Leukapheresis Does Not Improve Early Survival Outcome of Acute Myeloid Leukemia with Leukostasis Patients – A Dual-Center Retrospective Cohort Study

Abstract

Introduction:Leukostasis is a medical emergency with high mortality which often occurs in acute myeloid leukemia patients with hyperleukocytosis. One of the therapies that can be used for leukostasis in acute myeloid leukemia is leukapheresis. However, whether leukapheresis can provide better survival benefit when compared with patients not receiving leukapheresis is still unclear. Hence, we aimed to evaluate the effect of chemotherapy plus leukapheresis combination versus chemotherapy only on 28-day survival of acute myeloid leukemia patients with leukostasis. Methods: This study was a dual-center retrospective cohort using secondary data from medical records collected from November 2018 to March 2019. Inclusion criteria were adult patients aged 18 years old or above, diagnosed with acute leukemia with hyperleukocytosis status defined by WBC count greater than 100,000/uL, and with symptoms of leukostasis. One-month survival analysis was conducted using Kaplan-Meier curve method. Univariate and multivariate analyses were then conducted using Cox proportional hazards model to obtain value of hazard ratio (HR) with a 95% confidence interval (CI). Results: A total of 38 patients were obtained for analysis. The median overall survival was 25 days (95% CI: 17.001-32.999 days) in the chemotherapy only group and 20 days (95% CI: 1.497-38.503) in the chemotherapy with leukapheresis group. The use of leukapheresis did not affect 28-day survival (HR: 1.140; 95% CI: 0.396-3.283; p value: 0.809) and 7-day survival (HR: 1.073; 95% CI: 0.277-4.152; p value: 0.919). In the multivariate analysis, age ≥60 years, blast percentage ≥90%, creatinine ≥1.4 mg/dL, and presence of disseminated intravascular coagulation were associated with worse 28-day survival. Conclusion: AML patients with leukostasis who received both chemotherapy and leukapheresis did not have better 28-day survival and 7-day survival when compared with patients receiving chemotherapy only. Old age, high blast percentage, high creatinine, and presence of disseminated intravascular coagulation were prognostic factors for worse 28-day survival.

Guidelines on the Use of Therapeutic Apheresis in Clinical Practice – Evidence‐Based Approach from the Writing Committee of the American Society for Apheresis: The Ninth Special Issue

“…However, the use of leukocytapheresis in the absence of additional cytoreductive agents may provide only very temporary, if any, reduction in circulating WBC. Several retrospective studies have been recently published evaluating the use of leukocytapheresis; none demonstrate definitive benefit on survival (Rinaldi, 2021;Gelen 2022).…”

The survival of childhood leukemia: An 8‐year single‐center experience

“…It may indicate the likelihood of extramedullary dissemination of blats which in turn increases the risk of treatment failure and disease recurrence. 37 We also observed that normal ESR at diagnosis was associated with 10% higher mortality, though the estimate had a wide CI which makes the assumption less certain. High ESR is a non-specific sign of inflammation that is commonly observed in childhood leukemia.…”

“…We reported for the first time that hepatomegaly is associated with about five times higher risk of mortality in children with ALL. It may indicate the likelihood of extramedullary dissemination of blats which in turn increases the risk of treatment failure and disease recurrence 37 …”

“…It may indicate the likelihood of extramedullary dissemination of blats which in turn increases the risk of treatment failure and disease recurrence. 37 …”

Development of clinical pathways to improve multidisciplinary care of high-risk pediatric oncology patients

“…Of note, there is no definitive evidence demonstrating a mortality benefit for leukapheresis in patients with hyperleukocytosis and hence it is not a part of the treatment algorithm ( 14 , 16 ). Leukapheresis may be considered in patients with AML with ongoing leukostasis as an adjunct to initiation of chemotherapy ( 11 , 16 – 18 ) or patients with CML with evidence of priapism, hearing loss, visual changes, or pulmonary infiltrates ( 19 ). Initiation of leukapheresis is often time consuming as it requires placement of specialized central lines and mobilization of multiple services.…”