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Kaito S, Najima Y, Sadato D, Hirama C, Kishida Y, Nagata A, Konishi T, Yamada Y, Kurosawa S, Yoshifuji K, Shirane S, Shingai N, Toya T, Shimizu H, Haraguchi K, Kobayashi T, Harada H, Okuyama Y, Harada Y, Doki N. Azacitidine and gemtuzumab ozogamicin as post-transplant maintenance therapy for high-risk hematologic malignancies. Bone Marrow Transplant 2024; 59:1169-1175. [PMID: 38783125 DOI: 10.1038/s41409-024-02311-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 05/03/2024] [Accepted: 05/13/2024] [Indexed: 05/25/2024]
Abstract
Disease recurrence remains the principal cause of treatment failure after allogeneic hematopoietic stem cell transplantation. Post-transplant maintenance therapy with azacitidine (AZA) is promising to prevent relapse but the outcomes are unsatisfactory in patients at high risk of recurrence. Herein, we evaluated the outcome in patients who received AZA and gemtuzumab ozogamicin (GO), anti-CD33 antibody-calicheamicin conjugate, as post-transplant maintenance therapy. Twenty-eight patients with high-risk hematologic malignancies harboring CD33-positive leukemic blasts received the maintenance therapy. AZA (30 mg/m2) was administered for 7 days, followed by GO (3 mg/m2) on day 8. The maximum number of cycles was 4. At transplant, 21 patients (75.0%) had active disease. Their 2-year overall survival, disease-free survival, relapse, and non-relapse mortality rates were 53.6%, 39.3%, 50.0%, and 10.7%, respectively. Of these patients, those with minimal residual disease at the start of maintenance therapy (n = 9) had a higher recurrence rate (66.7% vs. 42.1% at 2 years, P = 0.069) and shorter disease-free survival (11.1% vs. 52.6% at 2 years, P = 0.003). Post-transplant maintenance therapy with AZA and GO was generally tolerable but more than half of the patients eventually relapsed. Further improvements are needed to prevent relapse after transplantation in patients with high-risk hematologic malignancies.
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Affiliation(s)
- Satoshi Kaito
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Yuho Najima
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan.
| | - Daichi Sadato
- Clinical Research Support Center, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Chizuko Hirama
- Clinical Research Support Center, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Yuya Kishida
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Akihito Nagata
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Tatsuya Konishi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Yuta Yamada
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Shuhei Kurosawa
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Kota Yoshifuji
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Shuichi Shirane
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Naoki Shingai
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Takashi Toya
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Hiroaki Shimizu
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Kyoko Haraguchi
- Division of Transfusion and Cell Therapy, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Takeshi Kobayashi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Hironori Harada
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
- Laboratory of Oncology, Tokyo University of Pharmacy and Life Sciences, Tokyo, Japan
| | - Yoshiki Okuyama
- Division of Transfusion and Cell Therapy, Tokyo Metropolitan Komagome Hospital, Tokyo, Japan
| | - Yuka Harada
- Clinical Research Support Center, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Noriko Doki
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
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Yang F, Ren Q, Zu Y, Gui R, Li Z, Wang J, Zhang Y, Yu F, Fang B, Fu Y, Wang Y, Liu Y, Zhang L, Zuo W, Li Y, Lin Q, Zhao H, Wang P, Zhang B, Huang Z, Song Y, Zhou J. Multiple small-dose infusions of G-CSF-mobilized haploidentical lymphocytes after autologous haematopoietic stem cell transplantation for acute myeloid leukaemia. Br J Haematol 2024. [PMID: 38972835 DOI: 10.1111/bjh.19597] [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: 12/25/2023] [Accepted: 06/06/2024] [Indexed: 07/09/2024]
Abstract
This retrospective study analysed 106 acute myeloid leukaemia (AML) patients undergoing autologous haematopoietic stem cell transplantation (ASCT) to assess the impact of multiple small-dose infusions of granulocyte-colony-stimulating factor (G-CSF)-mobilized haploidentical lymphocytes as post-ASCT maintenance therapy. Among them, 50 patients received lymphocyte maintenance therapy, 21 received alternative maintenance therapy, and 35 received no maintenance therapy. Patients receiving lymphocyte maintenance therapy demonstrated significantly higher overall survival (OS) and disease-free survival (DFS) compared to those without maintenance therapy, with 4-year OS and DFS rates notably elevated. While there were no significant differences in recurrence rates among the three groups, lymphocyte maintenance therapy showcased particular benefits for intermediate-risk AML patients, yielding significantly higher OS and DFS rates and lower relapse rates compared to alternative maintenance therapy and no maintenance therapy. The study suggests that multiple small-dose infusions of G-CSF-mobilized haploidentical lymphocytes may offer promising outcomes for AML patients after ASCT, particularly for those classified as intermediate-risk. These findings underscore the potential efficacy of lymphocyte maintenance therapy in reducing disease relapse and improving long-term prognosis in this patient population.
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Affiliation(s)
- Fei Yang
- Department of Haematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
- Department of Oncology, Anyang People's Hospital, Anyang, China
| | - Quan Ren
- Department of Haematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Yingling Zu
- Department of Haematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Ruirui Gui
- Department of Haematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Zhen Li
- Department of Haematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Juan Wang
- Department of Haematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Yanli Zhang
- Department of Haematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Fengkuan Yu
- Department of Haematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Baijun Fang
- Department of Haematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Yuewen Fu
- Department of Haematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Yongliang Wang
- Department of Oncology, Anyang People's Hospital, Anyang, China
| | - Yanyan Liu
- Department of Haematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Lina Zhang
- Department of Haematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Wenli Zuo
- Department of Haematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Yufu Li
- Department of Haematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Quande Lin
- Department of Haematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Huifang Zhao
- Department of Haematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Ping Wang
- Department of Haematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Binglei Zhang
- Department of Haematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Zhenghua Huang
- Department of Haematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
| | - Yongping Song
- Department of Haematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
- Department of Haematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jian Zhou
- Department of Haematology, The Affiliated Cancer Hospital of Zhengzhou University & Henan Cancer Hospital, Zhengzhou, China
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Américo AD, Silva CC, Kerbauy MN, Arcuri LJ, Ribeiro AAF, Hamerschlak N, Santos FPS. Subcutaneous low-dose azacitidine as maintenance therapy following hematopoietic stem cell transplantation for acute myeloid leukemia and high-risk myelodysplastic syndrome-A propensity score matched analysis. Hematol Transfus Cell Ther 2024:S2531-1379(24)00254-2. [PMID: 39095316 DOI: 10.1016/j.htct.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 03/04/2024] [Accepted: 03/12/2024] [Indexed: 08/04/2024] Open
Affiliation(s)
| | - Cinthya Correa Silva
- Sociedade Beneficente Israelita Brasileira Albert Einstein, São Paulo, SP, Brazil
| | | | | | | | - Nelson Hamerschlak
- Sociedade Beneficente Israelita Brasileira Albert Einstein, São Paulo, SP, Brazil
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Sackstein P, Williams A, Zemel R, Marks JA, Renteria AS, Rivero G. Transplant Eligible and Ineligible Elderly Patients with AML-A Genomic Approach and Next Generation Questions. Biomedicines 2024; 12:975. [PMID: 38790937 PMCID: PMC11117792 DOI: 10.3390/biomedicines12050975] [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: 03/17/2024] [Revised: 04/15/2024] [Accepted: 04/16/2024] [Indexed: 05/26/2024] Open
Abstract
The management of elderly patients diagnosed with acute myelogenous leukemia (AML) is complicated by high relapse risk and comorbidities that often preclude access to allogeneic hematopoietic cellular transplantation (allo-HCT). In recent years, fast-paced FDA drug approval has reshaped the therapeutic landscape, with modest, albeit promising improvement in survival. Still, AML outcomes in elderly patients remain unacceptably unfavorable highlighting the need for better understanding of disease biology and tailored strategies. In this review, we discuss recent modifications suggested by European Leukemia Network 2022 (ELN-2022) risk stratification and review recent aging cell biology advances with the discussion of four AML cases. While an older age, >60 years, does not constitute an absolute contraindication for allo-HCT, the careful patient selection based on a detailed and multidisciplinary risk stratification cannot be overemphasized.
