Analysis of relapse childhood acute lymphoblastic leukemia at Hue central hospital in Vietnam
Hue Central Hospital
ANALYSIS OF RELAPSE CHILDHOOD ACUTE LYMPHOBLASTIC
LEUKEMIA AT HUE CENTRAL HOSPITAL IN VIETNAM
Nguyen Thi Kim Hoa1, Tran Kiem Hao1, Chau Van Ha1, Kazuyo Watanabe1
ABSTRACT
Background: Treatment outcome of acute lymphoblastic leukemia (ALL) in children has shown an
improvement. However, relapse of disease is still a big protslen in developing countries. This study aimed
to analyze the percentage and survival rate of relapsed in patients with childhood acute lymphoblastic
leukemia treated at Hue Central Hospital, Vietnam, during the period of January 2012 - April 2018.
Methods: It was a retrospective and prospective descriptive study. Data were analyzed according to
age, gender, relapse type, relapse time.
Results: There were 156 new patients with ALL admitted hospital, in which, there were 26 relapsed
cases, accounted for 16.67%. Of 26 relapsed cases, the ratio of male to female was 2.71:1. High risk
group was 1.6 times higher than standard group (61.5% vs 38.5%). 85.5% of patients achieved remission
after induction phase. The mean time from diagnosis to relapse was 29.3 ± 18.2 months, in which the
rate of early, intermediate and late relapse were 38.5%, 26.9% and 34.6% respectively. Based on relapse
abandonment. Based on relapse type, bone marrow relapse accounted 38.5%, followed by isolated CNS,
bone marrow combined CNS relapse (23.1% and 23.1% for respectively), while the rest had a relapse in
testes, combination of testis and bone marrow, and testis combined CNS. The median time from relapse to
death were 7.5 ± 8.3 months. Until April 2018, 73.1% of relapsed cases passed away and 26.9% of cases
were are alive.
Conclusions:
marrow and CNS were the main sites of relapse.
Key words: Childhood acute lymphoblastic leukemia, relapse.
I. INTRODUCTION
of ALL occours between 2 to 5 year of age. With
advances in chemotherapy, hematopoietic stem
cell transplantation and supportive care, long-term
survival in childhood acute lymphoblastic leukemia
is now 85-90%. Despite increasing, concerns
regarding treatment related mortality and second
Acute lymphoblastic leukemia (ALL) is the most
common malignant disease in children. It accounts
for one-fourth of all childhood cancers and 72% of
all cases of childhood leukemia. The incidence is
about 2 to 5 per 100.000 children. The peak incidence
1. Hue Central Hospital
2. ACCL, Japan
- Received: 24/7/2018; Revised: 16/8/2018
- Accepted: 27/8/2018
- Corresponding author: Nguyen Thi Kim Hoa
- Email: kimhoa.fmi@gmail.com.
Journal of Clinical Medicine - No. 51/2018
19
T
malignancies, the main reason for treatment failure between the ages 1 months and 16 years old,
is still relapse. The prognostic factors most important registered at Hue Pediatric Center- Hue Central
for determining survival post-relapse include: site Hospital, between 1st January 2012 to 30th April
of relapse (bone marrow vs. isolated extramedullary 2018. Medical records of the patients who were
vs. combined), timing of relapse (early vs. late), diagnosed relapse during this period were further
phenotype of the original and recurrent disease, analyzed for the purpose of this study.
prognostic features characterizing the primary
diagnosis and depth of response [2], [3], [4]..
2.2. Methods
A describe retrospective and prospective study:
Hue Central Hospital plays an important role to We collected the data of 156 new patients diagnosed
treat childhood acute lymphoblastic leukemia in the acute lymphoblastic leukemia at Hue Pediatric
centralzoneofVietnamwhichcoversgeographically Center, then we analysed and followed up 26 cases
wide areas. Since 2008, ALL patients have treated with relapse ALL.
by
CCG 1882 & 1881 protocol. In order
Diagnosis of ALL at presentation was made on
to improve the treatment outcome, we carry out bone marrow morphology showed more than 25%
this research to analyze the incidence and survival leukemic blasts.
rate of relapse in patients with childhood acute
lymphoblastic leukemia treated at Hue Central CCG 1882 & 1881 protocol.
Hospital, Vietnam, during the period of January
2012 - April 2018.
diagnosis (early: <18 months; intermediate: 18-36
II. PATIENTS AND METHODS
2.1. Patients
Data were analyzed according to age, gender,
relapse type, relapse time.
