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Chang J, Douer D, Aldoss I, Vahdani G, Jeong AR, Ghaznavi Z, Zhang S, Yaghmour G, Lee KJ, Weissman A, Akhtari M. Combination chemotherapy plus dasatinib leads to comparable overall survival and relapse-free survival rates as allogeneic hematopoietic stem cell transplantation in Philadelphia positive acute lymphoblastic leukemia. Cancer Med 2019; 8:2832-2839. [PMID: 31016870 PMCID: PMC6558592 DOI: 10.1002/cam4.2153] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 02/14/2019] [Accepted: 03/26/2019] [Indexed: 12/19/2022] Open
Abstract
Background The Philadelphia chromosome is associated with a poor prognosis in acute lymphoblastic leukemia (ALL). While hematopoietic stem cell transplantation (HSCT) has been regarded as a favorable treatment option in adult Philadelphia‐positive (Ph+) ALL, its benefit is less clear in the era of newer generation tyrosine kinase inhibitors (TKIs) like dasatinib. Methods This was a retrospective study that analyzed the outcomes of adult patients with Ph+ ALL treated with either combination chemotherapy plus dasatinib or combination chemotherapy plus dasatinib followed by allogeneic HSCT. Results A total of 70 patients were included; 30 (42.9%) underwent allogeneic HSCT while 40 (57.1%) received only chemotherapy plus dasatinib. In comparing overall survival (OS) rates, results between the 2 groups were similar with a 1‐year OS of 93.3% versus 100% (P = 0.20), 2‐year OS of 89.8% versus 86.2% (P = 0.72), and 3‐year OS of 76% versus 71.3% (P = 0.56) in the transplant versus nontransplant groups, respectively. The 3‐year relapse‐free survival (RFS) rates were also similar at 70.5% in the transplant group and 80.1% in the nontransplant group (P = 0.94). Subgroup analyses were performed for patients with specific poor prognostic factors (higher white blood count, older age, positive minimal residual disease status), but results again showed no significant survival difference between transplant and nontransplant patients. Conclusions While HSCT has historically led to a survival advantage in Ph+ ALL, the results of our study demonstrate that it may have a less beneficial role in the era of newer generation TKIs such as dasatinib.
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Affiliation(s)
- Jeremy Chang
- Los Angeles County - University of Southern California, Los Angeles, California
| | - Dan Douer
- Jane Anne Nohl Division of Hematology and Center for the Study of Blood Diseases, Norris Cancer Center, Los Angeles, California
| | | | - Golnaz Vahdani
- Los Angeles County - University of Southern California, Los Angeles, California
| | - Ah-Reum Jeong
- Los Angeles County - University of Southern California, Los Angeles, California
| | - Zunera Ghaznavi
- Jane Anne Nohl Division of Hematology and Center for the Study of Blood Diseases, Norris Cancer Center, Los Angeles, California
| | - Sherry Zhang
- Harbor-UCLA Medical Center, Torrance, California
| | - George Yaghmour
- Jane Anne Nohl Division of Hematology and Center for the Study of Blood Diseases, Norris Cancer Center, Los Angeles, California
| | - Kum-Ja Lee
- University of Southern California School of Pharmacy, Los Angeles, California
| | - Ashley Weissman
- University of Southern California School of Pharmacy, Los Angeles, California
| | - Mojtaba Akhtari
- Jane Anne Nohl Division of Hematology and Center for the Study of Blood Diseases, Norris Cancer Center, Los Angeles, California
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Abou Dalle I, Jabbour E, Short NJ, Ravandi F. Treatment of Philadelphia Chromosome-Positive Acute Lymphoblastic Leukemia. Curr Treat Options Oncol 2019; 20:4. [PMID: 30675645 DOI: 10.1007/s11864-019-0603-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OPINION STATEMENT With the introduction of tyrosine kinase inhibitors (TKIs) in the management of Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL), the prognosis of patients has improved dramatically. Currently, the standard of care in the frontline setting for fit patients is TKI in combination with chemotherapy. Age-adjusted chemotherapy or corticosteroids alone have been used with TKIs in elderly patients with comorbidities with modest long-term benefit. The primary goal of treatment is the achievement of early deep molecular remission as the achievement of complete molecular remission (CMR) at 3 months has been demonstrated to be predictive of higher long-term survival. The probability of attaining this goal by a more potent TKIs like dasatinib or ponatinib is higher, thus we recommend the use of second- or third-generation TKIs over imatinib. Clinicians should be aware of possible fatal cardiovascular events mainly related to ponatinib. Allogeneic hematopoietic stem cell transplantation (alloHSCT) should still be considered in first remission, especially for younger patients treated with imatinib combination therapy. A subset of patients achieving CMR at 3 months may be able to continue consolidation and maintenance with chemotherapy and TKI without the need for alloHSCT. Because of higher risk of relapses in the central nervous system, intrathecal chemoprophylaxis is mandatory for all patients. New strategies incorporating novel agents, such as antibody-drug conjugates, bispecific monoclonal antibodies, potent TKIs, and CAR T cells are under investigation.
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Affiliation(s)
- Iman Abou Dalle
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd. Unit 0428, Houston, TX, 77030, USA
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd. Unit 0428, Houston, TX, 77030, USA
| | - Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd. Unit 0428, Houston, TX, 77030, USA
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd. Unit 0428, Houston, TX, 77030, USA.
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Abstract
PURPOSE OF REVIEW Treatment options for patients with acute lymphoblastic leukemia (ALL) beyond standard chemotherapy have grown significantly in recent years. In this review, we highlight new targeted therapies in ALL, with an emphasis on immunotherapy. RECENT FINDINGS Major advances include antibody-based therapies, such as naked monoclonal antibodies, antibody-drug conjugates and bispecific T cell engaging (BiTE) antibodies, as well as adoptive cellular therapies such as chimeric antigen receptor (CAR) T cells. Apart from the above immunotherapeutic approaches, other targeted therapies are being employed in Philadelphia chromosome-positive (Ph+) ALL, Philadelphia-like (Ph-like) ALL, and T cell ALL. These new treatment strategies are changing the treatment landscape of ALL and challenging the current standard of care. Clinical trials will hopefully help determine how to best incorporate these novel therapies into existing treatment algorithms.
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Affiliation(s)
- Kathleen W Phelan
- Cardinal Bernardin Cancer Center, Loyola University Medical Center, 2160 S. First Avenue, Maywood, IL, 60153, USA
| | - Anjali S Advani
- Taussig Cancer Center, Cleveland Clinic, 10201 Carnegie Avenue, Desk CA60, Cleveland, OH, 44195, USA.
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54
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Jabbour E, Short NJ, Ravandi F, Huang X, Daver N, DiNardo CD, Konopleva M, Pemmaraju N, Wierda W, Garcia-Manero G, Sasaki K, Cortes J, Garris R, Khoury JD, Jorgensen J, Jain N, Alvarez J, O'Brien S, Kantarjian H. Combination of hyper-CVAD with ponatinib as first-line therapy for patients with Philadelphia chromosome-positive acute lymphoblastic leukaemia: long-term follow-up of a single-centre, phase 2 study. Lancet Haematol 2018; 5:e618-e627. [PMID: 30501869 PMCID: PMC10020885 DOI: 10.1016/s2352-3026(18)30176-5] [Citation(s) in RCA: 156] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 10/01/2018] [Accepted: 10/02/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND The combination of chemotherapy and ponatinib in Philadelphia chromosome-positive acute lymphoblastic leukaemia has the potential to be a new standard of care for the disease; however, long-term efficacy and safety data are needed. Our aim was to evaluate the long-term efficacy and safety of this regimen in patients with newly diagnosed Philadelphia chromosome-positive acute lymphoblastic leukaemia in this ongoing phase 2 trial. METHODS In our single-centre, phase 2, single-arm trial in the USA, adult patients with previously untreated Philadelphia chromosome-positive acute lymphoblastic leukaemia were sequentially enrolled. Eligible patients had newly diagnosed Philadelphia chromosome-positive acute lymphoblastic leukaemia, were aged 18 years or older, had an Eastern Cooperative Oncology Group performance status of 2 or less, a left ventricular ejection fraction above 50%, and adequate hepatic and renal function (serum bilirubin ≤3·0 mg/dL and serum creatinine ≤3·0 mg/dL, unless higher levels were believed to be due to leukaemia at the discretion of the investigator). Patients received eight cycles of 21 days, alternating between two drug combinations: hyper-fractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone (hyper-CVAD) and high-dose methotrexate and cytarabine. Ponatinib was given orally at 45 mg per day for the first 14 days of cycle 1 then continuously at 45 mg per day for the subsequent cycles. After 37 patients were treated, the protocol was amended to reduce the dose of ponatinib to 30 mg per day at cycle 2, with further reduction to 15 mg once a complete molecular response (defined as absence of quantifiable BCR-ABL1 transcripts) was achieved. Patients in complete remission received maintenance with ponatinib daily (30 mg or 15 mg) indefinitely, and with vincristine (2 mg intravenously on day 1) and prednisone (200 mg orally on days 1-5) monthly for 2 years. The primary endpoint was 3-year event-free survival in the intention-to-treat population. The trial is registered at ClinicalTrials.gov, number NCT01424982, and is ongoing and still enrolling patients. FINDINGS 76 patients with a median age of 47 years (IQR 39-61) were enrolled and treated between Nov 19, 2011, and April 4, 2018. The 3-year event-free survival was 70% (95% CI 56-80). The most common grade 3 or 4 adverse events were infection (n=65, 86%), increased transaminases (n=24, 32%), increased bilirubin (n=13, 17%), pancreatitis (n=13, 17%), hypertension (n=12, 16%), bleeding (n=10, 13%), and skin rash (n=9, 12%). Six patients died while still on study treatment. Three patients (4%) died from infection and one (1%) from haemorrhage. Two patients died from myocardial infarction related to early ponatinib use; neither death occurred after protocol revision. INTERPRETATION The combination of chemotherapy with ponatinib is effective in achieving long-term remission in patients with newly diagnosed Philadelphia chromosome-positive acute lymphoblastic leukaemia. This regimen could represent a new standard of care for this population. A randomised, phase 3 study to evaluate the efficacy of this combination compared with chemotherapy plus earlier-generation tyrosine-kinase inhibitors is warranted. FUNDING Takeda Oncology.
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Affiliation(s)
- Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Xuelin Huang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naval Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Courtney D DiNardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Marina Konopleva
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William Wierda
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Koji Sasaki
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jorge Cortes
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rebecca Garris
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph D Khoury
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey Jorgensen
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joie Alvarez
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Susan O'Brien
- Chao Family Comprehensive Cancer Center, University of California Irvine, Orange, CA, USA
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Ribera JM, Ribera J, Genescà E. The role of stem cell transplantation in the management of Philadelphia chromosome-positive acute lymphoblastic leukemia. Ther Adv Hematol 2018; 9:357-368. [PMID: 33815735 PMCID: PMC7992773 DOI: 10.1177/2040620718811772] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Accepted: 10/15/2018] [Indexed: 02/03/2023] Open
Abstract
The concurrent administration of tyrosine kinase inhibitors (TKIs) with standard chemotherapy together with allogeneic hematopoietic stem cell transplantation (alloHSCT) has improved the outcome of patients with Philadelphia chromosome-positive (Ph+) acute lymphoblastic leukemia (ALL). Although to date, no study has shown alloHSCT to be inferior to chemotherapy plus TKIs in any subgroup of adult Ph+ ALL, there is some evidence suggesting no additional benefit of alloHSCT in patients with deep molecular responses to intensive chemotherapy with a second-generation, and especially, third-generation TKI. As none of these positive and negative studies are controlled, randomized trials are needed to fully define the role of alloHSCT in Ph+ ALL, especially in those with deep molecular response. However, if studies combining TKIs with new approaches such as immunotherapy lead to durable responses, alloHSCT in the first complete remission could be avoided in the near future in the majority of patients with Ph+ ALL.
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Affiliation(s)
- Jose-Maria Ribera
- Clinical Hematology Department, ICO-Hospital Germans Trias i Pujol, c/ Canyet s/n, 08916 Badalona, Spain
| | - Jordi Ribera
- Clinical Hematology Department, ICO-Hospital Germans Trias i Pujol, Josep Carreras Research Institute, Badalona, Universitat Autònoma de Barcelona, Spain
| | - Eulalia Genescà
- Clinical Hematology Department, ICO-Hospital Germans Trias i Pujol, Josep Carreras Research Institute, Badalona, Universitat Autònoma de Barcelona, Spain
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56
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How I treat Philadelphia chromosome-positive acute lymphoblastic leukemia. Blood 2018; 133:130-136. [PMID: 30442680 DOI: 10.1182/blood-2018-08-832105] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 11/13/2018] [Indexed: 01/27/2023] Open
Abstract
The introduction of agents targeted at specific molecular events is changing the treatment paradigms in a number of malignancies. Historically, we have relied entirely on DNA-interactive, cytotoxic drugs for treating patients with leukemia. Increased understanding of the leukemic cell biology and pathogenesis, and the ways they evade the immune surveillance mechanisms, will likely lead to the development of more effective agents, and regimens less reliant on chemotherapy, able to achieve deep levels of disease eradication. In Philadelphia chromosome-positive acute lymphoblastic leukemia, the introduction of increasingly potent tyrosine kinas inhibitors (TKIs) has revolutionized therapy. These drugs have been established as the cornerstone of any therapeutic strategy in this disease, and a number of trials have better defined the best ways to incorporate them into the established paradigms. Despite using TKIs, we have continued to remain reliant on cytotoxic chemotherapy regimens and allogeneic hematopoietic cell transplant to achieve the best long-term outcomes. However, with the introduction of more potent TKIs and other novel agents, as well as better methods for monitoring minimal/measurable residual disease, we are entering an era where we hope to diminish our reliance on transplantation and cytotoxic chemotherapy in this disease.