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Affiliation(s)
- Paul Sackstein
- Lombardi Cancer Institute, School of Medicine, Georgetown University, Washington, DC 20007, USA; (P.S.); (R.Z.); (J.A.M.)
| | - Alexis Williams
- Department of Medicine, New York University, New York, NY 10016, USA;
| | - Rachel Zemel
- Lombardi Cancer Institute, School of Medicine, Georgetown University, Washington, DC 20007, USA; (P.S.); (R.Z.); (J.A.M.)
| | - Jennifer A. Marks
- Lombardi Cancer Institute, School of Medicine, Georgetown University, Washington, DC 20007, USA; (P.S.); (R.Z.); (J.A.M.)
| | - Anne S. Renteria
- Lombardi Cancer Institute, School of Medicine, Georgetown University, Washington, DC 20007, USA; (P.S.); (R.Z.); (J.A.M.)
| | - Gustavo Rivero
- Lombardi Cancer Institute, School of Medicine, Georgetown University, Washington, DC 20007, USA; (P.S.); (R.Z.); (J.A.M.)
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Accorsi Buttini E, Doran C, Malagola M, Radici V, Galli M, Rubini V, Leoni A, Farina M, Polverelli N, Re F, Bernardi S, Mohty M, Russo D, Brissot E. Donor Lymphocyte Infusion in the Treatment of Post-Transplant Relapse of Acute Myeloid Leukemias and Myelodysplastic Syndromes Significantly Improves Overall Survival: A French-Italian Experience of 134 Patients. Cancers (Basel) 2024; 16:1278. [PMID: 38610955 PMCID: PMC11011045 DOI: 10.3390/cancers16071278] [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: 02/12/2024] [Revised: 03/10/2024] [Accepted: 03/19/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Disease relapse after allogeneic stem cell transplantation (allo-SCT) is the main challenge for curing acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS). We investigated the overall survival (OS) after allo-SCT relapse according to different therapeutic approaches. METHODS We analyzed 134 patients who relapsed after allo-SCT performed between 2015 and 2021 at Saint-Antoine University Hospital, Paris and Spedali Civili di Brescia, Brescia. Of these, 103 (77%) were treated, comprising 69/103 (67%) who received therapy in overt relapse and 34/103 (33%) who were treated in a pre-emptive manner when molecular/cytogenetics recurrence or mixed chimerism occurred. The treatment was donor lymphocyte infusion (DLI)-based for 40/103 (39%) patients. RESULTS The 1-, 2-, and 5-year OS of patients treated with DLI (n = 40) was 67%, 34%, and 34%, respectively, for those treated preventively (n = 20) and 43%, 20%, and 20%, respectively, for those treated in overt relapse (n = 20) (p < 0.01). The 1-, 2-, and 5-year OS of patients treated without DLI (n = 63) was 54%, 40%, and 26%, respectively, for those treated preventively (n = 14) and 17%, 5%, and 0%, respectively, for those treated in overt relapse (n = 49) (p < 0.01). CONCLUSIONS Relapse treatment with a pre-emptive strategy was associated with improved outcomes, particularly when DLI was employed.
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Affiliation(s)
- Eugenia Accorsi Buttini
- Unit of Blood Diseases and Bone Marrow Transplantation, Cell Therapies and Hematology, Research Program, Department of Clinical and Experimental Science, University of Brescia, ASST Spedali Civili di Brescia, 25123 Brescia, Italy; (M.M.); (V.R.); (M.G.); (V.R.); (M.F.); (S.B.); (D.R.)
| | - Cristina Doran
- Service d’ Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint Antoine, Centre de Recherche Saint-Antoine (CRSA), Sorbonne Université, 75012 Paris, France (E.B.)
| | - Michele Malagola
- Unit of Blood Diseases and Bone Marrow Transplantation, Cell Therapies and Hematology, Research Program, Department of Clinical and Experimental Science, University of Brescia, ASST Spedali Civili di Brescia, 25123 Brescia, Italy; (M.M.); (V.R.); (M.G.); (V.R.); (M.F.); (S.B.); (D.R.)
| | - Vera Radici
- Unit of Blood Diseases and Bone Marrow Transplantation, Cell Therapies and Hematology, Research Program, Department of Clinical and Experimental Science, University of Brescia, ASST Spedali Civili di Brescia, 25123 Brescia, Italy; (M.M.); (V.R.); (M.G.); (V.R.); (M.F.); (S.B.); (D.R.)
| | - Marco Galli
- Unit of Blood Diseases and Bone Marrow Transplantation, Cell Therapies and Hematology, Research Program, Department of Clinical and Experimental Science, University of Brescia, ASST Spedali Civili di Brescia, 25123 Brescia, Italy; (M.M.); (V.R.); (M.G.); (V.R.); (M.F.); (S.B.); (D.R.)
| | - Vicky Rubini
- Unit of Blood Diseases and Bone Marrow Transplantation, Cell Therapies and Hematology, Research Program, Department of Clinical and Experimental Science, University of Brescia, ASST Spedali Civili di Brescia, 25123 Brescia, Italy; (M.M.); (V.R.); (M.G.); (V.R.); (M.F.); (S.B.); (D.R.)
| | - Alessandro Leoni
- Research Center Ail (CREA), Department of Clinical and Experimental Science, University of Brescia, ASST Spedali Civili di Brescia, 25123 Brescia, Italy; (A.L.); (F.R.)
| | - Mirko Farina
- Unit of Blood Diseases and Bone Marrow Transplantation, Cell Therapies and Hematology, Research Program, Department of Clinical and Experimental Science, University of Brescia, ASST Spedali Civili di Brescia, 25123 Brescia, Italy; (M.M.); (V.R.); (M.G.); (V.R.); (M.F.); (S.B.); (D.R.)
| | - Nicola Polverelli
- Division of Hematology, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
| | - Federica Re
- Research Center Ail (CREA), Department of Clinical and Experimental Science, University of Brescia, ASST Spedali Civili di Brescia, 25123 Brescia, Italy; (A.L.); (F.R.)
| | - Simona Bernardi
- Unit of Blood Diseases and Bone Marrow Transplantation, Cell Therapies and Hematology, Research Program, Department of Clinical and Experimental Science, University of Brescia, ASST Spedali Civili di Brescia, 25123 Brescia, Italy; (M.M.); (V.R.); (M.G.); (V.R.); (M.F.); (S.B.); (D.R.)
