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Pandian J, Raghavan V, Manuprasad A, Shenoy PK, Nair CK. Infection at diagnosis-a unique challenge in acute myeloid leukemia treatment in developing world. Support Care Cancer 2020; 28:5449-5454. [PMID: 32166380 DOI: 10.1007/s00520-020-05379-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 02/24/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE A large number of AML patients present with infection at the time of initial presentation in Indian settings. There is lack of published data on the proportion of patients with infection at initial presentation and its impact on induction mortality. METHODS A retrospective audit of patients with newly diagnosed AML more than 14 years of age, who underwent standard induction chemotherapy between the periods of January 2011 to December 2018, was done. Infection at presentation if any was documented. Induction mortality was defined as death happening within 28 days of starting induction chemotherapy. RESULTS Among a total of 315 cases of AML, 96 (30%) patients underwent induction chemotherapy with 7 + 3 regimen. Documented infection at baseline was present in 30 (31%) of patients. Another 10 patients had fever at the time of presentation but without any documented infection focus. Fifteen patients died within 4 weeks of induction amounting to induction mortality of 15.6%. Induction mortality was 28% among patients with infection at baseline compared with 7% without baseline infections (P = 0.01). CONCLUSION Around 40% of patients had fever at the time of presentation, and 31% had documented infections. Baseline infections led to increase in induction mortality. We would like to propose that infection at baseline is to be considered as one of the potential variables in the predictive scoring system for induction mortality in developing countries.
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Affiliation(s)
- Jesu Pandian
- Department of Clinical Hematology & Medical Oncology, Malabar Cancer Centre, Thalassery, Kannur, Kerala, India
| | - Vineetha Raghavan
- Department of Clinical Hematology & Medical Oncology, Malabar Cancer Centre, Thalassery, Kannur, Kerala, India
| | - A Manuprasad
- Department of Clinical Hematology & Medical Oncology, Malabar Cancer Centre, Thalassery, Kannur, Kerala, India
| | - Praveen Kumar Shenoy
- Department of Clinical Hematology & Medical Oncology, Malabar Cancer Centre, Thalassery, Kannur, Kerala, India
| | - Chandran K Nair
- Department of Clinical Hematology & Medical Oncology, Malabar Cancer Centre, Thalassery, Kannur, Kerala, India.
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52
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Shallis RM, Boddu PC, Bewersdorf JP, Zeidan AM. The golden age for patients in their golden years: The progressive upheaval of age and the treatment of newly-diagnosed acute myeloid leukemia. Blood Rev 2020; 40:100639. [DOI: 10.1016/j.blre.2019.100639] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 10/29/2019] [Accepted: 11/05/2019] [Indexed: 12/25/2022]
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53
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Recent drug approvals for newly diagnosed acute myeloid leukemia: gifts or a Trojan horse? Leukemia 2020; 34:671-681. [PMID: 31915366 DOI: 10.1038/s41375-019-0704-5] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 11/26/2019] [Accepted: 12/24/2019] [Indexed: 01/04/2023]
Abstract
Since 2017 the US Food and Drug Administration (FDA) has approved glasdegib, venetoclax, ivosidenib, midostaurin, CPX- 351, and gemtuzumab ozogamicin (GO) to treat persons with newly diagnosed acute myeloid leukemia. The European Medicines Agency (EMA) has done likewise for midostaurin, CPX-351, and GO. While increasing options for persons, particularly older ones, for whom current therapy is unsatisfactory, or simply not given, these approvals raise several concerns. Although the venetoclax and glasdegib approvals were for persons considered "unfit" for intensive induction, the criteria for fitness were not well defined (age ≥75 per se being insufficient) and are frequently subjective, making it likely that many subjects in the venetoclax and glasdegib registration trials were fit for intensive induction; for example, none had performance status 3-4. Fitness must be assessed together with the potential efficacy of a proposed therapy. We note the modest complete remission rates and durations in the venetoclax + hypomethylating agent trial. Although these formed the basis for FDA approval, it is unclear that better results might not have obtained with more intense induction, as several studies, with considerably longer-follow up, have suggested. Hence, we question the venetoclax (and glasdegib) approvals absent randomized comparisons with intense induction. Given the uncertain relation in older individuals between survival and complete remission (CR), much less responses less than CR, we are skeptical of the sole use of these responses in the ivosidenib and venetoclax approvals; we also question the use of survival, without event-free survival, in the glasdegib approval. Noting the midostaurin and CPX-351 approvals included populations not participating in the registration studies we suggest means to address this issue as well as those involving fitness, randomization, and endpoints.
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Demichelis-Gómez R, Zapata-Canto N, Leyto-Cruz F, Terreros-Muñoz E, Carrillo A, Montaño-Figueroa E, Solís-Poblano JC, Colunga-Pedraza P, Díaz-Vargas G, Amador-Medina LF, Martínez-Hernández R, Turrubiates F, Cabrera-García A, Zaragoza A, Espinoza R, Gutiérrez-Serdán R, Apodaca E, Moreira C, García-Castillo C, García-Stivalet L, Limón A, Gómez-Almaguer D, Rozen-Fuller E, Espinosa-Bautista KA, Crespo-Solís E, Meillón L. Acute Myeloid Leukemia in Mexico: The Specific Challenges of a Developing Country. Results From a Multicenter National Registry. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2019; 20:e295-e303. [PMID: 32192977 DOI: 10.1016/j.clml.2019.12.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 12/13/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND In the past decades, long-term survival outcomes for younger patients with acute myeloid leukemia (AML) have improved. Nonetheless, developing nations might be lagging behind, highlighting the need to assess real-world outcomes in such regions. METHODS We performed a multicenter retrospective study, which included patients with AML diagnosed between January 2013 and December 2017 from 13 centers in Mexico. RESULTS A total of 525 patients with AML met the inclusion criteria and were included in the study. Median age for the entire cohort was 47 years. The patients were classified according to cytogenetic risk: favorable 16.0%, intermediate 55.6%, and unfavorable 28.4%. Most patients received intensive chemotherapy (80.2%), and among these 74.1% underwent a 7 + 3 induction regimen. A complete remission was achieved in 71.3% of patients. Induction-related mortality occurred in 17.8% and we identify the following as independent risk factors: >60 years (odds ratio [OR] 2.09 [1.09-4.02]), Eastern Cooperative Oncology Group >2 (OR 4.82 [2.46-9.43]), prior solid tumor (OR 3.8 [1.24-11.59]) and active infection (OR 1.82 [1.06-3.12]). Further, allogeneic hematopoietic stem-cell transplantation (AlloHSCT) was performed in 8.2% in CR1. The 3-year overall survival (OS) was 34.8%. In a multivariate analysis, several factors were independently associated with a worse OS, including secondary AML (hazard ratio [HR] 2.14 [1.15-4.01]) and unfavorable cytogenetic risk (HR 1.81 [1.16-2.82]), whereas maintenance therapy (HR 0.53 [0.32-0.86]) and AlloHSCT (HR 0.40 [0.17-0.94]) were associated with better OS. CONCLUSIONS This is the first multicenter report analyzing AML survival in Mexico. Challenges in this setting include a high induction-related mortality and low AlloHSCT rate, which should be addressed to improve outcomes.
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Affiliation(s)
- Roberta Demichelis-Gómez
- Hematology and Oncology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
| | - Nidia Zapata-Canto
- Hematology Department, Instituto Nacional de Cancerología, Mexico City, Mexico
| | | | | | | | | | | | - Perla Colunga-Pedraza
- Hematology Department, Hospital Universitario "Dr. JoséEleuterio González", Monterrey, Mexico
| | | | | | - Ramón Martínez-Hernández
- Hematology Department, Hospital Regional de Alta Especialidad de Ciudad Victoria, Ciudad Victoria, Mexico
| | - Francisco Turrubiates
- Hematology Department, Hospital Regional de Alta Especialidad de Ciudad Victoria, Ciudad Victoria, Mexico
| | - Alvaro Cabrera-García
- Hematology Department, Hospital Regional de Alta Especialidad de Ixtapaluca, Estado de México, Mexico
| | - Alva Zaragoza
- Hospital General Regional no. 1, IMSS, Chihuahua, Mexico
| | - Ramiro Espinoza
- Hematology Department, Instituto Nacional de Cancerología, Mexico City, Mexico
| | | | - Elia Apodaca
- Hematology and Oncology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Carolina Moreira
- Hematology Department, Hospital Juárez de México, Mexico City, Mexico
| | | | | | - Alejandro Limón
- Hospital de Especialidades CMN "Manuel Ávila Camacho", IMSS, Puebla, Mexico
| | - David Gómez-Almaguer
- Hematology Department, Hospital Universitario "Dr. JoséEleuterio González", Monterrey, Mexico
| | - Etta Rozen-Fuller
- Hematology Department, Hospital General de México, Mexico City, Mexico
| | | | - Erick Crespo-Solís
- Hematology Department, Hospital Regional de Alta Especialidad de Ciudad Victoria, Ciudad Victoria, Mexico
| | - Luis Meillón
- Hematology Department, Centro Médico ABC, Mexico City, Mexico
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Derolf Å, Juliusson G, Benson L, Fløisand Y, Lazarevic V, Antunovic P, Möllgård L, Lehmann S, Uggla B, Wahlin A, Höglund M, Deneberg S. Decreasing early mortality in acute myeloid leukaemia in Sweden 1997–2014: improving performance status is a major contributing factor. Br J Haematol 2019; 188:187-191. [DOI: 10.1111/bjh.16265] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Åsa Derolf
- Department of Hematology Karolinska University Hospital StockholmSweden
- Department of Internal Medicine Karolinska Institutet StockholmSweden
| | - Gunnar Juliusson
- Department of Hematology, Oncology and Radiation Physics Skåne University Hospital LundSweden
| | - Lina Benson
- Epidemiology and Regional Oncologic Center in Stockholm StockholmSweden
| | - Yngvar Fløisand
- Department of Hematology Oslo University Hospital OsloSweden
| | - Vladimir Lazarevic
- Department of Hematology, Oncology and Radiation Physics Skåne University Hospital LundSweden
| | - Petar Antunovic
- Department of Hematology Linköping University Hospital LinköpingSweden
| | - Lars Möllgård
- Department of Medicine Sahlgrenska University Hospital GöteborgSweden
| | - Sören Lehmann
- Department of Medical Sciences Unit of Haematology Uppsala University UppsalaSweden
| | - Bertil Uggla
- Department of Medicine School of Health and Medical Sciences Örebro University Hospital ÖrebroSweden
| | - Anders Wahlin
- Department of Radiation Sciences Umeå University Umeå Sweden
| | - Martin Höglund
- Department of Medical Sciences Unit of Haematology Uppsala University UppsalaSweden
| | - Stefan Deneberg
- Department of Hematology Karolinska University Hospital StockholmSweden
- Department of Internal Medicine Karolinska Institutet StockholmSweden
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56
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Bezerra ED, Othus M, Shawn C, Percival ME, Gardner K, Walter RB, Becker PS, Hendrie PC, Estey EH. Independent Associations Between Glomerular Filtration Rate and Serum Bilirubin Level and Early Mortality in Acute Myeloid Leukemia. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2019; 19:e633-e635. [PMID: 31648955 DOI: 10.1016/j.clml.2019.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 06/28/2019] [Indexed: 10/26/2022]
Affiliation(s)
| | - Megan Othus
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Carole Shawn
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Mary-Elizabeth Percival
- Department of Medicine, University of Washington, Seattle, WA; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA; Seattle Cancer Care Alliance, Seattle, WA
| | - Kelda Gardner
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Roland B Walter
- Department of Medicine, University of Washington, Seattle, WA; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA; Seattle Cancer Care Alliance, Seattle, WA
| | - Pamela S Becker
- Department of Medicine, University of Washington, Seattle, WA; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA; Seattle Cancer Care Alliance, Seattle, WA
| | - Paul C Hendrie
- Department of Medicine, University of Washington, Seattle, WA; Seattle Cancer Care Alliance, Seattle, WA
| | - Elihu H Estey
- Department of Medicine, University of Washington, Seattle, WA; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA; Seattle Cancer Care Alliance, Seattle, WA
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57
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Halpern AB, Howard NP, Othus M, Hendrie PC, Baclig NV, Buckley SA, Percival MEM, Becker PS, Scott BL, Oehler VG, Gernsheimer TB, Keel SB, Orozco JJ, Cassaday RD, Shustov AR, Hartley GA, Welch VL, Estey EH, Walter RB. Early hospital discharge after intensive induction chemotherapy for adults with acute myeloid leukemia or other high-grade myeloid neoplasm. Leukemia 2019; 34:635-639. [PMID: 31586148 DOI: 10.1038/s41375-019-0586-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 07/12/2019] [Accepted: 07/22/2019] [Indexed: 11/09/2022]
Affiliation(s)
- Anna B Halpern
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Nicholas P Howard
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Megan Othus
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Paul C Hendrie
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA
| | - Nikita V Baclig
- Department of Medicine, Residency Program, University of Washington, Seattle, WA, USA
| | - Sarah A Buckley
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Mary-Elizabeth M Percival
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Pamela S Becker
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Bart L Scott
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,Department of Medicine, Division of Medical Oncology, University of Washington, Seattle, WA, USA
| | - Vivian G Oehler
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Terry B Gernsheimer
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Siobán B Keel
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA
| | - Johnnie J Orozco
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.,Department of Medicine, Division of Medical Oncology, University of Washington, Seattle, WA, USA
| | - Ryan D Cassaday
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Andrei R Shustov
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | | | | | - Elihu H Estey
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Roland B Walter
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA. .,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA. .,Department of Pathology, University of Washington, Seattle, WA, USA. .,Department of Epidemiology, University of Washington, Seattle, WA, USA.
