Disseminated intravascular coagulation (DIC) occurs about 10% of adult patients with acute lymphoblastic leukemia (ALL) at presentation, and develops in approximately 30-40% of adult patients after starting induction therapy. Although reports of DIC developing with a high frequency in Philadelphia chromosome-positive (Ph+) ALL are scarce, we have experienced many cases of DIC in Ph+ ALL patients.
We start chemotherapy and prednisolone (PSL) at the same time after diagnosis of ALL, and give imatinib (IM) at the time it is found to be Ph+. However, we have experienced cases of early death due to severe DIC and tumor lysis syndrome (TLS) when utilizing this approach. Therefore, we have tried mild tumor reduction via initiation of PSL, IM and chemotherapy at different times.
We investigated the difference in the incidence of DIC between Ph+ ALL patients and Ph negative (Ph-) ALL patients and discuss the management of DIC and its effect.
Patients and methods
We examined ALL patients who received their first treatment at our institution between January 2012 and December 2014.
We monitored for DIC by twice daily blood testing, and diagnosed DIC according to the diagnostic criteria for DIC of the Japanese Ministry of Health, Labour and Welfare. When DIC developed, the patients were encouraged to rest, and we treated DIC with recombinant human soluble thrombomodulin (rTM) and/or gabexate mesylsate (FOY). To prevent bleeding episodes, platelet (Plt) and fresh frozen plasma transfusion were given to maintain Plt count >50,000/ul and fibrinogen (Fib) level >100 mg/dl.
For induction therapy, to avoid rapid development of DIC and TLS, we first administered PSL 60 mg/m2. While confirming a decrease in leukocyte counts and fibrin degradation products (FDP), we started IM followed by chemotherapy (daunorubicin + vincristine + cyclophosphamide + L-asparaginase) in Ph+ ALL patients. We began PSL followed by the same chemotherapy in Ph- ALL patients as well. We used rasburicase to prevent TLS.
A total of 35 patients with newly diagnosed ALL were examined: 18 patients were Ph+ and 17 were Ph-. The incidence of DIC was 82.3% (14/17) in Ph+ patients and 38.9% (7/18) in Ph- patients. The group with Ph+ showed a significantly higher rate of DIC (p value = 0.015). Duration of the treatment of DIC was 4-14 days (median, 10 days) in Ph+ patients, and 3-10 days (median, 5 days) in Ph- patients. The group with Ph+ also showed significantly longer duration of treatment (p value = 0.02).
Twelve Ph+ patients developed DIC (two patients were excluded because of treatment that was different from that described above); five were men and seven were women. Median age was 61 years (range, 34-78 years). Leukocyte counts at the time of diagnosis were 4400-542100 /ul (median 34400 /ul), hemoglobin value was 6.4-15.6 g/dl (median 11.6, g/dl), Plt counts were 6000-262000 /ul (median, 56000 /ul), Fib value was 199-707 mg/dl (median, 299 mg/dl), and FDP value was 3.4-45.7 ug/ml (median, 9.7 ug/ml). DIC occurred at 1-8 days (median, 3 days) from diagnosis. One patient (8%) had DIC at presentation, and the remaining 11 patients (92%) had DIC after the initiation of induction therapy. We started IM at day 3-6 (median, day 5), DIC developed in two patients starting IM, and chemotherapy was started at day 5-10 (median, day 7). Only one patient had slight elevation of FDP, and this value decreased in a progressive fashion in the remaining 11 patients. The maximum FDP value during the treatment of DIC was 32-1162.8 ug/ml (median, 140 ug/ml). We treated DIC with FOY single agent (one patient) or a combination of rTM and FOY (10 patients); all patients showed improvement. The period for improvement of DIC was 4-14 days (median, 8 days), and none of the patients had bleeding or organ damage. Only one patient had TLS, but it immediately improved. In these Ph+ patients, 11/12 patients (92%) achieved complete remission (CR), and one patient had partial remission. Further, 5/5 patients (100%) achieved CR, and none had TLS in the group with Ph-.
DIC occurred at a high incidence in Ph+ ALL patients. By starting PSL, IM, and chemotherapy at the right time, we can perform induction therapy without generating serious complication due to DIC.
No relevant conflicts of interest to declare.
Asterisk with author names denotes non-ASH members.