, and the 1-year probability of developing chronic extensive GVHD was 41%. The 1-year probabilities of transplant-related mortality (TRM), overall (OS) and progression-free survival were 20, 60 and 52%, respectively. Multivariate analyses found a better OS in: (i) patients <60 years; and (ii) recipients of a first SCT; and a higher TRM in: (i) age >60 years, (ii) recipients of a prior autologous SCT, and (iii) an ECOG performance status >1. The 1-year TRM in patients with 0 or 1 and >2 of the above-mentioned adverse prognostic factors were 17 vs 53%, respectively (P<0.001). In summary, our study shows that elderly patients have a higher TRM following an RIC protocol. However, age by itself should not preclude these RIC transplants, since TRM appears to be unacceptably high only in the presence of additional adverse factors.

Although acute myeloid and lymphoid leukemia initially respond to conventional chemotherapy, most patients relapse and succumb from their disease. For the past 30 years, efforts at intensifying induction or postremission conventional chemotherapy have met with limited success. Of all the therapies examined, allogeneic hematopoietic stem cell transplantation has achieved the best outcomes, with the first reports of cure 25 years ago. Most phase III studies have failed to demonstrate a clear advantage of allografting over chemotherapy because of significant risk of transplant-related mortality. However, there is reason for optimism based on the identification of high-risk groups and from improvements in the prevention and management of transplant-related complications. These accomplishments, along with a recent increase in the donor pool through the availability of unrelated donors and cryopreserved umbilical cord blood stem cells, continue to make allografting the most promising curative modality for acute leukemias.

Background and Purpose: To evaluate the efficacy and toxicity of a highly immuno- and myelo-suppressive conditioning regimen followed by the infusion of large numbers of T-cell-depleted mismatched haematopoietic stem cells in 43 high-risk acute leukaemia patients., Results: A high rate of engraftment (95%) and no graft-versus-host disease (GvHD) were observed. The 4-year probability of event-free survival was 0.25+/-0.09 for acute myeloid leukaemia and 0.17+/-0.07 for acute lymphoid leukaemia patients., Conclusions: This study shows that the main obstacles limiting the use of mismatched transplants, i.e. GvHD and rejection, were overcome.

Cytomegalovirus (CMV) pneumonia is reportedly unusual among adults with leukemia who have not undergone transplantation. To assess the frequency of CMV pneumonia and its outcome during the present time, we reviewed the experience of 2136 hospitalized adults with leukemia. Sixty-one patients (2.9%) had CMV pneumonia diagnosed. The frequency doubled from 1.4% in 1992--1994 to 2.8% in 1995--1997 (P<.05). Fifty-four patients (89%) had received treatment with an immunosuppressive chemotherapeutic regimen that contained fludarabine (n=37), high-dose cytoxan (n=17), or both (n=10), and 15 patients (25%) had received granulocyte transfusions that were stimulated with hematopoietic growth factors from unscreened donors. The overall CMV pneumonia--associated mortality rate was 57%. Among autopsied patients who had leukemia, the frequency of CMV pneumonia increased from 0%, 2.3%, and 0% in 1992, 1993, and 1994, respectively, to 4.6%, 6.5%, and 16% in 1995, 1996, and 1997, respectively (P<.05). CMV has emerged as an important cause of life-threatening pneumonia in adults with leukemia who have received potent immunosuppressive therapies and stimulated granulocyte transfusions from unscreened donors.

Monoclonal antibodies have become an important modality for cancer therapy. Genetically engineered chimeric and humanized antibodies have demonstrated activity against both overt leukemia and minimal residual disease. High-dose radioimmunotherapy can potentially allow intensification of antileukemic therapy before bone marrow transplantation yet minimize radiation exposure to normal organs. Targeted alpha particle therapy offers the possibility of selective tumor cell kill while sparing surrounding normal cells. Antibody-drug conjugates and immunotoxins have produced complete remissions in leukemia.

Chronic granulocytic leukemia (CGL) terminates in a disease similar to acute leukemia. Except for a study indicating an increased response rate to the drugs, vincristine and prednisone, therapy of this terminal phase has been universally disappointing. We have studied the bone marrows and clinical courses of 67 patients in the terminal phase of CGL to discern if any parameters were associated with an increased response rate or survival. The results of this study indicate that patients who have a lymphoblastic morphology or hypodiploid cytogenetics in the terminal phase respond better to treatment with the combination of vincristine and prednisone than those with myeloblastic morphology or hyperdiploid cytogenetics. Response rate and survival are significantly increased in those with lymphoblastic morphology. Recognition of the heterogeneity of the terminal phase of CGL may dictate specific therapeutic modalities.