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58
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Khan N, Bammidi S, Jayandharan GR. A CD33 Antigen-Targeted AAV6 Vector Expressing an Inducible Caspase-9 Suicide Gene Is Therapeutic in a Xenotransplantation Model of Acute Myeloid Leukemia. Bioconjug Chem 2019; 30:2404-2416. [PMID: 31436412 DOI: 10.1021/acs.bioconjchem.9b00511] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Current chemotherapeutic regimens for acute myeloid leukemia (AML) have been modestly effective in patients and are associated with poor long-term survival (<30% at 5 years). Viral vector-based suicide gene therapy is an attractive option, if these vectors can target the AML cells with high specificity and efficiency. In this study, we have developed a receptor-specific adeno-associated virus (AAV) based vector to target the CD33 antigen which is overexpressed in leukemic cells. A targeting peptide was rationally designed from the antigen-binding regions of a CD33 monoclonal antibody. This peptide was further expressed on the capsid of the AAV6 vector, since this serotype was most efficient among AAV1-rh10 vectors to infect the pro-monocytic, human myeloid leukemia cells (U937). AAV6-CD33 vectors expressing a suicide gene, the inducible caspase 9 (iCasp9), and its prodrug AP20187 significantly reduced (∼59%) the viability of U937 cells. To further test its efficacy and specificity in vivo, AAV6-CD33 vectors were administered into a xenotransplantation model of AML in zebrafish through systemic delivery. We observed a significant antileukemic effect with AAV6-CD33 vectors, with a markedly higher survival (100% for AAV6-CD33 vectors vs 15% for mock-treated) and a higher number of TUNEL positive apoptotic cells after systemic vector delivery. Taken together, our work demonstrates the efficacy and translational potential of CD33-targeted AAV6 vectors for cytotoxic gene therapy in AML.
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Affiliation(s)
- Nusrat Khan
- Department of Biological Sciences and Bioengineering , Indian Institute of Technology , Kanpur , 208016 , Uttar Pradesh , India
| | - Sridhar Bammidi
- Department of Biological Sciences and Bioengineering , Indian Institute of Technology , Kanpur , 208016 , Uttar Pradesh , India
| | - Giridhara R Jayandharan
- Department of Biological Sciences and Bioengineering , Indian Institute of Technology , Kanpur , 208016 , Uttar Pradesh , India
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59
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Wang SY, Cheng WY, Mao YF, Zhu YM, Liu FJ, Ma TT, Shen Y. Genetic alteration patterns and clinical outcomes of elderly and secondary acute myeloid leukemia. Hematol Oncol 2019; 37:456-463. [PMID: 31348835 PMCID: PMC6899678 DOI: 10.1002/hon.2656] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 07/16/2019] [Accepted: 07/20/2019] [Indexed: 12/19/2022]
Abstract
To illustrate the clinical and genetic features of elderly and secondary acute myeloid leukemia (AML) patients, we compared 145 elderly AML (e‐AML) and 55 secondary AML (s‐AML) patients with 451 young de novo AML patients. Both e‐AML and s‐AML patients showed lower white blood cell (WBC) and bone marrow (BM) blasts at diagnosis. NPM1, DNMT3A, and IDH2 mutations were more common while biallelic CEBPA and IDH1 mutations were less seen in e‐AML patients. s‐AML patients carried a higher frequency of KMT2A‐AF9. In treatment response and survival, e/s‐AML conferred a lower complete remission (CR) rate and shorter duration of event‐free survival (EFS) and overall survival (OS) compared with young patients. In multivariate analysis, s‐AML was an independent risk factor for OS but not EFS in the whole cohort. Importantly, intensive therapy tended to improve the survival of e/s‐AML patients without increasing the risk of early death, and hematopoietic stem cell transplantation (HSCT) could rescue the prognosis of s‐AML, which should be recommended for the treatment of fit patients.
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Affiliation(s)
- Shi-Yang Wang
- Shanghai Institute of Hematology, Department of Hematology, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wen-Yan Cheng
- Shanghai Institute of Hematology, Department of Hematology, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuan-Fei Mao
- Shanghai Institute of Hematology, Department of Hematology, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yong-Mei Zhu
- Shanghai Institute of Hematology, Department of Hematology, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fu-Jia Liu
- Shanghai Institute of Hematology, Department of Hematology, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ting-Ting Ma
- Shanghai Institute of Hematology, Department of Hematology, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yang Shen
- Shanghai Institute of Hematology, Department of Hematology, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Zeremski V, Fischer T, Schalk E. Dose reduction and high-risk disease as risk factors for early death in primary CNS lymphoma. Leuk Lymphoma 2019; 61:240-242. [PMID: 31393196 DOI: 10.1080/10428194.2019.1650176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Vanja Zeremski
- Department of Hematology and Oncology, Medical Center, Otto-von-Guericke University Magdeburg, Magdeburg, Germany.,Health Campus Immunology, Infectiology and Inflammation (GC-I³), Medical Center, Otto-von-Guericke University, Magdeburg, Germany
| | - Thomas Fischer
- Department of Hematology and Oncology, Medical Center, Otto-von-Guericke University Magdeburg, Magdeburg, Germany.,Health Campus Immunology, Infectiology and Inflammation (GC-I³), Medical Center, Otto-von-Guericke University, Magdeburg, Germany
| | - Enrico Schalk
- Department of Hematology and Oncology, Medical Center, Otto-von-Guericke University Magdeburg, Magdeburg, Germany.,Health Campus Immunology, Infectiology and Inflammation (GC-I³), Medical Center, Otto-von-Guericke University, Magdeburg, Germany
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61
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Bazhenov AV, Galstyan GM, Parovichnikova EN, Troitskaya VV, Kuzmina LA, Fidarova ZT, Gribanova EO, Makhinya SA, Latyshkevich OA, Chabaeva UA, Kulikov SM, Savchenko VG. [Role of the intensive care in treatment of patients with acute myeloid leukemia]. TERAPEVT ARKH 2019; 91:14-24. [PMID: 32598731 DOI: 10.26442/00403660.2019.07.000321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Indexed: 11/22/2022]
Abstract
AIM Remission induction can be associate, with the life threatening complications and transfer to ICU of de novo acute myeloid leukemia (AML) patients (pts). We evaluate influence of transfer to ICU and life threatening complication on early mortality and long - tram survival of de novo AML pts. MATERIALS AND METHODS Retrospective study. All de novo AML pts younger than 60 years old admitted in the National Research Center for Hematology from 2013 to 2016 years were enrolled in the study. Patients were divided into 2 groups: pts who were required ICU admission during remission induction (ICU-pts) and pts who did not require ICU admission and received chemotherapy only in hematology ward (non-ICU pts). The reasons for ICU admissions and results of life support were analyzed. Overall survival (OS) were assessed by the Kaplan-Meier method, long rank value p.
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62
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Micafungin prophylaxis for acute leukemia patients undergoing induction chemotherapy. BMC Cancer 2019; 19:358. [PMID: 30991992 PMCID: PMC6469030 DOI: 10.1186/s12885-019-5557-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 03/31/2019] [Indexed: 01/17/2023] Open
Abstract
Background Micafungin is a well-tolerated and effective prophylactic antifungal agent used in hematologic diseases. In this prospective trial, we evaluated the efficacy and safety of prophylactic micafungin during first induction chemotherapy in patients with acute leukemia. We also compared outcomes of prophylactic micafungin with those of prophylactic posaconazole in acute myeloid leukemia (AML). Methods Medically fit patients with newly diagnosed acute leukemia received 50 mg micafungin intravenously once daily from the initiation of first induction chemotherapy to recovery of neutrophil count, suspected fungal infection, or unacceptable drug-related toxicity (Clinicaltrials.gov number, NCT02440178). The primary end point was incidence of invasive fungal infection, and the secondary end points were adverse events of prophylactic micafungin and mortality during induction therapy. Results The 65 patients (median age = 51 years, male:female = 34:31) enrolled in this study had diagnoses of AML (33, 50.8%), acute lymphoblastic leukemia (31, 47.7%), and acute biphenotypic leukemia (1, 1.5%). Median duration of micafungin treatment was 24 days (range 1–68), with proven invasive fungal disease in one patient (1.5%) and possible fungal infection in two patients (3.1%). Three of the patients (4.6%) experienced the following adverse events, but all events were tolerable: liver function abnormality (Grade 2, n = 1; Grade 3, n = 1) and allergic reaction (Grade 2, n = 1). Three patients died during induction therapy, and invasive aspergillosis pneumonia was the cause of death for one of those patients. Overall, 19 patients (29.2%) discontinued prophylactic micafungin, and 18 (27.7%) patients switched to another antifungal agent. We observed no fungal infections caused by amphotericin B-resistant organisms. In AML patients, outcomes of prophylactic micafungin during induction chemotherapy did not differ significantly with those of prophylactic posaconazole with regard to incidence of fungal infections, rate of discontinuation, or safety. Conclusions Our study demonstrates that prophylactic micafungin is safe and effective in patients with acute leukemia undergoing induction chemotherapy. Outcomes in patients with AML were similar to those of prophylactic posaconazole, indicating the usefulness of micafungin as a prophylactic antifungal agent during induction chemotherapy for AML. Trial registration Clinicaltrials.gov NCT02440178, registered May 12th 2015.
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63
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Dysbiosis patterns during re-induction/salvage versus induction chemotherapy for acute leukemia. Sci Rep 2019; 9:6083. [PMID: 30988420 PMCID: PMC6465677 DOI: 10.1038/s41598-019-42652-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 04/05/2019] [Indexed: 01/05/2023] Open
Abstract
Acute leukemia (AL) patients undergoing intensive induction chemotherapy develop severe gut dysbiosis, placing them at heightened risk for infectious complications. Some AL patients will undergo “repeat therapy” (re-induction or salvage) due to persistent or relapsed disease. We hypothesized that prior injury to the microbiome during induction may influence dysbiosis patterns during repeat therapy. To test this hypothesis, we analyzed the bacterial microbiome profiles of thrice-weekly stool samples from 20 intensively treated AL patients (first induction: 13, repeat therapy: 7) by 16S rRNA sequencing. In mixed-effects modeling, repeat therapy was a significant predictor of Enterococcus expansion (P = 0.006), independently of antibiotic exposure, disease type, feeding mode, and week of chemotherapy. Bayesian analysis of longitudinal data demonstrated larger departures of microbial communities from the pre-chemotherapy baseline during repeat therapy compared to induction. This increased ecosystem instability during repeat therapy possibly impairs colonization resistance and increases vulnerability to Enterococcus outgrowth. Microbiota restoration therapies at the end of induction or before starting subsequent therapy warrant investigation.
