Minimal residual disease, long-term outcome, and IKZF1 deletions in children and adolescents with Down syndrome and acute lymphocytic leukaemia: a matched cohort study

Naomi Michels; Judith M Boer; Amir Enshaei; Rosemary Sutton; Mats Heyman; Sabine Ebert; Marta Fiocco; Hester A de Groot-Kruseman; Vincent H J van der Velden; Gisela Barbany; Gabriele Escherich; Ajay Vora; Toby Trahair; Luciano Dalla-Pozza; Rob Pieters; Udo Zur Stadt; Kjeld Schmiegelow; Anthony V Moorman; C Michel Zwaan; Monique L den Boer

doi:10.1016/S2352-3026(21)00272-6

Minimal residual disease, long-term outcome, and IKZF1 deletions in children and adolescents with Down syndrome and acute lymphocytic leukaemia: a matched cohort study

Standard

Minimal residual disease, long-term outcome, and IKZF1 deletions in children and adolescents with Down syndrome and acute lymphocytic leukaemia: a matched cohort study. / Michels, Naomi; Boer, Judith M; Enshaei, Amir; Sutton, Rosemary; Heyman, Mats; Ebert, Sabine; Fiocco, Marta; de Groot-Kruseman, Hester A; van der Velden, Vincent H J; Barbany, Gisela; Escherich, Gabriele; Vora, Ajay; Trahair, Toby; Dalla-Pozza, Luciano; Pieters, Rob; Zur Stadt, Udo; Schmiegelow, Kjeld; Moorman, Anthony V; Zwaan, C Michel; den Boer, Monique L.

In: LANCET HAEMATOL, Vol. 8, No. 10, 10.2021, p. e700-e710.

Research output: SCORING: Contribution to journal › SCORING: Journal article › Research › peer-review

Harvard

Michels, N, Boer, JM, Enshaei, A, Sutton, R, Heyman, M, Ebert, S, Fiocco, M, de Groot-Kruseman, HA, van der Velden, VHJ, Barbany, G, Escherich, G, Vora, A, Trahair, T, Dalla-Pozza, L, Pieters, R, Zur Stadt, U, Schmiegelow, K, Moorman, AV, Zwaan, CM & den Boer, ML 2021, 'Minimal residual disease, long-term outcome, and IKZF1 deletions in children and adolescents with Down syndrome and acute lymphocytic leukaemia: a matched cohort study', LANCET HAEMATOL, vol. 8, no. 10, pp. e700-e710. https://doi.org/10.1016/S2352-3026(21)00272-6

APA

Michels, N., Boer, J. M., Enshaei, A., Sutton, R., Heyman, M., Ebert, S., Fiocco, M., de Groot-Kruseman, H. A., van der Velden, V. H. J., Barbany, G., Escherich, G., Vora, A., Trahair, T., Dalla-Pozza, L., Pieters, R., Zur Stadt, U., Schmiegelow, K., Moorman, A. V., Zwaan, C. M., & den Boer, M. L. (2021). Minimal residual disease, long-term outcome, and IKZF1 deletions in children and adolescents with Down syndrome and acute lymphocytic leukaemia: a matched cohort study. LANCET HAEMATOL, 8(10), e700-e710. https://doi.org/10.1016/S2352-3026(21)00272-6

Vancouver

Michels N, Boer JM, Enshaei A, Sutton R, Heyman M, Ebert S et al. Minimal residual disease, long-term outcome, and IKZF1 deletions in children and adolescents with Down syndrome and acute lymphocytic leukaemia: a matched cohort study. LANCET HAEMATOL. 2021 Oct;8(10):e700-e710. https://doi.org/10.1016/S2352-3026(21)00272-6

Bibtex

@article{aa39d2cbcc3e478c8e3df5ab52a1e278,

title = "Minimal residual disease, long-term outcome, and IKZF1 deletions in children and adolescents with Down syndrome and acute lymphocytic leukaemia: a matched cohort study",

