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Krakow EF, Gyurkocza B, Storer BE, Chauncey TR, McCune JS, Radich JP, Bouvier ME, Estey EH, Storb R, Maloney DG, Sandmaier BM. Phase I/II multisite trial of optimally dosed clofarabine and low-dose TBI for hematopoietic cell transplantation in acute myeloid leukemia. Am J Hematol 2020; 95:48-56. [PMID: 31637757 DOI: 10.1002/ajh.25665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 10/15/2019] [Accepted: 10/16/2019] [Indexed: 11/11/2022]
Abstract
Clofarabine is an immunosuppressive purine nucleoside analog that may have better anti-leukemic activity than fludarabine. We performed a prospective phase I/II multisite trial of clofarabine with 2 Gy total body irradiation as non-myeloablative conditioning for allogeneic hematopoietic cell transplantation in adults with acute myeloid leukemia who were unfit for more intense regimens. Our main objective was to improve the 6-month relapse rate following non-myeloablative conditioning, while maintaining historic rates of non-relapse mortality (NRM) and engraftment. Forty-four patients, 53 to 74 (median: 69) years, were treated with clofarabine at 150 to 250 mg/m2 , of whom 36 were treated at the maximum protocol-specified dose. One patient developed multifactorial acute kidney injury and another developed multiorgan failure, but no other grade 3 to 5 non-hematologic toxicities were observed. All patients fully engrafted. The 6-month relapse rate was 16% (95% CI, 5%-27%) among all patients and 14% (95% CI, 3%-26%) among high-risk patients treated at the maximum dose, meeting the pre-specified primary efficacy endpoint. Overall survival was 55% (95% CI, 40%-70%) and leukemia-free survival was 52% (95% CI, 37%-67%) at 2 years. Compared to a historical high-risk cohort treated with the combination of fludarabine at 90 mg/m2 and 2 Gy TBI, protocol patients treated with the clofarabine-TBI regimen had lower rates of overall mortality (HR of 0.50, 95% CI, 0.28-0.91), disease progression or death (HR 0.48, 95% CI, 0.27-0.85), and morphologic relapse (HR 0.30, 95% CI, 0.13-0.69), and comparable NRM (HR 0.85, 95% CI 0.36-2.00). The combination of clofarabine with TBI warrants further investigation in patients with high-risk AML.
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Affiliation(s)
- Elizabeth F. Krakow
- Clinical Research DivisionFred Hutchinson Cancer Research Center Seattle Washington
- Department of MedicineUniversity of Washington Seattle Washington
| | - Boglarka Gyurkocza
- Clinical Research DivisionFred Hutchinson Cancer Research Center Seattle Washington
| | - Barry E. Storer
- Clinical Research DivisionFred Hutchinson Cancer Research Center Seattle Washington
| | - Thomas R. Chauncey
- Clinical Research DivisionFred Hutchinson Cancer Research Center Seattle Washington
- Department of MedicineUniversity of Washington Seattle Washington
- Bone Marrow Transplant Unit, VA Puget Sound Health Care System Seattle Washington
| | - Jeannine S. McCune
- Clinical Research DivisionFred Hutchinson Cancer Research Center Seattle Washington
- Department of PharmaceuticsUniversity of Washington Seattle Washington
| | - Jerald P. Radich
- Clinical Research DivisionFred Hutchinson Cancer Research Center Seattle Washington
- Department of MedicineUniversity of Washington Seattle Washington
| | - Michelle E. Bouvier
- Clinical Research DivisionFred Hutchinson Cancer Research Center Seattle Washington
| | - Elihu H. Estey
- Clinical Research DivisionFred Hutchinson Cancer Research Center Seattle Washington
- Department of MedicineUniversity of Washington Seattle Washington
| | - Rainer Storb
- Clinical Research DivisionFred Hutchinson Cancer Research Center Seattle Washington
- Department of MedicineUniversity of Washington Seattle Washington
| | - David G Maloney
- Clinical Research DivisionFred Hutchinson Cancer Research Center Seattle Washington
- Department of MedicineUniversity of Washington Seattle Washington
| | - Brenda M. Sandmaier
