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Advance in the Treatment of Pediatric Leukemia

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Hematology".

Deadline for manuscript submissions: closed (30 June 2021) | Viewed by 89157

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Prof. Dr. Rupert Handgretinger

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Department I–General Pediatrics, Hematology/Oncology, Children’s Hospital, University Hospital Tübingen, 72076 Tübingen, Germany
Interests: stem cell transplantation; immunotherapy
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Dear Colleagues,

Since the introduction of chemotherapy for the treatment of children with leukemia, tremendous progress has been made and most patients can be cured of their disease. While in the beginning, all patients received the same chemotherapy, risk-adapted chemotherapeutic strategies have been developed over time with less chemotherapy for some and more intensive chemotherapy, including allogeneic stem cell transplantation, for others. Detailed analysis of the genomic landscape of leukemic blasts, allowing for precision medicine and the introduction of the concept of MRD (minimal residual disease) response, has led to better stratification of various chemotherapeutic approaches and to an improved outcome and long-term survival. However, many children with leukemia will carry the burden of more or less intensive chemotherapy into adulthood. Therefore, new therapeutic approaches with less intensive chemotherapy should be investigated without compromising the good long-term survival. An example of such a strategy is the reduction in the risk of therapy-induced brain tumors by the omission of cranial irradiation in most patients with acute lymphoblastic leukemia (ALL) without compromising their good outcome. Progress has also been made in the field of allogeneic stem cell transplantation through improved donor selection and reductions in the morbidity and mortality of this approach. More recently, tremendous progress has been seen with the introduction of highly effective immunotherapeutic strategies, such as the use of bispecific T-cell engagers (BiTEs) and the use of chimeric antigen receptor (CAR) T-cells. Both approaches have shown impressive remission rates in children with chemotherapy-refractory pre-B ALL. Similar strategies are under investigation for the treatment of patients with T-cell leukemias (T-ALL) and acute myeloid leukemias (AML). A few carefully planned studies with more frontline immunotherapy and less chemotherapy are under way and more such studies focusing on early immunotherapy will be initiated in the future, which would allow us to significantly reduce the long-term burden of intensive chemotherapy for the affected children.

Prof. Dr. Rupert Handgretinger
Guest Editor

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Keywords

acute lymphoblastic leukemia
acute myeloid leukemia
chemotherapy
allogeneic stem cell transplantation
genomic landscape
precision medicine
immunotherapy
bispecific T-cell engager (BiTEs)
CAR T-cells
long-term side effects

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Published Papers (14 papers)

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Editorial

Jump to: Research, Review

6 pages, 179 KiB

Open AccessEditorial

Editorial to: Advance in the Treatment of Pediatric Leukemia

by Rupert Handgretinger

J. Clin. Med. 2022, 11(9), 2361; https://doi.org/10.3390/jcm11092361 - 22 Apr 2022

Viewed by 2019

Abstract

The history of leukemia goes back many years and John Bennet, a Scottish physician, described in 1845 a 28-year old patient with swelling of the spleen who then developed fever, bleeding and increasing swellings in his neck, groin and armpits [...] Full article

(This article belongs to the Special Issue Advance in the Treatment of Pediatric Leukemia)

Research

Jump to: Editorial, Review

22 pages, 4106 KiB

Open AccessArticle

Other (Non-CNS/Testicular) Extramedullary Localizations of Childhood Relapsed Acute Lymphoblastic Leukemia and Lymphoblastic Lymphoma—A Report from the ALL-REZ Study Group

by Andrej Lissat, Claudia van Schewick, Ingo G. Steffen, Ayumu Arakawa, Jean-Pierre Bourquin, Birgit Burkhardt, Guenter Henze, Georg Mann, Christina Peters, Lucie Sramkova, Cornelia Eckert, Arend von Stackelberg and Christiane Chen-Santel