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57
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Short NJ, Kantarjian H, Pui CH, Goldstone A, Jabbour E. SOHO State of the Art Update and Next Questions: Philadelphia Chromosome-Positive Acute Lymphoblastic Leukemia. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2018; 18:439-446. [DOI: 10.1016/j.clml.2018.05.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 05/17/2018] [Indexed: 10/16/2022]
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58
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Final analysis of the JALSG Ph+ALL202 study: tyrosine kinase inhibitor-combined chemotherapy for Ph+ALL. Ann Hematol 2018; 97:1535-1545. [PMID: 29694642 PMCID: PMC6097750 DOI: 10.1007/s00277-018-3323-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 03/31/2018] [Indexed: 12/13/2022]
Abstract
The Japan Adult Leukemia Study Group (JALSG) Ph+ALL202 study reported a high complete remission (CR) rate for Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ALL) patients treated with imatinib-combined chemotherapy. However, the long-term treatment efficacy remains uncertain. Here, we report a final analysis of the JALSG Ph+ALL202 study. The outcomes were compared with those of the JALSG ALL93 and ALL97 studies, which were conducted in the pre-imatinib era. Ninety-nine newly diagnosed Ph+ALL patients were enrolled in Ph+ALL202 (median age, 45 years; median follow-up, 4.5 years). CR was achieved in 96/99 (97%) patients. Fifty-nine of these 96 patients (61%) underwent allogeneic hematopoietic stem cell transplantation (allo-HSCT) in their first CR (CR1). The 5-year overall and disease-free survival (DFS) rates were 50 and 43%, respectively, which were significantly higher compared to those in the pre-imatinib era (15 and 19%, respectively). Multivariate analysis revealed that imatinib administration, allo-HSCT in CR1, and a white blood cell count < 30 × 109/L were favorable independent prognostic factors for long-term DFS. Improved odds of receiving allo-HSCT and a lower relapse rate leaded to good long-term outcomes. The 3-year DFS tended to be higher in PCR-negative than that in PCR-positive patients (29 vs. 14%) in the non-HSCT patients, and this tendency was also seen in the allo-HSCT patients (59 vs. 50%). The higher rate of CR upon imatinib use may have contributed to these improvements.
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59
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Jabbour E, DerSarkissian M, Duh MS, McCormick N, Cheng WY, McGarry LJ, Souroutzidis A, Huang H, O'Brien S, Ravandi F, Kantarjian HM. Efficacy of Ponatinib Versus Earlier Generation Tyrosine Kinase Inhibitors for Front-line Treatment of Newly Diagnosed Philadelphia-positive Acute Lymphoblastic Leukemia. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2018; 18:257-265. [PMID: 29519619 DOI: 10.1016/j.clml.2018.02.010] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 02/09/2018] [Accepted: 02/13/2018] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Complete molecular response (CMR) and 2- and 3-year overall survival (OS) were compared for patients with newly diagnosed Philadelphia-positive acute lymphoblastic leukemia (Ph+ ALL) who had undergone front-line combination chemotherapy plus ponatinib versus combination therapy plus earlier generation tyrosine kinase inhibitors (TKIs; imatinib, dasatinib, and nilotinib). PATIENTS AND METHODS We identified 26 Ph+ ALL studies: 25 of earlier generation TKIs and 1 of ponatinib. The outcomes from studies of combination chemotherapy plus earlier generation TKIs were summarized using pooled estimates with 95% confidence intervals (CIs) from a random-effects meta-analysis. A binomial distribution was assumed to calculate the 95% CIs for the results from the single-arm combination chemotherapy plus ponatinib trial. Adjusted logistic meta-regression analyses were used to compare the outcomes between the TKI groups. RESULTS The percentage of patients achieving a CMR was greater with combination chemotherapy plus ponatinib (79%) than the pooled percentage of patients achieving a CMR with combination chemotherapy plus earlier generation TKIs (34%). Greater OS was observed with ponatinib compared with the pooled OS for earlier generation TKIs (2-year, 83% vs. 58%; 3-year, 79% vs. 50%). Odds ratios for ponatinib versus earlier generation TKIs were 6.09 (95% CI, 1.16-31.90; P = .034) for CMR, 3.70 (95% CI, 0.93-14.73; P = .062) for 2-year OS, and 4.49 (95% CI, 1.00-20.13; P = .050) for 3-year OS. CONCLUSION Ponatinib plus chemotherapy might be associated with better outcomes than chemotherapy with earlier generation TKIs in patients with newly diagnosed Ph+ ALL.
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Affiliation(s)
- Elias Jabbour
- University of Texas MD Anderson Cancer Center, Houston, TX.
| | | | | | | | | | - Lisa J McGarry
- ARIAD Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, MA
| | | | - Hui Huang
- ARIAD Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, MA
| | - Susan O'Brien
- Chao Family Comprehensive Cancer Center, University of California, Irvine, Orange, CA
| | - Farhad Ravandi
- University of Texas MD Anderson Cancer Center, Houston, TX
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El Fakih R, Jabbour E, Ravandi F, Hassanein M, Anjum F, Ahmed S, Kantarjian H. Current paradigms in the management of Philadelphia chromosome positive acute lymphoblastic leukemia in adults. Am J Hematol 2018; 93:286-295. [PMID: 28971501 DOI: 10.1002/ajh.24926] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 09/27/2017] [Accepted: 09/27/2017] [Indexed: 02/03/2023]
Abstract
Philadelphia chromosome-positive (Ph-positive) acute lymphoblastic leukemia (ALL) is a biologically, clinically, and genetically distinct subtype of precursor-B ALL. The Ph chromosome, results from a reciprocal translocation of the ABL1 kinase gene on chromosome 9 to the breakpoint cluster region (BCR) gene on chromosome 22. Depending on the translocation breakpoint, typically a p210 BCR-ABL1 or a p190 BCR-ABL onc protein are generated; both are constitutively active tyrosine kinases that play a central role to alter signaling pathways of cell proliferation, survival, and self-renewal, leading to leukemogenesis. In Ph-positive ALL, the p190-BCR-ABL (minor [m]-bcr) subtype is more frequent than the p210-BCR-ABL (major [M]-bcr) subtype, commonly found in chronic myeloid leukemia. The Philadelphia chromosome is the most frequent recurrent cytogenetic abnormality in elderly patients with ALL. Its incidence increases with age, reaching ∼50% in patients with ALL aged 60 years and over. Patients traditionally had a very poor outcome with chemotherapy, particularly if they do not undergo allogeneic hematopoietic cell transplantation (allo-HCT) in first complete remission (CR1). With the availability of multiple tyrosine kinase inhibitors (TKI), the therapeutic armamentarium is expanding quickly. However, there is no consensus on how to best treat Ph-positive ALL. With modern therapy, improved outcomes have led to the emergence of a number of controversies, including the need for intensive chemotherapy, the ideal TKI, and whether all eligible patients should receive an allo-HSCT, and if so, what type. Here, we discuss these controversies in light of the available literature.
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Affiliation(s)
- Riad El Fakih
- King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Elias Jabbour
- Leukemia department, University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Farhad Ravandi
- Leukemia department, University of Texas, MD Anderson Cancer Center, Houston, Texas
| | - Mona Hassanein
- King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Farhan Anjum
- King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Syed Ahmed
- King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Hagop Kantarjian
- Leukemia department, University of Texas, MD Anderson Cancer Center, Houston, Texas
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61
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Dinner S, Gurbuxani S, Jain N, Stock W. Acute Lymphoblastic Leukemia in Adults. Hematology 2018. [DOI: 10.1016/b978-0-323-35762-3.00066-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Ravandi F. Current management of Philadelphia chromosome positive ALL and the role of stem cell transplantation. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:22-27. [PMID: 29222233 PMCID: PMC6142602 DOI: 10.1182/asheducation-2017.1.22] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Treatment of Philadelphia chromosome positive acute lymphoblastic leukemia exemplifies how the addition of potent targeted agents, directed at the molecular aberrations responsible for leukemic transformation, can overcome resistance mechanisms to traditional regimens and lead to improved outcomes. The introduction of BCR-ABL1 targeted tyrosine kinase inhibitors (TKIs) has significantly improved the outcomes not only by allowing more patients to undergo allogeneic hematopoietic cell transplantation (alloHCT) but also by decreasing our reliance on this potentially toxic strategy, particularly in the less fit population. Long-term data using chemotherapy and TKI combinations demonstrate that a proportion of patients treated can achieve durable relapse-free survival without undergoing alloHCT. Furthermore, the availability of sensitive minimal residual disease monitoring assays may allow early detection of the patients who are more likely to relapse and who are likely candidates for early alloHCT. The emergence of more potent TKIs with significant activity against resistant mutations has allowed deintensification of chemotherapy regimens. Available data indicate that complete reliance on TKIs, alone or with minimal additional therapy, and elimination of more intensive chemotherapy or alloHCT is unlikely to achieve long term cure in most patients. However, introduction of other highly effective agents that can be combined with TKIs may allow further minimization of chemotherapy and alloHCT in the future, as we have witnessed in acute promyelocytic leukemia.
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Affiliation(s)
- Farhad Ravandi
- Department of Leukemia, University of Texas-MD Anderson Cancer Center, Houston, TX
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63
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Brüggemann M, Kotrova M. Minimal residual disease in adult ALL: technical aspects and implications for correct clinical interpretation. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:13-21. [PMID: 29222232 PMCID: PMC6142572 DOI: 10.1182/asheducation-2017.1.13] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 08/21/2017] [Indexed: 06/07/2023]
Abstract
Nowadays, minimal residual disease (MRD) is accepted as the strongest independent prognostic factor in acute lymphoblastic leukemia (ALL). It can be detected by molecular methods that use leukemia-specific or patient-specific molecular markers (fusion gene transcripts, or immunoglobulin/T-cell receptor [IG/TR] gene rearrangements), and by multi-parametric flow cytometry. The sensitivity and specificity of these methods can vary across treatment time points and therapeutic settings. Thus, knowledge of the principles and limitations of each technology is of the utmost importance for correct interpretation of MRD results. Time will tell whether new molecular and flow cytometric high-throughput technologies can overcome the limitations of current standard methods and eventually bring additional benefits. MRD during standard ALL chemotherapy is the strongest overall prognostic indicator and has therefore been used for refining initial treatment stratification. Moreover, MRD positivity after the maintenance phase of treatment may point to an impending relapse and thus enable salvage treatment to be initiated earlier, which could possibly improve treatment results. The prognostic relevance of pretransplantation MRD was shown by several studies, and MRD high-risk patients were shown to benefit from stem cell transplantation (SCT). Also, MRD positivity after SCT correlates with worse outcomes. In addition, MRD information is very instructive in current clinical trials that test novel agents to evaluate their treatment efficacy. Although conventional clinical risk factors lose their independent prognostic significance when combined with MRD information, recently identified genetic markers may further improve the treatment stratification in ALL.
