Acute cytoreduction techniques in the early treatment of hyperleukocytosis associated with childhood hematologic malignancies

Abstract

Early and effective cytoreduction for high peripheral white blood cell counts in pediatric patients with acute leukemia may be helpful in preventing complications secondary to hyperviscosity. It also may be a useful adjunct to systemic chemotherapy. As an alternative to automated apheresis for this purpose, manual exchange transfusion is efficacious and does not require hemapheresis instrumentation and disposables and the related special staff. Two patients, a neonate with acute myeloblastic leukemia and a white blood cell count of 422.2 k/microliter as well as a 2 1/2-year-old with an admission diagnosis of acute promyelocytic leukemia and a white blood cell count of 617.4 k/microliter, underwent manual exchange hemotherapy for acute cytoreduction. The procedures were tolerated well, and significant leukocyte removal was achieved, with the respective leukocyte reductions being 81.1 and 68.7%. The techniques available for pediatric cytoreduction are compared, with emphasis on their efficiency and safety and appropriateness for very small children.

Management of Hyperleukocytosis and Prevention of Tumor Lysis Syndrome with Low-Dose Prednisone Continuous Infusion in Children with Acute Lymphoblastic Leukemia

“…Cytoreduction procedures are commonly recommended for patients with hyperleukocytosis based on case reports or retrospective studies [21,22,23]. There is a paucity of data demonstrating the benefit of cytoreduction in children with ALL [3, 21, 22, 24]. A prospective, randomized trial is necessary to evaluate the efficacy of this procedure in patients with hyperleukocytosis.…”

Hyperleukocytosis in infant acute leukemia: a role for manual exchange transfusion for leukoreduction

“…However, there currently are no specific recommendations on the preferred cytoreduction procedure in this group of patients due to the relative dearth of experiences documented in the medical literature. The available literature is limited to a few case reports and fails to adequately address questions that arise when performing leukapheresis in infants, such as when to perform manual WB exchange versus AL, optimal vascular access to be utilized, blood product selection, exchange (infusion/removal) rates, and the monitoring for complications. Highlighting our cases and those in the literature, if procedural cytoreduction is being performed, we recommend the use of manual WB exchange for infants weighing less than 10 kg with acute leukemia presenting with symptomatic hyperleukocytosis.…”

Hyperleukocytosis

“…Others have found a signifi cant improvement in early death rate in adult AML cohorts receiving leukapheresis without impact on overall survival (Thiébaut et al 2000 ;Giles et al 2001 ;Bug et al 2007 ). Although multiple case reports and case series are available in the pediatric literature in regard to the effectiveness of exchange transfusion and leukapheresis in HL, signifi cant pediatric data on resultant early mortality and long-term outcomes, especially in AML, are lacking (Carpentieri et al 1979 ;Kamen et al 1980 ;Shende et al 1981 ;Warrier et al 1981 ;Del Vasto et al 1982 ;Strauss et al 1985 ;Bunin et al 1987 ;Sykes et al 2011 ). Potential complications from apheresis procedures, especially in children, must also be considered, and such procedures should only be performed in specialized centers (Michon et al 2007 ).…”

“…Data to support this contraindication are limited to one small study in which a majority of patients undergoing leukapheresis for HL had an adverse event that was not temporally related to the leukapheresis procedure (Vahdat et al 1994 ;Tallman and Altman 2009 ). Strauss et al ( 1985 ) successfully performed exchange transfusion on a 2-year-old child with APL and a presenting WBC count of 617 × 10 9 /L. Zuckerman et al ( 2012 ) recommend leukapheresis in symptomatic adult AML patients with WBC >50 × 10 9 /L and in symptomatic ALL and CML adult patients with WBC >150 × 10 9 /L.…”