J. Clin. Med. 2021, 10(22), 5292; https://doi.org/10.3390/jcm10225292 - 14 Nov 2021

Cited by 5 | Viewed by 2456

Abstract

Children with other extramedullary relapse of acute lymphoblastic leukemia are currently poorly characterized. We aim to assess the prevalence and the clinical, therapeutic and prognostic features of extramedullary localizations other than central nervous system or testis in children with relapse of acute lymphoblastic leukemia (ALL) and lymphoblastic lymphoma (LBL) treated on a relapsed ALL protocol. Patients and Methods: Patients with relapse of ALL and LBL, treated according to the multicentric ALL-REZ BFM trials between 1983 and 2015, were analyzed for other extramedullary relapse (OEMR) of the disease regarding clinical features, treatment and outcome. Local treatment/irradiation has been recommended on an individual basis and performed only in a minority of patients. Results: A total of 132 out of 2323 (5.6%) patients with ALL relapse presented with an OEMR (combined bone marrow relapse n = 78; isolated extramedullary relapse n = 54). Compared to the non-OEMR group, patients with OEMR had a higher rate of T-immunophenotype (p < 0.001), a higher rate of LBL (p < 0.001) and a significantly different distribution of time to relapse, i.e., more very early and late relapses compared to the non-OEMR group (p = 0.01). Ten-year probabilities of event-free survival (pEFS) and overall survival (pOS) in non-OEMR vs. OEMR were 0.38 ± 0.01 and 0.32 ± 0.04 (p = 0.0204) vs. 0.45 ± 0.01 and 0.37 ± 0.04 (p = 0.0112), respectively. OEMRs have been classified into five subgroups according to the main affected compartment: lymphatic organs (n = 32, 10y-pEFS 0.50 ± 0.09), mediastinum (n = 35, 10y-pEFS 0.11 ± 0.05), bone (n = 12, 0.17 ± 0.11), skin and glands (n = 21, 0.32 ± 0.11) and other localizations (n = 32, 0.41 ± 0.09). Patients with OEMR and T-lineage ALL/LBL showed a significantly worse 10y-pEFS (0.15 ± 0.04) than those with B-Precursor-ALL (0.49 ± 0.06, p < 0.001). Stratified into standard risk (SR) and high risk (HR) groups, pEFS and pOS of OEMR subgroups were in the expected range whereas the mediastinal subgroup had a significantly worse outcome. Subsequent relapses involved more frequently the bone marrow (58.4%) than isolated extramedullary compartments (41.7%). In multivariate Cox regression, OEMR confers an independent prognostic factor for inferior pEFS and pOS. Conclusion: OEMR is adversely related to prognosis. However, the established risk classification can be applied for all subgroups except mediastinal relapses requiring treatment intensification. Generally, isolated OEMR of T-cell-origin needs an intensified treatment including allogeneic stem cell transplantation (HSCT) as a curative approach independent from time to relapse. Local therapy such as surgery and irradiation may be of benefit in selected cases. The indication needs to be clarified in further investigations. Full article

(This article belongs to the Special Issue Advance in the Treatment of Pediatric Leukemia)

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17 pages, 815 KiB

Open AccessArticle

Genetic Variation in ABCC4 and CFTR and Acute Pancreatitis during Treatment of Pediatric Acute Lymphoblastic Leukemia

by Thies Bartram, Peter Schütte, Anja Möricke, Richard S. Houlston, Eva Ellinghaus, Martin Zimmermann, Anke Bergmann, Britt-Sabina Löscher, Norman Klein, Laura Hinze, Stefanie V. Junk, Michael Forster, Claus R. Bartram, Rolf Köhler, Andre Franke, Martin Schrappe, Christian P. Kratz, Gunnar Cario and Martin Stanulla

J. Clin. Med. 2021, 10(21), 4815; https://doi.org/10.3390/jcm10214815 - 20 Oct 2021

Cited by 2 | Viewed by 6826

Abstract

Background: Acute pancreatitis (AP) is a serious, mechanistically not entirely resolved side effect of L-asparaginase-containing treatment for acute lymphoblastic leukemia (ALL). To find new candidate variations for AP, we conducted a genome-wide association study (GWAS). Methods: In all, 1,004,623 single-nucleotide variants (SNVs) were analyzed in 51 pediatric ALL patients with AP (cases) and 1388 patients without AP (controls). Replication used independent patients. Results: The top-ranked SNV (rs4148513) was located within the ABCC4 gene (odds ratio (OR) 84.1; p = 1.04 × 10⁻¹⁴). Independent replication of our 20 top SNVs was not supportive of initial results, partly because rare variants were neither present in cases nor present in controls. However, results of combined analysis (GWAS and replication cohorts) remained significant (e.g., rs4148513; OR = 47.2; p = 7.31 × 10⁻⁹). Subsequently, we sequenced the entire ABCC4 gene and its close relative, the cystic fibrosis associated CFTR gene, a strong AP candidate gene, in 48 cases and 47 controls. Six AP-associated variants in ABCC4 and one variant in CFTR were detected. Replication confirmed the six ABCC4 variants but not the CFTR variant. Conclusions: Genetic variation within the ABCC4 gene was associated with AP during the treatment of ALL. No association of AP with CFTR was observed. Larger international studies are necessary to more conclusively assess the risk of rare clinical phenotypes. Full article

