Adult T-cell leukemia medical therapy: Difference between revisions
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* The optimal therapy for adult T-cell leukemia depends on the clinical variant of the disease. | * The optimal therapy for adult T-cell leukemia depends on the clinical variant of the disease. | ||
* Chronic and smoldering adult T-cell leukemia patients are usually managed by either observation, [[skin]] directed therapies, or a combination of [[zidovudine]] and [[interferon]] therapy.<ref name="HermineBouscary1995">{{cite journal|last1=Hermine|first1=Olivier|last2=Bouscary|first2=Didier|last3=Gessain|first3=Antoine|last4=Turlure|first4=Pascal|last5=Leblond|first5=Veronique|last6=Franck|first6=Nathalie|last7=Buzyn-Veil|first7=Agnes|last8=Rio|first8=Bernard|last9=Macintyre|first9=Elisabeth|last10=Dreyfus|first10=Francois|last11=Bazarbachi|first11=Ali|title=Treatment of Adult T-Cell Leukemia-Lymphoma with Zidovudine and Interferon Alfa|journal=New England Journal of Medicine|volume=332|issue=26|year=1995|pages=1749–1751|issn=0028-4793|doi=10.1056/NEJM199506293322604}}</ref> | * Chronic and smoldering adult T-cell leukemia patients are usually managed by either observation, [[skin]] directed therapies, or a combination of [[zidovudine]] and [[interferon]] therapy.<ref name="HermineBouscary1995">{{cite journal|last1=Hermine|first1=Olivier|last2=Bouscary|first2=Didier|last3=Gessain|first3=Antoine|last4=Turlure|first4=Pascal|last5=Leblond|first5=Veronique|last6=Franck|first6=Nathalie|last7=Buzyn-Veil|first7=Agnes|last8=Rio|first8=Bernard|last9=Macintyre|first9=Elisabeth|last10=Dreyfus|first10=Francois|last11=Bazarbachi|first11=Ali|title=Treatment of Adult T-Cell Leukemia-Lymphoma with Zidovudine and Interferon Alfa|journal=New England Journal of Medicine|volume=332|issue=26|year=1995|pages=1749–1751|issn=0028-4793|doi=10.1056/NEJM199506293322604}}</ref> | ||
* Acute adult T-cell leukemia patients are usually managed by either [[chemotherapy]], supportive care, allogeneic [[stem cell]] transplant, or a combination of zidovudine and interferon therapy. | * Acute adult T-cell leukemia patients are usually managed by either [[chemotherapy]], supportive care, allogeneic [[stem cell]] transplant, or a combination of [[zidovudine]] and [[interferon]] therapy. | ||
* Adult T-cell lymphoma patients are usually managed by either chemotherapy, supportive care, or allogeneic stem cell transplant. | * Adult T-cell lymphoma patients are usually managed by either [[chemotherapy]], supportive care, or [[Allogeneic stem cell transplantation|allogeneic stem cell transplant]]. | ||
=== Management of Chronic/Smoldering Adult T-cell Leukemia=== | === Management of Chronic/Smoldering Adult T-cell Leukemia=== | ||
* Patients may be managed by observation and close follow-up for any symptomatic deterioration. Follow up of such patients must include: | * Patients may be managed by observation and close follow-up for any symptomatic deterioration. Follow up of such patients must include: | ||
:* A complete history and physical examination | :* A complete history and physical examination | ||
:* Serum calcium level | :* Serum [[calcium]] level | ||
:* [[Blood urea nitrogen]] | :* [[Blood urea nitrogen]] | ||
:* Serum [[creatinine]] level | :* Serum [[creatinine]] level | ||
:* Serum [[LDH]] | :* Serum [[LDH]] | ||
:* [[Chest]] and abdominal [[CT scan]] | :* [[Chest]] and abdominal [[CT scan]] | ||
* Skin directed therapies for the management of localized [[cutaneous]] lesions among such patients may include: | * [[Skin]] directed therapies for the management of localized [[cutaneous]] lesions among such patients may include: | ||
:* Topical [[corticosteroid]]s | :* Topical [[corticosteroid]]s | ||
