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Table of Contents
Year : 2022  |  Volume : 5  |  Issue : 1  |  Page : 153-154

Day 14 bone marrow response assessment in acute myeloid leukemia: Should we discontinue?

Department of Medical Oncology, Dr. B.R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India

Date of Submission23-Jan-2022
Date of Decision27-Jan-2022
Date of Acceptance27-Jan-2022
Date of Web Publication31-Mar-2022

Correspondence Address:
Sameer Bakhshi
Department of Medical Oncology, Dr. B.R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/crst.crst_44_22

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How to cite this article:
Chaudhary S, Ganguly S, Bakhshi S. Day 14 bone marrow response assessment in acute myeloid leukemia: Should we discontinue?. Cancer Res Stat Treat 2022;5:153-4

How to cite this URL:
Chaudhary S, Ganguly S, Bakhshi S. Day 14 bone marrow response assessment in acute myeloid leukemia: Should we discontinue?. Cancer Res Stat Treat [serial online] 2022 [cited 2022 May 21];5:153-4. Available from: https://www.crstonline.com/text.asp?2022/5/1/153/341286

The assessment of bone marrow response on day 14 of an induction course in acute myeloid leukemia (AML) is often the standard practice in many institutions, yet its clinical utility, especially for deciding re-induction, continues to remain controversial. In India, there are unique challenges in the management of AML due to the higher burden of induction mortality with resource constraints for optimum supportive care and increased risk of both bacterial and fungal infections.[1],[2],[3] The clinical evidence of day 14 bone marrow response assessment in such a setting has not been systematically examined; hence, the recent article by Manuprasad et al.[4] is an important addition to the literature.

In this study, the authors reported that the specificity of an inadequate bone marrow response on day 14 in predicting post-induction remission status was 89% with a positive predictive value of 100%, although this analysis did not include those who received a second induction or who had mortality, which limits the applicability of the conclusion. It is pertinent to note that, interpretation of the day 14 bone marrow response is often technically challenging due to significant hypocellularity. The cutoff for defining an inadequate response has also been variable across studies. In the above study,[2] the bone marrow was reported as inconclusive in only two patients. In a similar retrospective review of 586 adult patients,[5] 359 (61.2%) patients had less than 100 countable cells and the percentage of blasts could not be interpreted. Hence, interpreting the blast percentage in a significantly hypocellular marrow and subsequent clinical decisions based on the same should be done with caution.

Manuprasad et al. have not evaluated the impact of the day 14 bone marrow response on the long-term survival outcomes of the patients, which would have perhaps been more useful to help us reach a conclusion regarding the clinical utility of this practice. Even though patients requiring a second induction had inferior survival, the leukemia-free survival and relapse rates were similar. This makes the proportion of toxic deaths more concerning, especially while considering a second induction. In this study, less than half (9/19; 47%) were considered eligible for re-induction at day 14, which is likely to be similar in settings with higher infection burden and induction mortality.

A significant proportion (6/10; 60%) of patients with an inadequate response on day 14 achieved remission at count recovery, even without any further leukemia-directed therapy. A similar observation has also been reported by Yanada et al.[5] This may be partly due to slower kinetics of blast clearance or an incorrect interpretation of the blast percentage in a dilute marrow. Therefore, marrow assessment on day 14 is perhaps not useful for guiding the treatment decision of early re-induction in patients with AML, with similar views expressed by the authors and in the editorial as well.[4],[6]

Interestingly, it was observed in a recent study that not achieving a nadir absolute neutrophil count of zero was predictive of a lack of remission as well as poor long-term survival in relapsed AML.[7] Use of relatively less invasive tests like peripheral blood blast percentage on day 5 or monitoring for the nadir absolute neutrophil count may be more useful to evaluate as a predictor of remission/outcome rather than an invasive bone marrow evaluation that has minimal clinical utility.

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  References Top

Bahl A, Sharma A, Raina V, Kumar L, Bakhshi S, Gupta R, et al. Long-term outcomes for patients with acute myeloid leukemia: A single-center experience from AIIMS, India. Asia Pac J Clin Oncol 2015;11:242-52.  Back to cited text no. 1
Ghosh I, Raina V, Kumar L, Sharma A, Bakhshi S, Iqbal S. Serum galactomannan assay for diagnosis of probable invasive aspergillosis in acute leukemia and hematopoietic stem cell transplantation. Indian J Med Paediatr Oncol 2013;34:74-9.  Back to cited text no. 2
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Nayak L. Optimizing acute leukemia treatment in resource-constrained settings. Cancer Res Stat Treat 2020;3:287-9.  Back to cited text no. 3
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Manuprasad A, Raghavan V, Shenoy P, Krishnan A, Nair C. The utility of day 14 bone marrow response assessment in patients undergoing acute myeloid leukemia induction: A single institution retrospective experience. Cancer Res Stat Treat 2021;4:628-33.  Back to cited text no. 4
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Yanada M, Borthakur G, Ravandi F, Bueso-Ramos C, Kantarjian H, Estey E. Kinetics of bone marrow blasts during induction and achievement of complete remission in acute myeloid leukemia. Haematologica 2008;93:1263-5.  Back to cited text no. 5
Mirgh S. (F) utility of day 14 bone marrow in acute myeloid leukemia on 3+7 induction – Is it time to bid adieu to day 14 bone marrow? Cancer Res Stat Treat 2021;4:731-3.  Back to cited text no. 6
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Garg A, Ganguly S, Vishnubhatla S, Chopra A, Bakhshi S. Outpatient ADE (cytarabine, daunorubicin, and etoposide) is feasible and effective for the first relapse of pediatric acute myeloid leukemia: A prospective, phase II study. Pediatr Blood Cancer 2020;67:e28404.  Back to cited text no. 7


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