الفهرس 
Outcome of Acute Leukemia in Down Syndrome Single Institute Experience
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Abstract
In the end our study, from all the previously mentioned data, we concluded that:
Both ALL and AML patients with DS who were treated in NCI during the time of the study had low overall and event free survival. And they had high mortality rate.
The major cause of death in DS patients with leukemia was sepsis. These patients had high incidence of treatment related morbidity and mortality,
• The cumulative overall survival at 1 year was 50 %, at 2 years was 41.7 %, at 3 years was 33.3 %, and at end of the study was 33.3%.
• DS-ALL had increased mortality rate (66.7%) mostly due to infection and they low relapse rate.
• Patients who have WBCs ≥50 have lower survival probability as compared to patients who have WBCs <50, (hazard ratio=0.032), p-value=0.017.
• Patients who used prophylactic antifungal during induction phase had higher survival probability as compared to patients who didn’t use antifungal, (hazard ratio=0.044), p-value=0.037.
• Using prophylactic anti-fungal protocol during induction phase may help to decrease induction death in ALL-DS patients.
• While in DS-AML group. The cumulative overall survival at 1 year was 37.5% and at the end of the study 37.5%.which is considered lower than all comparative study.
• In DS-AML group, Most of the cases died due to septicemia during supportive care.
LIMITATION
• This study was created with the purpose of highlighting the challenges encountered in treatment DS children with leukemia. However, the major limitation for our study was the small sample size.
• Several patients did not stick to the recommended treatment protocol either due poor general conditions of some patients or availability of some drugs as in AAML0431 original protocol, daunorubicin was used which is less cardiotoxic than doxorubicin
• In our study, death occurred in some cases shortly after admission, their death was attributed to a late referral or arrival to the service for management or poor general condition at time of presentation.
RECOMMENDATIONS
• In this study, Patients with DS had a high mortality rate and TRM rate, so we recommend enhancing supportive care throughout the course of treatment especially induction phase, aggressively treating of any suspected infections.
• Modification of chemotherapy regimens to be less toxic.
• Use of daunorubicin which is less cardiotoxic and less myelosuppressive than doxorubicin may help to decrease cardiotoxicity and mortality rate.
• Regular cardiac (Echo) evaluation for early detection of any cardiotoxicity and early use of cardiac support.
• Using antifungal prophylaxis during induction phase may decrease induction death in ALL-DS patients and improve survival.
• IgG levels should be evaluated monthly, and if levels decline below 4 g/L, intravenous immunoglobulin (IVIG) at a dose of 0.5 g/kg every 3 to 4 weeks should be administered (Izraeli et al., 2014).
• Continuous observation during treatment, including the maintenance phase, and Clinicians should proceed with protocol-specific dose escalations in patients with stable counts without being hesitant out of fear of infection
• For Down syndrome children, adopting novel treatment approaches that may be very effective and less toxic than conventional treatment may be very important to improve their remission rates and decrease mortality rate. For example novel therapies that target distinctive