LIBYAN EXPERIENCE IN LIBYAN EXPERIENCE IN PEDIATRIC ACUTE MYELOID PEDIATRIC ACUTE MYELOID

LEUKEMIALEUKEMIA

Fathia El Riani, Rasem Al Ajnef, Elham Sbita, Fathia El Riani, Rasem Al Ajnef, Elham Sbita, Salem ZarrougSalem Zarroug

Departement of pediatric hematology-oncology Departement of pediatric hematology-oncology Tripoli Medical CenterTripoli Medical Center

MATERIAL AND METHODMATERIAL AND METHOD

Data were collected from the fills of all Data were collected from the fills of all children with the diagnosis of acute children with the diagnosis of acute

myeloid leukemia for the period from Jan. myeloid leukemia for the period from Jan. 1997 to Dec. 20021997 to Dec. 2002

Information regarding age ,gender, way of Information regarding age ,gender, way of diagnosis , clinical presentation treatment diagnosis , clinical presentation treatment

and end result were recorded and analyzedand end result were recorded and analyzed

RESULTSRESULTS

39 pts. Were identified 39 pts. Were identified 23 boys and 16 girls 23 boys and 16 girls M:F ratio 1.4 : 1 M:F ratio 1.4 : 1 Mean age 7.1 yrs. ( range 2ms. – 14 yrs. )Mean age 7.1 yrs. ( range 2ms. – 14 yrs. ) All patients were diagnosed by bone marrow All patients were diagnosed by bone marrow

and peripheral blood morphology. according and peripheral blood morphology. according to F.A.B. classifications.to F.A.B. classifications.

Cytochemical stains.( Sudan black + P.A.S.) Cytochemical stains.( Sudan black + P.A.S.) was done in some pts. was done in some pts.

CLINICAL MANIFESTATIONCLINICAL MANIFESTATION

Symptoms + signsSymptoms + signs patientspatients

**Pallor 39ptsPallor 39pts *Fever 29pts*Fever 29pts *Bleeding 25pts*Bleeding 25pts *Proved DIC. 4pts*Proved DIC. 4pts *Adenopathy 23pts*Adenopathy 23pts *Hepatosplenomegaly 15pts*Hepatosplenomegaly 15pts *Gingival hypertrophy 8pts*Gingival hypertrophy 8pts *Bone pain 8pts*Bone pain 8pts *Chloroma 4pts*Chloroma 4pts

HEMATOLOGICAL PARAMETERSHEMATOLOGICAL PARAMETERS

No of pts. W.B.C. countsNo of pts. W.B.C. counts

15pts. >50.000 (43.6%)15pts. >50.000 (43.6%) 22pt < 50.000 (56.4%22pt < 50.000 (56.4% 33.3% <4.000 33.3% <4.000 23% normal23% normal 2pts.2pts. > 200.000 ( 5% )> 200.000 ( 5% )

4pts has C.N.S. disease at diagnosis4pts has C.N.S. disease at diagnosis

SUB TYPES ACCOURDING TO FAB SUB TYPES ACCOURDING TO FAB CLASSIFICATIONCLASSIFICATION

Sub typesSub types Our studyOur study FABFAB M0 - -M0 - - M1 3(7.6) 18%M1 3(7.6) 18% M2 7 (17.9%) 28%M2 7 (17.9%) 28% M3 7(17.9%) 28%M3 7(17.9%) 28% M4 9(23.7%) 27%M4 9(23.7%) 27% M5 7((17.9%) 10%M5 7((17.9%) 10% M6 3(7.6%) 4%M6 3(7.6%) 4% M7 3(7.6%) 5%M7 3(7.6%) 5%

TREATMENTTREATMENT

All patient treated with DAT. Protocol All patient treated with DAT. Protocol

Daunarubicin 45Daunarubicin 45 mg/mmg/m22/iv daily for 3days /iv daily for 3days Cytarabine 100 mgs /mCytarabine 100 mgs /m22 iv continuous infusion iv continuous infusion

over 24hrs for 7 daysover 24hrs for 7 days 6Thioguanine 100 mgs /m6Thioguanine 100 mgs /m22 p.o. daily for 7 days p.o. daily for 7 days IT ( M.T.X +Ara c + HCT. )IT ( M.T.X +Ara c + HCT. )

ConsolidationConsolidation

11STST consolidation: consolidation: Cytarabine 100mg/mCytarabine 100mg/m22 /iv infusion over 24hrs daily /iv infusion over 24hrs daily

for /5daysfor /5days DNR 45mg/mDNR 45mg/m2 2 / d/ iv/ daily for 2days / d/ iv/ daily for 2days 6TG 100mg/m6TG 100mg/m22/d/oral daily for 5 days/d/oral daily for 5 days IT (MTX + ARA C + HCT )IT (MTX + ARA C + HCT )

From the beginning of 2001 From the beginning of 2001 22ndnd consolidation: consolidation: Cytarabine 100 mg/mCytarabine 100 mg/m22/iv/daily for 5 days/iv/daily for 5 days Etoposide 100mg/mEtoposide 100mg/m22/iv infusion over 2 hrs /iv infusion over 2 hrs

daily for 5days.daily for 5days.