We reviewed the medical records of pediatric
Statistical analysis: Data were analyzed using
patients treated for acute lymphoblastic leukemia Medcalc program.
III. RESULTS
3.1. The percentage of relapse rate
Table 1: The incidence of relapse rate
Characteristic
Relapsed patients
Non-relapsed patients
Total
n
%
26
16.67
83.33
100
130
156
Of 156 patients, relapsed cases accounted for 16.67%.
3.2. Characteristics of relapsed patients
Table 2: The characteristics of relapsed patients
Characteristics
Gender
Male
n
%
19
7
73.1
26.9
Female
20
Journal of Clinical Medicine - No. 51/2018
Hue Central Hospital
Standard
High
10
16
38.5
61.5
Yes
No
23
3
88.5
11.5
100
Total
26
standard group (61.5% vs 38.5%). 88.5% of patients achieved remission after induction phase.
Table 3: Time of relapse
n
10
7
%
Early relapse
Intermediate relapse
Late relapse
38.5
26.9
34.6
9
29.3 ± 18.2
Maintenance phase
Finishing treatment
14
6
53.8
23.1
15.4
7.7
4
Consolidation
Total
2
26
100
Of 26 relapsed cases: 14 (53.8%) occurred in maintenance phase, 4 (15.4%) occurred in delay
Table 4: Site of relapse
n
10
6
%
38.5
23.1
23.1
7.6
CNS
6
Testis
2
1
3.85
3.85
100
Testis + CNS
Total
1
26
by CNS and BM + CNS (23.1% and 23.1% respectively).
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3.5. Time from relapse to death
Table 5: Time from relapse to death
Status of patient until April 2018
n
%
Alive
7
19
26.9
73.1
100
dead
Total
26
Median time, month range
7.5 ± 8.3
Comment: Until April, 2018, there was only 7 (26.9%) alive patients, 19 (73.1%) patients passed away.
The median time from relapse to death was 7.5 ± 8.3 months
3.6. Relation between relapse events and survival after relapse
Survival after relapse
100
80
Relapse events
60
< 18 months
18-36 months
36 months
40
20
0
0
5
10
15
20
25
30
35
Time (months)
Figure 1: The relation between relapse events and the survival after relapse
Intermediate relapse had better survival time than early relapse
IV. DISCUSSION
4.2. Characteristics of relapse patients
Table 2 showed the ratio of male to female
was 2.7:1. Some researches also showed that the
incidence of ALL was higher among boys than girls,
and male has a distinctly poor prognosis factor, girls
has a better prognosis than boys [9], [10].
4.1. The incidence of relapse rate:
Table 1 showed the relapse rate for ALL was
16.67%. Similarly, Locatelli and Oskarsson showed
relapse occurred in 15-20% patients [4], [8].
According to Mulatsih and Nguyen, the rate were
higher: 24.5% and 20.5 % respectively [5], [6].
High risk group was 1.6 times higher than
22
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Hue Central Hospital
standard group (61.5% vs 38.5%) in our study.
[9]. According to Nguyen, 5 - year survival rates for
NCI SR: 50.4 ± 2.4% vs NCI HR: 22.6 ± 2.1% [6].
researches. It can be the seasson of our protocol.
some tests, such as MRD to evaluate the response.
3 patients (11.5%) didn’t achieve remission. This
induction therapy has prognositc value [8].
±
The median time from diagnosis to relapse
±
± 2.1%) or concurrent BM (39.4% ± 5.0%) relapses
[6].
34.6% respectively. Based on relapse timing, 53.8%
relapsed during maintenance phase, 23.1% relaspe
resonable. Time to relapse remains the strongest
predictor of survival. According to Nguyen,
estimates of 5 year survival rates for isolated
patient relapsed during maintenance phase [5].
± 1.9, 18.4 ± 3.1
respectively). The last percentage (15.3%) belonged
According to Mulatsih, the highest site for relapse
and 43.5 ± 5.2% respectively. The relative risk of
result (19.05% and 13.55% respectively) [5]. Philip
35% respectively [11].
Most relapse cases occurred at maintenance
these facts, modifying the protocol to use escalated
testicular relapse (2-3%) [9]. The reason for relapse
testes had long been considered a sanctuary site in
the blood-testes barrier can be overcome. And our
protocol couldn’t be strong enough to eradicate
ALL cell in testis [7].
therapies such as stem cell transplantation need to
be applied. With the support from Asian Children
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transplantation, we hope in the near future, we can do stem cell transplantation to save relapse children.
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