- Research Center Ail (CREA), Department of Clinical and Experimental Science, University of Brescia, ASST Spedali Civili di Brescia, 25123 Brescia, Italy; (A.L.); (F.R.)
| | - Mohamad Mohty
- Service d’ Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint Antoine, Centre de Recherche Saint-Antoine (CRSA), Sorbonne Université, 75012 Paris, France (E.B.)
| | - Domenico Russo
- Unit of Blood Diseases and Bone Marrow Transplantation, Cell Therapies and Hematology, Research Program, Department of Clinical and Experimental Science, University of Brescia, ASST Spedali Civili di Brescia, 25123 Brescia, Italy; (M.M.); (V.R.); (M.G.); (V.R.); (M.F.); (S.B.); (D.R.)
| | - Eolia Brissot
- Service d’ Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint Antoine, Centre de Recherche Saint-Antoine (CRSA), Sorbonne Université, 75012 Paris, France (E.B.)
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Murdock HM, Ho VT, Garcia JS. Innovations in conditioning and post-transplant maintenance in AML: genomically informed revelations on the graft-versus-leukemia effect. Front Immunol 2024; 15:1359113. [PMID: 38571944 PMCID: PMC10987864 DOI: 10.3389/fimmu.2024.1359113] [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: 12/20/2023] [Accepted: 02/20/2024] [Indexed: 04/05/2024] Open
Abstract
Acute Myeloid Leukemia (AML) is the prototype of cancer genomics as it was the first published cancer genome. Large-scale next generation/massively parallel sequencing efforts have identified recurrent alterations that inform prognosis and have guided the development of targeted therapies. Despite changes in the frontline and relapsed standard of care stemming from the success of small molecules targeting FLT3, IDH1/2, and apoptotic pathways, allogeneic stem cell transplantation (alloHSCT) and the resulting graft-versus-leukemia (GVL) effect remains the only curative path for most patients. Advances in conditioning regimens, graft-vs-host disease prophylaxis, anti-infective agents, and supportive care have made this modality feasible, reducing transplant related mortality even among patients with advanced age or medical comorbidities. As such, relapse has emerged now as the most common cause of transplant failure. Relapse may occur after alloHSCT because residual disease clones persist after transplant, and develop immune escape from GVL, or such clones may proliferate rapidly early after alloHSCT, and outpace donor immune reconstitution, leading to relapse before any GVL effect could set in. To address this issue, genomically informed therapies are increasingly being incorporated into pre-transplant conditioning, or as post-transplant maintenance or pre-emptive therapy in the setting of mixed/falling donor chimerism or persistent detectable measurable residual disease (MRD). There is an urgent need to better understand how these emerging therapies modulate the two sides of the GVHD vs. GVL coin: 1) how molecularly or immunologically targeted therapies affect engraftment, GVHD potential, and function of the donor graft and 2) how these therapies affect the immunogenicity and sensitivity of leukemic clones to the GVL effect. By maximizing the synergistic action of molecularly targeted agents, immunomodulating agents, conventional chemotherapy, and the GVL effect, there is hope for improving outcomes for patients with this often-devastating disease.
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Affiliation(s)
- H. Moses Murdock
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
| | - Vincent T. Ho
- Bone Marrow Transplant Program, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
| | - Jacqueline S. Garcia
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
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7
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Tao LL, Wen HT, Wang ZY, Cheng J, Zhao L. Azacitidine maintenance therapy for blastic plasmacytoid dendritic cell neoplasm allograft: A case report. World J Clin Cases 2024; 12:136-141. [PMID: 38292626 PMCID: PMC10824186 DOI: 10.12998/wjcc.v12.i1.136] [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: 08/25/2023] [Revised: 12/12/2023] [Accepted: 12/19/2023] [Indexed: 01/02/2024] Open
Abstract
BACKGROUND Blastic plasmacytoid dendritic cell neoplasm (BPDCN) is a rare, highly invasive malignant neoplasm. There is no universally accepted standard of care because of its rarity and the dearth of prospective research. It is still challenging for some patients to achieve persistent clinical remission or cure, despite the success of allogeneic hematopoietic stem cell transplantation (allo-HSCT), indicating that there is still a significant recurrence rate. We report a case of prevention of BPDCN allograft recurrence by azacitidine maintenance therapy and review the relevant literature. CASE SUMMARY We report a 41-year-old man with BPDCN who was admitted to hospital due to skin sclerosis for > 5 mo' duration. BPDCN was diagnosed by combined clinical assessment and laboratory examinations. Following diagnosis, the patients underwent induction consolidation chemotherapy to achieve the first complete remission, followed by bridging allo-HSCT. Post-transplantation, azacitidine (75 mg/m2 for 7 d) was administered as maintenance therapy, with repeat administration every 4-6 wk and appropriate extension of the chemotherapy cycle. After 10 cycles, the patient has been disease free for 26 mo after transplantation. Regular assessments of bone marrow morphology, minimal residual disease, full donor chimerism, Epstein-Barr virus, and cytomegalovirus all yielded normal results with no abnormalities detected. CONCLUSION Azacitidine may be a safe and effective maintenance treatment for BPDCN following transplantation because there were no overt adverse events during the course of treatment.
