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Othman T, Koller P, Tsai NC, Yang D, Pourhassan H, Agrawal V, Ngo D, Chen J, Farol L, Spielberger R, Sahebi F, Al Malki MM, Cai JL, Sandhu KS, Mansour J, Salhotra A, Ali H, Aribi A, Arslan S, Marcucci G, Forman SJ, Stein AS, Nakamura R, Pullarkat V, Aldoss I, Mei M. Toxicities associated with tyrosine kinase inhibitor maintenance following allogeneic hematopoietic cell transplantation in Philadelphia chromosome-positive acute lymphoblastic leukemia. Am J Hematol 2024; 99:1680-1690. [PMID: 38804599 DOI: 10.1002/ajh.27378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 04/29/2024] [Accepted: 05/12/2024] [Indexed: 05/29/2024]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) offers a potential cure in Philadelphia chromosome-positive (Ph+) acute lymphoblastic leukemia (ALL); nonetheless, relapses are common and the major cause of mortality. One strategy to prevent relapse is tyrosine kinase inhibitor (TKI) maintenance post-HCT, but published clinical experience is primarily with the first-generation TKI imatinib while data with newer generation TKIs are limited. We conducted a retrospective analysis of 185 Ph+ ALL patients who underwent HCT followed by TKI maintenance from 2003 to 2021 at City of Hope. Initially, 50 (27.0%) received imatinib, 118 (63.8%) received a second-generation TKI (2G-TKI), and 17 (9.2%) received ponatinib. A total of 77 patients (41.6%) required a dose reduction of their initial TKI due to toxicity. Sixty-six patients (35.7%) did not complete maintenance due to toxicity; 69 patients (37.3%) discontinued 1 TKI, and 11 (5.9%) discontinued 2 TKIs due to toxicity. Initial imatinib versus 2G-TKI versus ponatinib maintenance was discontinued in 19 (38.0%) versus 68 (57.6%) versus 3 (17.6%) patients due to toxicity (p = .003), respectively. Patients on ponatinib as their initial TKI had a longer duration of TKI maintenance versus 2G-TKI: 576.0 days (range, 72-921) versus 254.5 days (range, 3-2740; p = .02). The most common reasons for initial TKI discontinuation include gastrointestinal (GI) intolerance (15.1%), cytopenia (8.6%), and fluid retention (3.8%). The 5-year overall survival and progression-free survival for the total population were 78% and 71%, respectively. Our findings demonstrate the challenges of delivering post-HCT TKI maintenance in a large real-world cohort as toxicities leading to TKI interruptions, discontinuation, and dose reduction were common.
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Affiliation(s)
- Tamer Othman
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California, USA
| | - Paul Koller
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California, USA
| | - Ni-Chun Tsai
- Department of Computational and Quantitative Sciences, Beckman Research Institute, City of Hope, Duarte, California, USA
| | - Dongyun Yang
- Department of Computational and Quantitative Sciences, Beckman Research Institute, City of Hope, Duarte, California, USA
| | - Hoda Pourhassan
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California, USA
| | - Vaibhav Agrawal
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California, USA
| | - Dat Ngo
- Department of Pharmacy, City of Hope National Medical Center, California, Duarte, USA
| | - Jason Chen
- Department of Pharmacy, City of Hope National Medical Center, California, Duarte, USA
| | - Leonardo Farol
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California, USA
| | - Ricardo Spielberger
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California, USA
| | - Firoozeh Sahebi
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California, USA
| | - Monzr M Al Malki
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California, USA
| | - Ji-Lian Cai
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California, USA
| | - Karamjeet S Sandhu
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California, USA
| | - Joshua Mansour
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California, USA
| | - Amandeep Salhotra
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California, USA
| | - Haris Ali
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California, USA
| | - Ahmed Aribi
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California, USA
| | - Shukaib Arslan
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California, USA
| | - Guido Marcucci
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California, USA
| | - Stephen J Forman
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California, USA
| | - Anthony S Stein
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California, USA
| | - Ryotaro Nakamura
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California, USA
| | - Vinod Pullarkat
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California, USA
| | - Ibrahim Aldoss
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California, USA
| | - Matthew Mei
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, California, USA
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Tran V, Salafian K, Michaels K, Jones C, Reed D, Keng M, El Chaer F. MRD in Philadelphia Chromosome-Positive ALL: Methodologies and Clinical Implications. Curr Hematol Malig Rep 2024; 19:186-196. [PMID: 38888822 DOI: 10.1007/s11899-024-00736-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2024] [Indexed: 06/20/2024]
Abstract
PURPOSE OF REVIEW Measurable residual disease (MRD) is integral in the management of Philadelphia chromosome-positive (Ph+) acute lymphoblastic leukemia (ALL). This review discusses the current methods used to evaluate MRD as well as the interpretation, significance, and incorporation of MRD in current practice. RECENT FINDINGS New molecular technologies have allowed the detection of MRD to levels as low as 10- 6. The most used techniques to evaluate MRD are multiparametric flow cytometry (MFC), quantitative reverse transcription polymerase chain reaction (RT-qPCR), and high-throughput next-generation sequencing (NGS). Each method varies in terms of advantages, disadvantages, and MRD sensitivity. MRD negativity after induction treatment and after allogeneic hematopoietic cell transplantation (HCT) is an important prognostic marker that has consistently been shown to be associated with improved outcomes. Blinatumomab, a new targeted therapy for Ph + ALL, demonstrates high efficacy in eradicating MRD and improving patient outcomes. In the relapsed/refractory setting, the use of inotuzumab ozogamicin and tisagenlecleucel has shown promise in eradicating MRD. The presence of MRD has become an important predictive measure in Ph + ALL. Current studies evaluate the use of MRD in treatment decisions, especially in expanding therapeutic options for Ph + ALL, including tyrosine kinase inhibitors, targeted antibody therapies, chimeric antigen receptor cell therapy, and HCT.