(This article belongs to the Special Issue Advance in the Treatment of Pediatric Leukemia)

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17 pages, 3106 KiB

Open AccessArticle

Engineering of CD19 Antibodies: A CD19-TRAIL Fusion Construct Specifically Induces Apoptosis in B-Cell Precursor Acute Lymphoblastic Leukemia (BCP-ALL) Cells In Vivo

by Dorothee Winterberg, Lennart Lenk, Maren Oßwald, Fotini Vogiatzi, Carina Lynn Gehlert, Fabian-Simon Frielitz, Katja Klausz, Thies Rösner, Thomas Valerius, Anna Trauzold, Matthias Peipp, Christian Kellner and Denis Martin Schewe

J. Clin. Med. 2021, 10(12), 2634; https://doi.org/10.3390/jcm10122634 - 15 Jun 2021

Cited by 6 | Viewed by 3153

Abstract

B-cell precursor acute lymphoblastic leukemia (BCP-ALL) is the most frequent malignancy in children and also occurs in adulthood. Despite high cure rates, BCP-ALL chemotherapy can be highly toxic. This type of toxicity can most likely be reduced by antibody-based immunotherapy targeting the CD19 antigen which is commonly expressed on BCP-ALL cells. In this study, we generated a novel Fc-engineered CD19-targeting IgG1 antibody fused to a single chain tumor necrosis factor (TNF)-related apoptosis-inducing ligand (TRAIL) domain (CD19-TRAIL). As TRAIL induces apoptosis in tumor cells but not in healthy cells, we hypothesized that CD19-TRAIL would show efficient killing of BCP-ALL cells. CD19-TRAIL showed selective binding capacity and pronounced apoptosis induction in CD19-positive (CD19⁺) BCP-ALL cell lines in vitro and in vivo. Additionally, CD19-TRAIL significantly prolonged survival of mice transplanted with BCP-ALL patient-derived xenograft (PDX) cells of different cytogenetic backgrounds. Moreover, simultaneous treatment with CD19-TRAIL and Venetoclax (VTX), an inhibitor of the anti-apoptotic protein BCL-2, promoted synergistic apoptosis induction in CD19⁺ BCP-ALL cells in vitro and prolonged survival of NSG-mice bearing the BCP-ALL cell line REH. Therefore, IgG1-based CD19-TRAIL fusion proteins represent a new potential immunotherapeutic agent against BCP-ALL. Full article

(This article belongs to the Special Issue Advance in the Treatment of Pediatric Leukemia)

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Review

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43 pages, 2761 KiB

Open AccessReview

Development of CAR T Cell Therapy in Children—A Comprehensive Overview

by Michael Boettcher, Alexander Joechner, Ziduo Li, Sile Fiona Yang and Patrick Schlegel

J. Clin. Med. 2022, 11(8), 2158; https://doi.org/10.3390/jcm11082158 - 12 Apr 2022

Cited by 19 | Viewed by 8367

Abstract

CAR T cell therapy has revolutionized immunotherapy in the last decade with the successful establishment of chimeric antigen receptor (CAR)-expressing cellular therapies as an alternative treatment in relapsed and refractory CD19-positive leukemias and lymphomas. There are fundamental reasons why CAR T cell therapy has been approved by the Food and Drug administration and the European Medicines Agency for pediatric and young adult patients first. Commonly, novel therapies are developed for adult patients and then adapted for pediatric use, due to regulatory and commercial reasons. Both strategic and biological factors have supported the success of CAR T cell therapy in children. Since there is an urgent need for more potent and specific therapies in childhood malignancies, efforts should also include the development of CAR therapeutics and expand applicability by introducing new technologies. Basic aspects, the evolution and the drawbacks of childhood CAR T cell therapy are discussed as along with the latest clinically relevant information. Full article

(This article belongs to the Special Issue Advance in the Treatment of Pediatric Leukemia)

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16 pages, 1167 KiB

Open AccessReview

Pediatric Acute Myeloid Leukemia—Past, Present, and Future

by Dirk Reinhardt, Evangelia Antoniou and Katharina Waack

J. Clin. Med. 2022, 11(3), 504; https://doi.org/10.3390/jcm11030504 - 19 Jan 2022

Cited by 42 | Viewed by 7146

Abstract

This review reports about the main steps of development in pediatric acute myeloid leukemia (AML) concerning diagnostics, treatment, risk groups, and outcomes. Finally, a short overview of present and future approaches is given. Full article