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Affiliation(s)
- Li-Li Tao
- Department of Hematology, The First Clinical Medical College, Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Hui-Ting Wen
- Department of Hematology, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Zi-Yi Wang
- Department of Hematology, The First Clinical Medical College, Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Juan Cheng
- Department of Hematology, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Li Zhao
- Department of Hematology, The First Hospital of Lanzhou University, Lanzhou 730000, Gansu Province, China
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8
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Cao Y, Zheng X, Zhang H, Wang M, Guo W, Chen X, Zhai W, Wei J, Yang D, Huang Y, Pang A, Feng S, Jiang E, Han M. Refractory patients with favorable/intermediate-risk acute myeloid leukemia benefit from azacytidine maintenance therapy following allogeneic hematopoietic stem cell transplantation. Hematol Oncol 2024; 42:e3232. [PMID: 37793012 DOI: 10.1002/hon.3232] [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: 06/26/2023] [Revised: 08/29/2023] [Accepted: 09/21/2023] [Indexed: 10/06/2023]
Abstract
Recurrence following allogeneic hematopoietic stem cell transplantation (allo-HSCT) is the major cause of treatment failure in patients with myeloid malignancy. Azacytidine (AZA) maintenance is a promising therapy to prevent relapse and improve survival. We conducted a prospective, one-arm study involving 78 patients with myeloid malignancy at a high risk of recurrence who were enrolled between September 2019 and April 2022. Furthermore, 102 matched historical controls were selected using propensity score matching. With a median follow-up time of 19.6 (3.5-91.7) months, AZA maintenance therapy significantly improved relapse-free survival (RFS; log-rank test, p = 0.01). The AZA and control groups had a 1-year RFS of 87.7% (95% confidence interval [CI], 0.80-0.96) and 72.2% (95% CI, 0.64-0.82), respectively, with a hazard ratio (HR) of 0.21 (95% CI, 0.09-0. 47; p < 0.01). There were no grade 4 adverse effects or deaths related to AZA. Refractory patients with favorable/intermediate-risk acute myeloid leukemia (AML) benefited more from AZA maintenance therapy than those with adverse-risk AML according to the European Leukemia Net guidelines (RFS in favorable/intermediate-risk AML, HR = 0.29, 95% CI, 0.11-0.79; RFS in adverse-risk AML, HR = 0.57, 95% CI, 0.21-1.6; p for interaction = 0.03). Our findings suggest that AZA maintenance therapy following allo-HSCT was safe and could reduce the incidence of relapse, particularly for refractory patients with favorable/intermediate-risk AML.
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Affiliation(s)
- Yigeng Cao
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Xinhui Zheng
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Haixiao Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Mingyang Wang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Wenwen Guo
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Xin Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Weihua Zhai
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Jialin Wei
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Donglin Yang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Yong Huang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Aiming Pang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Sizhou Feng
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Erlie Jiang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Mingzhe Han
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
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9
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Xu Z, Choi J, Cooper M, King J, Fiala MA, Liu J, Pusic I, Romee R, Cashen A, Jacoby MA, Stockerl-Goldstein K, Abboud C, Vij R, Uy G, Westervelt P, Walter MJ, DiPersio JF, Schroeder MA. Phase I-II Trial of Early Azacitidine after Matched Unrelated Donor Hematopoietic Cell Transplantation. Transplant Cell Ther 2023; 29:699.e1-699.e9. [PMID: 37597685 DOI: 10.1016/j.jtct.2023.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 08/11/2023] [Accepted: 08/13/2023] [Indexed: 08/21/2023]
Abstract
Graft-versus-host disease (GVHD) is a major complication after allogeneic hematopoietic cell transplantation (allo-HCT). The hypomethylating agent azacitidine (AZA) has been shown to be effective in preclinical and clinical studies for the prevention of acute GVHD (aGVHD). We sought to determine the maximum tolerated dose (MTD) of AZA when given on days 1 to 5 of a 28-day cycle for 4 cycles, starting on day +7 after allo-HCT, as well as its impact on aGVHD and chronic GVHD (cGVHD), relapse, and overall survival (OS) in patients undergoing matched unrelated donor allo-HCT. This study was a single-arm, single-center, open-label phase I-II study with a total of 15 and 38 patients enrolled in the phase I and II portions of the trial, respectively. A standard 3+3 study design was used in phase I, and all patients in phase II received AZA at the MTD determined in phase I. The MTD of AZA starting at day +7 post-transplantation was 45 mg/m2. Phase II of the study was halted after enrolling 38 of the planned 46 patients following an interim analysis that suggested futility. Overall, AZA at 45 mg/m2 exhibited a side effect profile consistent with prior reports and had a minimal impact on engraftment. The cumulative incidence of clinically significant aGVHD by day +180 was 39.9% (95% confidence interval [CI], 22% to 53.7%). The incidence of all-grade cGVHD was 61.4% (95% CI, 40.3% to 75%). At 1 year, OS was 73.7% (95% CI, 60.9% to 89.1%), and the disease relapse rate was 11.4% (95% CI, .2% to 21.3%). Our results suggest that early post-allo-HCT AZA has limited efficacy in preventing aGVHD and cGVHD but could have a beneficial effect in preventing disease relapse.
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Affiliation(s)
- Ziheng Xu
- Washington University School of Medicine, St. Louis, Missouri
| | - Jaebok Choi
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Matthew Cooper
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Jeffrey King
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Mark A Fiala
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Jingxia Liu
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Iskra Pusic
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Rizwan Romee
- Department of Medicine, Harvard Medical School, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Amanda Cashen
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Meagan A Jacoby
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Keith Stockerl-Goldstein
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Camille Abboud
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Ravi Vij
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Geoffrey Uy
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Peter Westervelt
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Matthew J Walter
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - John F DiPersio
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Mark A Schroeder
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri.
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10
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Feng Y, Chen T, Zhang Y, Yao H, Wang P, Wang L, Cassady K, Zou Z, Liu Y, Zhao L, Gao L, Zhang X, Kong P. Azacitidine and lenalidomide combination: a novel relapse prophylaxis regimen after allogeneic hematopoietic stem-cell transplantation in patients with acute myeloid leukemia. Front Immunol 2023; 14:1182251. [PMID: 37435080 PMCID: PMC10332158 DOI: 10.3389/fimmu.2023.1182251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 06/07/2023] [Indexed: 07/13/2023] Open
Abstract
Introduction While allogeneic hematopoietic stem cell transplantation (allo-HSCT) can be a curative regimen for acute myeloid leukemia (AML), relapse of AML remains a serious risk post-transplantation. Once relapsed, salvage options are limited and management of AML is difficult. Here we designed a prospective study to examine the efficacy and tolerability of maintenance therapy with azacytidine (AZA) plus low-dose lenalidomide (LEN) to prevent relapse after allo-HSCT for AML patients (ChiCTR2200061803). Methods AML patients post-allo-HSCT were treated with AZA (75 mg/m2 for 7 days), followed by LEN (5 mg/m2, day 10-28), and a 4-week resting interval, which was defined as one treatment cycle. A total of 8 cycles was recommended. Results 37 patients were enrolled, 25 patients received at least 5 cycles, and 16 patients finished all 8 cycles. With a median follow-up time of 608 (43-1440) days, the estimated 1-year disease free survival (DFS) was 82%, cumulative incidence of relapse (CIR) was 18%, and overall survival (OS) was 100%. Three patients (8%) had grade 1-2 neutropenia without fever; one patient developed grade 3-4 thrombocytopenia and minor subdural hematoma; 4/37 patients (11%) developed chronic GVHD with a score of 1-2, without requiring systemic treatment; No patient developed acute GVHD. After AZA/LEN prophylaxis, increasing numbers of CD56+NK and CD8+ T, and decreasing of CD19+ B cells were observed. Discussion Azacitidine combined with low-dose lenalidomide was observed to be an effective relapse prophylaxis option after allo-HSCT in AML patients, and can be administered safely without significantly increasing the risk of GVHD, infection and other AEs. Clinical Trial Registration www.chictr.org, identifier ChiCTR2200061803.