abstract = "BACKGROUND: Patients with Down syndrome and acute lymphocytic leukaemia are at an increased risk of treatment-related mortality and relapse, which is influenced by unfavourable genetic aberrations (eg, IKZF1 deletion). We aimed to investigate the potential underlying effect of Down syndrome versus the effects of adverse cancer genetics on clinical outcome.METHOD: Patients (aged 1-23 years) with Down syndrome and acute lymphocytic leukaemia and matched non-Down syndrome patients with acute lymphocytic leukaemia (matched controls) from eight trials (DCOG ALL10 and ALL11, ANZCHOG ALL8, AIEOP-BFM ALL2009, UKALL2003, NOPHO ALL2008, CoALL 07-03, and CoALL 08-09) done between 2002 and 2018 across various countries (the Netherlands, the UK, Australia, Denmark, Finland, Iceland, Norway, Sweden, and Germany) were included. Participants were matched (1:3) for clinical risk factors and genetics, including IKZF1 deletion. The primary endpoint was the comparison of MRD levels (absolute MRD levels were categorised into two groups, low [<0·0001] and high [≥0·0001]) between patients with Down syndrome and acute lymphocytic leukaemia and matched controls, and the secondary outcomes were comparison of long-term outcomes (event-free survival, overall survival, relapse, and treatment-related mortality [TRM]) between patients with Down syndrome and acute lymphocytic leukaemia and matched controls. Two matched cohorts were formed: for MRD analyses and for long-term outcome analyses. For both cohorts, matching was based on induction regimen; for the long-term outcome cohort, matching also included MRD-guided treatment group. We used mixed-effect models, Cox models, and competing risk for statistical analyses.FINDINGS: Of 251 children and adolescents with Down syndrome and acute lymphocytic leukaemia, 136 were eligible for analyses and matched to 407 (of 8426) non-Down syndrome patients with acute lymphocytic leukaemia (matched controls). 113 patients with Down syndrome and acute lymphocytic leukaemia were excluded from matching in accordance with predefined rules, no match was available for two patients with Down syndrome and acute lymphocytic leukaemia. The proportion of patients with high MRD at the end of induction treatment was similar for patients with Down syndrome and acute lymphocytic leukaemia (52 [38%] of 136) and matched controls (157 [39%] of 403; OR 0·97 [95% CI 0·64-1·46]; p=0·88). Patients with Down syndrome and acute lymphocytic leukaemia had a higher relapse risk than did matched controls in the IKZF1 deleted group (relapse at 5 years 37·1% [17·1-57·2] vs 13·2% [6·1-23·1]; cause-specific hazard ratio [HRcs] 4·3 [1·6-11·0]; p=0·0028), but not in the IKZF1 wild-type group (relapse at 5 years 5·8% [2·1-12·2] vs 8·1% [5·1-12·0]; HRcs 1·0 [0·5-2·1]; p=0·99). In addition to increased induction deaths (15 [6%] of 251 vs 69 [0·8%] of 8426), Down syndrome and acute lymphocytic leukaemia was associated with a higher risk of post-induction TRM compared with matched controls (TRM at 5 years 12·2% [7·0-18·9] vs 2·7% [1·3-4·9]; HRcs 5·0 [2·3-10·8]; p<0·0001).INTERPRETATION: Induction treatment is equivalently effective for patients with Down syndrome and acute lymphocytic leukaemia and for matched patients without Down syndrome. Down syndrome itself provides an additional risk in individuals with IKZF1 deletions, suggesting an interplay between the germline environment and this poor risk somatic aberration. Different treatment strategies are warranted considering both inherent risk of relapse and high risk of TRM.FUNDING: Stichting Kinder Oncologisch Centrum Rotterdam and the Princess M{\'a}xima Center Foundation, NHMRC Australia, The Cancer Council NSW, Tour de Cure, Blood Cancer UK, UK Medical Research Council, Children with Cancer, Swedish Society for Pediatric Cancer, Swedish Childhood Cancer Fund, Danish Cancer Society and the Danish Childhood Cancer Foundation.",

keywords = "Adolescent, Child, Child, Preschool, Cohort Studies, Disease-Free Survival, Down Syndrome/complications, Female, Gene Deletion, Humans, Ikaros Transcription Factor/deficiency, Male, Neoplasm, Residual, Precursor Cell Lymphoblastic Leukemia-Lymphoma/complications",

author = "Naomi Michels and Boer, {Judith M} and Amir Enshaei and Rosemary Sutton and Mats Heyman and Sabine Ebert and Marta Fiocco and {de Groot-Kruseman}, {Hester A} and {van der Velden}, {Vincent H J} and Gisela Barbany and Gabriele Escherich and Ajay Vora and Toby Trahair and Luciano Dalla-Pozza and Rob Pieters and {Zur Stadt}, Udo and Kjeld Schmiegelow and Moorman, {Anthony V} and Zwaan, {C Michel} and {den Boer}, {Monique L}",

year = "2021",

month = oct,

doi = "10.1016/S2352-3026(21)00272-6",

language = "English",

volume = "8",

pages = "e700--e710",

journal = "LANCET HAEMATOL",

issn = "2352-3026",

publisher = "Lancet Publishing Group",

number = "10",

}

RIS

TY - JOUR

T1 - Minimal residual disease, long-term outcome, and IKZF1 deletions in children and adolescents with Down syndrome and acute lymphocytic leukaemia: a matched cohort study

