101
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Affiliation(s)
- Elihu Estey
- From the Division of Hematology, University of Washington Medical Center, and the Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle
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102
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Abstract
PURPOSE OF REVIEW Acute myeloid leukemia (AML) is an immensely heterogeneous disease based on the presence of varying combinations of morphologic, immunophenotypic, genetic, and molecular characteristics identified among those diagnosed with this disease. Although current therapeutic strategies provide a reasonable likelihood of achieving a complete remission for the majority of patients, relapse rates and subsequent disease-related mortality remain unacceptably high. Improved methods of risk stratification are needed to better identify patients at considerable risk of relapse in hopes of allowing for early therapeutic intervention and/or intensification that may lead to a higher likelihood of cure. The current status of risk stratification of AML and emerging technologies with potential to improve prognostic classification and outcomes are summarized in this review. RECENT FINDINGS Refinement of our understanding of the impact of current pretreatment AML cytogenetic, immunophenotypic, and molecular aberrations to predict outcomes and guide therapeutic decision-making is ongoing. Emerging data suggest that incorporation of the degree of posttreatment response and/or the detection of minimal residual disease can improve the accuracy of risk stratification for individual patients. SUMMARY Although pretreatment disease characteristics remain the hallmark of prognostication for AML patients, posttreatment parameters such as minimal residual disease assessment and degree of response to therapy possess the ability to further refine our identification of patients with unfavorable disease and thereby influence decisions regarding therapeutic planning.
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103
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Ravandi F, Jorgensen J, Borthakur G, Jabbour E, Kadia T, Pierce S, Brandt M, Wang S, Konoplev S, Wang X, Huang X, Daver N, DiNardo C, Andreeff M, Konopleva M, Estrov Z, Garcia-Manero G, Cortes J, Kantarjian H. Persistence of minimal residual disease assessed by multiparameter flow cytometry is highly prognostic in younger patients with acute myeloid leukemia. Cancer 2016; 123:426-435. [PMID: 27657543 DOI: 10.1002/cncr.30361] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 08/04/2016] [Accepted: 08/25/2016] [Indexed: 01/22/2023]
Abstract
BACKGROUND Predicting outcomes for patients with acute myeloid leukemia (AML) on the basis of pretreatment predictors has been the cornerstone of management. Posttreatment prognostic factors are increasingly being evaluated. METHODS Among 280 younger patients who were treated with intermediate-dose cytarabine (total ≥ 5 g/m2 ) and idarubicin-based induction chemotherapy and achieved remission, 186 were assessed for minimal residual disease (MRD) with an 8-color multiparameter flow cytometry panel performed on bone marrow specimens with a sensitivity of 0.1% or higher. RESULTS One hundred sixty-six patients had samples available 1 to 2 months after induction at the time of complete remission (CR), and 79% became negative for MRD, with an MRD-negative status associated with an improvement in relapse-free survival (RFS; P = .0002) and overall survival (OS; P = .0002). One hundred sixteen were evaluated for their MRD status during consolidation, and 86% were negative, with an MRD-negative status associated with a significant improvement in RFS (P < .0001) and OS (P < .0001). Sixty-nine patients were evaluated for their MRD status after completion of all therapy, and 84% were negative, with an MRD-negative status associated with an improvement in RFS (P < .0001) and OS (P < .0001). In a multivariate analysis including age, cytogenetics, response (CR vs CR with incomplete platelet recovery/incomplete blood count recovery), and MRD, achieving an MRD-negative status was the most important independent predictor of RFS and OS at response (P = .008 and P = .0008, respectively), during consolidation (P < .0001 for both), and at the completion of therapy (P < .0001 and P = .002, respectively). CONCLUSIONS Achieving an MRD-negative status according to multiparameter flow cytometry is associated with a highly significant improvement in the outcomes of younger patients with AML receiving cytosine arabinoside plus idarubicin-based induction and consolidation regimens. Cancer 2017;123:426-435. © 2016 American Cancer Society.
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Affiliation(s)
- Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jeffrey Jorgensen
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Gautam Borthakur
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Tapan Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sherry Pierce
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mark Brandt
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sa Wang
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sergej Konoplev
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Xuemei Wang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Xuelin Huang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Naval Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Courtney DiNardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Michael Andreeff
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Marina Konopleva
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Zeev Estrov
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Jorge Cortes
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
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104
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Pohlen M, Thoennissen NH, Braess J, Thudium J, Schmid C, Kochanek M, Kreuzer KA, Lebiedz P, Görlich D, Gerth HU, Rohde C, Kessler T, Müller-Tidow C, Stelljes M, Büchner T, Schlimok G, Hallek M, Waltenberger J, Hiddemann W, Berdel WE, Heilmeier B, Krug U. Patients with Acute Myeloid Leukemia Admitted to Intensive Care Units: Outcome Analysis and Risk Prediction. PLoS One 2016; 11:e0160871. [PMID: 27575819 PMCID: PMC5004890 DOI: 10.1371/journal.pone.0160871] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 07/26/2016] [Indexed: 01/13/2023] Open
Abstract
Background This retrospective, multicenter study aimed to reveal risk predictors for mortality in the intensive care unit (ICU) as well as survival after ICU discharge in patients with acute myeloid leukemia (AML) requiring treatment in the ICU. Methods and Results Multivariate analysis of data for 187 adults with AML treated in the ICU in one institution revealed the following as independent prognostic factors for death in the ICU: arterial oxygen partial pressure below 72 mmHg, active AML and systemic inflammatory response syndrome upon ICU admission, and need for hemodialysis and mechanical ventilation in the ICU. Based on these variables, we developed an ICU mortality score and validated the score in an independent cohort of 264 patients treated in the ICU in three additional tertiary hospitals. Compared with the Simplified Acute Physiology Score (SAPS) II, the Logistic Organ Dysfunction (LOD) score, and the Sequential Organ Failure Assessment (SOFA) score, our score yielded a better prediction of ICU mortality in the receiver operator characteristics (ROC) analysis (AUC = 0.913 vs. AUC = 0.710 [SAPS II], AUC = 0.708 [LOD], and 0.770 [SOFA] in the training cohort; AUC = 0.841 for the developed score vs. AUC = 0.730 [SAPSII], AUC = 0.773 [LOD], and 0.783 [SOFA] in the validation cohort). Factors predicting decreased survival after ICU discharge were as follows: relapse or refractory disease, previous allogeneic stem cell transplantation, time between hospital admission and ICU admission, time spent in ICU, impaired diuresis, Glasgow Coma Scale <8 and hematocrit of ≥25% at ICU admission. Based on these factors, an ICU survival score was created and used for risk stratification into three risk groups. This stratification discriminated distinct survival rates after ICU discharge. Conclusions Our data emphasize that although individual risks differ widely depending on the patient and disease status, a substantial portion of critically ill patients with AML benefit from intensive care.
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Affiliation(s)
- Michele Pohlen
- Department of Medicine A, Hematology and Oncology, University Hospital Muenster, Muenster, Germany
- * E-mail:
| | - Nils H. Thoennissen
- Department of Medicine A, Hematology and Oncology, University Hospital Muenster, Muenster, Germany
| | - Jan Braess
- Department of Medicine III, Hematology and Oncology, University Hospital Grosshadern, Munich, Germany
| | - Johannes Thudium
- Department of Medicine III, Hematology and Oncology, University Hospital Grosshadern, Munich, Germany
| | | | - Matthias Kochanek
- Department of Medicine I, University Hospital Cologne, Cologne, Germany
| | | | - Pia Lebiedz
- Department of Cardiovascular Medicine, University Hospital Muenster, Muenster, Germany
| | - Dennis Görlich
- Institute of Biostatistics and Clinical Research, University Muenster, Muenster, Germany
| | - Hans U. Gerth
- Department of Medicine D, Hematology and Oncology, University Hospital Muenster, Muenster, Germany
| | - Christian Rohde
- Department of Medicine A, Hematology and Oncology, University Hospital Muenster, Muenster, Germany
| | - Torsten Kessler
- Department of Medicine A, Hematology and Oncology, University Hospital Muenster, Muenster, Germany
| | - Carsten Müller-Tidow
- Department of Medicine A, Hematology and Oncology, University Hospital Muenster, Muenster, Germany
| | - Matthias Stelljes
- Department of Medicine A, Hematology and Oncology, University Hospital Muenster, Muenster, Germany
| | - Thomas Büchner
- Department of Medicine A, Hematology and Oncology, University Hospital Muenster, Muenster, Germany
| | - Günter Schlimok
- Department of Medicine II, Klinikum Augsburg, Augsburg, Germany
| | - Michael Hallek
- Department of Medicine I, University Hospital Cologne, Cologne, Germany
| | - Johannes Waltenberger
- Department of Cardiovascular Medicine, University Hospital Muenster, Muenster, Germany
| | - Wolfgang Hiddemann
- Department of Medicine III, Hematology and Oncology, University Hospital Grosshadern, Munich, Germany
| | - Wolfgang E. Berdel
- Department of Medicine A, Hematology and Oncology, University Hospital Muenster, Muenster, Germany
| | | | - Utz Krug
- Department of Medicine A, Hematology and Oncology, University Hospital Muenster, Muenster, Germany
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105
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Rashidi A, Walter RB, Tallman MS, Appelbaum FR, DiPersio JF. Maintenance therapy in acute myeloid leukemia: an evidence-based review of randomized trials. Blood 2016; 128:763-73. [PMID: 27354720 PMCID: PMC4982451 DOI: 10.1182/blood-2016-03-674127] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 06/20/2016] [Indexed: 11/20/2022] Open
Affiliation(s)
- Armin Rashidi
- Section of Bone Marrow Transplantation and Leukemia Program, Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Roland B Walter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA; Division of Hematology, Department of Medicine, and Department of Epidemiology, University of Washington, Seattle, WA
| | - Martin S Tallman
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY; and
| | - Frederick R Appelbaum
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA; Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA
| | - John F DiPersio
- Section of Bone Marrow Transplantation and Leukemia Program, Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
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106
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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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107
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Termini CM, Lidke KA, Gillette JM. Tetraspanin CD82 Regulates the Spatiotemporal Dynamics of PKCα in Acute Myeloid Leukemia. Sci Rep 2016; 6:29859. [PMID: 27417454 PMCID: PMC4945921 DOI: 10.1038/srep29859] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 06/22/2016] [Indexed: 02/08/2023] Open
Abstract
Patients with acute myeloid leukemia (AML) have increased myeloid cells within their bone marrow that exhibit aberrant signaling. Therefore, therapeutic targets that modulate disrupted signaling cascades are of significant interest. In this study, we demonstrate that the tetraspanin membrane scaffold, CD82, regulates protein kinase c alpha (PKCα)-mediated signaling critical for AML progression. Utilizing a palmitoylation mutant form of CD82 with disrupted membrane organization, we find that the CD82 scaffold controls PKCα expression and activation. Combining single molecule and ensemble imaging measurements, we determine that CD82 stabilizes PKCα activation at the membrane and regulates the size of PKCα membrane clusters. Further evaluation of downstream effector signaling identified robust and sustained activation of ERK1/2 upon CD82 overexpression that results in enhanced AML colony formation. Together, these data propose a mechanism where CD82 membrane organization regulates sustained PKCα signaling that results in an aggressive leukemia phenotype. These observations suggest that the CD82 scaffold may be a potential therapeutic target for attenuating aberrant signal transduction in AML.