- Clinical Research DivisionFred Hutchinson Cancer Research Center Seattle Washington
- Department of MedicineUniversity of Washington Seattle Washington
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Peccatori J, Mastaglio S, Giglio F, Greco R, Crocchiolo R, Patriarca F, Forno B, Deola S, Assanelli A, Lupo Stanghellini MT, Marcatti M, Zecca M, Cortelazzo S, Fanin R, Fagioli F, Locatelli F, Ciceri F. Clofarabine and Treosulfan as Conditioning for Matched Related and Unrelated Hematopoietic Stem Cell Transplantation: Results from the Clo3o Phase II Trial. Biol Blood Marrow Transplant 2019; 26:316-322. [PMID: 31605823 DOI: 10.1016/j.bbmt.2019.09.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 09/17/2019] [Accepted: 09/30/2019] [Indexed: 10/25/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) can be curative for patients with hematologic malignancies. The ideal conditioning regimen before allo-HSCT has not been established. We conducted a Phase II study to evaluate the tolerability and efficacy of clofarabine and treosulfan as conditioning regimen before allo-HSCT. The primary objective was to evaluate the cumulative incidence of nonrelapse mortality (NRM) on day +100. Forty-four patients (36 with acute myelogenous leukemia, 5 with acute lymphoblastic leukemia, 3 with myelodysplastic syndromes) were enrolled. The median patient age was 47 years, and the median duration of follow-up was 27 months. The conditioning regimen was based on clofarabine 40 mg/m2 (days -6 to -2) and treosulfan 14 g/m2 (days -6 to -4). Allogeneic hematopoietic stem cells were derived from a sibling (n = 22) or a well-matched unrelated donor (n = 22). Graft-versus-host disease (GVHD) prophylaxis consisted of antithymocyte globulin, rituximab, cyclosporine, and a short-course of methotrexate. The regimen allowed for rapid engraftment and a 100-day NRM of 18%, due mainly to bacterial infections. The incidences of grade II-IV acute GVHD and chronic GVHD were 16% and 19%, respectively. The rates of overall survival (OS), progression-free survival, and relapse at 2 years were 51%, 31%, and 50%, respectively. Significantly different outcomes were observed between patients with low-intermediate and patients with high-very high Disease Risk Index (DRI) scores (1-year OS, 78% and 24%, respectively). Our findings show that the use of treosulfan and clofarabine as a conditioning regimen for allo-HSCT is feasible, with a 78% 1-year OS in patients with a low-intermediate DRI score. However, 1-year NRM was 18%, and despite the intensified conditioning regimen, relapse incidence remains a major issue in patients with poor prognostic risk factors.
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Affiliation(s)
- Jacopo Peccatori
- Hematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sara Mastaglio
- Hematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fabio Giglio
- Hematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Raffaella Greco
- Hematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Francesca Patriarca
- Carlo Melzi Hematology and Cellular Therapy Unit, Azienda Sanitaria Universitaria Integrata di Udine, Undine, Italy
| | - Barbara Forno
- Hematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sara Deola
- Department of Hematology, Ospedale Regionale, Bolzano, Italy
| | - Andrea Assanelli
- Hematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Magda Marcatti
- Hematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marco Zecca
- Pediatric Hematology/Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Renato Fanin
- Carlo Melzi Hematology and Cellular Therapy Unit, Azienda Sanitaria Universitaria Integrata di Udine, Undine, Italy
| | - Franca Fagioli
- Pediatric Onco-Hematology, University of Torino, Torino, Italy
| | - Franco Locatelli
- Department of Pediatric Hematology and Oncology, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Fabio Ciceri
- Hematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.
