Rev. Bras. Hematol. Hemoter. vol.37 número1

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rev bras hematol hemoter. 2015;37(1):3–4

Revista

Brasileira

de

Hematologia

e

Hemoterapia

Brazilian

Journal

of

Hematology

and

Hemotherapy

w w w . r b h h . o r g

Scientific

comment

Myeloid

leukemia:

are

we

getting

better?

夽

Nelson

Hamerschlak

∗

HospitalIsraelitaAlbertEinstein,SãoPaulo,SP,Brazil

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t

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Articlehistory:

Availableonline21November2014

Thestudy by Callera et al., published in this issue of the

Revista Brasileira de Hematologia e Hemoterapia (RBHH),1

revealsevidence ofacontinuous decrease inthe mortality

rateinadultpatientswithmyeloidleukemias from1994to

2011insoutheastBrazil.Undoubtedly,thisdeclineisrelated

tothebetterunderstandingandtreatmentofchronicmyeloid

leukemia(CML),acutemyeloidleukemia(AML)and

promy-elocyticleukemia(APL, M3).2–4 _The_words_myeloid _retirar_a

palavraandleukemiarefertoaverywiderangeofdisorders

withvaryingseverityand manifestations.Weaddress here

CML,AMLandAPLmainlytobetterunderstandtheadvances

ineachofthem.

IbelievethatthereisreallyatrendinBraziltofollow

devel-opedcountries which havereported significant changes in

prognosis.Unfortunately,westill experiencemany

difficul-ties,butwehavehadprogressaswell:first,tyrosinekinase

iswidelydistributedtopatientswithCMLinBrazil;second,

thehealthauthoritieshavejustopenedapublicconsultation

aboutAMLtreatment,includingcytogeneticsandthe

recom-mendation forthe useofmolecular testsin thetreatment

protocol;andthird,theresultsoftreatmentsofLPAshow

sub-stantialimprovement.3

Evolution in the treatment of leukemia has greatly

improvedthechancesofcureanddiseasecontrol.Morethan

7500peopledevelopleukemiainthecountrytodayand9000

DOIoforiginalarticle:http://dx.doi.org/10.1016/j.bjhh.2014.11.011.

夽

SeepaperbyCalleraetal.onpages7–11.

∗ _{Correspondence}_to:_Centro_de_Pesquisa_Clínica,_Instituto_Israelita_de_Ensino_e_Pesquisa_Albert_Einstein,_Av._Albert_Einstein,_627/520,

05651-901SãoPaulo,SP,Brazil.

E-mailaddress:hamer@einstein.br

people die ofthe disease every year in Brazilaccording to

the National Cancer Institute (INCA). Despite the lethality,

leukemiaisnowacurabletypeofcancer.

Prognosisofleukemiapatientstodayisgenerallygood.CML

iscontrolledwithadailypillandacuteleukemiasarecuredin

50–80%ofcases.In recentyears,greatadvanceshavebeen

made intreatment, including chemotherapy,bone marrow

transplantation and targeted-treatments.2 _The_introduction

oftyrosinekinaseinhibitorsinthetreatmentofCML,which

waspreviouslytreatedwithtransplantation,isanevolution.In

addition,greaterknowledgeofthegeneticsbehindthedisease

leads to betterchoices and individualization of treatment.

These improvements intreatment have increasedchances

ofcureanddiseasecontrol,andbetterqualityoflifeforthe

patients. Hence,themostusedtreatmentforCMLtodayis

targetedtherapywiththedrugsimatinib,dasatinibor

niloti-nib.Thetreatmentmustbecontinuedforlife,ensuringthat

thepersonstaysinremissionwhiletakingthedrugs.Thisis

calledfunctionalcure.2

For acute cases, treatment is planned in stages. First

chemotherapyisproposed,usuallywithagood resultfora

shorttime.Thereisaneedtoprovideapostremission

ther-apy.Duringthisperiod,certaincombineddrugsareusedto

extend and maintaindisease remission. In AML,the main

inductionregimen(3+7)hasbeenusedformorethan40years.

