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Cui T, Li H, Zhou S, Li J, Zhu Q, Zhu W, Tang Z, Ma X, Qiu H, Wu D, Wu X. Impact of cladribine, cytarabine, and G-CSF (CLAG) as a bridging therapy prior to allogeneic hematopoietic stem cell transplantation in relapsed or refractory acute myeloid leukemia. Ann Hematol 2024; 103:2463-2473. [PMID: 38758360 DOI: 10.1007/s00277-024-05791-z] [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] [Received: 09/29/2023] [Accepted: 05/01/2024] [Indexed: 05/18/2024]
Abstract
The combination of cladribine, cytarabine, and G-CSF (CLAG) has exhibited robust synergistic anti-leukemia activity as an induction therapy (IT) in acute myeloid leukemia (AML). However, the impact of CLAG as a bridging therapy (BT) administered between IT and allogeneic hematopoietic stem cell transplantation (allo-HSCT) for patients with relapsed or refractory (R/R) AML remains uncertain. In this retrospective study, we examined the efficacy of CLAG as a transitional strategy prior to allo-HSCT in R/R AML. We included 234 patients with R/R AML who received the modified busulfan plus cyclophosphamide conditioning regimen for allo-HSCT in our center during the past 6 years, performed a propensity-score matching analysis, partitioned them into four distinct cohorts, and further integrated them into the CLAG group and non-CLAG group based on response to IT and utilization of CLAG. Our cohorts encompassed 12 patients in Cohort A (modified composite complete remission (mCRc) after IT, CLAG), 31 in Cohort B (mCRc after IT, non-CLAG), 35 in Cohort C (non-complete remission (non-CR) after IT, CLAG), and 80 in Cohort D (non-CR after IT, non-CLAG). Intriguingly, among patients with non-CR status, the administration of CLAG correlated with a notably statistically diminished risk of relapse and improved survival at 2-year follow-up (Cohort C vs. Cohort D). Employing CLAG as a BT prior to allo-HSCT demonstrates substantial effectiveness, a relative degree of safety, and manageable toxicity in selected R/R AML cases.
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Affiliation(s)
- Tong Cui
- Department of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Huiyu Li
- Department of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Shiyuan Zhou
- Department of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Jing Li
- Department of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Qian Zhu
- Soochow Hopes Hematonosis Hospital, Suzhou, China
| | - Wenjuan Zhu
- Department of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Zaixiang Tang
- Department of Epidemiology and Statistics, School of Public Health, Faculty of Medicine, Soochow University, Suzhou, China
| | - Xiao Ma
- Department of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Huiying Qiu
- Department of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, Suzhou, China
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Depei Wu
- Department of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, Suzhou, China.
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.
| | - Xiaojin Wu
- Department of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, Suzhou, China.
- Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.
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Pan Q, Li J. Efficacy and safety of cladribine addition to induction treatment of newly diagnosed acute myeloid leukemia: a systematic review and meta-analysis. ACTA ACUST UNITED AC 2021; 26:577-587. [PMID: 34384339 DOI: 10.1080/16078454.2021.1962047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Compared with the 3 + 7 regimen, the cladribine-containing regimen has led to improvements in the rate of complete remission (CR) in the treatment of newly diagnosed acute myeloid leukemia (AML) patients. We conducted a systematic review and meta-analysis to investigate the overall efficacy and safety of cladribine-containing regimens in the induction treatment of newly diagnosed AML patients. METHODS Eligible studies were identified from the PubMed, EMBASE, and Cochrane Library databases. Efficacy was assessed by CR rate, disease-free survival (DFS), and overall survival (OS). Safety was evaluated based on the early death (ED) rate, days for neutrophils<0.5 × 109/L, days for platelets<50 × 109/L, and duration of hospital stay after treatment. RESULTS A total of 14 clinical trials were included in this meta-analysis, enrolling a total of 1058 newly diagnosed AML patients. The pooled estimate with a 95% confidence interval (CI) for CR was 64% (95% CI: 58-70%). Compared with the control group, the CR rate of the cladribine-containing regimen was higher (OR was 1.92 (95% CI: 1.55-2.38)). The combined ED rate was estimated to be 10% (95% CI: 5-14%). Compared with the control group, the ED rate of the cladribine-containing regimen was not increased (OR was 1.09 (95% CI: 0.78-1.53)). CONCLUSION This meta-analysis suggests that cladribine-containing regimens are likely to be effective and safe for induction treatment of newly diagnosed AML patients. However, large sample size and prospective controlled studies are needed to confirm our findings.
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Affiliation(s)
- Qianying Pan
- Department of Hematology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Juan Li
- Department of Hematology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
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Hui Y, Li Y, Tong X, Huang L, Mao X, Huang L, Zhang D. Reinduction chemotherapy regimen involved decitabine and cladribine improves the prognosis of patients with relapsed or refractory acute myeloid leukemia: A preliminary study. Int J Cancer 2021; 149:901-908. [PMID: 33837553 DOI: 10.1002/ijc.33595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 03/29/2021] [Accepted: 03/30/2021] [Indexed: 11/10/2022]
Abstract
Relapsed/refractory acute myeloid leukemia (R/R-AML) is characterized by a high incidence, short survival and poor prognosis. Presently, no unified effective reinduction chemotherapy regimen has been developed. Therefore, the use of reinduction chemotherapy regimens before allogeneic hematopoietic stem cell transplantation (allo-HSCT) is controversial. Our study aims to analyze the prognostic factors of R/R-AML and to evaluate the efficacy of the regimen involved decitabine, cladribine, idarubicin or homoharringtonine, and cytarabine (DCIA/DCHA). Clinical and survival data of 112 R/R-AML patients were obtained. Among the 102 R/R-AML patients that were treated with conventional regimens, we found that poor prognosis was related to a greater proportion of bone marrow blasts (>70%) and not achieving complete remission (non-CR) after the first reinduction chemotherapy. Hematopoietic stem cell transplantation (of which 89.47% was allo-HSCT) following CR after the first reinduction chemotherapy often improves the prognosis. Of the 10 R/R-AML patients that were treated with the DCIA/DCHA regimen, nine patients achieved CR or complete response with incomplete hematopoietic recovery (CRi) after one course of chemotherapy. The median overall survival of the 10 patients was 10.14 (1.23-29.13) months. In conclusion, non-CR was associated with poor prognosis in R/R-AML. Therefore, intensive reinduction chemotherapy should be selected to achieve CR. This creates conditions for allo-HSCT and improves prognosis of R/R-AML patients. The DCIA/DCHA regimen showed good efficacy and tolerable adverse reactions in R/R-AML treatment. This combination may be used as a bridging regimen for allo-HSCT in R/R-AML.
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Affiliation(s)
- Yan Hui
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yi Li
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiwen Tong
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lifang Huang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xia Mao
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Liang Huang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Donghua Zhang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Huang J, Yang XY, Rong LC, Xue Y, Zhu J, Fang YJ. CLAG-M chemotherapy followed by umbilical cord blood stem cell transplantation for primary refractory acute myeloid leukaemia in a child: A case report. World J Clin Cases 2020; 8:5603-5610. [PMID: 33344550 PMCID: PMC7716300 DOI: 10.12998/wjcc.v8.i22.5603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 10/05/2020] [Accepted: 10/20/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The prognosis of paediatric primary refractory/relapsed acute myeloid leukaemia (R/R AML) remains poor. Intensive therapy is typically used as salvage treatment for those with R/R AML. No data are currently available about the use of the CLAG-M protocol as salvage therapy in paediatric patients with R/R AML.