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Age-related clonal hematopoiesis: implications for hematopoietic stem cell transplantation. Curr Opin Hematol 2019; 25:441-445. [PMID: 30124476 DOI: 10.1097/moh.0000000000000465] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Over the past decade, advances in hematopoietic stem cell transplantation (HSCT) have enabled older individuals to undergo the procedure as well as to serve as donors. Recently, aging has been linked with the development of age-related clonal hematopoiesis (ARCH), defined as the gradual clonal expansion of hematopoietic stem and progenitor cells (HSPC) carrying recurrent disruptive genetic variants in individuals without a diagnosis of hematologic malignancy. Here we will review the implications of ARCH in the context of HSCT. RECENT FINDINGS ARCH is highly prevalent in the general population and commonly involves genes that are recurrently mutated in hematologic malignancies. Nevertheless, the vast majority of individuals with ARCH will not develop overt hematologic disease in their lifetime. The presence of ARCH may increase the risk of therapy-related myeloid neoplasms (t-MN) in individuals undergoing autologous HSCT. In the setting of allogeneic HSCT, ARCH present in the donor may contribute to adverse outcomes such as unexplained cytopenias posttransplant and donor cell leukemia. SUMMARY A better understanding of the hematopoietic milieu of HSCT recipients and of the importance of ARCH in the context of the replicative pressures imposed on transplanted HSPCs is needed in order to optimize conditioning regimens, donor selection and clinical outcomes post-HSCT.
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Liu Y, Yuan HL, Duan XL, Xu JL, Qu JH, Chen G, Shi J, Han CX, Ding LL, Jiang M. [Clinical research of HLA-haploidentical peripheral hematopoietic stem cell transplantation following reduced intensity conditioning regimen with hematological malignancy patients over 50 years old]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2019; 40:667-672. [PMID: 31495134 PMCID: PMC7342871 DOI: 10.3760/cma.j.issn.0253-2727.2019.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
目的 分析减低剂量预处理单倍型外周血造血干细胞移植(RIC-haplo-PBSCT)治疗50岁以上恶性血液肿瘤患者的疗效。 方法 18例50岁以上恶性血液肿瘤患者纳入研究,男8例,女10例,中位年龄52(50~66)岁;急性髓系白血病(AML)8例,慢性髓性白血病(CML)2例,骨髓增生异常综合征(MDS)5例,急性淋巴细胞白血病(ALL)2例,急性NK细胞白血病(ANKL)1例;采用FAB+ATG(氟达拉滨+阿糖胞苷+白消安+兔抗人胸腺细胞免疫球蛋白)减低剂量预处理方案,输注供者高剂量非去T细胞外周血造血干细胞(PBSC),应用强化移植物抗宿主病(GVHD)预防方案及感染防控措施。 结果 16例患者在移植后15 d获得完全供者嵌合,其中1例在移植后1个月发生移植排斥,其余2例在移植后15 d为混合嵌合并于移植后1个月发生移植排斥。急性GVHD发生率为61.1%(95%CI 49.6%~72.6%),Ⅱ~Ⅳ度急性GVHD发生率为35.4%(95%CI 21.1%~49.7%),Ⅲ/Ⅳ度急性GVHD发生率为13.8%(95%CI 4.7%~22.9%)。2年慢性GVHD累积发生率为38.2%(95%CI 25.5%~50.9%),未发生广泛型慢性GVHD。中位随访14.5(3~44)个月,2年总生存率、无病生存率分别为72.6%(95%CI 60.1%~85.1%)、63.7%(95%CI 49.2%~78.2%),2年累积复发率为31.2%(95%CI 16.5%~45.9%),2年非复发死亡率为12.5%(95%CI 4.2%~20.8%)。 结论 RIC-haplo-PBSCT治疗50岁以上恶性血液肿瘤患者可获得较好的疗效。
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Affiliation(s)
- Y Liu
- Hematologic Disease Center, First Affiliated Hospital of Xinjiang Medical University, Urumqi 830054, China; Xinjiang Uygur Autonomous Region Research Institute of Hematology, Urumqi 830061, China
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Gong F, Meng Q, Liu C, Zhao Y. Efficacy and association analysis of high-dose methotrexate in the treatment of children with acute lymphoblastic leukemia. Oncol Lett 2019; 17:4423-4428. [PMID: 30988812 PMCID: PMC6447950 DOI: 10.3892/ol.2019.10128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 02/15/2019] [Indexed: 01/24/2023] Open