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Affiliation(s)
- Valerie Tran
- Division of Hematology and Oncology, Department of Medicine, The University of Virginia, Charlottesville, VA, USA
| | - Kiarash Salafian
- Department of Medicine, The University of Virginia, Charlottesville, VA, USA
| | - Kenan Michaels
- Department of Medicine, The University of Virginia, Charlottesville, VA, USA
| | - Caroline Jones
- Division of Hematology and Oncology, Department of Medicine, The University of Virginia, Charlottesville, VA, USA
| | - Daniel Reed
- Division of Hematology and Oncology, Department of Medicine, The University of Virginia, Charlottesville, VA, USA
| | - Michael Keng
- Division of Hematology and Oncology, Department of Medicine, The University of Virginia, Charlottesville, VA, USA
| | - Firas El Chaer
- Division of Hematology and Oncology, Department of Medicine, The University of Virginia, Charlottesville, VA, USA.
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Kassner J, Abdellatif B, Yamshon S, Monge J, Kaner J. Current landscape of CD3 bispecific antibodies in hematologic malignancies. Trends Cancer 2024; 10:708-732. [PMID: 38987076 DOI: 10.1016/j.trecan.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 05/23/2024] [Accepted: 06/03/2024] [Indexed: 07/12/2024]
Abstract
Over the past 30 years the incorporation of monoclonal antibody (mAb) treatments into the management of hematologic malignancies has led to significant improvements in patient outcomes. The key limitation of mAb treatments is the necessity for target antigen presentation on major histocompatibility complex (MHC) and costimulatory molecules to elicit a cytotoxic immune response. With the advent of bispecific antibodies (BsAbs), these limitations can be overcome through direct stimulation of cytotoxic T cells, thus limiting tumor cell evasion. BsAbs are rapidly being incorporated into treatment regimens for hematologic malignancies, and there are now seven FDA-approved treatments in this class, six of which have been approved in the past year. In this review we describe the function, complications, and clinical trial data available for CD3 BsAbs in the treatment of lymphoma, myeloma, and leukemia.
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Affiliation(s)
- Joshua Kassner
- Department of Internal Medicine, New York Presbyterian/Weill Cornell Medical Center, New York, NY, USA; Division of Hematology and Medical Oncology, Weill Cornell Medicine, New York, NY, USA
| | | | - Samuel Yamshon
- Division of Hematology and Medical Oncology, Weill Cornell Medicine, New York, NY, USA
| | - Jorge Monge
- Division of Hematology and Medical Oncology, Weill Cornell Medicine, New York, NY, USA
| | - Justin Kaner
- Division of Hematology and Medical Oncology, Weill Cornell Medicine, New York, NY, USA.
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Huang YJ, Chen SH, Liu HC, Jaing TH, Yeh TC, Kuo MC, Lin TL, Chen CC, Wang SC, Chang TK, Hsiao CC, Liang DC, Shih LY. Evaluation of next-generation sequencing for measurable residual disease monitoring in three major fusion transcript subtypes of B-precursor acute lymphoblastic leukaemia. Pathology 2024; 56:681-687. [PMID: 38719770 DOI: 10.1016/j.pathol.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 01/18/2024] [Accepted: 02/07/2024] [Indexed: 07/07/2024]
Abstract
The use of next-generation sequencing (NGS) for monitoring measurable residual disease (MRD) in acute lymphoblastic leukaemia (ALL) has been gaining traction. This study aimed to investigate the utility of NGS in MRD monitoring for the three major fusion transcript (FT) subtypes of B-precursor ALL (B-ALL). The MRD results for 104 bone marrow samples from 56 patients were analysed through NGS and real time quantitative reverse transcription PCR (RT-qPCR) for the three major FTs: BCR::ABL1, TCF3::PBX1, and ETV6::RUNX1. To validate the NGS approach, NGS-MRD was initially compared with allele-specific oligonucleotide-qPCR-MRD, and the coefficient of determination was good (R2=0.8158). A subsequent comparison of NGS-MRD with FT-MRD yielded a good coefficient of determination (R2=0.7690), but the coefficient varied by subtype. Specifically, the R2 was excellent for TCF3::PBX1 ALL (R2=0.9157), good for ETV6::RUNX1 ALL (R2=0.8606), and subpar for BCR::ABL1 ALL (R2=0.5763). The overall concordance between the two methods was 83.7%, and an excellent concordance rate of 95.8% was achieved for TCF3::PBX1 ALL. Major discordance, which was defined as a >1 log difference between discordant NGS-MRD and FT-MRD, occurred in 6.7% of the samples, with all but one sample being BCR::ABL1 ALL. Among the four non-transplanted patients with BCR::ABL1-MRD (+)/NGS-MRD (-), three did not relapse after long-term follow-up. Our finding indicates that NGS-MRD has a better prognostic impact than RT-qPCR-MRD in ETV6::RUNX1 and BCR::ABL1 ALL, whereas in TCF3::PBX1 ALL, both methods exhibit comparable efficacy.
