Guía de manejo para el tratamiento de la Leucemia linfoide aguda hospital de San José, Bogotá D.C.

Treatment guidelines for acute lym phoblastic leukemia at hospital de San Jose, Bogota DC.

Los esquemas para el tratamiento de leucemia linfoblástica aguda, muestran tasas de remisión completa entre 70 y 90%, pero con pobres resultados a largo plazo y supervivencia libre de enfermedad a cinco años de 30 a 40%. Ante los múltiples protocolos a nivel mundial, las diferentes respuestas clínicas, la controversia en las opciones terapéuticas y la dificultad de adaptar las estrategias de tratamiento en nuestro país, se justifica la realización de una guía para nuestra institución. Se realizó una búsqueda de literatura sobre el tratamiento de LLA en adultos. Se excluyeron los de LLA en pediatría y LLA de precursores T. Se encontraron 335 artículos y se seleccionaron 48 que cumplieron los criterios de inclusión. Objetivo: establecer estrategias terapéuticas en adultos con LLA basadas en la evidencia disponible y adaptándolas a los recursos institucionales. Materiales y métodos: la revisión ampliada se basó en la evaluación de estudios secundarios como guías de práctica clínica, metaanálisis, revisiones sistemáticas publicadas entre enero 2005 y febrero 2009, o bien se recurrió a ensayos clínicos. Las bases de datos analizadas incluyeron PubMed a través de Medline, Clinical Evidence, la colaboración Cochrane, así como treinta y cuatro entidades compiladoras. Conclusiones: 1) Para adultos con LLA las series más grandes concluyen que el tratamiento de inducción debe incluir corticoides, antracíclicos, vincristina y L asparaginasa, con profilaxis del sistema nervioso central. 2) Los adolescentes y adultos jóvenes deben recibir protocolos pediátricos pero no hay evidencia suficiente para aceptar uno estándar. 3) El imatinib está indicado para todos los pacientes con LLA Ph+ con dosis entre 400 y 800 mg/día desde la inducción hasta el final del tratamiento. El beneficio es mayor cuando se incorpora desde la inducción y se administra en forma concurrente, con la quimioterapia, más que de forma secuencial. 4) Los esquemas consistentes con quimioterapia de alta intensidad asociada con imatinib y consolidación con trasplante alogénico en la primera remisión completa, han mostrado los mejores resultados a largo plazo y constituyen la terapia estándar. 5) Se recomienda monitorizar la enfermedad mínima residual en LLA Ph+ luego de trasplante alogénico por ser factor predictor de recaída. 6) No existen estudios comparativos aleatorios controlados que evalúen el impacto del imatinib en presencia de enfermedad mínima residual y es difícil llevarlos a cabo por la baja incidencia. La investigación de Wassmann y col. sugiere un beneficio a largo término en quienes logran respuesta molecular completa temprana con imatinib.

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