Abstract
Effect of high-dose methotrexate (MTX) on children with acute lymphoblastic leukemia (ALL) with different subtypes and disease courses was investigated. A retrospective analysis of 207 children with ALL who were admitted to the People's Hospital of Pingyi County from March 2014 to June 2017 was carried out. According to the subtype of the disease, the children were divided into two groups. B-lineage group: ALL occurred in B-lineage lymphocytes (n=128); T-lineage group: ALL occurred in T-lineage lymphocytes (n=79). According to the disease course, the children were divided into three groups. High-risk group: disease course >15 days (n=67); moderate-risk group: disease course >8 and <15 days (n=58); low-risk group: disease course <8 days (n=82). The plasma concentration, calcium formyltetrahydrofolate (CF) rescue times and adverse reactions were compared at 12 h (T1), 48 h (T2), and 72 h (T3) after MTX infusion. The plasma concentration in B-lineage group was significantly higher than that in the T-lineage group at T2 and T3 (P<0.05). The incidence of adverse reactions in children with ALL in the B-lineage group was significantly higher than that in the T-lineage group (P<0.05). The CF rescue times in high-risk group were more than that in moderate- and low-risk groups (P<0.05). The incidence of adverse reactions in the high-risk group was significantly higher than that in the moderate- and low-risk groups (P<0.05), and in the moderate-risk group was significantly higher than that in the low-risk group (P<0.05). Compared with T-lineage ALL children, high-dose MTX causes more toxic injury to B-lineage ALL children. During clinical application of MTX in the treatment of ALL, close attention should be paid to the changes of the vital signs of patients, and timely CF rescue should be performed.
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Affiliation(s)
- Fangwei Gong
- Ward 2, Department of Pediatrics, The People's Hospital of Pingyi County, Linyi, Shandong 273300, P.R. China
| | - Qingjun Meng
- Ward 2, Department of Pediatrics, The People's Hospital of Pingyi County, Linyi, Shandong 273300, P.R. China
| | - Chengjuan Liu
- Ward 2, Department of Pediatrics, The People's Hospital of Pingyi County, Linyi, Shandong 273300, P.R. China
| | - Yeqi Zhao
- Ward 6, Department of Pediatrics, The People's Hospital of Pingyi County, Linyi, Shandong 273300, P.R. China
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Admiraal R, Boelens JJ. Pharmacotherapy in Pediatric Hematopoietic Cell Transplantation. Handb Exp Pharmacol 2019; 261:471-489. [PMID: 31375921 DOI: 10.1007/164_2019_247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Hematopoietic cell transplantation (HCT) is a curative treatment option for both malignant and nonmalignant diseases. Success of the procedure mainly depends on disease control and treatment-related complications. Pharmacotherapy plays a major role in HCT and significantly impacts the outcomes. Main drug use within HCT includes conditioning, GvHD prophylaxis, and prevention/treatment of infections.Increasing evidence suggests individualized dosing in (pediatric) HCT may improve outcome. Dose individualization may result in a better predictable drug treatment in terms of safety and efficacy, including timely immune reconstitution after HCT and optimal tumor or disease control, which may result in improved survival chances.