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Affiliation(s)
- Ying-Jung Huang
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Shih-Hsiang Chen
- College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Hematology-Oncology, Chang Gung Children's Hospital at Linkou, Taoyuan, Taiwan
| | - Hsi-Che Liu
- Department of Hematology-Oncology, MacKay Children's Hospital and Mackay Medical College, Taipei, Taiwan
| | - Tang-Her Jaing
- College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Hematology-Oncology, Chang Gung Children's Hospital at Linkou, Taoyuan, Taiwan
| | - Ting-Chi Yeh
- Department of Hematology-Oncology, MacKay Children's Hospital and Mackay Medical College, Taipei, Taiwan
| | - Ming-Chung Kuo
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Tung-Liang Lin
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Chiu-Chen Chen
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Shih-Chung Wang
- Division of Pediatric Hematology-Oncology, Changhua Christian Children's Hospital, Changhua, Taiwan
| | - Te-Kau Chang
- Division of Pediatric Hematology and Oncology, China Medical University Children's Hospital, Taichung, Taiwan
| | - Chih-Cheng Hsiao
- College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Pediatrics, Chang Gung Memorial Hospital at Kaohsiung, Kaohsiung, Taiwan
| | - Der-Cherng Liang
- Department of Hematology-Oncology, MacKay Children's Hospital and Mackay Medical College, Taipei, Taiwan
| | - Lee-Yung Shih
- Division of Hematology-Oncology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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Kantarjian H, Short NJ, Haddad FG, Jain N, Huang X, Montalban-Bravo G, Kanagal-Shamanna R, Kadia TM, Daver N, Chien K, Alvarado Y, Garcia-Manero G, Issa GC, Garris R, Nasnas C, Nasr L, Ravandi F, Jabbour E. Results of the Simultaneous Combination of Ponatinib and Blinatumomab in Philadelphia Chromosome-Positive ALL. J Clin Oncol 2024:JCO2400272. [PMID: 39028925 DOI: 10.1200/jco.24.00272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 03/26/2024] [Accepted: 05/07/2024] [Indexed: 07/21/2024] Open
Abstract
Clinical trials frequently include multiple end points that mature at different times. The initial report, typically based on the primary end point, may be published when key planned co-primary or secondary analyses are not yet available. Clinical Trial Updates provide an opportunity to disseminate additional results from studies, published in JCO or elsewhere, for which the primary end point has already been reported.In this analysis, we update our experience with the chemotherapy-free regimen of blinatumomab and ponatinib in 60 patients with newly diagnosed Philadelphia chromosome (Ph)-positive ALL. At a median follow-up of 24 months, the complete molecular response rate by reverse transcriptase-polymerase chain reaction was 83% (67% at the end of course one), and the rate of measurable residual disease negativity by next-generation clono-sequencing was 98% (45% at the end of course one). Only two patients underwent hematopoietic stem cell transplantation (HSCT). Seven patients relapsed: two with systemic disease, four with isolated CNS relapse, and one with extramedullary Ph-negative, CRLF2-positive pre-B ALL. The estimated 3-year overall survival rate was 91% and event-free survival rate was 77%. Three patients discontinued blinatumomab because of adverse events (related, n = 1; unrelated, n = 2) and nine discontinued ponatinib because of cerebrovascular ischemia, coronary artery stenosis, persistent rash, elevated liver function tests with drug-induced fatty liver, atrial thrombus, severe arterial occlusive disease of lower extremities, pleuro-pericardial effusion, and debilitation. In conclusion, the simultaneous combination of ponatinib and blinatumomab is a highly effective and relatively safe nonchemotherapy regimen. This regimen also reduces the need for intensive chemotherapy and HSCT in first remission in the majority of patients.
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Affiliation(s)
- Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Fadi G Haddad
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Xuelin Huang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Rashmi Kanagal-Shamanna
- Department of Hematopathology and Molecular Diagnostics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Tapan M Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Naval Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kelly Chien
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Yesid Alvarado
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Ghayas C Issa
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Rebecca Garris
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Cedric Nasnas
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lewis Nasr
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
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Muffly L, Liang EC, Dolan JG, Pulsipher MA. How I use next-generation sequencing-MRD to plan approach and prevent relapse after HCT for children and adults with ALL. Blood 2024; 144:253-261. [PMID: 38728375 PMCID: PMC11302453 DOI: 10.1182/blood.2023023699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/11/2024] [Accepted: 04/24/2024] [Indexed: 05/12/2024] Open
Abstract
ABSTRACT Measurable residual disease (MRD) evaluation by multiparameter flow cytometry (MFC) or quantitative polymerase chain reaction methods is an established standard of care for assessing risk of relapse before or after hematopoietic cell transplantation (HCT) for acute lymphoblastic leukemia (ALL). Next-generation sequencing (NGS)-MRD has emerged as a highly effective approach that allows for the detection of lymphoblasts at a level of <1 in 106 nucleated cells, increasing sensitivity of ALL detection by 2 to 3 logs. Early studies have shown superior results compared with MFC and suggest that NGS-MRD may allow for the determination of patients in whom reduced toxicity transplant preparative approaches could be deployed without sacrificing outcomes. Many centers/study groups have implemented immune modulation approaches based on MRD measurements that have resulted in improved outcomes. Challenges remain with NGS-MRD, because it is not commercially available in many countries, and interpretation of results can be complex. Through patient case review, discussion of relevant studies, and detailed expert opinion, we share our approach to NGS-MRD testing before and after HCT in pediatric and adult ALL. Improved pre-HCT risk classification and post-HCT monitoring for relapse in bone marrow and less invasive peripheral blood monitoring by NGS-MRD may lead to alternative approaches to prevent relapse in patients undergoing this challenging procedure.
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Affiliation(s)
- Lori Muffly
- Division of Blood and Marrow Transplantation, Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Emily C. Liang
- Division of Hematology and Oncology, Department of Medicine, University of Washington, Seattle, WA
| | - J. Gregory Dolan
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Intermountain Primary Children’s Hospital, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, UT
| | - Michael A. Pulsipher
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Intermountain Primary Children’s Hospital, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, UT
- Division of Pediatric Hematology and Oncology, Huntsman Cancer Institute, Spencer Fox Eccles School of Medicine at the University of Utah, Salt Lake City, UT
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Short NJ, Jabbour E, Kantarjian H. SOHO State of the Art Updates and Next Questions, Measurable Residual Disease in Philadelphia Chromosome-Positive Acute Lymphoblastic Leukemia. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2024; 24:427-432. [PMID: 38485650 DOI: 10.1016/j.clml.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 02/16/2024] [Indexed: 06/22/2024]
Abstract
Assessment of measurable residual disease (MRD) provides important prognostic information and can inform decision-making about appropriate consolidative therapy in patients with Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL). Many contemporary treatment protocols for Ph+ ALL achieve high rates of MRD negativity, and several analyses suggest that allogeneic hematopoietic stem cell transplant in first remission can be safely deferred in most patients who achieve MRD negativity by PCR for BCR::ABL1 within 3 months. Given the close association between achievement of MRD negativity and favorable long-term outcomes in Ph+ ALL, MRD response rates may aid in the evaluation of novel regimens, particularly in the absence of randomized data or robust survival data. While most studies in Ph+ ALL have used PCR for BCR::ABL1 to measure MRD and correlate with outcomes, this assay has several limitations. PCR or next-generation sequencing-based assays for immunoglobin or T-cell receptor (IG/TR) gene rearrangements may provide a more accurate assessment of clinically significant MRD in Ph+ ALL, particularly in patients with multilineage involvement of BCR::ABL1. Herein, we discuss the prognostic and therapeutic role of MRD in Ph+ ALL. We review the available methods of MRD assessment in Ph+ ALL and discuss the advantages of MRD assays that track IG/TR rearrangements rather than BCR::ABL1.
