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Gökbuget N, Boissel N, Chiaretti S, Dombret H, Doubek M, Fielding A, Foà R, Giebel S, Hoelzer D, Hunault M, Marks DI, Martinelli G, Ottmann O, Rijneveld A, Rousselot P, Ribera J, Bassan R. Management of ALL in adults: 2024 ELN recommendations from a European expert panel. Blood 2024; 143:1903-1930. [PMID: 38306595 DOI: 10.1182/blood.2023023568] [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: 12/19/2023] [Revised: 01/19/2024] [Accepted: 01/21/2024] [Indexed: 02/04/2024] Open
Abstract
ABSTRACT Experts from the European Leukemia Net (ELN) working group for adult acute lymphoblastic leukemia have identified an unmet need for guidance regarding management of adult acute lymphoblastic leukemia (ALL) from diagnosis to aftercare. The group has previously summarized their recommendations regarding diagnostic approaches, prognostic factors, and assessment of ALL. The current recommendation summarizes clinical management. It covers treatment approaches, including the use of new immunotherapies, application of minimal residual disease for treatment decisions, management of specific subgroups, and challenging treatment situations as well as late effects and supportive care. The recommendation provides guidance for physicians caring for adult patients with ALL which has to be complemented by regional expertise preferably provided by national academic study groups.
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Affiliation(s)
- Nicola Gökbuget
- Department of Medicine II, Hematology/Oncology, Goethe University, University Hospital, Frankfurt, Germany
| | - Nicolas Boissel
- Hospital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Sabina Chiaretti
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Hervé Dombret
- Leukemia Department, University Hospital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Saint-Louis Research Institute, Université Paris Cité, Paris, France
| | - Michael Doubek
- Department of Internal Medicine-Hematology and Oncology, University Hospital Brno, Brno, Czech Republic
| | | | - Robin Foà
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Sebastian Giebel
- Department of Bone Marrow Transplantation and Onco-Hematology, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | - Dieter Hoelzer
- Department of Medicine II, Hematology/Oncology, Goethe University, University Hospital, Frankfurt, Germany
| | - Mathilde Hunault
- Maladies du Sang University Hospital of Angers, FHU Goal, INSERM, National Centre for Scientific Research, Angers, France
| | - David I Marks
- University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| | - Giovanni Martinelli
- IRCCS Istituto Romagnolo per lo Studio dei Tumori Dino Amadori, Meldola, Italy
| | - Oliver Ottmann
- Division of Cancer and Genetics, Cardiff University School of Medicine, Cardiff, United Kingdom
| | | | - Philippe Rousselot
- Clinical Hematology Department, Centre Hospitalier de Versailles, Université Paris-Saclay, Versailles, France
| | - Josep Ribera
- Clinical Hematology Department, Institut Catala d'Oncologia Hospital Germans Trias I Pujol, Josep Carreras Research Institute, Badalona, Spain
| | - Renato Bassan
- Division of Hematology, Ospedale dell'Angelo, Mestre-Venice, Italy
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2
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Shimony S, Luskin MR. SOHO State of the Art Updates and Next Questions | Approach to Older Adults With Phildadelphia-Chromosome Negative Acute Lymphoblastic Leukemia. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2024; 24:133-140. [PMID: 38102012 DOI: 10.1016/j.clml.2023.10.011] [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: 10/01/2023] [Revised: 10/27/2023] [Accepted: 10/27/2023] [Indexed: 12/17/2023]
Abstract
Philadelphia-chromosome-negative (Ph-neg) acute lymphoblastic leukemia (ALL) has historically been associated with poor outcomes in older patients due to adverse disease biology, as well as inferior tolerance of conventional chemotherapy. Fortunately, novel therapies, including inotuzumab ozogamicin, blinatumomab, and venetoclax, are now being incorporated into first-line therapy to improve efficacy and decrease toxicity of initial therapy. Inotuzumab ozogamicin, alone or in combination with low intensity chemotherapy, appears to be best suited for the induction phase of treatment due to efficacy in the setting of high tumor burden. In contrast, blinatumomab may be best suited for consolidation due to superior efficacy in setting of morphologic remission, with or without measurable residual disease (MRD). Venetoclax is being investigated in combination with chemotherapy and can be used for treatment of older adults with both B-cell and T-cell ALL. Ongoing trials incorporating inotuzumab, blinatumomab, and venetoclax demonstrate high rates of MRD-negative complete remissions with low early mortality. Long-term outcomes have been less favorable so far, with several trials reporting nonrelapse mortality during subsequent treatment. Unanswered questions remain regarding the optimal treatment of older adults with Ph-neg ALL, including central nervous system (CNS) prophylaxis, the most appropriate consolidation to minimize toxicity without compromising efficacy, and the role of transplant and cellular therapy. T-cell ALL remains an area of unmet need and effort is required to ensure that therapeutic advances benefit all populations equitably. In this manuscript, we review current data and ongoing trials regarding the treatment of older adults with Ph-neg ALL and define topics for further research.