CASE SUMMARY An 8-year-old patient was diagnosed with acute myeloid leukaemia by bone marrow morphology and immunophenotype. The patient showed poor response to two cycles of induction therapy with 60% blast cells in the bone marrow after the second induction cycle. The patient achieved complete remission after being treated with the CLAG-M protocol as salvage therapy before undergoing umbilical cord blood stem cell transplantation. Morphological complete remission with haematological recovery has hitherto been maintained over 4 mo. Abnormal gene mutations detected at diagnosis were undetectable after haematopoietic stem cell transplantation.
CONCLUSION Here we present a paediatric patient with primary refractory acute myeloid leukaemia who was successfully treated with the CLAG-M protocol. Given the positive results of the presented patient, large-scale clinical studies are required to assess the role of the CLAG-M protocol in the salvage treatment of refractory or relapsed AML in childhood.
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Affiliation(s)
- Jie Huang
- Department of Haematology and Oncology, Children’s Hospital of Nanjing Medical University, Nanjing 210008, Jiangsu Province, China
| | - Xiao-Yun Yang
- Department of Haematology and Oncology, Children’s Hospital of Nanjing Medical University, Nanjing 210008, Jiangsu Province, China
| | - Liu-Cheng Rong
- Department of Haematology and Oncology, Children’s Hospital of Nanjing Medical University, Nanjing 210008, Jiangsu Province, China
| | - Yao Xue
- Department of Haematology and Oncology, Children’s Hospital of Nanjing Medical University, Nanjing 210008, Jiangsu Province, China
| | - Jun Zhu
- Department of Haematology and Oncology, Children’s Hospital of Nanjing Medical University, Nanjing 210008, Jiangsu Province, China
| | - Yong-Jun Fang
- Department of Haematology and Oncology, Children’s Hospital of Nanjing Medical University, Nanjing 210008, Jiangsu Province, China
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Re-induction with modified CLAG regimen in relapsed or refractory acute myeloid leukemia in children bridging to allogeneic hematopoietic stem cell transplantation. World J Pediatr 2020; 16:152-158. [PMID: 31748985 DOI: 10.1007/s12519-019-00321-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 10/16/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND The prognosis for relapsed or refractory acute myeloid leukemia (RR-AML) in children is poor, and the preferred salvage chemotherapy is unclear. One regimen is cladribine, cytarabine, and granulocyte-colony stimulating factor (CLAG), but little is known about its efficacy and safety in children with RR-AML. METHODS We enrolled RR-AML patients aged 0-18 years who received modified CLAG regimen for re-induction between July 1, 2015 and April 1, 2018, or conventional induction between August 1, 2011 and April 1, 2018. Patients were followed up to March 31, 2019. Patients underwent allogeneic stem cell transplantation (allo-SCT) or chemotherapy after the induction of complete remission (CR). The CR rate, survival, and side effects were analyzed. RESULTS The CR rate for induction was 66.7% after one cycle and 75.0% after two cycles of the CLAG regimen in 12 children. The nine children who received conventional chemotherapy had a CR rate of 22.2% after one cycle and 33.3% after two cycles (P = 0.087 vs. CLAG). The 3-year event-free survival (EFS) of the CLAG group and the conventional treatment group were 44.4 ± 15.7% and 22.2 ± 13.8% (P = 0.112). The 3-year overall survival of the two groups were 59.5 ± 16.2% and 22.2% ± 13.8% (P = 0.057). The 3-year EFS for allo-SCT and chemotherapy after CLAG regimen was 66.7 ± 19.2% and 25.0 ± 21.7% (P = 0.015). A single case of chemotherapy-related death was recorded. CONCLUSION Our data suggest a promising CR rate using CLAG salvage treatment in childhood RR-AML. Allo-SCT after CR may improve the long-term outcome in these patients.
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Mayer K, Hahn-Ast C, Schwab K, Schmidt-Wolf IGH, Brossart P, Glasmacher A, von Lilienfeld-Toal M. Long-term follow-up of Cladribine, high-dose Cytarabine, and Idarubicin as salvage treatment for relapsed acute myeloid leukemia and literature review. Eur J Haematol 2020; 104:538-545. [PMID: 32049382 DOI: 10.1111/ejh.13395] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 02/07/2020] [Accepted: 02/07/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE Outcome for relapsed acute myeloid leukemia (AML) is poor. Cladribine has activity in AML, and an enhancing effect on other cytostatic drugs thus may help overcome resistance. Here, we present the final analysis of our phase II trial evaluating safety and efficacy of cladribine, cytarabine, and idarubicin (CAI) in relapsed AML. METHODS Patients with relapsed AML after at least 6 months remission received two courses of CAI. After 9 patients, prolonged neutropenia prompted protocol change (omission of idarubicin in 2nd course and dose-reduction of cytarabine). Primary endpoints were remission rate and safety. RESULTS Twenty patients received treatment, fourteen one, and six two courses CAI/CA. After first course, complete remission (CR/CRi) was achieved in 60%. Most frequent toxicity was infection. Median OS was 8.8 months in all patients and 21.1 months in those with CR. Nine patients (48%) proceeded to allogeneic stem cell transplantation (allo-SCT), four of those are still alive and in CR, accounting for a 5-year survival rate of 55% of transplanted patients. CONCLUSION Cladribine, cytarabine, and idarubicin in relapsed AML is feasible and induces good response rates. As expected, infections are the most important complication. However, combined with allo-SCT, long-term survival can be achieved in a substantial number of patients.
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Affiliation(s)
- Karin Mayer
- Medizinische Klinik III, Hämatologie/Onkologie/Rheumatologie, Universitätsklinikum Bonn, Bonn, Germany
| | - Corinna Hahn-Ast
- Medizinische Klinik III, Hämatologie/Onkologie/Rheumatologie, Universitätsklinikum Bonn, Bonn, Germany
| | - Katjana Schwab
- Medizinische Klinik III, Hämatologie/Onkologie/Rheumatologie, Universitätsklinikum Bonn, Bonn, Germany
| | | | - Peter Brossart
- Medizinische Klinik III, Hämatologie/Onkologie/Rheumatologie, Universitätsklinikum Bonn, Bonn, Germany
| | - Axel Glasmacher
- Medizinische Klinik III, Hämatologie/Onkologie/Rheumatologie, Universitätsklinikum Bonn, Bonn, Germany
| | - Marie von Lilienfeld-Toal
- Klinik für Innere Medizin II, Abteilung für Hämatologie und Onkologie, Universitätsklinikum Jena, Jena, Germany.,Leibniz-Institut für Naturstoff-Forschung und Infektionsbiologie, Hans-Knöll Institut, Jena, Germany.,Center for Sepsis Control and Care (CSCC), Universitätsklinikum Jena, Jena, Germany
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Palmieri R, Buckley SA, Othus M, Halpern AB, Percival MEM, Scott BL, Hendrie PC, Becker PS, Oehler VG, Estey EH, Walter RB. Randomized phase 1 study of sequential ("primed") vs. concurrent decitabine in combination with cladribine, cytarabine, G-CSF, and mitoxantrone (CLAG-M) in adults with newly diagnosed or relapsed/refractory acute myeloid leukemia (AML) or other high-grade myeloid neoplasm. Leuk Lymphoma 2020; 61:1728-1731. [PMID: 32077361 DOI: 10.1080/10428194.2020.1728754] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Affiliation(s)
- Raffaele Palmieri
- Clinical Research Division, Fred Hutchinson Cancer Research Center/University of Washington, Seattle, WA, USA
| | - Sarah A Buckley
- Clinical Research Division, Fred Hutchinson Cancer Research Center/University of Washington, Seattle, WA, USA
| | - Megan Othus
- Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Anna B Halpern
- Clinical Research Division, Fred Hutchinson Cancer Research Center/University of Washington, Seattle, WA, USA.,Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA
| | - Mary-Elizabeth M Percival
- Clinical Research Division, Fred Hutchinson Cancer Research Center/University of Washington, Seattle, WA, USA.,Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA
| | - Bart L Scott