AU - Michels, Naomi

AU - Boer, Judith M

AU - Enshaei, Amir

AU - Sutton, Rosemary

AU - Heyman, Mats

AU - Ebert, Sabine

AU - Fiocco, Marta

AU - de Groot-Kruseman, Hester A

AU - van der Velden, Vincent H J

AU - Barbany, Gisela

AU - Escherich, Gabriele

AU - Vora, Ajay

AU - Trahair, Toby

AU - Dalla-Pozza, Luciano

AU - Pieters, Rob

AU - Zur Stadt, Udo

AU - Schmiegelow, Kjeld

AU - Moorman, Anthony V

AU - Zwaan, C Michel

AU - den Boer, Monique L

PY - 2021/10

Y1 - 2021/10

N2 - BACKGROUND: Patients with Down syndrome and acute lymphocytic leukaemia are at an increased risk of treatment-related mortality and relapse, which is influenced by unfavourable genetic aberrations (eg, IKZF1 deletion). We aimed to investigate the potential underlying effect of Down syndrome versus the effects of adverse cancer genetics on clinical outcome.METHOD: Patients (aged 1-23 years) with Down syndrome and acute lymphocytic leukaemia and matched non-Down syndrome patients with acute lymphocytic leukaemia (matched controls) from eight trials (DCOG ALL10 and ALL11, ANZCHOG ALL8, AIEOP-BFM ALL2009, UKALL2003, NOPHO ALL2008, CoALL 07-03, and CoALL 08-09) done between 2002 and 2018 across various countries (the Netherlands, the UK, Australia, Denmark, Finland, Iceland, Norway, Sweden, and Germany) were included. Participants were matched (1:3) for clinical risk factors and genetics, including IKZF1 deletion. The primary endpoint was the comparison of MRD levels (absolute MRD levels were categorised into two groups, low [<0·0001] and high [≥0·0001]) between patients with Down syndrome and acute lymphocytic leukaemia and matched controls, and the secondary outcomes were comparison of long-term outcomes (event-free survival, overall survival, relapse, and treatment-related mortality [TRM]) between patients with Down syndrome and acute lymphocytic leukaemia and matched controls. Two matched cohorts were formed: for MRD analyses and for long-term outcome analyses. For both cohorts, matching was based on induction regimen; for the long-term outcome cohort, matching also included MRD-guided treatment group. We used mixed-effect models, Cox models, and competing risk for statistical analyses.FINDINGS: Of 251 children and adolescents with Down syndrome and acute lymphocytic leukaemia, 136 were eligible for analyses and matched to 407 (of 8426) non-Down syndrome patients with acute lymphocytic leukaemia (matched controls). 113 patients with Down syndrome and acute lymphocytic leukaemia were excluded from matching in accordance with predefined rules, no match was available for two patients with Down syndrome and acute lymphocytic leukaemia. The proportion of patients with high MRD at the end of induction treatment was similar for patients with Down syndrome and acute lymphocytic leukaemia (52 [38%] of 136) and matched controls (157 [39%] of 403; OR 0·97 [95% CI 0·64-1·46]; p=0·88). Patients with Down syndrome and acute lymphocytic leukaemia had a higher relapse risk than did matched controls in the IKZF1 deleted group (relapse at 5 years 37·1% [17·1-57·2] vs 13·2% [6·1-23·1]; cause-specific hazard ratio [HRcs] 4·3 [1·6-11·0]; p=0·0028), but not in the IKZF1 wild-type group (relapse at 5 years 5·8% [2·1-12·2] vs 8·1% [5·1-12·0]; HRcs 1·0 [0·5-2·1]; p=0·99). In addition to increased induction deaths (15 [6%] of 251 vs 69 [0·8%] of 8426), Down syndrome and acute lymphocytic leukaemia was associated with a higher risk of post-induction TRM compared with matched controls (TRM at 5 years 12·2% [7·0-18·9] vs 2·7% [1·3-4·9]; HRcs 5·0 [2·3-10·8]; p<0·0001).INTERPRETATION: Induction treatment is equivalently effective for patients with Down syndrome and acute lymphocytic leukaemia and for matched patients without Down syndrome. Down syndrome itself provides an additional risk in individuals with IKZF1 deletions, suggesting an interplay between the germline environment and this poor risk somatic aberration. Different treatment strategies are warranted considering both inherent risk of relapse and high risk of TRM.FUNDING: Stichting Kinder Oncologisch Centrum Rotterdam and the Princess Máxima Center Foundation, NHMRC Australia, The Cancer Council NSW, Tour de Cure, Blood Cancer UK, UK Medical Research Council, Children with Cancer, Swedish Society for Pediatric Cancer, Swedish Childhood Cancer Fund, Danish Cancer Society and the Danish Childhood Cancer Foundation.