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Affiliation(s)
- Yimei Feng
- Medical Center of Hematology, The Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Ting Chen
- Medical Center of Hematology, The Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Yun Zhang
- Medical Center of Hematology, The Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Han Yao
- Medical Center of Hematology, The Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Ping Wang
- Medical Center of Hematology, The Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Lu Wang
- Medical Center of Hematology, The Xinqiao Hospital of Army Medical University, Chongqing, China
| | | | - Zhongmin Zou
- Department of Chemical Defense, School of Military Preventive Medicine, Army Medical University, Chongqing, China
| | - Yuqing Liu
- Medical Center of Hematology, The Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Lu Zhao
- Medical Center of Hematology, The Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Lei Gao
- Medical Center of Hematology, The Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Xi Zhang
- Medical Center of Hematology, The Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Peiyan Kong
- Medical Center of Hematology, The Xinqiao Hospital of Army Medical University, Chongqing, China
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11
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Pang Y, Holtzman NG. Immunopathogenic mechanisms and modulatory approaches to graft-versus-host disease prevention in acute myeloid leukaemia. Best Pract Res Clin Haematol 2023; 36:101475. [PMID: 37353287 PMCID: PMC10291443 DOI: 10.1016/j.beha.2023.101475] [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: 04/23/2023] [Revised: 05/03/2023] [Accepted: 05/03/2023] [Indexed: 06/25/2023]
Abstract
Allogeneic haematopoietic stem cell transplantation (HSCT) remains the only potential cure for intermediate to high-risk acute myeloid leukaemia (AML). The therapeutic effect of HSCT is largely dependent on the powerful donor-derived immune response against recipient leukaemia cells, known as graft-versus-leukaemia effect (GvL). However, the donor-derived immune system can also cause acute or chronic damage to normal recipient organs and tissues, in a process known as graft-versus-host disease (GvHD). GvHD is a leading cause of non-relapse mortality in HSCT recipients. There are many similarities and cross talk between the immune pathways of GvL and GvHD. Studies have demonstrated that both processes require the presence of mismatched alloantigens between the donor and recipient, and activation of immune responses centered around donor T-cells, which can be further modulated by various recipient or donor factors. Dissecting GvL from GvHD to achieve more effective GvHD prevention and enhanced GvL has been the holy grail of HSCT research. In this review, we focused on the key factors that contribute to the immune responses of GvL and GvHD, the effect on GvL with different GvHD prophylactic strategies, and the potential impact of various AML relapse prevention therapy or treatments on GvHD.
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Affiliation(s)
- Yifan Pang
- Department of Haematologic Oncology and Blood Disorders, Levine Cancer Institute, Charlotte, NC, USA.
| | - Noa G Holtzman
- Immune Deficiency Cellular Therapy Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
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12
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Rashidi A, Huselton EJ, Stefanski HE, DeFor TE, Shanley R, Choi J, DiPersio JF, Juckett M, Miller JS, Weisdorf DJ, Schroeder MA. A Multicenter Phase 2 Clinical Trial of 10-Day Decitabine, Dose-Escalated Donor Lymphocyte Infusion, and Ruxolitinib for Relapsed Acute Myeloid Leukemia and Myelodysplastic Syndromes after Allogeneic Hematopoietic Cell Transplantation. Transplant Cell Ther 2023; 29:328.e1-328.e6. [PMID: 36804933 PMCID: PMC10149582 DOI: 10.1016/j.jtct.2023.02.010] [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: 09/27/2022] [Revised: 12/22/2022] [Accepted: 02/10/2023] [Indexed: 02/22/2023]
Abstract
Post-transplantation relapse of acute myeloid leukemia and myelodysplastic syndromes has a poor prognosis. Donor lymphocyte infusion (DLI) is one treatment approach. However, efficacy is limited, and toxicity, mostly in the form of acute graft-versus-host disease (GVHD), is frequent. We tested a novel approach using 10-day decitabine, dose-escalated DLI, and ruxolitinib in a multicenter phase 2 trial aimed at increasing the efficacy of DLI and reducing its toxicity. Up to four 28-day cycles were administered. The primary endpoint was 6-month overall survival (OS). Of the 14 patients who started cycle 1, 13 received 1 DLI, 6 received 2 DLIs, and 1 received 3 4 DLIs. A preplanned interim analysis after enrolling 14 patients suggested futility, and the trial was closed to accrual. The final analysis showed a 6-month OS of 36% (95% confidence interval [CI], 18 to 72), a 1-year progression-free survival of 7% (95% CI, 1% to 47%), a 6-month cumulative incidence of grade II-IV acute GVHD of 57% (95% CI, 26% to 80%), and a 1-year nonrelapse mortality of 14% (95% CI, 2% to 38%). The combined modality treatment studied in this trial was ineffective and did not reduce DLI toxicity.
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Affiliation(s)
- Armin Rashidi
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota; Clinical Research Division, Fred Hutchinson Cancer Center and Division of Oncology, University of Washington, Seattle, Washington.
| | - Eric J Huselton
- Division of Hematology and Oncology, University of Rochester, Rochester, New York
| | - Heather E Stefanski
- Division of Blood and Marrow Transplantation, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Todd E DeFor
- Biostatistics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Ryan Shanley
- Biostatistics Core, Masonic Cancer Center, University of Minnesota, Minneapolis, Minnesota
| | - Jaebok Choi
- Division of Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - John F DiPersio
- Division of Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Mark Juckett
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Jeffrey S Miller
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Daniel J Weisdorf
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Mark A Schroeder
- Division of Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri
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13
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Najima Y. Overcoming relapse: prophylactic or pre-emptive use of azacitidine or FLT3 inhibitors after allogeneic transplantation for AML or MDS. Int J Hematol 2023:10.1007/s12185-023-03596-w. [PMID: 37036626 DOI: 10.1007/s12185-023-03596-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 03/24/2023] [Accepted: 03/28/2023] [Indexed: 04/11/2023]
Abstract
Relapse remains the most critical obstacle in treatment by allogeneic hematopoietic stem cell transplantation (HSCT). Non-relapse mortality has improved annually, but relapse mortality remains high. Post-transplant maintenance treatment, such as hypomethylating agents and FMS-like tyrosine kinase 3 (FLT3) inhibitors, has been investigated for decades as a means of preventing disease relapse after HSCT. Other factors besides the relapse tendency of the primary disease that can affect the transition of estimated disease burden in patients undergoing HSCT are disease status at HSCT (non-remission, remission with minimal/measurable residual disease (MRD), and remission without MRD) and conditioning regimen intensity. Optimal selection of patients at high risk for relapse who can tolerate a long duration of therapy is pivotal for successful post-transplant maintenance therapy. In this review, we provide an overview of current progress in research on post-transplant maintenance treatment using azacitidine or FLT3 inhibitors for preventing disease relapse after HSCT for AML or MDS, and discuss the future outlook in this area.
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Affiliation(s)
- Yuho Najima
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, 3-8-22 Honkomagome, Bunkyo-Ku, Tokyo, 113-8677, Japan.