- Clinical Research Division, Fred Hutchinson Cancer Research Center/University of Washington, Seattle, WA, USA.,Department of Medicine, Division of Medical Oncology, University of Washington, Seattle, WA, USA
| | - Paul C Hendrie
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Seattle Cancer Care Alliance, Seattle, WA, USA
| | - Pamela S Becker
- Clinical Research Division, Fred Hutchinson Cancer Research Center/University of Washington, Seattle, WA, USA.,Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA
| | - Vivian G Oehler
- Clinical Research Division, Fred Hutchinson Cancer Research Center/University of Washington, Seattle, WA, USA.,Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA
| | - Elihu H Estey
- Clinical Research Division, Fred Hutchinson Cancer Research Center/University of Washington, Seattle, WA, USA.,Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA
| | - Roland B Walter
- Clinical Research Division, Fred Hutchinson Cancer Research Center/University of Washington, Seattle, WA, USA.,Department of Medicine, Division of Hematology, University of Washington, Seattle, WA, USA.,Department of Pathology, University of Washington, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA
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Jurcic JG. Targeted Alpha-Particle Therapy for Hematologic Malignancies. J Med Imaging Radiat Sci 2019; 50:S53-S57. [PMID: 31253514 DOI: 10.1016/j.jmir.2019.05.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 05/24/2019] [Accepted: 05/27/2019] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The short range and high linear energy transfer of α-particles offer the potential for efficient tumor killing while sparing surrounding normal cells. Hematologic malignancies are ideally suited to targeted α-therapy because of easy accessibility of malignant cells in blood and bone marrow and their radiosensitivity. METHODS A series of clinical trials were conducted to assess the safety and antileukemic effects of lintuzumab, an anti-CD33 antibody, labeled with the α-emitters bismuth-213 (213Bi) and actinium-225 (225Ac) in patients with acute myeloid leukemia (AML). RESULTS Initial studies showed that 213Bi-lintuzumab had antileukemic activity and could produce remissions after partial cytoreduction with cytarabine. A phase I trial demonstrated that a single infusion of 225Ac-lintuzumab could be given safely at doses up to 111 kBq/kg with antileukemic activity at all dose levels studied. A second phase I study showed that 28% of older patients with untreated AML had objective responses after receiving fractionated-dose 225Ac-lintuzumab and low-dose cytarabine. A phase II study of 225Ac-lintuzumab monotherapy in this population produced remissions in 69% of patients receiving two fractions of 74 kBq/kg and 22% of patients receiving two 55.5-kBq/kg fractions. CONCLUSIONS Studies with 213Bi-lintuzumab provided proof of principle for systemically administered α-particle therapy. 225Ac-lintuzumab was active against advanced AML and produced remissions in older patients with untreated AML in combination with low-dose cytarabine and as a single agent. These studies provide the rationale for development of 225Ac-lintuzumab in combination with a variety of agents in AML and in other hematologic malignancies such as myelodysplastic syndrome and multiple myeloma.
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Affiliation(s)
- Joseph G Jurcic
- Division of Hematology/Oncology, Department of Medicine, Columbia University Medical Center, New York-Presbyterian Hospital, Herbert Irving Comprehensive Cancer Center, New York, New York, USA.
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Zhou A, Han Q, Song H, Zi J, Ma J, Ge Z. Efficacy and toxicity of cladribine for the treatment of refractory acute myeloid leukemia: a meta-analysis. Drug Des Devel Ther 2019; 13:1867-1878. [PMID: 31213774 PMCID: PMC6549775 DOI: 10.2147/dddt.s207425] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 04/26/2019] [Indexed: 01/23/2023] Open
Abstract
Purpose: To investigate the overall efficacy and toxicity of cladribine and cladribine-based chemotherapy in the treatment of patients with refractory acute myeloid leukemia (AML) based on meta-analysis. Methods: PubMed, EMBASE database, and the Cochrane Library were searched for relevant studies. Eligible studies were clinical trials of refractory AML assigned to cladribine with data on efficacy including complete remission (CR) rate, overall response rate (ORR) and overall survival. Toxicity was evaluated based on the early death rate and the incidence of grade 3 and 4 adverse events (AEs). Results: A total of 10 clinical trials including 422 refractory AML patients were analyzed. The overall CR rate was 42.2% (95% CI: 31.0-54.3%). And the ORR of seven trials including 235 patients was 49.7% (95% CI: 33.5-66.0%). The overall early death rate of 260 patients enrolled in five trials was 6.8% (95% CI: 4.3-10.6%). Thrombocytopenia, anemia, neutropenia, and infection were the most common grade 3 and 4 AEs. Conclusion: Cladribine is effective for refractory AML, and its efficacy can be increased with the combination of cladribine, cytarabine, and granulocyte-colony stimulating factor regimen.
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Affiliation(s)
- Anqi Zhou
- Department of Hematology, Zhongda Hospital Southeast University, Institute of Hematology Southeast University, Nanjing210009, People’s Republic of China
| | - Qi Han
- Department of Hematology, Zhongda Hospital Southeast University, Institute of Hematology Southeast University, Nanjing210009, People’s Republic of China
| | - Huihui Song
- Department of Hematology, Zhongda Hospital Southeast University, Institute of Hematology Southeast University, Nanjing210009, People’s Republic of China
| | - Jie Zi
- Department of Hematology, Zhongda Hospital Southeast University, Institute of Hematology Southeast University, Nanjing210009, People’s Republic of China
| | - Jinlong Ma
- Department of Hematology, Zhongda Hospital Southeast University, Institute of Hematology Southeast University, Nanjing210009, People’s Republic of China
| | - Zheng Ge
- Department of Hematology, Zhongda Hospital Southeast University, Institute of Hematology Southeast University, Nanjing210009, People’s Republic of China
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Xiao H, Li L, Pang Y, Wu Y, Jiang Z, Liu Z, Wu J, Xiao Y, Huang F, Liu Q, Zhang H, Luo Y, Huang H. Sequential treatment combining cladribine-based re-induction, myeloablative allogeneic HSCT, and prophylactic donor lymphocyte infusion: a promising treatment for refractory acute myeloid leukemia. Ann Hematol 2018; 97:2479-2490. [PMID: 30078144 DOI: 10.1007/s00277-018-3453-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 07/19/2018] [Indexed: 11/26/2022]
Abstract
We describe the first multicenter prospective study to assess the efficacy, safety, and immune reconstitution of a novel sequential transplant approach in 24 patients with primary induction failure/relapsed acute myeloid leukemia (AML). The sequential regimen consisted of cladribine 5 mg/m2/day and cytarabine 2 g/m2/day for 5 days and mitoxantrone 7 mg/m2/day for 3 days, followed by myeloablative allogeneic hematopoietic stem cell transplantation (allo-HSCT) using intravenous busulfan (3.2 mg/kg/day) for 4 days and cyclophosphamide (60 mg/kg/day) for 2 days. Patients in CR without acute graft-versus-host disease at day + 90 received prophylactic donor lymphocyte infusion (pDLI). At the time of transplantation, a marrow blast infiltration > 20% or any level of circulating blasts was found in 62.5% of patients. The cumulative incidence of relapse at 2 years was 29.8%. Overall survival (OS) was 74.5% at 1 year and 56.5% at 2 years. Leukemia-free survival (LFS) at 1 and 2 years was 62.5 and 50.5%, respectively. Multivariate analysis demonstrated that haploidentical related donor, pDLI, and experiencing chronic graft-versus-host disease (cGVHD) were protective from relapse. Total T cells and T cell subsets in peripheral blood recovered at 3 months post-HSCT. The expressions of immune checkpoints (cytotoxic T lymphocyte antigen 4 and programmed death 1) were extremely low in T cells over the first 1 year post-transplantation.
