Quel Bilan? Quel Protocole? Data Management?

Transcription

1 Quel Bilan? Quel Protocole? Data Management?

2 Standardization of Diagnosis of childhood Acute Lymphoblastic leukaemia

3 SPECIMEN All patients with a suspicion of acute leukemia should have bone marrow aspiration and trephine biopsy. Peripheral blood sample may be used for 1. Dry tap 2. Clinically unstable patient with peripheral blast count 20% of total peripheral blood WBC and absolute blast count >500 /ml.

4 Type of sample and volume required 1. BMA to make slides (0.5 ml). 2. Flowcytometry sample: ml should be collected in preservative free Heparin or in K2 or K3 EDTA 3. Cytogenetic sample: 1-2 ml of bone marrow aspirate. This should be transferred immediately into the appropriate transport media. Or sodium heparin 4. Molecular studies: ml to be collected in EDTA. Avoid heparin as anticoagulant. 5. Electron Microscopy should be done when MPO is negative 6. Cytochemistry - SBB/MPO to be requested 7. BM Trephine

5 IMMUNOPHENOTYPING At lest 3 colors flocytometry technique Positive and negative controls should be carried out for each MAb in case of infrequently used tests, and it is essential when a new MAb or batch is introduced. Gating strategies: CD45 is the most commonly used gating strategy. The cut-off point for considering a sample to be positive for a marker is 20% of the total number of the analyzed cells.

6 Monoclonal panel Leukemia Panel, BM or PB: CD14/CD11/CD45 CD3/CD8/CD45/CD4 CD10/CD20/CD45/CD19 CD61/CD34/CD45/CD33 CD7/CD13/CD45/HLD-DR KAPPA/LAMBDA/CD45/CD19 CD9/CD2/CD45/CD22 CD64/CD117/CD45/CD56 Lineage specific and lineage associated markers: TdT MPO Cyt IgG Cyt CD79a Cyto CD3 CD 15 Glycophorin-A TCR a/b Cyt IgM TCR g/d CD57 CD16 CD11b CD1a

7 Proposed Protocol for Immunophenotyping of Acute Leukemia by Flow Cytometry Screening Panel FITC ccd3 TdT PE cmpo ccd22 PerCP45 ccd79a AML FITC CD33 CD15 CD64 CD65 PE CD7 CD13 CD56 Glycophorin A PerCP45 CD45 CD45 CD45 CD45 B-ALL FITC CD20 CD22 CD34 PE Lambda Kappa CD10 PerCP45 CD45 CD45 CD45 T-ALL FITC PE PerCP45 CD3 CD4 CD5 CD7 CD8 CD1a CD45 CD45 CD45

8 DNA INDEX It is a Flowcytometry technique that detect the DNA ploidy. Will be reported for all cases of precursor B-cell acute lymphoblastic leukemia A value between 1.16 and 1.60 is associated with good prognosis. IF no bone marrow aspirate for flowcytometry, DNA Index SHOULD be done from the trephine biopsy or peripheral blood sample.

9 HEMATOGONES These are B cells with lymphoid precursor phenotype and blast like morphology They are encountered more frequently in infants, children and post chemotherapy and viral infection in adults. For differentiating hematogones from leukemic blasts the Four-color Flowcytometry. The expression of myeloid or T-cell marker or IgH rearrangement in the original disease can be helpful.

10 Cytogenetics and Molecular Karyotype vs. FISH When to do it? Turnaround Time Quality Control For molecular studies 1. DNA save for ALL cases of acute leukemia 2. MRD 3. Where to do it?

11 Follow up BM D7 vs. D14 Confirmation of residual leukemia 1. Immunophenotyping 2. Molecular D28 vs. D43 Confirmation of residual leukemia 1. Immunophenotyping 2. Molecular

12 Quel Bilan? Quel Protocole?

13 Principes du Traitement des LAL Groupes de Risque Standard Elevé Induction Intensification Prophylaxie SNC Entretien Il n y a pas une LAL Il y a des LAL

14 Induction VCR PRED (DEXA) L-Aspa - Anthracycline 2 ou 3 ou 4 DROGUES? PRED ou DEXA?

15 Total XV: Risk Classification Schema B-lineage T-lineage t(9;22)/bcr-abl WBC <50 X 10 9 /L & age 1 to 9.9 years, DNA index 1.16, or TEL-AML1 WBC 50 X 10 9 /L, Age 10 years, CNS leukemia, Testicular leukemia, MLL rearrangement, t(1;19)/e2a-pbx1 <45 chromosomes Minimal residual leukemia detection at remission date Minimal residual leukemia detection at remission date High-risk ~5% 1% <0.01% Low-risk ~45% 0.01% to 1% 1% 0.01% to <1% Standard-risk ~50% Pui et al. Lancet Oncology 2: , 2001

16 Consolidation BUT: Eradiquer les blastes leucémiques résiduels après Rémission Complète 6 MP + MTX (+++) MTX HD [5g/m2 (T) et 2,5g/m2 (B)] Intérêt systémique Intérêt SNC et Testicules Dexaméthasone (SNC+) IT MTX (HC / Arac?)

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18 RTP SNC. Qui en a besoin? Rechutes SNC 24 mois du début TTT Prévention efficace et précoce Effets secondaires: Clinique et Gliomes À supprimer (au moins RS et IR) RTP nécessaire au moine dans [12 Gy + IT?] LAL T et âge > 1 an Groupe Haut Risque

19 Réinduction = Intensification tardive Intérêt majeur dans la diminution des rechutes Après Consolidation (vers le 5è mois / Dg) 1ère Phase Dexa x 21j VCR x4 L-Aspa x 4 Doxo x 4 2è Phase END 6-TG Ara-C

20 EFS dans les LAL Risque Standard avec ou sans Reinduction (BFM 86) Reiter et al Blood 84: , 1994

21 Entretien = Maintenance Buts diminuer le pool des cellules leucémiques résiduelles supprimer la réémergence d un clone chimiorésistant Gold Standard 6-MP (50mg/m2/j) + MTX (20mg/m2/s) 2000 < GB > /- VCR + Corticoïdes? Durée Minimum: 2 ans Maximum: 3 ans?

22 Greffe de Cellules Souches Hématopoïétiques 2è Rémission Complète 1ère RC : Groupe Haut Risque t(9;22) ou t(4;11) BCR/ABL ou MLL/AF4 Corticorésistance à J8 non RC en fin d induction < âge 1 an? MRD ( 1%)?

23 Supportive Care Lutte contre les infections Pneumocystis carinii (Cotrimoxazole) Traitement antimycosique des muqueuses Prophylaxie de la varicelle Traitement de toute infection potentielle Troubles métaboliques (SLT) Toxicité médicamenteuse (MTX END, ) Transfusion sanguine Etat nutritionnel correct Support psycho-socio-economique du patient / famille.

24 LAL L3 = LAL B = LAL de Burkitt 2-4% des LAL de l enfant LAL3 = Lymphome de Burkitt LMB ; BFM ; St-Jude ; POG ; NCI polychimiothérapie intensive, rapprochée et courte Endoxan ; MTX HD ; Ara-C HD VCR ; Corticoïdes ; Doxorubicine ; VP16 ; Holoxan

25 Quel Bilan? Quel Protocole? Data Management?

26 Data Management Avez-vous des personnes spécialisées dans la collecte des données? le traitement statistique des données? Sont-elles des Secrétaires ; Médecins ; autres etc.? Travaillent-elles à temps plein? ou partiel? Ont-elles la logistique nécessaire?

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