|LETTER TO EDITOR
|Year : 2022 | Volume
| Issue : 1 | Page : 153-154
Day 14 bone marrow response assessment in acute myeloid leukemia: Should we discontinue?
Shilpi Chaudhary, Shuvadeep Ganguly, Sameer Bakhshi
Department of Medical Oncology, Dr. B.R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
|Date of Submission||23-Jan-2022|
|Date of Decision||27-Jan-2022|
|Date of Acceptance||27-Jan-2022|
|Date of Web Publication||31-Mar-2022|
Department of Medical Oncology, Dr. B.R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
|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.,, 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. 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, the bone marrow was reported as inconclusive in only two patients. In a similar retrospective review of 586 adult patients, 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. 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.,
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. 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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