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Affiliation(s)
- Haowen Xiao
- Department of Hematology, Guangzhou General Hospital of Guangzhou Military Command, No. 111 Liuhua Rd., Guangzhou, 510010, Guangdong Province, People's Republic of China.
- Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, People's Republic of China.
| | - Li Li
- Center of Cell-Biological Therapy and Research, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, Guangdong Province, People's Republic of China
| | - Yan Pang
- Department of Hematology, Guangzhou General Hospital of Guangzhou Military Command, No. 111 Liuhua Rd., Guangzhou, 510010, Guangdong Province, People's Republic of China
| | - Yuanbin Wu
- Department of Hematology, Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong Province, People's Republic of China
| | - Zujun Jiang
- Department of Hematology, Guangzhou General Hospital of Guangzhou Military Command, No. 111 Liuhua Rd., Guangzhou, 510010, Guangdong Province, People's Republic of China
| | - Zenghui Liu
- Department of Hematology, Guangzhou General Hospital of Guangzhou Military Command, No. 111 Liuhua Rd., Guangzhou, 510010, Guangdong Province, People's Republic of China
| | - Jiulong Wu
- Center of Cell-Biological Therapy and Research, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, Guangdong Province, People's Republic of China
| | - Yang Xiao
- Department of Hematology, Guangzhou General Hospital of Guangzhou Military Command, No. 111 Liuhua Rd., Guangzhou, 510010, Guangdong Province, People's Republic of China
| | - Fen Huang
- Department of Hematology, Nanfang Hospital of Southern Medical University, Guangzhou, Guangdong Province, People's Republic of China
| | - Qifa Liu
- Department of Hematology, Nanfang Hospital of Southern Medical University, Guangzhou, Guangdong Province, People's Republic of China
| | - Hang Zhang
- Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, People's Republic of China
| | - Yi Luo
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, People's Republic of China
| | - He Huang
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, People's Republic of China
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11
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Hassan IB, Kristensen J, Al Qawasmeh K, Alam A. Re-induction chemotherapy using FLAG-mitoxantrone for adult patients with relapsed acute leukemia: a single-center experience from United Arab Emirates. Int J Hematol 2018; 108:390-401. [PMID: 29951735 DOI: 10.1007/s12185-018-2478-3] [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: 03/04/2018] [Revised: 06/04/2018] [Accepted: 06/14/2018] [Indexed: 10/28/2022]
Abstract
We studied the outcome of 47 adult patients with relapsed acute leukaemia (AML = 25 and ALL = 22) treated with FLAG-mitoxantrone regimen. Median time to relapse was 10.7 months (range 1.9-27.7). Complete remission (CR2) was 60.1% which was significantly more frequent in ALL compared to AML (P = 0.049). WBC count < 100 × 109/L at initial diagnosis and time to relapse > 1 year were significantly predictor for CR2 in AML (P = 0.005 for both). Induction death was significantly higher in ALL compared to AML (P = 0.039). Median follow-up was 4.0 months (0.9-119.8) for AML and 2.1 months (range 0.6-118.1) for ALL. Nine patients underwent allogeneic stem-cell transplantation (allo-SCT). Estimated overall survival (OS) at 12 and 18 months was 60.5 and 34.6%, respectively, for AML, and 39.9 and 29.9%, respectively, for ALL. For AML patients failure to achieve CR, WBC count at initial diagnosis > 5 × 109/L and poor cytogenetic risk group was significant predictors of poor OS (P = 0.010, P = 0.025, and P = 0.015, respectively). For ALL patients failure to achieve of CR, WBC count at relapse < 5 × 109/L (CR patients) and lack of any type of consolidation therapy were significant predictor of poor OS (P < 0.001, P = 0.008, P = 0.008, respectively).
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Affiliation(s)
- Inaam Bashir Hassan
- Department of Internal Medicine, Faculty of Medicine and Health Sciences, United Arab Emirates University, P.O. Box 17666, Al Ain, United Arab Emirates. .,Department of Hematology, Oncology Tawam Hospital, Al Ain, United Arab Emirates.
| | | | - Khalid Al Qawasmeh
- Department of Hematology, Oncology Tawam Hospital, Al Ain, United Arab Emirates
| | - Arif Alam
- Department of Hematology, Oncology Tawam Hospital, Al Ain, United Arab Emirates
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12
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Megías-Vericat JE, Martínez-Cuadrón D, Sanz MÁ, Montesinos P. Salvage regimens using conventional chemotherapy agents for relapsed/refractory adult AML patients: a systematic literature review. Ann Hematol 2018; 97:1115-1153. [DOI: 10.1007/s00277-018-3304-y] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 03/12/2018] [Indexed: 12/26/2022]
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13
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Wang J, Zhao J, Fei X, Yin Y, Cheng H, Zhang W, Gu J, Yang F, Yang Y, Xue S, Tian Z, He J, Zhang S, Wang X. A new intensive conditioning regimen for allogeneic hematopoietic stem cell transplantation in patients with refractory or relapsed acute myeloid leukemia. Medicine (Baltimore) 2018; 97:e0228. [PMID: 29702970 PMCID: PMC5944519 DOI: 10.1097/md.0000000000010228] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
To explore the efficacy, and safety of the intensive conditioning regimen consisting of cladribine, cytarabine (Ara-C), and granulocyte colony-stimulating factor (G-CSF) plus modified busulfan (Bu) combined with cytoxan (Cy) (BuCy), prior to allogeneic hematopoietic stem cell transplantation (allo-HSCT) in patients with refractory, or relapsed acute myeloid leukemia (R/R AML).Thirty-Six R/R AML patients scheduled to receive allo-HSCT were consecutively, enrolled in this prospective study, and treated using intensive conditioning regimen consisting of CLAG plus modified BuCy. Median follow-up duration was 11.25 (range 0.5 - 21.0) months and the last follow up date was August 15, 2017.All patients (100%) achieved white blood cell (WBC) recovery within a median time of 16.00 (13.25 - 18.00) days, and 34 of them (94%) attained platelet (PLT) recovery within a median time of 13.50 (9.25 - 19.75) days. Incidence of acute graft-versus-host disease (aGVHD) was 50.00%, with median time of 71.50 (41.00 - 401.25) days. Three patients developed Grade I; nine, Grade II; 5, Grade III; and 1, Grade IV aGVHD. The incidence of chronic GVHD (cGVHD) was 44.40%, with median time of 255.00 (120.00 - 390.00) days. Four patients developed limited cGVHD, and 12, extensive cGVHD. One-year accumulating leukemia free survival (LFS), and overall survival (OS) rates between 52.9 ± 8.8% to 69.4 ± 7.7%, respectively. Eighteen (50%) patients were infected with cytomegalovirus; 2 (5.6%), with Epstein-Barr virus (EBV), 7 (19.4%), with hemorrhagic cystitis; 13 (36.1%), with bacteria; and 8 (22.2%), with fungus.Intensive conditioning regimen of CLAG plus modified BuCy for allo-HSCT may be effective and well-tolerated in R/R AML patients.