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LeBlanc TW, Erba HP. Shifting paradigms in the treatment of older adults with AML. Semin Hematol 2019; 56:110-117. [DOI: 10.1053/j.seminhematol.2019.02.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 02/22/2019] [Indexed: 12/31/2022]
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65
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Capodanno I, Tamagnini E, Alfieri P, Codeluppi K, Luminari S, Merli F. Home care of acute leukaemia patients: From active therapy to end‐of‐life and palliative care. The 3‐year experience of a single centre. Eur J Haematol 2019; 102:424-431. [DOI: 10.1111/ejh.13224] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 02/08/2019] [Accepted: 02/11/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Isabella Capodanno
- Department of Hematology Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia Reggio Emilia Italy
| | - Enrica Tamagnini
- Department of Hematology Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia Reggio Emilia Italy
| | - Pierluigi Alfieri
- Department of Hematology Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia Reggio Emilia Italy
| | - Katia Codeluppi
- Department of Hematology Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia Reggio Emilia Italy
| | - Stefano Luminari
- Department of Hematology Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia Reggio Emilia Italy
| | - Francesco Merli
- Department of Hematology Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia Reggio Emilia Italy
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Jia B, Zhao C, Rakszawski KL, Claxton DF, Ehmann WC, Rybka WB, Mineishi S, Wang M, Shike H, Bayerl MG, Sivik JM, Schell TD, Drabick JJ, Hohl RJ, Zheng H. Eomes +T-bet low CD8 + T Cells Are Functionally Impaired and Are Associated with Poor Clinical Outcome in Patients with Acute Myeloid Leukemia. Cancer Res 2019; 79:1635-1645. [PMID: 30709927 DOI: 10.1158/0008-5472.can-18-3107] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 12/12/2018] [Accepted: 01/29/2019] [Indexed: 11/16/2022]
Abstract
Acute myeloid leukemia (AML) is a devastating blood cancer with poor prognosis. Immunotherapy targeting inhibitory pathways to unleash the antileukemia T-cell response is a promising strategy for the treatment of leukemia, but we must first understand the underlying molecular mechanisms. Eomesodermin (Eomes) and T-bet are both T-box transcription factors that regulate CD8+ T-cell responses in a context-specific manner. Here, we examined the role of these transcription factors in CD8+ T-cell immunity in AML patients. We report that the frequency of Eomes+T-betlow CD8+ T cells increased in newly diagnosed AML. This cell subset produced fewer cytokines and displayed reduced killing capacity, whereas depletion of Eomes by siRNA reversed these functional defects. Furthermore, Eomes bound the promoter of T-cell immunoglobulin and ITIM domain (TIGIT) and positively regulated the expression of this inhibitory receptor on patient-derived T cells. A high frequency of Eomes+T-betlow CD8+ T cells was associated with poor response to induction chemotherapy and shorter overall survival in AML patients. These findings have significant clinical implications as they not only identify a predictive and prognostic biomarker for AML, but they also provide an important target for effective leukemia therapeutics. SIGNIFICANCE: These findings reveal that a high frequency of Eomes+T-betlow CD8+ T cells predicts poor clinical outcome in AML and that targeting Eomes may provide a therapeutic benefit against AML.
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Affiliation(s)
- Bei Jia
- Penn State Cancer Institute, Penn State University College of Medicine, Hershey, Pennsylvania
| | - Chenchen Zhao
- Penn State Cancer Institute, Penn State University College of Medicine, Hershey, Pennsylvania.,Institute of Infectious Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Kevin L Rakszawski
- Penn State Cancer Institute, Penn State University College of Medicine, Hershey, Pennsylvania
| | - David F Claxton
- Penn State Cancer Institute, Penn State University College of Medicine, Hershey, Pennsylvania
| | - W Christopher Ehmann
- Penn State Cancer Institute, Penn State University College of Medicine, Hershey, Pennsylvania
| | - Witold B Rybka
- Penn State Cancer Institute, Penn State University College of Medicine, Hershey, Pennsylvania
| | - Shin Mineishi
- Penn State Cancer Institute, Penn State University College of Medicine, Hershey, Pennsylvania
| | - Ming Wang
- Department of Public Health Sciences, Penn State University College of Medicine, Hershey, Pennsylvania
| | - Hiroko Shike
- Department of Pathology, Penn State University College of Medicine, Hershey, Pennsylvania
| | - Michael G Bayerl
- Department of Pathology, Penn State University College of Medicine, Hershey, Pennsylvania
| | - Jeffrey M Sivik
- Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Todd D Schell
- Penn State Cancer Institute, Penn State University College of Medicine, Hershey, Pennsylvania.,Department of Microbiology and Immunology, Penn State University College of Medicine, Hershey, Pennsylvania
| | - Joseph J Drabick
- Penn State Cancer Institute, Penn State University College of Medicine, Hershey, Pennsylvania
| | - Raymond J Hohl
- Penn State Cancer Institute, Penn State University College of Medicine, Hershey, Pennsylvania
| | - Hong Zheng
- Penn State Cancer Institute, Penn State University College of Medicine, Hershey, Pennsylvania. .,Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
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67
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Klepin HD, Estey E, Kadia T. More Versus Less Therapy for Older Adults With Acute Myeloid Leukemia: New Perspectives on an Old Debate. Am Soc Clin Oncol Educ Book 2019; 39:421-432. [PMID: 31099627 DOI: 10.1200/edbk_239097] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Most patients with newly diagnosed acute myeloid leukemia (AML) are at least age 65 and continue to have short survival, with many patients receiving no specific anti-AML therapy, particularly if they are older than age 75. Although consensus regarding optimal treatment of this growing population is lacking, treatment options are expanding even for the oldest patients. A fundamental question when seeing an older patient with AML is whether to recommend "more intensive" or "less intensive" induction therapy. Existing data can support more intensive treatment strategies for selected older adults, although there is growing evidence to support less intensive therapies as well. Randomized trials to provide clear comparisons between treatment strategies among well-characterized older adult populations are lacking. Reliance on age alone to determine treatment choice is problematic, as "fitness" or "unfitness" varies dramatically among patients of the same chronologic age and remains poorly characterized in existing studies. This article will provide differing perspectives on the "more" versus "less" question, with particular attention to recent drug approvals. Issues relevant to both treatment decision-making in practice and alternative trial design to inform gaps in knowledge will be discussed. Given the heterogeneity, an important conclusion will be that there is unlikely to be a single best approach and that appropriate decision-making requires considerations of many factors specific to individual patients.
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Affiliation(s)
- Heidi D Klepin
- 1 Wake Forest Baptist Comprehensive Cancer Center, Winston Salem, NC
| | - Elihu Estey
- 2 University of Washington and Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Tapan Kadia
- 3 The University of Texas MD Anderson Cancer Center, Houston, TX
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68
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Schink K, Reljic D, Herrmann HJ, Meyer J, Mackensen A, Neurath MF, Zopf Y. Whole-Body Electromyostimulation Combined With Individualized Nutritional Support Improves Body Composition in Patients With Hematological Malignancies - A Pilot Study. Front Physiol 2018; 9:1808. [PMID: 30618820 PMCID: PMC6305403 DOI: 10.3389/fphys.2018.01808] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 11/30/2018] [Indexed: 12/22/2022] Open
Abstract
Patients undergoing the complex treatment for hematological malignancies are exposed to a high physiological and psychological distress inducing fatigue and physical inactivity. In line with cancer-related metabolic changes patients are predisposed for skeletal muscle mass loss that leads to a functional decline, affects therapeutic success, and quality of life. Benefits of physical exercise and nutritional interventions on muscle maintenance are observed in solid cancer patients, but marginally investigated in patients with hematological cancer. We here studied the effects of a combined supportive exercise and nutrition intervention using whole-body electromyostimulation (WB-EMS) training and individualized nutritional support in patients actively treated for hematological malignancy. In a controlled pilot trial, 31 patients (67.7% male; 58.0 ± 16.7 years) with various hematological cancers were allocated to a control group (n = 9) receiving nutritional support of usual care regarding a high protein intake (>1.0 g/kg/d) or to a physical exercise group (n = 22) additionally performing WB-EMS training twice weekly for 12 weeks. Bodyweight and body composition assessed by bioelectrical impedance analysis were measured every 4 weeks. Physical function, blood parameters, quality of life and fatigue were assessed at baseline and after 12 weeks. No WB-EMS-related adverse effects occurred. Patients attending the exercise program presented a higher skeletal muscle mass than controls after 12-weeks (1.51 kg [0.41, 2.60]; p = 0.008). In contrast, patients of the control group showed a higher fat mass percentage than patients of the WB-EMS group (-4.46% [-7.15, -1.77]; p = 0.001) that was accompanied by an increase in serum triglycerides in contrast to a decrease in the WB-EMS group (change ± SD, control 36.3 ± 50.6 mg/dl; WB-EMS -31.8 ± 68.7 mg/dl; p = 0.064). No significant group differences for lower limb strength, quality of life, and fatigue were detected. However, compared to controls the WB-EMS group significantly improved in physical functioning indicated by a higher increase in the 6-min-walking distance (p = 0.046). A combined therapeutic intervention of WB-EMS and protein-rich nutritional support seems to be safe and effective in improving skeletal muscle mass and body composition in hematological cancer patients during active oncological treatment. Clinical Trial Registration: www.ClinicalTrials.gov, identifier NCT02293239.
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Affiliation(s)
- Kristin Schink
- Hector-Center for Nutrition, Exercise and Sports, Department of Medicine 1, University Hospital Erlangen, Friedrich–Alexander University Erlangen–Nürnberg, Erlangen, Germany
| | - Dejan Reljic
- Hector-Center for Nutrition, Exercise and Sports, Department of Medicine 1, University Hospital Erlangen, Friedrich–Alexander University Erlangen–Nürnberg, Erlangen, Germany
| | - Hans J. Herrmann
- Hector-Center for Nutrition, Exercise and Sports, Department of Medicine 1, University Hospital Erlangen, Friedrich–Alexander University Erlangen–Nürnberg, Erlangen, Germany
| | - Julia Meyer
- Hector-Center for Nutrition, Exercise and Sports, Department of Medicine 1, University Hospital Erlangen, Friedrich–Alexander University Erlangen–Nürnberg, Erlangen, Germany
| | - Andreas Mackensen
- Department of Medicine 5 – Haematology and Oncology, University Hospital Erlangen, Friedrich–Alexander University Erlangen–Nürnberg, Erlangen, Germany
| | - Markus F. Neurath
- Department of Medicine 1 – Gastroenterology, Pneumology and Endocrinology, University Hospital Erlangen, Friedrich–Alexander University Erlangen–Nürnberg, Erlangen, Germany
| | - Yurdagül Zopf
- Hector-Center for Nutrition, Exercise and Sports, Department of Medicine 1, University Hospital Erlangen, Friedrich–Alexander University Erlangen–Nürnberg, Erlangen, Germany
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69
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Pain in patients with newly diagnosed or relapsed acute leukemia. Support Care Cancer 2018; 27:2789-2797. [PMID: 30535882 DOI: 10.1007/s00520-018-4583-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Accepted: 11/28/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE Acute leukemia (AL) is associated with substantial morbidity and mortality. We assessed the prevalence and correlates of pain in patients with newly diagnosed or relapsed AL. METHODS Patients with newly diagnosed or relapsed AL admitted to a comprehensive cancer center completed the Memorial Symptom Assessment Scale (MSAS), which assesses prevalence, severity, and distress associated with pain and other symptoms. Factors associated with severe pain were assessed using logistic regression. Two raters completed chart reviews in duplicate for patients with severe pain (MSAS severity ≥ 3/4) to determine the site of pain. RESULTS Three hundred eighteen patients were recruited from January 2008 to October 2013: 245 (77.0%) had acute myeloid or acute promyelocytic leukemia (AML/APL) and 73 (23.0%) had acute lymphoblastic leukemia (ALL); 289 (90.9%) were newly diagnosed and 29 (9.1%) had relapsed disease. Pain was reported in 156/318 (49.2%), of whom 55/156 (35.3%) reported severe pain (≥ 3/4). Pain was associated with all psychological symptoms (all p < 0.005) and some physical symptoms. Severe pain was associated with younger age (p = 0.02), worse performance status (p = 0.04), ALL diagnosis (p = 0.04), and time from onset of chemotherapy (p = 0.03), with pain peaking at 4 weeks after chemotherapy initiation. The most common sites of severe pain were oropharynx (22; 40%), head (12; 21.8%), and abdomen (11; 20%). Only 3 patients (0.9%) were referred to the symptom control/palliative care team during the month prior to or following assessment. CONCLUSIONS Pain is frequent, distressing, and predictable in patients undergoing induction chemotherapy for AL. Further research is needed to assess the efficacy of early supportive care in this population.