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Affiliation(s)
- Christina M Termini
- Department of Pathology, University of New Mexico Health Sciences Center, University of New Mexico, MSC 08-4640, Albuquerque, NM 87131, USA
| | - Keith A Lidke
- Department of Physics and Astronomy, University of New Mexico, MSC 07-4220, Albuquerque, NM 87131, USA
| | - Jennifer M Gillette
- Department of Pathology, University of New Mexico Health Sciences Center, University of New Mexico, MSC 08-4640, Albuquerque, NM 87131, USA
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108
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Chen Y, Yang T, Zheng X, Yang X, Zheng Z, Zheng J, Liu T, Hu J. The outcome and prognostic factors of 248 elderly patients with acute myeloid leukemia treated with standard-dose or low-intensity induction therapy. Medicine (Baltimore) 2016; 95:e4182. [PMID: 27472687 PMCID: PMC5265824 DOI: 10.1097/md.0000000000004182] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The prognosis of elderly patients with acute myeloid leukemia (AML) is poor, and the recommendation of standard-dose or low-intensity induction regimen for these patients remains controversial. We retrospectively analyzed treatment outcome and prognostic factors of elderly AML patients who had received either standard-dose or low-intensity induction regimens.Two hundred forty-eight elderly AML patients with good Eastern Cooperative Oncology Group performance status (ECOG PS ≤ 2) received one of three regimens for induction in this study: standard-dose cytarabine plus idarubicin (IA; n = 144) or daunorubicin (DA; n = 42); low-intensity cytarabine, aclarubicin, and granulocyte colony-stimulating factor (G-CSF) (CAG; n = 62).After first induction treatment cycle, the overall complete remission (CR) rate was 42.7%. Patients in IA group had a higher CR rate than in DA or CAG group (49.3%, 35.7%, and 32.3%, respectively; P = 0.046). The 1-year, 3-year, and 5-year overall survival (OS) rates were 42.2%, 18.9%, and 13.5% for these 248 patients, with median survival of 9.2 months. Long-term survival of IA group was better than DA or CAG group. The 1-year, 3-year, and 5-year OS rates of IA group were 45.9%, 23.5%, and 19.4%, respectively, as compared to 39.8%, 8.3%, and estimated 2.4% in DA group, and 34.9%, 15.9%, and 6.3% in CAG group, respectively. Early induction mortality and 2-year relapse rates showed no difference among 3 groups. Univariate analysis and multivariate analysis identified lactic dehydrogenase (LDH) more than two times of upper normal limit at diagnosis and nonremission after first induction cycle as adverse prognostic factors for OS. A simple and valid scoring model was constructed for risk stratification and prediction of long-term survival of elderly AML patients.Standard-dose IA regimen could improve the prognosis of elderly AML patients with good performance status compared with standard-dose DA or low-intensity CAG regimen. All prognostic factors and risk assessment should be considered to ensure that each patient receives the suitable individualized treatment.
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Affiliation(s)
| | | | | | | | | | | | | | - Jianda Hu
- Fujian Provincial Key Laboratory of Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, Fujian, P. R. China
- Correspondence: Jianda Hu, Fujian Provincial Key Laboratory of Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian, P. R. China (e-mail: )
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109
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De Kouchkovsky I, Abdul-Hay M. 'Acute myeloid leukemia: a comprehensive review and 2016 update'. Blood Cancer J 2016; 6:e441. [PMID: 27367478 PMCID: PMC5030376 DOI: 10.1038/bcj.2016.50] [Citation(s) in RCA: 797] [Impact Index Per Article: 99.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 05/03/2016] [Accepted: 05/19/2016] [Indexed: 12/13/2022] Open
Abstract
Acute myeloid leukemia (AML) is the most common acute leukemia in adults, with an incidence of over 20 000 cases per year in the United States alone. Large chromosomal translocations as well as mutations in the genes involved in hematopoietic proliferation and differentiation result in the accumulation of poorly differentiated myeloid cells. AML is a highly heterogeneous disease; although cases can be stratified into favorable, intermediate and adverse-risk groups based on their cytogenetic profile, prognosis within these categories varies widely. The identification of recurrent genetic mutations, such as FLT3-ITD, NMP1 and CEBPA, has helped refine individual prognosis and guide management. Despite advances in supportive care, the backbone of therapy remains a combination of cytarabine- and anthracycline-based regimens with allogeneic stem cell transplantation for eligible candidates. Elderly patients are often unable to tolerate such regimens, and carry a particularly poor prognosis. Here, we review the major recent advances in the treatment of AML.
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Affiliation(s)
- I De Kouchkovsky
- Department of Medicine, New York University School of Medicine, New York, NY, USA
| | - M Abdul-Hay
- Department of Medicine, New York University School of Medicine, New York, NY, USA.,Department of Hematology/Oncology, New York University Perlmutter Cancer Center, New York, NY, USA
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110
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Duan MH, Zhang Y, Zhang M, Han X, Zhang Y, Yang C, Feng J, Zhang L, Zhang W, Li J, Tian LP, Zhang Y, Zhou DB. [Efficacy and safety analysis of the combination of cladribine, cytarabine, granulocyte colonystimulating factor (CLAG) regime in patients with refractory or relapsed acute myeloid leukemia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2016; 37:571-5. [PMID: 27535856 PMCID: PMC7365013 DOI: 10.3760/cma.j.issn.0253-2727.2016.07.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To analyze efficacy and safety of CLAG regimen in patients with refractory or relapsed acute myeloid leukemia (AML). METHODS Efficacy and adverse events of patients with refractory or relapsed AML who were treated with one course of CLAG from April 1st, 2014 through December 9th, 2015 in our hospital were retrospectively reviewed. RESULTS Thirty- three patients (16 males and 17 females) with refractory or relapsed AML were treated with one course of CLAG with a median age of 49 (14-68) years. According to FAB subtype, there were 22 patients with M2, and 11 with other types. According to NCCN criteria, there were 6, 18 and 9 patients with favorable, intermediate and unfavorable risk respectively, including 5 with FLT3- ITD mutation. Of 16 refractory and 17 relapsed patients; the median previous chemotherapy courses were 2(1-36). After one course of CLAG, 78.8% (26/33) patients achieved hematological complete response (CR), with 93.8 %(15/16) in relapsed and 64.7 %(11/17) in refractory groups respectively. All five patients with FLT3- ITD mutation achieved CR. All patients had grade 4 neutropenia and thrombocytopenia and infection in different sites; three patients died early from infections. Five patients received allogeneic hematopoietic stem cell transplantation (allo- HSCT). Ten patients relapsed and thirteen patients died after the median follow-up 142(9-525) days. The median EFS and OS were 230 (9- 525) and 419(9- 525) days respectively, which in CR group (n=26) were significantly longer than those in NR one (n=7) [447 (165- 525) d vs 52 (9- 162) d,P <0.001]. CONCLUSIONS CLAG regimen was effective and well tolerable in patients with refractory or relapsed AML, with the CR rate in relapsed patients higher than in refractory counterparts. Control of infections was imperative for treatment.
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Affiliation(s)
- M H Duan
- Department of Hematology, PUMC Hospital, CAMS & PUMC, Beijing 100730, China
| | | | | | | | | | | | | | | | | | | | | | | | - D B Zhou
- Department of Hematology, PUMC Hospital, CAMS & PUMC, Beijing 100730, China
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111
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Yamazaki E, Kanamori H, Itabashi M, Ogusa E, Numata A, Yamamoto W, Ito S, Tachibana T, Hagihara M, Matsumoto K, Koharazawa H, Taguchi J, Tomita N, Fujimaki K, Fujita H, Fujisawa S, Ogawa K, Ishigatsubo Y. Hyper-recovery of platelets after induction therapy is a predictor of relapse-free survival in acute myeloid leukemia. Leuk Lymphoma 2016; 58:104-109. [PMID: 27267543 DOI: 10.1080/10428194.2016.1190969] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
We verified the association between standard clinical and laboratory variables and the risk of relapse in acute myeloid leukemia (AML), which led us to retrospectively examine the effect of regeneration of hematopoiesis in patients with newly diagnosed AML. We used data from 230 patients who obtained remission after cytarabine-based induction chemotherapy. Platelet counts ≥500 × 109/L and hemoglobin levels ≥9 g/dL on day 28 after treatment initiation were significantly associated with relapse-free survival (RFS) rate, conferring respective multivariate risk ratios of 0.38 (95% CI: 0.18-0.79) and 0.60 (95% CI: 0.40-0.89) for the occurrence of relapse or death. No disease relapse occurred in core binding factor leukemia patients whose platelet counts recovered ≥500 × 109/L at 28 days after therapy initiation. We conclude that regeneration of hematopoiesis, especially platelet hyper-recovery, after induction chemotherapy is a significant predictor of RFS in patients with AML.
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Affiliation(s)
- Etsuko Yamazaki
- a Department of Internal Medicine and Clinical Immunology , Yokohama City University Graduate School of Medicine , Yokohama, Japan
| | - Heiwa Kanamori
- b Department of Hematology , Kanagawa Cancer Center , Yokohama , Japan
| | - Megumi Itabashi
- c Department of Hematology , Yokohama City University Medical Center , Yokohama , Japan
| | - Eriko Ogusa
- b Department of Hematology , Kanagawa Cancer Center , Yokohama , Japan
| | - Ayumi Numata
- c Department of Hematology , Yokohama City University Medical Center , Yokohama , Japan
| | - Wataru Yamamoto
- b Department of Hematology , Kanagawa Cancer Center , Yokohama , Japan
| | - Satomi Ito
- d Department of Hematology , Shizuoka Red Cross Hospital , Shizuoka , Japan
| | - Takayoshi Tachibana
- a Department of Internal Medicine and Clinical Immunology , Yokohama City University Graduate School of Medicine , Yokohama, Japan
| | - Maki Hagihara
- c Department of Hematology , Yokohama City University Medical Center , Yokohama , Japan
| | - Kenji Matsumoto
- b Department of Hematology , Kanagawa Cancer Center , Yokohama , Japan
| | - Hideyuki Koharazawa
- e Department of Hematology/Oncology , Yamato Municipal Hospital , Yamato , Japan
| | - Jun Taguchi
- d Department of Hematology , Shizuoka Red Cross Hospital , Shizuoka , Japan
| | - Naoto Tomita
- a Department of Internal Medicine and Clinical Immunology , Yokohama City University Graduate School of Medicine , Yokohama, Japan
| | - Katsumichi Fujimaki
- f Department of Hematology/Immunology , Fujisawa City Hospital , Fujisawa , Japan
| | - Hiroyuki Fujita
- g Department of Hematology , Saiseikai Yokohama Nanbu Hospital , Yokohama , Japan
| | - Shin Fujisawa
- c Department of Hematology , Yokohama City University Medical Center , Yokohama , Japan
| | - Koji Ogawa
- h Department of Hematology , Yokosuka City Hospital , Yokosuka , Japan
| | - Yoshiaki Ishigatsubo
- a Department of Internal Medicine and Clinical Immunology , Yokohama City University Graduate School of Medicine , Yokohama, Japan
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112
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Kaplan JB, Altman JK, Platanias LC. SNPing away to individualize induction therapy for acute myelogenous leukemia. Leuk Lymphoma 2016; 57:742-3. [DOI: 10.3109/10428194.2015.1136743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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113
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Li X, Zhu H, Zhang Y, Zhao W, Mi J, Hu J, Li J. The Time to Clearance of Peripheral Blood Blasts Predicts Complete Remission and Survival in Chinese Adults with Acute Myeloid Leukemia. Acta Haematol 2016; 135:217-23. [PMID: 26967450 DOI: 10.1159/000443468] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 12/15/2015] [Indexed: 11/19/2022]
Abstract
The value of clearance of peripheral blood blasts (PBB) as a predictor of outcomes in acute myeloid leukemia (AML) is controversial. To investigate the prognostic significance of the time to clearance of PBB after induction in Chinese patients with AML, a retrospective analysis of 146 patients with newly diagnosed AML at Shanghai Ruijin Hospital was performed. Patients were categorized into early blast clearance (EBC; ≤5 days) and delayed blast clearance (DBC; >5 days) groups based on a receiver operating characteristic analysis. Complete remission (CR) after induction chemotherapy was related to the time to clearance of PBB (p < 0.001). Relapse-free survival (RFS; p = 0.003) and overall survival (p < 0.001) were longer in the EBC group. Multivariate analysis demonstrated that the time to clearance of PBB and cytogenetic risk independently predicted CR and RFS. Early clearance of PBB after induction chemotherapy can be a significant predictor of survival outcomes in AML patients.