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14
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Zhang J, Sun Y, Zhang X, Long B, Lu Y, Li X. Treatment of High-Risk Acute Myeloid Leukemia With Cladribine, Cytarabine, Mitoxantrone, and Granulocyte Colony-Stimulating Factor Then Subsequent Bridging to Myeloablative Allogeneic Hematopoietic Stem Cell Transplantation: A Case Series. Transplant Proc 2018; 50:246-249. [DOI: 10.1016/j.transproceed.2017.11.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Accepted: 11/03/2017] [Indexed: 01/15/2023]
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15
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Pluta A, Robak T, Wrzesien-Kus A, Katarzyna Budziszewska B, Sulek K, Wawrzyniak E, Czemerska M, Zwolinska M, Golos A, Holowiecka-Goral A, Kyrcz-Krzemien S, Piszcz J, Kloczko J, Mordak-Domagala M, Lange A, Razny M, Madry K, Wiktor-Jedrzejczak W, Grosicki S, Butrym A, Kuliczkowski K, Warzocha K, Holowiecki J, Giebel S, Szydlo R, Wierzbowska A. Addition of cladribine to the standard induction treatment improves outcomes in a subset of elderly acute myeloid leukemia patients. Results of a randomized Polish Adult Leukemia Group (PALG) phase II trial. Am J Hematol 2017; 92:359-366. [PMID: 28103640 DOI: 10.1002/ajh.24654] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 01/13/2017] [Accepted: 01/14/2017] [Indexed: 11/09/2022]
Abstract
Intensive induction chemotherapy using anthracycline and cytarabine backbone is considered the most effective upfront therapy in physically fit older patients with acute myeloid leukemia (AML). However, outcomes of the standard induction in elderly AML are inferior to those observed in younger patients, and they are still unsatisfactory. As addition of cladribine to the standard induction therapy is known to improve outcome in younger AML patients. The present randomized phase II study compares efficacy and toxicity of the DAC (daunorubicin plus cytarabine plus cladribine) regimen with the standard DA (daunorubicin plus cytarabine) regimen in the newly diagnosed AML patients over 60 years of age. A total of 171 patients were enrolled in the study (DA, 86; DAC, 85). A trend toward higher complete remission (CR) was observed in the DAC arm compared to the DA arm (44% vs. 34%; P = .19), which did not lead to improved median overall survival, which in the case of the DAC group was 8.6 months compared to in 9.1 months in the DA group (P = .64). However, DAC appeared to be superior in the group of patients aged 60-65 (CR rate: DAC 51% vs. DA 29%; P = .02). What is more, a subgroup of patients, with good and intermediate karyotypes, benefited from addition of cladribine also in terms of overall survival (P = .02). No differences in hematological and nonhematological toxicity between the DA and DAC regimens were observed.
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Affiliation(s)
- Agnieszka Pluta
- Department of Hematology; Medical University of Lodz; Lodz Poland
| | - Tadeusz Robak
- Department of Hematology; Medical University of Lodz; Lodz Poland
| | | | | | - Kazimierz Sulek
- Department of Clinical Hematology; Military Medical Academy; Warsaw Poland
| | - Ewa Wawrzyniak
- Department of Hematology; Medical University of Lodz; Lodz Poland
| | | | | | - Aleksandra Golos
- Department of Hematology; Medical University of Lodz; Lodz Poland
| | | | | | - Jaroslaw Piszcz
- Department of Hematology; Bialystok Medical Academy; Bialystok Poland
| | - Janusz Kloczko
- Department of Hematology; Bialystok Medical Academy; Bialystok Poland
| | - Monika Mordak-Domagala
- L. Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Wrocław, Poland and Lower Silesian Center for Cellular Transplantation & National Bone Marrow Donor Registry; Wrocław Poland
| | - Andrzej Lange
- L. Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Wrocław, Poland and Lower Silesian Center for Cellular Transplantation & National Bone Marrow Donor Registry; Wrocław Poland
| | - Małgorzata Razny
- Hematology Department; Rydygier Memorial Hospital; Krakow Poland
| | - Krzysztof Madry
- Department of Hematology, Oncology and Internal Diseases; Medical University of Warsaw; Warsaw Poland
| | | | - Sebastian Grosicki
- Department of Cancer Prevention, Faculty of Public Health; Silesian Medical University; Katowice Poland
| | - Aleksandra Butrym
- Department of Physiology; Wroclaw Medical University; Wroclaw Poland
| | - Kazimierz Kuliczkowski
- Department of Hematology and Proliferative Diseases; Wroclaw Medical Academy; Wroclaw Poland
| | - Krzysztof Warzocha
- Department of Hematology; Institute of Hematology and Transfusion Medicine; Warsaw Poland
| | - Jerzy Holowiecki
- Department of Bone Marrow Transplantation; Comprehensive Cancer Center, M. Sklodowska-Curie Memorial Institute; Gliwice Poland
| | - Sebastian Giebel
- Department of Bone Marrow Transplantation; Comprehensive Cancer Center, M. Sklodowska-Curie Memorial Institute; Gliwice Poland
| | - Richard Szydlo
- Hammersmith Hospital; Centre for Haematology, Imperial College London; London United Kingdom
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16
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Park H, Youk J, Kim I, Yoon SS, Park S, Lee JO, Bang SM, Koh Y. Comparison of cladribine- and fludarabine-based induction chemotherapy in relapsed or refractory acute myeloid leukaemia. Ann Hematol 2016; 95:1777-86. [PMID: 27539617 DOI: 10.1007/s00277-016-2774-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 07/29/2016] [Indexed: 01/09/2023]
Abstract
Induction regimens integrating cladribine or fludarabine have shown promising outcomes in relapsed or refractory (R/R) acute myeloid leukaemia (AML). We compared the outcome of a cladribine- versus a fludarabine-based regimen as induction chemotherapy for R/R-AML. We included patients with R/R-AML who were treated with a cladribine- or fludarabine-based chemotherapy between 2006 and 2015. We analysed 120 patients, 65 treated with cladribine and 55 treated with fludarabine. The CR rates were 62.7 and 61.4 % for the cladribine group and fludarabine group, respectively (p = 0.890). Poor prognostic factors included older age, secondary AML, poor cytogenetic risk group, prior induction failure, and short first CR duration. No significant overall survival (OS) or relapse-free survival (RFS) differences were found between the groups (OS, p = 0.213; RFS, p = 0.143). However, in a certain subset, survival outcomes were better with cladribine than with fludarabine, including de novo AML, CR at first induction therapy, and not-poor cytogenetic risk group inclusion without overt chemotherapy-refractoriness. By contrast, secondary AML patients had improved survival outcomes when treated with the fludarabine regimen. After CR, better outcomes were observed when allogeneic stem cell transplantation (SCT) was given as consolidation. In R/R-AML, cladribine- and fludarabine-based combination induction chemotherapy had differential survival outcomes according to disease characteristics. Allogeneic SCT after CR with a purine analogue-based regimen improved long-term outcome in these patients.
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Affiliation(s)
- Hyunkyung Park
- Department of Internal Medicine, Seoul National University Hospital, 101 Daehag-ro, Jongno-gu, Seoul, 110-744, Republic of Korea
| | - Jeonghwan Youk
- Department of Internal Medicine, Seoul National University Hospital, 101 Daehag-ro, Jongno-gu, Seoul, 110-744, Republic of Korea
| | - Inho Kim
- Department of Internal Medicine, Seoul National University Hospital, 101 Daehag-ro, Jongno-gu, Seoul, 110-744, Republic of Korea.,Cancer Research Institute, College of Medicine, Seoul National University, Seoul, Republic of Korea.,Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sung-Soo Yoon
- Department of Internal Medicine, Seoul National University Hospital, 101 Daehag-ro, Jongno-gu, Seoul, 110-744, Republic of Korea.,Cancer Research Institute, College of Medicine, Seoul National University, Seoul, Republic of Korea.,Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Seonyang Park
- Department of Internal Medicine, Seoul National University Hospital, 101 Daehag-ro, Jongno-gu, Seoul, 110-744, Republic of Korea.,Cancer Research Institute, College of Medicine, Seoul National University, Seoul, Republic of Korea.,Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jeong-Ok Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Soo-Mee Bang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Youngil Koh
- Department of Internal Medicine, Seoul National University Hospital, 101 Daehag-ro, Jongno-gu, Seoul, 110-744, Republic of Korea. .,Cancer Research Institute, College of Medicine, Seoul National University, Seoul, Republic of Korea. .,Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea.