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Affiliation(s)
- Monika Brüggemann
- Department of Hematology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Michaela Kotrova
- Department of Hematology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
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Nishiwaki S, Sugiura I, Miyata Y, Saito S, Sawa M, Nishida T, Miyamura K, Kuwatsuka Y, Kohno A, Yuge M, Kasai M, Iida H, Kurahashi S, Osaki M, Goto T, Terakura S, Murata M, Nishikawa H, Kiyoi H. Efficacy and safety of autologous peripheral blood stem cell transplantation for Philadelphia chromosome-positive acute lymphoblastic leukemia: A study protocol for a multicenter exploratory prospective study (Auto-Ph17 study). Medicine (Baltimore) 2017; 96:e9568. [PMID: 29384978 PMCID: PMC6393033 DOI: 10.1097/md.0000000000009568] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION The prognosis of Philadelphia chromosome positive acute lymphoblastic leukemia (Ph + ALL) has been dramatically improved since the introduction of tyrosine kinase inhibitors (TKIs). Although allogeneic hematopoietic cell transplantation (allo-HCT) is a major treatment option, the role of autologous peripheral blood stem cell transplantation (auto-PBSCT) has been reconsidered, especially in patients who achieved early molecular remission. METHODS AND ANALYSIS This is a multicenter exploratory study for Ph + ALL patients aged between 55 and 70 years who achieved complete molecular remission within 3 cycles of chemotherapy. The target sample size is 5, and the registration period is 2 years. The primary endpoint is Day100- mortality after transplantation, and the secondary endpoints are survival, relapse rate, nonrelapse mortality, and adverse events.This study is divided into 3 phases: peripheral blood stem cell harvest, transplantation, and maintenance. Chemomobilization is performed using a combination of cyclophosphamide (CPM), doxorubicin, vincristine (VCR), and prednisolone (PSL). As a preparative regimen, the LEED regimen is used, which consists of melphalan, CPM, etoposide, and dexamethasone. Twelve cycles of maintenance therapy using a combination of VCR, PSL, and dasatinib are performed.In association with relapse, the minimal residual disease (MRD) of BCR-ABL chimeric gene and T-cell subsets are analyzed both before and after auto-PBSCT. ETHICS AND DISSEMINATION The protocol was approved by the institutional review board of Nagoya University Hospital and all the participating hospitals. Written informed consent was obtained from all patients before registration, in accordance with the Declaration of Helsinki. Results of the study will be disseminated via publications in peer-reviewed journals. TRIAL REGISTRATION Trial registration number UMIN000026445.
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Affiliation(s)
- Satoshi Nishiwaki
- Center for Advanced Medicine and Clinical Research, Nagoya University Hospital, Nagoya
| | - Isamu Sugiura
- Division of Hematology and Oncology, Toyohashi Municipal Hospital, Toyohashi
| | - Yasuhiko Miyata
- Department of Hematology, National Hospital Organization Nagoya Medical Center
| | - Shigeki Saito
- Department of Hematology and Oncology, Japanese Red Cross Nagoya Daini Hospital, Nagoya
| | - Masashi Sawa
- Department of Hematology, Anjo Kosei Hospital, Anjo
| | - Tetsuya Nishida
- Department of Hematology and Oncology, Nagoya University Graduate School of Medicine
| | - Koichi Miyamura
- Department of Hematology, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya
| | - Yachiyo Kuwatsuka
- Center for Advanced Medicine and Clinical Research, Nagoya University Hospital, Nagoya
| | - Akio Kohno
- Department of Hematology and Oncology, JA Aichi Konan Kosei Hospital, Konan
| | - Masaaki Yuge
- Division of Hematology, Ichinomiya Municipal Hospital, Ichinomiya
| | - Masanobu Kasai
- Department of Hematology and Oncology, Japanese Red Cross Nagoya Daini Hospital, Nagoya
| | - Hiroatsu Iida
- Department of Hematology, National Hospital Organization Nagoya Medical Center
| | - Shingo Kurahashi
- Division of Hematology and Oncology, Toyohashi Municipal Hospital, Toyohashi
| | - Masahide Osaki
- Department of Hematology, Japanese Red Cross Nagoya Daiichi Hospital, Nagoya
| | - Tatsunori Goto
- Department of Hematology and Oncology, Nagoya University Graduate School of Medicine
| | - Seitaro Terakura
- Department of Hematology and Oncology, Nagoya University Graduate School of Medicine
| | - Makoto Murata
- Department of Hematology and Oncology, Nagoya University Graduate School of Medicine
| | - Hiroyoshi Nishikawa
- Department of Immunology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hitoshi Kiyoi
- Department of Hematology and Oncology, Nagoya University Graduate School of Medicine
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65
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El Fakih R, Ahmed S, Alfraih F, Hanbali A. Hematopoietic cell transplantation for acute lymphoblastic leukemia in adult patients. Hematol Oncol Stem Cell Ther 2017. [DOI: 10.1016/j.hemonc.2017.05.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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66
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Minimal residual disease in adult ALL: technical aspects and implications for correct clinical interpretation. Blood Adv 2017; 1:2456-2466. [PMID: 29296895 DOI: 10.1182/bloodadvances.2017009845] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 08/21/2017] [Indexed: 12/18/2022] Open
Abstract
Nowadays, minimal residual disease (MRD) is accepted as the strongest independent prognostic factor in acute lymphoblastic leukemia (ALL). It can be detected by molecular methods that use leukemia-specific or patient-specific molecular markers (fusion gene transcripts, or immunoglobulin/T-cell receptor [IG/TR] gene rearrangements), and by multi-parametric flow cytometry. The sensitivity and specificity of these methods can vary across treatment time points and therapeutic settings. Thus, knowledge of the principles and limitations of each technology is of the utmost importance for correct interpretation of MRD results. Time will tell whether new molecular and flow cytometric high-throughput technologies can overcome the limitations of current standard methods and eventually bring additional benefits. MRD during standard ALL chemotherapy is the strongest overall prognostic indicator and has therefore been used for refining initial treatment stratification. Moreover, MRD positivity after the maintenance phase of treatment may point to an impending relapse and thus enable salvage treatment to be initiated earlier, which could possibly improve treatment results. The prognostic relevance of pretransplantation MRD was shown by several studies, and MRD high-risk patients were shown to benefit from stem cell transplantation (SCT). Also, MRD positivity after SCT correlates with worse outcomes. In addition, MRD information is very instructive in current clinical trials that test novel agents to evaluate their treatment efficacy. Although conventional clinical risk factors lose their independent prognostic significance when combined with MRD information, recently identified genetic markers may further improve the treatment stratification in ALL.
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67
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Arber DA, Borowitz MJ, Cessna M, Etzell J, Foucar K, Hasserjian RP, Rizzo JD, Theil K, Wang SA, Smith AT, Rumble RB, Thomas NE, Vardiman JW. Initial Diagnostic Workup of Acute Leukemia: Guideline From the College of American Pathologists and the American Society of Hematology. Arch Pathol Lab Med 2017; 141:1342-1393. [PMID: 28225303 DOI: 10.5858/arpa.2016-0504-cp] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT - A complete diagnosis of acute leukemia requires knowledge of clinical information combined with morphologic evaluation, immunophenotyping and karyotype analysis, and often, molecular genetic testing. Although many aspects of the workup for acute leukemia are well accepted, few guidelines have addressed the different aspects of the diagnostic evaluation of samples from patients suspected to have acute leukemia. OBJECTIVE - To develop a guideline for treating physicians and pathologists involved in the diagnostic and prognostic evaluation of new acute leukemia samples, including acute lymphoblastic leukemia, acute myeloid leukemia, and acute leukemias of ambiguous lineage. DESIGN - The College of American Pathologists and the American Society of Hematology convened a panel of experts in hematology and hematopathology to develop recommendations. A systematic evidence review was conducted to address 6 key questions. Recommendations were derived from strength of evidence, feedback received during the public comment period, and expert panel consensus. RESULTS - Twenty-seven guideline statements were established, which ranged from recommendations on what clinical and laboratory information should be available as part of the diagnostic and prognostic evaluation of acute leukemia samples to what types of testing should be performed routinely, with recommendations on where such testing should be performed and how the results should be reported. CONCLUSIONS - The guideline provides a framework for the multiple steps, including laboratory testing, in the evaluation of acute leukemia samples. Some aspects of the guideline, especially molecular genetic testing in acute leukemia, are rapidly changing with new supportive literature, which will require on-going updates for the guideline to remain relevant.
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68
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Fedorov VD, Upadhyay VA, Fathi AT. The Approach to Acute Lymphoblastic Leukemia in Older Patients: Conventional Treatments and Emerging Therapies. Curr Hematol Malig Rep 2017; 11:165-74. [PMID: 26939921 DOI: 10.1007/s11899-016-0316-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Acute lymphoblastic leukemia (ALL) among older adult patients presents significant clinical challenges. As opposed to pediatric populations, in whom long-term outcomes are markedly superior, those for adults remain grim. Nevertheless, younger adults with ALL have experienced a steady improvement in long-term survival in the last few decades. This is significantly different for older ALL patients, for whom long-term outcomes remain poor. Conventional chemotherapies are associated with sub-optimal outcomes and increased toxicity in this population. However, several emerging therapies, including antibody-drug conjugates, bi-specific engagers, and chimeric antigen receptor (CAR) T cells, have demonstrated much promise and are either incorporated into the existing therapeutic paradigms or being actively investigated to improve outcomes.
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Affiliation(s)
- Victor D Fedorov
- Stanbury Service PSP Group, Department of Medicine, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Vivek A Upadhyay
- Department of Medicine, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Amir T Fathi
- Harvard Medical School, Massachusetts General Hospital, Division of Hematology and Medical Oncology, Zero Emerson Place, Suite 118, Boston, MA, 02114, USA.
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69
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Short NJ, Kantarjian H, Jabbour E, Ravandi F. Which tyrosine kinase inhibitor should we use to treat Philadelphia chromosome-positive acute lymphoblastic leukemia? Best Pract Res Clin Haematol 2017; 30:193-200. [PMID: 29050692 DOI: 10.1016/j.beha.2017.05.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 05/09/2017] [Accepted: 05/29/2017] [Indexed: 02/03/2023]
Abstract
The incorporation of tyrosine kinase inhibitors (TKIs) into chemotherapy regimens has significantly improved the long-term survival of patients with Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL). Successive generations of TKIs with increased potency against BCR-ABL and broader spectrum of activity against ABL kinase domain mutations have led to incremental improvements in the outcomes of patients with this disease. In particular, ponatinib, a potent pan-BCR-ABL TKI capable of overcoming the T315I mutation, holds significant promise in the treatment of Ph+ ALL, although the potential cardiovascular toxicity of this agent remains a concern. With the development of more potent TKIs that are capable of inducing deep and sustained remissions, future studies re-evaluating the need for intensive chemotherapy as well as the role for stem cell transplantation in first remission for patients with Ph+ ALL are warranted.
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Affiliation(s)
- Nicholas J Short
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hagop Kantarjian
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elias Jabbour
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Farhad Ravandi
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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70
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Gu S, Sayad A, Chan G, Yang W, Lu Z, Virtanen C, Van Etten RA, Neel BG. SHP2 is required for BCR-ABL1-induced hematologic neoplasia. Leukemia 2017; 32:203-213. [PMID: 28804122 PMCID: PMC6005183 DOI: 10.1038/leu.2017.250] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 07/14/2017] [Accepted: 07/18/2017] [Indexed: 12/16/2022]
Abstract
BCR-ABL1-targeting tyrosine kinase inhibitors (TKIs) have revolutionized treatment of Philadelphia chromosome-positive (Ph+) hematologic neoplasms. Nevertheless, acquired TKI resistance remains a major problem in chronic myeloid leukemia (CML), and TKIs are less effective against Ph+ B-cell acute lymphoblastic leukemia (B-ALL). GAB2, a scaffolding adaptor that binds and activates SHP2, is essential for leukemogenesis by BCR-ABL1, and a GAB2 mutant lacking SHP2 binding cannot mediate leukemogenesis. Using a genetic loss-of-function approach and bone marrow transplantation (BMT) models for CML and BCR-ABL1+ B-ALL, we show that SHP2 is required for BCR-ABL1-evoked myeloid and lymphoid neoplasia. Ptpn11 deletion impairs initiation and maintenance of CML-like myeloproliferative neoplasm, and compromises induction of BCR-ABL1+ B-ALL. SHP2, and specifically, its SH2 domains, PTP activity and C-terminal tyrosines, is essential for BCR-ABL1+, but not WT, pre-B cell proliferation. The MEK/ERK pathway is regulated by SHP2 in WT and BCR-ABL1+ pre-B cells, but is only required for the proliferation of BCR-ABL1+ cells. SHP2 is required for SRC family kinase (SFK) activation only in BCR-ABL1+ pre-B cells. RNAseq reveals distinct SHP2-dependent transcriptional programs in BCR-ABL1+ and WT pre-B cells. Our results suggest that SHP2, via SFKs and ERK, represses MXD3/4 to facilitate a MYC-dependent proliferation program in BCR-ABL1-transformed pre-B cells.
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Affiliation(s)
- S Gu
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.,Princess Margaret Cancer Center, Toronto, Ontario, Canada
| | - A Sayad
- Princess Margaret Cancer Center, Toronto, Ontario, Canada
| | - G Chan
- Princess Margaret Cancer Center, Toronto, Ontario, Canada
| | - W Yang
- Department of Orthopaedics, Brown University Alpert Medical School, Providence, RI, USA
| | - Z Lu
- Princess Margaret Cancer Center, Toronto, Ontario, Canada
| | - C Virtanen
- Princess Margaret Cancer Center, Toronto, Ontario, Canada
| | - R A Van Etten
- Chao Family Comprehensive Cancer Center, Division of Hematology/Oncology, University of California, Irvine, Irvine, CA, USA
| | - B G Neel
- Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.,Princess Margaret Cancer Center, Toronto, Ontario, Canada
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71
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Bachanova V. Philadelphia-positive Acute Lymphoblastic Leukemia: Do We Still Need Allogeneic Transplantation? Argument "Pro". CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2017; 17S:S10-S15. [PMID: 28760293 DOI: 10.1016/j.clml.2017.03.296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 03/22/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Veronika Bachanova
- Bone Marrow Transplantation Program, University of Minnesota, Minneapolis, MN.