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Affiliation(s)
- Xiaoyang Li
- Department of Hematology, Ruijin Hospital affiliated to the Shanghai Jiao Tong University School of Medicine, Shanghai, PR China
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114
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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: 225] [Impact Index Per Article: 28.1] [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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Should acute myeloid leukemia patients with actionable targets be offered investigational treatment after failing one cycle of standard induction therapy? Curr Opin Hematol 2016; 23:102-7. [PMID: 26766538 DOI: 10.1097/moh.0000000000000213] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Therapeutic failure in acute myeloid leukemia remains common. It may be advantageous to identify patients with suboptimal treatment responses early as they may benefit from timely care strategy changes. Here, responses portending failure of standard induction therapy are reviewed and therapeutic options examined, including use of investigational, targeted agents for suitable patients. RECENT FINDINGS Patients entering complete remission without minimal residual disease early, that is, with one cycle of standard induction chemotherapy, have a lower relapse risk and live longer than other similarly-treated patients, supporting the proposition of early complete remission without minimal residual disease as a criterion for induction therapy success. Investigational small molecule drugs are appealing for patients who fail standard therapies, but complete remission rates as a single agent are typically modest. SUMMARY The relative value of different treatment strategies if a first standard induction therapy cycle fails to produce complete remission is unknown. However, retreatment with the same therapy often leads to complete remission and provides a benchmark against which other approaches should be compared. Addition of investigational small molecule drugs to standard reinduction therapy in patients with actionable targets could offer an attractive therapeutic strategy in this situation that might improve outcomes and facilitate clinical drug testing.
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Araki D, Wood BL, Othus M, Radich JP, Halpern AB, Zhou Y, Mielcarek M, Estey EH, Appelbaum FR, Walter RB. Allogeneic Hematopoietic Cell Transplantation for Acute Myeloid Leukemia: Time to Move Toward a Minimal Residual Disease-Based Definition of Complete Remission? J Clin Oncol 2015; 34:329-36. [PMID: 26668349 DOI: 10.1200/jco.2015.63.3826] [Citation(s) in RCA: 314] [Impact Index Per Article: 34.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Patients with acute myeloid leukemia (AML) who are in morphologic complete remission are typically considered separately from patients with active disease (ie, ≥ 5% marrow blasts by morphology) in treatment algorithms for allogeneic hematopoietic cell transplantation (HCT), which implies distinct outcomes for these two groups. It is well recognized that the presence of minimal residual disease (MRD) at the time of transplantation is associated with adverse post-HCT outcome for those patients in morphologic remission. This effect of pre-HCT MRD prompted us to compare outcomes in consecutive patients in MRD-positive remission with patients with active AML who underwent myeloablative allogeneic HCT at our institution. PATIENTS AND METHODS We retrospectively studied 359 consecutive adults with AML who underwent myeloablative allogeneic HCT from a peripheral blood or bone marrow donor between 2006 and 2014. Pre-HCT disease staging included 10-color multiparametric flow cytometry on bone marrow aspirates in all patients. Any level of residual disease was considered to be MRD positive. RESULTS Three-year relapse estimates were 67% in 76 patients in MRD-positive morphologic remission and 65% in 48 patients with active AML compared with 22% in 235 patients in MRD-negative remission. Three-year overall survival estimates were 26%, 23%, and 73% in these three groups, respectively. After multivariable adjustment, MRD-negative remission status remained statistically significantly associated with longer overall and progression-free survival as well as lower risk of relapse compared with MRD-positive morphologic remission status or having active disease, with similar outcomes between the latter two groups. CONCLUSION The similarities in outcomes between patients in MRD-positive morphologic remission and those with active disease at the time of HCT support the use of treatment algorithms that use MRD- rather than morphology-based disease assessments.
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Affiliation(s)
- Daisuke Araki
- Daisuke Araki, Brent L. Wood, Jerald P. Radich, Anna B. Halpern, Yi Zhou, Marco Mielcarek, Elihu H. Estey, Frederick R. Appelbaum, and Roland B. Walter, University of Washington; and Megan Othus, Jerald P. Radich, Marco Mielcarek, Elihu H. Estey, Frederick R. Appelbaum, and Roland B. Walter, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Brent L Wood
- Daisuke Araki, Brent L. Wood, Jerald P. Radich, Anna B. Halpern, Yi Zhou, Marco Mielcarek, Elihu H. Estey, Frederick R. Appelbaum, and Roland B. Walter, University of Washington; and Megan Othus, Jerald P. Radich, Marco Mielcarek, Elihu H. Estey, Frederick R. Appelbaum, and Roland B. Walter, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Megan Othus
- Daisuke Araki, Brent L. Wood, Jerald P. Radich, Anna B. Halpern, Yi Zhou, Marco Mielcarek, Elihu H. Estey, Frederick R. Appelbaum, and Roland B. Walter, University of Washington; and Megan Othus, Jerald P. Radich, Marco Mielcarek, Elihu H. Estey, Frederick R. Appelbaum, and Roland B. Walter, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Jerald P Radich
- Daisuke Araki, Brent L. Wood, Jerald P. Radich, Anna B. Halpern, Yi Zhou, Marco Mielcarek, Elihu H. Estey, Frederick R. Appelbaum, and Roland B. Walter, University of Washington; and Megan Othus, Jerald P. Radich, Marco Mielcarek, Elihu H. Estey, Frederick R. Appelbaum, and Roland B. Walter, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Anna B Halpern
- Daisuke Araki, Brent L. Wood, Jerald P. Radich, Anna B. Halpern, Yi Zhou, Marco Mielcarek, Elihu H. Estey, Frederick R. Appelbaum, and Roland B. Walter, University of Washington; and Megan Othus, Jerald P. Radich, Marco Mielcarek, Elihu H. Estey, Frederick R. Appelbaum, and Roland B. Walter, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Yi Zhou
- Daisuke Araki, Brent L. Wood, Jerald P. Radich, Anna B. Halpern, Yi Zhou, Marco Mielcarek, Elihu H. Estey, Frederick R. Appelbaum, and Roland B. Walter, University of Washington; and Megan Othus, Jerald P. Radich, Marco Mielcarek, Elihu H. Estey, Frederick R. Appelbaum, and Roland B. Walter, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Marco Mielcarek
- Daisuke Araki, Brent L. Wood, Jerald P. Radich, Anna B. Halpern, Yi Zhou, Marco Mielcarek, Elihu H. Estey, Frederick R. Appelbaum, and Roland B. Walter, University of Washington; and Megan Othus, Jerald P. Radich, Marco Mielcarek, Elihu H. Estey, Frederick R. Appelbaum, and Roland B. Walter, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Elihu H Estey
- Daisuke Araki, Brent L. Wood, Jerald P. Radich, Anna B. Halpern, Yi Zhou, Marco Mielcarek, Elihu H. Estey, Frederick R. Appelbaum, and Roland B. Walter, University of Washington; and Megan Othus, Jerald P. Radich, Marco Mielcarek, Elihu H. Estey, Frederick R. Appelbaum, and Roland B. Walter, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Frederick R Appelbaum
- Daisuke Araki, Brent L. Wood, Jerald P. Radich, Anna B. Halpern, Yi Zhou, Marco Mielcarek, Elihu H. Estey, Frederick R. Appelbaum, and Roland B. Walter, University of Washington; and Megan Othus, Jerald P. Radich, Marco Mielcarek, Elihu H. Estey, Frederick R. Appelbaum, and Roland B. Walter, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Roland B Walter
- Daisuke Araki, Brent L. Wood, Jerald P. Radich, Anna B. Halpern, Yi Zhou, Marco Mielcarek, Elihu H. Estey, Frederick R. Appelbaum, and Roland B. Walter, University of Washington; and Megan Othus, Jerald P. Radich, Marco Mielcarek, Elihu H. Estey, Frederick R. Appelbaum, and Roland B. Walter, Fred Hutchinson Cancer Research Center, Seattle, WA.
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Abstract
The prognostic power of minimal residual disease after therapy for acute leukemias is not in question. It is only logical that the finding of leukemic blast cells after therapy predicts for impending relapse or at least the need for additional treatment. Which level of what is called minimal residual disease (MRD) is clinically relevant, however, depends on the efficacy of the initial treatment as well as the treatment strategies available to target MRD. There are a multitude of additional factors that can alter the clinical significance of MRD, including the genotype of the patient's leukemic cells. The fact that methodologies of MRD detection are not standardized and thresholds for defining MRD positivity vary depending upon MRD detection method and the operator's skills or convictions only add to the complexity of MRD interpretation. While enormous efforts are devoted to enhancing the sensitivity of MRD detection, eg, by next-generation sequencing, improvements of methods for detecting MRD per se will not automatically lead to a more reliable estimation of total tumor burden. Most importantly, even the best assay will yield accurate MRD results only if the tissue source for MRD determination is of good quality. Another aspect of potentially crucial importance is the heterogenous distribution of leukemic cells throughout the skeleton after treatment, recently demonstrated for acute myeloid leukemia (AML) by bone marrow imaging. Once technical difficulties of MRD measurement are resolved and better MRD-targeting drugs are developed, we still need to learn about alternate proposed mechanisms to explain MRD-independent prognostication, well described in acute lymphoid leukemia, before MRD can be included routinely in the guidance of therapy in AML.