High dose cytarabineHigh dose cytarabine

2gms /m2gms /m22 /12 hly/ iv infusion daily for 3 days /12 hly/ iv infusion daily for 3 days

Given as an intensification.Given as an intensification.

Maintenance therapyMaintenance therapy Block I Block I

Cytarabine 100 mg/mCytarabine 100 mg/m22/iv/daily for 4ds./iv/daily for 4ds. 6TG 100mg/m6TG 100mg/m22/oral/daily for 4 days /oral/daily for 4 days I T (MTX+ ARA C + HCT ) I T (MTX+ ARA C + HCT )

BlockIIBlockII Cytarabine 100 mg/mCytarabine 100 mg/m22 iv/daily for 4 days iv/daily for 4 days Etoposide 100 mg/mEtoposide 100 mg/m22/iv infusion over 2hrs daily for /iv infusion over 2hrs daily for

4days4daysBlock I alternate with block II every 21 daysBlock I alternate with block II every 21 days

Total period of 2 yrsTotal period of 2 yrs

Treatment resultTreatment result

32/39 82% attained CR 32/39 82% attained CR

(median duration of remission 13.3ms)(median duration of remission 13.3ms)

4 pts. Died during induction4 pts. Died during induction 2 pts. Were refractory2 pts. Were refractory 1 pts. Transferred to another hospital1 pts. Transferred to another hospital 22 / 32 relapsed (19 in B.M.+3B.M. and CNS) 22 / 32 relapsed (19 in B.M.+3B.M. and CNS)

TREAMENT 0F RELAPSED TREAMENT 0F RELAPSED PATIENTPATIENT

All relapsed pts. Received DAT as initial All relapsed pts. Received DAT as initial treatmenttreatment

Etoposide was added to 6 pts.Etoposide was added to 6 pts. M-amsacrine was given to 2pts. After DAT M-amsacrine was given to 2pts. After DAT

failurefailure Allogenic B.M.T.was done abroad for 2 pts.Allogenic B.M.T.was done abroad for 2 pts.

Results of treatment of relapsed patientsResults of treatment of relapsed patients

13 / 22 (59% ) attained a second remission13 / 22 (59% ) attained a second remission

Median duration of remission 4.6 msMedian duration of remission 4.6 ms

Range(2 ms. - 12 ms.)Range(2 ms. - 12 ms.)

DEATHSDEATHS

Total number of deaths 31pts (79.5% ) Total number of deaths 31pts (79.5% ) 4 during induction. 4 during induction.

((infection and bleedinginfection and bleeding) ) 2 pts. Were refractory to treatment. 2 pts. Were refractory to treatment.

and died of diseaseand died of disease 3 died in remission 3 died in remission 2 pts. Who had B.M.T. died shortly 2 pts. Who had B.M.T. died shortly

after transplantafter transplant 20pts .died because of disease 20pts .died because of disease

progression. progression.

Over allOver all 6 patients are alive (15.4% ) 6 patients are alive (15.4% ) 4 are off therapy4 are off therapy 2 still on chemotherapy 2 still on chemotherapy 2pts are lost for follow up.2pts are lost for follow up.

CONCLUSIONCONCLUSION Our study shows that CR attained in 82% of acute myeloid leukemia Our study shows that CR attained in 82% of acute myeloid leukemia

treated with conventional dose anthracycline and cytarabine.treated with conventional dose anthracycline and cytarabine. The diagnosis were done according to FAB classification The diagnosis were done according to FAB classification

morphologically and all pts. treated in the same way regardless of their morphologically and all pts. treated in the same way regardless of their risk group.risk group.

68.7% (22/32) relapsed and 79.5% died68.7% (22/32) relapsed and 79.5% died whichwhich indicate indicate thatthat our protocol was not effective in maintaining remission. our protocol was not effective in maintaining remission.

High dose cytosar did not improve remission duration or survival in High dose cytosar did not improve remission duration or survival in our study.our study.

Cytochemical ,cytogenetic and immunophenotyping are necessary to Cytochemical ,cytogenetic and immunophenotyping are necessary to identify risk group.identify risk group.

Change of chemotherapy to more effective drugs.Change of chemotherapy to more effective drugs. B.M.T is an alternative treatment for high risk patients .B.M.T is an alternative treatment for high risk patients .