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14
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Serroukh Y, Hébert J, Busque L, Mercier F, Rudd CE, Assouline S, Lachance S, Delisle JS. Blasts in context: the impact of the immune environment on acute myeloid leukemia prognosis and treatment. Blood Rev 2023; 57:100991. [PMID: 35941029 DOI: 10.1016/j.blre.2022.100991] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/22/2022] [Accepted: 07/13/2022] [Indexed: 01/28/2023]
Abstract
Acute myeloid leukemia (AML) is a cancer that originates from the bone marrow (BM). Under physiological conditions, the bone marrow supports the homeostasis of immune cells and hosts memory lymphoid cells. In this review, we summarize our present understanding of the role of the immune microenvironment on healthy bone marrow and on the development of AML, with a focus on T cells and other lymphoid cells. The types and function of different immune cells involved in the AML microenvironment as well as their putative role in the onset of disease and response to treatment are presented. We also describe how the immune context predicts the response to immunotherapy in AML and how these therapies modulate the immune status of the bone marrow. Finally, we focus on allogeneic stem cell transplantation and summarize the current understanding of the immune environment in the post-transplant bone marrow, the factors associated with immune escape and relevant strategies to prevent and treat relapse.
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Affiliation(s)
- Yasmina Serroukh
- Centre de recherche de l'Hôpital Maisonneuve-Rosemont, 5415 Boul. de L'Assomption, Montréal, Canada; Erasmus Medical center Cancer Institute, University Medical Center Rotterdam, Department of Hematology, Rotterdam, the Netherlands; Department of Medicine, Université de Montréal, Montreal, Canada; Institute for Hematology-Oncology, Transplantation, Cell and Gene Therapy, Hôpital Maisonneuve-Rosemont, Montreal, Canada.
| | - Josée Hébert
- Centre de recherche de l'Hôpital Maisonneuve-Rosemont, 5415 Boul. de L'Assomption, Montréal, Canada; Department of Medicine, Université de Montréal, Montreal, Canada; Institute for Hematology-Oncology, Transplantation, Cell and Gene Therapy, Hôpital Maisonneuve-Rosemont, Montreal, Canada; The Quebec Leukemia Cell Bank, Canada
| | - Lambert Busque
- Centre de recherche de l'Hôpital Maisonneuve-Rosemont, 5415 Boul. de L'Assomption, Montréal, Canada; Department of Medicine, Université de Montréal, Montreal, Canada; Institute for Hematology-Oncology, Transplantation, Cell and Gene Therapy, Hôpital Maisonneuve-Rosemont, Montreal, Canada
| | - François Mercier
- Division of Hematology and Experimental Medicine, Department of Medicine, McGill University, 3755 Côte-Sainte-Catherine Road, Montreal, Canada; Lady Davis Institute for Medical Research, Jewish General Hospital, 3755 Côte-Sainte-Catherine Road, Montreal, Canada
| | - Christopher E Rudd
- Centre de recherche de l'Hôpital Maisonneuve-Rosemont, 5415 Boul. de L'Assomption, Montréal, Canada; Department of Medicine, Université de Montréal, Montreal, Canada; Institute for Hematology-Oncology, Transplantation, Cell and Gene Therapy, Hôpital Maisonneuve-Rosemont, Montreal, Canada
| | - Sarit Assouline
- Division of Hematology and Experimental Medicine, Department of Medicine, McGill University, 3755 Côte-Sainte-Catherine Road, Montreal, Canada; Lady Davis Institute for Medical Research, Jewish General Hospital, 3755 Côte-Sainte-Catherine Road, Montreal, Canada
| | - Silvy Lachance
- Department of Medicine, Université de Montréal, Montreal, Canada; Institute for Hematology-Oncology, Transplantation, Cell and Gene Therapy, Hôpital Maisonneuve-Rosemont, Montreal, Canada
| | - Jean-Sébastien Delisle
- Centre de recherche de l'Hôpital Maisonneuve-Rosemont, 5415 Boul. de L'Assomption, Montréal, Canada; Department of Medicine, Université de Montréal, Montreal, Canada; Institute for Hematology-Oncology, Transplantation, Cell and Gene Therapy, Hôpital Maisonneuve-Rosemont, Montreal, Canada
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15
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Ciurea SO, Kothari A, Sana S, Al Malki MM. The mythological chimera and new era of relapse prediction post-transplant. Blood Rev 2023; 57:100997. [PMID: 35961800 DOI: 10.1016/j.blre.2022.100997] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 07/13/2022] [Accepted: 07/21/2022] [Indexed: 01/28/2023]
Abstract
Allogeneic hemopoietic stem cell transplantation is the treatment of choice for high-risk or relapsed acute leukemia. However, unfortunately, relapse post-transplant continues to be the most common cause of treatment failure with 20-80% of patients relapsing based on disease risk and status at transplant. Advances in molecular profiling of different hematological malignancies have enabled us to monitor low level disease before and after transplant and develop a more personalized approach to the management of these disease including early detection post-transplant. While, in general, detectable disease by morphology remains the gold standard to diagnosing relapse, multiple approaches have allowed detection of cancer cells earlier, using peripheral blood-based methods with sensitivities as high as 1:106, together called minimal/measurable residual disease (MRD) detection. However, a in significant number of patients with acute leukemia where no such molecular markers exist it remains challenging to detect early relapse. In such patients who receive transplantation, chimerism monitoring remains the only option. An increase in mixed chimerism in post allogeneic HCT patients has been correlated with relapse in multiple studies. However, chimerism monitoring, while commonly accepted as a tool for assessing engraftment, has not been routinely used for relapse detection, at least in part because of the lack of standardized, high sensitivity, reliable methods for chimerism detection. In this paper, we review the various methods employed for MRD and chimerism detection post-transplant and discuss future trends in MRD and chimerism monitoring from the viewpoint of the practicing transplant physician.
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Affiliation(s)
- Stefan O Ciurea
- University of California Irvine, Orange, CA, United States of America.
| | | | - Sean Sana
- CareDx Inc., Brisbane, CA, United States of America
| | - Monzr M Al Malki
- City of Hope National Medical Center, Duarte, CA, United States of America
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16
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Maffini E, Ursi M, Barbato F, Dicataldo M, Roberto M, Campanini E, Dan E, De Felice F, De Matteis S, Storci G, Bonafè M, Arpinati M, Bonifazi F. The prevention of disease relapse after allogeneic hematopoietic cell transplantation in acute myeloid leukemia. Front Oncol 2022; 12:1066285. [DOI: 10.3389/fonc.2022.1066285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 11/11/2022] [Indexed: 12/02/2022] Open
Abstract
Disease relapse represents by far the most frequent cause of hematopoietic cell transplantation (HCT) failure. Patients with acute leukemia suffering relapse after HCT have limited conventional treatment options with little possibility of cure and represent, de facto, suitable candidates for the evaluation of novel cellular and biological-based therapies. Donor lymphocyte infusions (DLI) has been one of the first cellular therapies adopted to treat post HCT relapse of acute leukemia patients and still now, it is widely adopted in preemptive and prophylactic settings, with renewed interest for manipulated cellular products such as NK-DLI. The acquisition of novel biological insights into pathobiology of leukemia relapse are translating into the clinic, with novel combinations of target therapies and novel agents, helping delineate new therapeutical landscapes. Hypomethylating agents alone or in combination with novel drugs demonstrated their efficacy in pre-clinical models and controlled trials. FLT3 inhibitors represent an essential therapeutical instrument incorporated in post-transplant maintenance strategies. The Holy grail of allogeneic transplantation lies in the separation of graft-vs.-host disease from graft vs. tumor effects and after more than five decades, is still the most ambitious goal to reach and many ways to accomplish are on their way.