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72
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Motlló C, Ribera JM, Morgades M, Granada I, Montesinos P, Mercadal S, González-Campos J, Moreno MJ, Barba P, Cervera M, Barrios M, Novo A, Bernal T, Hernández-Rivas JM, Abella E, Amigo ML, Tormo M, Martino R, Lavilla E, Bergua J, Serrano A, García-Belmonte D, Guàrdia R, Grau J, Feliu E. Frequency and prognostic significance of additional cytogenetic abnormalities to the Philadelphia chromosome in young and older adults with acute lymphoblastic leukemia. Leuk Lymphoma 2017; 59:146-154. [DOI: 10.1080/10428194.2017.1326596] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Cristina Motlló
- Department of Hematology, ICO-Hospital Universitari Germans Trias i Pujol, Josep Carreras Leukemia Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Josep-Maria Ribera
- Department of Hematology, ICO-Hospital Universitari Germans Trias i Pujol, Josep Carreras Leukemia Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Mireia Morgades
- Department of Hematology, ICO-Hospital Universitari Germans Trias i Pujol, Josep Carreras Leukemia Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Isabel Granada
- Department of Hematology, ICO-Hospital Universitari Germans Trias i Pujol, Josep Carreras Leukemia Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Pau Montesinos
- Department of Hematology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Santiago Mercadal
- ICO-Hospital Duran i Reynals, L’Hospitalet de Llobregat, Barcelona, Spain
| | | | | | | | | | | | - Andrés Novo
- Hospital Son Espases, Palma de Mallorca, Palma, Spain
| | | | | | | | | | | | | | | | - Juan Bergua
- Hospital San Pedro de Alcántara, Cáceres, Spain
| | | | | | - Ramon Guàrdia
- Department of Hematology, ICO – Hospital Josep Trueta, Girona, Spain
| | - Javier Grau
- Department of Hematology, ICO-Hospital Universitari Germans Trias i Pujol, Josep Carreras Leukemia Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Evarist Feliu
- Department of Hematology, ICO-Hospital Universitari Germans Trias i Pujol, Josep Carreras Leukemia Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
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Fujisawa S, Mizuta S, Akiyama H, Ueda Y, Aoyama Y, Hatta Y, Kakihana K, Dobashi N, Sugiura I, Onishi Y, Maeda T, Imai K, Ohtake S, Miyazaki Y, Ohnishi K, Matsuo K, Naoe T. Phase II study of imatinib-based chemotherapy for newly diagnosed BCR-ABL-positive acute lymphoblastic leukemia. Am J Hematol 2017; 92:367-374. [PMID: 28103625 DOI: 10.1002/ajh.24653] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 01/11/2017] [Accepted: 01/14/2017] [Indexed: 01/29/2023]
Abstract
This study investigated the efficacy of imatinib based therapy with intensified consolidation therapy in patients with Philadelphia chromosome (Ph)-positive acute lymphoblastic leukemia (ALL) to prevent early relapse. We conducted a phase II trial of imatinib-combined chemotherapy for newly diagnosed BCR-ABL-positive ALL in adults. Sixty-eight patients were included in the trial between October 2008 and December 2010. The median age was 49 years, with 28 patients >55 years of age. Sixty-five patients achieved CR (95.6%). The estimated 2-year event-free survival (EFS) and overall survival (OS) were 62.3% and 67.4%, respectively. Allogeneic stem cell transplantation (allo-SCT) at initial CR was performed in 43 patients. Thirty-five of 39 patients <55 years and 8 of 26 patients >55 years underwent allo-SCT at first CR. The 3-year OS in patients <55 years receiving allo-SCT at first CR, patients >55 years receiving allo-SCT at first CR, patients <55 years not receiving allo-SCT at first CR, and patients >55 years not receiving allo-SCT at first CR were 80.4%, 41.1%, 32.5%, and 52.0%, respectively (P = 0.058). The three-year EFS in each group was 76.7%, 53.6%, not reached, and 26.4%, respectively (P = 0.150). A high CR rate was observed with imatinib-based chemotherapy allowing allo-SCT in a high proportion of patients, particularly those <55 years. Moreover, intensified consolidation therapy reduced early relapse rates following induction therapy and resulted in improved OS and EFS rates following allo-SCT. This trial was registered with the UMIN (000001226).
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Affiliation(s)
- Shin Fujisawa
- Department of Hematology; Yokohama City University Medical Center; Yokohama Japan
| | - Shuichi Mizuta
- Department of Hematology; Fujita Health University Hospital; Toyoake Japan
| | - Hideki Akiyama
- Tokyo Metropolitan Health and Medical Treatment Corporation Tama-Hokubu Medical Center; Tokyo Japan
| | - Yasunori Ueda
- Department of Hematology/Oncology; Kurashiki Central Hospital; Kurashiki Japan
| | - Yasutaka Aoyama
- Department of Hematology; Seichokai Fuchu Hospital; Osaka Japan
| | - Yoshihiro Hatta
- Department of Hematology and Rheumatology; Nihon University School of Medicine; Tokyo Japan
| | - Kazuhiko Kakihana
- Hematology Division; Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital; Tokyo Japan
| | - Nobuaki Dobashi
- Division of Clinical Oncology and Hematology; Department of Internal Medicine, The Jikei University School of Medicine; Tokyo Japan
| | - Isamu Sugiura
- Division of Hematology and Oncology; Toyohashi Municipal Hospital; Toyohashi Japan
| | - Yasushi Onishi
- Department of Hematology and Rheumatology; Tohoku University Hospital; Sendai Japan
| | - Tomoya Maeda
- Department of Hemato-Oncology; Saitama Medical University International Medical Center; Hidaka Japan
| | - Kiyotoshi Imai
- Department of Hematology; Sapporo Hokuyu Hospital; Sapporo Japan
| | - Shigeki Ohtake
- Institute of Liberal Arts and Science, Kanazawa University; Kanazawa Japan
| | - Yasushi Miyazaki
- Department of Hematology; Atomic Bomb Disease Institute, Nagasaki University; Nagasaki Japan
| | - Kazunori Ohnishi
- Oncology Center, Hamamatsu University School of Medicine; Hamamatsu Japan
| | - Keitaro Matsuo
- Division of Molecular Medicine, Aichi Cancer Center Research Institute; Nagoya Japan
| | - Tomoki Naoe
- National Hospital Organization Nagoya Medical Center; Nagoya Japan
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Martinelli G, Boissel N, Chevallier P, Ottmann O, Gökbuget N, Topp MS, Fielding AK, Rambaldi A, Ritchie EK, Papayannidis C, Sterling LR, Benjamin J, Stein A. Complete Hematologic and Molecular Response in Adult Patients With Relapsed/Refractory Philadelphia Chromosome-Positive B-Precursor Acute Lymphoblastic Leukemia Following Treatment With Blinatumomab: Results From a Phase II, Single-Arm, Multicenter Study. J Clin Oncol 2017; 35:1795-1802. [PMID: 28355115 DOI: 10.1200/jco.2016.69.3531] [Citation(s) in RCA: 311] [Impact Index Per Article: 44.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Purpose Few therapeutic options are available for patients with Philadelphia chromosome-positive (Ph+) B-precursor acute lymphoblastic leukemia (ALL) who progress after failure of tyrosine kinase inhibitor (TKI) -based therapy. Here, we evaluated the efficacy and tolerability of blinatumomab in patients with relapsed or refractory Ph+ ALL. Patients and Methods This open-label phase II study enrolled adults with Ph+ ALL who had relapsed after or were refractory to at least one second-generation or later TKI or were intolerant to second-generation or later TKIs and intolerant or refractory to imatinib. Blinatumomab was administered in 28-day cycles by continuous intravenous infusion. The primary end point was complete remission (CR) or CR with partial hematologic recovery (CRh) during the first two cycles. Major secondary end points included minimal residual disease response, rate of allogeneic hematopoietic stem-cell transplantation, relapse-free survival, overall survival, and adverse events (AEs). Results Of 45 patients, 16 (36%; 95% CI, 22% to 51%) achieved CR/CRh during the first two cycles, including four of 10 patients with the T315I mutation; 88% of CR/CRh responders achieved a complete minimal residual disease response. Seven responders (44%) proceeded to allogeneic hematopoietic stem-cell transplantation, including 55% (six of 11) of transplantation-naïve responders. Median relapse-free survival and overall survival were 6.7 and 7.1 months, respectively. The most frequent AEs were pyrexia (58%), febrile neutropenia (40%), and headache (31%). Three patients had cytokine release syndrome (all grade 1 or 2), and three patients had grade 3 neurologic events, one of which (aphasia) required temporary treatment interruption. There were no grade 4 or 5 neurologic events. Conclusion Single-agent blinatumomab showed antileukemia activity in high-risk patients with Ph+ ALL who had relapsed or were refractory to TKIs. AEs were consistent with previous experience in Ph- ALL.