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Affiliation(s)
- Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
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8
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Abou Dalle I, Moukalled N, El Cheikh J, Mohty M, Bazarbachi A. Philadelphia-chromosome positive acute lymphoblastic leukemia: ten frequently asked questions. Leukemia 2024:10.1038/s41375-024-02319-2. [PMID: 38902471 DOI: 10.1038/s41375-024-02319-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 06/11/2024] [Accepted: 06/14/2024] [Indexed: 06/22/2024]
Abstract
Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) constitutes a distinctive cytogenetic entity associated with challenging outcomes, particularly in adult patients. Current upfront chemotherapy-tyrosine kinase inhibitor (TKI)-based therapies include first, second and third-generation TKIs that have revolutionized patient outcomes including molecular remission and overall survival. Chemotherapy-free regimens such as blinatumomab-dasatinib or blinatumomab-ponatinib offer exciting possibilities, yet challenges arise, particularly in preventing central nervous system relapse. Monitoring measurable residual disease is now a cornerstone particularly using next-generation sequencing (NGS)-Clonoseq for accurate assessment. Controversy regarding the ability to omit consolidation with allogeneic stem cell transplantation, specifically for patients achieving early molecular remission, is related to the excellent survival achieved with novel combinations in the upfront setting, however challenged by the lower disease control when transplant is utilized beyond first remission. Post-transplant maintenance introduces new dilemmas: the optimal TKI, dosing, and duration of therapy are open questions. Meanwhile, a myriad of new combinations and cellular therapies are used for relapsed Ph+ ALL, prompting us to unravel the optimal sequencing of these promising regimen. In this review, we delve into the breakthroughs and controversies in Ph+ ALL with ten commonly asked questions.
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Affiliation(s)
- Iman Abou Dalle
- Hematology-Oncology Division, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Nour Moukalled
- Hematology-Oncology Division, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Jean El Cheikh
- Hematology-Oncology Division, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mohamad Mohty
- Sorbonne University, Department of Clinical Hematology and Cellular Therapy, Saint-Antoine Hospital, AP-HP, INSERM UMRs 938, Paris, France
| | - Ali Bazarbachi
- Hematology-Oncology Division, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
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Pagliaro L, Chen SJ, Herranz D, Mecucci C, Harrison CJ, Mullighan CG, Zhang M, Chen Z, Boissel N, Winter SS, Roti G. Acute lymphoblastic leukaemia. Nat Rev Dis Primers 2024; 10:41. [PMID: 38871740 DOI: 10.1038/s41572-024-00525-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/01/2024] [Indexed: 06/15/2024]
Abstract
Acute lymphoblastic leukaemia (ALL) is a haematological malignancy characterized by the uncontrolled proliferation of immature lymphoid cells. Over past decades, significant progress has been made in understanding the biology of ALL, resulting in remarkable improvements in its diagnosis, treatment and monitoring. Since the advent of chemotherapy, ALL has been the platform to test for innovative approaches applicable to cancer in general. For example, the advent of omics medicine has led to a deeper understanding of the molecular and genetic features that underpin ALL. Innovations in genomic profiling techniques have identified specific genetic alterations and mutations that drive ALL, inspiring new therapies. Targeted agents, such as tyrosine kinase inhibitors and immunotherapies, have shown promising results in subgroups of patients while minimizing adverse effects. Furthermore, the development of chimeric antigen receptor T cell therapy represents a breakthrough in ALL treatment, resulting in remarkable responses and potential long-term remissions. Advances are not limited to treatment modalities alone. Measurable residual disease monitoring and ex vivo drug response profiling screening have provided earlier detection of disease relapse and identification of exceptional responders, enabling clinicians to adjust treatment strategies for individual patients. Decades of supportive and prophylactic care have improved the management of treatment-related complications, enhancing the quality of life for patients with ALL.
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Affiliation(s)
- Luca Pagliaro
- Department of Medicine and Surgery, University of Parma, Parma, Italy
- Translational Hematology and Chemogenomics (THEC), University of Parma, Parma, Italy
- Hematology and BMT Unit, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Sai-Juan Chen
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Daniel Herranz
- Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, USA
| | - Cristina Mecucci
- Department of Medicine, Hematology and Clinical Immunology, University of Perugia, Perugia, Italy
| | - Christine J Harrison
- Leukaemia Research Cytogenetics Group, Translational and Clinical Research Institute, Newcastle University Centre for Cancer, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Charles G Mullighan
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Ming Zhang
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Zhu Chen
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Nicolas Boissel
- Hôpital Saint-Louis, APHP, Institut de Recherche Saint-Louis, Université Paris Cité, Paris, France
| | - Stuart S Winter
- Children's Minnesota Cancer and Blood Disorders Program, Minneapolis, MN, USA
| | - Giovanni Roti
- Department of Medicine and Surgery, University of Parma, Parma, Italy.
- Translational Hematology and Chemogenomics (THEC), University of Parma, Parma, Italy.
- Hematology and BMT Unit, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy.