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Michaelis LC. Cytotoxic therapy in acute myeloid leukemia: not quite dead yet. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:51-62. [PMID: 30504291 PMCID: PMC6246033 DOI: 10.1182/asheducation-2018.1.51] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Given the recent approvals of new agents for acute myeloid leukemia (AML), a clinical trial pipeline stocked with novel therapies, and the rapid integration of imaginative approaches in diseases like acute lymphocytic leukemia and chronic lymphocytic leukemia, it is reasonable to ask whether treatment of AML might finally depart from the classical cytotoxic induction therapy that has been employed since the 1970s. However, for better or worse, in 2018, cytotoxic induction regimens remain the standard of care for most patients. Indeed, the future likely lies in combinations of therapies that act with a spectrum of mechanisms. Using a case-based format, this review will outline current treatment expectations for patients according to karyotypic risk and familiarize readers with the basis for common induction choices. Relapsed/refractory disease may be especially amenable to interventions with novel agents or clinical trials; however, there are still some patients who most benefit from intensive chemotherapy. This review will outline risk systems that help the practitioner identify those with the best chances for response and survival. Finally, clinical tools, including geriatric assessments and comorbidity calculators, may help clinicians recognize patients for whom disease risk and comorbidity tip the balance against classical chemotherapy, a frequent challenge for those who treat this devastating disease.
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Affiliation(s)
- Laura C Michaelis
- Department of Medicine, Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI
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71
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Estey EH. Acute myeloid leukemia: 2019 update on risk-stratification and management. Am J Hematol 2018; 93:1267-1291. [PMID: 30328165 DOI: 10.1002/ajh.25214] [Citation(s) in RCA: 245] [Impact Index Per Article: 40.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 06/26/2018] [Accepted: 07/10/2018] [Indexed: 12/14/2022]
Abstract
Outcome in patients with acute myeloid leukemia (AML) ranges from death within a few days of beginning treatment (treatment related mortality, TRM) to likely cure. The major reason patients are not cured is resistance to treatment, often manifested as relapse from remission, rather than, even in older patients, TRM, whose incidence is decreasing. Knowledge of the pre-treatment mutation status of various genes has improved our ability to assign initial treatment and, of particular importance, knowledge of whether patients ostensibly in remission have measurable residual disease should influence subsequent management. Several new drugs have been approved by the FDA and we discuss their role in treatment.
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Affiliation(s)
- Elihu H. Estey
- Division of Hematology, Clinical Research Division; Fred Hutchinson Cancer Research Center, University of Washington and Member; Seattle Washington
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72
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Abstract
For several decades, few substantial therapeutic advances have been made for patients with acute myeloid leukaemia. However, since 2017 unprecedented growth has been seen in the number of drugs available for the treatment of acute myeloid leukaemia, with several new drugs receiving regulatory approval. In addition to advancing our therapeutic armamentarium, an increased understanding of the biology and genomic architecture of acute myeloid leukaemia has led to refined risk assessment of this disease, with consensus risk stratification guidelines now incorporating a growing number of recurrent molecular aberrations that aid in the selection of risk-adapted management strategies. Despite this promising recent progress, the outcomes of patients with acute myeloid leukaemia remain unsatisfactory, with more than half of patients ultimately dying from their disease. Enrolment of patients into clinical trials that evaluate novel drugs and rational combination therapies is imperative to continuing this progress and further improving the outcomes of patients with acute myeloid leukaemia.
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MESH Headings
- Aminoglycosides/therapeutic use
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antineoplastic Agents/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Consolidation Chemotherapy
- Cytarabine/administration & dosage
- Gemtuzumab
- Genomics
- Hematopoietic Stem Cell Transplantation
- Humans
- Leukemia, Myeloid, Acute/diagnosis
- Leukemia, Myeloid, Acute/drug therapy
- Leukemia, Myeloid, Acute/genetics
- Leukemia, Myeloid, Acute/therapy
- Patient Selection
- Recurrence
- Remission Induction
- Risk Assessment
- Risk Factors
- Staurosporine/analogs & derivatives
- Staurosporine/therapeutic use
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Affiliation(s)
- Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael E Rytting
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Pediatrics-Patient Care, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jorge E Cortes
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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73
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Cladribine and low-dose cytarabine alternating with decitabine as front-line therapy for elderly patients with acute myeloid leukaemia: a phase 2 single-arm trial. LANCET HAEMATOLOGY 2018; 5:e411-e421. [PMID: 30115541 DOI: 10.1016/s2352-3026(18)30132-7] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 07/19/2018] [Accepted: 07/19/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Front-line therapy for elderly or unfit patients with acute myeloid leukaemia (AML) remains unsatisfactory with poor outcomes and excessive toxicity. We studied a new low-intensity regimen of cladribine combined with low-dose cytarabine alternating with decitabine, aimed at improving outcomes in this population. Based on our previous experience, we hypothesised that this combination would be safe and more effective than current approaches with hypomethylating agents. METHODS In this single-arm, open-label, single-centre phase 2 study, we enrolled patients aged 60 years or older with previously untreated AML or high-risk myelodysplastic syndrome who had adequate organ function and an Eastern Cooperative Oncology Group performance status of 2 or less. Patients were treated with cladribine plus low-dose cytarabine for two 28-day cycles alternating with decitabine for two 28-day cycles, for up to 18 cycles. Induction therapy (cycle 1) consisted of cladribine 5 mg/m2 intravenously over 1-2 h on days 1-5 and cytarabine 20 mg subcutaneously twice daily on days 1-10. Patients who had remission during this induction regimen moved on to consolidation therapy (cladribine 5 mg/m2 intravenously over 1-2 h on days 1-3 and cytarabine 20 mg twice daily on days 1-10, alternating with decitabine 20 mg/m2 intravenously on days 1-5). The primary outcome measure was disease-free survival. Secondary outcomes were overall survival, proportion of patients achieving complete response, proportion of patients achieving response, toxicity, and induction mortality. All treated patients were included in the analyses. This trial is ongoing and is registered with ClinicalTrials.gov, number NCT01515527. FINDINGS Between Feb 17, 2012, and July 6, 2017, 118 patients were enrolled and treated, among whom 48 (41%) had an adverse karyotype, 20 (17%) had therapy-related AML, 18 (15%) had treated secondary AML, and 20 (17%) had TP53 mutations. Median disease-free survival was 10·8 months (IQR 5·4-25·9). 80 (68%) patients achieved objective response: 69 (58%) achieved a complete response and 11 (9%) patients had complete response with incomplete count recovery. The median overall survival was 13·8 months (6·9-28·6). The regimen was well tolerated, with one (1%) death within the first 4 weeks and eight (7%) deaths within the first 8 weeks. The most common non-haematological adverse events of grade 3 or worse were infection (88 [75%] patients), elevated total bilirubin (26 [22%] patients), rash (13 [11%] patients), and nausea (13 [11%] patients). INTERPRETATION The combination of cladribine and low-dose cytarabine alternating with decitabine appears to be a safe and highly effective regimen for the treatment of elderly or unfit patients with newly diagnosed AML. Further testing of this regimen is warranted, and could help to provide a new, effective option for reduced-intensity therapy in this population. FUNDING Part supported by the National Institutes of Health.
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74
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Acute myeloid leukemia induction with cladribine: Outcomes by age and leukemia risk. Leuk Res 2018; 68:72-78. [DOI: 10.1016/j.leukres.2018.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 03/01/2018] [Accepted: 03/05/2018] [Indexed: 11/18/2022]
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Michaelis LC, Klepin HD, Walter RB. Advancements in the management of medically less-fit and older adults with newly diagnosed acute myeloid leukemia. Expert Opin Pharmacother 2018; 19:865-882. [PMID: 29697000 DOI: 10.1080/14656566.2018.1465562] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Treating acute myeloid leukemia (AML) in older adults remains daunting. The unique biology often renders conventional chemotherapies less effective. Accurately predicting the toxicities of treatment is another unresolved challenge. Treatment planning thus requires a good knowledge of the current trial data and familiarity with clinical tools, including formal fitness and geriatric assessments. Both obstacles - disease biology and patient fitness - might be easier overcome with specific, AML cell-targeted agents rather than traditional cytotoxic chemotherapy. This may be the future of AML therapy, but it is not our current state. AREAS COVERED Herein, the authors appraise the data supporting a standard induction approach, including an outline of how to predict treatment-related mortality and a review of the most up-to-date methods of geriatric assessment. They also discuss treatment expectations with less-intense therapies and highlight novel agents in development. Finally, they provide a basic approach to choosing treatment intensity. EXPERT OPINION In an older and/or medically less-fit patient, treatment choice should begin with a thorough disease assessment, a formal evaluation of patient fitness and frailty. There should also be a clear communication with the patient and patient's family about the risks and anticipated benefits of either an intense or nonintense treatment approach.
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Affiliation(s)
- Laura C Michaelis
- a Associate Professor of Medicine, Department of Hematology and Oncology , Medical College of Wisconsin , Milwaukee , WI , USA
| | - Heidi D Klepin
- b Associate Professor of Internal Medicine, Section on Hematology and Oncology , Wake Forest School of Medicine , Winston-Salem , NC , USA
| | - Roland B Walter
- c Associate Member, Clinical Research Division , Fred Hutchinson Cancer Research Center , Seattle , WA , USA.,d Associate Professor of Medicine, Department of Medicine, Division of Hematology , University of Washington , Seattle , WA , USA.,e Adjunct Associate Professor, Department of Epidemiology , University of Washington , Seattle , WA , USA
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76
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Sellar RS, Gale RE, Khwaja A, Garbowski M, Loddo M, Stoeber K, Williams GH, Linch DC. Immunophenotypic analysis of cell cycle status in acute myeloid leukaemia: relationship to cytogenetics, genotype and clinical outcome. Br J Haematol 2018; 181:486-494. [PMID: 29676467 DOI: 10.1111/bjh.15211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 02/01/2018] [Indexed: 11/30/2022]
Abstract
Cell cycle status may play an important role in directing patient therapy. We therefore determined the cell cycle status of leukaemic cells by immunophenotypic analysis of bone marrow trephine biopsies from 181 patients with acute myeloid leukaemia (AML) and correlated the results with biological features and clinical outcome. There was considerable heterogeneity between patients. The presenting white cell count significantly correlated with the proportion of non-quiescent cells (P < 0·0001), of cycling cells beyond G1 (P < 0·0001) and the speed of cycling (P < 0·0001). Profiles in acute promyelocytic leukaemia (APL) differed from non-APL and were consistent with more differentiated cells with reduced proliferative potential, but no significant differences were observed between non-APL cytogenetic risk groups. NPM1 mutations but not FLT3 internal tandem duplication (FLT3ITD ) were significantly associated with a higher proportion of cells beyond G1 (P = 0·002) and faster speed of cycling (P = 0·003). Resistance to standard cytosine arabinoside and daunorubicin induction chemotherapy was significantly related to a slower speed of cycling (P = 0·0002), as was a higher relapse rate (P = 0·05), but not with the proportion of non-quiescent cells or actively cycling cells. These results show a link between the cycling speed of AML cells and the response to chemotherapy, and help to identify a group with a very poor prognosis.
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Affiliation(s)
- Rob S Sellar
- Department of Haematology, UCL Cancer Institute, London, UK
| | | | - Asim Khwaja
- Department of Haematology, UCL Cancer Institute, London, UK
| | | | - Marco Loddo
- Department of Pathology, UCL Cancer Institute, London, UK
| | - Kai Stoeber
- Department of Pathology, UCL Cancer Institute, London, UK.,Shinogi Ltd, London, UK
| | - Gareth H Williams
- Department of Pathology, UCL Cancer Institute, London, UK.,Oncologica Ltd, Cambridge, UK
| | - David C Linch
- Department of Haematology, UCL Cancer Institute, London, UK
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Phase 1/2 trial of GCLAM with dose-escalated mitoxantrone for newly diagnosed AML or other high-grade myeloid neoplasms. Leukemia 2018; 32:2352-2362. [PMID: 29720734 PMCID: PMC6192860 DOI: 10.1038/s41375-018-0135-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Accepted: 04/04/2018] [Indexed: 12/17/2022]
Abstract
Outcomes with “7+3” are often unsatisfactory in acute myeloid leukemia (AML). Trials demonstrating improved outcomes with high-dose cytarabine, addition of cladribine, or escalated anthracycline doses prompted a phase 1/2 study (NCT02044796) of G-CSF, cladribine, high-dose cytarabine, and dose-escalated mitoxantrone (GCLAM) in adults with newly-diagnosed AML or other high-grade myeloid neoplasms. 121 patients, median age 60 (range: 21–81) years, were enrolled. In phase 1, cohorts of 6–12 patients were assigned to 12–18mg/m2/day of mitoxantrone as part of GCLAM. Because all dose levels were well-tolerated, mitoxantrone at 18mg/m2 was declared the recommended phase 2 dose (RP2D). 74/94 (79%) patients treated at the RP2D achieved a complete remission (CR; 67/74 without measureable residual disease [MRD]) for an overall MRDneg CR rate of 71% (primary phase 2 endpoint). Seven patients achieved a CR with incomplete blood count recovery (CRi; 7%, 5 MRDneg) for a CR/CRi rate of 81/94 (86%). 4-week mortality was 2%. After adjustment, the MRDneg CR and CR/CRi rates compared favorably to 100 matched controls treated with 7+3 at our center and 245 matched patients treated with 7+3 on a cooperative group trial. Our data indicate GCLAM with mitoxantrone at 18mg/m2/day is safe and induces high-quality remissions in adults with newly-diagnosed AML.