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Affiliation(s)
- Shai Shimony
- Dana-Farber Cancer Institute, Boston, MA; Rabin Medical Center and Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
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3
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Luskin MR. SOHO State of the Art Updates and Next Questions: Mini-Hyper-CVD Combinations for Older Adults: Results of Recent Trials and a Glimpse into the Future. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:436-441. [PMID: 34996739 DOI: 10.1016/j.clml.2021.12.005] [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: 09/07/2021] [Revised: 11/20/2021] [Accepted: 12/06/2021] [Indexed: 06/14/2023]
Abstract
Acute lymphoblastic leukemia (ALL) is an aggressive blood cancer that affects both children and adults. Although the majority of children diagnosed with ALL are now cured and outcomes are improving for younger adults, older adults diagnosed with ALL usually succumb to their disease. Traditional chemotherapy regimens are poorly tolerated and ineffective in most older adults. Recently, novel chemotherapy agents such as inotuzumab ozogamicin and venetoclax have been successfully combined with dose reduced chemotherapy (mini-hyper-CVD) with promising results. Further study is needed to define the optimal combination and sequencing of novel agents and chemotherapy for different patient populations. This review discusses the challenge of treating older adults with traditional chemotherapy, experience to date with novel agents in combination with mini-hyper-CVD, as well as future directions and unanswered questions.
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4
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Salter B, Burns I, Fuller K, Eshaghpour A, Lionel AC, Crowther M. Tyrosine kinase inhibitors and tumor lysis syndrome in hematologic malignancies: A systemic review. Eur J Haematol 2022; 109:166-181. [PMID: 35531791 DOI: 10.1111/ejh.13786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/28/2022] [Accepted: 05/03/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Effective treatments for hematologic malignancies include therapies that target tyrosine kinase (TK) signaling pathways. Tumor lysis syndrome (TLS) is an oncologic emergency that can occur due to rapid turnover following the initiation of treatments for hematologic malignancy. The incidence of TLS is under-reported and it is unclear as to whether TK inhibitors (TKIs) are associated with TLS. OBJECTIVE To conduct a systematic review to determine the incidence of TLS with TKIs. METHODS A search was performed using EMBASE, MEDLINE, and Web of Science electronic databases, as well as a manual search of the American Society of Hematology and American Society of Clinical Oncology abstract databases. Keywords included: "tumor lysis syndrome," "tyrosine kinase inhibitors," "lymphoma," and "leukemia." RESULTS We identified a total of 57 publications that commented on the incidence of TLS with TKIs for hematologic malignancy. Thirty-nine of those publications reported TLS as an adverse event. TLS was described as an adverse event among essentially all the subclasses of TKIs that are used to manage hematologic malignancies. CONCLUSION The overall number of articles commenting on TLS as an adverse event is sparse and there needs to be more transparency regarding the incidence of TLS when employing newer targeted therapies. Physicians should consider the risk of TLS on an individual basis and the added risk of TLS when using TKIs to treat hematologic malignancy.
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Affiliation(s)
| | - Ian Burns
- McMaster University, Hamilton, Ontario, Canada
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5
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Curran E, Muffly L, Luskin MR. Innovative Approaches to the Management of Acute Lymphoblastic Leukemia Across the Age Spectrum. Am Soc Clin Oncol Educ Book 2022; 42:1-11. [PMID: 35503981 DOI: 10.1200/edbk_349647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Adults compose nearly half of all patients diagnosed with acute lymphoblastic leukemia (ALL) and historically have had poor survival compared with pediatric patients. Recently approved therapies, such as monoclonal antibodies, CAR T-cell constructs, and next-generation tyrosine kinase inhibitors, have improved survival in relapsed and refractory ALL, and studies are now examining incorporating these treatments and others into the upfront setting. In adolescent and young adult patients, use of pediatric-based regimens has already improved survival compared with historical controls, and the addition of monoclonal antibodies, such as inotuzumab ozogamicin and blinatumomab, may further enhance this survival benefit. In older adults, approaches have centered on minimizing conventional chemotherapy to decrease toxicity by incorporating monoclonal antibodies and other novel therapies to increase efficacy. With the addition of tyrosine kinase inhibitors to chemotherapy for patients with Philadelphia chromosome-positive ALL, survival of this once poor-prognosis ALL subtype now approaches or exceeds outcomes of other subtypes of adult ALL. Further refinements in the backbone treatment regimen and optimal consolidation approaches will likely improve survival further. Although allogeneic hematopoietic stem cell transplant was previously routinely used as consolidation for adults with ALL, incorporation of measurable residual disease and other risk stratification strategies has enabled better identification of patients who will benefit from allogeneic hematopoietic stem cell transplant. Ongoing clinical trials investigating these approaches will continue the evolution of treatment approaches for adults with ALL, with further improvement in outcomes anticipated.