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17
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Yang G, Wang X, Huang S, Huang R, Wei J, Wang X, Zhang X. Generalist in allogeneic hematopoietic stem cell transplantation for MDS or AML: Epigenetic therapy. Front Immunol 2022; 13:1034438. [PMID: 36268012 PMCID: PMC9577610 DOI: 10.3389/fimmu.2022.1034438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 09/20/2022] [Indexed: 11/24/2022] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains the only curative treatment for patients with myeloid malignancies such as myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML). However, relapse and graft-versus-host disease (GvHD) still affect the survival of patients who receive allo-HSCT, and more appropriate therapeutic strategies should be applied at all stages of transplantation to prevent these adverse events. The use of epigenetics agents, such as hypomethylating agents (HMAs), has been explored to decrease the risk of relapse by epigenetic modulation, which is especially effective among AML patients with poor mutations in epigenetic regulators. Furthermore, epigenetic agents have also been regarded as prophylactic methods for GvHD management without abrogating graft versus leukemia (GvL) effects. Therefore, the combination of epigenetic therapy and HSCT may optimize the transplantation process and prevent treatment failure. Existing studies have investigated the feasibility and effectiveness of using HMAs in the pretransplant, transplant and posttransplant stages among MDS and AML patients. This review examines the application of HMAs as a bridge treatment to reduce the tumor burden and the determine appropriate dose during allo-HSCT. Within this review, we also examine the efficacy and safety of HMAs alone or HMA-based strategies in posttransplant settings for MDS and AML. Finally, we provide an overview of other epigenetic candidates, which have been discussed in the nontransplant setting.
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Affiliation(s)
- Guancui Yang
- Medical Center of Hematology, Xinqiao Hospital, Third Military Medical University (Army Medical University), Chongqing, China
- State Key Laboratory of Trauma, Burns and Combined Injury, Third Military Medical University (Army Medical University), Chongqing, China
- Department of Hematology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Xiang Wang
- Medical Center of Hematology, Xinqiao Hospital, Third Military Medical University (Army Medical University), Chongqing, China
- State Key Laboratory of Trauma, Burns and Combined Injury, Third Military Medical University (Army Medical University), Chongqing, China
| | - Shiqin Huang
- Medical Center of Hematology, Xinqiao Hospital, Third Military Medical University (Army Medical University), Chongqing, China
- State Key Laboratory of Trauma, Burns and Combined Injury, Third Military Medical University (Army Medical University), Chongqing, China
| | - Ruihao Huang
- Medical Center of Hematology, Xinqiao Hospital, Third Military Medical University (Army Medical University), Chongqing, China
- State Key Laboratory of Trauma, Burns and Combined Injury, Third Military Medical University (Army Medical University), Chongqing, China
| | - Jin Wei
- Department of Hematology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Xiaoqi Wang
- Medical Center of Hematology, Xinqiao Hospital, Third Military Medical University (Army Medical University), Chongqing, China
- State Key Laboratory of Trauma, Burns and Combined Injury, Third Military Medical University (Army Medical University), Chongqing, China
- *Correspondence: Xi Zhang, ; Xiaoqi Wang,
| | - Xi Zhang
- Medical Center of Hematology, Xinqiao Hospital, Third Military Medical University (Army Medical University), Chongqing, China
- State Key Laboratory of Trauma, Burns and Combined Injury, Third Military Medical University (Army Medical University), Chongqing, China
- Department of Hematology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
- *Correspondence: Xi Zhang, ; Xiaoqi Wang,
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Najima Y, Tachibana T, Takeda Y, Koda Y, Aoyama Y, Toya T, Igarashi A, Tanaka M, Sakaida E, Abe R, Onizuka M, Kobayashi T, Doki N, Ohashi K, Kanamori H, Ishizaki T, Yokota A, Morita S, Okamoto S, Kanda Y. Dose-finding trial of azacitidine as post-transplant maintenance for high-risk MDS: a KSGCT prospective study. Ann Hematol 2022; 101:2719-2729. [PMID: 36149461 DOI: 10.1007/s00277-022-04981-x] [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: 10/28/2021] [Accepted: 09/15/2022] [Indexed: 11/28/2022]
Abstract
This 3+3 dose-escalation phase I multicenter study investigated the optimal dose of azacitidine (AZA) for post-hematopoietic stem cell transplantation (HSCT) maintenance, which remains unknown in Japan. Recipients of a first HSCT for high-risk myelodysplastic syndromes (MDS, n = 12) or acute myeloid leukemia (AML) with antecedent MDS (n = 3) received post-HSCT AZA maintenance in 2015-2019. The optimal AZA dose was defined as the dose at which 50-70% of patients can complete four cycles without dose-limiting toxicity (DLT). The initial dose level 1 was set as 30 mg/m2 for 5 days per 28-day cycle, and dose levels 0, 2, and 3 were set as 20, 40, and 50 mg/m2. DLT was defined as any grade 3 non-hematological or grade 4 hematological toxicity. The 15 evaluable patients were 55 (37-64) years old. The median observation of the post-HSCT survivors was 935 (493-1915) days. The median number of days post-HSCT to the start of AZA was 101 (59-176). In the first, second, and third cohorts, five of nine patients completed four cycles at dose level 1. In the final cohort, five of six additional patients completed at the same dose. In total, 10 (67%) patients tolerated AZA 30 mg/m2, which was determined as optimal. DLT occurred in five cases: grade 3 hepatotoxicity, pneumonia, enterocolitis, and grade 4 thrombocytopenia and neutropenia. The 2-year overall survival and disease-free survival rates post-HSCT were 77.0% and 73.3%. Post-HSCT AZA maintenance was well-tolerated and merits further evaluation for patients with MDS or AML with antecedent MDS. Trial registration: UMIN000018791.