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Affiliation(s)
- Elisabeth Paietta
- Montefiore Medical Center, Albert Einstein College of Medicine, 111East 210th Street, Bronx, NY 10467, USA.
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119
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Klco JM, Miller CA, Griffith M, Petti A, Spencer DH, Ketkar-Kulkarni S, Wartman LD, Christopher M, Lamprecht TL, Helton NM, Duncavage EJ, Payton JE, Baty J, Heath SE, Griffith OL, Shen D, Hundal J, Chang GS, Fulton R, O'Laughlin M, Fronick C, Magrini V, Demeter RT, Larson DE, Kulkarni S, Ozenberger BA, Welch JS, Walter MJ, Graubert TA, Westervelt P, Radich JP, Link DC, Mardis ER, DiPersio JF, Wilson RK, Ley TJ. Association Between Mutation Clearance After Induction Therapy and Outcomes in Acute Myeloid Leukemia. JAMA 2015; 314:811-22. [PMID: 26305651 PMCID: PMC4621257 DOI: 10.1001/jama.2015.9643] [Citation(s) in RCA: 260] [Impact Index Per Article: 28.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE Tests that predict outcomes for patients with acute myeloid leukemia (AML) are imprecise, especially for those with intermediate risk AML. OBJECTIVES To determine whether genomic approaches can provide novel prognostic information for adult patients with de novo AML. DESIGN, SETTING, AND PARTICIPANTS Whole-genome or exome sequencing was performed on samples obtained at disease presentation from 71 patients with AML (mean age, 50.8 years) treated with standard induction chemotherapy at a single site starting in March 2002, with follow-up through January 2015. In addition, deep digital sequencing was performed on paired diagnosis and remission samples from 50 patients (including 32 with intermediate-risk AML), approximately 30 days after successful induction therapy. Twenty-five of the 50 were from the cohort of 71 patients, and 25 were new, additional cases. EXPOSURES Whole-genome or exome sequencing and targeted deep sequencing. Risk of identification based on genetic data. MAIN OUTCOMES AND MEASURES Mutation patterns (including clearance of leukemia-associated variants after chemotherapy) and their association with event-free survival and overall survival. RESULTS Analysis of comprehensive genomic data from the 71 patients did not improve outcome assessment over current standard-of-care metrics. In an analysis of 50 patients with both presentation and documented remission samples, 24 (48%) had persistent leukemia-associated mutations in at least 5% of bone marrow cells at remission. The 24 with persistent mutations had significantly reduced event-free and overall survival vs the 26 who cleared all mutations. Patients with intermediate cytogenetic risk profiles had similar findings. [table: see text]. CONCLUSIONS AND RELEVANCE The detection of persistent leukemia-associated mutations in at least 5% of bone marrow cells in day 30 remission samples was associated with a significantly increased risk of relapse, and reduced overall survival. These data suggest that this genomic approach may improve risk stratification for patients with AML.
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MESH Headings
- Adult
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Bone Marrow
- Cytarabine/administration & dosage
- Daunorubicin/administration & dosage
- Disease-Free Survival
- Female
- Genome, Human
- Humans
- Idarubicin/administration & dosage
- Induction Chemotherapy
- Leukemia, Myeloid, Acute/drug therapy
- Leukemia, Myeloid, Acute/genetics
- Leukemia, Myeloid, Acute/mortality
- Male
- MicroRNAs/analysis
- Middle Aged
- Mutation
- Outcome Assessment, Health Care
- Polymorphism, Genetic
- Prognosis
- RNA, Messenger/analysis
- Recurrence
- Sequence Analysis, RNA/methods
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Affiliation(s)
- Jeffery M Klco
- Department of Pathology and Immunology, Washington University School of Medicine, St Louis, Missouri2Department of Pathology, St Jude Children's Research Hospital, Memphis, Tennessee
| | - Christopher A Miller
- The McDonnell Genome Institute, Washington University, St Louis, Missouri4Division of Genomics and Bioinformatics, Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Malachi Griffith
- The McDonnell Genome Institute, Washington University, St Louis, Missouri5Department of Genetics, Washington University School of Medicine, St Louis, Missouri
| | - Allegra Petti
- The McDonnell Genome Institute, Washington University, St Louis, Missouri4Division of Genomics and Bioinformatics, Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | - David H Spencer
- Department of Pathology and Immunology, Washington University School of Medicine, St Louis, Missouri
| | - Shamika Ketkar-Kulkarni
- The McDonnell Genome Institute, Washington University, St Louis, Missouri6Division of Oncology, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Lukas D Wartman
- Department of Genetics, Washington University School of Medicine, St Louis, Missouri
| | - Matthew Christopher
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Tamara L Lamprecht
- Department of Pathology, St Jude Children's Research Hospital, Memphis, Tennessee6Division of Oncology, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Nicole M Helton
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Eric J Duncavage
- Department of Pathology and Immunology, Washington University School of Medicine, St Louis, Missouri
| | - Jacqueline E Payton
- Department of Pathology and Immunology, Washington University School of Medicine, St Louis, Missouri
| | - Jack Baty
- Division of Biostatistics, Washington University School of Medicine, St Louis, Missouri
| | - Sharon E Heath
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Obi L Griffith
- The McDonnell Genome Institute, Washington University, St Louis, Missouri6Division of Oncology, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Dong Shen
- The McDonnell Genome Institute, Washington University, St Louis, Missouri8Medimmune/AstraZeneca, Gaithersburg, Maryland
| | - Jasreet Hundal
- The McDonnell Genome Institute, Washington University, St Louis, Missouri
| | - Gue Su Chang
- The McDonnell Genome Institute, Washington University, St Louis, Missouri
| | - Robert Fulton
- The McDonnell Genome Institute, Washington University, St Louis, Missouri5Department of Genetics, Washington University School of Medicine, St Louis, Missouri
| | | | - Catrina Fronick
- The McDonnell Genome Institute, Washington University, St Louis, Missouri
| | - Vincent Magrini
- The McDonnell Genome Institute, Washington University, St Louis, Missouri5Department of Genetics, Washington University School of Medicine, St Louis, Missouri
| | - Ryan T Demeter
- The McDonnell Genome Institute, Washington University, St Louis, Missouri
| | - David E Larson
- The McDonnell Genome Institute, Washington University, St Louis, Missouri5Department of Genetics, Washington University School of Medicine, St Louis, Missouri
| | - Shashikant Kulkarni
- Department of Pathology and Immunology, Washington University School of Medicine, St Louis, Missouri5Department of Genetics, Washington University School of Medicine, St Louis, Missouri9Division of Hematology/Oncology, Department of Pediatrics, Washington
| | - Bradley A Ozenberger
- The McDonnell Genome Institute, Washington University, St Louis, Missouri6Division of Oncology, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - John S Welch
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Matthew J Walter
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Timothy A Graubert
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St Louis, Missouri10Department of Medicine, Massachusetts General Hospital, Boston
| | - Peter Westervelt
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | | | - Daniel C Link
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Elaine R Mardis
- The McDonnell Genome Institute, Washington University, St Louis, Missouri4Division of Genomics and Bioinformatics, Department of Medicine, Washington University in St Louis, St Louis, Missouri5Department of Genetics, Washington University School of Medici
| | - John F DiPersio
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Richard K Wilson
- The McDonnell Genome Institute, Washington University, St Louis, Missouri4Division of Genomics and Bioinformatics, Department of Medicine, Washington University in St Louis, St Louis, Missouri5Department of Genetics, Washington University School of Medici
| | - Timothy J Ley
- The McDonnell Genome Institute, Washington University, St Louis, Missouri5Department of Genetics, Washington University School of Medicine, St Louis, Missouri6Division of Oncology, Department of Medicine, Washington University School of Medicine, St Louis
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Vaughn JE, Storer BE, Armand P, Raimondi R, Gibson C, Rambaldi A, Ciceri F, Oneto R, Bruno B, Martin PJ, Sandmaier BM, Storb R, Sorror ML. Design and Validation of an Augmented Hematopoietic Cell Transplantation-Comorbidity Index Comprising Pretransplant Ferritin, Albumin, and Platelet Count for Prediction of Outcomes after Allogeneic Transplantation. Biol Blood Marrow Transplant 2015; 21:1418-24. [PMID: 25862589 PMCID: PMC4506728 DOI: 10.1016/j.bbmt.2015.04.002] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 04/01/2015] [Indexed: 01/19/2023]
Abstract
Pretransplant values of serum ferritin, albumin, and peripheral blood counts were previously suggested to provide prognostic information about hematopoietic cell transplantation (HCT) outcomes. Whether these "biomarkers" have prognostic value independent of each other and the HCT-comorbidity index (HCT-CI) is unknown. We analyzed data from 3917 allogeneic HCT recipients at multiple sites in the United States and Italy using multivariate models including each biomarker and the HCT-CI. Data from all sites were then randomly divided into a training set (n = 2352) to develop weights for the relevant biomarkers to be added to the HCT-CI scores and a validation set (n = 1407) to validate an augmented HCT-CI compared with the original index. Multivariate analysis with data from one site showed that ferritin, albumin, and platelets-not neutrophils or hemoglobin-were independently associated with increased nonrelapse mortality (NRM) and decreased overall survival. Findings were validated in data from the other sites. Subsequently, in a training set from all sites, ferritin >2500 mg/dL (hazard ratio [HR], 1.69); albumin 3 to 3.5 g/dL (HR, 1.61) and <3.0 g/dL (HR, 2.27); and platelets 50 to <100,000 (HR, 1.28), 20 to <50,000 (HR, 1.29), and <20,000 (HR, 1.55) were statistically significantly associated with NRM. Weights were assigned to these laboratory values following the same equation used to design the original index. In the validation set, the addition of the biomarkers to the original index to develop an augmented HCT-CI resulted in a statistically significant increase in a higher c-statistic estimate for prediction of NRM (P = .0007). Ferritin, albumin, and platelet counts are important prognostic markers that further refine the discriminative power of the HCT-CI for transplant outcomes.
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Affiliation(s)
- Jennifer E Vaughn
- Transplantation Biology Program, Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Barry E Storer
- Clinical Statistics Program, Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Department of Biostatistics, University of Washington School of Public Health, Seattle, Washington
| | - Philippe Armand
- Medical Oncology, Dana Farber Cancer Institute, Boston, Massachusetts
| | | | | | - Alessandro Rambaldi
- Hematology and Bone Marrow Transplant Unit, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - Fabio Ciceri
- Hematology and BMT Unit, San Raffaele Scientific Institute, Milano, Italy
| | - Rosi Oneto
- Division of Hematology, Ospedale San Martino, Genova, Italy
| | - Benedetto Bruno
- Department of Hematology/Oncology, University of Torino, Torino, Italy
| | - Paul J Martin
- Transplantation Biology Program, Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Brenda M Sandmaier
- Transplantation Biology Program, Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Rainer Storb
- Transplantation Biology Program, Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Mohamed L Sorror
- Transplantation Biology Program, Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington.
