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Initial Respiratory Status in Acute Myeloid Leukemia With Pulmonary Leukostasis: Prognostic Significance and Effect of Leukapheresis FREE TO VIEW

Ruchi Desai, MD; Coursen Schneider, MD; David Claxton, MD; Andry Van de Louw, MD
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Penn State Milton S Hershey Medical Center and College of Medicine, Hershey, PA

Chest. 2015;148(4_MeetingAbstracts):196A. doi:10.1378/chest.2231350
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SESSION TITLE: Critical Care - It's Not Just the Lungs

SESSION TYPE: Original Investigation Slide

PRESENTED ON: Monday, October 26, 2015 at 07:30 AM - 08:30 AM

PURPOSE: In acute myeloid leukemia (AML), hyperleukocytosis is associated with pulmonary leukostasis and increased mortality. Leukapheresis has been proposed to reduce white blood cell count (WBC) and improve leukostasis, but remains controversial. In AML patients requiring leukapheresis for pulmonary leukostasis, we assessed whether initial respiratory status was 1) related to survival and 2) improved by leukapheresis.

METHODS: Retrospective chart review between 2003 and 2013. Demographic, clinical and biological data were reviewed before and within 24 hours after leukapheresis. Respiratory status was defined as 0= no oxygen; 1= oxygen nasal cannula; 2= high flow oxygen; 3= noninvasive mechanical ventilation; 4= invasive mechanical ventilation. A Wilcoxon signed ranks test and a Kaplan-Meier survival analysis were used to assess the relationship between respiratory status, leukapheresis and survival. Results were expressed as median (range).

RESULTS: Eighty one patients (48 males, 33 females) were included, aged 57 (19-87) years, with a WBC of 152.6 (55.6-475).109/L, decreasing to 60.3 (16.8-259.4).109/L after the first leukapheresis (p<0.01). Patients underwent 1 (n=55), 2 (n=19), 3 (n=5) or 4 (n=2) leukapheresis. Respiratory status was 0 (n=39), 1 (n=27), 2 (n=6), 3 (n=2) or 4 (n=7) before first leukapheresis and significantly deteriorated after either leukapheresis 1 or 2 as compared to pre-leukapheresis (p<0.01). Compared to post leukapheresis 1, respiratory status declined after leukapheresis 2 (p=0.024). Among 66 patients with initial minimal or no O2 requirements (0 or 1), 6 required mechanical ventilation within 72 hours, while 1 out of 9 patients initially on mechanical ventilation (3 or 4) was weaned after leukapheresis. Overall survival significantly decreased with worsening respiratory status (no oxygen vs oxygen nasal cannula vs invasive mechanical ventilation, all p<0.01) . Day 28 survival was 40% in patients requiring high flow oxygen or mechanical ventilation versus 74% for those with little or no oxygen requirements (p=0.01).

CONCLUSIONS: In AML with pulmonary leukostasis, initial respiratory status is associated with overall survival, and hypoxia requiring high flow oxygen or mechanical ventilation carries a high early mortality rate. Leukapheresis is effective in decreasing WBC but does not improve respiratory status.

CLINICAL IMPLICATIONS: Prospective studies are warranted to better define the role of leukapheresis in AML with leukostasis and find alternative ways of improving early outcome.

DISCLOSURE: The following authors have nothing to disclose: Ruchi Desai, Coursen Schneider, David Claxton, Andry Van de Louw

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