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10
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Short NJ, Kantarjian H, Jabbour E. Advances in the treatment of adults with newly diagnosed B-cell acute lymphoblastic leukemia: the role of frontline immunotherapy-based regimens. Leuk Lymphoma 2024:1-13. [PMID: 38850572 DOI: 10.1080/10428194.2024.2364043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 05/30/2024] [Indexed: 06/10/2024]
Abstract
Blinatumomab and inotuzumab ozogamicin (INO) are both active in relapsed/refractory B-cell acute lymphoblastic leukemia (ALL) and improve outcomes compared with conventional chemotherapy in this setting. Several prospective clinical trials have explored the use of these agents in adults with newly diagnosed B-cell ALL, with promising outcomes observed in younger and older adults and in both Philadelphia chromosome (Ph)-positive and Ph-negative ALL. These novel regimens result in high rates of deep measurable residual disease (MRD) negativity and may improve survival compared with chemotherapy-only approaches, allowing for less reliance on intensive chemotherapy and allogeneic hematopoietic stem cell transplantation (HSCT). This review discusses novel approaches to integrating INO and/or blinatumomab into frontline ALL regimens, including the potential role of chemotherapy-free regimens in some subgroups. The role of MRD monitoring is also discussed, including how this can inform decisions for consolidative allogeneic HSCT or investigational approaches with CD19 CAR T-cells.
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Affiliation(s)
- Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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11
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Chalandon Y, Rousselot P, Chevret S, Cayuela JM, Kim R, Huguet F, Chevallier P, Graux C, Thiebaut-Bertrand A, Chantepie S, Thomas X, Vincent L, Berthon C, Hicheri Y, Raffoux E, Escoffre-Barbe M, Plantier I, Joris M, Turlure P, Pasquier F, Belhabri A, Guepin GR, Blum S, Gregor M, Lafage-Pochitaloff M, Quessada J, Lhéritier V, Clappier E, Boissel N, Dombret H. Nilotinib with or without cytarabine for Philadelphia-positive acute lymphoblastic leukemia. Blood 2024; 143:2363-2372. [PMID: 38452207 DOI: 10.1182/blood.2023023502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 02/15/2024] [Accepted: 02/27/2024] [Indexed: 03/09/2024] Open
Abstract
ABSTRACT We previously demonstrated that a reduced-intensity chemotherapy schedule can safely replace hyper-CVAD (cyclophosphamide-vincristine-doxorubicin [Adriamycin]-dexamethasone) cycle 1 when combined with imatinib in adults with Philadelphia-positive acute lymphoblastic leukemia. In the present randomized GRAAPH-2014 trial, we used nilotinib and addressed the omission of cytarabine (Ara-C) in consolidation. The primary objective was the major molecular response (MMR) rate measured by BCR::ABL1 quantification after cycle 4 (end of consolidation). All patients were eligible for allogeneic stem cell transplant (SCT), whereas those in MMR could receive autologous SCT, followed by 2-year imatinib maintenance in both cases. After the enrollment of 156 of 265 planed patients, the data and safety monitoring board decided to hold the randomization because of an excess of relapse in the investigational arm. Among the 155 evaluable patients, 76 received Ara-C during consolidation (arm A) and 79 did not (arm B). Overall, 133 patients (85%) underwent SCT, 93 allogeneic and 40 autologous. The noninferiority end point regarding MMR was reached with 71.1% (arm A) and 77.2% (arm B) of patients reaching MMR. However, the 4-year cumulative incidence of relapse was higher in arm B compared with arm A (31.3% [95% confidence interval {CI}, 21.1%-41.9%] vs 13.2% [95% CI, 6.7%-21.9%]; P = .017), which translated to a lower relapse-free survival. With a median follow-up of 3.8 years, 4-year overall survival was 79.0% (95% CI, 70.6%-89.3%) in arm A vs 73.4% (95% CI, 63.9%-84.4%) in arm B (P = .35). Despite a noninferior rate of MMR, more relapses were observed when ARA-C was omitted without impact on survival. ClinicalTrials.gov ID, NCT02611492.
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Affiliation(s)
- Yves Chalandon
- Division of Hematology, Department of Oncology, University Hospital of Geneva and Medical School, University of Geneva, Geneva, Switzerland
- Swiss Group for Clinical Cancer Research, Bern, Switzerland
| | - Philippe Rousselot
- Division of Hematology, Centre Hospitalier de Versailles, Université Versailles Paris-Saclay, Le Chesnay, France
| | - Sylvie Chevret
- Division of Biostatistics, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Jean-Michel Cayuela
- Division of Hematology, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Institut de Recherche Saint-Louis, Paris, France
| | - Rathana Kim
- Division of Hematology, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Institut de Recherche Saint-Louis, Paris, France
| | - Françoise Huguet
- Division of Hematology, Institut Universitaire du Cancer de Toulouse-Oncopole, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | | | - Carlos Graux
- Université Catholique de Louvain, Centre Hospitalier Universitaire Université Catholique Louvain Namur (Godinne), Yvoir, Belgium
| | | | - Sylvain Chantepie
- Institut d'Hématologie de Basse Normandie, Centre Hospitalier Universitaire, Caen, France
| | - Xavier Thomas
- Division of Hematology, Hospices Civils de Lyon, Hôpital Lyon Sud, Pierre Bénite, France
| | - Laure Vincent
- Centre Hospitalier Universitaire de Montpellier/Département d'Hématologie Clinique, Hôpital Saint-Eloi, Montpellier, France
| | - Céline Berthon
- Division of Hematology, Hôpital Claude Huriez, Lille, France
| | | | - Emmanuel Raffoux
- Division of Hematology, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Institut de Recherche Saint-Louis, Paris, France
| | | | - Isabelle Plantier
- Service d'Hématologie Clinique, Centre Hospitalier Roubaix, Roubaix, France
| | | | - Pascal Turlure
- Hematology Department, Centre Hospitalier Régional Universitaire Limoges, Limoges, France
| | - Florence Pasquier
- Institut Gustave Roussy, Département Clinique d'Hématologie, INSERM UMR1170, Villejuif, France
| | - Amine Belhabri
- Centre Léon Bérard, Département d'Oncologie Médicale, Lyon, France
