Risk Factors for Traumatic and Bloody Lumbar Puncture in Children With Acute Lymphoblastic Leukemia

Howard, Scott C.; Gajjar, Amar; Cheng, Cheng; Kritchevsky, Stephen B.; Somes, Grant W.; Harrison, Patricia; Ribeiro, Raul C.; Rivera, Gaston K.; Rubnitz, Jeffrey E.; Sandlund, John T.; Armendi, Alberto J. de; Razzouk, Bassem I.; Pui, Ching‐Hon

doi:10.1001/jama.288.16.2001

Cited by 141 publications

(106 citation statements)

References 34 publications

(49 reference statements)

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“…Since the outcome of patients with TLPþ was shown to be unfavorable [2,[9][10][11], many efforts to minimize TLPþ have been made, including correction of thrombocytopenia, use of deep sedation, orgeneral anesthesia, and cautious procedure by the most skilled clinicians [7,19]. Although the design of the present study was not a randomized fashion, ourresults indicate thatthefrequencyofpatients with TLPþ was reduced considerably (below 1%) by performing the initial LP after 7-day monotherapy of PSL, which was consistent with our previous L89-12 study [12].…”

Section: Discussionmentioning

confidence: 99%

The utility of performing the initial lumbar puncture on day 8 in remission induction therapy for childhood acute lymphoblastic leukemia: TCCSG L99‐15 study

Hasegawa

Manabe

Ohara

et al. 2011

Pediatric Blood & Cancer

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INTRODUCTIONThe long-term cure rate in childhood acute lymphoblastic leukemia (ALL) is as high as 80% [1,2], and this is largely attributable to sufficient central nervous system (CNS)-directed therapy, such as prophylactic cranial irradiation (pCRT) and intrathecal chemotherapy (IT) [3]. However, administering CNS-directed therapy always results in a dilemma between sufficient intensity and treatmentrelated toxicity. Especially, the use of pCRT should be avoided because of its substantial risk for late complications such as second malignancies, endocrinopathies, neurocognitive dysfunctions, and neurotoxic effects [4][5][6]. On the other hand, CNS relapse still occurs in 2-5% of children with ALL and remains to be a treatment obstacle [7]. Therefore, proper assessment of risk factors for CNS relapse is required.Risk factors for CNS relapse include a T-cell immunophenotype, hyperleukocytosis, specific genetic alterations such as t(9;22) and t(4;11), and the presence of CNS involvement [7]. The prognostic significance of the presence of leukemic blasts in the cerebrospinal fluid (CSF) without pleocytosis, referred to as CNS-2, has varied in clinical trials and is heavily dependent on the effectiveness of systemic and CNS-directed therapy [8][9][10][11]. By contrast, traumatic lumbar puncture with leukemic blasts (TLPþ) adversely affects the outcome of patients with ALL as well as overt CNS leukemia [2,9-11]. Though controversy over whether TLPþ is an iatrogenic event or intrinsically inevitable status still exists, clinicians should pay attention to keep the rate of TLPþ to a minimum.To overcome the problem concerning TLPþ, the Tokyo Children's Cancer Study Group (TCCSG) adopted a strategy to postpone the initial lumbar puncture (LP) and IT until 7 days after prednisolone (PSL) monotherapy in the L89-12 study in order to decrease circulating leukemic blasts substantially before the initial LP/IT [12]. This strategy yielded a significant reduction of TLPþ [12], but the net effect on the outcome was not clarified because over 80% of the patients received cranial irradiation in the L89-12 study [12,13]. We hypothesized that deferring the initial LP/ITuntil day 8 in remission induction therapy could reduce the frequency of cases with TLPþ without compromising outcome, even if the indication for pCRT is restricted. Here, we report the results of the L99-15 study adopting the day 8 LP/IT strategy and restricting the indication for pCRT.

