Comparación del hyper-CVAD con un régimen institucional en el tratamiento de la leucemia linfoblástica aguda del adulto en un hospital de México

Abstract

RESUMENCon el objetivo de evaluar la mortalidad y toxicidad del protocolo Hyper-CVAD utilizado como primera línea de tratamiento de la leucemia linfoblástica aguda se realizó un estudio de cohorte retrospectiva en pacientes de 40 años a menos durante marzo a septiembre de 2011 atendidos con el régimen Hyper-CVAD. La mortalidad y toxicidad se comparó con los resultados de los pacientes atendidos con el régimen institucional HGMLAL07 entre 2009 a 2012. Se incluyeron 18 pacientes, la mediana de edad fue de 26 años. Tanto las remisiones completas (67,7% frente a 81,9%) como la supervivencia a un año (40% frente a 62%) y 2 años (18% frente a 34%) fueron menores con el régimen Hyper-CVAD. Al seleccionar exclusivamente pacientes menores de 35 años, la eficacia de Hyper-CVAD también fue menor. Según esta experiencia y debido a su alto costo y toxicidad, el régimen Hyper-CVAD debe de limitarse a aquellos pacientes con leucemias refractarias o en recaída. Palabras clave: Leucemia linfoblástica; Protocolos de quimioterapia combinada antineoplásica; Adulto (fuente DeCS BIREME). COMPARISON OF THE HYPER-CVAD WITH AN INSTITUTIONAL REGIMEN FOR THE TREATMENT OF ACUTE LYMPHOBLASTIC LEUKEMIA IN ADULTS IN A HOSPITAL OF MEXICO ABSTRACTIn order to assess the mortality and toxicity of the Hyper-CVAD protocol used as first-line treatment of acute lymphoblastic leukemia, a retrospective cohort study was performed in patients less than 40 years of age from March to September 2011 treated with Hyper-CVAD regimen. Mortality and toxicity was compared with the results of patients treated with the institutional HGMLAL07 regimen between 2009-2012. 18 patients were included; the median age was 26 years old. Complete remissions (67.7% versus 81.9%) as well as one-year (40% versus 62%) and 2 year survival rates (18% versus 34%) were lower with the Hyper-CVAD regimen. By selecting only patients younger than 35 years, the effectiveness of Hyper-CVAD was also lower. In our experience and because of its high cost and toxicity, the Hyper-CVAD regimen should be limited to patients with relapsed or refractory leukemia.

Survival analysis of adult patients with ALL in Mexico City: first report from the Acute Leukemia Workgroup (ALWG) (GTLA)

“…Another limitation of our study of a retrospective nature, is the scarce availability of certain immunophenotype markers such as aberrant myeloid markers; this precludes trustworthy correlation analyses between aberrant markers and the Philadelphia chromosome status, as well their inclusion in the survival analysis. ALL‐T cases were identified in 2.9%; which is less than previously reported by other authors in Mexico (5–10%) as well as in other countries (10–30%) . We do not have an explanation for this finding.…”

“…The most frequently used treatment protocol was hyper-CVAD, but the CR and relapse rates as well as the survival curves were inferior to those reported by developed societies [13][14][15][16] and this has been a constant feature in the country's publications [21,24]. Although we found that the AYA group had better CR rates (80.1%) in comparison with the adult and elderly adult group (65.6%), these rates are still low compared with the data reported by developed societies [13][14][15][16].…”

“…However, with the available data we were able to document high‐risk disease in at least 52% of cases. In the studies conducted in Mexico, the frequency of high‐risk patients is estimated to be between 59% and 81%, but criteria have changed over time . In American and European developed societies, the risk classification has also fluctuated between 47% and 77%, due to modifications in criteria over time .…”

“…Unfortunately, there are no large ALL patient series in many Latin American countries.Reports in Mexico have referred CR rates between 60% and 80% with hyper-CVAD and other locally designed institutional regimens. Among the limitations of studies published in Mexico are the use of diverse treatment protocols that make interinstitutional comparisons difficult, the series are small, there are deficiencies in cytogenetic results (inaccessible or technique failures), all impinging on the reported incidence of Philadelphia-positive ALL (Ph + -ALL); also, most studies lack a survival analysis and risk factor identification [1,[21][22][23][24]. A recent series of 94 patients at the Hospital Universitario de Monterrey, Nuevo León [25] treated with the Berlin-Frankfurt-Münster (BFM) regimen, reported a CR of 71.3% and a 5-year OS of 31.1%.…”

CD20, generalidades básicas-moleculares y su posible relación como marcador de mal pronóstico en leucemia

“…Sin embargo, en un estudio publicado en población colombiana, este esquema proporcionó resultados desalentadores con una sobrevida global mediana de menos de 11,3 meses, sobrevida libre de eventos de 7,34 meses y 61% de remisión completa (76). De igual manera, otros estudios latinoamericanos también informan una peor supervivencia al utilizar el mismo esquema quimioterapeútico (77,78), lo que evidencia que la respuesta a estos tratamientos se ve influenciada por múltiples factores, entre ellos el tipo de población.…”