| | | | - Sabine Blum
- Swiss Group for Clinical Cancer Research, Bern, Switzerland
- Division of Hematology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Michael Gregor
- Swiss Group for Clinical Cancer Research, Bern, Switzerland
- Division of Hematology, Cantonal Hospital of Lucerne, Lucerne, Switzerland
| | - Marina Lafage-Pochitaloff
- Division of Hematology, Hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille University, Marseille, France
| | - Julie Quessada
- Division of Hematology, Hôpital de la Timone, Assistance Publique-Hôpitaux de Marseille, Aix-Marseille University, Marseille, France
| | - Véronique Lhéritier
- Group for Research on Adult Acute Lymphoblastic Leukemia, Hospices Civils de Lyon, Hôpital Lyon Sud, Pierre-Bénite, France
| | - Emmanuelle Clappier
- Division of Hematology, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Institut de Recherche Saint-Louis, Paris, France
| | - Nicolas Boissel
- Division of Hematology, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Institut de Recherche Saint-Louis, Paris, France
| | - Hervé Dombret
- Division of Hematology, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Institut de Recherche Saint-Louis, Paris, France
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Senapati J, Kantarjian H, Haddad FG, Short NJ, Welch MA, Jain N, Jabbour E. SOHO State of the Art Updates and Next Questions | Next Questions: Acute Lymphoblastic Leukemia. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2024; 24:333-339. [PMID: 38195323 DOI: 10.1016/j.clml.2023.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 12/20/2023] [Indexed: 01/11/2024]
Abstract
The integration of immune and targeted therapies into the treatment of acute lymphoblastic leukemia (ALL) has significantly improved outcomes, reduced the intensity and duration of chemotherapy, and the reliance on allogeneic stem cell transplantation (SCT). In younger patients with Philadelphia chromosome (Ph)-negative ALL, treatment with Hyper-CVAD and blinatumomab +/- inotuzumab has improved the 3-year overall survival (OS) to above 85%. In older patients, using less intensive chemotherapy (mini-Hyper-CVD) in combination with inotuzumab and blinatumomab has improved the 5-year OS rate to 50%. In Ph+ ALL, the chemotherapy-free combinations of blinatumomab and ponatinib (or dasatinib) have become a new standard of care resulting in 3-year OS of 85% to 90%. Because the methotrexate-cytarabine courses were omitted in the nonchemotherapy regimens, central nervous system (CNS) relapses were noted, particularly in patients with a WBC count > 70 × 109/L, requiring to consider increasing the number of prophylactic intrathecals (from 12 to 15) and perhaps developing a CNS risk-directed high-dose systemic chemotherapy. In relapsed/refractory ALL, a dose-dense regimen integrating blinatumomab and inotuzumab with low-intensity chemotherapy followed by consolidation with chimeric antigen receptor T-cell therapy is being investigated. The detection of measurable residual disease (MRD) following ALL therapy is predictive of disease relapse. Using next-generation sequencing allows the detection of MRD at 1 × 10-6 which was shown to be superior to multiparameter flow cytometry and polymerase chain reaction in predicting relapse, and could be used to decide on the duration of therapy or need to change therapy. Herein, we review the recent updates and areas of unmet need in ALL.
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Affiliation(s)
- Jayastu Senapati
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Fadi G Haddad
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mary Alma Welch
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX.
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Short NJ, Kantarjian H, Jabbour E. Is next-generation sequencing the future of measurable residual disease assays for Philadelphia chromosome-positive acute lymphoblastic leukemia? Expert Rev Hematol 2024; 17:189-191. [PMID: 38726703 DOI: 10.1080/17474086.2024.2354922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 05/09/2024] [Indexed: 05/15/2024]
Affiliation(s)
- Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Haddad FG, Jabbour E, Short NJ, Jain N, Kantarjian H. SOHO State of the Art Updates and Next Questions: Update on the Approach to Philadelphia Chromosome-Positive Acute Lymphoblastic Leukemia. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2024; 24:271-276. [PMID: 38185587 DOI: 10.1016/j.clml.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 12/06/2023] [Accepted: 12/08/2023] [Indexed: 01/09/2024]
Abstract
The outcome of Philadelphia chromosome (Ph)-positive acute lymphoblastic leukemia (ALL) has improved significantly following the introduction of the BCR::ABL1 tyrosine kinase inhibitors (TKIs). The addition of newer-generation and more potent TKIs resulted in higher rates of molecular responses and better survival. Achieving a complete molecular remission (CMR; disappearance of the BCR::ABL1 transcripts) within the first 3 months of therapy is an important endpoint in newly diagnosed Ph-positive ALL that identifies patients who have an excellent long-term survival and who may not need to receive an allogeneic hematopoietic stem cell transplantation (HSCT) in first complete remission (CR). Chemotherapy-free combinations with blinatumomab plus TKIs showed encouraging results with estimated 2 to 4 year overall survival (OS) rates of 80% to 90%. Treatment with blinatumomab and ponatinib resulted in a CMR rate of 84%, a 2-year event-free survival (EFS) of 78%, and a 2-year OS rate of 90%; only 1 patient underwent HSCT. The detection of measurable residual disease (MRD) is the most important factor predicting for disease relapse. Studies have shown that the next-generation sequencing (NGS) assay is more sensitive than RT-PCR for the detection of MRD in Ph-positive ALL. Approximately 15% to 30% of patients who achieve NGS MRD negativity at a sensitivity of 1 × 10-6 may still have detectable BCR::ABL1 transcripts by RT-PCR. Achieving NGS MRD negativity can also identify patients who may have durable remissions with a low risk of relapse. Herein, we discuss the current approach to the management of adults with Ph-positive ALL, the role of HSCT, MRD monitoring, and future therapies.
