How I Treat Adult Acute Lymphoblastic Leukemia in India

Survival of children with acute lymphoblastic leukemia (ALL) has improved from 10% to 90% over the last six decades. Survival gains in adult ALL have been more modest and confined to the adolescent and young adult population. Age is an important factor in determining outcomes in ALL. Additional factors like adverse biology, less intense treatment regimens, and poorer tolerance to therapy contribute to inferior survival among adults. Indian physicians face unique challenges while managing these patients. These are high infection rates, limited access to high-end investigations, and newer drugs. In this context, the management decisions in an individual patient are highly nuanced. Through a case-based review, we discuss representative scenarios in adult ALL where we detail our current approach to treatment in the context of available evidence.

Maintenance Treatment With Low-Dose Decitabine After Allogeneic Hematopoietic Cell Transplantation in Patients With Adult Acute Lymphoblastic Leukemia

BackgroundPost-transplant relapse remains a principal leading cause of failure after allogeneic hematopoietic stem cell transplantation (allo-HSCT) in patients with adult acute lymphoblastic leukemia (ALL). The aim of this study was to investigate the efficacy and safety of low-dose decitabine on the prevention of adult ALL relapse after allo-HSCT.MethodsIn this prospective study, we enrolled 34 patients with ALL who underwent allo-HSCT from August 2016 to April 2020 and received low-dose decitabine maintenance treatment after transplantation. The primary objectives were cumulative incidence of relapse rate (CIR), overall survival (OS), and disease-free survival (DFS). The secondary objectives were graft-versus-host disease (GVHD) and safety.ResultsAmong the enrolled 34 patients, 6 patients relapsed and 6 patients died. The 2-year CIR, OS, and DFS were 20.2, 77.5, and 73.6%, respectively. Subgroup analysis revealed the 2-year CIR, OS, and DFS rates of 12 patients with T-ALL/lymphoblastic lymphoma (LBL) were 8.3, 90, and 81.5%, respectively. None of the seven patients with T-ALL relapsed. During maintenance treatment, only one patient (2.9%) developed grade IV acute GVHD and four (11.8%) patients had severe chronic GVHD. Thirty-two patients (94.1%) developed only grade I to II myelosuppression, and two patients (5.8%) developed grade III to IV granulocytopenia.ConclusionsMaintenance treatment with low-dose decitabine after allo-HSCT may be used as a therapeutic option to reduce relapse in patients with adult ALL, especially in patients with T-ALL. Our findings require confirmation in larger-scale controlled trials.Clinical Trial RegistrationChinese Clinical Trials Registry, identifier ChiCTR1800014888.