Clinical impact of the baseline echocardiogram in children with high-risk acute lymphoblastic leukemia

It is common practice to hold anthracycline induction chemotherapy in children with high-risk acute lymphoblastic leukemia (HR-ALL) until an echocardiogram is performed and interpreted. It is unclear whether withholding therapy in HR-ALL children is justified by echocardiogram findings. We reviewed the initial echocardiograms in a cohort of children with HR-ALL to determine the incidence of contraindications for anthracycline treatment.

We identified 50 consecutive children (<21 years old) with HR-ALL presenting at our institution over a 10-year period. One didn't have an initial echocardiogram, 39 had pre-therapy studies, and 10 were studied within 6 days of beginning chemotherapy. These 49 studies were reviewed to determine the incidence and clinical significance of abnormalities.

All 49 patients had normal cardiac function. Initial echocardiogram findings had no impact on induction chemotherapy administration in any patient. However, only 22(45%) of the studies were completely normal. Echocardiographic abnormalities included pericardial effusion (17/49), trivial or mild mitral or aortic insufficiency (13/49), left ventricular enlargement (3/49), and structural heart disease (4/49). Twelve percent of the children had a patent foramen ovale. None of the cardiac findings required therapeutic intervention other than repositioning of indwelling lines (6/49) due to intracardiac positioning.

In our experience, findings on echocardiograms in childhood HR-ALL did not impact anthracycline administration. This study suggests that induction chemotherapy should not be delayed for an echocardiogram. However, whenever possible, a pre-therapy echocardiogram is still recommended for determining baseline function and to identify associated problems like pericardial effusions which were common in this study.