Infant leukaemias differ from childhood leukaemias in ways which suggest that when haemopoietic neoplasms combine fetal origins with rapid growth rates they prevent normal development of the reticuloendothelial system and thus cause the sudden death of apparently healthy babies (stillbirths or cot deaths). Cot deaths are commoner in boys and have a peak incidence during the first half of infancy-that is, during the period most affected by the switch from passive to active immunity. Babies born from July to December, who are intensively exposed to winter conditions form 1 to 5 months of age, are also at special risk. During this period more girls and more children born form January to June die of leukaemia; and within three months of birth an exceptionally high ratio of myeloid to lymphatic leukaemias has been replaced by a low ratio, which persists throughout childhood.

Survival and response to chemotherapy were evaluated in 84 adults with granulocytic leukemia (AGL) and 22 with acute lymphocytic leukemia (ALL). Twenty-two of the 84 patients with AGL reveived no chemotherapy (untreated group). The median survival for patients with AGL who achieved complete remission (CR) was 17.1 months, compared to 6.5 months for those who achieved partial remission (PR (p less than 0.05), 2.8 months for those who failed chemotherapy (p less than 0.01), and 2.1 months for the untreated group (p less than 0.01). The median survival for patients with ALL who achieved a CR was 18.2 months, compared to 7.3 months for those who achieved a PR and 7.0 months for those who failed chemotherapy. Of patients with AGL who reveived an adequate trial of chemotherapy, 43% achieved a CR and 16% a PR; 75% of patients with ALL achieved a CR and 13% a PR. Improved survival depends on the induction of a complete or partial remission with the use of aggressive chemotherapy.

Survival times in 100 cases of acute leukemia (74 granulocytic, 14 lymphocytic, and 12 undifferentiated) were correlated with classic morphologic and cytochemical criteria. The 14 patients who had lymphocytic leukemia had significantly longer survival compared with the two other groups. Undifferentiated leukemias had a shorter survival time than granulocytic leukemias. Several subclasses of granulocytic leukemias were formed according to the presence or absence of Auer rods and the percentage of peroxidase-positive blasts. Neither of these two features significantly influenced the survival of these patients. In the lymphocytic leukemia group, PAS-positive and negative leukemias had similar survival expectancies. It is concluded that division into lymphocytic and nonlymphocytic leukemias is still helpful in predicting survival times of patients who have acute leukemia, but that further subclassification of these groups based on the presence or absence of Auer rods and the percentages of peroxidase-positive blasts is of no additional benefit.

This study consists of 25 patients with chronic granulocytic leukemia in blast crisis (BC) or with acute leukemia who had a Ph1 chromosome and one or more other chromosome abnormalities and who were investigated by cytochemistry and immunocytochemistry techniques to determine whether the predominant blasts were myeloid or lymphoid. The disorder was myeloid in 15 patients, lymphoid in 8, and mixed in 2. Among the 15 patients with myeloid disorders, 13 (86.6%) had an additional Ph1 chromosome, i(17q), +8, +19, or some combination of these abnormalities. None of the eight patients with a lymphoid disorder had +8, +19, or i(17q), but one had an additional Ph1 chromosome. Among the eight patients with lymphoid disorders, two had structural abnormalities of chromosome 7 and two were monosomy 7. None of the patients with myeloid disease had a structurally abnormal chromosome 7, but one was monosomy 7. Our findings suggest that the number of chromosomes in an abnormal clone may be unreliable for distinguishing between lymphoid and myeloid BC. Most patients with myeloid disease had only abnormal metaphases, whereas many patients with lymphoid disorders had both normal and abnormal metaphases. This finding may partially explain why many patients with lymphoid BC respond better to treatment than do those with myeloid BC.

Over the past ten years several centers have studied bone marrow transplantation following high-dose chemotherapy and radiation in patients with resistant acute leukemia. These data indicate a 10-20% two-year disease-free survival; results superior to alternative approaches. Leukemic relapse and graft-versus-host disease have been major problems. Recently, marrow transplantation has been evaluated in patients with leukemia in remission. This has resulted in improved survival in patients with acute lymphoblastic leukemia but leukemic relapse remains a major problem. Acute myelogenous leukemia patients transplanted in remission have a low rate of leukemic relapse and two-year disease-free survival rates exceeding 50%. Recently, autologous bone marrow transplantation has also been considered in patients with acute leukemia. Results to date have been disappointing with a high relapse rate. Limited studies in patients with chronic myelogenous leukemia have also been reported. Transplantation during the acute phase is usually unsuccessful and is complicated by incomplete engraftment and resistant leukemia. Transplants performed during the chronic phase have produced more encouraging results. In summary: there is an evolving role for bone marrow transplantation in the treatment of patients with acute and chronic leukemia. A final evaluation of the utility approach awaits results of controlled clinical trials.

