Written in Blood

While most patients with acute leukemia have disease with a lymphoid or myeloid linage , 2 to 5 percent have “ acute leukemia of ambiguous lineage ” ( ALAL ), expressing features of both lymphoid and myeloid lineage . Given the rarity and heterogeneity of this disease subtype , there are no standard treatment recommendations for these patients . In a retrospective study published in Blood , researchers collected data on the biologic features , treatment , and outcome of 233 children with ALAL and were able to outline treatment algorithms that can be tested in prospective trials .

“[ This is ] the largest study to date on childhood ALAL ,” wrote the authors , led by Ondrej Hrusak , MD , PhD , of the Department of Pediatric Hematology / Oncology at Charles University in Prague . Their analysis “[ revealed ] a better prognosis of children who started on lymphoiddirected treatment , [ while ] myeloid type of primary treatment correlated with dismal outcomes in [ those with ] CD19-positive leukemias .”

The multicenter , international study included data from children who were diagnosed with acute leukemia between 2002 and 2015 and treated at one of 18 international centers . Of the 233 eligible patients : assumption is incorrect : In addition to the poorer results seen with myeloid-directed treatment , “ both ALL- and AML-types of treatment are close to maximum tolerable intensity , [ so ] by intending to combine these treatments , we either compromise their efficacy or increase the risk of toxicity beyond acceptable margins .”

Treatment-related toxicity was “ relatively high ,”

according to the researchers , accounting for 18 of 63 on-study deaths , but appeared to be distributed evenly between ALL-type , AML-type , and combined-therapy cohorts ( 7.4 %, 8.3 %, and 8 %, respectively ).

Patients who initiated lymphoid-directed treatment had greater rates of five-year event-free survival ( EFS ; 80 ± 4.0 %), compared with those who initiated either myeloid-directed treatment ( 36 ± 7.2 %) or combination treatment ( 50 ± 12 %; p values not reported ).

Bilineal ALAL ( in which two separate clones of different lineages coexist ) also was associated with better

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• 176 had single-population ALAL ( a single population of leukemic blasts co-expressing both lymphoid and myeloid lineages )

• 45 had bilineal leukemia ( more than one population of leukemic blasts expressing a single lineage ) myPKFiT SOFTWARE HELPS YOU :

• acute lymphocytic leukemia ( ALL )– type therapy ( n = 148 )

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• acute myeloid leukemia ( AML )– type therapy ( n = 60 )

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• combined therapy ( n = 25 )

“ Given that the phenotype of ALAL is in between classical ALL and AML , it has always been tempting to speculate that these leukemias would respond best to therapy which would comprise elements of both ALL and AML types of treatment ,” the authors wrote . “ This speculation assumes that what has been proven empirically for ‘ pure ’ ALL or AML would analogically hold true for borderline cases .”

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22 ASH Clinical News