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Affiliation(s)
- Giovanni Martinelli
- Giovanni Martinelli and Cristina Papayannidis, Institute of Hematology and Medical Oncology "L. and A. Seràgnoli", Bologna; Alessandro Rambaldi, University of Milan Hematology and Bone Marrow Transplant Unit, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy; Nicolas Boissel, University Paris Diderot, Hôpital Saint-Louis, Paris; Patrice Chevallier, Centre Hospitalier Universitaire Nantes, Nantes, France; Oliver Ottmann, Cardiff University, Cardiff; Adele K. Fielding, University College London Cancer Institute, London, United Kingdom; Nicola Gökbuget, University Hospital, Goethe University, Frankfurt; Max S. Topp, Universitätsklinikum Würzburg, Würzburg, Germany; Ellen K. Ritchie, Weill Cornell Medical College and New York Presbyterian Hospital, New York, NY; Lulu Ren Sterling, Amgen, San Francisco; Jonathan Benjamin, Amgen, Thousand Oaks; and Anthony Stein, Gehr Family Center for Leukemia Research, City of Hope, Duarte, CA
| | - Nicolas Boissel
- Giovanni Martinelli and Cristina Papayannidis, Institute of Hematology and Medical Oncology "L. and A. Seràgnoli", Bologna; Alessandro Rambaldi, University of Milan Hematology and Bone Marrow Transplant Unit, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy; Nicolas Boissel, University Paris Diderot, Hôpital Saint-Louis, Paris; Patrice Chevallier, Centre Hospitalier Universitaire Nantes, Nantes, France; Oliver Ottmann, Cardiff University, Cardiff; Adele K. Fielding, University College London Cancer Institute, London, United Kingdom; Nicola Gökbuget, University Hospital, Goethe University, Frankfurt; Max S. Topp, Universitätsklinikum Würzburg, Würzburg, Germany; Ellen K. Ritchie, Weill Cornell Medical College and New York Presbyterian Hospital, New York, NY; Lulu Ren Sterling, Amgen, San Francisco; Jonathan Benjamin, Amgen, Thousand Oaks; and Anthony Stein, Gehr Family Center for Leukemia Research, City of Hope, Duarte, CA
| | - Patrice Chevallier
- Giovanni Martinelli and Cristina Papayannidis, Institute of Hematology and Medical Oncology "L. and A. Seràgnoli", Bologna; Alessandro Rambaldi, University of Milan Hematology and Bone Marrow Transplant Unit, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy; Nicolas Boissel, University Paris Diderot, Hôpital Saint-Louis, Paris; Patrice Chevallier, Centre Hospitalier Universitaire Nantes, Nantes, France; Oliver Ottmann, Cardiff University, Cardiff; Adele K. Fielding, University College London Cancer Institute, London, United Kingdom; Nicola Gökbuget, University Hospital, Goethe University, Frankfurt; Max S. Topp, Universitätsklinikum Würzburg, Würzburg, Germany; Ellen K. Ritchie, Weill Cornell Medical College and New York Presbyterian Hospital, New York, NY; Lulu Ren Sterling, Amgen, San Francisco; Jonathan Benjamin, Amgen, Thousand Oaks; and Anthony Stein, Gehr Family Center for Leukemia Research, City of Hope, Duarte, CA
| | - Oliver Ottmann
- Giovanni Martinelli and Cristina Papayannidis, Institute of Hematology and Medical Oncology "L. and A. Seràgnoli", Bologna; Alessandro Rambaldi, University of Milan Hematology and Bone Marrow Transplant Unit, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy; Nicolas Boissel, University Paris Diderot, Hôpital Saint-Louis, Paris; Patrice Chevallier, Centre Hospitalier Universitaire Nantes, Nantes, France; Oliver Ottmann, Cardiff University, Cardiff; Adele K. Fielding, University College London Cancer Institute, London, United Kingdom; Nicola Gökbuget, University Hospital, Goethe University, Frankfurt; Max S. Topp, Universitätsklinikum Würzburg, Würzburg, Germany; Ellen K. Ritchie, Weill Cornell Medical College and New York Presbyterian Hospital, New York, NY; Lulu Ren Sterling, Amgen, San Francisco; Jonathan Benjamin, Amgen, Thousand Oaks; and Anthony Stein, Gehr Family Center for Leukemia Research, City of Hope, Duarte, CA
| | - Nicola Gökbuget
- Giovanni Martinelli and Cristina Papayannidis, Institute of Hematology and Medical Oncology "L. and A. Seràgnoli", Bologna; Alessandro Rambaldi, University of Milan Hematology and Bone Marrow Transplant Unit, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy; Nicolas Boissel, University Paris Diderot, Hôpital Saint-Louis, Paris; Patrice Chevallier, Centre Hospitalier Universitaire Nantes, Nantes, France; Oliver Ottmann, Cardiff University, Cardiff; Adele K. Fielding, University College London Cancer Institute, London, United Kingdom; Nicola Gökbuget, University Hospital, Goethe University, Frankfurt; Max S. Topp, Universitätsklinikum Würzburg, Würzburg, Germany; Ellen K. Ritchie, Weill Cornell Medical College and New York Presbyterian Hospital, New York, NY; Lulu Ren Sterling, Amgen, San Francisco; Jonathan Benjamin, Amgen, Thousand Oaks; and Anthony Stein, Gehr Family Center for Leukemia Research, City of Hope, Duarte, CA
| | - Max S Topp
- Giovanni Martinelli and Cristina Papayannidis, Institute of Hematology and Medical Oncology "L. and A. Seràgnoli", Bologna; Alessandro Rambaldi, University of Milan Hematology and Bone Marrow Transplant Unit, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy; Nicolas Boissel, University Paris Diderot, Hôpital Saint-Louis, Paris; Patrice Chevallier, Centre Hospitalier Universitaire Nantes, Nantes, France; Oliver Ottmann, Cardiff University, Cardiff; Adele K. Fielding, University College London Cancer Institute, London, United Kingdom; Nicola Gökbuget, University Hospital, Goethe University, Frankfurt; Max S. Topp, Universitätsklinikum Würzburg, Würzburg, Germany; Ellen K. Ritchie, Weill Cornell Medical College and New York Presbyterian Hospital, New York, NY; Lulu Ren Sterling, Amgen, San Francisco; Jonathan Benjamin, Amgen, Thousand Oaks; and Anthony Stein, Gehr Family Center for Leukemia Research, City of Hope, Duarte, CA
| | - Adele K Fielding
- Giovanni Martinelli and Cristina Papayannidis, Institute of Hematology and Medical Oncology "L. and A. Seràgnoli", Bologna; Alessandro Rambaldi, University of Milan Hematology and Bone Marrow Transplant Unit, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy; Nicolas Boissel, University Paris Diderot, Hôpital Saint-Louis, Paris; Patrice Chevallier, Centre Hospitalier Universitaire Nantes, Nantes, France; Oliver Ottmann, Cardiff University, Cardiff; Adele K. Fielding, University College London Cancer Institute, London, United Kingdom; Nicola Gökbuget, University Hospital, Goethe University, Frankfurt; Max S. Topp, Universitätsklinikum Würzburg, Würzburg, Germany; Ellen K. Ritchie, Weill Cornell Medical College and New York Presbyterian Hospital, New York, NY; Lulu Ren Sterling, Amgen, San Francisco; Jonathan Benjamin, Amgen, Thousand Oaks; and Anthony Stein, Gehr Family Center for Leukemia Research, City of Hope, Duarte, CA
| | - Alessandro Rambaldi
- Giovanni Martinelli and Cristina Papayannidis, Institute of Hematology and Medical Oncology "L. and A. Seràgnoli", Bologna; Alessandro Rambaldi, University of Milan Hematology and Bone Marrow Transplant Unit, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy; Nicolas Boissel, University Paris Diderot, Hôpital Saint-Louis, Paris; Patrice Chevallier, Centre Hospitalier Universitaire Nantes, Nantes, France; Oliver Ottmann, Cardiff University, Cardiff; Adele K. Fielding, University College London Cancer Institute, London, United Kingdom; Nicola Gökbuget, University Hospital, Goethe University, Frankfurt; Max S. Topp, Universitätsklinikum Würzburg, Würzburg, Germany; Ellen K. Ritchie, Weill Cornell Medical College and New York Presbyterian Hospital, New York, NY; Lulu Ren Sterling, Amgen, San Francisco; Jonathan Benjamin, Amgen, Thousand Oaks; and Anthony Stein, Gehr Family Center for Leukemia Research, City of Hope, Duarte, CA
| | - Ellen K Ritchie
- Giovanni Martinelli and Cristina Papayannidis, Institute of Hematology and Medical Oncology "L. and A. Seràgnoli", Bologna; Alessandro Rambaldi, University of Milan Hematology and Bone Marrow Transplant Unit, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy; Nicolas Boissel, University Paris Diderot, Hôpital Saint-Louis, Paris; Patrice Chevallier, Centre Hospitalier Universitaire Nantes, Nantes, France; Oliver Ottmann, Cardiff University, Cardiff; Adele K. Fielding, University College London Cancer Institute, London, United Kingdom; Nicola Gökbuget, University Hospital, Goethe University, Frankfurt; Max S. Topp, Universitätsklinikum Würzburg, Würzburg, Germany; Ellen K. Ritchie, Weill Cornell Medical College and New York Presbyterian Hospital, New York, NY; Lulu Ren Sterling, Amgen, San Francisco; Jonathan Benjamin, Amgen, Thousand Oaks; and Anthony Stein, Gehr Family Center for Leukemia Research, City of Hope, Duarte, CA
| | - Cristina Papayannidis
- Giovanni Martinelli and Cristina Papayannidis, Institute of Hematology and Medical Oncology "L. and A. Seràgnoli", Bologna; Alessandro Rambaldi, University of Milan Hematology and Bone Marrow Transplant Unit, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy; Nicolas Boissel, University Paris Diderot, Hôpital Saint-Louis, Paris; Patrice Chevallier, Centre Hospitalier Universitaire Nantes, Nantes, France; Oliver Ottmann, Cardiff University, Cardiff; Adele K. Fielding, University College London Cancer Institute, London, United Kingdom; Nicola Gökbuget, University Hospital, Goethe University, Frankfurt; Max S. Topp, Universitätsklinikum Würzburg, Würzburg, Germany; Ellen K. Ritchie, Weill Cornell Medical College and New York Presbyterian Hospital, New York, NY; Lulu Ren Sterling, Amgen, San Francisco; Jonathan Benjamin, Amgen, Thousand Oaks; and Anthony Stein, Gehr Family Center for Leukemia Research, City of Hope, Duarte, CA
| | - Lulu Ren Sterling
- Giovanni Martinelli and Cristina Papayannidis, Institute of Hematology and Medical Oncology "L. and A. Seràgnoli", Bologna; Alessandro Rambaldi, University of Milan Hematology and Bone Marrow Transplant Unit, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy; Nicolas Boissel, University Paris Diderot, Hôpital Saint-Louis, Paris; Patrice Chevallier, Centre Hospitalier Universitaire Nantes, Nantes, France; Oliver Ottmann, Cardiff University, Cardiff; Adele K. Fielding, University College London Cancer Institute, London, United Kingdom; Nicola Gökbuget, University Hospital, Goethe University, Frankfurt; Max S. Topp, Universitätsklinikum Würzburg, Würzburg, Germany; Ellen K. Ritchie, Weill Cornell Medical College and New York Presbyterian Hospital, New York, NY; Lulu Ren Sterling, Amgen, San Francisco; Jonathan Benjamin, Amgen, Thousand Oaks; and Anthony Stein, Gehr Family Center for Leukemia Research, City of Hope, Duarte, CA
| | - Jonathan Benjamin
- Giovanni Martinelli and Cristina Papayannidis, Institute of Hematology and Medical Oncology "L. and A. Seràgnoli", Bologna; Alessandro Rambaldi, University of Milan Hematology and Bone Marrow Transplant Unit, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy; Nicolas Boissel, University Paris Diderot, Hôpital Saint-Louis, Paris; Patrice Chevallier, Centre Hospitalier Universitaire Nantes, Nantes, France; Oliver Ottmann, Cardiff University, Cardiff; Adele K. Fielding, University College London Cancer Institute, London, United Kingdom; Nicola Gökbuget, University Hospital, Goethe University, Frankfurt; Max S. Topp, Universitätsklinikum Würzburg, Würzburg, Germany; Ellen K. Ritchie, Weill Cornell Medical College and New York Presbyterian Hospital, New York, NY; Lulu Ren Sterling, Amgen, San Francisco; Jonathan Benjamin, Amgen, Thousand Oaks; and Anthony Stein, Gehr Family Center for Leukemia Research, City of Hope, Duarte, CA
| | - Anthony Stein
- Giovanni Martinelli and Cristina Papayannidis, Institute of Hematology and Medical Oncology "L. and A. Seràgnoli", Bologna; Alessandro Rambaldi, University of Milan Hematology and Bone Marrow Transplant Unit, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy; Nicolas Boissel, University Paris Diderot, Hôpital Saint-Louis, Paris; Patrice Chevallier, Centre Hospitalier Universitaire Nantes, Nantes, France; Oliver Ottmann, Cardiff University, Cardiff; Adele K. Fielding, University College London Cancer Institute, London, United Kingdom; Nicola Gökbuget, University Hospital, Goethe University, Frankfurt; Max S. Topp, Universitätsklinikum Würzburg, Würzburg, Germany; Ellen K. Ritchie, Weill Cornell Medical College and New York Presbyterian Hospital, New York, NY; Lulu Ren Sterling, Amgen, San Francisco; Jonathan Benjamin, Amgen, Thousand Oaks; and Anthony Stein, Gehr Family Center for Leukemia Research, City of Hope, Duarte, CA
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Wang L, Liu DH. Tyrosine Kinase Inhibitor for Treatment of Adult Allogeneic Hematopoietic Stem Cell Transplantation Candidate with Philadelphia-Positive Acute Lymphoblastic Leukemia. Chin Med J (Engl) 2017; 130:127-129. [PMID: 28091401 PMCID: PMC5282666 DOI: 10.4103/0366-6999.197976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Indexed: 12/03/2022] Open
Affiliation(s)
- Lu Wang
- Department of Hematology, Chinese People's Liberation Army General Hospital, Beijing 100082, China
| | - Dai-Hong Liu
- Department of Hematology, Chinese People's Liberation Army General Hospital, Beijing 100082, China
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77
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Chiaretti S, Gianfelici V, O'Brien SM, Mullighan CG. Advances in the Genetics and Therapy of Acute Lymphoblastic Leukemia. Am Soc Clin Oncol Educ Book 2017; 35:e314-22. [PMID: 27249738 DOI: 10.1200/edbk_156628] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Acute lymphoblastic leukemia (ALL) remains an important cause of morbidity in children and adults. In this article, we highlight advances in the genetics and therapy of three key subtypes of ALL: T-cell ALL, BCR-ABL1 (Philadelphia [Ph] chromosone-positive), and Ph-like ALL. T-ALL is an aggressive disease that accounts for about 15% and 25% of ALL among pediatric and adult cohorts, respectively, and exhibits a multistep nature of cancer initiation and progression. The integration of cytogenetics, molecular biology, and immunophenotype analyses has led to the identification of defined T-ALL subgroups, such as early T-cell precursor ALL and novel lesions with a prognostic role, for which specific inhibitors are being developed. Ph-positive ALL was historically regarded as a subtype of ALL with a poor prognosis, and allogeneic stem cell transplant was recommended for all patients who could undergo this procedure. The deep complete responses seen with combination tyrosine kinase inhibitors (TKIs) and chemotherapy in Ph-positive ALL, and the reports of long-term survival among some patients not undergoing allogeneic stem cell transplant, has raised the question of whether there is a subset of patients who could be cured without this intervention. Ph-like ALL is a subtype of B-progenitor ALL common among older children and adults and associated with a diverse range of genetic alterations that activate kinase signaling. Ph-like ALL is also associated with poor outcome, for which precision medicine trials identifying kinase alterations and testing TKI therapy are being developed.