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Affiliation(s)
- Emily Curran
- University of Cincinnati, Division of Hematology and Oncology, Department of Internal Medicine and Department of Pediatrics, Cincinnati, OH
| | - Lori Muffly
- Division of Blood and Marrow Transplantation and Cellular Therapy, Department of Internal Medicine, Stanford University, Stanford, CA
| | - Marlise R Luskin
- Dana-Farber Cancer Institute, Division of Leukemia, Department of Medical Oncology, Boston, MA
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Luskin MR. Acute lymphoblastic leukemia in older adults: curtain call for conventional chemotherapy? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:7-14. [PMID: 34889389 PMCID: PMC8791151 DOI: 10.1182/hematology.2021000226] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Unlike younger adults with acute lymphoblastic leukemia (ALL), older adults are rarely cured due to a combination of intrinsic disease resistance and treatment-related toxicities. Novel therapeutics such as inotuzumab ozogamicin, blinatumomab, venetoclax, and ABL kinase inhibitors have high activity in ALL and are well tolerated by older adults. Frontline treatment regimens for older adults using novel therapeutics with reduction or omission of conventional chemotherapy are being developed with early results demonstrating high remission rates and lower toxicity, but long-term efficacy and toxicity data are lacking. Collaboration between academic and pharmaceutical stakeholders is needed to develop clinical trials to define the optimal treatment regimens for older adults with ALL.
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Affiliation(s)
- Marlise R. Luskin
- Correspondence Marlise R. Luskin, Dana-Farber Cancer Institute, Department of Medical Oncology, Division of Leukemia, 450 Brookline Ave, Dana 2056, Boston, MA 02215; e-mail:
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7
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Bazarbachi AH, Labopin M, Kröger N, Brecht A, Blaise D, Clausen J, Fanin R, Einsele H, Cavanna L, Itäla-Remes M, Bulabois CE, Kündgen L, Martin H, Schmid C, Wagner-Drouet EM, Alakel N, Bazarbachi A, Savani B, Nagler A, Mohty M. Predictive Factors for Outcome of First Allogeneic Transplant for Elderly Patients With Acute Lymphoblastic Leukemia. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 21:831-840. [PMID: 34373225 DOI: 10.1016/j.clml.2021.07.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 07/08/2021] [Accepted: 07/09/2021] [Indexed: 11/15/2022]
Abstract
INTRODUCTION/BACKGROUND The treatment of acute lymphoblastic leukemia (ALL) in patients older than 70 is extremely challenging with dismal outcome. Allogeneic stem cell transplantation (alloHCT) has seen many advancements in the last decades showing benefits in younger ALL patients, but this treatment modality is decreasingly used with increasing age due to high treatment-related mortality. PATIENTS AND METHODS We identified 84 ALL patients 70 to 84 years old allografted In 2002 to 2019 from a matched related (23%), unrelated (58%), haploidentical (17%), or cord blood (2%) donor at EBMT participating centers with a median follow-up of 23 months. RESULTS The 2-year relapse incidence (RI) and non-relapse mortality were 37% and 28%, respectively, and 2-year leukemia-free survival (LFS), overall survival (OS) and GVHD-free, relapse-free survival (GRFS) were 35%, 39% and 23%, respectively. The strongest predictor of outcome was disease status at transplant whereby patients in first complete remission (CR1) had >50% 2-year OS, reflected in multivariate analysis (MVA) with significant improvement in RI, LFS, and GRFS (HR 0.23, 0.49, and 0.54, respectively). Furthermore, karnofsky score ≥90 reflective of good functional status positively influenced non-relapse mortality in both univariate and MVA (HR 0.37), and interestingly, donor CMV positivity appeared to negatively affect RI, LFS and OS in univariate analysis and RI in MVA (HR 2.87). CONCLUSION Our data suggest that alloHCT is an option for elderly ALL patients, particularly those carefully selected and transplanted in CR1 especially if failed or without access to novel non-chemotherapy-based approaches.
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Affiliation(s)
- Abdul Hamid Bazarbachi
- Department of Clinical Hematology and Cellular Therapy, Saint Antoine Hospital, INSERM UMR 938, Sorbonne University, Paris, France; Department of Internal Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, New York, NY
| | - Myriam Labopin
- Department of Clinical Hematology and Cellular Therapy, Saint Antoine Hospital, INSERM UMR 938, Sorbonne University, Paris, France
| | - Nicolaus Kröger
- Department for Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Arne Brecht
- German Clinic for Diagnistics, KMT Zentrum, Wiesbaden, Germany
| | - Didier Blaise
- Departement D'Hematologie, Programme de Transplantation et de Therapie Cellulaire, Centre de Recherche en Cancerologie de Marseille, Institut Paoli Calmettes, Marseille, France
| | - Johannes Clausen
- Department of Internal Medicine I, Ordensklinikum Linz -Elisabethinen, Linz, Austria
| | - Renato Fanin
- Clinica Ematologica, Azienda sanitaria Universitaria Integrata, DAMe, Università di Udine, Udine, Italy
| | - Herman Einsele
- Department of Internal Medicine II, University Hospital Würzburg, Germany
| | - Luigi Cavanna
- Departments of Oncology-Hematology, Ospedale "G. da Saliceto", Piacenza, Italy.
