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DiNardo CD, Maiti A, Rausch CR, Pemmaraju N, Naqvi K, Daver NG, Kadia TM, Borthakur G, Ohanian M, Alvarado Y, Issa GC, Montalban-Bravo G, Short NJ, Yilmaz M, Bose P, Jabbour EJ, Takahashi K, Burger JA, Garcia-Manero G, Jain N, Kornblau SM, Thompson PA, Estrov Z, Masarova L, Sasaki K, Verstovsek S, Ferrajoli A, Weirda WG, Wang SA, Konoplev S, Chen Z, Pierce SA, Ning J, Qiao W, Ravandi F, Andreeff M, Welch JS, Kantarjian HM, Konopleva MY. 10-day decitabine with venetoclax for newly diagnosed intensive chemotherapy ineligible, and relapsed or refractory acute myeloid leukaemia: a single-centre, phase 2 trial. LANCET HAEMATOLOGY 2020; 7:e724-e736. [PMID: 32896301 DOI: 10.1016/s2352-3026(20)30210-6] [Citation(s) in RCA: 192] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/22/2020] [Accepted: 05/27/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Venetoclax combined with hypomethylating agents is a new standard of care for newly diagnosed patients with acute myeloid leukaemia (AML) who are 75 years or older, or unfit for intensive chemotherapy. Pharmacodynamic studies have suggested superiority of the longer 10-day regimen of decitabine that has shown promising results in patients with high-risk AML in phase 2 trials. We hypothesised that venetoclax with 10-day decitabine could have improved activity in patients with newly diagnosed AML and those with relapsed or refractory AML, particularly in high-risk subgroups. METHODS This single centre, phase 2 trial was done at the University of Texas MD Anderson Cancer Center (Houston, TX, USA). The study enrolled older patients (aged >60 years) with newly diagnosed AML, not eligible for intensive chemotherapy; secondary AML (progressed after myelodysplastic syndrome or chronic myelomonocytic leukaemia); and relapsed or refractory AML. Patients were required to have an Eastern Cooperative Oncology Group (ECOG) performance status of 3 or less, white blood cell count less than 10 × 109 per L, and adequate end-organ function. Patients with favourable-risk cytogenetics (eg, t[15;17] or core-binding factor AML) or who had received previous BCL2-inhibitor therapy were excluded. Patients received decitabine 20 mg/m2 intravenously for 10 days with oral venetoclax 400 mg daily for induction, followed by decitabine for 5 days with daily venetoclax for consolidation. The primary endpoint was overall response rate. The secondary endpoints analysed within this report include safety, overall survival, and duration of response, in keeping with recommendations of European LeukemiaNet 2017 guidelines. All patients who received at least one dose of treatment were eligible for safety and response assessments. The trial was registered on ClinicalTrials.gov (NCT03404193) and continues to accrue patients. FINDINGS Between Jan 19, 2018, and Dec 16, 2019, we enrolled 168 patients; 70 (42%) had newly diagnosed AML, 15 (9%) had untreated secondary AML, 28 (17%) had treated secondary AML, and 55 (33%) had relapsed or refractory AML. The median age was 71 years (IQR 65-76) and 30% of patients had ECOG performance status of 2 or higher. The median follow-up for all patients was 16 months (95% CI 12-18; actual follow-up 6·5 months; IQR 3·4-12·4). The overall response rate was 74% (125 of 168 patients; 95% CI 67-80) and in disease subgroups were: 89% in newly diagnosed AML (62 of 70 patients; 79-94), 80% in untreated secondary AML (12 of 15 patients; 55-93), 61% in treated secondary AML (17 of 28 patients; 42-76), and 62% in relapsed or refractory AML (34 of 55 patients; 49-74). The most common treatment-emergent adverse events included infections with grades 3 or 4 neutropenia (n=79, 47%) and febrile neutropenia (n=49, 29%). 139 (83%) of 168 patients had serious adverse events, most frequently neutropenic fever (n=63, 38%), followed by pneumonia (n=17, 10%) and sepsis (n=16, 10%). The 30-day mortality for all patients was 3·6% (n=6, 95% CI 1·7-7·8). The median overall survival was 18·1 months (95% CI 10·0-not reached) in newly diagnosed AML, 7·8 months (2·9-10·7) in untreated secondary AML, 6·0 months (3·4-13·7) in treated secondary AML, and 7·8 months (5·4-13·3) relapsed or refractory AML. The median duration of response was not reached (95% CI 9·0-not reached) in newly diagnosed AML, 5·1 months (95% CI 0·9-not reached) in untreated secondary AML, not reached (95% CI 2·5-not reached) in previously treated secondary AML, and 16·8 months (95% CI 6·6-not reached) in relapsed or refractory AML. INTERPRETATION Venetoclax with 10-day decitabine has a manageable safety profile and showed high activity in newly diagnosed AML and molecularly defined subsets of relapsed or refractory AML. Future larger and randomised studies are needed to clarify activity in high-risk subsets. FUNDING US National Institutes of Health and National Cancer Institute.