AB - BACKGROUND: Patients with Down syndrome and acute lymphocytic leukaemia are at an increased risk of treatment-related mortality and relapse, which is influenced by unfavourable genetic aberrations (eg, IKZF1 deletion). We aimed to investigate the potential underlying effect of Down syndrome versus the effects of adverse cancer genetics on clinical outcome.METHOD: Patients (aged 1-23 years) with Down syndrome and acute lymphocytic leukaemia and matched non-Down syndrome patients with acute lymphocytic leukaemia (matched controls) from eight trials (DCOG ALL10 and ALL11, ANZCHOG ALL8, AIEOP-BFM ALL2009, UKALL2003, NOPHO ALL2008, CoALL 07-03, and CoALL 08-09) done between 2002 and 2018 across various countries (the Netherlands, the UK, Australia, Denmark, Finland, Iceland, Norway, Sweden, and Germany) were included. Participants were matched (1:3) for clinical risk factors and genetics, including IKZF1 deletion. The primary endpoint was the comparison of MRD levels (absolute MRD levels were categorised into two groups, low [<0·0001] and high [≥0·0001]) between patients with Down syndrome and acute lymphocytic leukaemia and matched controls, and the secondary outcomes were comparison of long-term outcomes (event-free survival, overall survival, relapse, and treatment-related mortality [TRM]) between patients with Down syndrome and acute lymphocytic leukaemia and matched controls. Two matched cohorts were formed: for MRD analyses and for long-term outcome analyses. For both cohorts, matching was based on induction regimen; for the long-term outcome cohort, matching also included MRD-guided treatment group. We used mixed-effect models, Cox models, and competing risk for statistical analyses.FINDINGS: Of 251 children and adolescents with Down syndrome and acute lymphocytic leukaemia, 136 were eligible for analyses and matched to 407 (of 8426) non-Down syndrome patients with acute lymphocytic leukaemia (matched controls). 113 patients with Down syndrome and acute lymphocytic leukaemia were excluded from matching in accordance with predefined rules, no match was available for two patients with Down syndrome and acute lymphocytic leukaemia. The proportion of patients with high MRD at the end of induction treatment was similar for patients with Down syndrome and acute lymphocytic leukaemia (52 [38%] of 136) and matched controls (157 [39%] of 403; OR 0·97 [95% CI 0·64-1·46]; p=0·88). Patients with Down syndrome and acute lymphocytic leukaemia had a higher relapse risk than did matched controls in the IKZF1 deleted group (relapse at 5 years 37·1% [17·1-57·2] vs 13·2% [6·1-23·1]; cause-specific hazard ratio [HRcs] 4·3 [1·6-11·0]; p=0·0028), but not in the IKZF1 wild-type group (relapse at 5 years 5·8% [2·1-12·2] vs 8·1% [5·1-12·0]; HRcs 1·0 [0·5-2·1]; p=0·99). In addition to increased induction deaths (15 [6%] of 251 vs 69 [0·8%] of 8426), Down syndrome and acute lymphocytic leukaemia was associated with a higher risk of post-induction TRM compared with matched controls (TRM at 5 years 12·2% [7·0-18·9] vs 2·7% [1·3-4·9]; HRcs 5·0 [2·3-10·8]; p<0·0001).INTERPRETATION: Induction treatment is equivalently effective for patients with Down syndrome and acute lymphocytic leukaemia and for matched patients without Down syndrome. Down syndrome itself provides an additional risk in individuals with IKZF1 deletions, suggesting an interplay between the germline environment and this poor risk somatic aberration. Different treatment strategies are warranted considering both inherent risk of relapse and high risk of TRM.FUNDING: Stichting Kinder Oncologisch Centrum Rotterdam and the Princess Máxima Center Foundation, NHMRC Australia, The Cancer Council NSW, Tour de Cure, Blood Cancer UK, UK Medical Research Council, Children with Cancer, Swedish Society for Pediatric Cancer, Swedish Childhood Cancer Fund, Danish Cancer Society and the Danish Childhood Cancer Foundation.

KW - Adolescent

KW - Child

KW - Child, Preschool

KW - Cohort Studies

KW - Disease-Free Survival

KW - Down Syndrome/complications

KW - Female

KW - Gene Deletion

KW - Humans

KW - Ikaros Transcription Factor/deficiency

KW - Male

KW - Neoplasm, Residual

KW - Precursor Cell Lymphoblastic Leukemia-Lymphoma/complications

U2 - 10.1016/S2352-3026(21)00272-6

DO - 10.1016/S2352-3026(21)00272-6

M3 - SCORING: Journal article

C2 - 34560013

VL - 8

SP - e700-e710

JO - LANCET HAEMATOL

JF - LANCET HAEMATOL

SN - 2352-3026

IS - 10

ER -