Outcome of Induction Chemotherapy in Acute Lymphoblastic Leukemia in a Resource Constrained Setting
Authors: Ur Rahman Khalil , Abbasi Sumyyia , Ahmed Parvez , Mahmood Syed Karman , Chaudhry Qamar Un Nisa , Naseeb Summaira , Peter Hina , Fatima Mehroz , Bahadur Laila , Barlas Sidra 
Published: December 2024

Background: Treatment of acute leukemia requires advanced healthcare setup with availability of advanced diagnostic, blood components and chemotherapeutic agents. In resource constrained settings there are suboptimal facilities for treating acute leukemias leading to early death. Pathwel center of hematology and bone marrow transplant (PATHWEL) is a recently established nonprofit facility for diagnosis and management of blood diseases. This center has adopted certain measures like intensive human resource training, optimizing the use of blood components and chemotherapeutic agents to make the treatment sustainable for poor patients in the limited available resources.

Objective: To analyze the outcome of induction chemotherapy in patients with acute lymphoblastic leukemia (ALL) in a -resource constrained setting.

Methods: Retrospective observational analysis

Patients and Methods: All patients diagnosed as ALL and treated at PATHWEL from March 2022 till June 2024 were included. Medical records of all patients were reviewed and data was collected including patient demographics, disease subtype, induction chemotherapy regimen, response to induction chemotherapy and treatment complications. SPSS software version 23 was used for data analysis.

Results: A total of 69 patients with ALL were registered at PATHWEL during the study period. Clinical data and treatment response of 49 patients was available and they were included in this analysis. Out of 49 patients, 42 (86%) were male, 7 (14%) female. Median age was 22 years (range 5 to 58). Thirty-seven patients (75.5%) were newly diagnosed, 7 (14.3%) had relapsed disease, 2 (4.1%) had refractory disease and 3 (6.1%) lymphoid blast transformation of chronic myeloid leukemia (CML). Thirty-five (71.4%) had B-ALL, 10 (20.4%) T- ALL, 3 (6.1%) patients were in lymphoid blast phase of CML and 1 (2%) had acute undifferentiated leukemia. Molecular workup was available for 41 (83.6%) patients out of which 6 (12.2%) were BCR-ABL positive including 3 (6.1%) with de novo ALL and 3 (6.1%) in CML blast transformation, 1 (2%) had TEL-AML1 and the rest had negative molecular panel. Cytogenetics reports were available for 36 (73.4%) out of which 31 (63.2%) were normal, 2 (4.1%) had complex karyotype and one each had double Philadelphia chromosome, Trisomy 8 and hyperdiploidy. All patients except 8, received multiagent induction chemotherapy based on UK-ALI-2011 Regimen B induction, 1 (2%) received modified UKALL 2011 Reg B induction, 6 (12.2%) patients received Fludarabine, cytarabine and daunorubicin/ Idarubicin (FLAG Dauno/Ida) and 2 (4.1%) patients received high dose cytarabine, vincristine, daunorubicin and dexamethasone (Hyper CVAD). Additionally, BCR ABLI positive patients received a tyrosine kinase inhibitor (TKI). The complications were mainly infectious. Twenty-one patients (42.8%) had infectious complications during induction therapy including sepsis in 13 patients (26.5%), neutropenic enterocolitis in 2 cases (4%) and one patient each of pneumocystis pneumonia, viral encephalitis, bacterial meningitis, otitis media, and septic arthritis. Other complications included cardiomyopathy in 1 patient, steroid induced hyperglycemia in 3, proximal myopathy in 1, peripheral neuropathy in 1 and hoarseness of voice with vocal cord mass in 1 case. Thirty-six patients (73.4 %) achieved remission after induction, 6 (12.2%) had refractory disease, and 2 (4%) died during induction, 1(2%) had iatrogenic hypoplasia with residual blasts. Remission status could not be assessed in 4 (8.1%) due to loss to follow up.

Conclusion: Our data show encouraging early results of induction chemotherapy in ALL in resource constrained setting by optimizing the available healthcare facilities which is significant as this was a diverse patient population including relapsed and refractory patients. Long term follow up and larger studies may help to refine optimal treatment approach for patients in resource constrained settings.