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Affiliation(s)
- Fadi G Haddad
- Department of Leukemia, The University of Texas MD Anderson Cancer Center,1515 Holcombe Blvd. Box 428, Houston, Texas 77030. USA
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center,1515 Holcombe Blvd. Box 428, Houston, Texas 77030. USA.
| | - Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center,1515 Holcombe Blvd. Box 428, Houston, Texas 77030. USA
| | - Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center,1515 Holcombe Blvd. Box 428, Houston, Texas 77030. USA
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center,1515 Holcombe Blvd. Box 428, Houston, Texas 77030. USA
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15
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Maia Moço L, Fraga A, Maia I, Almeida M. Philadelphia Chromosome-Positive Acute Lymphoblastic Leukemia in Children: A Retrospective Cohort Study at a Pediatric Oncology Center. Cureus 2024; 16:e54154. [PMID: 38496108 PMCID: PMC10940871 DOI: 10.7759/cureus.54154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2024] [Indexed: 03/19/2024] Open
Abstract
Background and objective Philadelphia chromosome-positive acute lymphoblastic leukemia (ALL Ph+) is quite rare among pediatric patients. Its management has undergone significant changes in the past few years, leading to some variability in how it is approached. At the Portuguese Oncology Institute of Porto (IPOP), a tertiary oncological center, the standard of care has been aligned with the guidelines proposed by the European intergroup study of post-induction treatment of ALL Ph+ (EsPhALL). In this study, we aimed to examine the experience and outcomes related to the treatment of pediatric patients with ALL Ph+ at IPOP. Methods This retrospective cohort study involved pediatric patients diagnosed with ALL Ph+ at IPOP between January 2008 and December 2022 and analyzed their outcomes. Results A total of 14 patients were included. IKFZ1 was altered in five patients (out of nine in whom it was searched). Five patients were treated according to EsPhALL 2004, which involved starting imatinib later in a discontinuous manner [resulting in both five-year overall survival (OS) and progression-free survival (PFS) of 60%]. The EsPhALL 2010 (preconizing a continuous imatinib regimen instead) was employed in three patients, with a five-year OS and PFS of 66.7%. All children mentioned above received cranial irradiation therapy (CRT). Finally, six were treated according to the EsPhALL 2015, which stopped including CRT in its backbone. The five-year OS was 100%, whereas every patient progressed with an increase in BCR::ABL1 levels greater than 1-log. Moreover, until 2015, all patients had been recommended to undergo allogeneic hematopoietic stem cell transplantation (alloHSCT). However, since 2015, alloHSCT has been exclusively reserved for relapsed/refractory (R/R) disease or poor responders with positive measurable residual disease (MRD). In total, alloHSCT was performed in nine patients. Conclusions Although initially associated with a poor prognosis, the ALL Ph+ paradigm is drastically shifting. Further studies will hopefully clarify the outcomes in this population and help understand the role of central nervous system (CNS) prophylaxis, alloHSCT, and MRD quantification.
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Affiliation(s)
- Leonardo Maia Moço
- Hematology and Bone Marrow Transplantation, Instituto Português de Oncologia do Porto Francisco Gentil, Porto, PRT
| | - Ana Fraga
- Pediatric Oncology, Instituto Português de Oncologia do Porto Francisco Gentil, Porto, PRT
| | - Iris Maia
- Pediatric Oncology, Instituto Português de Oncologia do Porto Francisco Gentil, Porto, PRT
| | - Marta Almeida
- Pediatric Oncology, Instituto Português de Oncologia do Porto Francisco Gentil, Porto, PRT
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Silva W, Rego E. How to Manage Philadelphia-Positive Acute Lymphoblastic Leukemia in Resource-Constrained Settings. Cancers (Basel) 2023; 15:5783. [PMID: 38136329 PMCID: PMC10741425 DOI: 10.3390/cancers15245783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 10/17/2023] [Accepted: 10/20/2023] [Indexed: 12/24/2023] Open
Abstract
Recent studies have indicated that more than half of adult patients newly diagnosed with Ph+ ALL can now achieve a cure. However, determining the most suitable protocol for less-resourced settings can be challenging. In these situations, we must consider the potential for treatment toxicity and limited access to newer agents and alloSCT facilities. Currently, it is advisable to use less intensive induction regimens for Ph+ ALL. These regimens can achieve high rates of complete remission while causing fewer induction deaths. For consolidation therapy, chemotherapy should remain relatively intensive, with careful monitoring of the BCR-ABL1 molecular transcript and minimal residual disease. AlloSCT may be considered, especially for patients who do not achieve complete molecular remission or have high-risk genetic abnormalities, such as IKZF1-plus. If there is a loss of molecular response, it is essential to screen patients for ABL mutations and, ideally, change the TKI therapy. The T315I mutation is the most common mechanism for disease resistance, being targetable to ponatinib. Blinatumomab, a bispecific antibody, has shown significant synergy with TKIs in treating this disease. It serves as an excellent salvage therapy, aside from achieving outstanding results when incorporated into the frontline.
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Affiliation(s)
- Wellington Silva
- Discipline of Hematology, Hospital das Clínicas da Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 05403-010, Brazil;
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Molina JC. Leveraging health care technology to improve health outcomes and reduce outcome disparities in AYA leukemia. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:573-580. [PMID: 38066875 PMCID: PMC10727055 DOI: 10.1182/hematology.2023000510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Significant improvements have occurred for adolescent and young adult (AYA) B-cell acute lymphoblastic leukemia (B-ALL) patients following the widespread adoption of "pediatric-inspired" treatment regimens for AYA patients cared for in adult oncology settings. However, for AYA patients, aged 15 to 39, an outcomes gap remains in B-ALL, necessitating the incorporation of novel therapies into up-front treatment regimens. As a result, clinical trial enrollment remains the current standard of care for AYA B-ALL across disease subtypes when available and accessible. Currently, several up-front trials are looking to incorporate the use of inotuzumab, blinatumomab, and chimeric antigen receptor T-cell therapy into existing chemotherapy backbones for AYA patients, as well as tyrosine kinase inhibitors for both Philadelphia-positive (Ph+) and Ph-like B-ALL. In addition to ongoing attempts to improve up-front treatments by incorporating immunotherapy and targeted approaches, the increased use of next generation sequencing for measurable residual disease evaluation has led to superior risk-stratification and a decreased need to pursue consolidative hematopoietic stem cell transplantation during the first complete remission for many patients.
