Untreated Adult Acute Lymphoblastic Leukemia
Standard treatment options for remission induction therapy:
Most current induction regimens for patients with adult acute lymphoblastic leukemia (ALL) include prednisone, vincristine, and an anthracycline. Some regimens, including those used in a Cancer and Leukemia Group B study (CLB-8811), also add other drugs, such as asparaginase or cyclophosphamide. Current multiagent induction regimens result in complete response rates that range from 60% to 90%.[1,2,3]
The decision whether to sedate a patient at the end of life is difficult and involves many factors. The goal of palliative sedation is not to shorten life but to make the end of life more comfortable. Palliative sedation may be considered in order to relieve uncontrolled physical suffering, depression, or anxiety. Certain drugs are given to sedate the patient and may be combined with treatment for pain and agitation. Palliative sedation may be temporary, as in patients with delirium or trouble...
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Imatinib mesylate is often incorporated into the therapeutic plan for patients with Ph1-positive ALL. Several studies have suggested that the addition of imatinib results in complete response rates, event-free survival rates, and overall survival rates that are higher than those in historical controls. In each of these studies, common toxicities were nausea and liver enzyme abnormalities necessitating interruption and/or dose reduction of imatinib. (For more information on nausea, refer to the PDQ summary on Nausea and Vomiting.) Subsequent allogeneic transplant does not appear to be adversely affected by the addition of imatinib to the treatment regimen. At the present time, no conclusions can be drawn from these studies regarding which imatinib dose or schedule should be used.[4,5,6]
Two additional subtypes of adult ALL require special consideration. B-cell ALL [which expresses surface immunoglobulin and cytogenetic abnormalities such as t(8;14), t(2;8), and t(8;22)] is not usually cured with typical ALL regimens. Aggressive brief-duration, high-intensity regimens, including those used in CLB-9251, which are similar to those used in aggressive non-Hodgkin lymphoma, have shown high response rates and cure rates (75% complete remission; 40% failure-free survival).[7,8] T-cell ALL, including lymphoblastic lymphoma, similarly has shown high cure rates when treated with cyclophosphamide-containing regimens.[3] Whenever possible, such patients should be entered in clinical trials designed to improve the outcomes in these subsets. (Refer to the B cell (Burkitt) lymphoma and T cell (lymphoblastic) lymphoma sections in the PDQ summary on Adult Non-Hodgkin Lymphoma Treatment for more information.)
Since myelosuppression is an anticipated consequence of both the leukemia and its treatment with chemotherapy, patients must be closely monitored during remission induction treatment. Facilities must be available for hematological support as well as for the treatment of infectious complications.
Supportive care during remission induction treatment should routinely include red blood cell and platelet transfusions when appropriate.[9,10] Randomized trials have shown similar outcomes for patients who received prophylactic platelet transfusions at a level of 10,000/mm3 rather than 20,000/mm3.[11] The incidence of platelet alloimmunization was similar among groups randomly assigned to receive pooled platelet concentrates from random donors; filtered, pooled platelet concentrates from random donors; ultraviolet B-irradiated, pooled platelet concentrates from random donors; or filtered platelets obtained by apheresis from single random donors.[12] Empiric broad spectrum antimicrobial therapy is an absolute necessity for febrile patients who are profoundly neutropenic.[13,14] Careful instruction in personal hygiene, dental care, and recognition of early signs of infection are appropriate in all patients. Elaborate isolation facilities, including filtered air, sterile food, and gut flora sterilization are not routinely indicated but may benefit transplant patients.[15,16] Rapid marrow ablation with consequent earlier marrow regeneration decreases morbidity and mortality. White blood cell transfusions can be beneficial in selected patients with aplastic marrow and serious infections that are not responding to antibiotics.[17] Prophylactic oral antibiotics may be appropriate in patients with expected prolonged, profound granulocytopenia (<100/mm3 for 2 weeks), though further studies are necessary.[18] To detect the presence or acquisition of resistant organisms, serial surveillance cultures may be helpful in such patients. As suggested in a Cancer and Leukemia Group B study (CLB-9111), the use of myeloid growth factors during remission induction therapy appears to decrease the time to hematopoietic reconstitution.[19,20]
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