(This article belongs to the Special Issue Advance in the Treatment of Pediatric Leukemia)

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22 pages, 2289 KiB

Open AccessReview

Curing the Curable: Managing Low-Risk Acute Lymphoblastic Leukemia in Resource Limited Countries

by Bernice L. Z. Oh, Shawn H. R. Lee and Allen E. J. Yeoh

J. Clin. Med. 2021, 10(20), 4728; https://doi.org/10.3390/jcm10204728 - 15 Oct 2021

Cited by 12 | Viewed by 3199

Abstract

Although childhood acute lymphoblastic leukemia (ALL) is curable, global disparities in treatment outcomes remain. To reduce these global disparities in low-middle income countries (LMIC), a paradigm shift is needed: start with curing low-risk ALL. Low-risk ALL, which accounts for >50% of patients, can be cured with low-toxicity therapies already defined by collaborative studies. We reviewed the components of these low-toxicity regimens in recent clinical trials for low-risk ALL and suggest how they can be adopted in LMIC. In treating childhood ALL, the key is risk stratification, which can be resource stratified. NCI standard-risk criteria (age 1–10 years, WBC < 50,000/uL) is simple yet highly effective. Other favorable features such as ETV6-RUNX1, hyperdiploidy, early peripheral blood and bone marrow responses, and simplified flow MRD at the end of induction can be added depending on resources. With limited supportive care in LMIC, more critical than relapse is treatment-related morbidity and mortality. Less intensive induction allows early marrow recovery, reducing the need for intensive supportive care. Other key elements in low-toxicity protocol designs include: induction steroid type; high-dose versus low-dose escalating methotrexate; judicious use of anthracyclines; and steroid pulses during maintenance. In summary, the first effective step in curing ALL in LMIC is to focus on curing low-risk ALL with less intensive therapy and less toxicity. Full article

(This article belongs to the Special Issue Advance in the Treatment of Pediatric Leukemia)

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15 pages, 269 KiB

Open AccessReview

Chronic Myeloid Leukemia in Children: Immune Function and Vaccinations

by Meinolf Suttorp, Andrea Webster Carrion and Nobuko Hijiya

J. Clin. Med. 2021, 10(18), 4056; https://doi.org/10.3390/jcm10184056 - 8 Sep 2021

Cited by 5 | Viewed by 3540

Abstract

Children with CML need TKI treatment for many years, and the lack of knowledge about immune dysfunction with TKI has hindered routine immunizations. This review attempts to provide an overview of the effects of TKIs licensed for children (e.g., imatinib, dasatinib, and nilotinib) on immune function, as well as its implications on immunizations. We discuss surveillance strategies (e.g., immunoglobulin blood serum levels and hepatitis B reactivation) and immunizations. All inactivated vaccines (e.g., influenza, pneumococcal, and streptococcal) can be given during the treatment of CML in the chronic phase, although their efficacy may be lower. As shown in single cases of children and adults with CML, live vaccines (e.g., varicella, measles, mumps, rubella, and yellow fever) may be administered under defined circumstances with great precautions. We also highlight important aspects of COVID-19 in this patient population (e.g., the outcome of COVID-19 infection in adults with CML and in children with varying hemato-oncological diseases) and discuss the highly dynamic field of presently available different vaccination options. In conclusion, TKI treatment for CML causes humoral and cellular immune dysfunction, which is mild in most patients, and thus infectious complications are rare. Routine immunizations are important for health maintenance of children, but vaccinations for children with CML on TKI therapy should be carefully considered. Full article

(This article belongs to the Special Issue Advance in the Treatment of Pediatric Leukemia)

