1
|
Sun W, Orgel E, Malvar J, Sposto R, Wilkes JJ, Gardner R, Tolbert VP, Smith A, Hur M, Hoffman J, Rheingold SR, Burke MJ, Wayne AS. Treatment-related adverse events associated with a modified UK ALLR3 induction chemotherapy backbone for childhood relapsed/refractory acute lymphoblastic leukemia. Pediatr Blood Cancer 2016; 63:1943-8. [PMID: 27437864 PMCID: PMC7451261 DOI: 10.1002/pbc.26129] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 05/25/2016] [Accepted: 06/08/2016] [Indexed: 01/16/2023]
Abstract
BACKGROUND The UK ALLR3 (R3) regimen has been adopted to treat pediatric relapsed acute lymphoblastic leukemia (ALL) by many centers in the United States and has become a preferred therapeutic backbone for testing novel agents in clinical trials. A detailed toxicity profile of this platform has not previously been reported. The toxicity and response rates for its use beyond first relapse are unknown. PROCEDURES We performed a multi-institutional, retrospective study including children with relapsed ALL treated with the R3 reinduction chemotherapy backbone block 1 across five pediatric centers. Data were extracted from medical records and analyzed. RESULTS Fifty-nine patients were included in the study, including 16 patients with ≥2nd relapse. Ninety-seven percent of patients experienced at least one Grade ≥3 nonhematologic adverse event (AE). Grade 3 or higher infection was reported in 90% of patients. Other nonhematologic Grade ≥3 AEs included electrolyte abnormalities, elevation in hepatic enzymes, and pain. Eighty-five percent of patients achieved a complete remission (CR). There were no significant differences in the incidence of AEs, CR rate, and rate of minimal residual disease negativity between patients with 1st or ≥2nd relapse. CONCLUSION Our study confirmed that R3 block 1 is a highly active reinduction regimen in childhood relapsed ALL. However, it was associated with a high incidence of severe toxicities, particularly infection. The toxicity profiled in our report should be used to inform optimal supportive care and future clinical trial design with the R3 backbone, particularly when new agents are combined with this regimen.
Collapse
Affiliation(s)
- Weili Sun
- Children's Center for Cancer and Blood Diseases, Children's Hospital Los Angeles, California. .,Keck School of Medicine, USC-Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California.
| | - Etan Orgel
- Children’s Center for Cancer and Blood Diseases, Children’s Hospital Los Angeles, California,Keck School of Medicine, USC-Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California
| | - Jemily Malvar
- Children’s Center for Cancer and Blood Diseases, Children’s Hospital Los Angeles, California
| | - Richard Sposto
- Children’s Center for Cancer and Blood Diseases, Children’s Hospital Los Angeles, California,Keck School of Medicine, USC-Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California
| | - Jennifer J. Wilkes
- Department of Pediatrics, Division of Oncology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Rebecca Gardner
- Department of Pediatrics, Seattle Children’s Hospital, Seattle, Washington
| | - Vanessa P. Tolbert
- Department of Pediatrics, Seattle Children’s Hospital, Seattle, Washington
| | - Alison Smith
- Keck School of Medicine, USC-Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California
| | - Minjun Hur
- School of Medicine, St. Louis University, St. Louis, Missouri
| | - Jill Hoffman
- Keck School of Medicine, USC-Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California,Infectious Disease, Children’s Hospital Los Angeles, California
| | - Susan R. Rheingold
- Department of Pediatrics, Division of Oncology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Michael J. Burke
- Pediatric Leukemia and Lymphoma, Children’s Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Alan S. Wayne
- Children’s Center for Cancer and Blood Diseases, Children’s Hospital Los Angeles, California,Keck School of Medicine, USC-Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California
| |
Collapse
|
2
|
Al Mulla N, Kahn JM, Jin Z, Qureshi M, Karamehmet E, Yoon-Jeong Kim G, Levinson AL, Bhatia M, Garvin JH, George D, Kung AL, Satwani P. Survival Impact of Early Post-Transplant Toxicities in Pediatric and Adolescent Patients Undergoing Allogeneic Hematopoietic Cell Transplantation for Malignant and Nonmalignant Diseases: Recognizing Risks and Optimizing Outcomes. Biol Blood Marrow Transplant 2016; 22:1525-1530. [PMID: 27223110 DOI: 10.1016/j.bbmt.2016.05.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 05/10/2016] [Indexed: 11/27/2022]