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Affiliation(s)
- Sabina Chiaretti
- From the Department of Cellular Biotechnologies and Hematology, Sapienza University of Rome, Rome, Italy; Chao Family Comprehensive Cancer Center, School of Medicine, University of California, Irvine, CA; Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN
| | - Valentina Gianfelici
- From the Department of Cellular Biotechnologies and Hematology, Sapienza University of Rome, Rome, Italy; Chao Family Comprehensive Cancer Center, School of Medicine, University of California, Irvine, CA; Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN
| | - Susan M O'Brien
- From the Department of Cellular Biotechnologies and Hematology, Sapienza University of Rome, Rome, Italy; Chao Family Comprehensive Cancer Center, School of Medicine, University of California, Irvine, CA; Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN
| | - Charles G Mullighan
- From the Department of Cellular Biotechnologies and Hematology, Sapienza University of Rome, Rome, Italy; Chao Family Comprehensive Cancer Center, School of Medicine, University of California, Irvine, CA; Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN
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78
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Paul S, Kantarjian H, Jabbour EJ. Adult Acute Lymphoblastic Leukemia. Mayo Clin Proc 2016; 91:1645-1666. [PMID: 27814839 DOI: 10.1016/j.mayocp.2016.09.010] [Citation(s) in RCA: 128] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 09/26/2016] [Accepted: 09/26/2016] [Indexed: 02/08/2023]
Abstract
Conventional cytotoxic chemotherapy used to treat acute lymphoblastic leukemia (ALL) results in high cure rates in pediatric patients but is suboptimal in the treatment of adult patients. The 5-year overall survival is approximately 90% in children and 30% to 40% in adults and elderly patients. Adults with ALL tend to have higher risk factors at diagnosis, more comorbidities, and increasing age that often requires dose reductions. Major advancements have been made in redefining the pathologic classification of ALL, identifying new cytogenetic-molecular abnormalities, and developing novel targeted agents in order to improve survival. The addition of new monoclonal antibodies and tyrosine kinase inhibitors to conventional chemotherapy in the frontline setting has resulted in increased rates of complete remission and overall survival. These new developments are changing the treatment of adult ALL from a "one therapy fits all" approach to individualized treatment based on patient's cytogenetic and molecular profile.
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Affiliation(s)
- Shilpa Paul
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Hagop Kantarjian
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Elias J Jabbour
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX.
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79
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Thomas X, Heiblig M. Diagnostic and treatment of adult Philadelphia chromosome-positive acute lymphoblastic leukemia. Int J Hematol Oncol 2016; 5:77-90. [PMID: 30302206 PMCID: PMC6171979 DOI: 10.2217/ijh-2016-0009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 08/30/2016] [Indexed: 01/24/2023] Open
Abstract
The outcome of adult patients with Philadelphia chromosome-positive (Ph+) acute lymphoblastic leukemia (ALL) has improved substantially with the introduction of tyrosine kinase inhibitors (TKIs). TKIs are now integral components of therapy for Ph+ ALL. The current consensus is that they improve patient outcomes compared with historical control patients treated with chemotherapy alone, and increase the number of patients able to receive stem cell transplant. New challenges have emerged with respect to induction of resistance mainly via Abelson tyrosine kinase mutations. Several novel kinase inhibitors with significantly more potent antileukemic activity are currently being developed. Furthermore novel immune therapies, which recruit or modify patient's own T cells to fight leukemic cells, are being developed and could find an important place in Ph+ ALL therapy by few years. In this article, we reviewed treatment approaches in adults with Ph+ ALL with a focus on TKIs and combined chemotherapy regimens.
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Affiliation(s)
- Xavier Thomas
- Hematology Department, Lyon-Sud Hospital, Hospices Civils de Lyon, Pierre Bénite, France
| | - Maël Heiblig
- Hematology Department, Lyon-Sud Hospital, Hospices Civils de Lyon, Pierre Bénite, France
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80
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Chiaretti S, Vitale A, Vignetti M, Piciocchi A, Fazi P, Elia L, Falini B, Ronco F, Ferrara F, De Fabritiis P, Luppi M, La Nasa G, Tedeschi A, Califano C, Fanin R, Dore F, Mandelli F, Meloni G, Foà R. A sequential approach with imatinib, chemotherapy and transplant for adult Ph+ acute lymphoblastic leukemia: final results of the GIMEMA LAL 0904 study. Haematologica 2016; 101:1544-1552. [PMID: 27515250 DOI: 10.3324/haematol.2016.144535] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 08/09/2016] [Indexed: 01/09/2023] Open
Abstract
In the GIMEMA LAL 0904 protocol, adult Philadelphia positive acute lymphoblastic leukemia patients were treated with chemotherapy for induction and consolidation, followed by maintenance with imatinib. The protocol was subsequently amended and imatinib was incorporated in the induction and post-remission phase together with chemotherapy. Due to the toxicity of this combined approach, the protocol was further amended to a sequential scheme based on imatinib plus steroids as induction, followed by consolidation with chemotherapy plus imatinib and, when applicable, by a hematopoietic stem cell transplant. Fifty-one patients (median age 45.9 years) were enrolled in the final sequential protocol. At the end of induction (day +50), 96% of evaluable patients (n=49) achieved a complete hematologic remission; after consolidation, all were in complete hematologic remission. No deaths in induction were recorded. Overall survival and disease-free survival at 60 months are 48.8% and 45.8%, respectively. At day +50 (end of imatinib induction), a more than 1.3 log-reduction of BCR-ABL1 levels was associated with a significantly longer disease-free survival (55.6%, 95%CI: 39.0-79.3 vs. 20%, 95%CI: 5.8-69.1; P=0.03), overall survival (59.1%, 95%CI: 42.3-82.6 vs. 20%, 95%CI: 5.8-69.1; P=0.02) and lower incidence of relapse (20.5%, 95%CI: 7.2-38.6 vs. 60.0%, 95%CI: 21.6-84.3; P=0.01). Mean BCR-ABL1 levels remained significantly higher in patients who subsequently relapsed. Finally, BCR-ABL1p190 patients showed a significantly faster molecular response than BCR-ABL1p210 patients (P=0.023). Though the study was not powered to evaluate the role of allogeneic stem cell transplant, allografting positively impacted on both overall and disease-free survival. In conclusion, a sequential approach with imatinib alone in induction, consolidated by chemotherapy plus imatinib followed by a stem cell transplant is a feasible, well-tolerated and effective strategy for adult Philadelphia positive acute lymphoblastic leukemia, leading to the best long-term survival rates so far reported. (clinicaltrials.gov identifier: 00458848).
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Affiliation(s)
- Sabina Chiaretti
- Hematology, Department of Cellular Biotechnologies and Hematology, Policlinico Umberto 1, "Sapienza" University of Rome, Italy
| | - Antonella Vitale
- Hematology, Department of Cellular Biotechnologies and Hematology, Policlinico Umberto 1, "Sapienza" University of Rome, Italy
| | | | | | | | - Loredana Elia
- Hematology, Department of Cellular Biotechnologies and Hematology, Policlinico Umberto 1, "Sapienza" University of Rome, Italy
| | | | - Francesca Ronco
- Hematology Unit, Azienda Ospedaliera Bianchi Melacrino Morelli, Reggio Calabria, Italy
| | - Felicetto Ferrara
- Division of Hematology and Stem Cell Transplantation Unit, Cardarelli Hospital, Naples, Italy
| | - Paolo De Fabritiis
- Hematology Unit and Department of Pharmacy Services, Sant'Eugenio Hospital, Rome, Italy
| | - Mario Luppi
- Hematology Division, Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Giorgio La Nasa
- Hematology Unit, Department of Medical Sciences, University of Cagliari, Italy
| | - Alessandra Tedeschi
- Department of Oncology/Hematology, Niguarda Cancer Center, Niguarda Ca' Granda Hospital, Milano, Italy
| | | | - Renato Fanin
- Division of Hematology and Bone Marrow Transplantation, University Hospital, Udine, Italy
| | - Fausto Dore
- Department of Biomedical Sciences, University of Sassari, Italy
| | | | - Giovanna Meloni
- Hematology, Department of Cellular Biotechnologies and Hematology, Policlinico Umberto 1, "Sapienza" University of Rome, Italy
| | - Robin Foà
- Hematology, Department of Cellular Biotechnologies and Hematology, Policlinico Umberto 1, "Sapienza" University of Rome, Italy
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El Fakih R, Kharfan-Dabaja MA, Aljurf M. Refining the Role of Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia as Novel Therapies Emerge. Biol Blood Marrow Transplant 2016; 22:2126-2133. [PMID: 27375123 DOI: 10.1016/j.bbmt.2016.06.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Accepted: 06/27/2016] [Indexed: 11/26/2022]
Abstract
Acute lymphoblastic leukemia (ALL) is a rare adult neoplasm. The disorder consists of precursor B or T phenotypes. In the pediatric population, ALL was a success story in that 80% of children with ALL enjoy long-term survival. In adults, similar complete remission rates are achieved with current induction regimens; however, less than 50% of patients are alive at 5 years, with most deaths due to relapsed disease. Accordingly, optimizing post remission consolidation therapy might improve in outcomes. Such strategies may include chemotherapy and autologous or allogeneic transplant. Moreover, the ability to modify such therapy based on better disease risk stratification while taking into account patient characteristics such as performance status and presence of comorbidities is necessary to tailor treatment accordingly. Here, we review available medical literature on the use of hematopoietic cell transplantation as a consolidation modality in the treatment of adult ALL.
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Affiliation(s)
- Riad El Fakih
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia.
| | - Mohamed A Kharfan-Dabaja
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Mahmoud Aljurf
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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82
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Hematopoietic Cell Transplantation for Acute Lymphoblastic Leukemia in Adults. Curr Hematol Malig Rep 2016; 11:175-84. [DOI: 10.1007/s11899-016-0317-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Al Ustwani O, Gupta N, Bakhribah H, Griffiths E, Wang E, Wetzler M. Clinical updates in adult acute lymphoblastic leukemia. Crit Rev Oncol Hematol 2015; 99:189-99. [PMID: 26777876 DOI: 10.1016/j.critrevonc.2015.12.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Revised: 11/30/2015] [Accepted: 12/15/2015] [Indexed: 12/29/2022] Open
Abstract
Acute lymphoblastic leukemia (ALL) is a clonal disease characterized by B or T lineage. Here we cover the clinical manifestations, pathophysiology and therapy for ALL. Additionally, we will discuss the evidence for minimal residual disease assessment, novel molecular targets and newly developed targeted therapies. The separation of ALL into Philadelphia chromosome positive and recently into Philadelphia-like disease represents the most exciting developments in this disease. Finally, the advent of new immunotherapeutic approaches led us to predict that in few years, ALL therapy might be based heavily on non-chemotherapeutic approaches.
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Affiliation(s)
- Omar Al Ustwani
- Leukemia Section, Department of Medicine, Roswell Park Cancer Institute, Buffalo, New York, United States.
| | - Neha Gupta
- Department of Medicine, State University of New York at Buffalo, Buffalo, New York, United States
| | - Hatoon Bakhribah
- Leukemia Section, Department of Medicine, Roswell Park Cancer Institute, Buffalo, New York, United States
| | - Elizabeth Griffiths
- Leukemia Section, Department of Medicine, Roswell Park Cancer Institute, Buffalo, New York, United States
| | - Eunice Wang
- Leukemia Section, Department of Medicine, Roswell Park Cancer Institute, Buffalo, New York, United States
| | - Meir Wetzler
- Leukemia Section, Department of Medicine, Roswell Park Cancer Institute, Buffalo, New York, United States
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Abstract
Abstract
Philadelphia-positive acute lymphoblastic leukemia (Ph+ ALL) has been regarded for decades as the ALL subgroup with the worse outcome. It represents the most frequent genetic subtype of adult ALL, and increases progressively with age. The introduction of tyrosine kinase inhibitors (TKIs) has enabled to obtain complete hematologic remissions (CHRs) in virtually all patients, including the elderly, to improve disease-free survival and overall survival, as well as to increase the percentage of patients who can undergo an allogeneic stem cell transplant (allo-SCT).
The current management of adult Ph+ ALL patients relies on the use of a TKI with or without chemotherapy followed by an allo-SCT, which still remains the only curative option. Minimal residual disease screening is permitting not only a better stratification of patients, but has also allowed to reconsider the role of autologous stem cell transplant for a set of patients who do not have a donor or are not eligible for an allo-SCT. At present, clinical challenges are represented by the emergence of resistant mutations, particularly the gatekeeper T315I, for which alternative approaches, comprising novel TKIs or therapies based on the combination of TKI with immunotherapeutic strategies, are being considered in order to overcome resistance.
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Abstract
Blinatumomab is a novel bispecific CD19-directed CD3 T-cell engager recently approved for the treatment of relapsed or refractory Ph-negative acute lymphoblastic leukemia in adults. The drug was approved after a phase II trial in adults with relapsed/refractory disease demonstrated complete remission or hematologic complete remission in 43% of patients within two treatment cycles, of which 40% went on to receive an allogeneic hematopoietic stem cell transplant. In a long-term survival analysis of patients with minimal residual disease after chemotherapy, hematologic relapse-free survival was estimated at 61% at a median of 33 months after blinatumomab. Nine patients underwent hematopoietic stem cell transplant, and six patients remained in complete remission without hematopoietic stem cell transplant or further therapy. Limited data in relapsed pediatric acute lymphoblastic leukemia are reviewed. Blinatumomab carries boxed warnings for neurotoxicity and cytokine release syndrome, which may be serious and lead to treatment interruption and discontinuation. Clinical controversies with blinatumomab include use in patients with Ph-positive acute lymphoblastic leukemia, dosing in underweight adults, and the optimal management of cytokine release syndrome. Oncology pharmacists must be aware of detailed preparation and administration procedures required for safe use of blinatumomab. Clinical trials are ongoing in the first-line setting for patients with Ph-negative acute lymphoblastic leukemia, in Ph-positive acute lymphoblastic leukemia, and other B-cell malignancies.