24 pages, 1384 KiB

Open AccessReview

Biologic and Therapeutic Implications of Genomic Alterations in Acute Lymphoblastic Leukemia

by Ilaria Iacobucci, Shunsuke Kimura and Charles G. Mullighan

J. Clin. Med. 2021, 10(17), 3792; https://doi.org/10.3390/jcm10173792 - 25 Aug 2021

Cited by 59 | Viewed by 8206

Abstract

Acute lymphoblastic leukemia (ALL) is the most successful paradigm of how risk-adapted therapy and detailed understanding of the genetic alterations driving leukemogenesis and therapeutic response may dramatically improve treatment outcomes, with cure rates now exceeding 90% in children. However, ALL still represents a leading cause of cancer-related death in the young, and the outcome for older adolescents and young adults with ALL remains poor. In the past decade, next generation sequencing has enabled critical advances in our understanding of leukemogenesis. These include the identification of risk-associated ALL subtypes (e.g., those with rearrangements of MEF2D, DUX4, NUTM1, ZNF384 and BCL11B; the PAX5 P80R and IKZF1 N159Y mutations; and genomic phenocopies such as Ph-like ALL) and the genomic basis of disease evolution. These advances have been complemented by the development of novel therapeutic approaches, including those that are of mutation-specific, such as tyrosine kinase inhibitors, and those that are mutation-agnostic, including antibody and cellular immunotherapies, and protein degradation strategies such as proteolysis-targeting chimeras. Herein, we review the genetic taxonomy of ALL with a focus on clinical implications and the implementation of genomic diagnostic approaches. Full article

(This article belongs to the Special Issue Advance in the Treatment of Pediatric Leukemia)

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29 pages, 472 KiB

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The Role of Allogeneic Hematopoietic Stem Cell Transplantation in Pediatric Leukemia

by Mattia Algeri, Pietro Merli, Franco Locatelli and Daria Pagliara

J. Clin. Med. 2021, 10(17), 3790; https://doi.org/10.3390/jcm10173790 - 25 Aug 2021

Cited by 15 | Viewed by 4374

Abstract

Allogeneic hematopoietic stem cell transplantation (HSCT) offers potentially curative treatment for many children with high-risk or relapsed acute leukemia (AL), thanks to the combination of intense preparative radio/chemotherapy and the graft-versus-leukemia (GvL) effect. Over the years, progress in high-resolution donor typing, choice of conditioning regimen, graft-versus-host disease (GvHD) prophylaxis and supportive care measures have continuously improved overall transplant outcome, and recent successes using alternative donors have extended the potential application of allotransplantation to most patients. In addition, the importance of minimal residual disease (MRD) before and after transplantation is being increasingly clarified and MRD-directed interventions may be employed to further ameliorate leukemia-free survival after allogeneic HSCT. These advances have occurred in parallel with continuous refinements in chemotherapy protocols and the development of targeted therapies, which may redefine the indications for HSCT in the coming years. This review discusses the role of HSCT in childhood AL by analysing transplant indications in both acute lymphoblastic and acute myeloid leukemia, together with current and most promising strategies to further improve transplant outcome, including optimization of conditioning regimen and MRD-directed interventions. Full article

(This article belongs to the Special Issue Advance in the Treatment of Pediatric Leukemia)

15 pages, 507 KiB

Open AccessReview

Antibody–Drug Conjugates for the Treatment of Acute Pediatric Leukemia

by Jamie L. Stokke and Deepa Bhojwani

J. Clin. Med. 2021, 10(16), 3556; https://doi.org/10.3390/jcm10163556 - 13 Aug 2021

Cited by 15 | Viewed by 4352

Abstract

The clinical development of antibody–drug conjugates (ADCs) has gained momentum in recent years and these agents are gradually moving into frontline regimens for pediatric acute leukemias. ADCs consist of a monoclonal antibody attached to a cytotoxic payload by a cleavable linker. This structure allows for highly cytotoxic agents to be directly delivered to leukemia cells leading to cell death and avoids excessive off-tumor toxicity. Near universal expression on B-cell acute lymphoblastic leukemia (ALL) blasts and the ability of rapid internalization has rendered CD22 an ideal target for ADC in B-ALL. Inotuzumab ozogamicin, the anti-CD22 antibody linked to calicheamicin led to complete remission rates of 60–80% in patients with relapsed/refractory B-ALL. In acute myeloid leukemia (AML), the CD33 targeting gemtuzumab ozogamicin has demonstrated modest improvements in survival and is the only ADC currently licensed in the United States for pediatric patients with de novo AML. Several other ADCs have been developed and tested clinically for leukemia but have achieved limited success to date. The search for additional leukemia-specific targets and optimization of ADC structure and specificity are ongoing efforts to improve their therapeutic window. This review provides a comprehensive overview of ADCs in acute leukemias, with a focus on pediatric ALL and AML. Full article

(This article belongs to the Special Issue Advance in the Treatment of Pediatric Leukemia)