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Affiliation(s)
- R Admiraal
- Blood and Marrow Transplantation Program, Prinses Maxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - J J Boelens
- Stem Cell Transplantation and Cellular Therapies Pediatrics, New York, NY, USA. .,Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Hochberg J, Zahler S, Geyer MB, Chen N, Krajewski J, Harrison L, Militano O, Ozkaynak MF, Cheerva AC, Talano J, Moore TB, Gillio AP, Walters MC, Baxter-Lowe LA, Hamby C, Cairo MS. The safety and efficacy of clofarabine in combination with high-dose cytarabine and total body irradiation myeloablative conditioning and allogeneic stem cell transplantation in children, adolescents, and young adults (CAYA) with poor-risk acute leukemia. Bone Marrow Transplant 2018; 54:226-235. [PMID: 29899571 DOI: 10.1038/s41409-018-0247-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 04/16/2018] [Accepted: 05/19/2018] [Indexed: 01/19/2023]
Abstract
Acute leukemias in children with CR3, refractory relapse, or induction failure (IF) have a poor prognosis. Clofarabine has single agent activity in relapsed leukemia and synergy with cytarabine. We sought to determine the safety and overall survival in a Phase I/II trial of conditioning with clofarabine (doses 40 - 52 mg/m2), cytarabine 1000 mg/m2, and 1200 cGy TBI followed by alloSCT in children, adolescents, and young adults with poor-risk leukemia. Thirty-seven patients; Age 12 years (1-22 years); ALL/AML: 34:3 (18 IF, 10 CR3, 13 refractory relapse); 15 related, 22 unrelated donors. Probabilities of neutrophil, platelet engraftment, acute GvHD, and chronic GvHD were 94%, 84%, 49%, and 30%, respectively. Probability of day 100 TRM was 8.1%. 2-year EFS (event free survival) and OS (overall survival) were 38.6% (CI95: 23-54%), and 41.3% (CI95: 25-57%). Multivariate analysis demonstrated overt disease at time of transplant (relative risk (RR) 3.65, CI95: 1.35-9.89, P = 0.011) and umbilical cord blood source (RR 2.17, CI95: 1.33-4.15, P = 0.019) to be predictors of worse EFS/OS. This novel myeloablative conditioning regimen followed by alloSCT is safe and well tolerated in CAYA with very poor-risk ALL or AML. Further investigation in CAYA with better risk ALL and AML undergoing alloSCT is warranted.
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Affiliation(s)
| | - Stacey Zahler
- Pediatric Institute, Cleveland Clinic Children's, Cleveland, Ohio, USA
| | - Mark B Geyer
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nan Chen
- Departments of Pediatrics, Valhalla, NY, USA
| | - Jennifer Krajewski
- Department of Pediatrics, Hackensack University Medical Center, Hackensack, NJ, USA
| | | | | | | | | | - Julie Talano
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Theodore B Moore
- Department of Pediatrics, University of California at Los Angeles, Los Angeles, CA, USA
| | - Alfred P Gillio
- Department of Pediatrics, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Mark C Walters
- Department of Hematology/Oncology, Children's Hospital and Research Center of Oakland, Oakland, CA, USA
| | - Lee Ann Baxter-Lowe
- Department of Pathology and Laboratory Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Carl Hamby
- Departments of Microbiology and Immunology, Valhalla, NY, USA
| | - Mitchell S Cairo
- Departments of Pediatrics, Valhalla, NY, USA. .,Departments of Microbiology and Immunology, Valhalla, NY, USA. .,Departments of Medicine, Valhalla, NY, USA. .,Departments of Pathology, Valhalla, NY, USA. .,Departments of Cell Biology and Anatomy, New York Medical College, Valhalla, NY, USA.