The authors reviewed 181 patients who received local radiation therapy for the prevention or control of extramedullary disease resulting from acute leukemia. 126 had acute lymphocytic leukemia and 55 had acute granulocytic leukemia. They were treated over a 18-year period of time with different forms of chemotherapy. Most had not received prophylactic CNS radiation therapy. Patients were evaluated for local control until death or hematologic relapse intervened. More than 80% of patients with clinical ALL meningeal leukemia had a successful response to doses over 1000 rads. This same response was not apparent in AML. More than 80% of clinical non-CNS extra medullary leukemia was controlled with doses of 600 rads or greater. Only one patient with extra-medullary relapse is still alive. The authors feel that lower preventative doses of radiation to the CNS are compatible with similar control rates, based on their own data and other suggestive data.

Patients with acute (2,569) and chronic (957) leukemia diagnosed at 19 institutes took part in the study on the "Multidisciplinary Treatment of Leukemia" between 1971 and 1985 and were investigated retrospectively. By dividing the 15 years into three five-year periods, we were able to compare patient ratios in the different periods. The proportions of acute to chronic leukemia cases showed no obvious change; however, the proportions of cases diagnosed as acute lymphocytic leukemia in acute leukemia showed a significant increase. The main chemotherapeutic drugs used during the three time periods were cytarabine or its analogues, the anthracyclines, 6-mercaputopurine and prednisolone, against acute myelogenous leukemia, and the vinca alkaloids, prednisolone and the anthracyclines against acute lymphocytic leukemia. The rate of complete remission from acute myelogenous leukemia made marked progress, from 45.1% during 1971-1975 to 62.3% during 1981-1985, but that of acute lymphocytic leukemia showed no significant progress, being 65% during 1971-1975 and 69.7% during 1981-1985. The durations of remission, however, and the survival times for patients with acute lymphocytic leukemia, as well as for those with acute myelogenous leukemia, became significantly longer over the three periods. Median survival times from chronic myelocytic leukemia were 37-40 mo in all three periods, showing no progress. There was a better prognosis in cases of chronic myelocytic leukemia with, than without, Philadelphia chromosome. Except for a low incidence of chronic lymphocytic leukemia in Japan, adult leukemia patients' characteristics and prognoses seem to be almost the same in Japan as in the U.S.A. and Europe.

The causes of death were investigated in 315 adults with acute leukemia during a 7-year period (1966-1972). Infection alone or in combination was the most common cause (75%), followed by hemorrhage (24%) and organ failure (9%). Most of the infections were either systemic or pulmonary. Seventy-five percent of the systemic infections and 72% of the pneumonias were caused by bacteria. Klebsiella pneumoniae, Escherichia coli and Pseudomonas aeruginosa were the most frequent organisms isolated. After 1968, there was a sharp decrease in the number of fatal infections caused by Pseudomonas aeruginosa and a marked increase in the incidence of fatal infections caused by Klebsiella spp. and E. coli. Infections caused by Gram-positive cocci occurred in only 3% of the cases. The incidence of systemic fungal infections was 13%; most common fungi causing infection were Candida spp. and Aspergillus spp. Eighty-five percent of 159 patients with a terminal neutrophil count of less than 100/mm3 died of infection, compared to 48% of 62 patients with a terminal neutrophil count of greater than 1000/mm3. Hemorrhage was mostly due to thrombocytopenia (61%) and disseminated intravascular coagulation (12%). This study indicates that infection continues to be the most common cause of death in patients with acute leukemia. Although advances in antibiotic therapy have changed the distribution of causative organisms, ultimate control of infection requires further improvements in supportive care measures which rectify impairments in the patients' host defense mechanisms.

A decline, the first ever observed, has recently occurred in leukemia mortality rates for the white population of the United States between the ages of 1 and 74. Possible explanations include diminished exposure to medical x-rays following the release in the United States and Great Britain in 1956 of widely publicized reports on the biologic effects of ionizing radiation.