Abstract
In pediatric and adolescent patients undergoing allogeneic hematopoietic cell transplantation, treatment-related toxicities remain a clinical challenge. A paucity of data investigates the risks for and survival impact of treatment-related toxicities in this population. Here the authors assess the relative toxicity of myeloablative, reduced-toxicity, and reduced-intensity conditioning regimens; identify patient-related predictors of post-transplant toxicities; and investigate the impact of early post-transplant toxicities on transplant-related mortality (TRM). In this retrospective study, 164 patients (aged 1 to 22 years) underwent allogeneic stem cell transplantation after busulfan-based conditioning for malignant and nonmalignant diseases between 2000 and 2014. The number of grades III to IV toxicities between days 0 and +30 was calculated for each patient. TRM was calculated to 2 years. Median patient age was 9 years, and median number of toxicities was 3 (range, 0 to 17). The 100-person day incidence of post-transplant toxicities in myeloablative conditioning was not different from the incidence in reduced-toxicity conditioning (13.88 versus 13.59, P = .812). Reduced intensity was less toxic than both myeloablative and reduced toxicity (13.75 versus 8.41, P < .001). Age ≥ 12 years (.276 with SE = .138, P = .045) and unrelated donor transplant (.318 with SE = 0.113, P = .005) were risk factors for ≥3 toxicities. Having ≥3 toxicities or a performance score < 90 conferred higher risk of TRM (P = .021). In pediatric and adolescent patients undergoing hematopoietic cell transplantation, reduced-toxicity conditioning was not significantly less toxic than myeloablative conditioning. Additionally, the number of post-transplant toxicities correlated with the risk of mortality. Further investigations to confirm our findings are warranted.
Collapse
Affiliation(s)
- Naima Al Mulla
- Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Justine M Kahn
- Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Zhezhen Jin
- Department of Pediatrics, Columbia University Medical Center, New York, New York; Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York
| | - Mahvish Qureshi
- Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Esra Karamehmet
- Department of Pediatrics, Columbia University Medical Center, New York, New York
| | | | - Anya L Levinson
- Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Monica Bhatia
- Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - James H Garvin
- Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Diane George
- Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Andrew L Kung
- Department of Pediatrics, Columbia University Medical Center, New York, New York
| | - Prakash Satwani
- Department of Pediatrics, Columbia University Medical Center, New York, New York.
| |
Collapse
|
3
|
A clofarabine-based bridging regimen in patients with relapsed ALL and persistent minimal residual disease (MRD). Bone Marrow Transplant 2013; 49:440-2. [PMID: 24317126 DOI: 10.1038/bmt.2013.195] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Revised: 09/06/2013] [Accepted: 10/21/2013] [Indexed: 11/09/2022]
Abstract
In patients with relapsed ALL, minimal residual disease (MRD) identified prior to allogeneic hematopoietic cell transplantation (HCT) is a strong predictor of relapse. We report our experience using a combination of reduced-dosing clofarabine, CY and etoposide as a 'bridge' to HCT in eight patients with high risk or relapsed ALL and pre-HCT MRD. All patients had detectable MRD (>0.01%, flow cytometry) at the start of therapy with all eight achieving MRD reduction following one cycle. The regimen was well tolerated with seven grade 3/4 toxicities occurring among four of the eight patients. Five patients (62.5%) are alive, one died from relapse (12.5%) and two from transplant-related mortality (25%). The combination of reduced-dose clofarabine, CY and etoposide as bridging therapy appears to be well tolerated in patients with relapsed ALL and is effective in reducing pre-HCT MRD.
Collapse
|