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78
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Kalaskar P, Anand A, Panchal H, Patel A, Parikh S, Shah S. A comparative study of bloodstream infections in acute myeloid leukemia according to different phases of treatment: Can we predict the organism? South Asian J Cancer 2017; 6:132-133. [PMID: 28975124 PMCID: PMC5615885 DOI: 10.4103/2278-330x.214584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Introduction: The treatment of acute myeloid leukemia (AML) consists of induction therapy with anthracyclines and cytarabine followed by two to four cycles of consolidation therapy with high-dose cytarabine after achieving remission. There have been very few studies comparing infections during induction and consolidation. We have analyzed blood cultures of patients with AML during episodes of fever occurring during induction and consolidation, for comparing the bloodstream infections in both the phases. Materials and Methods: Blood cultures of patients during febrile episodes were collected from central venous catheters and peripheral blood, both during induction and consolidation therapy of AML. Results: The study population included 52 AML patients. During induction, there were 52 episodes of fever and 25 (48%) blood cultures were positive, 15 of these blood cultures reported Gram-negative organisms, 9 reported Gram-positive organisms and 1 as yeast. During consolidation, 47 episodes of fever were recorded and blood cultures were positive in 12, of which 7 were Gram-negative, 5 were Gram-positive. Conclusion: The incidence of blood culture positive infections during therapy of AML at our center was higher. The predominant organism isolated was Gram-negative both during induction and consolidation. The incidence of blood culture positive infections had decreased by 50% during consolidation.
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Affiliation(s)
- Preetam Kalaskar
- Department of Medical and Pediatric Oncology, Gujarat Cancer and Research Institute Regional Cancer Center, B.J. Medical College, Ahmedabad, Gujarat, India
| | - Asha Anand
- Department of Medical and Pediatric Oncology, Gujarat Cancer and Research Institute Regional Cancer Center, B.J. Medical College, Ahmedabad, Gujarat, India
| | - Harsha Panchal
- Department of Medical and Pediatric Oncology, Gujarat Cancer and Research Institute Regional Cancer Center, B.J. Medical College, Ahmedabad, Gujarat, India
| | - Apurva Patel
- Department of Medical and Pediatric Oncology, Gujarat Cancer and Research Institute Regional Cancer Center, B.J. Medical College, Ahmedabad, Gujarat, India
| | - Sonia Parikh
- Department of Medical and Pediatric Oncology, Gujarat Cancer and Research Institute Regional Cancer Center, B.J. Medical College, Ahmedabad, Gujarat, India
| | - Sandip Shah
- Department of Medical and Pediatric Oncology, Gujarat Cancer and Research Institute Regional Cancer Center, B.J. Medical College, Ahmedabad, Gujarat, India
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Abstract
OPINION STATEMENT There is no standard of care for older patients with acute myeloid leukemia (AML) unfit for intensive chemotherapy. AML in older patients remains an area of significant unmet need necessitating novel therapeutic strategies. In older patients with normal cytogenetics, molecular variables can be helpful in refining risk. This molecular revolution has promoted a shift in the treatment paradigm of AML. Open new questions concern the necessity of an individualized therapy that may take into account not only an increase in survival but also the maintenance or improvement in terms of quality of life, the management of symptoms, and a maximization of time outside of hospital care. Molecular abnormalities provide the genomic footprint for the development of targeted therapies. Clinical trials testing the activity of these new agents are ongoing and may reshape treatment strategies for these patients. One promising strategy is to combine low-intensity treatments with novel agents.
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Affiliation(s)
- Xavier Thomas
- Department of Hematology, Hospices Civils de Lyon, Lyon-Sud Hospital, Bat.1G, 165 chemin du Grand Revoyet, 69495, Pierre Bénite, France.
| | - Caroline Le Jeune
- Department of Hematology, Hospices Civils de Lyon, Lyon-Sud Hospital, Bat.1G, 165 chemin du Grand Revoyet, 69495, Pierre Bénite, France
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Kolonen A, Sinisalo M, Huttunen R, Syrjänen J, Aittoniemi J, Huhtala H, Sankelo M, Rintala H, Räty R, Jantunen E, Nousiainen T, Säily M, Kauppila M, Itälä-Remes M, Ollikainen H, Rauhala A, Koistinen P, Elonen E. Bloodstream infections in acute myeloid leukemia patients treated according to the Finnish Leukemia Group AML-2003 protocol - a prospective nationwide study. Infect Dis (Lond) 2017; 49:799-808. [PMID: 28683646 DOI: 10.1080/23744235.2017.1347814] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Infections greatly influence the outcome of acute myeloid leukemia (AML) patients receiving intensive treatment. The aim of this study was to establish the incidence, microbial etiology, risk factors and prognosis of bloodstream infections (BSIs) in patients with AML and compare the results with the previous treatment protocol (AML-92). METHODS Registery data were gathered prospectively from 357 patients aged 16-65 years recruited on the AML-2003 treatment protocol between November 2003 and November 2011 during different treatment cycles. RESULTS Blood culture data were available on 977 treatment episodes, in which there were 503 BSIs (51%). The overall incidence rate (IR) for BSIs (per 1000 hospital days) was 16.7. Twenty patients (5.6%) died due to an infection and 16 of them (80%) had a BSI. The most commonly detected microbes (polymicrobial episodes included) in blood cultures were coagulase-negative staphylococci (CoNS, 24.7%), viridans group streptococci (VGS, 19.1%), enterococci (13.9%) and Enterobacteriacae group (25.9%). The etiology of BSIs varied greatly from treatment cycle to cycle. CONCLUSIONS Enterococcal BSIs have increased compared to our previous treatment protocol, and they represent significant pathogens in blood cultures. Infection-related mortality has decreased despite the increase in the IR of BSIs. Enterococci seem to be an increasingly prominent pathogen underlying BSIs in the AML patients, especially during induction therapy (20%).
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Affiliation(s)
- Aarne Kolonen
- a Department of Internal Medicine , Tampere University Hospital , Tampere , Finland
| | - Marjatta Sinisalo
- a Department of Internal Medicine , Tampere University Hospital , Tampere , Finland
| | - Reetta Huttunen
- a Department of Internal Medicine , Tampere University Hospital , Tampere , Finland
| | - Jaana Syrjänen
- a Department of Internal Medicine , Tampere University Hospital , Tampere , Finland
| | | | - Heini Huhtala
- c Faculty of Social Sciences , University of Tampere , Tampere , Finland
| | - Marja Sankelo
- a Department of Internal Medicine , Tampere University Hospital , Tampere , Finland
| | - Hannele Rintala
- a Department of Internal Medicine , Tampere University Hospital , Tampere , Finland
| | - Riikka Räty
- d Department of Hematology , Helsinki University Hospital Comprehensive Cancer Center and University of Helsinki, Finland
| | - Esa Jantunen
- e Department of Internal Medicine, Kuopio University Hospital , Kuopio , Finland
| | - Tapio Nousiainen
- e Department of Internal Medicine, Kuopio University Hospital , Kuopio , Finland
| | - Marjaana Säily
- f Department of Internal Medicine, Oulu University Hospital , Oulu , Finland
| | - Marjut Kauppila
- g Division of Medicine, Turku University Hospital , Turku , Finland.,h Department of Hematology and Stem Cell Transplantation, Turku University Hospital , Turku , Finland
| | - Maija Itälä-Remes
- g Division of Medicine, Turku University Hospital , Turku , Finland.,h Department of Hematology and Stem Cell Transplantation, Turku University Hospital , Turku , Finland
| | - Hanna Ollikainen
- i Department of Hematology, Satakunta Central Hospital , Pori , Finland
| | | | - Pirjo Koistinen
- f Department of Internal Medicine, Oulu University Hospital , Oulu , Finland
| | - Erkki Elonen
- d Department of Hematology , Helsinki University Hospital Comprehensive Cancer Center and University of Helsinki, Finland
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81
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Ho G, Jonas BA, Li Q, Brunson A, Wun T, Keegan THM. Early mortality and complications in hospitalized adult Californians with acute myeloid leukaemia. Br J Haematol 2017; 177:791-799. [PMID: 28419422 DOI: 10.1111/bjh.14631] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 12/20/2016] [Accepted: 12/31/2016] [Indexed: 11/28/2022]
Abstract
Few studies have evaluated the impact of complications, sociodemographic and clinical factors on early mortality (death ≤60 days from diagnosis) in acute myeloid leukaemia (AML) patients. Using data from the California Cancer Registry linked to hospital discharge records from 1999 to 2012, we identified patients aged ≥15 years with AML who received inpatient treatment (N = 6359). Multivariate logistic regression analyses were used to assess the association of complications with early mortality, adjusting for sociodemographic factors, comorbidities and hospital type. Early mortality decreased over time (25·3%, 1999-2000; 16·8%, 2011-2012) across all age groups, but was higher in older patients (6·9%, 15-39, 11·4%, 40-54, 18·6% 55-65, and 35·8%, >65 years). Major bleeding [Odds ratio (OR) 1·5, 95% confidence interval (CI) 1·3-1·9], liver failure (OR 1·9, 95% CI 1·1-3·1), renal failure (OR 2·4, 95% CI 2·0-2·9), respiratory failure (OR 7·6, 95% CI 6·2-9·3) and cardiac arrest (OR 15·8, 95% CI 8·7-28·6) were associated with early mortality. Higher early mortality was also associated with single marital status, low neighbourhood socioeconomic status, lack of health insurance and comorbidities. Treatment at National Cancer Institute-designated cancer centres was associated with lower early mortality (OR 0·5, 95% CI 0·4-0·6). In conclusion, organ dysfunction, hospital type and sociodemographic factors impact early mortality. Further studies should investigate how differences in healthcare delivery affect early mortality.