:* Topical [[chemotherapy]] ([[mechlorethamine]]) | :* Topical [[chemotherapy]] ([[mechlorethamine]]) | ||
| Line 27: | Line 27: | ||
* [[Zidovudine]] and [[interferon]] combination therapy: | * [[Zidovudine]] and [[interferon]] combination therapy: | ||
:* Chronic/smoldering adult T-cell leukemia patients should be evaluated for response after two months of initiating the combination therapy. | :* Chronic/smoldering adult T-cell leukemia patients should be evaluated for response after two months of initiating the combination therapy. | ||
:* Patients who respond to the therapy should be continued on zidovudine and interferon therapy. | :* Patients who respond to the therapy should be continued on [[zidovudine]] and [[interferon]] therapy. | ||
:* | :* Patients who did not respond to the therapy, should be managed by either [[chemotherapy]] or supportive care depending on the patients preference. | ||
* The criteria for complete remission of adult T-cell leukemia patients includes: | * The criteria for complete remission of adult T-cell leukemia patients includes: | ||
:* Absence of [[lymphadenopathy]] | :* Absence of [[lymphadenopathy]] | ||
| Line 34: | Line 34: | ||
:* Absence of [[cutaneous]] lesions | :* Absence of [[cutaneous]] lesions | ||
:* Absence of [[malignant]] cells on [[peripheral blood smear]] | :* Absence of [[malignant]] cells on [[peripheral blood smear]] | ||
:* Absence of malignant cells on [[bone marrow]] [[biopsy]] | :* Absence of [[malignant]] cells on [[bone marrow]] [[biopsy]] | ||
===Management of Acute Adult T-cell Leukemia=== | ===Management of Acute Adult T-cell Leukemia=== | ||
* The first line chemotherapeutic regimens used for the initial management of adult T-cell leukemia include: | * The first line chemotherapeutic regimens used for the initial management of adult T-cell leukemia include: | ||
:* [[Cyclophosphamide]] {{and}} [[doxorubicin]] {{and}} [[vincristine]] {{and}} [[prednisone]] (CHOP) | :* [[Cyclophosphamide]] {{and}} [[doxorubicin]] {{and}} [[vincristine]] {{and}} [[prednisone]] ([[CHOP]]) | ||
:* Cyclophosphamide {{and}} doxorubicin {{and}} vincristine {{and}} [[etoposide]] {{and}} prednisone (CHOEP) | :* [[Cyclophosphamide]] {{and}} [[Doxorubicin hydrochloride|doxorubicin]] {{and}} [[Vincristine sulfate|vincristine]] {{and}} [[etoposide]] {{and}} [[prednisone]] ([[CHOEP regimen|CHOEP]]) | ||
:* Etoposide {{and}} prednisone {{and}} vincristine {{and}} cyclophosphamide {{and}} doxorubicin (Dose-adjusted EPOCH) | :* [[Etoposide]] {{and}} [[prednisone]] {{and}} [[Vincristine sulfate|vincristine]] {{and}} [[cyclophosphamide]] {{and}} [[Doxorubicin hydrochloride|doxorubicin]] ([[DA-EPOCH regimen|Dose-adjusted EPOCH]]) | ||
:* Cyclophosphamide {{and}} vincristine {{and}} doxorubicin {{and}} [[dexamethasone]] (HyperCVAD) alternating with high-dose [[methotrexate]] and [[cytarabine]] | :* [[Cyclophosphamide]] {{and}} [[Vincristine sulfate|vincristine]] {{and}} [[Doxorubicin hydrochloride|doxorubicin]] {{and}} [[dexamethasone]] (HyperCVAD) alternating with high-dose [[methotrexate]] and [[cytarabine]] | ||
* Consider | * Consider [[allogeneic stem cell transplantation]] for patients who respond to first line [[Chemotherapy|chemotherapeutic]] agents. | ||
* Patients who do not respond to the initial chemotherapeutic regimens may be managed by other second line chemotherapeutic agents such as: | * Patients who do not respond to the initial [[Chemotherapy|chemotherapeutic]] regimens may be managed by other second line [[Chemotherapy|chemotherapeutic]] agents such as: | ||
:* [[Bendamustine]] | :* [[Bendamustine]] | ||
:* [[Belinostat]] | :* [[Belinostat]] | ||