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Affiliation(s)
- Courtney D DiNardo
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Abhishek Maiti
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA; Division of Cancer Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Caitlin R Rausch
- Division of Pharmacy, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naveen Pemmaraju
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kiran Naqvi
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naval G Daver
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tapan M Kadia
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gautam Borthakur
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maro Ohanian
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yesid Alvarado
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ghayas C Issa
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Nicholas J Short
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Musa Yilmaz
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Prithviraj Bose
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elias J Jabbour
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Koichi Takahashi
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jan A Burger
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Nitin Jain
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Steven M Kornblau
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Philip A Thompson
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zeev Estrov
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lucia Masarova
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Koji Sasaki
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Srdan Verstovsek
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alessandra Ferrajoli
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William G Weirda
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sa A Wang
- Department of Hematopathology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sergej Konoplev
- Department of Hematopathology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zhining Chen
- Department of Hematopathology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sherry A Pierce
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jing Ning
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Wei Qiao
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Farhad Ravandi
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael Andreeff
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - John S Welch
- Division of Hematology & Oncology, Washington University School of Medicine, St Louis, MO, USA
| | - Hagop M Kantarjian
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Marina Y Konopleva
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Ferreira-Facio CS, Milito C, Botafogo V, Fontana M, Thiago LS, Oliveira E, da Rocha-Filho AS, Werneck F, Forny DN, Dekermacher S, de Azambuja AP, Ferman SE, de Faria PAS, Land MGP, Orfao A, Costa ES. Contribution of multiparameter flow cytometry immunophenotyping to the diagnostic screening and classification of pediatric cancer. PLoS One 2013; 8:e55534. [PMID: 23472067 PMCID: PMC3589426 DOI: 10.1371/journal.pone.0055534] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Accepted: 12/27/2012] [Indexed: 12/13/2022] Open
Abstract
Pediatric cancer is a relatively rare and heterogeneous group of hematological and non-hematological malignancies which require multiple procedures for its diagnostic screening and classification. Until now, flow cytometry (FC) has not been systematically applied to the diagnostic work-up of such malignancies, particularly for solid tumors. Here we evaluated a FC panel of markers for the diagnostic screening of pediatric cancer and further classification of pediatric solid tumors. The proposed strategy aims at the differential diagnosis between tumoral vs. reactive samples, and hematological vs. non-hematological malignancies, and the subclassification of solid tumors. In total, 52 samples from 40 patients suspicious of containing tumor cells were analyzed by FC in parallel to conventional diagnostic procedures. The overall concordance rate between both approaches was of 96% (50/52 diagnostic samples), with 100% agreement for all reactive/inflammatory and non-infiltrated samples as well as for those corresponding to solid tumors (n = 35), with only two false negative cases diagnosed with Hodgkin lymphoma and anaplastic lymphoma, respectively. Moreover, clear discrimination between samples infiltrated by hematopoietic vs. non-hematopoietic tumor cells was systematically achieved. Distinct subtypes of solid tumors showed different protein expression profiles, allowing for the differential diagnosis of neuroblastoma (CD56hi/GD2+/CD81hi), primitive neuroectodermal tumors (CD271hi/CD99+), Wilms tumors (>1 cell population), rhabdomyosarcoma (nuMYOD1+/numyogenin+), carcinomas (CD45−/EpCAM+), germ cell tumors (CD56+/CD45−/NG2+/CD10+) and eventually also hemangiopericytomas (CD45−/CD34+). In summary, our results show that multiparameter FC provides fast and useful complementary data to routine histopathology for the diagnostic screening and classification of pediatric cancer.
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Affiliation(s)
| | - Cristiane Milito
- Department of Pathology, Faculty of Medicine, UFRJ, Rio de Janeiro, Brazil
| | - Vitor Botafogo
- Pediatric Institute IPPMG, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Marcela Fontana
- Pediatric Institute IPPMG, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Leandro S. Thiago
- Pediatric Institute IPPMG, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
- Pediatric Hematology and Oncology Program, Cancer Research Center, Brazilian National Cancer Institute (INCa), Rio de Janiero, Brazil
| | - Elen Oliveira
- Pediatric Institute IPPMG, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | | | | | - Danielle N. Forny
- Pediatric Institute IPPMG, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | | | | | - Sima Esther Ferman
- Department of Pediatric Oncology/Brazilian National Cancer Institute (INCa), Rio de Janiero, Brazil
| | | | - Marcelo G. P. Land
- Pediatric Institute IPPMG, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Alberto Orfao
- Cytometry Service, Department of Medicine and Cancer Research Center (IBMCC, University of Salamanca-CSIC and IBSAL), University of Salamanca, Salamanca, Spain
| | - Elaine S. Costa
- Pediatric Institute IPPMG, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
- * E-mail:
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