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Lowe KL, Mackall CL, Norry E, Amado R, Jakobsen BK, Binder G. Fludarabine and neurotoxicity in engineered T-cell therapy. Gene Ther 2018; 25:176-191. [DOI: 10.1038/s41434-018-0019-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 01/25/2018] [Accepted: 03/09/2018] [Indexed: 12/13/2022]
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Phase I Study of Clofarabine and 2-Gy Total Body Irradiation as a Nonmyeloablative Preparative Regimen for Hematopoietic Stem Cell Transplantation in Pediatric Patients with Hematologic Malignancies: A Therapeutic Advances in Childhood Leukemia Consortium Study. Biol Blood Marrow Transplant 2017; 23:1134-1141. [PMID: 28396162 DOI: 10.1016/j.bbmt.2017.03.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 03/22/2017] [Indexed: 11/21/2022]
Abstract
Clofarabine is a purine nucleoside analog with immunosuppressive and antileukemic activity and its inclusion in reduced-intensity regimens could potentially improve outcomes. We performed a prospective phase I study of clofarabine combined with 2 Gy total body irradiation (TBI) as a nonmyeloablative preparative regimen for allogeneic stem cell transplantation in pediatric patients who were considered at high risk of mortality from standard myeloablative regimens. The main goal of the study was to delineate the maximum feasible dose (MFD) of clofarabine in combination with 2 Gy TBI. Eighteen patients, 1 to 21 years of age and in complete remission, were enrolled in 2 strata (matched related donor and unrelated donor) and evaluated for day100 dose-limiting events (DLE) (nonengraftment, nonrelapse mortality [NRM], and severe renal insufficiency) after receiving clofarabine at the starting dose level of 40 mg/m2. All 6 patients (3 in each stratum) engrafted with no day 100 DLE seen in the first cohort. The dose was increased to 52 mg/m2 in the next and an expanded cohort (total of 12 patients) and no DLE were observed at day 100 and at the 1-year study endpoint. The regimen was well tolerated with transient transaminitis and gastrointestinal and skin reactions as the common reversible toxicities observed with clofarabine. The dose of 52 mg/m2 of clofarabine was deemed the MFD. Disease relapse led to mortality in 6 (33%) patients during follow-up with 1-year event-free survival and overall survival of 60% (95% confidence interval [CI], 34 to 79) and 71% (95% CI, 44 to 87), respectively. This regimen leads to successful engraftment using both related and unrelated donors with exceptionally low rates of NRM.
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Palmer J, McCune JS, Perales MA, Marks D, Bubalo J, Mohty M, Wingard JR, Paci A, Hassan M, Bredeson C, Pidala J, Shah N, Shaughnessy P, Majhail N, Schriber J, Savani BN, Carpenter PA. Personalizing Busulfan-Based Conditioning: Considerations from the American Society for Blood and Marrow Transplantation Practice Guidelines Committee. Biol Blood Marrow Transplant 2016; 22:1915-1925. [PMID: 27481448 DOI: 10.1016/j.bbmt.2016.07.013] [Citation(s) in RCA: 107] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 07/21/2016] [Indexed: 12/12/2022]
Abstract
The Practice Guidelines Committee of the American Society of Blood or Marrow Transplantation (ASBMT) sought to develop an evidence-based review about personalizing busulfan-based conditioning. The Committee sought to grade the relevant published studies (June 1, 2008 through March 31, 2016) according to criteria set forth by the Steering Committee for Evidence Based Reviews from ASBMT. Unfortunately, the published literature was too heterogeneous and lacked adequately powered and sufficiently controlled studies for this to be feasible. Despite this observation, the continued interest in this topic led the Practice Guidelines Committee to develop a list of most frequently asked questions (FAQs) regarding personalized busulfan dosing. This "Considerations" document is a list of these FAQs and their responses, addressing topics of practical relevance to hematopoietic cell transplantation clinicians.
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Affiliation(s)
- Jeanne Palmer
- Division of Hematology/Oncology, Mayo Clinic, Phoenix, Arizona.
| | - Jeannine S McCune
- Department of Pharmacology University of Washington, Fred Hutchinson Cancer Research Center, Seattle, Washington.