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Lazzarotto D, Candoni A, Nadali G, Pavan L, Lessi F, Mosna F, Simeone E, Ventura G, Gherlinzoni F, Semenzato G, Pizzolo G, Fanin R. Multicentre survey to explore current survival of patients with acute myeloid leukaemia who failed induction chemotherapy. Eur J Haematol 2015; 96:586-92. [PMID: 26186084 DOI: 10.1111/ejh.12635] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Acute myeloid leukaemia not responsive to first induction chemotherapy (PIF-AML) still remains a challenge, and there are only few recent epidemiological data regarding the outcome of these patients. In this multicentre survey, we evaluate the prognosis and outcome of patients with PIF-AML, who were diagnosed and treated in the last 5 yrs in four Italian institutions. RESULTS One hundred PIF-AML were recorded, 57 males and 43 females, with a median age of 63 yrs (19-79), 42% were younger than 60 yrs; 42% had a secondary AML and 40% had an adverse karyotype. According to cytogenetic/molecular risk stratification at diagnosis, 33% of patients were classified as favourable/intermediate-1 risk and 56% as intermediate-2/adverse risk. After a median follow-up of 11 months (1-49), 77% of patients died, while 23% were alive (with 12/23 in cCR). Thirty-six patients underwent allogeneic SCT, and of these, 11 of 36 (31%) were alive at last follow-up. The 12- and 24-month OS probability of the whole population was 45% and 21%, respectively. In multivariate analysis, the probability of OS of the whole population was significantly improved by Allo-SCT procedure (12-month OS probability 60% vs. 35%; P < 0.0001) and was better in patients with favourable/intermediate-1 risk at diagnosis (12-month OS probability 58% vs. 40%; P = 0.028). In transplanted cases, a pretransplant responsive disease was the only significant factor to predict a favourable outcome after Allo-SCT (P = 0.006). CONCLUSION Treatment options of PIF-AML still are limited and the prognosis, even recently, remains extremely poor. This survey shows that PIF-AML is still rarely cured without Allo-SCT and confirms the importance of initiating an urgent unrelated donor search in cases without a matched sibling donor. Moreover, the outcome of Allo-SCT is better in patients who achieve a good AML debulking before transplant. To reach this goal, new predictive scores and new protocols of salvage therapy (with target drugs or combinations) need to be explored urgently in PIF-AML.
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Affiliation(s)
- Davide Lazzarotto
- Division of Hematology and SCT, University Hospital of Udine, Udine, Italy
| | - Anna Candoni
- Division of Hematology and SCT, University Hospital of Udine, Udine, Italy
| | | | - Laura Pavan
- Division of Hematology, University of Padua, Padua, Italy
| | - Federica Lessi
- Division of Hematology, University of Padua, Padua, Italy
| | - Federico Mosna
- Division of Hematology, Hospital of Treviso, Treviso, Italy
| | - Erica Simeone
- Division of Hematology and SCT, University Hospital of Udine, Udine, Italy
| | - Giovanna Ventura
- Division of Hematology and SCT, University Hospital of Udine, Udine, Italy
| | | | | | | | - Renato Fanin
- Division of Hematology and SCT, University Hospital of Udine, Udine, Italy
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Shadman M, Mawad R, Dean C, Chen TL, Shannon-Dorcy K, Sandhu V, Hendrie PC, Scott BL, Walter RB, Becker PS, Pagel JM, Estey EH. Idarubicin, cytarabine, and pravastatin as induction therapy for untreated acute myeloid leukemia and high-risk myelodysplastic syndrome. Am J Hematol 2015; 90:483-6. [PMID: 25689471 DOI: 10.1002/ajh.23981] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 02/12/2015] [Indexed: 11/08/2022]
Abstract
Previous studies suggest that idarubicin/cytarabine(ara-C)/pravastatin (IAP) is an active salvage regimen for patients with AML. We therefore investigated this regimen in patients with newly-diagnosed AML or MDS (≥10% blasts). Patients were eligible if the anticipated treatment-related mortality (TRM) was <10%. Patients received pravastatin (1,280 mg/day po; days 1-8), cytarabine (1.5 g/m(2) /day; days 4-7), and idarubicin (12 mg/m(2) /day, days 4-6). Up to 3 cycles of consolidation with a shortened course was permitted. The primary endpoints were "good CR" rate (CR on day 35 without minimal residual disease) and TRM in the first 28 days. The study was to stop if after each cohort of 5 patients (a) the Bayesian posterior probability was < 5% that the true "good CR rate" was ≥ 70% or (b) the posterior probability was >25% that the TRM rate was ≥5%. Twenty-four patients were included. Conventional CR was achieved in 15 (63%) patients but only 12 (50%) achieved "good CR". 4 of 12 (33%) patients with "good CR" relapsed at median of 16 weeks (10.5-19). Five (21%) patients had refractory disease. Survival probability at 1 year was 72% (48.7-64). Two (8.3%) patients died within 28 days from multiorgan failure. The most common grade 3-4 adverse effects were febrile neutropenia (75%) and diarrhea (25%). Based on the stopping rules accrual ceased after entry of these 24 patients. IAP did not meet the predefined efficacy criteria for success. Therefore, we would not recommend this regimen for phase three testing in this patient subset.
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Affiliation(s)
- Mazyar Shadman
- Clinical Research Division, Fred Hutchinson Cancer Research Center; Seattle Washington
- Medical Oncology Division; Department of Medicine; University of Washington; Seattle Washington
| | - Raya Mawad
- Swedish Cancer Institute, Swedish Medical Center; Seattle Washington
| | - Carol Dean
- Clinical Research Division, Fred Hutchinson Cancer Research Center; Seattle Washington
| | - Tara L. Chen
- Department of Pharmacy; University of Washington; Seattle Washington
| | | | - Vicky Sandhu
- Clinical Research Division, Fred Hutchinson Cancer Research Center; Seattle Washington
| | - Paul C. Hendrie
- Hematology Division; Department of Medicine, University of Washington; Seattle Washington
| | - Bart L. Scott
- Clinical Research Division, Fred Hutchinson Cancer Research Center; Seattle Washington
- Medical Oncology Division; Department of Medicine; University of Washington; Seattle Washington
| | - Rol B. Walter
- Clinical Research Division, Fred Hutchinson Cancer Research Center; Seattle Washington
- Hematology Division; Department of Medicine, University of Washington; Seattle Washington
| | - Pamela S. Becker
- Clinical Research Division, Fred Hutchinson Cancer Research Center; Seattle Washington
- Hematology Division; Department of Medicine, University of Washington; Seattle Washington
| | - John M. Pagel
- Swedish Cancer Institute, Swedish Medical Center; Seattle Washington
| | - Elihu H. Estey
- Clinical Research Division, Fred Hutchinson Cancer Research Center; Seattle Washington
- Hematology Division; Department of Medicine, University of Washington; Seattle Washington
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Walter RB. How Do Pretransplantation Peripheral Blood Counts Inform Us about Post-Transplantation Outcomes in Acute Myeloid Leukemia? Biol Blood Marrow Transplant 2015; 21:1340-2. [PMID: 26001694 DOI: 10.1016/j.bbmt.2015.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 05/15/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Roland B Walter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington; Division of Hematology, Department of Medicine, University of Washington, Seattle, Washington; Department of Epidemiology, University of Washington, Seattle, Washington.
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Chen X, Xie H, Wood BL, Walter RB, Pagel JM, Becker PS, Sandhu VK, Abkowitz JL, Appelbaum FR, Estey EH. Relation of Clinical Response and Minimal Residual Disease and Their Prognostic Impact on Outcome in Acute Myeloid Leukemia. J Clin Oncol 2015; 33:1258-64. [DOI: 10.1200/jco.2014.58.3518] [Citation(s) in RCA: 183] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Purpose Both presence of minimal residual disease (MRD) and achievement of complete remission (CR) with incomplete platelet recovery (CRp) rather than CR after induction therapy predict relapse in acute myeloid leukemia (AML). These results suggest a correlation between response (peripheral count recovery) and MRD at the time of morphologic remission. Here we examine this hypothesis and whether MRD and response provide independent prognostic information after accounting for other relevant covariates. Patients and Methods We retrospectively analyzed data from 245 adults with AML who achieved CR, CRp, or CR with incomplete blood count recovery (CRi) after induction therapy. Bone marrow samples were collected on or closest to the first date of blood count recovery, and MRD was determined by 10-color multiparameter flow cytometry. Results The 71.0% of patients who achieved CR had MRD less frequently and had lower levels of MRD than the 19.6% of patients achieving CRp and 9.4% achieving CRi. Although pretreatment covariates such as cytogenetics, monosomal karyotype, relapsed or refractory rather than newly diagnosed AML, and FLT3 internal tandem duplication were associated with relapse, their prognostic effect was much lower once MRD and response were taken into account, the univariable statistical effect of which was not materially affected by inclusion of pretreatment covariates. Conclusion Our data indicate that post-therapy parameters including MRD status and response are important independent prognostic factors for outcome in patients with AML achieving remission. MRD status and type of response (CR v CRp or CRi) should play important, and perhaps dominant, roles in planning postinduction therapy.