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Affiliation(s)
- Matthew J Newman
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Dina J Benani
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD, USA
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86
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Huguet F. Dasatinib for acute lymphoblastic leukemia. Expert Opin Orphan Drugs 2015. [DOI: 10.1517/21678707.2015.1098530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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87
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Liu Q, Yang D, Feng S. [The impact of imatinib on hematopoietic stem cell transplantation for Ph chromosome positive adult acute lymphoblastic leukemia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2015; 36:805-8. [PMID: 26462789 PMCID: PMC7342702 DOI: 10.3760/cma.j.issn.0253-2727.2015.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Qingzhen Liu
- Institute of Hematology and Blood Disease Hospital, CAMS & PUMC, Tianjin 300020, China
| | - Donglin Yang
- Institute of Hematology and Blood Disease Hospital, CAMS & PUMC, Tianjin 300020, China
| | - Sizhou Feng
- Institute of Hematology and Blood Disease Hospital, CAMS & PUMC, Tianjin 300020, China
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Jabbour E, Kantarjian H, Ravandi F, Thomas D, Huang X, Faderl S, Pemmaraju N, Daver N, Garcia-Manero G, Sasaki K, Cortes J, Garris R, Yin CC, Khoury JD, Jorgensen J, Estrov Z, Bohannan Z, Konopleva M, Kadia T, Jain N, DiNardo C, Wierda W, Jeanis V, O'Brien S. Combination of hyper-CVAD with ponatinib as first-line therapy for patients with Philadelphia chromosome-positive acute lymphoblastic leukaemia: a single-centre, phase 2 study. Lancet Oncol 2015; 16:1547-1555. [PMID: 26432046 DOI: 10.1016/s1470-2045(15)00207-7] [Citation(s) in RCA: 202] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 07/27/2015] [Accepted: 07/28/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Combination of chemotherapy with a tyrosine-kinase inhibitor is effective in the treatment of Philadelphia chromosome-positive acute lymphoblastic leukaemia. Ponatinib is a more potent BCR-ABL1 inhibitor than all other tyrosine-kinase inhibitors and selectively suppresses the resistant T315I clones. We examined the activity and safety of combining chemotherapy with ponatinib for patients with Philadelphia chromosome-positive acute lymphoblastic leukaemia in this continuing phase 2 trial. METHODS In this single-centre, phase 2, single-arm trial, adult patients with previously untreated Philadelphia chromosome-positive acute lymphoblastic leukaemia were sequentially enrolled. Patients who had received fewer than two courses of previous chemotherapy with or without tyrosine-kinase inhibitors were also eligible. Patients had to be aged 18 years or older, have an Eastern Cooperative Oncology Group performance status of 2 or less, have normal cardiac function (defined by ejection fraction above 50%), and have adequate organ function (serum bilirubin ≤3·0 mg/dL and serum creatinine ≤3·0 mg/dL, unless higher concentrations were believed to be due to a tumour). Patients received eight cycles of hyperfractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone (hyper-CVAD) alternating with high-dose methotrexate and cytarabine every 21 days. Ponatinib 45 mg was given daily for the first 14 days of cycle 1 then continuously for the subsequent cycles. Patients in complete remission received maintenance with ponatinib 45 mg daily with vincristine and prednisone monthly for 2 years followed by ponatinib indefinitely. The primary endpoint for this study was event-free survival. The trial is registered at ClinicalTrials.gov, number NCT01424982. FINDINGS 37 patients were enrolled and treated from Nov 1, 2011, to Sept 1, 2013. 2-year event-free survival rate was 81% (95% CI 64-90). Grade 3 or more toxic effects included infections during induction (20 [54%] patients), increased aspartate aminotransferase and alanine aminotransferase concentration (14 [38%] patients), thrombotic events (three [8%]), myocardial infarction (three [8%]), hypertension (six [16%]), skin rash (eight [22%]), and pancreatitis (six [16%] patients). Two patients died from from myocardial infarction potentially related to treatment; another patient also died from myocardial infarction related to sepsis. Two further patients died, one from bleeding and another from infection, both deemed unrelated to treatment. INTERPRETATION The first results of this ongoing trial indicate that the combination of chemotherapy with ponatinib is effective in achieving early sustained remissions in patients with newly diagnosed Philadelphia chromosome-positive acute lymphoblastic leukaemia. New strategies, including dosing titration of ponatinib and optimised control of vascular risk factors, might further improve outcomes. FUNDING ARIAD Pharmaceuticals Inc.
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Affiliation(s)
- Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Deborah Thomas
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Xuelin Huang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Stefan Faderl
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naval Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Koji Sasaki
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jorge Cortes
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rebecca Garris
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - C Cameron Yin
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph D Khoury
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey Jorgensen
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zeev Estrov
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zachary Bohannan
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Marina Konopleva
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tapan Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Courtney DiNardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William Wierda
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Vicky Jeanis
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Susan O'Brien
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Impact of MRD and TKI on allogeneic hematopoietic cell transplantation for Ph+ALL: a study from the adult ALL WG of the JSHCT. Bone Marrow Transplant 2015; 51:43-50. [PMID: 26389833 DOI: 10.1038/bmt.2015.217] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 08/03/2015] [Indexed: 11/08/2022]
Abstract
To assess the impact of minimal residual disease (MRD) and tyrosine kinase inhibitor (TKI) administration on allogeneic hematopoietic cell transplantation (allo-HCT) for Ph-positive ALL (Ph+ALL), we retrospectively analyzed data from a registry database for 432 adult Ph+ALL patients in first CR (CR1) who received pre-transplant TKI administration. Negative MRD (MRD(-)) at allo-HCT was achieved in 277 patients. OS in patients transplanted in MRD(-) was significantly better than that in patients transplanted in MRD(+) (MRD(-): 67% vs MRD(+): 55% at 4 years; P=0.001). MRD(-) at allo-HCT was a significant risk factor for survival along with age at allo-HCT in multivariate analyses. Incidence of relapse in patients transplanted in MRD(-) was significantly lower than that in patients transplanted in MRD(+) (MRD(-): 19% vs MRD(+): 29% at 4 years; P=0.006). In multivariate analyses, MRD(+) at allo-HCT was a significant risk factor for relapse. A post-transplant TKI was administered to 103 patients. In subanalyses regarding the effect of post-transplant TKI administration, post-transplant TKI administration was a significant risk factor for relapse in multivariate analyses (P<0.0001). MRD status at allo-HCT is one of the most important predictive factors for Ph+ALL patients transplanted in CR1.
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90
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Ravandi F, O'Brien SM, Cortes JE, Thomas DM, Garris R, Faderl S, Burger JA, Rytting ME, Ferrajoli A, Wierda WG, Verstovsek S, Champlin R, Kebriaei P, McCue DA, Huang X, Jabbour E, Garcia-Manero G, Estrov Z, Kantarjian HM. Long-term follow-up of a phase 2 study of chemotherapy plus dasatinib for the initial treatment of patients with Philadelphia chromosome-positive acute lymphoblastic leukemia. Cancer 2015; 121:4158-64. [PMID: 26308885 DOI: 10.1002/cncr.29646] [Citation(s) in RCA: 149] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 07/01/2015] [Accepted: 07/16/2015] [Indexed: 11/08/2022]
Abstract
BACKGROUND The long-term efficacy of a combination of chemotherapy and dasatinib in patients with Philadelphia chromosome-positive (Ph+) acute lymphoblastic leukemia (ALL) is not well established. METHODS Patients received dasatinib with 8 cycles of alternating hyperfractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone and high-dose cytarabine and methotrexate. Patients in complete remission (CR) continued maintenance dasatinib, vincristine, and prednisone for 2 years, which was followed by dasatinib indefinitely. Patients eligible for allogeneic stem cell transplantation (SCT) received it during their first CR. RESULTS Seventy-two patients with a median age of 55 years (range, 21-80 years) were treated; 69 (96%) achieved CR. Among them, 57 (83%) achieved cytogenetic CR after 1 cycle, and 64 (93%) achieved a major molecular response at a median of 4 weeks (range, 2-38 weeks). Sixty-five patients (94%) were negative for minimal residual disease assessed by flow cytometry at a median of 3 weeks (range, 2-37 weeks). Dasatinib-related grade 3 and 4 adverse events included bleeding, pleural/pericardial effusions, and elevated transaminases. With a median follow-up of 67 months (range, 33-97 months), 33 patients (46%) were alive, and 30 (43%) were in CR; 12 underwent allogeneic SCT. Thirty-nine patients died (3 at induction, 19 after relapse, 7 after SCT performed during first CR, and 10 during CR). The median disease-free survival and overall survival were 31 (range, 0.3-97 months) and 47 months (range, 0.2-97 months), respectively. Seven relapsed patients had BCR-ABL kinase domain mutations, including 4 with T315I. CONCLUSIONS A combination of chemotherapy with dasatinib is effective in achieving long-term remission for patients with newly diagnosed Ph + ALL.
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Affiliation(s)
- Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Susan M O'Brien
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jorge E Cortes
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Deborah M Thomas
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Rebecca Garris
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Stefan Faderl
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jan A Burger
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael E Rytting
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Alessandra Ferrajoli
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - William G Wierda
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Srdan Verstovsek
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Richard Champlin
- Department of Cellular Therapy and Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Partow Kebriaei
- Department of Cellular Therapy and Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Deborah A McCue
- Department of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Xuelin Huang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Zeev Estrov
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Hagop M Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
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91
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Beyond Philadelphia: 'Ph-like' B cell precursor acute lymphoblastic leukemias - diagnostic challenges and therapeutic promises. Curr Opin Hematol 2015; 21:289-96. [PMID: 24848770 DOI: 10.1097/moh.0000000000000050] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW The presence of the Philadelphia chromosome causing the fusion between BCR to ABL1 in B cell precursor acute lymphoblastic leukemias (ALLs) was associated with a particularly bad prognosis, which has been markedly improved with the addition of imatinib to chemotherapy. Recent genomic studies have lead to the identification of 'Philadelphia like' or 'BCR-ABL1 like' ALLs lacking BCR-ABL1 fusion. RECENT FINDINGS About 10% of childhood ALL and a higher percentage of adolescents and adults with ALLs are characterized by activation of cytokine receptors and signaling kinases. Aberrant expression, point mutations or fusion translocations cause activation of either the ABL1 or JAK signaling pathways. In general, these leukemias are associated with worse prognosis. Preclinical studies and limited clinical experience suggest that these leukemias respond to tyrosine kinase inhibitors. Thus, their identification is important. However, as most of these fusion translocations are rare, their diagnosis is challenging. SUMMARY The diagnosis of 'Philadelphia like' poor prognosis ALLs is technically challenging but of paramount importance as they are likely to respond to targeted therapy with currently available ABL or JAK inhibitors.
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Šálek C, Folber F, Froňková E, Procházka B, Marinov I, Cetkovský P, Mayer J, Doubek M. Early MRD response as a prognostic factor in adult patients with acute lymphoblastic leukemia. Eur J Haematol 2015; 96:276-84. [DOI: 10.1111/ejh.12587] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2015] [Indexed: 01/23/2023]
Affiliation(s)
- Cyril Šálek
- Institute of Hematology and Blood Transfusion; Prague Czech Republic
| | - František Folber
- Department of Internal Medicine, Hematology and Oncology; University Hospital Brno; Brno Czech Republic
| | - Eva Froňková
- Department of Pediatric Hematology and Oncology; 2nd Faculty of Medicine; Charles University and University Hospital Motol; Prague Czech Republic
| | - Bohumír Procházka
- Institute of Hematology and Blood Transfusion; Prague Czech Republic
| | - Iuri Marinov
- Institute of Hematology and Blood Transfusion; Prague Czech Republic
| | - Petr Cetkovský
- Institute of Hematology and Blood Transfusion; Prague Czech Republic
| | - Jiří Mayer
- Department of Internal Medicine, Hematology and Oncology; University Hospital Brno; Brno Czech Republic
| | - Michael Doubek
- Department of Internal Medicine, Hematology and Oncology; University Hospital Brno; Brno Czech Republic
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93
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Nilotinib combined with multiagent chemotherapy for newly diagnosed Philadelphia-positive acute lymphoblastic leukemia. Blood 2015; 126:746-56. [PMID: 26065651 DOI: 10.1182/blood-2015-03-636548] [Citation(s) in RCA: 133] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 06/05/2015] [Indexed: 11/20/2022] Open
Abstract
We investigated the effects of nilotinib plus multiagent chemotherapy, followed by consolidation/maintenance or allogeneic hematopoietic cell transplantation (allo-HCT) for adult patients with newly diagnosed Philadelphia-positive (Ph-pos) acute lymphoblastic leukemia (ALL). Study subjects received induction treatment that comprised concurrent vincristine, daunorubicin, prednisolone, and nilotinib. After achieving complete hematologic remission (HCR), subjects received either 5 courses of consolidation, followed by 2-year maintenance with nilotinib, or allo-HCT. Minimal residual disease (MRD) was assessed at HCR, and every 3 months thereafter. The molecular responses (MRs) were defined as MR3 for BCR-ABL1/G6PDH ratios ≤10(-3) and MR5 for ratios <10(-5). Ninety evaluable subjects, ages 17 to 71 years, were enrolled in 17 centers. The HCR rate was 91%; 57 subjects received allo-HCT. The cumulative MR5 rate was 94%; the 2-year hematologic relapse-free survival (HRFS) rate was 72% for 82 subjects that achieved HCR, and the 2-year overall survival rate was 72%. Subjects that failed to achieve MR3 or MR5 were 9.1 times (P = .004) or 6.3 times (P = .001) more prone to hematologic relapse, respectively, than those that achieved MR3 or MR5. MRD statuses just before allo-HCT and at 3 months after allo-HCT were predictive of 2-year HRFS. Adverse events occurred mainly during induction, and most were reversible with dose reduction or transient interruption of nilotinib. The combination of nilotinib with high-dose cytotoxic drugs was feasible, and it effectively achieved high cumulative complete molecular remission and HRFS rates. The MRD status at early postremission time was predictive of the HRFS. This trial was registered at www.clinicaltrials.gov as #NCT00844298.
