Adult T-cell leukemia medical therapy
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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]; Grammar Reviewer: Natalie Harpenau, B.S.[3]
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. The first line chemotherapeutic regimens used for the initial management of adult T-cell leukemia include CHOP, CHOEP, or Dose-adjusted EPOCH. Second line chemotherapeutic agents might be DHAP, ESHAP, GDP, GemOx, or ICE.
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.