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17 pages, 680 KiB

Open AccessReview

Current Treatment of Juvenile Myelomonocytic Leukemia

by Christina Mayerhofer, Charlotte M. Niemeyer and Christian Flotho

J. Clin. Med. 2021, 10(14), 3084; https://doi.org/10.3390/jcm10143084 - 13 Jul 2021

Cited by 26 | Viewed by 9127

Abstract

Juvenile myelomonocytic leukemia (JMML) is a rare pediatric leukemia characterized by mutations in five canonical RAS pathway genes. The diagnosis is made by typical clinical and hematological findings associated with a compatible mutation. Although this is sufficient for clinical decision-making in most JMML cases, more in-depth analysis can include DNA methylation class and panel sequencing analysis for secondary mutations. NRAS-initiated JMML is heterogeneous and adequate management ranges from watchful waiting to allogeneic hematopoietic stem cell transplantation (HSCT). Upfront azacitidine in KRAS patients can achieve long-term remissions without HSCT; if HSCT is required, a less toxic preparative regimen is recommended. Germline CBL patients often experience spontaneous resolution of the leukemia or exhibit stable mixed chimerism after HSCT. JMML driven by PTPN11 or NF1 is often rapidly progressive, requires swift HSCT and may benefit from pretransplant therapy with azacitidine. Because graft-versus-leukemia alloimmunity is central to cure high risk patients, the immunosuppressive regimen should be discontinued early after HSCT. Full article

(This article belongs to the Special Issue Advance in the Treatment of Pediatric Leukemia)

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15 pages, 587 KiB

Open AccessReview

Blinatumomab in Pediatric Acute Lymphoblastic Leukemia—From Salvage to First Line Therapy (A Systematic Review)

by Manon Queudeville and Martin Ebinger

J. Clin. Med. 2021, 10(12), 2544; https://doi.org/10.3390/jcm10122544 - 8 Jun 2021

Cited by 42 | Viewed by 6020

Abstract

Acute lymphoblastic leukemia is by far the most common malignancy in children, and new immunotherapeutic approaches will clearly change the way we treat our patients in future years. Blinatumomab is a bispecific T-cell-engaging antibody indicated for the treatment of relapsed/refractory acute lymphoblastic leukemia (R/R-ALL). The use of blinatumomab in R/R ALL has shown promising effects, especially as a bridging tool to hematopoietic stem cell transplantation. For heavily pretreated patients, the response to one or two cycles of blinatumomab ranges from 34% to 66%. Two randomized controlled trials have very recently demonstrated an improved reduction in minimal residual disease as well as an increased survival for patients treated with blinatumomab compared to standard consolidation treatment in first relapse. Current trials using blinatumomab frontline for high-risk patients or as a consolidation treatment post-transplant will show whether efficacy is even higher in less heavily pretreated patients. Due to the distinct pattern of adverse events compared to high-dose conventional chemotherapy, blinatumomab could play an important role for patients with a risk for severe chemotherapy-associated toxicities. This systematic review discusses all published results for blinatumomab in children as well as all ongoing clinical trials. Full article

(This article belongs to the Special Issue Advance in the Treatment of Pediatric Leukemia)

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24 pages, 1788 KiB

Open AccessReview

Advances in the Diagnosis and Treatment of Pediatric Acute Lymphoblastic Leukemia

by Hiroto Inaba and Ching-Hon Pui

J. Clin. Med. 2021, 10(9), 1926; https://doi.org/10.3390/jcm10091926 - 29 Apr 2021

Cited by 107 | Viewed by 18547

Abstract

The outcomes of pediatric acute lymphoblastic leukemia (ALL) have improved remarkably during the last five decades. Such improvements were made possible by the incorporation of new diagnostic technologies, the effective administration of conventional chemotherapeutic agents, and the provision of better supportive care. With the 5-year survival rates now exceeding 90% in high-income countries, the goal for the next decade is to improve survival further toward 100% and to minimize treatment-related adverse effects. Based on genome-wide analyses, especially RNA-sequencing analyses, ALL can be classified into more than 20 B-lineage subtypes and more than 10 T-lineage subtypes with prognostic and therapeutic implications. Response to treatment is another critical prognostic factor, and detailed analysis of minimal residual disease can detect levels as low as one ALL cell among 1 million total cells. Such detailed analysis can facilitate the rational use of molecular targeted therapy and immunotherapy, which have emerged as new treatment strategies that can replace or reduce the use of conventional chemotherapy. Full article

(This article belongs to the Special Issue Advance in the Treatment of Pediatric Leukemia)

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