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Table of Contents
Year : 2022  |  Volume : 5  |  Issue : 1  |  Page : 155-156

The day 14 conundrum still remains unresolved!

Department of Medical Oncology, Sri Ram Cancer Center, Mahatma Gandhi Medical College Hospital, Jaipur, Rajasthan, India

Date of Submission24-Jan-2022
Date of Decision25-Jan-2022
Date of Acceptance26-Jan-2022
Date of Web Publication31-Mar-2022

Correspondence Address:
Hemant Malhotra
Department of Medical Oncology, Sri Ram Cancer Center, Mahatma Gandhi Medical College Hospital, Jaipur, Rajasthan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/crst.crst_49_22

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How to cite this article:
Soni P, Gupta N, Malhotra H. The day 14 conundrum still remains unresolved!. Cancer Res Stat Treat 2022;5:155-6

How to cite this URL:
Soni P, Gupta N, Malhotra H. The day 14 conundrum still remains unresolved!. Cancer Res Stat Treat [serial online] 2022 [cited 2022 May 28];5:155-6. Available from: https://www.crstonline.com/text.asp?2022/5/1/155/341287

We read with interest the article titled, “The utility of day 14 bone marrow response assessment in patients undergoing acute myeloid leukemia induction: A single-institution retrospective experience,” by Manuprasad et al.[1] This article contributes important Indian data about the clinical implication of the day 14 bone marrow examination in patients with acute myeloid leukemia (AML).

The authors have presented an excellent interpretation of the data which replicates the results of previous studies.[2],[3] It is important to re-evaluate the practice of doing a day 14 bone marrow assessment to aid the clinical decision-making process and to improve the outcomes in AML. The authors have expressed concerns about the low specificity of the day 14 marrow examination. In the accompanying editorial, Mirgh has eloquently discussed the subject matter and highlighted the shortcomings of the study (retrospective nature, observer bias in marrow assessment, lack of conventional cytogenetics, and a lack of uniformity in the choice of second induction).[4] As he rightly pointed out, the available evidence does not make a strong case for performing a day 14 marrow examination in all patients undergoing intensive induction. An additional point to be kept in mind is the inconvenience and discomfort to the patient and the technical expertise and experience needed by the hematopathologist to search for and count the blasts in a grossly hypocellular marrow.

What is the way is the way forward for this tool in the modern day management of AML? We wish to suggest some directions which may be explored in future studies. First, the incorporation of minimal residual disease (MRD). While mid-induction and post-induction MRD assessment is the standard of care in lymphoblastic leukemia,[5] the same cannot be said of AML yet as there has been a lack of consensus for the interpretation and implications of the same. The recently published European Leukemia Network consensus document may serve to standardize the practice of MRD assessment in AML.[6] Future studies may explore whether the assessment of MRD on day 14 could serve as a tool for prognostication and a guide for escalation or de-escalation of treatment intensity.[7] Second, as genetic and molecular assessment becomes more readily accessible in India, it would be interesting to observe the kinetics of disease clearance of the various genetic subtypes during intensive induction therapy. Last, the management of AML is making its long-awaited move beyond the standard 3 + 7 regimen into the realm of novel targeted treatments. Mid-induction measurement of residual disease may be used to fine-tune these treatment regimens (e.g., truncation of dose and duration of venetoclax in patients who show a good response).

In its current avatar, we believe that the day 14 marrow assessment should be limited to those patients who are fit to receive a second induction and as a part of prospectively planned clinical trials. However, a lack of uniformity in clinical practice is expected to remain in the near future. The only thing we can all agree upon is that we have not yet heard the last on this contentious issue! It would be good for Indian cooperative groups to collaborate and conduct prospective multicenter studies using uniform second induction regimens.[8] It would also be important to compare this with MRD assessments, both on day 14 and post-induction. This will help us in evaluating this parameter in order to formulate scientific recommendations for its use, especially in resource-limited settings.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Manuprasad A, Raghavan V, Shenoy PK, Krishnan A, Nair CK. 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. 1
  [Full text]  
Alsaleh K, Aleem A, Almomen A, Anjum F, Alotaibi GS. Impact of day 14 bone marrow biopsy on re-induction decisions and prediction of a complete response in acute myeloid leukemia cases. Asian Pac J Cancer Prev 2018;19:421-5.  Back to cited text no. 2
Nataraj KS, Mandal PK, Ghosh MK, Bhattacharyya M. Does day 14 bone marrow status predict response to chemotherapy in acute myeloid leukemia? Experience of a hemato-oncology care center from Eastern India. Clin Cancer Investig J 2020;9:221-6.  Back to cited text no. 3
  [Full text]  
Mirgh S. Futility 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. 4
  [Full text]  
Pandey A, Ahlawat S, Singh A, Singh S, Murari K, Aryan R. Outcomes and impact of Minimal Residual Disease (MRD) in pediatric, Adolescent And Young Adults (AYA) with acute lymphoblastic leukemia treated with modified MCP 841 protocol. Cancer Res Stat Treat 2020;3:183-91.  Back to cited text no. 5
  [Full text]  
Schuurhuis GJ, Heuser M, Freeman S, Béné MC, Buccisano F, Cloos J, et al. Minimal/measurable residual disease in AML: A consensus document from the European leukemianet MRD working party. Blood 2018;131:1275-91.  Back to cited text no. 6
Martín-Rojas RM, Badiola J, De Tena PS, Pérez-Corral A, Gómez-Centurión I, Rodríguez-Macias G, et al. Day 14 measurable residual disease as a predictor of post-induction response in patients with acute myeloid leukemia. Blood 2021;138 Suppl 1:1287.  Back to cited text no. 7
Noronha V. Making a case for cancer research in India. Cancer Res Stat Treat 2018;1:71-4.  Back to cited text no. 8
  [Full text]  


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