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17
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Duan MH, Zhang Y, Zhang M, Han X, Zhang Y, Yang C, Feng J, Zhang L, Zhang W, Li J, Tian LP, Zhang Y, Zhou DB. [Efficacy and safety analysis of the combination of cladribine, cytarabine, granulocyte colonystimulating factor (CLAG) regime in patients with refractory or relapsed acute myeloid leukemia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2016; 37:571-5. [PMID: 27535856 PMCID: PMC7365013 DOI: 10.3760/cma.j.issn.0253-2727.2016.07.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To analyze efficacy and safety of CLAG regimen in patients with refractory or relapsed acute myeloid leukemia (AML). METHODS Efficacy and adverse events of patients with refractory or relapsed AML who were treated with one course of CLAG from April 1st, 2014 through December 9th, 2015 in our hospital were retrospectively reviewed. RESULTS Thirty- three patients (16 males and 17 females) with refractory or relapsed AML were treated with one course of CLAG with a median age of 49 (14-68) years. According to FAB subtype, there were 22 patients with M2, and 11 with other types. According to NCCN criteria, there were 6, 18 and 9 patients with favorable, intermediate and unfavorable risk respectively, including 5 with FLT3- ITD mutation. Of 16 refractory and 17 relapsed patients; the median previous chemotherapy courses were 2(1-36). After one course of CLAG, 78.8% (26/33) patients achieved hematological complete response (CR), with 93.8 %(15/16) in relapsed and 64.7 %(11/17) in refractory groups respectively. All five patients with FLT3- ITD mutation achieved CR. All patients had grade 4 neutropenia and thrombocytopenia and infection in different sites; three patients died early from infections. Five patients received allogeneic hematopoietic stem cell transplantation (allo- HSCT). Ten patients relapsed and thirteen patients died after the median follow-up 142(9-525) days. The median EFS and OS were 230 (9- 525) and 419(9- 525) days respectively, which in CR group (n=26) were significantly longer than those in NR one (n=7) [447 (165- 525) d vs 52 (9- 162) d,P <0.001]. CONCLUSIONS CLAG regimen was effective and well tolerable in patients with refractory or relapsed AML, with the CR rate in relapsed patients higher than in refractory counterparts. Control of infections was imperative for treatment.
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Affiliation(s)
- M H Duan
- Department of Hematology, PUMC Hospital, CAMS & PUMC, Beijing 100730, China
| | | | | | | | | | | | | | | | | | | | | | | | - D B Zhou
- Department of Hematology, PUMC Hospital, CAMS & PUMC, Beijing 100730, China
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18
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Bryan JC, Jabbour EJ. Management of Relapsed/Refractory Acute Myeloid Leukemia in the Elderly: Current Strategies and Developments. Drugs Aging 2016; 32:623-37. [PMID: 26286093 DOI: 10.1007/s40266-015-0285-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Elderly patients with acute myeloid leukemia (AML) who are refractory to or relapse following frontline treatment constitute a poor-risk group with a poor long-term outcome. Host-related factors and unfavorable disease-related features contribute to early treatment failures following frontline therapy, thus making attainment of remission and long-term survival with salvage therapy particularly challenging for elderly patients. Currently, no optimal salvage strategy exists for responding patients, and allogeneic hematopoietic stem cell transplant is the only curative option in this setting; however, the vast majority of elderly patients are not candidates for this procedure due to poor functional status secondary to age and age-related comorbidities. Furthermore, the lack of effective salvage programs available for elderly patients with recurrent AML underscores the need for therapies that consistently yield durable remissions or durable control of their disease. The purpose of this review was to highlight the currently available strategies, as well as future strategies under development, for treating older patients with recurrent AML.
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Affiliation(s)
- Jeffrey C Bryan
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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19
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Grosicki S, Holowiecki J, Kuliczkowski K, Skotnicki A, Hellmann A, Kyrcz-Krzemien S, Dmoszynska A, Sułek K, Kloczko J, Jedrzejczak WW, Warzocha K, Zdziarska B, Wierzbowska A, Pluta A, Komarnicki M, Giebel S. Assessing the efficacy of allogeneic hematopoietic stem cells transplantation (allo-HSCT) by analyzing survival end points in defined groups of acute myeloid leukemia patients: a retrospective, multicenter Polish Adult Leukemia Group study. Am J Hematol 2015; 90:904-9. [PMID: 26149802 DOI: 10.1002/ajh.24113] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 05/05/2015] [Accepted: 07/02/2015] [Indexed: 11/07/2022]
Abstract
The importance of allogeneic hematopoietic stem cell transplantation (allo-HSCT) for survival outcomes in patients with acute myeloid leukemia (AML) currently remains unclear. The study aimed to compare measures of clinical treatment for patients with AML in CR1 (the first complete remission) with or without being subjected to allo-HSCT. These consisted of leukemia-free survival (LFS), overall survival (OS), cumulative incidence of relapse (CIR), and non-relapse mortality disease (NRM). Subjects were 622 patients, median age of 44, forming part of the prospective, randomized, and multicenter clinical Polish Adult Leukemia Group trials during 1999-2008. The Mantel-Byar approach was used to assess allo-HSCT on survival endpoints, accounting for a changing transplant status. Undergoing allo-HSCT significantly improved the LFS and OS for the entire group of patients with AML in CR1, along with the DAC induction subgroup and for the group with unfavorable cytogenetics aged 41-60. The CIR demonstrated that allo-HSCT reduced the risk of relapse for patients with AML in CR1 and those with an unfavorable cytogenetic risk. In addition, the NRM analysis showed that allo-HSCT significantly reduced the risk of death unrelated to relapse for the entire group of AML patients in CR1 and aged 41-60. The allo-HSCT treatment particularly benefitted survival for the AML in CR1 group having an unfavorable cytogenetic prognosis.