:* [[Dexamethasone]] {{and}} [[cisplatin]] {{and}} [[cytarabine]] (DHAP) | :* [[Dexamethasone]] {{and}} [[cisplatin]] {{and}} [[cytarabine]] ([[DHAP regimen|DHAP]]) | ||
:* [[Etoposide]] {{and}} [[methylprednisolone]] {{and}} [[cytarabine]] {{and}} [[cisplatin]] (ESHAP) | :* [[Etoposide]] {{and}} [[methylprednisolone]] {{and}} [[cytarabine]] {{and}} [[cisplatin]] ([[ESHAP regimen|ESHAP]]) | ||
:* [[Gemcitabine]] {{and}} [[dexamethasone]] {{and}} [[cisplatin]] (GDP) | :* [[Gemcitabine]] {{and}} [[dexamethasone]] {{and}} [[cisplatin]] (GDP) | ||
:* Gemcitabine {{and}} [[oxaliplatin]] (GemOx) | :* [[Gemcitabine]] {{and}} [[oxaliplatin]] (GemOx) | ||
:* Ifosfamide {{and}} [[carboplatin]] {{and}} [[etoposide]] (ICE) | :* [[Ifosfamide]] {{and}} [[carboplatin]] {{and}} [[etoposide]] (ICE) | ||
:* | :* [[Pralatrexate]] | ||
:* Romidepsin | :* [[Romidepsin]] | ||
* Consider allogeneic stem cell | * Consider [[allogeneic stem cell transplantation]] for patients who respond to second line [[Chemotherapy|chemotherapeutic]] agents. | ||
* Zidovudine and interferon combination therapy: | * [[Zidovudine]] and [[interferon]] combination therapy: | ||
:* Chronic/smoldering adult T-cell leukemia patients should be evaluated for response after two months of initiating the combination therapy. | :* Chronic/smoldering adult T-cell leukemia patients should be evaluated for response after two months of initiating the combination therapy. | ||
:* Patients who respond to the therapy may be further managed by either | :* Patients who respond to the therapy may be further managed by either [[allogeneic stem cell transplantation]] or continue on [[zidovudine]] and [[interferon]] combination therapy. | ||
:* | :* Patients who did not respond to the therapy, should be managed by either [[chemotherapy]] or supportive care depending on the patients preference. | ||
==Supportive Therapy== | ==Supportive Therapy== | ||
===Opportunistic Infections Prophylaxis=== | ===Opportunistic Infections Prophylaxis=== | ||
:* [[Sulfamethoxazole | :* [[Sulfamethoxazole-Trimethoprim|Sulfamethoxazole/trimethoprim]] prophylaxis is recommended among adult T-cell leukemia patients to protect against [[opportunistic infection]]s. | ||
==References== | ==References== | ||
Revision as of 16:10, 3 February 2019
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Haytham Allaham, M.D. [2]
Overview
The optimal therapy for adult T-cell leukemia depends on the clinical variant of the disease. Chronic and smoldering adult T-cell leukemia patients are usually managed by either observation, skin directed therapies, or a combination of zidovudine and interferon therapy. Acute adult T-cell leukemia patients are usually managed by either chemotherapy, supportive care, allogeneic stem cell transplant, or a combination of zidovudine and interferon therapy. While adult T-cell lymphoma patients are usually managed by either chemotherapy, supportive care, or allogeneic stem cell transplant.
Medical Therapy
The following are the various options for management of adult-T cell leukemia according to the National Comprehensive Cancer Network (NCCN) guidelines:[1][2]
- The optimal therapy for adult T-cell leukemia depends on the clinical variant of the disease.
- Chronic and smoldering adult T-cell leukemia patients are usually managed by either observation, skin directed therapies, or a combination of zidovudine and interferon therapy.[3]
- Acute adult T-cell leukemia patients are usually managed by either chemotherapy, supportive care, allogeneic stem cell transplant, or a combination of zidovudine and interferon therapy.
- Adult T-cell lymphoma patients are usually managed by either chemotherapy, supportive care, or allogeneic stem cell transplant.