http://dx.doi.org/10.1016/j.bjhh.2014.11.006

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revbrashematolhemoter.2015;37(1):3–4

Forcaseswithgoodprognosis,consolidationchemotherapy

orautologoustransplantationhasbeenused.Forcaseswith

badprognosisorwhenrelapseoccurs,allogeneicbone

mar-rowtransplantshavebroughtgoodresults.Theseprocedures

todayareverysafeandrecommended.3

Thus,acytogeneticevaluationthataddressestheso-called

molecular factors, in particular FMS-like tyrosine kinase-3

(FLT3),nucleophosmin(NPM1)andCantharidin-binding

pro-tein(CBP)alphasubunit,isessential,astheyallocatepatients

toreceive consolidationwith chemotherapyand/or

autolo-goustransplants,whenprognosisisfavorable,ortoundergo

allogeneictransplantsincasesofpoorprognosis.Properuse

ofalgorithmsimprovesprognosis.3

Elderlypatients,amongwhomleukemiaismoreprevalent,

startedtobetreatedmoreaggressively,justlikeyoung

peo-ple,becausetheinfrastructureofcarehasimprovedgreatlyin

recentyears.Thisyieldsahighrateofremissionand,inthose

patientswithbetterperformancestatusand lower ratesof

fragility,thepossibilityofundergoinglowtoxicity,allogeneic,

non-myeloablativetransplantation.Data from ourgroup in

partnershipwithMDAndersonHospitalshowresultsinthe

elderlysimilartothoseobtainedwithyoungerpatients.5

Fur-thermore,theadventofhypomethylatingagentsopensnew

perspectivesforthetreatmentofAMLinelderlypatients.6–8

Finally,theeffortinBraziltoimprovethecareofpatients

withAPL throughthe programheadedbyDr.Eduardo Rego

usingaBrazilianprotocolbasedonthatoftheSpanishgroup

(PETHEMA),broughtouroutcomesuptointernationallevels.4

Forallthat,hopefully,inafewyears,myeloidleukemiaswill

becurablediseases

Conflicts

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1.CalleraF,CalleraAF,RosaES.Trendsinmortalityofadult patientsdiagnosedwithmyeloidleukemiafrom1994to2011 insoutheasternBrazil.RevBrasHematolHemoter.

2015;37(1):7–11.

2.CortesJ,DeSouzaC,Ayala-SanchezM,BenditI,Best-Aguilera C,EnricoA,etal.Currentpatientmanagementofchronic myeloidleukemiainLatinAmerica:astudybytheLatin AmericanLeukemiaNet(LALNET).Cancer.

2010;116(21):4991–5000.

3.SillaLM,DulleyF,SaboyaR,PatonE,KerbauyF,ArantesAde M,etal.Bonemarrowtransplantationandacuteleukemia: Brazilianguidelines.RevBrasHematolHemoter.

2013;35(1):56–61.

4.RegoEM,KimHT,Ruiz-ArgüellesGJ,UndurragaMS,Uriarte MdelR,JacomoRH,etal.Improvingacutepromyelocytic leukemia(APL)outcomeindevelopingcountriesthrough networking,resultsoftheInternationalConsortiumonAPL. Blood.2013;121(11):1935–43.

5.AlatrashG,deLimaM,HamerschlakN,PelosiniM,WangX, XiaoL,etal.Myeloablativereduced-toxicityi.v.

busulfan-fludarabineandallogeneichematopoieticstemcell transplantforpatientswithacutemyeloidleukemiaor myelodysplasticsyndromeinthesixththrougheighthdecades oflife.BiolBloodMarrowTransplant.2011;17(10):1490–6.

6.KirschbaumM,GojoI,GoldbergSL,BredesonC,KujawskiLA, YangA,etal.Aphase1studyofvorinostatincombination withdecitabineinpatientswithacuteleukaemiaor

myelodysplasticsyndrome.BrJHaematol.2014[Epubaheadof print].

7.MalikP,CashenAF.Decitabineinthetreatmentofacute myeloideleukemiainelderlypatients.CancerManagRes. 2014;6:53–61.