| | - Miguel-Angel Perales
- Division of Hematology/Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - David Marks
- Pediatric Bone Marrow Transplant, University Hospitals Bristol NHS Trust, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Joseph Bubalo
- Department of Pharmacy Practice, Oregon Health Sciences University, Portland, Oregon
| | - Mohamad Mohty
- Department of Hematology, Hospital Saint-Antoine, University UPMC, Paris, France
| | - John R Wingard
- Division of Hematology/Oncology, University of Florida, Gainesville, Florida
| | - Angelo Paci
- Pharmacology and Drug Analysis Department, Institut de Cancerologie Gustav Roussy, Villejuif, France
| | - Moustapha Hassan
- Department of Clinical Research Centre, Karolinska Institutet, Stockholm, Sweden
| | - Christopher Bredeson
- Hematology, Department of Medicine, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Joseph Pidala
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Nina Shah
- Department of Stem Cell Transplantation and Cellular Therapy, MD Anderson Cancer Center, Houston, Texas
| | - Paul Shaughnessy
- Adult Blood and Marrow Transplant, Texas Transplant Physician's Group, San Antonio, Texas
| | - Navneet Majhail
- Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, Ohio
| | - Jeff Schriber
- Cancer Transplant Institute, Honor Health, Scottsdale, Arizona
| | - Bipin N Savani
- Division of Hematology/Oncology, Vanderbuilt-Ingram Cancer Center, Nashville, Tennessee
| | - Paul A Carpenter
- Department of Pediatrics, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, Washington
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Alatrash G, Thall PF, Valdez BC, Fox PS, Ning J, Garber HR, Janbey S, Worth LL, Popat U, Hosing C, Alousi AM, Kebriaei P, Shpall EJ, Jones RB, de Lima M, Rondon G, Chen J, Champlin RE, Andersson BS. Long-Term Outcomes after Treatment with Clofarabine ± Fludarabine with Once-Daily Intravenous Busulfan as Pretransplant Conditioning Therapy for Advanced Myeloid Leukemia and Myelodysplastic Syndrome. Biol Blood Marrow Transplant 2016; 22:1792-1800. [PMID: 27377901 DOI: 10.1016/j.bbmt.2016.06.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 06/22/2016] [Indexed: 12/12/2022]
Abstract
Pretransplant conditioning regimens critically determine outcomes in the setting of allogeneic stem cell transplantation (allo-SCT). The use of nucleoside analogs such as fludarabine (Flu) in combination with i.v. busulfan (Bu) has been shown to be highly effective as a pretransplant conditioning regimen in acute myeloid leukemia (AML), chronic myeloid leukemia (CML), and myelodysplastic syndrome (MDS). Because leukemia relapse remains the leading cause of death after allo-SCT, we studied whether clofarabine (Clo), a nucleoside analog with potent antileukemia activity, can be used to complement Flu. In a preliminary report, we previously showed the safety and efficacy of Clo ± Flu with i.v. Bu in 51 patients with high-risk AML, CML, and MDS. The study has now been completed, and we present long-term follow-up data on the entire 70-patient population, which included 49 (70%), 8 (11%), and 13 (19%) patients with AML, MDS, and CML, respectively. Thirteen patients (19%) were in complete remission, and 41 patients (59%) received matched unrelated donor grafts. Engraftment was achieved in all patients. Sixty-three patients (90%) achieved complete remission. There were no deaths reported at day +30, and the 100-day nonrelapse mortality rate was 4% (n = 3). Thirty-one percent of patients (n = 22) developed grades II to IV acute graft-versus-host disease, and the median overall survival and progression-free survival times were 2.4 years and .9 years, respectively. Our results confirm the safety and overall and progression-free survival advantage of the arms with higher Clo doses and lower Flu doses, which was most prominent in the AML/MDS group.
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Affiliation(s)
- Gheath Alatrash
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Peter F Thall
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Benigno C Valdez
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Patricia S Fox
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jing Ning
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Haven R Garber
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Selma Janbey
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Laura L Worth
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Uday Popat
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Chitra Hosing
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Amin M Alousi
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Partow Kebriaei
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Elizabeth J Shpall
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Roy B Jones
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Marcos de Lima
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas; Department of Hematologic Malignancies and Stem Cell Transplant, Case Western Reserve University, Cleveland, Ohio
| | - Gabriela Rondon
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Julianne Chen
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Richard E Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Borje S Andersson
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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