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Affiliation(s)
- Xueyan Chen
- Xueyan Chen, Brent L. Wood, Roland B. Walter, Pamela S. Becker, Janis L. Abkowitz, and Elihu H. Estey, University of Washington; and Hu Xie, Roland B. Walter, John M. Pagel, Pamela S. Becker, Vicky K. Sandhu, Frederick R. Appelbaum, and Elihu H. Estey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Hu Xie
- Xueyan Chen, Brent L. Wood, Roland B. Walter, Pamela S. Becker, Janis L. Abkowitz, and Elihu H. Estey, University of Washington; and Hu Xie, Roland B. Walter, John M. Pagel, Pamela S. Becker, Vicky K. Sandhu, Frederick R. Appelbaum, and Elihu H. Estey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Brent L. Wood
- Xueyan Chen, Brent L. Wood, Roland B. Walter, Pamela S. Becker, Janis L. Abkowitz, and Elihu H. Estey, University of Washington; and Hu Xie, Roland B. Walter, John M. Pagel, Pamela S. Becker, Vicky K. Sandhu, Frederick R. Appelbaum, and Elihu H. Estey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Roland B. Walter
- Xueyan Chen, Brent L. Wood, Roland B. Walter, Pamela S. Becker, Janis L. Abkowitz, and Elihu H. Estey, University of Washington; and Hu Xie, Roland B. Walter, John M. Pagel, Pamela S. Becker, Vicky K. Sandhu, Frederick R. Appelbaum, and Elihu H. Estey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - John M. Pagel
- Xueyan Chen, Brent L. Wood, Roland B. Walter, Pamela S. Becker, Janis L. Abkowitz, and Elihu H. Estey, University of Washington; and Hu Xie, Roland B. Walter, John M. Pagel, Pamela S. Becker, Vicky K. Sandhu, Frederick R. Appelbaum, and Elihu H. Estey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Pamela S. Becker
- Xueyan Chen, Brent L. Wood, Roland B. Walter, Pamela S. Becker, Janis L. Abkowitz, and Elihu H. Estey, University of Washington; and Hu Xie, Roland B. Walter, John M. Pagel, Pamela S. Becker, Vicky K. Sandhu, Frederick R. Appelbaum, and Elihu H. Estey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Vicky K. Sandhu
- Xueyan Chen, Brent L. Wood, Roland B. Walter, Pamela S. Becker, Janis L. Abkowitz, and Elihu H. Estey, University of Washington; and Hu Xie, Roland B. Walter, John M. Pagel, Pamela S. Becker, Vicky K. Sandhu, Frederick R. Appelbaum, and Elihu H. Estey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Janis L. Abkowitz
- Xueyan Chen, Brent L. Wood, Roland B. Walter, Pamela S. Becker, Janis L. Abkowitz, and Elihu H. Estey, University of Washington; and Hu Xie, Roland B. Walter, John M. Pagel, Pamela S. Becker, Vicky K. Sandhu, Frederick R. Appelbaum, and Elihu H. Estey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Frederick R. Appelbaum
- Xueyan Chen, Brent L. Wood, Roland B. Walter, Pamela S. Becker, Janis L. Abkowitz, and Elihu H. Estey, University of Washington; and Hu Xie, Roland B. Walter, John M. Pagel, Pamela S. Becker, Vicky K. Sandhu, Frederick R. Appelbaum, and Elihu H. Estey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Elihu H. Estey
- Xueyan Chen, Brent L. Wood, Roland B. Walter, Pamela S. Becker, Janis L. Abkowitz, and Elihu H. Estey, University of Washington; and Hu Xie, Roland B. Walter, John M. Pagel, Pamela S. Becker, Vicky K. Sandhu, Frederick R. Appelbaum, and Elihu H. Estey, Fred Hutchinson Cancer Research Center, Seattle, WA
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125
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Vu K, Manjappa S, DiPersio JF, Gao F, Westervelt P, Vij R, Stockerl-Goldstein KE, Uy GL, Abboud CN, Schroeder MA, Fehniger TA, Cashen AF, Romee R. Hematologic Recovery after Pretransplant Chemotherapy Does Not Influence Survival after Allogeneic Hematopoietic Cell Transplantation in Acute Myeloid Leukemia Patients. Biol Blood Marrow Transplant 2015; 21:1425-30. [PMID: 25840336 DOI: 10.1016/j.bbmt.2015.03.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 03/25/2015] [Indexed: 10/23/2022]
Abstract
Pretransplant remission status in patients with acute myeloid leukemia (AML) is 1 of the most important factors determining their outcomes after allogeneic hematopoietic cell transplantation (allo-HCT). Most patients are in complete remission with full hematologic recovery (CR) before undergoing allo-HCT. However, some patients achieve CR without recovery of platelet count (CRp) or a morphologic leukemia-free state (MLFS), defined as meeting all CR criteria without recovery of both neutrophil and platelet counts. Currently, there is a paucity of data regarding transplant outcomes in AML patients achieving MLFS after chemotherapy. To address this question, we evaluated transplant outcomes in 270 AML patients who received 6/6 HLA-matched sibling or 10/10 HLA-matched unrelated donor transplantation at a single institution between 2006 and 2013. Of our 270 patients, 206 were in CR, 45 were in CRp, and 19 were in MLFS before allo-HCT. Patients in CR, CRp, or MLFS had similar 3-year overall survival rates (49%, 46%, and 47%, respectively; P = .88) and 3-year event-free survival rates (45%, 36%, and 40%, respectively; P = .53). However, the cumulative incidence of nonrelapse mortality was significantly higher in patients in MLFS compared with those in CR (58% versus 22%, P = .0004), whereas the cumulative incidence of relapse in patients in MLFS was significantly lower compared with those in CR (11% versus 36%, P = .03). Our results suggest that survival outcomes in AML patients are not influenced by degree of hematologic recovery before allo-HCT.
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Affiliation(s)
- Khoan Vu
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Shivaprasad Manjappa
- Department of Hospital Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - John F DiPersio
- Section of Bone Marrow Transplant and Leukemia, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Feng Gao
- Division of Biostatistics, Washington University School of Medicine, St. Louis, Missouri
| | - Peter Westervelt
- Section of Bone Marrow Transplant and Leukemia, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Ravi Vij
- Section of Bone Marrow Transplant and Leukemia, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Keith E Stockerl-Goldstein
- Section of Bone Marrow Transplant and Leukemia, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Geoffrey L Uy
- Section of Bone Marrow Transplant and Leukemia, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Camille N Abboud
- Section of Bone Marrow Transplant and Leukemia, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Mark A Schroeder
- Section of Bone Marrow Transplant and Leukemia, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Todd A Fehniger
- Section of Bone Marrow Transplant and Leukemia, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Amanda F Cashen
- Section of Bone Marrow Transplant and Leukemia, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Rizwan Romee
- Section of Bone Marrow Transplant and Leukemia, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri.
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Abstract
The contemporary care of patients with acute myeloid leukemia (AML) is made complex by potentially toxic treatments, continuously advancing science, aging patients, and individual treatment goals. By taking a survey of present-day approaches, we aim to dispel some of the trepidation surrounding that care of patients with AML. At the beginning is the initial presentation, and we will discuss whether or not AML should be considered a medical emergency. We will explore the complex realm of patient decision-making about initial therapy, including the intricate straits of patient-doctor communication, and available options for initial treatment. We will then address post-remission approaches and the controversies that lie therein, and survivorship issues. Finally, we will investigate the current role molecular assessments are playing in therapy recommendations.
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Affiliation(s)
- Mikkael A Sekeres
- Leukemia Program, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH.
| | - Aaron T Gerds
- Leukemia Program, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH
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127
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128
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Abstract
Acute myeloid leukemia (AML) in older patients presents a notable therapeutic challenge to the clinical hematologist. The clinical biology of AML among patients is highly heterogeneous. Interpatient variations are relevant for prognosis and treatment choice. Outcome of treatment for patients of advanced age is often compromised by comorbid conditions and an enhanced susceptibility to toxicities from therapy. Here we present selected clinical vignettes that highlight distinct representative situations derived from clinical practice. The vignettes are specifically discussed in light of the perspective of treating older patients with leukemia. We review the clinical significance of various cytogenetic and molecular features of the disease, and we examine the various currently available treatment options as well as the emerging prognostic algorithms that may offer guidance in regard to personalized therapy recommendations. The dilemmas in tailoring treatment selection in this category of patients with AML are the central theme in this discussion.
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129
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Sorror ML, Estey E. Allogeneic hematopoietic cell transplantation for acute myeloid leukemia in older adults. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2014; 2014:21-33. [PMID: 25696831 DOI: 10.1182/asheducation-2014.1.21] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Acute myeloid leukemia (AML) is primarily a disease of the elderly and the numbers of these patients are increasing. Patients ≥60 years of age continue to have poor prognosis. Preliminary results suggest benefit from reduced-intensity allogeneic hematopoietic cell transplantation (HCT) in selected patients 60-80 years of age. However, although patients in this age range comprise >50% of those with AML, they currently constitute only 17% of those offered HCT. In the absence of prospective randomized studies comparing HCT and chemotherapy, the decision to recommend HCT rests on retrospective analyses of the risks of relapse and nonrelapse mortality after each approach. There is strong evidence that pre-HCT comorbidities can predict HCT-related morbidity and mortality. Age alone does not appear predictive and, particularly if the risk of relapse with chemotherapy is high, should not be the sole basis for deciding against HCT. Use of geriatric assessment tools, inflammatory biomarkers, and genetic polymorphism data may further aid in predicting nonrelapse mortality after HCT. Disease status and pretreatment cytogenetics with FLT3-TID, NPM-1, and CEBP-α status are the main factors predicting relapse and these are likely to be supplemented by incorporation of other molecular markers and the level of minimal residual disease after chemotherapy. HLA-matched related and unrelated donor grafts seem preferable to those from other donor sources. Donor age is of no clear significance. Models combining comorbidities with AML risk factors are useful in risk assessment before HCT. In this chapter, we integrated information on AML-specific, HCT-specific, and patient-specific risk factors into a risk-adapted approach to guide decisions about HCT versus no HCT.
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Affiliation(s)
- Mohamed L Sorror
- Clinical Research Division, Fred Hutchinson Cancer Research Center, and Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Elihu Estey
- Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, WA
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130
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Estey EH. Acute myeloid leukemia: 2014 update on risk-stratification and management. Am J Hematol 2014; 89:1063-81. [PMID: 25318680 DOI: 10.1002/ajh.23834] [Citation(s) in RCA: 101] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Indexed: 12/11/2022]
Abstract
OVERVIEW Evidence suggests 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.
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Affiliation(s)
- Elihu H. Estey
- Division of Hematology; University of Washington and Member, Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
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131
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Walter RB, Estey EH. Management of older or unfit patients with acute myeloid leukemia. Leukemia 2014; 29:770-5. [PMID: 25005246 DOI: 10.1038/leu.2014.216] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 05/01/2014] [Accepted: 05/19/2014] [Indexed: 12/21/2022]
Abstract
Acute myeloid leukemia (AML) is primarily a disease of older adults, for whom optimal treatment strategies remain controversial. Because of the concern for therapeutic resistance and, in particular, excessive toxicity or even treatment-related mortality, many older or medically unfit patients do not receive AML-directed therapy. Yet, evidence suggests that outcomes are improved if essentially all of these patients are offered AML therapy, ideally at a specialized cancer center. Medical fitness for tolerating intensive chemotherapy can be estimated relatively accurately with multiparameter assessment tools; this information should serve as basis for the assignment to intensive or non-intensive therapy. Until our accuracy in predicting the success of individual therapies improves, all patients should be considered for participation in a randomized controlled trial. Comparisons between individual trials will be facilitated once standardized, improved response criteria are developed, and standard treatment approaches have been defined against which novel therapies can be tested.
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Affiliation(s)
- R B Walter
- 1] Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA [2] Division of Hematology, Department of Medicine, University of Washington, Seattle, WA, USA [3] Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - E H Estey
- 1] Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA [2] Division of Hematology, Department of Medicine, University of Washington, Seattle, WA, USA
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132
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Lancet JE, Cortes JE, Hogge DE, Tallman MS, Kovacsovics TJ, Damon LE, Komrokji R, Solomon SR, Kolitz JE, Cooper M, Yeager AM, Louie AC, Feldman EJ. Phase 2 trial of CPX-351, a fixed 5:1 molar ratio of cytarabine/daunorubicin, vs cytarabine/daunorubicin in older adults with untreated AML. Blood 2014; 123:3239-46. [PMID: 24687088 PMCID: PMC4624448 DOI: 10.1182/blood-2013-12-540971] [Citation(s) in RCA: 259] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 03/04/2014] [Indexed: 12/18/2022] Open
Abstract
CPX-351 is a liposomal formulation of cytarabine:daunorubicin designed to deliver synergistic drug ratios to leukemia cells. In this phase 2 study, newly diagnosed older acute myeloid leukemia (AML) patients were randomized 2:1 to first-line CPX-351 or 7+3 treatment. The goal was to determine efficacy and identify patient subgroups that may benefit from CPX-351 treatment. Response rate (complete remission + incomplete remission) was the primary end point, with event-free survival (EFS) and overall survival (OS) as secondary end points. The 126 patients entered were balanced for disease and patient-specific risk factors. Overall, CPX-351 produced higher response rates (66.7% vs 51.2%, P = .07), meeting predefined criteria for success (P < .1). Differences in EFS and OS were not statistically significant. A planned analysis of the secondary AML subgroup demonstrated an improved response rate (57.6% vs 31.6%, P = .06), and prolongation of EFS (hazard ratio [HR] = 0.59, P = .08) and OS (HR = 0.46, P = .01). Recovery from cytopenias was slower after CPX-351 (median days to absolute neutrophil count ≥1000: 36 vs 32; platelets >100 000: 37 vs 28) with more grade 3-4 infections but without increase in infection-related deaths (3.5% vs 7.3%) or 60-day mortality (4.7% vs 14.6%), indicating acceptable safety. These results suggest a clinical benefit with CPX-351, particularly among patients with secondary AML, and provide the rationale for a phase 3 trial currently underway in newly diagnosed secondary AML patients. This study is registered at Clinicaltrials.gov as #NCT00788892.