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Affiliation(s)
- John C. Molina
- Leukemia Program, Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH
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18
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Short NJ, Senapati J, Jabbour E. An Update on the Management of Advanced Phase Chronic Myeloid Leukemia. Curr Hematol Malig Rep 2023; 18:234-242. [PMID: 37651057 DOI: 10.1007/s11899-023-00709-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2023] [Indexed: 09/01/2023]
Abstract
PURPOSE OF REVIEW While most patients with chronic myeloid leukemia (CML) present in a chronic phase and are expected to have a normal life expectancy, some patients present with or progress to a more aggressive accelerated phase (AP) or blast phase (BP) of CML. Herein, we discuss the diagnostic considerations of advanced phase CML and review its contemporary management. RECENT FINDINGS Later-generation, more potent BCR::ABL1 tyrosine kinase inhibitors (TKIs) such as ponatinib may result in superior outcomes in patients with advanced phase CML. For CML-BP, combination approaches directed against the blast immunophenotype appear superior to TKI monotherapy. The role of allogeneic stem cell transplantation is controversial in CML-AP but has consistently been shown to improve outcomes for patients with CML-BP. Advanced phase CML, particularly CML-BP, remains a poor risk subtype of CML. However, novel combination approaches using later-generation TKIs are being explored in clinical trials and may lead to improved outcomes.
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Affiliation(s)
- Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Unit 428, 1515 Holcombe Boulevard, Houston, TX, 77030, USA.
| | - Jayastu Senapati
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Unit 428, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Unit 428, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
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Rahman ZA, Kebriaei P. SOHO State of the Art Updates and Next Questions | Philadelphia Chromosome Positive Acute Lymphoblastic Leukemia in Adults: Therapeutic Options and Challenges in 2023. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:779-785. [PMID: 37438208 DOI: 10.1016/j.clml.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 06/23/2023] [Indexed: 07/14/2023]
Abstract
The therapeutic landscape of Philadelphia chromosome positive acute lymphoblastic leukemia (ALL) for adults has dramatically changed over the past 2 decades; the emergence of newer generations of tyrosine kinase inhibitors and incorporation of targeted immunotherapies into front-line therapy have significantly improved outcomes to the point where an argument can be made that this entity may no longer be considered a high-risk ALL subgroup. In this review article, we discuss different front-line regimens (both intensive and deintensified regimens including chemotherapy-free regimens). We also review disease monitoring strategies, discuss the role of allogeneic hematopoietic stem cell transplantation, and discuss the rapidly changing therapeutic landscape for patients with relapsed disease.
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Affiliation(s)
- Zaid Abdel Rahman
- Department of Stem Cell Transplantation and Cellular Therapy, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Partow Kebriaei
- Department of Stem Cell Transplantation and Cellular Therapy, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX.
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Zuna J, Hovorkova L, Krotka J, Winkowska L, Novak Z, Sramkova L, Stary J, Trka J, Cazzaniga G, Cario G, Zaliova M. Posttreatment positivity of BCR::ABL1 in acute lymphoblastic leukemia: Should we keep track? Am J Hematol 2023; 98:E269-E271. [PMID: 37449465 DOI: 10.1002/ajh.27022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 06/26/2023] [Accepted: 06/30/2023] [Indexed: 07/18/2023]
Affiliation(s)
- Jan Zuna
- CLIP (Childhood Leukaemia Investigation Prague), Prague, Czech Republic
- Department of Pediatric Hematology and Oncology, Second Faculty of Medicine, Charles University, Prague, Czech Republic
- University Hospital Motol, Prague, Czech Republic
| | - Lenka Hovorkova
- CLIP (Childhood Leukaemia Investigation Prague), Prague, Czech Republic
- Department of Pediatric Hematology and Oncology, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Justina Krotka
- CLIP (Childhood Leukaemia Investigation Prague), Prague, Czech Republic
- Department of Pediatric Hematology and Oncology, Second Faculty of Medicine, Charles University, Prague, Czech Republic
- University Hospital Motol, Prague, Czech Republic
| | - Lucie Winkowska
- CLIP (Childhood Leukaemia Investigation Prague), Prague, Czech Republic
- Department of Pediatric Hematology and Oncology, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Zbynek Novak
- Department of Pediatrics, Faculty of Medicine and Dentistry, Palacky University and University Hospital Olomouc, Olomouc, Czech Republic
| | - Lucie Sramkova
- Department of Pediatric Hematology and Oncology, Second Faculty of Medicine, Charles University, Prague, Czech Republic
- University Hospital Motol, Prague, Czech Republic
| | - Jan Stary
- Department of Pediatric Hematology and Oncology, Second Faculty of Medicine, Charles University, Prague, Czech Republic
- University Hospital Motol, Prague, Czech Republic
| | - Jan Trka
- CLIP (Childhood Leukaemia Investigation Prague), Prague, Czech Republic
- Department of Pediatric Hematology and Oncology, Second Faculty of Medicine, Charles University, Prague, Czech Republic
- University Hospital Motol, Prague, Czech Republic
| | - Giovanni Cazzaniga
- Tettamanti Research Center, Department of Pediatrics, University of Milano-Bicocca/Fondazione Tettamanti, Monza, Italy
| | - Gunnar Cario
- Department of Pediatrics, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Marketa Zaliova
- CLIP (Childhood Leukaemia Investigation Prague), Prague, Czech Republic
- Department of Pediatric Hematology and Oncology, Second Faculty of Medicine, Charles University, Prague, Czech Republic
- University Hospital Motol, Prague, Czech Republic
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Saliba AN, Foà R. Minimal residual disease in Philadelphia-positive acute lymphoblastic leukemia: Maximizing the clinical yield of testing. Am J Hematol 2023. [PMID: 37314420 DOI: 10.1002/ajh.26993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 06/02/2023] [Indexed: 06/15/2023]
Affiliation(s)
| | - Robin Foà
- Hematology, Department of Translational and Precision Medicine, "Sapienza" University, Rome, Italy
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