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Therapeutic Leukapheresis in Patients with Leukostasis Secondary to Acute Myelogenous Leukemia

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Therapeutic Leukapheresis in Patients with Leukostasis Secondary to Acute Myelogenous Leukemia Journal of Clinical Apheresis 26:181–185 (2011) Therapeutic Leukapheresis in Patients with Leukostasis Secondary to Acute Myelogenous Leukemia Gil Cunha De Santis,1 Luciana Correa Oliveira de Oliveira,1,2*y Lucas Gabriel Maltoni Romano,3 Benedito de Pina Almeida Prado Jr.,1 Belinda Pinto Simoes,1,2 Eduardo Magalhaes Rego,1,2 Dimas Tadeu Covas,1,2 and Roberto Passetto Falcao1,2 1Center for Cell Based Therapy, Medical School of Ribeirao Preto, University of Sao Paulo, Brazil 2Department of Internal Medicine, Hematology Division, Medical School of Ribeirao Preto, University of Sao Paulo, Brazil 3Medical School of Ribeirao Preto, University of Sao Paulo, Brazil Leukostasis is a relatively uncommon but potentially catastrophic complication of acute myelogenous leukemia (AML). Prompt leukoreduction is considered imperative to reduce the high mortality rate in this condition. Leu- kapheresis, usually associated with chemotherapy, is an established approach to diminish blast cell counts. We report a single center experience in managing leukostasis with leukapheresis. Fifteen patients with leukostasis of 187 patients with AML (8.02%) followed at our institution were treated with leukapheresis associated with chem- otherapy. The procedures were scheduled to be performed on a daily basis until clinical improvement was achieved and WBC counts were significantly reduced. Overall and early mortalities, defined as that occurred in the first 7 days from diagnosis, were reported. A high proportion of our patients with leukostasis (46.66%) had a monocytic subtype AML (M4/M5, according to French-American-British classification). The median overall sur- vival was 10 days, despite a significant WBC reduction after the first apheresis procedure (from 200.7 3 109/L to 150.3 3 109/L). Almost half of patients (7/15) had an early death. Therapeutic leukapheresis, associated or not to chemotherapy, is an effective approach to reduce WBC counts in patients with AML and leukostasis; how- ever, this therapeutic procedure does not appear to change significantly the sombre prognosis observed in the ma- jority of patients with this complication. Other forms of treatment must be found to reduce the high mortality rate related to leukostasis. J. Clin. Apheresis 26:181–185, 2011. VC 2011 Wiley-Liss, Inc. Key words: leukapheresis; leukostasis; acute myeloid leukemia; hyperleukocytosis INTRODUCTION gressive syndrome and fatal in the majority of patients [10]. Hyperleukocytosis in acute myelogenous leukemia Leukoreduction is the treatment of leukostasis, either (AML) is generally defined as blast count superior to by leukapheresis or chemotherapy. Leukapheresis is an 50–100 3 109/L in peripheral blood (PB) and has been invasive procedure that frequently requires the insertion associated with higher rates of early death (ED) and/or of a central vein catheter. It is often initiated as soon relapse [1–3]. Hyperleukocytosis is observed in 5–18% as possible in patients with clinical signs of leukostasis. of adults with AML depending on the leukemia sub- However, data on its impact on overall mortality and type, being the highest in AML with monocytic differ- ED rate are scarce and contradictory [11,12]. In this entiation [4]. Malignant myeloid blasts adhere to the study, we report a single center experience in treating vascular endothelium, clog circulatory flow, and trans- migrate into tissues [5–7]. This phenomenon results in Contract grant sponsors: Centro Regional de Hemoterapia de organ dysfunction due to hypoxia, tissue infiltration, Ribeirao Preto, Hospital das Clı´nicas da Faculdade de Medicina de and hemorrhage, a condition called leukostasis [4,8]. Ribeirao Preto, Universidade de Sa˜o Paulo-USP, Ribeirao Preto, Sao Leukostasis usually compromises respiratory system, Paulo, Brazil; Grant number: 306/2008 central nervous system (CNS), and renal function. Re- *Correspondence to: Luciana Correa Oliveira de Oliveira, Rua Ten- spiratory distress, possibly the single worst prognostic ente Cata˜o Roxo, 2501. Ribeira˜o Preto-SP, Brazil 14051-140. factor in patients with AML and hyperleukocytosis, is E-mail: [email protected] characterized by hypoxemia and diffuse interstitial Gil Cunha De Santis and Luciana Correa Oliveira de Oliveira con- infiltrate on chest radiograph and occurs in nearly 80% tributed equally to this work. of the patients [9]. Neurological features include confu- Received 22 December 2010; Accepted 24 March 2011 sion, lethargy, stupor, headache, blurred vision, seizure, Published online 13 May 2011 in Wiley Online Library coma, papilledema, retinal vein distension, or retinal (wileyonlinelibrary.com). hemorrhages. This clinical