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Affiliation(s)
| | - Jorge E Cortes
- University of Texas MD Anderson Cancer Center, Houston, TX
| | - Donna E Hogge
- British Columbia Cancer Agency, Vancouver, BC, Canada
| | - Martin S Tallman
- Memorial Sloan-Kettering Cancer Center and Weill Cornell Medical College, New York, NY
| | | | - Lloyd E Damon
- University of California, San Francisco, San Francisco, CA
| | - Rami Komrokji
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Scott R Solomon
- Blood & Marrow Transplant at Northside Hospital, Atlanta, GA
| | - Jonathan E Kolitz
- Hofstra North Shore-Long Island Jewish School of Medicine, Lake Success, NY
| | - Maureen Cooper
- St. Francis Hospital and Health Centers, Indianapolis, IN
| | | | | | - Eric J Feldman
- Weill Medical College of Cornell University and New York Presbyterian Hospital, New York, NY
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133
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The protein phosphatase 2A regulatory subunit B55α is a modulator of signaling and microRNA expression in acute myeloid leukemia cells. BIOCHIMICA ET BIOPHYSICA ACTA-MOLECULAR CELL RESEARCH 2014; 1843:1969-77. [PMID: 24858343 DOI: 10.1016/j.bbamcr.2014.05.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Revised: 05/12/2014] [Accepted: 05/13/2014] [Indexed: 01/22/2023]
Abstract
We recently discovered that the protein phosphatase 2A (PP2A) B55α subunit (PPP2R2A) is under-expressed in primary blast cells and is unfavorable for remission duration in AML patients. In this study, reverse phase protein analysis (RPPA) of 230 proteins in 511 AML patient samples revealed a strong correlation of B55α with a number of proteins including MYC, PKC α, and SRC. B55α suppression in OCI-AML3 cells by shRNA demonstrated that the B subunit is a PKCα phosphatase. B55α does not target SRC, but rather the kinase suppresses protein expression of the B subunit. Finally, the correlation between B55α and MYC levels reflected a complex stoichiometric competition between B subunits. Loss of B55α in OCI-AML3 cells did not change global PP2A activity and the only isoform that is induced is the one containing B56α. In cells containing B55α shRNA, MYC was suppressed with concomitant induction of the competing B subunit B56α (PPP2R5A). A recent study determined that FTY-720, a drug whose action involves the activation of PP2A, resulted in the induction of B55α In AML cells, and a reduction of the B subunit rendered these cells resistant to FTY-720. Finally, reduction of the B subunit resulted in an increase in the expression of miR-191-5p and a suppression of miR-142-3p. B55α regulation of these miRs was intriguing as high levels of miR-191 portend poor survival in AML, and miR-142-3p is mutated in 2% of AML patient samples. In summary, the suppression of B55α activates signaling pathways that could support leukemia cell survival.
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134
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Foran JM. Frontline Therapy of AML: Should the Older Patient be Treated Differently? Curr Hematol Malig Rep 2014; 9:100-8. [DOI: 10.1007/s11899-014-0211-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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135
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Ornstein MC, Mukherjee S, Mohan S, Elson P, Tiu RV, Saunthararajah Y, Kendeigh C, Advani A, Kalaycio M, Maciejewski JP, Sekeres MA. Predictive factors for latency period and a prognostic model for survival in patients with therapy-related acute myeloid leukemia. Am J Hematol 2014; 89:168-73. [PMID: 24123154 DOI: 10.1002/ajh.23605] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Accepted: 10/01/2013] [Indexed: 01/05/2023]
Abstract
Therapy-related acute myeloid leukemia (t-AML) is an increasingly recognized sequela in patients receiving chemotherapy or radiotherapy for a primary malignancy or autoimmune disease. This study assessed factors related to the latency period (LP) between the antecedent disorder (AD) and t-AML diagnosis and developed a comprehensive prognostic model to predict overall survival (OS). We evaluated a cohort of newly diagnosed t-AML patients treated with cytarabine-based induction therapy from 2001 to 2011. Multivariable linear and proportional hazards models were used to assess the impact of different classes of chemotherapy on the LP and to identify independent prognostic factors for OS. Of 730 treated AML patients, 58 (7.9%) had t-AML. Median LP to t-AML was 5.6 years (range, 0.5-38.4). 64% of patients achieved CR and median OS was 10.7 months. Independent prognostic factors of short LP were age at AD (P < 0.0001) and prior treatment with mitotic inhibitors (P = 0.05). Unfavorable cytogenetics (P = 0.004), antecedent hematologic or autoimmune disease (P = 0.01), age >60 (P = 0.03), and platelet count <30,000 μL (P = 0.04) at the time of t-AML diagnosis were prognostic for inferior OS. A prognostic model using these factors was developed that risk stratified t-AML patients into two groups: favorable and unfavorable. Patients in the favorable group had a median OS of 37.6 months compared with 6.4 months in patients comprising the unfavorable group (P < 0.0001). Multicomponent prognostic models integrating disease or treatment-related covariates can help better understand how t-AML evolves; and can be clinically useful in risk stratifying t-AML patients undergoing induction therapy.
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Affiliation(s)
- Moshe C. Ornstein
- Leukemia Program, Department of Hematologic Oncology and Blood Disorders; Cleveland Clinic Taussig Cancer Institute; Cleveland Ohio
| | - Sudipto Mukherjee
- Leukemia Program, Department of Hematologic Oncology and Blood Disorders; Cleveland Clinic Taussig Cancer Institute; Cleveland Ohio
| | - Sanjay Mohan
- Department of Medicine; Division of Hematology/Oncology; Vanderbilt University; Nashville TN
| | - Paul Elson
- Department of Quantitative Health Sciences; Cleveland Clinic; Cleveland OH
| | - Ramon V. Tiu
- Leukemia Program, Department of Hematologic Oncology and Blood Disorders; Cleveland Clinic Taussig Cancer Institute; Cleveland Ohio
| | - Yogenthiran Saunthararajah
- Leukemia Program, Department of Hematologic Oncology and Blood Disorders; Cleveland Clinic Taussig Cancer Institute; Cleveland Ohio
| | - Cassie Kendeigh
- Leukemia Program, Department of Hematologic Oncology and Blood Disorders; Cleveland Clinic Taussig Cancer Institute; Cleveland Ohio
| | - Anjali Advani
- Leukemia Program, Department of Hematologic Oncology and Blood Disorders; Cleveland Clinic Taussig Cancer Institute; Cleveland Ohio
| | - Matt Kalaycio
- Leukemia Program, Department of Hematologic Oncology and Blood Disorders; Cleveland Clinic Taussig Cancer Institute; Cleveland Ohio
| | - Jaroslaw P. Maciejewski
- Leukemia Program, Department of Hematologic Oncology and Blood Disorders; Cleveland Clinic Taussig Cancer Institute; Cleveland Ohio
| | - Mikkael A. Sekeres
- Leukemia Program, Department of Hematologic Oncology and Blood Disorders; Cleveland Clinic Taussig Cancer Institute; Cleveland Ohio
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Suzuki T, Yamauchi T, Ando K, Nagai T, Kakihana K, Miyata Y, Uchida T, Tabata Y, Ogura M. Phase I study of clofarabine in adult patients with acute myeloid leukemia in Japan. Jpn J Clin Oncol 2013; 43:1177-83. [PMID: 24130086 DOI: 10.1093/jjco/hyt155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE There are limited treatment options for relapsed/refractory acute myeloid leukemia patients or previously untreated elderly (≥60 years) patients with acute myeloid leukemia. In Phase II studies from the USA and Europe, single-agent clofarabine demonstrated activity and acceptable toxicity in elderly patients with previously untreated acute myeloid leukemia. This Phase I, multicenter study assessed the maximum-tolerated dose, safety, pharmacokinetics and efficacy of clofarabine in Japanese adults with acute myeloid leukemia. METHODS Intravenous clofarabine (20, 30 and 40 mg/m(2)/day) was administered for 5 days to Japanese adult patients with relapsed or refractory acute myeloid leukemia or elderly patients with newly diagnosed acute myeloid leukemia. RESULTS Fourteen patients, median age of 67.5 (59-72) years, were enrolled in this study. Eleven out of 14 patients had relapsed/refractory acute myeloid leukemia. Three patients received clofarabine at 20 mg/m(2), six at 30 mg/m(2) and five at 40 mg/m(2). Frequently reported treatment-related adverse events included thrombocytopenia (100%), anemia (93%), neutropenia (86%), nausea (86%), alanine aminotransferase increase (71%), headache (71%) and febrile neutropenia (57%). Three patients experienced reversible dose-limiting toxicities; two had increased alanine aminotransferase with 30 and 40 mg/m(2) and one had Grade 3 elevation of serum amylase with 40 mg/m(2). The maximum-tolerated dose was 30 mg/m(2)/day. Cmax and exposure area under the curve0-24h increased with increasing dose and were proportional to dose through the tested dose range. Among the 14 assessable patients, four (29%) achieved complete remission and two (14%) complete remission without platelet recovery. The overall remission rate was 43%. CONCLUSIONS These results demonstrate safety and preliminary, promising activity of clofarabine in Japanese patients with acute myeloid leukemia. Further investigation is warranted.
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Affiliation(s)
- Tatsuya Suzuki
- *Department of Hematology and Oncology, Nagoya Daini Red Cross Hospital, 2-9 Myoken-cho, Showa-ku, Nagoya 466-8650 Japan.
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137
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Sorror ML, Appelbaum FR. Risk assessment before allogeneic hematopoietic cell transplantation for older adults with acute myeloid leukemia. Expert Rev Hematol 2013; 6:547-62. [PMID: 24083472 DOI: 10.1586/17474086.2013.827418] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Acute myeloid leukemia (AML) most commonly affects patients older than 60 years. Outcomes of treatment of older AML patients have been poor. The advent of reduced-intensity conditioning (RIC) regimens made allogeneic hematopoietic cell transplantation (HCT) an available treatment option with curative intent for older AML patients. Because older patients are often excluded from clinical trials, little is known about the stratification of their risks before allogeneic HCT. While recent studies of RIC and allogeneic HCT have shown little impact of age on outcomes, other variables such as the recipient health status and the AML disease status and chromosomal aberrations have proven to be of prognostic significance. Here, the authors review recent studies of allogeneic HCT for older patients with AML with detailed evaluation of risk factors for relapse as well as non-relapse mortality. The authors have integrated the currently available information on transplant risks into a five-category risk-benefit system that could aid in the decision-making in this patient population.