Management of Chronic/Smoldering Adult T-cell Leukemia
- Patients may be managed by observation and close follow-up for any symptomatic deterioration. Follow up of such patients must include:
- A complete history and physical examination
- Serum calcium level
- Blood urea nitrogen
- Serum creatinine level
- Serum LDH
- Chest and abdominal CT scan
- Skin directed therapies for the management of localized cutaneous lesions among such patients may include:
- Topical corticosteroids
- Topical chemotherapy (mechlorethamine)
- Local radiotherapy (8–36 Gy)
- Topical retinoids (bexarotene, tazarotene)
- Phototherapy (UVB, NB-UVB for management of patch/thin plaques; PUVA for management of thicker plaques)
- Topical imiquimod
- Zidovudine and interferon combination therapy:
- Chronic/smoldering adult T-cell leukemia patients should be evaluated for response after two months of initiating the combination therapy.
- Patients who respond to the therapy should be continued on zidovudine and interferon therapy.
- Patients who did not respond to the therapy, should be managed by either chemotherapy or supportive care depending on the patients preference.
- The criteria for complete remission of adult T-cell leukemia patients includes:
- Absence of lymphadenopathy
- Absence of hepatomegaly and splenomegaly
- Absence of cutaneous lesions
- Absence of malignant cells on peripheral blood smear
- Absence of malignant cells on bone marrow biopsy
Management of Acute Adult T-cell Leukemia
- The first line chemotherapeutic regimens used for the initial management of adult T-cell leukemia include:
- Cyclophosphamide AND doxorubicin AND vincristine AND prednisone (CHOP)
- Cyclophosphamide AND doxorubicin AND vincristine AND etoposide AND prednisone (CHOEP)
- Etoposide AND prednisone AND vincristine AND cyclophosphamide AND doxorubicin (Dose-adjusted EPOCH)
- Cyclophosphamide AND vincristine AND doxorubicin AND dexamethasone (HyperCVAD) alternating with high-dose methotrexate and cytarabine
- Consider allogeneic stem cell transplantation for patients who respond to first line chemotherapeutic agents.
- Patients who do not respond to the initial chemotherapeutic regimens may be managed by other second line chemotherapeutic agents such as:
- Bendamustine
- Belinostat
- Dexamethasone AND cisplatin AND cytarabine (DHAP)
- Etoposide AND methylprednisolone AND cytarabine AND cisplatin (ESHAP)
- Gemcitabine AND dexamethasone AND cisplatin (GDP)
- Gemcitabine AND oxaliplatin (GemOx)
- Ifosfamide AND carboplatin AND etoposide (ICE)
- Pralatrexate
- Romidepsin
- Consider allogeneic stem cell transplantation for patients who respond to second line chemotherapeutic agents.
- Zidovudine and interferon combination therapy:
- Chronic/smoldering adult T-cell leukemia patients should be evaluated for response after two months of initiating the combination therapy.
- Patients who respond to the therapy may be further managed by either allogeneic stem cell transplantation or continue on zidovudine and interferon combination therapy.
- Patients who did not respond to the therapy, should be managed by either chemotherapy or supportive care depending on the patients preference.
Supportive Therapy
Opportunistic Infections Prophylaxis
- Sulfamethoxazole/trimethoprim prophylaxis is recommended among adult T-cell leukemia patients to protect against opportunistic infections.
References
- ↑ Adult T-Cell Leukemia/Lymphoma. NCCN Guidelines Version 2 (2015) http://www.nccn.org/professionals/physician_gls/PDF/nhl.pdf Accessed on January, 25 2016
- ↑ Hermine, Olivier; Bouscary, Didier; Gessain, Antoine; Turlure, Pascal; Leblond, Veronique; Franck, Nathalie; Buzyn-Veil, Agnes; Rio, Bernard; Macintyre, Elisabeth; Dreyfus, Francois; Bazarbachi, Ali (1995). "Treatment of Adult T-Cell Leukemia-Lymphoma with Zidovudine and Interferon Alfa". New England Journal of Medicine. 332 (26): 1749–1751. doi:10.1056/NEJM199506293322604. ISSN 0028-4793.
- ↑ Hermine, Olivier; Bouscary, Didier; Gessain, Antoine; Turlure, Pascal; Leblond, Veronique; Franck, Nathalie; Buzyn-Veil, Agnes; Rio, Bernard; Macintyre, Elisabeth; Dreyfus, Francois; Bazarbachi, Ali (1995). "Treatment of Adult T-Cell Leukemia-Lymphoma with Zidovudine and Interferon Alfa". New England Journal of Medicine. 332 (26): 1749–1751. doi:10.1056/NEJM199506293322604. ISSN 0028-4793.