| | - Maija Itäla-Remes
- Stem Cell Transplantation Unit, HUCH Comprehensive Cancer Center, Helsinki, Finland
| | | | - Lukas Kündgen
- Department of Hematology and Oncology, Städtisches Klinikum Karlsruhe, Karlsruhe, Germany
| | - Hans Martin
- Department of Medicine II, Goethe University, Frankfurt, Germany
| | - Christof Schmid
- Department of Internal Medicine I, University Hospital Cologne, Cologne, Germany
| | - Eva Maria Wagner-Drouet
- 3rd Medical Department, Hematology, Oncology and Pneumology, University Medical Center Mainz, Mainz, Germany
| | - Nael Alakel
- Medizinische Klinik und Poliklinik I, Universitätsklinikum, Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Ali Bazarbachi
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Bipin Savani
- Vanderbilt University Medical Center, Nashville, TN
| | - Arnon Nagler
- Hematology Division, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Mohamad Mohty
- Department of Clinical Hematology and Cellular Therapy, Saint Antoine Hospital, INSERM UMR 938, Sorbonne University, Paris, France.
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Zhu F, Wei G, Zhang M, Zhao H, Wu W, Yang L, Hu Y, Huang H. Factors Associated with Costs in Chimeric Antigen Receptor T-Cell Therapy for Patients with Relapsed/Refractory B-Cell Malignancies. Cell Transplant 2021; 29:963689720919434. [PMID: 32314613 PMCID: PMC7444226 DOI: 10.1177/0963689720919434] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background: Chimeric antigen receptor T cells (CAR-Ts) constitute a novel therapeutic strategy for relapsed/refractory B-cell malignancies. CAR-T therapy has been extensively applied in the clinical setting; however, few systematic studies have evaluated the cost of CAR-T treatment. This study was conducted to evaluate the total cost and cost structure of CAR-T therapy and identify potential risk factors leading to increased costs. Methods: We identified the associated risk factors in 89 patients in a phase 1/2 study. The cohort included patients with acute lymphoblastic leukemia (ALL, n = 55) and non-Hodgkin’s lymphoma (NHL, n = 34). Results: Overall, the treatment of the ALL cohort was costlier than that of the NHL cohort (P < 0.001). Furthermore, in the ALL cohort, it was costlier to treat patients with a high tumor burden (P < 0.001), high cytokine release syndrome (CRS) grade (P < 0.001), and complications of infection after CAR-T cell infusion (CTI) in the whole cohort (P = 0.013) than patients with a low tumor burden, with low CRS grade, and without infection, respectively. CRS grade and length of stay (P ≤ 0.005) were independent risk factors associated with the total cost in both the ALL and NHL cohorts during CAR-T therapy. A high tumor burden, duration of fever, and treatment with tocilizumab were independent risk factors associated with the total cost in the ALL cohort (P < 0.05). Conclusions: CAR-T treatment should be extended to patients with a low tumor burden or patients in a state of complete remission, and a corticosteroid approach, as opposed to tocilizumab, may reduce costs.
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Affiliation(s)
- Feng Zhu
- Department of Hematology, Zhoushan Hospital, China.,Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Both the authors contributed equally to this work
| | - Guoqing Wei
- Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China.,Institute of Hematology, Zhejiang University, Hangzhou, China.,Both the authors contributed equally to this work
| | - Mingming Zhang
- Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China.,Institute of Hematology, Zhejiang University, Hangzhou, China
| | - Houli Zhao
- Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China.,Institute of Hematology, Zhejiang University, Hangzhou, China
| | - Wenjun Wu
- Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China.,Institute of Hematology, Zhejiang University, Hangzhou, China
| | - Luxin Yang
- Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China.,Institute of Hematology, Zhejiang University, Hangzhou, China
| | - Yongxian Hu
- Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China.,Institute of Hematology, Zhejiang University, Hangzhou, China
| | - He Huang
- Bone Marrow Transplantation Center, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China.,Institute of Hematology, Zhejiang University, Hangzhou, China
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9
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Schwartz M, Wieduwilt MJ. New approaches to the treatment of older adults with acute lymphoblastic leukemia. Semin Hematol 2020; 57:122-129. [PMID: 33256901 DOI: 10.1053/j.seminhematol.2020.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 08/25/2020] [Accepted: 09/03/2020] [Indexed: 11/11/2022]
Abstract
Outcomes for older adults (defined here as ≥55-65 years old) with acute lymphoblastic leukemia (ALL) are poor, with long-term survival less than 20%. Pediatric chemotherapy regimens produce long-term cure rates of 80% to 90% in children and 60% to 70% in adolescents and young adults with Ph-negative ALL, however, tolerability of intensive chemotherapy becomes problematic with advanced age due to comorbidities and reduced tolerability of chemotherapy leading to high rates of treatment-related mortality. For older adults with Ph-positive ALL, BCR-ABL1-directed tyrosine kinase inhibitors in combination with corticosteroids or chemotherapy produce deep remissions with low treatment-related toxicity but optimal postremission therapy is not known. New therapeutic approaches for older adults with ALL involve integration of the novel targeted agents including monoclonal antibody-based therapy with blinatumomab and inotuzumab ozogamicin in the frontline. Ongoing studies will ideally define optimal combinations and sequencing of novel agents with or without chemotherapy, tyrosine kinase inhibitors, and/or corticosteroids to maximize efficacy while avoiding treatment-related death. Anti-CD19 chimeric antigen receptor modified T cells are a promising modality, with high rates of remission and minimal residual disease negativity achieved in early phase trials for adults with relapsed/refractory B-cell ALL but the tolerability of chimeric antigen receptor modified T cell therapies in older adults is yet to be well defined. Advances in minimal residual disease detection have helped to effectively stratify adults in complete response in terms of relapse risk and predicted relative benefit for allogeneic hematopoietic cell transplant. For older adults with ALL in complete response at high risk for relapse for whom myeloablative conditioning is predicted to result in excessive transplant-related mortality, reduced-intensity conditioning allogeneic hematopoietic cell transplant is a less toxic approach for providing a graft-versus-leukemia effect and long-term disease control.