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Section: Discussionmentioning

confidence: 99%

The utility of performing the initial lumbar puncture on day 8 in remission induction therapy for childhood acute lymphoblastic leukemia: TCCSG L99‐15 study

Hasegawa

Manabe

Ohara

et al. 2011

Pediatric Blood & Cancer

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“…Even though the poor prognostic impact of traumatic lumbar puncture can be abolished by intensive systemic and intrathecal therapy, 15 every effort should be made to prevent its occurrence because intrathecal therapy can also adversely affect neuropsychologic and spinal cord functions. 32,33 Since recognition of the adverse consequences of traumatic lumbar puncture, 34 we correct thrombocytopenia before the diagnostic lumbar puncture, which is followed immediately by intrathecal treatment. Finally, intrathecal therapy is routinely performed by the most experienced clinician in our center, with patients under deep sedation or general anesthesia.…”

Section: Intrathecal Therapymentioning

confidence: 99%

Central Nervous System Disease in Acute Lymphoblastic Leukemia: Prophylaxis and Treatment

Pui

2006

Hematology

105

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Improved treatment for acute lymphoblastic leukemia (ALL) has virtually eliminated testicular relapse. However, the control of central nervous system (CNS) leukemia remains a therapeutic challenge in childhood ALL, partly because of the late complications arising from cranial irradiation. In most current pediatric protocols, cranial irradiation (12 to 18 Gy) is given to 5% to 25% of patients—those with T-cell ALL, overt CNS disease (CNS3 status) or high-risk cytogenetics. CNS control is a less urgent concern in adults with ALL, in whom systemic relapse remains the major problem. With current approaches, approximately 2% to 10% of patients can be expected to develop CNS relapse. Children with B-cell precursor ALL who have a late CNS relapse (after an initial remission of 18 months or more) and did not receive cranial irradiation have an excellent outcome after retrieval therapy, with a 5-year event-free survival (EFS) rate approaching that in newly diagnosed patients. Innovative treatment options are needed for children who develop CNS relapses after a short initial remission or after receiving cranial irradiation, and in any adults with CNS leukemia at diagnosis or relapse.

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“…[153][154][155] We recently identified several factors associated with the risk of traumatic lumbar puncture, including experience of the clinician, platelet count and the use of sedation or anesthesia (Table 2). 156 In our center, the lumbar puncture is now performed by the most experienced clinician and under deep sedation or general anesthesia. We transfuse all thrombocytopenic patients with platelets before lumbar puncture at diagnosis, and administer intrathecal chemotherapy immediately after collection of cerebrospinal fluid.…”

Section: The Remaining Challenges In All (Ching-hon Pui Md)mentioning

confidence: 99%

“…Allopurinol is a very potent inhibitor of xanthine oxidase and it blocks the formation of uric acid 156 (Figure 11). But this drug is unable to degrade the uric acid already formed.…”

Section: Prevention Of Uric Acid Overproduction Relies On Allopurinolmentioning

confidence: 99%

Treatment by design in leukemia, a meeting report, Philadelphia, Pennsylvania, December 2002

Larson

Schiffer

et al. 2003

Leukemia

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Novel approaches have been designed to treat leukemia based on our understanding of the genetic and biochemical lesions present in different malignancies. This meeting report summarizes some of the recent advances in leukemia treatment. Based on the discoveries of cellular oncogenes, chromosomal translocations, monoclonal antibodies, multidrug resistance pumps, signal transduction pathways, genomics/proteonomic approaches to clinical diagnosis and mutations in biochemical pathways, clinicians and basic scientists have been able to identify the particular genetic mutations and signal transduction pathways involved as well as design more appropriate treatments for the leukemia patient. This meeting report discusses these exciting new therapies and the results obtained from ongoing clinical trials. Furthermore, rational approaches to treat complications of tumor lysis syndrome by administration of the recombinant urate oxidase protein, also known as rasburicase, which corrects the biochemical defect present in humans, were discussed. Clearly, over the past 25 years, molecular biology and biotechnology has provided the hematologist/oncologist novel bullets in their arsenal that will allow treatment by design in leukemia.

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Risk Factors for Traumatic and Bloody Lumbar Puncture in Children With Acute Lymphoblastic Leukemia

Cited by 141 publications

References 34 publications

The utility of performing the initial lumbar puncture on day 8 in remission induction therapy for childhood acute lymphoblastic leukemia: TCCSG L99‐15 study

The utility of performing the initial lumbar puncture on day 8 in remission induction therapy for childhood acute lymphoblastic leukemia: TCCSG L99‐15 study

Central Nervous System Disease in Acute Lymphoblastic Leukemia: Prophylaxis and Treatment

Treatment by design in leukemia, a meeting report, Philadelphia, Pennsylvania, December 2002

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