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Affiliation(s)
- Sebastian Grosicki
- Department of Cancer Prevention, School of Public Health; Medical University of Silesia; Katowice Poland
| | - Jerzy Holowiecki
- Department of Bone Marrow Transplantation, Branch Gliwice; Comprehensive Cancer Center M. Sklodowska-Curie Memorial Institute; Gliwice Poland
| | - Kazimierz Kuliczkowski
- Department of Haematology, Hematopoietic Malignancies and BMT; Medical University; Wroclaw Poland
| | - Aleksander Skotnicki
- Department of Haematology, Collegium Medicum; Jagiellonian University; Cracow Poland
| | - Andrzej Hellmann
- Department of Haematology and Transplantology; Medical University; Gdansk Poland
| | - Slawomira Kyrcz-Krzemien
- Department of Haematology and Bone Marrow Transplantation; Medical University of Silesia; Katowice Poland
| | - Anna Dmoszynska
- Samodzielna Pracownia Transplantologii Klinicznej; Uniwersytet Medyczny; Lublin Poland
| | | | - Janusz Kloczko
- Department of Hematology; Medical University; Bialystok Poland
| | - Wieslaw W. Jedrzejczak
- Department of Hematology, Oncology and Internal Medicine; Medical University; Warsaw Poland
| | - Krzysztof Warzocha
- Department of Haematology; Institute of Haematology and Transfusion Medicine; Warsaw Poland
| | - Barbara Zdziarska
- Department of Internal Medicine and Haematology; SPSK Nr 1; Szczecin Poland
| | - Agnieszka Wierzbowska
- Department of Haematology, Copernicus Memorial Hospital; Medical University; Lodz Poland
| | - Agnieszka Pluta
- Department of Haematology, Copernicus Memorial Hospital; Medical University; Lodz Poland
| | - Mieczyslaw Komarnicki
- Department of Hematology and Proliferative Diseases of The Hematopoietic Systems; Poznan University of Medical Sciences; Poznan Poland
| | - Sebastian Giebel
- Department of Bone Marrow Transplantation, Branch Gliwice; Comprehensive Cancer Center M. Sklodowska-Curie Memorial Institute; Gliwice Poland
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20
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21
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Freyer CW, Gupta N, Wetzler M, Wang ES. Revisiting the role of cladribine in acute myeloid leukemia: an improvement on past accomplishments or more old news? Am J Hematol 2015; 90:62-72. [PMID: 25284482 DOI: 10.1002/ajh.23862] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 09/28/2014] [Accepted: 09/29/2014] [Indexed: 01/19/2023]
Abstract
Originally studied in lymphoid diseases, cladribine (CdA) is an adenosine deaminase resistant analog of adenosine that was later discovered to induce myeloid cell apoptosis. The activity of CdA in myeloid malignancies was first reported in relapsed/refractory (RR) pediatric acute myeloid leukemia (AML) with complete response (CR) rates of up to 47%. Consequently, several studies have confirmed the efficacy of single agent CdA or CdA combination regimens in AML. Established CR rates for combination regimens in RR adults are approximately 50%, while CR rates for newly diagnosed (ND) adults are approximately 70% and show similar toxicity profiles to previously used regimens. Despite these promising data, many centers have yet to adopt CdA combination regimens for these difficult to treat populations. We review the pharmacology, pharmacokinetics, clinical data, and safety of CdA monotherapy and combination regimens for the management of pediatric and adult ND and RR-AML.
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Affiliation(s)
- Craig W. Freyer
- Department of Pharmacy; Roswell Park Cancer Institute; Buffalo New York
| | - Neha Gupta
- Department of Medicine; SUNY-UB School of Medicine; Buffalo New York
| | - Meir Wetzler
- Department of Medicine, Leukemia Service; Roswell Park Cancer Institute; Buffalo New York
| | - Eunice S. Wang
- Department of Medicine, Leukemia Service; Roswell Park Cancer Institute; Buffalo New York
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22
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Jaglal MV, Duong VH, Bello CM, Al Ali NH, Padron E, Fernandez HF, List AF, Lancet JE, Komrokji RS. Cladribine, cytarabine, filgrastim, and mitoxantrone (CLAG-M) compared to standard induction in acute myeloid leukemia from myelodysplastic syndrome after azanucleoside failure. Leuk Res 2014; 38:443-6. [DOI: 10.1016/j.leukres.2013.12.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Revised: 12/03/2013] [Accepted: 12/14/2013] [Indexed: 12/18/2022]
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23
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Yu W, Mao L, Qian J, Qian W, Meng H, Mai W, Tong H, Tong Y, Jin J. Homoharringtonine in combination with cytarabine and aclarubicin in the treatment of refractory/relapsed acute myeloid leukemia: a single-center experience. Ann Hematol 2013; 92:1091-100. [PMID: 23595277 DOI: 10.1007/s00277-013-1758-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Accepted: 04/05/2013] [Indexed: 10/27/2022]
Abstract
To assess the efficacy and toxicity of HAA regimen (Homoharringtonine 4 mg/m(2)/day, days 1-3; cytarabine 150 mg/m(2)/day, days 1-7; aclarubicin 12 mg/m(2)/day, days 1-7) as a salvage therapy in the treatment of refractory and/or relapsed acute myeloid leukemia (AML), 46 patients with refractory and/or relapsed AML, median age 37 (16-65) years, participated in this clinical study. The median follow-up was 41 (10-86) months. Eighty percent of patients achieved complete remission (CR), and the first single course of re-induction HAA regimen resulted in CR rate of 76.1 %. The study protocol allowed two courses of induction. The CR rates of patients with favorable, intermediate and unfavorable cytogenetics were 90 %, 88.9 %, and 37.5 %, respectively. For all patients, the estimated 3-year overall survival (OS) rate was 42 %, and the estimated relapse free survival (RFS) at 3 years for the 36 CR cases was 49 %. The toxicities associated with HAA regimen were acceptable. HAA is a good choice in cases with refractory/relapsing AML for salvage chemotherapy, preferably with a high-efficacy and low-toxicity profile.
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Affiliation(s)
- Wenjuan Yu
- Department of Hematology, the First Affiliated Hospital, Zhejiang University College of Medicine, No. 79 Qingchun Road, Hangzhou, Zhejiang, People's Republic of China
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Robak P, Robak T. Older and new purine nucleoside analogs for patients with acute leukemias. Cancer Treat Rev 2013; 39:851-61. [PMID: 23566572 DOI: 10.1016/j.ctrv.2013.03.006] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Revised: 03/05/2013] [Accepted: 03/14/2013] [Indexed: 02/05/2023]
Abstract
Purine nucleoside analogs (PNAs) compose a class of cytotoxic drugs that have played an important role in the treatment of hematological neoplasms, especially lymphoid and myeloid malignancies. All PNA drugs have a chemical structure similar to adenosine or guanosine, and they have similar mechanisms of action. They have many intracellular targets: they act as antimetabolites, competing with natural nucleosides during DNA or RNA synthesis, and as inhibitors of key cell enzymes. In contrast to other antineoplastic drugs, PNAs act cytotoxically, both in the mitotic and quiescent cell cycle phases. In the last few years, three PNAs have been approved for the treatment of lymphoid malignancies and other hematological disorders: 2-chlorodeoxyadenosine (2-CdA), fludarabine and pentostatin. 2-CdA and fludarabine are also active in the treatment of acute myeloid leukemia (AML). These drugs, in combination with cytarabine and other agents, are commonly used as salvage regimens in relapsed or refractory AML. Moreover, the addition of 2-CdA to the standard induction regimen is associated with an increased rate of complete remission and improved survival of adult patients with AML. More recently three novel PNAs have been synthesized and introduced into clinical trials: clofarabine, nelarabine and forodesine. Clofarabine is the most promising PNA in current clinical trials in pediatric and adult patients with acute leukemias. Nelarabine is more cytotoxic in T-lineage than in B-lineage leukemias. Clofarabine and nelarabine have been approved for the treatment of refractory patients with acute lymphoblastic leukemia (ALL) and lymphoblastic lymphoma. Clofarabine is also an active drug in AML treatment when administered either alone or in combination regimens as front-line treatment and in relapsed or refractory patients. Unlike other PNA, forodesine is not incorporated into DNA but displays a highly selective purine nucleoside phosphorylase inhibitory action. Forodesine is undergoing clinical trials for the treatment of T-cell malignancies, including T-cell ALL. This article summarizes recent achievements in the mechanism of action, pharmacological properties and clinical activity and toxicity of PNAs, as well as their emerging role in lymphoid and myeloid acute leukemias.