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Affiliation(s)
- Marc Schwartz
- Division of Hematology/Oncology, University of California, San Diego, CA
| | - Matthew J Wieduwilt
- Division of Blood and Marrow Transplantation, Moores Cancer Center, University of California, San Diego, CA.
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10
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Luskin MR, DeAngelo DJ. Mini-Hyper-CVD Combinations for Older Adults: Results of Recent Trials and a Glimpse into the Future. CLINICAL LYMPHOMA MYELOMA AND LEUKEMIA 2020; 20 Suppl 1:S44-S47. [DOI: 10.1016/s2152-2650(20)30458-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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11
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Kamphuis JAM, Linschoten M, Cramer MJ, Gort EH, van Rhenen A, Asselbergs FW, Doevendans PA, Teske AJ. Cancer Therapy-Related Cardiac Dysfunction of Nonanthracycline Chemotherapeutics: What Is the Evidence? JACC: CARDIOONCOLOGY 2019; 1:280-290. [PMID: 34396190 PMCID: PMC8352330 DOI: 10.1016/j.jaccao.2019.09.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 08/26/2019] [Accepted: 09/04/2019] [Indexed: 11/07/2022]
Abstract
Cancer therapy–related cardiac dysfunction (CTRCD) is one of the most concerning cardiovascular side effects of cancer treatment. Important reviews within the field of cardio-oncology have described various agents to be associated with a high risk of CTRCD, including mitomycin C, ifosfamide, vincristine, cyclophosphamide, and clofarabine. The aim of this study was to provide insight into the data on which these incidence rates are based. We observed that the reported cardiotoxicity of mitomycin C and ifosfamide is based on studies in which most patients received anthracyclines, complicating the interpretation of their association with CTRCD. The high incidence of vincristine-induced cardiotoxicity is based on an incorrect interpretation of a single study. Incidence rates of clofarabine remain uncertain due to a lack of cardiac screening in clinical trials. The administration of high-dose cyclophosphamide (>1.5 g/m2/day) is associated with a high incidence of CTRCD. Based on our findings, a critical re-evaluation of the cardiotoxicity of these agents is warranted. CTRCD is one of the most concerning cardiovascular side effects of anticancer treatment. Mitomycin C, ifosfamide, cyclophosphamide, clofarabine, and vincristine are frequently recognized as being highly cardiotoxic, causing CTRCD in ≥10% of patients. This primer provides insight into the data upon which the CTRCD incidence rates of these agents have been based. A critical re-evaluation of CTRCD rates is necessary because these numbers have been based on data in which most patients received prior or concurrent treatment with other cardiotoxic drugs, including anthracyclines. Systematic reviews, meta-analyses, consistent and detailed reporting of cardiovascular toxicity, and international registries are of pivotal importance to establish the cardiotoxicity profile of these chemotherapeutics.
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Affiliation(s)
- Janine A M Kamphuis
- Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, University of Utrecht, Utrecht, the Netherlands
| | - Marijke Linschoten
- Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, University of Utrecht, Utrecht, the Netherlands
| | - Maarten J Cramer
- Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, University of Utrecht, Utrecht, the Netherlands
| | - Eelke H Gort
- Department of Medical Oncology, University Medical Center Utrecht, University of Utrecht, Utrecht, the Netherlands
| | - Anna van Rhenen
- Department of Haematology, University Medical Center Utrecht, University of Utrecht, Utrecht, the Netherlands
| | - Folkert W Asselbergs
- Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, University of Utrecht, Utrecht, the Netherlands.,Institute of Cardiovascular Science, Faculty of Population Health Sciences, University College London, London, United Kingdom.,Health Data Research UK and Institute of Health Informatics, University College London, London, United Kingdom
| | - Pieter A Doevendans
- Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, University of Utrecht, Utrecht, the Netherlands.,Netherlands Heart Institute, Utrecht, the Netherlands
| | - Arco J Teske
- Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht, University of Utrecht, Utrecht, the Netherlands
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12
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Varadarajan I, Ballen KK. What have we learned from transplanting older patients? Best Pract Res Clin Haematol 2019; 32:101110. [PMID: 31779974 DOI: 10.1016/j.beha.2019.101110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Aggressive curative therapies have now been extended to patients older than 65 years, a fast-growing segment of the population. As the number of allogeneic transplants in patients older than age 65 is increasing, attention is now focused on improving outcomes in this group. This paper discusses important aspects of allogeneic transplant in the older patient, focusing on donor and patient selection, choice of conditioning regimen and graft source, and the importance of timely access to a transplant center.