condition is a rapidly pro- DOI: 10.1002/jca.20290 VC 2011 Wiley-Liss, Inc. 182 De Santis et al. patients with AML complicated by hyperleukocytosis and leukostasis. We retrospectively analyzed the clini- (days) cal outcome of patients with AML with a white blood Survival cell count of more than 50 3 109/L and with clinical signs suggestive of leukostasis. MATERIALS AND METHODS Patients Chemotherapy (at least 2 days) We reviewed the medical chart of each of 187 con- secutive adult (age over 15 years) patients with AML (excluded patients with acute promyelocytic leukemia) AB classification [13]. ydrogenase; CNS, central nervous system. treated at our institution (Hospital das Clinicas de Ribeirao Preto da Universidade de Sao Paulo-USP) between January 1998 and June 2008, as previously reported [3]. Fifteen of the 187 (8.02%) were diag- nosed with leukostasis and submitted to therapeutic leukapheresis (Table I). Patients with hyperleukocytosis but without signs of leukostasis were not usually sub- mitted to leukapheresis. They were treated with con- ventional chemotherapy for AML. CNS The diagnosis and classification of AML were done involvement Hepatosplenomegaly based on blast cell morphology, cytochemistry, accord- ing to the French-American-British (FAB) classification [13], and immune phenotypical analysis. Cytogenetic studies were performed in a few patients only; for this Respiratory reason, the karyotype results were not considered for involvement the analyses. It was recorded the gender, age at diagno- sis, white blood cell counts at presentation and daily until suspension of apheresis or death, serum creatinine, blood urea nitrogen, lactic dehydrogenase (LDH). We also evaluated clinical variables at presentation sugges- tive of leukostasis, such as signs of respiratory (hypoxe- mia, tachypnea, pulmonary infiltration on chest radio- graphs) and CNS involvement (defined as confusion, lethargy, stupor, blurred vision, coma, papilledema, reti- (mg/dL) LDH (U/L) Creatinine nal vein distension or retinal hemorrhages), renal dys- function (blood urea nitrogen and creatinine levels), and presence of hepatomegaly and splenomegaly. /L) at 9 10 Leukapheresis admission 3 WBC count ( Leukapheresis procedures were initiated as soon as possible, always within 12 h from admission to hospital, a and before the first course of chemotherapy. The equip- AML (FAB) ment used was a continuous-flow blood cell separator subtype COBE Spectra (Caridian BCTTM, Lakewood, CO). For anticoagulation, acid citrate dextrose Formula A was added at a ratio of 1:12. We processed two blood vol- umes for each session, which took approximately 2–3 h. Sedimentation agents, such as hydroxyethyl starch, were not used. The collection rate was adjusted according to WBC count to optimize cell removal. The leukapheresis procedures were scheduled to be performed on daily ba- sis until clinical improvement and/or the leukemic blast 9 The diagnosis and classification of AML were done based on blast cell morphology, cytochemistry, and immune phenotypical analysis according to the F 1234 M5 F6 M7 M8 51 F9 F10 22 75 M11 M4 78 M12 NC F13 M1 45 F14 M4 23 F 4615 M2 M 62 107.7 M2 MM indicates male; M5 64 F, female; F AML, 71 289 acute myeloid M4 leukemia; M 299 FAB, 58 French-American-British; 162.3 NC, not M1 categorized; 71 WBC, white M5 blood cell; 1.9 76 LDH, 95.5 lactic deh M1 95.1 M2 27 60 402 M4 104.7 1 1.8 3.2 M1 394.4 M4 0.5 721 271 1.7 201 2.3 142 1,859 2,887 1.2 128.4 589 1.1 118.0 5,079 Yes 0.7 3,347 88 1.6 1,995 0.8 Yes No 375 1.8 No 5,877 0.6 Yes 4,347 Yes Yes 1.6 2,002 Yes Yes 293 Yes Yes 782 Yes Yes 322 Yes No Yes No 453 Yes No No Yes No Yes No Yes No No Yes Yes No No Yes No Yes No Yes No No Yes Yes Yes No No Yes Yes Yes Yes No Yes 0 No Yes Yes Yes Yes 1 1 3 Yes Yes 5 5 Yes Yes 10 6 11 Yes 15 yes 16 30 30 273 417 count dropped to levels below 100 3 10 /L. Blood cell TABLE I. Characteristics of Patients with AML and Leukostasis Patient Gender Age a Journal of Clinical Apheresis DOI 10.1002/jca Leukapheresis in Patients with Leukostasis 183 count (for patients’ characteristics, see Table I). The absolute peripheral WBC, given as mean, was 200.7 3 109/L Æ 110.1 3 109/L at diagnosis, reduced to 150.3 3 109/L Æ 86.5 3 109/L after the first leukapheresis procedure (P 5 0.035). Six patients were submitted to a second procedure. WBC count decreased from 279.2 3 109/L Æ 110.1 3 109/L to 198.3 3 109/L Æ 84.6 3 109/L (first procedure) and to 105.9 3 109/L Æ 24.4 3 109/L (second procedure; P 5 0.006; Fig. 1). Only one patient was submitted to third procedure with further WBC reduction (data not shown). Patients did not pres- ent any severe complication that could be attributed to aphereses procedures. Seven of 15 patients (46.66%) with leukostasis had a monocytic subtype AML according to FAB classifi- cation, whereas 31 of 172 patients (18.02%) without leukostasis had this subtype (P 5 0.0154) [3].
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