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Affiliation(s)
- Pawel Robak
- Department of Experimental Hematology, Medical University of Lodz, Copernicus Memorial Hospital, 93-510 Lodz, ul. Ciołkowskiego 2, Poland ul. Ciołkowskiego 2, Poland
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Martin MG, Welch JS, Augustin K, Hladnik L, DiPersio JF, Abboud CN. Cladribine in the Treatment of Acute Myeloid Leukemia: A Single-Institution Experience. ACTA ACUST UNITED AC 2009; 9:298-301. [DOI: 10.3816/clm.2009.n.058] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Lech-Maranda E, Seweryn M, Giebel S, Holowiecki J, Piatkowska-Jakubas B, Wegrzyn J, Skotnicki A, Kielbinski M, Kuliczkowski K, Paluszewska M, Jedrzejczak WW, Dutka M, Hellmann A, Flont M, Zdziarska B, Palynyczko G, Konopka L, Szpila T, Gawronski K, Sulek K, Sokolowski J, Kloczko J, Warzocha K, Robak T. Infectious complications in patients with acute myeloid leukemia treated according to the protocol with daunorubicin and cytarabine with or without addition of cladribine. A multicenter study by the Polish Adult Leukemia Group (PALG). Int J Infect Dis 2009; 14:e132-40. [PMID: 19581118 DOI: 10.1016/j.ijid.2009.02.021] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2008] [Revised: 09/22/2008] [Accepted: 02/04/2009] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES The addition of cladribine to the standard regimen consisting of daunorubicin and cytarabine has been reported to increase the efficacy of induction therapy in acute myeloid leukemia (AML). The goal of this study was to determine the effect of this modification on the incidence and spectrum of infectious complications. METHODS Case report forms of 309 patients with newly diagnosed AML who had been enrolled in the prospective, randomized 'DAC-7 vs. DA-7' trial were reviewed. The frequency, etiology, localization, severity, and outcome of infections were compared for patients receiving only daunorubicin and cytarabine (DA-7) and those additionally treated with cladribine (DAC-7). RESULTS A total of 443 febrile episodes were reported with no significant difference between the treatment groups. A trend towards a higher frequency of bacteremias was observed among DA-7 patients compared to those in the DAC-7 group (31% vs. 21%; p=0.08). The treatment arms did not differ in terms of the distribution of the isolated Gram-positive, Gram-negative, fungal, and viral organisms. However, when bacteremias were considered, Gram-positive blood cultures tended to be more frequent in the DA-7 compared to the DAC-7 group (16% vs. 8.5%; p=0.07). This difference reached statistical significance when major blood bacteremias were analyzed separately (13% vs. 5%; p=0.02). Complete recovery from infections was observed in the majority of patients across both treatment arms and no significant difference was noted regarding infection-related mortality. CONCLUSIONS The addition of cladribine to standard induction chemotherapy has no impact on the incidence and spectrum of infectious complications in newly diagnosed AML patients.
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Affiliation(s)
- Ewa Lech-Maranda
- Department of Hematology, Medical University of Lodz, Copernicus Hospital, Ciolkowskiego 2 str, 93-510 Lodz, Poland
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Twice daily fludarabine/Ara-C associated to idarubicin, G-CSF and ATRA is an effective salvage regimen in non-promyelocytic acute myeloid leukemia. Leuk Res 2009; 33:1072-8. [PMID: 19187960 DOI: 10.1016/j.leukres.2008.12.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2008] [Revised: 12/06/2008] [Accepted: 12/12/2008] [Indexed: 11/22/2022]
Abstract
Preclinical data suggest that all-trans retinoic acid (ATRA) synergizing with granulocyte colony stimulating factor (G-CSF), can improve the effectiveness of chemotherapy in acute myeloid leukemia (AML). Fludarabine 15 mg/m(2) is the minimum dose able to optimize intensification with fludarabine-arabinosylcytosine regimen. In this study 52 patients with relapsed/refractory AML obtained a complete remission (CR) rate of 69.2% after FLAIRG regimen (Fludarabine and arabinosylcytosine twice daily, idarubicin, G-CSF, ATRA). This schedule resulted effective and tolerable enabling 53% of the responding patients to receive transplant procedure. FLAIRG regimen could be proposed as a "bridge" to transplant treatment in this poor risk setting.
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Abstract
PURPOSE OF REVIEW Treatment for relapsed or refractory acute myeloid leukemia remains a major challenge for the leukemia community. Although several approaches have been tested in phase II study designs, few comparative data exist to guide treatment choices. We searched the recent literature in Medline, EMBASE and BIOSIS, and abstracts from the American Society of Hematology and American Society of Clinical Oncology published between 2005 and 2007. We reviewed each report to identify studies that used a phase II or III design and that included a majority of adults with non-M3 acute myeloid leukemia described as 'relapsed' or 'refractory'. RECENT FINDINGS Several studies utilized novel cytotoxic chemotherapies, immunotherapies, epigenetic agents, and small molecule inhibitors. It is not possible to identify a single regimen or approach as the standard of care in relapsed and refractory acute myeloid leukemia. New and promising approaches are being explored, however. SUMMARY Outcomes in patients treated for relapsed or refractory acute myeloid leukemia remain inadequate. Striking a balance between the treatment-related mortality associated with salvage therapies, response rates of salvage regimens, and the likelihood of long-term disease-free survival are critical in planning a treatment approach for the individual patient with relapsed or refractory acute myeloid leukemia.
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Daunorubicin, cytarabine and fludarabine (DAF) for remission induction in relapsed or refractory acute myeloid leukemia. Evaluation of safety, tolerance and early outcome—Polish Adult Leukemia Group (PALG) pilot study. Ann Hematol 2007; 87:361-7. [DOI: 10.1007/s00277-007-0421-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2007] [Accepted: 11/20/2007] [Indexed: 11/27/2022]
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Wierzbowska A, Robak T, Pluta A, Wawrzyniak E, Cebula B, Hołowiecki J, Kyrcz-Krzemień S, Grosicki S, Giebel S, Skotnicki AB, Piatkowska-Jakubas B, Kuliczkowski K, Kiełbiński M, Zawilska K, Kłoczko J, Wrzesień-Kuś A. Cladribine combined with high doses of arabinoside cytosine, mitoxantrone, and G-CSF (CLAG-M) is a highly effective salvage regimen in patients with refractory and relapsed acute myeloid leukemia of the poor risk: a final report of the Polish Adult Leukemia Group. Eur J Haematol 2007; 80:115-26. [PMID: 18076637 DOI: 10.1111/j.1600-0609.2007.00988.x] [Citation(s) in RCA: 107] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Patients with primary refractory AML and with early relapses have unfavorable prognoses and require innovative therapeutic approaches. Purine analogs fludarabine (FA) and cladribine (2-CdA) increase cytotoxic effect of Ara-C in leukemic blasts and inhibit DNA repair mechanisms; therefore its association with Ara-C and mitoxantrone (MIT) results in a synergistic effect. In the current report, we present the final results of multi-center phase II study evaluating the efficacy and toxicity of CLAG-M salvage regimen in poor risk refractory/relapsed AML patients. METHODS The induction chemotherapy consisted of 2-CdA 5 mg/m2, Ara-C 2 g/m2, MIT 10 mg/m2, and granulocyte-colony stimulating factor. In the case of PR, a second CLAG-M was administered. Patients in CR received consolidation courses based on high doses of Ara-C and MIT with or without 2-CdA. RESULTS One hundred and eighteen patients from 11 centers were registered; 78 primary resistant and 40 relapsed. Sixty-six patients (58%) achieved CR after one or two courses of CLAG-M, 49 (35%) were refractory, and 8 (7%) died early. WBC >10 g/L and age >34 yr were factors associated with increased risk of treatment failure. Hematological toxicity was the most prominent toxicity of this regimen. The probability of OS at 4 yr was 14% (95% CI 4-23%). OS was influenced by age, WBC >10 g/L and poor karyotype in both univariate and multivariate analyses. The probability of 4 yr DFS was 30% for all 66 patients in CR (95% CI 11-49%). Poor karyotype was the only factor associated with decreased probability of DFS. CONCLUSIONS We conclude that CLAG-M is a well-tolerated and highly effective salvage regimen in poor risk refractory/relapsed AML.
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Current Awareness in Hematological Oncology. Hematol Oncol 2005. [DOI: 10.1002/hon.731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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