Chronic Myelogenous Supportive Care in Pediatric Oncology irantextbook.ir 93df

alkalinization due to potential risk of calcium phosphate precipitation are not recommended Coiffi er et al. 2008 ; Tosi et al. 2008 ; Howard et al. 2011 ; Vaitkevičienė et al. 2013 . Rasburicase is contraindicated in patients with glucose- 6-phosphate dehydrogenase G6PD defi ciency and methemoglobinemia Tosi et al. 2008 ; Cairo et al. 2010 ; Howard et al. 2011 ; Vaitkevičienė et al. 2013 .

6.7 Leukapheresis

The most recent recommendations by the American Society for Apheresis ASFA suggest leukapheresis as fi rst-line therapy for patients with leukostasis secondary to HL due to the potential to impact early death, although long- term outcome is unaffected Schwartz et al. 2013 . However, the potential to impact early death through leukapheresis was not shown in a meta-analysis of AML studies by Oberoi et al. 2014 . The role of apheresis as leukostasis pro- phylaxis with HL is not established but may be considered Schwartz et al. 2013 . Per the ASFA guidelines, the utilization of leukapheresis is listed as a strong recommendation with moder- ate-quality evidence for treatment of leukostasis symptoms and should be considered as a weak recommendation for leukostasis prophylaxis in higher-risk AML patients e.g., M4M5 sub- types, rapidly rising blast count with WBC 100 × 10 9 L and ALL patients with WBC 400 × 10 9 L Schwartz et al. 2013 . Per the ASFA guidelines, leukapheresis should not be utilized solely for the prevention or treatment of TLS in patients with HL Schwartz et al. 2013 . These recommendations are unchanged from the previous 2007 and 2010 ASFA guidelines Szczepiorkowski et al. 2007 , 2010 . No specifi c contraindication to the use of leukapheresis in APL patients is included in these guidelines although it is mentioned as a relative contraindi- cation in other guidelines due to the theoretical risk of worsening DIC and the increasing risk of ICH with lysis of leukemic promyelocytes Blum and Porcu 2007 ; Szczepiorkowski et al. 2007 ; Sanz et al. 2009 ; Szczepiorkowski et al. 2010 ; Zuckerman et al. 2012 ; Kim and Sloan 2013 ; Schwartz et al. 2013 . Data to support this contraindication are limited to one small study in which a majority of patients undergoing leu- kapheresis for HL had an adverse event that was not temporally related to the leukapheresis pro- cedure Vahdat et al. 1994 ; Tallman and Altman 2009 . Strauss et al. 1985 successfully per- formed exchange transfusion on a 2-year-old child with APL and a presenting WBC count of 617 × 10 9 L. Zuckerman et al. 2012 recom- mend leukapheresis in symptomatic adult AML patients with WBC 50 × 10 9 L and in symptom- atic ALL and CML adult patients with WBC 150 × 10 9 L. Additionally, although stating a lack of evidence, they recommend leukapheresis in asymptomatic adult AML patients with WBC 100 × 10 9 L to prevent leukostasis and asymp- tomatic adult ALL patients with WBC 300 × 10 9 L to prevent TLS. Whether leukapheresis is an effective modality to reduce early mortality is controversial. McCarthy et al. 1997 studied 48 unselected adult and pediatric patients with WBC 100 × 10 9 L who were leukoreduced and found no statistical difference in early mortality rate compared with similar unselected patients who were not leukoreduced. Porcu et al. 1997 simi- larly showed that effective leukapheresis did not impact early mortality in adult patients, especially those presenting with symptoms of leukostasis. Additional adult studies, mainly with AML patients, have had similar fi ndings Tan et al. 2005 ; Chang et al. 2007 ; De Santis et al. 2011 . Others have found a signifi cant improvement in early death rate in adult AML cohorts receiving leukapheresis without impact on overall survival Thiébaut et al. 2000 ; Giles et al. 2001 ; Bug et al. 2007 . Although multiple case reports and case series are available in the pediatric literature in regard to the effectiveness of exchange transfu- sion and leukapheresis in HL, signifi cant pediatric data on resultant early mortality and long-term outcomes, especially in AML, are lacking Carpentieri et al. 1979 ; Kamen et al. 1980 ; Shende et al. 1981 ; Warrier et al. 1981 ; Del Vasto et al. 1982 ; Strauss et al. 1985 ; Bunin et al. 1987 ; Sykes et al. 2011 . Potential complications from