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Affiliation(s)
- Indumathy Varadarajan
- University of Virginia Cancer Center, 1300 Jefferson Park Avenue, Charlottesville, VA, 22908, USA
| | - Karen K Ballen
- University of Virginia Cancer Center, 1300 Jefferson Park Avenue, Charlottesville, VA, 22908, USA.
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Aldoss I, Forman SJ, Pullarkat V. Acute Lymphoblastic Leukemia in the Older Adult. J Oncol Pract 2019; 15:67-75. [DOI: 10.1200/jop.18.00271] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Acute lymphoblastic leukemia (ALL) in older adults presents a real challenge as a result of adverse disease biology and comorbidities that preclude delivering curative regimens. Conventional chemotherapy approaches have generally yielded unsatisfactory results in older patients with ALL as a result of excessive induction mortality, chemotherapy resistance of the leukemia, and the need to omit or dose reduce key drugs during the course of therapy because of adverse effects. Philadelphia chromosome–positive ALL represents about a quarter of newly diagnosed older adults, and the striking single-agent activity and excellent safety profile of tyrosine kinase inhibitors has allowed incorporation of these agents into therapy, significantly improving the outcome of older adults with Philadelphia chromosome–positive ALL. Allogeneic hematopoietic cell transplantation using reduced-intensity conditioning is a potentially curative approach in the older adult with ALL, and ironically, it may be better tolerated than intensive combination chemotherapy in a subset of older patients with ALL. Immunotherapies such as chimeric antigen receptor–modified T-cells, the bispecific T-cell–engaging antibody targeting CD19 (blinatumomab), and the antibody-drug conjugate targeting CD22 (inotuzumab) have shown safety and exceptional activity even in advanced ALL, and the efficacy of these agents has been observed irrespective of patient age. Several promising studies tailored specifically toward older adults with ALL are ongoing, with the majority of them incorporating novel immunotherapies, targeted therapies, or third-generation tyrosine kinase inhibitors into the front-line treatment regimen.
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Affiliation(s)
- Ibrahim Aldoss
- Gehr Family Leukemia Research Center, City of Hope National Medical Center, Duarte, CA
| | - Stephen J. Forman
- Gehr Family Leukemia Research Center, City of Hope National Medical Center, Duarte, CA
| | - Vinod Pullarkat
- Gehr Family Leukemia Research Center, City of Hope National Medical Center, Duarte, CA
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Medinger M, Passweg J. What the internist should know about stem cell transplant in the elderly patient. Eur J Intern Med 2018; 58:43-47. [PMID: 29960832 DOI: 10.1016/j.ejim.2018.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 06/21/2018] [Indexed: 11/23/2022]
Abstract
Most hematological malignancies are increasing in frequency with age. Allogeneic hematopoietic cell transplantation (allo-HCT) is a potentially curative therapeutic option for patients with malignant and non-malignant hematological diseases. The treatment of elderly patients with advanced hematological malignancies has expanded to include reduced intensity conditioning allo-HCT. Physicians increasingly refer older patients for allo-HCT due to more experience and improved supportive care in allo-HCT. This review article discusses the available data regarding the feasibility, tolerability, toxicity, and effectiveness of allo-HCT in different hematological diseases in the elderly. Over the past decade, utilization and survival after allo-HCT have increased in patients ≥70 years. Selected adults ≥70 years with hematological diseases should be evaluated for transplantation.
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Affiliation(s)
- Michael Medinger
- Division of Hematology, Department of Medicine, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland; Division of Internal Medicine, Department of Medicine, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Jakob Passweg
- Division of Hematology, Department of Medicine, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland.
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Sawalha Y, Advani AS. Management of older adults with acute lymphoblastic leukemia: challenges & current approaches. Int J Hematol Oncol 2018; 7:IJH02. [PMID: 30302234 PMCID: PMC6176956 DOI: 10.2217/ijh-2017-0023] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 03/14/2018] [Indexed: 11/21/2022] Open
Abstract
The management of acute lymphoblastic leukemia (ALL) in older patients is challenging. Older patients often have multiple comorbidities and poor performance status, and disease factors associated with poor prognosis are more common in this age group. Patient and disease-related factors should be taken into account to determine whether intensive therapy is appropriate. The use of comorbidity indices and comprehensive geriatric assessment tools can be valuable in this setting. Fit patients should be considered for aggressive therapies including allogeneic hematopoietic stem cell transplantation, whereas low intensity options may be more suitable for the frail. The Philadelphia (Ph) chromosome is present in up to half of the cases of ALL in older patients. The incorporation of TK inhibitors into the treatment plans of older patients with Ph-positive ALL has improved the outcomes significantly. For less fit patients with Ph-positive ALL, the use of TK inhibitors with reduced-intensity chemotherapy or steroids alone results in high rates of remission, but, without further consolidation, relapses are inevitable. Many novel targeted and immunotherapeutic agents are being developed, offering more effective and tolerable treatment options.