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Affiliation(s)
- Gwendolyn Ho
- Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology and Oncology, Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, CA, USA
| | - Brian A Jonas
- Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology and Oncology, Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, CA, USA
| | - Qian Li
- Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology and Oncology, Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, CA, USA
| | - Ann Brunson
- Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology and Oncology, Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, CA, USA
| | - Ted Wun
- Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology and Oncology, Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, CA, USA
| | - Theresa H M Keegan
- Center for Oncology Hematology Outcomes Research and Training (COHORT), Division of Hematology and Oncology, Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, CA, USA
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83
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Halpern AB, Culakova E, Walter RB, Lyman GH. Association of Risk Factors, Mortality, and Care Costs of Adults With Acute Myeloid Leukemia With Admission to the Intensive Care Unit. JAMA Oncol 2017; 3:374-381. [PMID: 27832254 DOI: 10.1001/jamaoncol.2016.4858] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Importance Adults with acute myeloid leukemia (AML) commonly require support in the intensive care unit (ICU), but risk factors for admission to the ICU and adverse outcomes remain poorly defined. Objective To examine risk factors, mortality, length of stay, and cost associated with admission to the ICU for patients with AML. Design, Setting, and Participants This study extracted information from the University HealthSystem Consortium database on patients 18 years or older with AML who were hospitalized for any cause between January 1, 2004, and December 31, 2012. The University HealthSystem Consortium database contains demographic, clinical, and cost variables prospectively abstracted by certified coders from discharge summaries. Outcomes were analyzed using univariate and multivariable statistical techniques. Data analysis was performed from November 15, 2013, to August 15, 2016. Main Outcomes and Measures Primary outcomes were admission to the ICU and inpatient mortality among patients requiring ICU care. Secondary outcomes included length of stay in the ICU, total hospitalization length of stay, and cost. Results Of the 43 249 patients with AML (mean [SD] age, 59.5 [16.6] years; 23 939 men and 19 310 women), 11 277 (26.1%) were admitted to the ICU. On multivariable analysis (with results reported as odds ratios [95% CIs]), independent risk factors for admission to the ICU included age younger than 80 years (1.56 [1.42-1.70]), hospitalization in the South (1.81 [1.71-1.92]), hospitalization at a low- or medium-volume hospital (1.25 [1.19-1.31]), number of comorbidities (10.64 [8.89-12.62] for 5 vs none), sepsis (4.61 [4.34-4.89]), invasive fungal infection (1.24 [1.11-1.39]), and pneumonia (1.73 [1.63-1.82]). In-hospital mortality was higher for patients requiring ICU care (4857 of 11 277 [43.1%] vs 2959 of 31 972 [9.3%]). On multivariable analysis, independent risk factors for death in patients requiring ICU care included age 60 years or older (1.16 [1.06-1.26]), nonwhite race/ethnicity (1.18 [1.07-1.30]), hospitalization on the West coast (1.19 [1.06-1.34]), number of comorbidities (18.76 [13.7-25.67] for 5 vs none), sepsis (2.94 [2.70-3.21]), invasive fungal infection (1.20 [1.02-1.42]), and pneumonia (1.13 [1.04-1.24]). Mean costs of hospitalization were higher for patients requiring ICU care ($83 354 vs $41 973) and increased with each comorbidity, from $50 543 for patients with no comorbidities to $124 820 for those with 5 or more comorbidities. Conclusions and Relevance Admission to the ICU is associated with high mortality and cost that increase proportionally with the comorbidity burden in adults with AML. Several demographic factors and medical characteristics identify patients at risk for admission to the ICU and mortality and provide an opportunity for testing primary prevention strategies.
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Affiliation(s)
- Anna B Halpern
- Hematology/Oncology Fellowship Program, Fred Hutchinson Cancer Research Center/University of Washington, Seattle
| | - Eva Culakova
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, Washington3Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Roland B Walter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington5Division of Hematology, Department of Medicine, University of Washington, Seattle6Department of Epidemiology, University of Washington, Seattle
| | - Gary H Lyman
- Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, Washington3Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington4Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington7Division of Medical Oncology, Department of Medicine, University of Washington, Seattle
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84
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Guolo F, Minetto P, Clavio M, Miglino M, Lemoli RM, Gobbi M. Intesive fludarabine-high dose cytarabine-idarubicin combination as induction therapy with risk-adapted consolidation may improve treatment efficacy in younger Acute Myeloid Leukemia (AML) patients: Rationales, evidences and future perspectives. Biosci Trends 2017; 11:110-114. [PMID: 28123146 DOI: 10.5582/bst.2016.01221] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Acute Myeloid Leukemia (AML) is the commonest form of leukemia in the adults, with an incidence of 3-4 cases per 100,000 people/year. After the first description of the effective cytarabine + antracycline (3+7) induction regimen, in the last 3 decades, no effective targeted drug has been included in the standard treatment of AML. Many efforts of modifying 3+7 adding a third drug or increasing the dose of anthracycline, cytarabine or both did not lead to substantial improvements, mainly due to increased toxicity. Many in vitro and in vivo evidences suggested that fludarabine may increase efficacy of cytarabine through a synergistic effect. Considering the continuous improvements in supportive care and management of infectious complications the feasibility of more intensive induction strategies have increased and a renewed interest in fludarabine-containing induction strategies arose. The recent MRC AML 15 trial has shown that a fludarabine-containing induction, FLAG-Ida, resulted superior to conventional 3+7 in terms of complete remission rates, relapse incidence and survival, although only a minority of patients could complete the whole planned consolidation program due to an excessive hematological toxicity. Our group recently published a 10-year experience with a fludarabine-containing induction that slightly differed from the MRC one and resulted in good efficacy and higher feasibility. In this commentary we review the major evidences supporting the employ of a fludarabine-containing induction in AML, and discuss the future perspectives.
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Affiliation(s)
- Fabio Guolo
- Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, IRCCS AOU San Martino-IST
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85
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Sperr WR, Zach O, Pöll I, Herndlhofer S, Knoebl P, Weltermann A, Streubel B, Jaeger U, Kundi M, Valent P. Karyotype plus NPM1 mutation status defines a group of elderly patients with AML (≥60 years) who benefit from intensive post-induction consolidation therapy. Am J Hematol 2016; 91:1239-1245. [PMID: 27643573 DOI: 10.1002/ajh.24560] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 09/13/2016] [Accepted: 09/15/2016] [Indexed: 12/15/2022]
Abstract
Although it is generally appreciated that a subset of elderly patients with acute myeloid leukemia (AML) may benefit from intensive consolidation, little is known about variables predicting such benefit. We analyzed 192 consecutive patients with de novo AML aged ≥60 years who were treated with intensive chemotherapy. About 115 patients (60%) achieved complete hematologic remission (CR). Among several parameters, the karyotype was the only independent variable predicting CR (P < 0.05). About 92% (105/115) of the CR-patients received up to four consolidation cycles of intermediate dose ARA-C. Median continuous CR (CCR) and disease-free survival (DFS) were 1.3 and 1.1 years, respectively. CCR, DFS, and survival at 5 years were 23%, 18%, and 15%, respectively. Only karyotype and mutated NPM1 (NPM1mut) were independent predictors of survival. NPM1mut showed a particular prognostic impact in patients with normal (CN) or non-monosomal (Mkneg) karyotype by Haemato-Oncology Foundation for Adults in the Netherlands (HOVON)-criteria, or intermediate karyotype by Southwest Oncology Group (SWOG)-criteria. The median CCR was 0.94, 1.6, 0.9, and 0.5 years for core-binding-factor, CN/Mkneg-NPM1mut, CN/Mkneg-NPM1-wild-type AML, and AML with monosomal karyotype, respectively, and the 5-year survival was 25%, 39%, 2%, and 0%, respectively (P < 0.05). Similar results (0.9, 1.5, 0.9, and 0.5 years) were obtained using modified SWOG criteria and NPM1 mutation status (P < 0.05). In summary, elderly patients with CN/Mkneg-NPM1mut or CBF AML can achieve long term CCR when treated with intensive induction and consolidation therapy whereas most elderly patients with CN/Mkneg-NPM1wt or Mkpos AML may not benefit from intensive chemotherapy. For these patients either hematopoietic-stem-cell-transplantation or alternative treatments have to be considered. Am. J. Hematol. 91:1239-1245, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Wolfgang R. Sperr
- Department of Internal Medicine I, Division of Hematology and HemostaseologyMedical University of ViennaVienna Austria
- Ludwig Boltzmann Cluster Oncology, Medical University of ViennaVienna Austria
| | - Otto Zach
- Department of Internal Medicine IHospital of the ElisabethinenLinz Austria
| | - Iris Pöll
- Department of Internal Medicine IHospital of the ElisabethinenLinz Austria
| | - Susanne Herndlhofer
- Department of Internal Medicine I, Division of Hematology and HemostaseologyMedical University of ViennaVienna Austria
- Ludwig Boltzmann Cluster Oncology, Medical University of ViennaVienna Austria
| | - Paul Knoebl
- Department of Internal Medicine I, Division of Hematology and HemostaseologyMedical University of ViennaVienna Austria
| | - Ansgar Weltermann
- Department of Internal Medicine IHospital of the ElisabethinenLinz Austria
| | - Berthold Streubel
- Department of Obstetrics and GynecologyMedical University of ViennaVienna Austria
| | - Ulrich Jaeger
- Department of Internal Medicine I, Division of Hematology and HemostaseologyMedical University of ViennaVienna Austria
- Ludwig Boltzmann Cluster Oncology, Medical University of ViennaVienna Austria
| | - Michael Kundi
- Institute of Environmental Health, Medical University of ViennaVienna Austria
| | - Peter Valent
- Department of Internal Medicine I, Division of Hematology and HemostaseologyMedical University of ViennaVienna Austria
- Ludwig Boltzmann Cluster Oncology, Medical University of ViennaVienna Austria
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86
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Diagnosis and management of AML in adults: 2017 ELN recommendations from an international expert panel. Blood 2016; 129:424-447. [PMID: 27895058 DOI: 10.1182/blood-2016-08-733196] [Citation(s) in RCA: 3916] [Impact Index Per Article: 489.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 11/15/2016] [Indexed: 12/13/2022] Open
Abstract
The first edition of the European LeukemiaNet (ELN) recommendations for diagnosis and management of acute myeloid leukemia (AML) in adults, published in 2010, has found broad acceptance by physicians and investigators caring for patients with AML. Recent advances, for example, in the discovery of the genomic landscape of the disease, in the development of assays for genetic testing and for detecting minimal residual disease (MRD), as well as in the development of novel antileukemic agents, prompted an international panel to provide updated evidence- and expert opinion-based recommendations. The recommendations include a revised version of the ELN genetic categories, a proposal for a response category based on MRD status, and criteria for progressive disease.
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88
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ICU intervention during induction chemotherapy for adult patients with newly diagnosed acute myeloid leukemia. Leuk Res 2016; 48:16-9. [DOI: 10.1016/j.leukres.2016.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 06/15/2016] [Accepted: 07/07/2016] [Indexed: 11/24/2022]
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89
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Geng Y, Jian C, Yang S, Wu S, Zhou J, Li D. The Prognostic Value of D-Dimer in De Novo Acute Myeloid Leukemia. Am J Med Sci 2016; 352:129-33. [PMID: 27524209 DOI: 10.1016/j.amjms.2016.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 04/09/2016] [Accepted: 04/15/2016] [Indexed: 01/11/2023]
Abstract
BACKGROUND The aim of this study was to evaluate the prognostic value of D-dimer in patients with newly diagnosed de novo non-M3 subtypes of acute myeloid leukemia (AML). MATERIALS AND METHODS We retrospectively analyzed the clinical data from 245 patients with newly diagnosed de novo non-M3 subtypes of AML at the Tongji Hospital from January 2010 to December 2014. RESULTS The comparison results indicated that the D-dimer values were higher in patients with AML with the following characteristics: WBC count ≥ 20 × 10(9)/L (2.20 versus 6.00, P = 0.001), percentage of bone marrow (BM) blasts ≥ 60% (2.06 versus 5.69, P = 0.003), and poor-risk stratification (P < 0.001). Cox univariate regression analysis showed that overall survival was negatively affected by the following factors: age > 60 years, poor-risk stratification, BM blast cell count ≥60%, and D-dimer ≥1μg/mL. Multivariate analysis showed that only age > 60 years (P < 0.001), BM blast cell counts ≥60% (P = 0.001) and D-dimer values ≥1μg/mL (P = 0.014) were independent adverse prognostic factors. CONCLUSIONS D-dimer ≥1μg/mL is related to high tumor burden and can be considered as an independent prognostic factor in patients with de novo non-M3 AML.
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Affiliation(s)
- Yudi Geng
- Department of Hematology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Cui Jian
- Clinical laboratory, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Shijia Yang
- Department of Hematology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Sijing Wu
- Department of Hematology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Jianfeng Zhou
- Department of Hematology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Dengju Li
- Department of Hematology, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, Hubei, China.