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Affiliation(s)
- Mohamed L Sorror
- Clinical Research Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue North, Seattle WA 98109-1024, USA
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138
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Kharfan-Dabaja MA, Hamadani M, Reljic T, Pyngolil R, Komrokji RS, Lancet JE, Fernandez HF, Djulbegovic B, Kumar A. Gemtuzumab ozogamicin for treatment of newly diagnosed acute myeloid leukaemia: a systematic review and meta-analysis. Br J Haematol 2013; 163:315-25. [PMID: 24033280 DOI: 10.1111/bjh.12528] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Accepted: 07/19/2013] [Indexed: 11/28/2022]
Abstract
Evidence regarding the efficacy of gemtuzumab ozogamicin (GO) addition to standard induction chemotherapy in newly diagnosed acute myeloid leukaemia (AML) is conflicting. This systematic review aimed to identify and summarize all evidence regarding the benefits and harms of adding GO to conventional chemotherapy for induction treatment of AML. A comprehensive literature search of two databases (PUBMED and Cochrane) from inception up to November 22, 2012, and 4 years of proceedings from four major haematology/oncology conferences was undertaken. Endpoints included benefits (complete remission, relapse-free, event-free, and overall survival), and harms (early mortality and incidence of hepatic veno-occlusive disease/sinusoidal obstructive syndrome). Seven trials (3942 patients) met all inclusion criteria. Addition of GO showed improved relapse-free [Hazard Ratio (HR) = 0·84 (95% confidence interval (CI) 0·71-0·99)] and event-free survival [HR = 0·59 (95%CI 0·48-0·74)] but not overall survival [HR = 0·95 (95%CI 0·83-1·08)]. Addition of GO resulted in higher rate of early mortality [Risk Ratio = 1·60 (95%CI 1·07-2·39)]. Improved overall survival was observed in studies using a lower cumulative GO dose (<6 mg/m(2) ) [HR = 0·89 (95%CI 0·81-0·99)]. Addition of GO to conventional chemotherapy as induction therapy may improve relapse-free and event-free survival, but does not impact overall survival and significantly increases early mortality in AML.
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Affiliation(s)
- Mohamed A Kharfan-Dabaja
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center, Tampa, FL, USA; Department of Oncologic Sciences, H. Lee Moffitt Cancer Center/University of South Florida College of Medicine, Tampa, FL, USA
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139
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Epigenetics in clinical practice: the examples of azacitidine and decitabine in myelodysplasia and acute myeloid leukemia. Leukemia 2013; 27:1803-12. [DOI: 10.1038/leu.2013.173] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Revised: 05/24/2013] [Accepted: 06/03/2013] [Indexed: 01/02/2023]
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De novo AML patients with favourable–intermediate karyotype may benefit from the addition of low-dose gemtuzumab ozogamicin (GO) to fludarabine, Ara-C and idarubicin (FLAI): a contribution to the reopened “GO question”. Ann Hematol 2013; 92:1309-18. [DOI: 10.1007/s00277-013-1780-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 04/28/2013] [Indexed: 10/26/2022]
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141
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Estey E. Recent developments in management of older patients with acute myeloid leukemia. Ther Adv Hematol 2013; 3:89-96. [PMID: 23556115 DOI: 10.1177/2040620711434319] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Yang J, Schiffer CA. Genetic biomarkers in acute myeloid leukemia: will the promise of improving treatment outcomes be realized? Expert Rev Hematol 2013; 5:395-407. [PMID: 22992234 DOI: 10.1586/ehm.12.32] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Recent progress in the molecular genetics of acute myeloid leukemia (AML) has shown this disease to be more heterogeneous than previously realized. Recurrent cytogenetic and mutational changes in leukemic blasts have been confirmed to have high prognostic significance. High-throughput techniques to analyze the AML genome in greater depth have revealed novel mutations with putative roles in leukemogenesis. The use of prognostic biomarkers has allowed for a more detailed categorization of AML based on risk. Despite this tremendous progress, the understanding of the mechanisms by which these changes influence leukemia growth and response to treatment is still limited, which in turn has hindered the development of rationally targeted therapies for AML. The integration of clinical, cytogenetic and molecular data will be essential to translate the current research momentum into better outcomes for patients with AML.
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Affiliation(s)
- Jay Yang
- Department of Oncology, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI, USA.
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Abstract
The outlook for patients with acute myeloid leukaemia has improved in the past 30 years. Unlike other cancers, much of this progress is attributable to refinement of supportive treatment, rather than the introduction of new drugs. New antibacterial and antifungal agents, antiemetics, and improved transfusion support have decreased the rate of early death, and morbidity and mortality from allogeneic stem cell transplantation has been substantially reduced. However, more than half of young adult patients and about 90% of older patients still die from their disease. Refractoriness to initial induction treatment and, more frequently, relapse after complete remission, are still the main obstacles to cure. Accordingly, new treatment approaches with mechanisms of action different from those of conventional chemotherapy are needed. Our knowledge of the various chromosomal and molecular abnormalities implicated in the pathogenesis of the many subtypes of the disease has greatly expanded; as a result, clinical research is moving towards the investigation of new non-cytotoxic agents in combination with chemotherapy. The goal is to target the molecular abnormalities identified at diagnosis; however, several aberrations can coexist in subclones of acute myeloid leukaemia, making the disease less likely to be inhibited by a single agent.
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MESH Headings
- Adult
- Age Factors
- Age of Onset
- Antineoplastic Combined Chemotherapy Protocols/administration & dosage
- Bone Marrow Transplantation/methods
- Bone Marrow Transplantation/mortality
- Combined Modality Therapy
- Disease-Free Survival
- Female
- Hematopoietic Stem Cell Transplantation/methods
- Hematopoietic Stem Cell Transplantation/mortality
- Humans
- Leukemia, Myeloid, Acute/diagnosis
- Leukemia, Myeloid, Acute/epidemiology
- Leukemia, Myeloid, Acute/therapy
- Male
- Middle Aged
- Neoplasm Recurrence, Local/mortality
- Neoplasm Recurrence, Local/therapy
- Prognosis
- Risk Assessment
- Severity of Illness Index
- Sex Factors
- Survival Analysis
- Transplantation, Autologous
- Transplantation, Homologous
- Treatment Outcome
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Affiliation(s)
- Felicetto Ferrara
- Division of Haematology and Stem Cell Transplantation Unit, Naples, Italy.
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Sekeres MA, Steensma DP. Boulevard of Broken Dreams: Drug Approval for Older Adults With Acute Myeloid Leukemia. J Clin Oncol 2012; 30:4061-3. [DOI: 10.1200/jco.2012.44.2962] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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De Castro N, Mazoyer E, Porcher R, Raffoux E, Suarez F, Ribaud P, Lortholary O, Molina JM. Hepatosplenic candidiasis in the era of new antifungal drugs: a study in Paris 2000-2007. Clin Microbiol Infect 2012; 18:E185-7. [DOI: 10.1111/j.1469-0691.2012.03819.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Affiliation(s)
- Elihu Estey
- University of Washington Medical Center, Seattle, WA, USA.
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147
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Arellano M, Pakkala S, Langston A, Tighiouart M, Pan L, Chen Z, Heffner LT, Lonial S, Winton E, Khoury HJ. Early clearance of peripheral blood blasts predicts response to induction chemotherapy in acute myeloid leukemia. Cancer 2012; 118:5278-82. [DOI: 10.1002/cncr.27494] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Revised: 12/30/2011] [Accepted: 01/10/2012] [Indexed: 11/06/2022]
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Estey EH. Acute myeloid leukemia: 2012 update on diagnosis, risk stratification, and management. Am J Hematol 2012; 87:89-99. [PMID: 22180162 DOI: 10.1002/ajh.22246] [Citation(s) in RCA: 114] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
DISEASE OVERVIEW Acute myeloid leukemia (AML) results from accumulation of abnormal immature cells in the marrow. These cells interfere with normal hematopoiesis can escape into the blood and infiltrate lung and CNS. The most common cause of death is bone marrow failure. It is likely that many different mutations and/or epigenetic aberrations can produce the same disease, with these differences responsible for the very variable response to therapy, which is AML's principal clinical feature. DIAGNOSIS This rests on demonstration that the marrow or blood has >20% blasts of myeloid lineage. Blast lineage is assessed by multiparameter flow cytometry with CD33 and CD13 being surface markers typically expressed by myeloid blasts. It should be realized that clinical/prognostic considerations, not the blast % per se, should be the main factor determining how a patient is treated. RISK STRATIFICATION Two features determine risk: the probability of treatment-related mortality (TRM) and, more important, even in patients aged >75 with Zubrod performance status 1, the probability of resistance to standard therapy despite not incurring TRM. The chief predictor of resistance is cytogenetics with a monosomal karyotype (MK) denoting the disease is essentially incurable with standard therapy even if followed by a standard allogeneic transplant (HCT). The most common cytogenetic finding is a normal karyotype (NK) and those of such patients with an NPM1 mutation but no FLT3 internal tandem duplication (ITD), or with a CEBPA mutation, have a prognosis similar to that of patients with the most favorable cytogenetics [inv(16) or t(8;21)] (60-70% cure rate). In contrast, NK patients with a FLT3 ITD have only a 30-40% chance of cure even after HCT. Accordingly analyses of NPM1, FLT3, and CEBPA should be part of routine evaluation, much as is cytogenetics. Risk is best assessed considering several variables simultaneously rather than, for example, only age. RISK-ADAPTED THERAPY Patients with inv(16) or t(8;21) or who are NPM1+/FLT3ITD- can receive standard therapy (daunorubicin + cytarabine) and should not receive HCT in first CR. It seems likely that use of a daily daunorubicin dose of 90 mg/m(2) will further improve outcome in these patients. There appears no reason to use doses of cytarabine > 1 g/m(2) (for example, bid × 6 days), as opposed to the more commonly used 3 g/m(2) . Patients with an unfavorable karyotype (particularly MK) are unlikely to benefit from standard therapy (even with dose escalation) and are thus prime candidates for clinical trials of new drugs or new approaches to HCT; the latter should be done in first CR. Patients with intermediate prognoses (for example, NK and NPM and FLT3ITD negative) should also receive HCT in first CR and can plausibly receive either investigational or standard induction therapy, with the same prognostic information about standard therapy leading one patient to choose the standard and another an investigational option.
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Affiliation(s)
- Elihu H Estey
- Division of Hematology, University of Washington, USA.
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150
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Estey E. What is the optimal induction strategy for older patients? Best Pract Res Clin Haematol 2011; 24:515-22. [DOI: 10.1016/j.beha.2011.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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