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Affiliation(s)
- Yazeed Sawalha
- Department of Medical Oncology & Hematology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, 44195, USA
| | - Anjali S Advani
- Department of Medical Oncology & Hematology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, 44195, USA
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16
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Arai Y, Kondo T, Shigematsu A, Tanaka J, Ohashi K, Fukuda T, Hidaka M, Kobayashi N, Iwato K, Sakura T, Onizuka M, Ozawa Y, Eto T, Kurokawa M, Kahata K, Uchida N, Atsuta Y, Mizuta S, Kako S. Improved prognosis with additional medium-dose VP16 to CY/TBI in allogeneic transplantation for high risk ALL in adults. Am J Hematol 2018; 93:47-57. [PMID: 28983949 DOI: 10.1002/ajh.24933] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 09/28/2017] [Accepted: 09/29/2017] [Indexed: 02/06/2023]
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) with the conventional cyclophosphamide and total body irradiation (CY/TBI) regimen is an essential therapeutic strategy for acute lymphoblastic leukemia (ALL) in adults. Medium-dose etoposide (VP16, 30-40 mg/kg) can be added to intensify this CY/TBI regimen and reduce relapse; however, differences in prognosis between the VP16/CY/TBI and CY/TBI regimens have not yet been fully analyzed. We conducted a retrospective cohort study using a Japanese transplant registry database to compare the prognosis between the VP16/CY/TBI (VP16, total 30-40 mg/kg) (N = 376) and CY/TBI (N = 1178) regimens in adult patients with ALL transplanted at complete remission (CR) between January 1, 2000 and December 31, 2014. Our analyses indicated that VP16/CY/TBI significantly reduced relapse compared with CY/TBI (risk ratio, 0.75; 95% confidence interval [CI], 0.56-1.00; P = .05) with a corresponding improvement in leukemia-free survival (hazard ratio [HR], 0.76; 95%CI, 0.62-0.93; P = .01), particularly in patients transplanted at CR1 with advanced-risk (positive minimal residual disease, presence of poor-risk cytogenetics, or an initial elevated leukocyte count) (HR, 0.75; 95%CI, 0.56-1.00; P = .05) or those transplanted beyond CR2 (HR, 0.58; 95%CI, 0.39-0.88; P = .01). The addition of VP16 did not increase post-transplant complications or nonrelapse mortality (HR, 0.88; 95%CI, 0.65-1.18; P = .38). This study is the first to reveal the efficacy of the addition of medium-dose VP16 to CY/TBI in high-risk ALL. To establish new myeloablative conditioning regimens including VP16, a large-scale prospective study is necessary.
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Affiliation(s)
- Yasuyuki Arai
- Department of Hematology and Oncology; Graduate School of Medicine, Kyoto University; Kyoto Japan
- Laboratory of Host Defenses; National Institute of Allergy and Infectious Diseases, National Institutes of Health; Bethesda Maryland
| | - Tadakazu Kondo
- Department of Hematology and Oncology; Graduate School of Medicine, Kyoto University; Kyoto Japan
| | - Akio Shigematsu
- Department of Hematology; Sapporo Hokuyu Hospital; Sapporo Japan
| | - Junji Tanaka
- Department of Hematology; Tokyo Women's Medical University; Tokyo Japan
| | - Kazuteru Ohashi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center; Komagome Hospital; Tokyo Japan
| | - Takahiro Fukuda
- Department of Hematopoietic Stem Cell Transplantation; National Cancer Center Hospital; Tokyo Japan
| | - Michihiro Hidaka
- Department of Hematology; National Hospital Organization Kumamoto Medical Center, Kumamoto; Japan
| | - Naoki Kobayashi
- Department of Hematology; Sapporo Hokuyu Hospital; Sapporo Japan
| | - Koji Iwato
- Department of Hematology; Hiroshima Red Cross Hospital & Atomic-bomb Survivors Hospital; Hiroshima Japan
| | - Toru Sakura
- Leukemia Research Center, Saiseikai Maebashi Hospital; Maebashi Japan
| | - Makoto Onizuka
- Department of Hematology/Oncology; Tokai University School of Medicine; Isehara Japan
| | - Yukiyasu Ozawa
- Department of Hematology; Japanese Red Cross Nagoya First Hospital; Nagoya Japan
| | - Tetsuya Eto
- Department of Hematology; Hamanomachi Hospital; Fukuoka Japan
| | - Mineo Kurokawa
- Department of Cell Therapy and Transplantation Medicine; The University of Tokyo Hospital; Tokyo Japan
| | - Kaoru Kahata
- Department of Hematology; Hokkaido University Hospital; Hokkaido Japan
| | - Naoyuki Uchida
- Department of Hematology; Federation of National Public Service Personnel Mutual Aid Associations, Toranomon Hospital; Tokyo Japan
| | - Yoshiko Atsuta
- Japanese Data Center for Hematopoietic Cell Transplantation; Nagoya Japan
- Department of Healthcare Administration; Nagoya University Graduate School of Medicine; Nagoya Japan
| | - Shuichi Mizuta
- Department of Hematology; National Hospital Organization Toyohashi Medical Center; Toyohashi Japan
| | - Shinichi Kako
- Division of Hematology; Jichi Medical University; Saitama Japan
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Pretransplant Consolidation Is Not Beneficial for Adults with ALL Undergoing Myeloablative Allogeneic Transplantation. Biol Blood Marrow Transplant 2017; 24:945-955. [PMID: 29275139 DOI: 10.1016/j.bbmt.2017.12.784] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 12/13/2017] [Indexed: 11/24/2022]
Abstract