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90
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Estey E. Acute myeloid leukemia: 2016 Update on risk-stratification and management. Am J Hematol 2016; 91:824-46. [PMID: 27417880 DOI: 10.1002/ajh.24439] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 05/26/2016] [Indexed: 11/09/2022]
Abstract
Evidence suggest that even patients aged 70 or above benefit from specific AML therapy. The fundamental decision in AML then becomes whether to recommend standard or investigational treatment. This decision must rest on the likely outcome of standard treatment. Hence we review factors that predict treatment related mortality and resistance to therapy, the latter the principal cause of failure even in patients aged 70 or above. We emphasize the limitations of prediction of resistance based only on pre- treatment factors and stress the need to incorporate post-treatment factors, for example indicators of minimal residual disease. We review various newer therapeutic options and considerations that underlie the decision to recommend allogeneic hematopoietic cell transplant. Am. J. Hematol. 91:825-846, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Elihu Estey
- Division of Hematology, University of Washington School of Medicine, Seattle, WA, Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
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91
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Guolo F, Minetto P, Clavio M, Miglino M, Di Grazia C, Ballerini F, Pastori G, Guardo D, Colombo N, Kunkl A, Fugazza G, Rebesco B, Sessarego M, Lemoli RM, Bacigalupo A, Gobbi M. High feasibility and antileukemic efficacy of fludarabine, cytarabine, and idarubicin (FLAI) induction followed by risk-oriented consolidation: A critical review of a 10-year, single-center experience in younger, non M3 AML patients. Am J Hematol 2016; 91:755-62. [PMID: 27084986 DOI: 10.1002/ajh.24391] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Revised: 03/16/2016] [Accepted: 04/13/2016] [Indexed: 11/09/2022]
Abstract
About 105 consecutive acute myeloid leukemia (AML) patients treated with the same induction-consolidation program between 2004 and 2013 were retrospectively analyzed. Median age was 47 years. The first induction course included fludarabine (Flu) and high-dose cytarabine (Ara-C) plus idarubicin (Ida), with or without gemtuzumab-ozogamicin (GO) 3 mg/m(2) (FLAI-5). Patients achieving complete remission (CR) received a second course without fludarabine but with higher dose of idarubicin. Patients not achieving CR received an intensified second course. Patients not scheduled for early allogeneic bone marrow transplantation (HSCT) where planned to receive at least two courses of consolidation therapy with Ara-C. Our double induction strategy significantly differs from described fludarabine-containing regimens, as patients achieving CR receive a second course without fludarabine, to avoid excess toxicity, and Ara-C consolidation is administrated at the reduced cumulative dose of 8 g/m(2) per cycle. Toxicity is a major concern in fludarabine containing induction, including the recent Medical Research Council AML15 fludarabine, cytarabine, idaraubicin and G-CSF (FLAG-Ida) arm, and, despite higher anti-leukemic efficacy, only a minority of patients is able to complete the full planned program. In this article, we show that our therapeutic program is generally well tolerated, as most patients were able to receive subsequent therapy at full dose and in a timely manner, with a 30-day mortality of 4.8%. The omission of fludarabine in the second course did not reduce efficacy, as a CR rate of 83% was achieved and 3-year disease-free survival and overall survival (OS) were 49.6% and 50.9%, respectively. Our experience shows that FLAI-5/Ara-C + Ida double induction followed by risk-oriented consolidation therapy can result in good overall outcome with acceptable toxicity. Am. J. Hematol. 91:755-762, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Fabio Guolo
- Hematology Clinic, Department of Internal Medicine (DiMI); University of Genoa, IRCCS AOU S. Martino-IST; Genoa Italy
| | - Paola Minetto
- Hematology Clinic, Department of Internal Medicine (DiMI); University of Genoa, IRCCS AOU S. Martino-IST; Genoa Italy
| | - Marino Clavio
- Hematology Clinic, Department of Internal Medicine (DiMI); University of Genoa, IRCCS AOU S. Martino-IST; Genoa Italy
| | - Maurizio Miglino
- Hematology Clinic, Department of Internal Medicine (DiMI); University of Genoa, IRCCS AOU S. Martino-IST; Genoa Italy
| | - Carmen Di Grazia
- Second Division of Hematology and Bone Marrow Transplantation; IRCCS AOU S. Martino-IST; Genoa Italy
| | - Filippo Ballerini
- Hematology Clinic, Department of Internal Medicine (DiMI); University of Genoa, IRCCS AOU S. Martino-IST; Genoa Italy
| | - Giordana Pastori
- Hematology Clinic, Department of Internal Medicine (DiMI); University of Genoa, IRCCS AOU S. Martino-IST; Genoa Italy
| | - Daniela Guardo
- Hematology Clinic, Department of Internal Medicine (DiMI); University of Genoa, IRCCS AOU S. Martino-IST; Genoa Italy
| | - Nicoletta Colombo
- Hematology Clinic, Department of Internal Medicine (DiMI); University of Genoa, IRCCS AOU S. Martino-IST; Genoa Italy
| | - Annalisa Kunkl
- Service of Flow-Cytometry, Department of Pathology; IRCCS AOU S. Martino-IST; Genoa Italy
| | - Giuseppina Fugazza
- Hematology Clinic, Department of Internal Medicine (DiMI); University of Genoa, IRCCS AOU S. Martino-IST; Genoa Italy
| | - Barbara Rebesco
- Pharmacology Division; IRCCS AOU S. Martino-IST; Genoa Italy
| | - Mario Sessarego
- Hematology Clinic, Department of Internal Medicine (DiMI); University of Genoa, IRCCS AOU S. Martino-IST; Genoa Italy
| | - Roberto Massimo Lemoli
- Hematology Clinic, Department of Internal Medicine (DiMI); University of Genoa, IRCCS AOU S. Martino-IST; Genoa Italy
| | - Andrea Bacigalupo
- Second Division of Hematology and Bone Marrow Transplantation; IRCCS AOU S. Martino-IST; Genoa Italy
| | - Marco Gobbi
- Hematology Clinic, Department of Internal Medicine (DiMI); University of Genoa, IRCCS AOU S. Martino-IST; Genoa Italy
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Sanford D, Ravandi F. Management of Newly Diagnosed Acute Myeloid Leukemia in the Elderly: Current Strategies and Future Directions. Drugs Aging 2016; 32:983-97. [PMID: 26446152 DOI: 10.1007/s40266-015-0309-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The incidence of acute myeloid leukemia (AML) increases with age, and the majority of cases occur in adults aged >55 years. The prognosis of AML in older adults is generally poor; however, AML is a heterogeneous disease regardless of age, and prognosis depends on cytogenetic changes, genetic mutations, and patient characteristics. Several lines of evidence support offering treatment to the vast majority of older patients, and the survival benefit associated with this approach generally outweighs the risk of toxicity. Response and long-term survival using intensive induction regimens are significantly lower in older patients, although a small proportion of patients can achieve durable remissions. Selection of patients for intensive induction therapy requires comprehensive assessment of disease characteristics, performance status, and comorbidities. In unfit patients, options for treatment include hypomethylating agents, low-dose ara-C, or consideration of a clinical trial if available. The incorporation of novel therapies into treatment, such as FLT3 inhibitors and antibody-drug conjugates, offers significant promise in older patients, although, thus far, increased responses using novel agents have often not translated to improved survival outcomes. The development of reduced-intensity conditioning regimens and improvements in supportive care has increased the use of allogeneic stem cell transplant (ASCT) in older patients. Selection of patients for ASCT requires an estimation of the trade-off between toxicity and risk of relapse.
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Affiliation(s)
- David Sanford
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Farhad Ravandi
- Department of Leukemia, Unit 428, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA.
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Pettit K, Stock W, Walter RB. Incorporating measurable ('minimal') residual disease-directed treatment strategies to optimize outcomes in adults with acute myeloid leukemia. Leuk Lymphoma 2016; 57:1527-33. [PMID: 27269126 DOI: 10.3109/10428194.2016.1160085] [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] [Indexed: 11/13/2022]
Abstract
Curative-intent therapy leads to complete remissions in many adults with acute myeloid leukemia (AML), but relapse remains common. Numerous studies have unequivocally demonstrated that the persistence of measurable ('minimal') residual disease (MRD) at the submicroscopic level during morphologic remission identifies patients at high risk of disease recurrence and short survival. This association has provided the impetus to customize anti-leukemia therapy based on MRD data, a strategy that is now routinely pursued in acute promyelocytic leukemia (APL). While it is currently uncertain whether this approach will improve outcomes in AML other than APL, randomized studies have validated MRD-based risk-stratified treatment algorithms in acute lymphoblastic leukemia. Here, we review the available studies examining MRD-directed therapy in AML, appraise their strengths and limitations, and discuss avenues for future investigation.
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Affiliation(s)
- Kristen Pettit
- a Section of Hematology/Oncology and University of Chicago Comprehensive Cancer Center , University of Chicago , Chicago , IL , USA
| | - Wendy Stock
- a Section of Hematology/Oncology and University of Chicago Comprehensive Cancer Center , University of Chicago , Chicago , IL , USA
| | - Roland B Walter
- b Clinical Research Division , Fred Hutchinson Cancer Research Center , Seattle , WA , USA ;,c Department of Medicine, Division of Hematology , University of Washington , Seattle , WA , USA ;,d Department of Epidemiology , University of Washington , Seattle , WA , USA
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94
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Delaney C, Milano F, Cicconi L, Othus M, Becker PS, Sandhu V, Nicoud I, Dahlberg A, Bernstein ID, Appelbaum FR, Estey EH. Infusion of a non-HLA-matched ex-vivo expanded cord blood progenitor cell product after intensive acute myeloid leukaemia chemotherapy: a phase 1 trial. LANCET HAEMATOLOGY 2016; 3:e330-9. [PMID: 27374466 DOI: 10.1016/s2352-3026(16)30023-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 04/05/2016] [Accepted: 04/06/2016] [Indexed: 01/05/2023]
Abstract
BACKGROUND The intensive chemotherapy regimens used to treat acute myeloid leukaemia routinely result in serious infections, largely due to prolonged neutropenia. We investigated the use of non-HLA-matched ex-vivo expanded cord blood progenitor cells to accelerate haemopoietic recovery and reduce infections after chemotherapy. METHODS We enrolled patients with a diagnosis of acute myeloid leukaemia by WHO criteria and aged 18-70 years inclusive at our institution (Fred Hutchinson Cancer Research Center) into this phase 1 trial. The primary endpoint of the study was safety of infusion of non-HLA-matched expanded cord blood progenitor cells after administration of clofarabine, cytarabine, and granulocyte-colony stimulating factor priming. The protocol is closed to accrual and analysis was performed per protocol. The trial is registered with ClinicalTrials.gov, NCT01031368. FINDINGS Between June 29, 2010, and June 26, 2012, 29 patients with acute myeloid leukaemia (19 newly diagnosed, ten relapsed or refractory) were enrolled. The most common adverse events were fever (27 [93%] of 29 patients) and infections (25 [86%] of 29 patients). We observed one case of acute infusional toxicity (attributed to an allergic reaction to dimethyl sulfoxide) in the 29 patients enrolled, who received 42 infusions of expanded progenitor cells. The following additional serious but expected adverse events were observed (each in one patient): grade 4 atrial fibrillation, grade 4 febrile neutropenia, lung infection with grade 4 absolute neutrophil count, colon infection with grade 4 absolute neutrophil count, grade 4 changed mental status, and one death from liver failure. No unexpected toxicity or graft-versus-host disease was observed. There was no evidence of in-vivo persistence of the expanded progenitor cell product in any patient beyond 14 days or induced alloimmunisation. INTERPRETATION Infusion of the expanded progenitor cell product seemed safe and might provide a promising treatment method for patients with acute myeloid leukaemia. FUNDING Biomedical Advanced Research and Development Authority in the US Department of Health and Human Services and Genzyme (Sanofi).
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Affiliation(s)
- Colleen Delaney
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Department of Pediatrics, University of Washington, Seattle, WA, USA.
| | - Filippo Milano
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Department of Medical Oncology, University of Washington, Seattle, WA, USA
| | - Laura Cicconi
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Megan Othus
- Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; SWOG Statistical Center, Seattle, WA, USA
| | - Pamela S Becker
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Department of Medical Oncology, University of Washington, Seattle, WA, USA
| | - Vicky Sandhu
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Ian Nicoud
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Ann Dahlberg
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Irwin D Bernstein
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Frederick R Appelbaum
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Department of Medical Oncology, University of Washington, Seattle, WA, USA
| | - Elihu H Estey
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Department of Medical Oncology, University of Washington, Seattle, WA, USA
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Vaughn JE, Buckley SA, Walter RB. Outpatient care of patients with acute myeloid leukemia: Benefits, barriers, and future considerations. Leuk Res 2016; 45:53-8. [PMID: 27101148 PMCID: PMC5383350 DOI: 10.1016/j.leukres.2016.03.011] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 03/14/2016] [Accepted: 03/31/2016] [Indexed: 11/23/2022]
Abstract
Patients with acute myeloid leukemia (AML) who receive intensive induction or re-induction chemotherapy with curative intent typically experience prolonged cytopenias upon completion of treatment. Due to concerns regarding infection and bleeding risk as well as significant transfusion and supportive care requirements, patients have historically remained in the hospital until blood count recovery-a period of approximately 30 days. The rising cost of AML care has prompted physicians to reconsider this practice, and a number of small studies have suggested the safety and feasibility of providing outpatient supportive care to patients following intensive AML (re-) induction therapy. Potential benefits include a significant reduction of healthcare costs, improvement in quality of life, and decreased risk of hospital-acquired infections. In this article, we will review the currently available literature regarding this practice and discuss questions to be addressed in future studies. In addition, we will consider some of the barriers that must be overcome by institutions interested in implementing an "early discharge" policy. While outpatient management of selected AML patients appears safe, careful planning is required in order to provide the necessary support, education and rapid management of serious complications that occur among this very vulnerable patient population.