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94
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Retrospective Study of Allogeneic Hematopoietic Stem Cell Transplantation in Philadelphia Chromosome–Positive Leukemia: 25 Years' Experience at Gustave Roussy Cancer Campus. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2015; 15 Suppl:S129-40. [DOI: 10.1016/j.clml.2015.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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95
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Jabbour E, O'Brien S, Konopleva M, Kantarjian H. New insights into the pathophysiology and therapy of adult acute lymphoblastic leukemia. Cancer 2015; 121:2517-28. [PMID: 25891003 DOI: 10.1002/cncr.29383] [Citation(s) in RCA: 172] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 02/26/2015] [Accepted: 03/02/2015] [Indexed: 01/13/2023]
Abstract
Significant advances have been made in the last decade toward a better understanding of the disease pathogenesis and the development of novel therapies that target specific subsets of adult acute lymphoblastic leukemia (ALL). Risk-adapted strategies are transforming the disease treatment and prognosis. With current treatment regimens, long-term survival is achieved by approximately 50% of patients with B-cell ALL, 50% to 60% of patients with Philadelphia chromosome-positive ALL, and approximately 80% of patients with Burkitt's leukemia. Genomic profiling in ALL has identified new prognostic markers, new therapeutic targets, and novel ALL subtypes. These may be amenable to future targeted therapies that can further improve outcomes. The early recognition of early precursor T-cell ALL, a distinct pathobiological entity with a poor prognosis, is essential for the development of an effective clinical management strategy. The role of monoclonal antibodies and cytotoxic T-cell therapies continues to be defined. Many of the approaches are currently being evaluated for ALL salvage. Their incorporation into frontline adult ALL therapy, in concomitant or sequential strategies, may increase the cure rates to levels achieved in pediatric ALL and may reduce the need for prolonged intensive and maintenance chemotherapy.
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Affiliation(s)
- Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Susan O'Brien
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Marina Konopleva
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
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96
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Randomized study of reduced-intensity chemotherapy combined with imatinib in adults with Ph-positive acute lymphoblastic leukemia. Blood 2015; 125:3711-9. [PMID: 25878120 DOI: 10.1182/blood-2015-02-627935] [Citation(s) in RCA: 243] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 04/11/2015] [Indexed: 01/28/2023] Open
Abstract
In this study, we randomly compared high doses of the tyrosine kinase inhibitor imatinib combined with reduced-intensity chemotherapy (arm A) to standard imatinib/hyperCVAD (cyclophosphamide/vincristine/doxorubicin/dexamethasone) therapy (arm B) in 268 adults (median age, 47 years) with Philadelphia chromosome-positive (Ph+) acute lymphoblastic leukemia (ALL). The primary objective was the major molecular response (MMolR) rate after cycle 2, patients being then eligible for allogeneic stem cell transplantation (SCT) if they had a donor, or autologous SCT if in MMolR and no donor. With fewer induction deaths, the complete remission (CR) rate was higher in arm A than in arm B (98% vs 91%; P = .006), whereas the MMolR rate was similar in both arms (66% vs 64%). With a median follow-up of 4.8 years, 5-year event-free survival and overall survival (OS) rates were estimated at 37.1% and 45.6%, respectively, without difference between the arms. Allogeneic transplantation was associated with a significant benefit in relapse-free survival (hazard ratio [HR], 0.69; P = .036) and OS (HR, 0.64; P = .02), with initial white blood cell count being the only factor significantly interacting with this SCT effect. In patients achieving MMolR, outcome was similar after autologous and allogeneic transplantation. This study validates an induction regimen combining reduced-intensity chemotherapy and imatinib in Ph+ ALL adult patients and suggests that SCT in first CR is still a good option for Ph+ ALL adult patients. This trial was registered at www.clinicaltrials.gov as #NCT00327678.
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97
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Brissot E, Labopin M, Beckers MM, Socié G, Rambaldi A, Volin L, Finke J, Lenhoff S, Kröger N, Ossenkoppele GJ, Craddock CF, Yakoub-Agha I, Gürman G, Russell NH, Aljurf M, Potter MN, Nagler A, Ottmann O, Cornelissen JJ, Esteve J, Mohty M. Tyrosine kinase inhibitors improve long-term outcome of allogeneic hematopoietic stem cell transplantation for adult patients with Philadelphia chromosome positive acute lymphoblastic leukemia. Haematologica 2014; 100:392-9. [PMID: 25527562 DOI: 10.3324/haematol.2014.116954] [Citation(s) in RCA: 123] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
This study aimed to determine the impact of tyrosine kinase inhibitors given pre- and post-allogeneic stem cell transplantation on long-term outcome of patients allografted for Philadelphia chromosome-positive acute lymphoblastic leukemia. This retrospective analysis from the EBMT Acute Leukemia Working Party included 473 de novo Philadelphia chromosome-positive acute lymphoblastic leukemia patients in first complete remission who underwent an allogeneic stem cell transplantation using a human leukocyte antigen-identical sibling or human leukocyte antigen-matched unrelated donor between 2000 and 2010. Three hundred and ninety patients received tyrosine kinase inhibitors before transplant, 329 at induction and 274 at consolidation. Kaplan-Meier estimates of leukemia-free survival, overall survival, cumulative incidences of relapse incidence, and non-relapse mortality at five years were 38%, 46%, 36% and 26%, respectively. In multivariate analysis, tyrosine-kinase inhibitors given before allogeneic stem cell transplantation was associated with a better overall survival (HR=0.68; P=0.04) and was associated with lower relapse incidence (HR=0.5; P=0.01). In the post-transplant period, multivariate analysis identified prophylactic tyrosine-kinase inhibitor administration to be a significant factor for improved leukemia-free survival (HR=0.44; P=0.002) and overall survival (HR=0.42; P=0.004), and a lower relapse incidence (HR=0.40; P=0.01). Over the past decade, administration of tyrosine kinase inhibitors before allogeneic stem cell transplantation has significantly improved the long-term allogeneic stem cell transplantation outcome of adult Philadelphia chromosome-positive acute lymphoblastic leukemia. Prospective studies will be of great interest to further confirm the potential benefit of the prophylactic use of tyrosine kinase inhibitors in the post-transplant setting.
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Affiliation(s)
- Eolia Brissot
- Université Pierre et Marie Curie, Paris, France INSERM, UMRs 938, Paris, France Service d'Hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint Antoine, APHP, Paris, France CHRU Hôtel-Dieu, Nantes, France
| | - Myriam Labopin
- Université Pierre et Marie Curie, Paris, France INSERM, UMRs 938, Paris, France Service d'Hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint Antoine, APHP, Paris, France
| | | | | | | | - Liisa Volin
- Helsinki University Central Hospital, Finland
| | | | | | | | | | | | | | - Günhan Gürman
- Ankara University, Faculty of Medicine, Ankara, Turkey
| | | | - Mahmoud Aljurf
- King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | | | | | | | - Jan J Cornelissen
- Erasmus Medical Center-Daniel den Hoed Cancer Center, Rotterdam, The Netherlands
| | - Jordi Esteve
- Hospital Clinic Institut d'investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Mohamad Mohty
- Université Pierre et Marie Curie, Paris, France INSERM, UMRs 938, Paris, France Service d'Hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint Antoine, APHP, Paris, France
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98
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Impact of IKZF1 deletions on long-term outcomes of allo-SCT following imatinib-based chemotherapy in adult Philadelphia chromosome-positive ALL. Bone Marrow Transplant 2014; 50:354-62. [DOI: 10.1038/bmt.2014.281] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 10/29/2014] [Accepted: 11/03/2014] [Indexed: 11/08/2022]
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Susceptibility of Ph-positive all to TKI therapy associated with Bcr-Abl rearrangement patterns: a retrospective analysis. PLoS One 2014; 9:e110431. [PMID: 25415187 PMCID: PMC4240579 DOI: 10.1371/journal.pone.0110431] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 09/22/2014] [Indexed: 12/14/2022] Open
Abstract
Background Tyrosine kinase inhibitors (TKIs) have demonstrated success in the treatment of acute lymphoblastic leukemia (ALL) in patients that express BCR-ABL rearrangements (Philadelphia chromosome [Ph]). The current study aimed to assess the efficacy of TKIs and prognostic factors in the treatment of adults with Ph+-ALL. Methods In this multicenter retrospective study, the relationship between Ph+-ALL and treatment outcomes among Chinese patients receiving TKI-containing induction/consolidation chemotherapy was examined. A total of 86 Ph+-ALL patients were included and followed for 3.85 (0.43–9.30) years. Overall survival (OS) and event-free survival (EFS) were analyzed. Results A total of 86 Ph+-ALL patients (40 females and 46 males; median age: 34.0 years) were enrolled, including those with BCR/ABL transcripts 190 (n = 52), 210 (n = 25), and 230 (n = 2); BCR/ABL isoform determination was not available for 7 patients. Mortality was influenced by variable BCR/ABL transcripts and TKI administration, and BCR/ABL transcripts, hematopoietic stem cell transplantation (HSCT), and TKI administration were associated with the occurrence of events. The OS rate in the TKI administration group during steady state was significantly higher compared with those patients who did not receive TKI administration (P = 0.008), the EFS rate in the TKI administration group during steady state was significantly higher compared with those patients who did not receive TKIs (P = 0.012), and also higher than those with TKI salvage administration (P = 0.004). BCR/ABL transcripts 210 showed preferable OS and EFS compared with BCR/ABL transcripts 190 and 230 (P<0.05 for each). Conclusions The susceptibility of Ph+-ALL to TKI associated with the patterns of BCR-ABL rearrangement is demonstrated for the first time, thus adding another risk-stratifying molecular prognostic tool for the management of patients with Ph+-ALL.
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100
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Ma L, Hao S, Diong C, Goh YT, Gopalakrishnan S, Ho A, Hwang W, Koh LP, Koh M, Lim ZY, Loh Y, Poon M, Tan LK, Tan P, Linn YC. Pre-transplant achievement of negativity in minimal residual disease and French-American-British L1 morphology predict superior outcome after allogeneic transplant for Philadelphia chromosome positive acute lymphoblastic leukemia: an analysis of Southeast Asian patients. Leuk Lymphoma 2014; 56:1362-9. [PMID: 25139689 DOI: 10.3109/10428194.2014.956318] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
To better understand predictive factors and improve the clinical outcome of allogeneic transplant for patients with Philadelphia positive acute lymphoblastic leukemia, we analyzed 67 Southeast Asian patients transplanted in our institutions. Multivariate analysis showed that disease status before transplant, year of transplant and, interestingly, French-American-British (FAB) subtype had a significant impact on overall survival (OS) and non-relapse mortality. Patients who were minimal residual disease (MRD) negative at transplant had a 3-year OS of 73% compared to those who were MRD positive (45%) and refractory (0%). The 3-year cumulative incidence of relapse was 18% and 36% for the MRD negative and positive groups, respectively. FAB L1 subtype had a significantly superior 3-year OS of 63% vs. 29% for L2 subtype. Pre-transplant use of a tyrosine kinase inhibitor significantly improved outcomes in univariate but not multivariate analysis, as it served to induce more patients into MRD negativity, which was the factor that directly improved transplant outcome.
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Affiliation(s)
- Liyuan Ma
- Division of Hematology, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine , Shanghai , People's Republic of China
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