Allogeneic hematopoietic cell transplantation (alloHCT) is curative for patients with acute lymphoblastic leukemia (ALL) who achieve complete remission (CR1) with chemotherapy. However, the benefit of consolidation chemotherapy remains uncertain in patients undergoing alloHCT. We compared clinical outcomes of 524 adult patients with ALL in CR1 who received ≥2 (n = 109), 1 (n = 93), or 0 cycles (n = 322) of consolidation before myeloablative alloHCT from 2008 to 2012. As expected, time to alloHCT was longer with increasing cycles of consolidation. Patients receiving ≥2, 1, or 0 cycles of consolidation had an adjusted 3-year cumulative incidence of relapse of 20%, 27%, and 22%; 1-year transplant-related mortality (TRM) of 16%, 18%, and 23%; adjusted 3-year leukemia-free survival (LFS) of 54%, 48%, and 47%; and 3-year overall survival (OS) of 63%, 59%, and 54% (all P values >.40). Multivariable analysis confirmed that consolidation was not prognostic for LFS (relative risk, 1.20, 95% confidence interval, .86 to 1.67; P = .28 for no consolidation; RR, 1.18, 95% confidence interval, .79 to 1.76; P = .41 for 1 cycle versus ≥2 cycles = reference). Similarly, consolidation was not associated with OS, relapse, TRM, or graft-versus-host disease. We conclude that consolidation chemotherapy does not appear to provide added benefit in adult ALL patients with available donors who undergo myeloablative alloHCT in CR1.
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19
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Wolach O, Amitai I, DeAngelo DJ. Current challenges and opportunities in treating adult patients with Philadelphia-negative acute lymphoblastic leukaemia. Br J Haematol 2017; 179:705-723. [PMID: 29076138 DOI: 10.1111/bjh.14916] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Significant advances have been made in recent years in the field of Philadelphia-negative acute lymphoblastic leukaemia (ALL). New insights into the biology and genetics of ALL as well as novel clinical observations and new drugs are changing the way we diagnose, risk-stratify and treat adult patients with ALL. New genetic subtypes and alterations refine risk stratification and uncover new actionable therapeutic targets. The incorporation of more intensive, paediatric and paediatric-inspired approaches for young adults seem to have a positive impact on survival in this population. Minimal residual disease at different time points can assist in tailoring risk-adapted interventions for patients based on individual response. Finally, novel targeted approaches with monoclonal antibodies, immunotherapies and small molecules are moving through clinical development and entering the clinic. The aim of this review is to consolidate the abundance of emerging data and to review and revisit the concepts of risk-stratification, choice of induction and post-remission strategies as well as to discuss and update the approach to specific populations with ALL, such as young adult, elderly/unfit and relapsed/refractory patients with ALL.
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Affiliation(s)
- Ofir Wolach
- Institute of Haematology, Davidoff Cancer Centre, Beilinson Hospital, Rabin Medical Centre, Petah-Tikva and Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Irina Amitai
- Institute of Haematology, Davidoff Cancer Centre, Beilinson Hospital, Rabin Medical Centre, Petah-Tikva and Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Daniel J DeAngelo
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
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O'Dwyer KM, Liesveld JL. Philadelphia chromosome negative B-cell acute lymphoblastic leukemia in older adults: Current treatment and novel therapies. Best Pract Res Clin Haematol 2017; 30:184-192. [DOI: 10.1016/j.beha.2017.08.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 07/31/2017] [Accepted: 08/01/2017] [Indexed: 10/19/2022]
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Gökbuget N. Treatment of older patients with acute lymphoblastic leukemia. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:573-579. [PMID: 27913531 PMCID: PMC6142461 DOI: 10.1182/asheducation-2016.1.573] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
The treatment of older patients with acute lymphoblastic leukemia (ALL) is an unmet medical need. With increasing age, ALL patients have a significantly lower clinical remission rate, higher early mortality, higher relapse rate, and poorer survival compared with younger patients. This is only partly explained by a higher incidence of poor prognostic factors in the older age group. Most importantly, intensive chemotherapy with or without stem cell transplantation (SCT) is less well tolerated in older patients. Some progress has been made with delivering age-adapted, moderately intensive chemotherapy protocols for Ph/BCR-ABL-negative ALL and combinations of tyrosine kinase inhibitors with chemotherapy in Ph/BCR-ABL-positive ALL. For the future, optimizing supportive care, introducing targeted therapies, novel immunotherapies, moderately intensified consolidation strategies, and reduced intensity SCT are promising approaches. Prospective clinical trials for older patients are urgently needed to test these approaches.
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Affiliation(s)
- Nicola Gökbuget
- Department of Medicine II, Goethe University Hospital, Frankfurt am Main, Germany
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