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Affiliation(s)
- Jennifer E Vaughn
- Department of Internal Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA, USA; Virginia Tech Carilion Research Institute, Roanoke, VA, USA; Blue Ridge Cancer Care, Roanoke, VA, USA.
| | - Sarah A Buckley
- Hematology/Oncology Fellowship Program, University of Washington, Seattle, WA, USA
| | - Roland B Walter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA; Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA
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96
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Vaughn JE, Othus M, Powell MA, Gardner KM, Rizzuto DL, Hendrie PC, Becker PS, Pottinger PS, Estey EH, Walter RB. Resource Utilization and Safety of Outpatient Management Following Intensive Induction or Salvage Chemotherapy for Acute Myeloid Leukemia or Myelodysplastic Syndrome: A Nonrandomized Clinical Comparative Analysis. JAMA Oncol 2016; 1:1120-7. [PMID: 26355382 DOI: 10.1001/jamaoncol.2015.2969] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Adults with acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS) typically remain hospitalized after induction or salvage chemotherapy until blood cell count recovery, with resulting prolonged inpatient stays being a primary driver of health care costs. Pilot studies suggest that outpatient management following chemotherapy might be safe and could reduce costs for these patients. OBJECTIVE To compare safety, resource utilization, infections, and costs between adults discharged early following AML or MDS induction or salvage chemotherapy and inpatient controls. DESIGN Nonrandomized, phase 2, single-center study conducted at the University of Washington Medical Center. Over a 43-month period (January 1, 2011, through July 31, 2014), 178 adults receiving intensive AML or MDS chemotherapy were enrolled. After completion of chemotherapy, 107 patients met predesignated medical and logistical criteria for early discharge, while 29 met medical criteria only and served as inpatient controls. INTERVENTIONS Early-discharge patients were released from the hospital at the completion of chemotherapy, and supportive care was provided in the outpatient setting until blood cell count recovery (median, 21 days; range, 2-45 days). Controls received inpatient supportive care (median, 16 days; range, 3-42 days). MAIN OUTCOMES AND MEASURES We analyzed differences in early mortality, resource utilization including intensive care unit (ICU) days, transfusions per study day, and use of intravenous (IV) antibiotics per study day), numbers of infections, and total and inpatient charges per study day among early-discharge patients vs controls. RESULTS Four of the 107 early-discharge patients and none of the 29 control patients died within 30 days of enrollment (P=.58). Nine early-discharge patients (8%) but no controls required ICU-level care (P=.20). No differences were noted in the median daily number of transfused red blood cell units (0.27 vs 0.29; P=.55) or number of transfused platelet units (0.26 vs 0.29; P=.31). Early-discharge patients had more positive blood cultures (37 [35%] vs 4 [14%]; P=.04) but required fewer IV antibiotic days per study day (0.48 vs 0.71; P=.01). Overall, daily charges among early-discharge patients were significantly lower than for inpatients (median, $3840 vs $5852; P<.001) despite increased charges per inpatient day when readmitted (median, $7405 vs $5852; P<.001). CONCLUSIONS AND RELEVANCE Early discharge following intensive AML or MDS chemotherapy can reduce costs and use of IV antibiotics, but attention should be paid to complications that may occur in the outpatient setting.
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Affiliation(s)
- Jennifer E Vaughn
- Hematology/Oncology Fellowship Program, University of Washington, Seattle2Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington3now with Blue Ridge Cancer Care, Department of Medicine, Virginia Tech Carilion School of Med
| | - Megan Othus
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Morgan A Powell
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | | | - Paul C Hendrie
- Division of Hematology, Department of Medicine, University of Washington, Seattle
| | - Pamela S Becker
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington6Division of Hematology, Department of Medicine, University of Washington, Seattle
| | - Paul S Pottinger
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle
| | - Elihu H Estey
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington6Division of Hematology, Department of Medicine, University of Washington, Seattle
| | - Roland B Walter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington6Division of Hematology, Department of Medicine, University of Washington, Seattle8Department of Epidemiology, University of Washington, Seattle
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Khwaja A, Bjorkholm M, Gale RE, Levine RL, Jordan CT, Ehninger G, Bloomfield CD, Estey E, Burnett A, Cornelissen JJ, Scheinberg DA, Bouscary D, Linch DC. Acute myeloid leukaemia. Nat Rev Dis Primers 2016; 2:16010. [PMID: 27159408 DOI: 10.1038/nrdp.2016.10] [Citation(s) in RCA: 214] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Acute myeloid leukaemia (AML) is a disorder characterized by a clonal proliferation derived from primitive haematopoietic stem cells or progenitor cells. Abnormal differentiation of myeloid cells results in a high level of immature malignant cells and fewer differentiated red blood cells, platelets and white blood cells. The disease occurs at all ages, but predominantly occurs in older people (>60 years of age). AML typically presents with a rapid onset of symptoms that are attributable to bone marrow failure and may be fatal within weeks or months when left untreated. The genomic landscape of AML has been determined and genetic instability is infrequent with a relatively small number of driver mutations. Mutations in genes involved in epigenetic regulation are common and are early events in leukaemogenesis. The subclassification of AML has been dependent on the morphology and cytogenetics of blood and bone marrow cells, but specific mutational analysis is now being incorporated. Improvements in treatment in younger patients over the past 35 years has largely been due to dose escalation and better supportive care. Allogeneic haematopoietic stem cell transplantation may be used to consolidate remission in those patients who are deemed to be at high risk of relapse. A plethora of new agents - including those targeted at specific biochemical pathways and immunotherapeutic approaches - are now in trial based on improved understanding of disease pathophysiology. These advances provide good grounds for optimism, although mortality remains high especially in older patients.
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Affiliation(s)
- Asim Khwaja
- Department of Haematology, University College London, UCL Cancer Institute, 72 Huntley Street, London WC1E 6DD, UK
| | - Magnus Bjorkholm
- Department of Medicine, Karolinska Institutet and University Hospital, Stockholm, Sweden
| | - Rosemary E Gale
- Department of Haematology, University College London, UCL Cancer Institute, 72 Huntley Street, London WC1E 6DD, UK
| | - Ross L Levine
- Human Oncology and Pathogenesis Program, Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Craig T Jordan
- Division of Hematology, University of Colorado Denver, Denver, Colorado, USA
| | - Gerhard Ehninger
- Department of Internal Medicine, Technical University Dresden, Dresden, Germany
| | | | - Eli Estey
- Division of Hematology, University of Washington and Clinical Research Division Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | | | | | - David A Scheinberg
- Molecular Pharmacology Program, Experimental Therapeutics Center, Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Didier Bouscary
- Institut Cochin, Département Développement Reproduction Cancer, CNRS UMR8104, INSERM U1016, Paris, France.,Service d'Hématologie, Hôpital Cochin, AP-HP, Paris, France.,Université Paris Descartes, Faculté de Médecine Sorbonne Paris Cité, Paris, France
| | - David C Linch
- Department of Haematology, University College London, UCL Cancer Institute, 72 Huntley Street, London WC1E 6DD, UK
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Hallböök H, Lidström AK, Pauksens K. Ciprofloxacin prophylaxis delays initiation of broad-spectrum antibiotic therapy and reduces the overall use of antimicrobial agents during induction therapy for acute leukaemia: A single-centre study. Infect Dis (Lond) 2016; 48:443-8. [PMID: 27030917 DOI: 10.3109/23744235.2016.1143963] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Due to an outbreak of extended-spectrum β-lactamase (ESBL)-producing Escherichia coli and Klebsiella pneumoniae, the routine use of fluoroquinolone prophylaxis was questioned. As a result, this study was conducted with the aim to evaluate the impact of ciprofloxacin-prophylaxis on the use of broad-spectrum antibioctics and anti-mycotics. METHODS A cohort of 139 consecutive patients with acute leukaemia treated with remission-inducing induction chemotherapy between 2004-2012 at the Department of Haematology in Uppsala University Hospital was analysed. RESULTS Fifty-three patients (38%) received broad-spectrum antibiotics at the initiation of chemotherapy and were not eligible for prophylaxis. Of the remaining patients, the initiation of broad-spectrum antibiotics was delayed by 3 days in those receiving ciprofloxacin prophylaxis (n = 47) compared with those receiving no prophylaxis (n = 39). The median duration of systemic antibiotic treatment was 6 days shorter in patients receiving ciprofloxacin prophylaxis (12 vs 18 days; p = 0.0005) and the cumulative (total) median days on systemic antibiotic treatment was shortened by 8 days (15 vs 23 days, p = 0.0008). Piperacillin/tazobactam (p = 0.02), carbapenems (p = 0.05) and empiric broad-spectrum antifungals (p < 0.01) were used significantly less often when ciprofloxacin prophylaxis was given. CONCLUSIONS Ciprofloxacin prophylaxis delayed empiric therapy by 3 days and reduced overall antibiotic use in this study. These benefits must be evaluated vs the risks of development of resistant bacterial strains, making fluoroquinolone prophylaxis an open question for debate.
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Affiliation(s)
- Helene Hallböök
- a Department of Medical Sciences , Section of Hematology, Uppsala University , Uppsala
| | - Anna-Karin Lidström
- b Department of Medical Sciences , Section of Infectious Diseases, Uppsala University , Uppsala
| | - Karlis Pauksens
- b Department of Medical Sciences , Section of Infectious Diseases, Uppsala University , Uppsala
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Abstract
Acute myeloid leukemia in older patients has historically had a dismal 10-15% long-term survival rate. Although patient frailty plays a role in this disappointing outcome, the primary driver of poor results remains the resistance of disease to current therapies. The optimal management of this difficult-to-treat disease should include a careful consideration of disease, patient and treatment factors. Disease factors include cytogenetic and molecular features and the history of an antecedent hematological disorder. Patient factors include age, performance status, comorbid conditions and individual patient preference. We favor intensive induction in most fit older patients but alternatives such as hypomethylating agents and low-dose cytarabine may be considered in patients with other comorbidities. Enrollment of patients into well designed clinical trials addressing important questions remains of utmost importance in order to advance the understanding and treatment of this disease although the best means of drug development remains a challenging dilemma.
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Affiliation(s)
- Jay Yang
- a Division of Hematology/Oncology, Department of Oncology , Barbara Ann Karmanos Cancer Center and Wayne State University School of Medicine , Detroit , MI 48201 , USA
| | - Charles A Schiffer
- a Division of Hematology/Oncology, Department of Oncology , Barbara Ann Karmanos Cancer Center and Wayne State University School of Medicine , Detroit , MI 48201 , USA
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100
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Buckley SA, Walter RB. Update on antigen-specific immunotherapy of acute myeloid leukemia. Curr Hematol Malig Rep 2016; 10:65-75. [PMID: 25896530 DOI: 10.1007/s11899-015-0250-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Among the few drugs that have shown a benefit for patients with acute myeloid leukemia (AML) in randomized clinical trials over the last several decades is the CD33 antibody-drug conjugate, gemtuzumab ozogamicin (GO). Undoubtedly, this experience has highlighted the value of antigen-specific immunotherapy in AML. A wide variety of therapeutics directed against several different antigens on AML cells are currently explored in preclinical and early clinical studies. On the one hand, these include passive strategies such as unconjugated antibodies targeting one or more antigens, antibodies armed with drugs, toxic proteins, or radionuclides, or adoptive immunotherapies, in particular utilizing T cells engineered to express chimeric antigen receptors (CARs) or modified T cell receptor (TCR) genes; on the other hand, these include active strategies such as vaccinations. With the documented benefit for GO and the emerging data with several classes of therapeutics in other leukemias, in particular small bispecific antibodies and CAR T cells, the future is bright. Nevertheless, a number of important questions related to the choice of target antigen(s), patient population, exact treatment modality, and supportive care needs remain open. Addressing such questions in upcoming studies will ultimately be required to optimize the clinical use of antigen-specific immunotherapies in AML and ensure that such treatments become an effective, versatile tool for this disease for which the outcomes have remained unsatisfactory in many patients.
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Affiliation(s)
- Sarah A Buckley
- Hematology/Oncology Fellowship Program, University of Washington, Seattle, WA, USA
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