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Affiliation(s)
- Yuho Najima
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, 113-8677, Japan.
| | | | - Yusuke Takeda
- Department of Hematology, Chiba University Hospital, Chiba, Japan
| | - Yuya Koda
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yasuhisa Aoyama
- Department of Hematology and Oncology, Tokai University School of Medicine, Isehara, Japan
| | - Takashi Toya
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, 113-8677, Japan
| | - Aiko Igarashi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, 113-8677, Japan
| | - Masatsugu Tanaka
- Department of Hematology, Kanagawa Cancer Center, Yokohama, Japan
| | - Emiko Sakaida
- Department of Hematology, Chiba University Hospital, Chiba, Japan
| | - Ryohei Abe
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Makoto Onizuka
- Department of Hematology and Oncology, Tokai University School of Medicine, Isehara, Japan
| | - Takeshi Kobayashi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, 113-8677, Japan
| | - Noriko Doki
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, 113-8677, Japan
| | - Kazuteru Ohashi
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, 113-8677, Japan
| | - Heiwa Kanamori
- Department of Hematology, Kanagawa Cancer Center, Yokohama, Japan
| | - Takuma Ishizaki
- Department of Hematology, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Akira Yokota
- Department of Hematology, Chiba Aoba Municipal Hospital, Chiba, Japan
| | - Satoshi Morita
- Department of Biomedical Statistics and Bioinformatics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Shinichiro Okamoto
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yoshinobu Kanda
- Division of Hematology, Department of Medicine, Jichi Medical University, Tochigi, Japan
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Hematopoietic Cell Transplantation in the Treatment of Pediatric Acute Myelogenous Leukemia and Myelodysplastic Syndromes: Guidelines from the American Society of Transplantation and Cellular Therapy. Transplant Cell Ther 2022; 28:530-545. [DOI: 10.1016/j.jtct.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 06/09/2022] [Indexed: 11/20/2022]
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20
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Kreidieh F, Abou Dalle I, Moukalled N, El-Cheikh J, Brissot E, Mohty M, Bazarbachi A. Relapse after allogeneic hematopoietic stem cell transplantation in acute myeloid leukemia: an overview of prevention and treatment. Int J Hematol 2022; 116:330-340. [PMID: 35841458 DOI: 10.1007/s12185-022-03416-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/29/2022] [Accepted: 06/29/2022] [Indexed: 12/17/2022]
Abstract
Despite therapeutic progress in acute myeloid leukemia (AML), relapse post-allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains a major challenge. Here, we aim to provide an overview of prevention and treatment of relapse in this population, including cell-based and pharmacologic options. Post-transplant maintenance therapy is used in patients who have undetectable measurable residual disease (MRD), while pre-emptive treatment is administered upon detection of MRD. Prompt transfusion of prophylactic donor lymphocyte infusion (DLI) was found to be effective in preventing relapse and overcoming the negative impact of detectable MRD. In addition, patients with persistent targetable mutations can benefit from targeted post-transplant pharmacological interventions. IDH inhibitors have shown promising results in relapsed/refractory AML. Hypomethylating agents, such as decitabine and azacitidine, have been studied in the post-allo-HSCT setting, both as pre-emptive and prophylactic. Venetoclax has been shown effective in combination with hypomethylating agents or low-dose cytarabine in patients with newly diagnosed AML, especially those unfit for intensive chemotherapy. FLT3 inhibitors, the topic of another section in this review series, have significantly improved survival in FLT-3-ITD mutant AML. The role of other cell-based therapies, including CAR-T cells, in AML is currently being investigated.
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Affiliation(s)
- Firas Kreidieh
- Department of Internal Medicine, Medical Center, Bone Marrow Transplant Program, American University of Beirut, Beirut, Lebanon
| | - Iman Abou Dalle
- Department of Internal Medicine, Medical Center, Bone Marrow Transplant Program, American University of Beirut, Beirut, Lebanon
| | - Nour Moukalled
- Department of Internal Medicine, Medical Center, Bone Marrow Transplant Program, American University of Beirut, Beirut, Lebanon
| | - Jean El-Cheikh
- Department of Internal Medicine, Medical Center, Bone Marrow Transplant Program, American University of Beirut, Beirut, Lebanon
| | - Eolia Brissot
- Department of Clinical Hematology and Cellular Therapy, Saint-Antoine Hospital, INSERM UMR 938 and Sorbonne University, Paris, France
| | - Mohamed Mohty
- Department of Clinical Hematology and Cellular Therapy, Saint-Antoine Hospital, INSERM UMR 938 and Sorbonne University, Paris, France
| | - Ali Bazarbachi
- Department of Internal Medicine, Medical Center, Bone Marrow Transplant Program, American University of Beirut, Beirut, Lebanon.
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21
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Manobianco SA, Rakiewicz T, Wilde L, Palmisiano ND. Novel Mechanisms for Post-Transplant Maintenance Therapy in Acute Myeloid Leukemia. Front Oncol 2022; 12:892289. [PMID: 35912243 PMCID: PMC9336463 DOI: 10.3389/fonc.2022.892289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 06/08/2022] [Indexed: 11/13/2022] Open
Abstract
Allogeneic stem cell transplantation has improved survival for patients with acute myeloid leukemia (AML), especially for patients with disease at high risk of relapse. However, relapse remains the most common cause of treatment failure and death in the post-transplant period. Maintenance therapy, an extended course of treatment after achieving remission to reduce the rate of relapse, is an important component of the treatment of various hematologic malignancies; however, its role in the treatment of AML is far less well-defined. Recently, there has been significant interest in the use of novel therapeutic agents as maintenance therapy after allogeneic stem cell transplant, utilizing new mechanisms of treatment and more favorable toxicity profiles. In this review, we will discuss the mechanistic and clinical data for post-transplant maintenance therapies in AML. Then, we will review several emergent and current clinical trials which aim to incorporate novel agents into maintenance therapy regimens.
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Affiliation(s)
- Steven A. Manobianco
- Thomas Jefferson University Hospital, Jefferson University Hospitals, Philadelphia, PA, United States
| | - Tara Rakiewicz
- Thomas Jefferson University Hospital, Jefferson University Hospitals, Philadelphia, PA, United States
| | - Lindsay Wilde
- Department of Medical Oncology, Division of Hematologic Malignancy and Stem Cell Transplantation, Philadelphia, PA, United States
| | - Neil D. Palmisiano
- Department of Medical Oncology, Division of Hematologic Malignancy and Stem Cell Transplantation, Philadelphia, PA, United States
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22
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Pan T, Han S, Zhou M, Qi J, Wang H, Xu X, Li X, Yao Y, Han Y. Efficacy of azacitidine in preventing relapse after hematopoietic stem cell transplantation for advanced myeloid malignancies: a systematic review and meta-analysis. Expert Rev Hematol 2022; 15:457-464. [PMID: 35535679 DOI: 10.1080/17474086.2022.2073214] [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: 11/04/2022]
Abstract
BACKGROUND Relapse is the leading cause of death from myeloid malignancies after allogeneic hematopoietic stem cell transplantation (HSCT). Azacitidine has gained attention in recent years in the prophylaxis of relapsed refractory hematologic malignancies. This study evaluated the efficacy of AZA in preventing relapse after HSCT in patients with myeloid malignancies. METHODS A systematic review and meta-analysis of all available cohort studies were performed regarding the application of AZA for prophylaxis of relapse after HSCT for advanced MDS and AML. Databases were searched for relevant studies. Endpoints included 2-year relapse rate, survival, relapse-related mortality, as well as the incidence of graft-versus-host disease (GVHD). RESULTS A total of 444 patients from 13 studies were included in this analysis. The pooled estimate of the cumulative incidence of relapse after two years in enrolled patients was 25% (95% confidence interval [CI], 18%-33%). The pooled estimates of 2-year survival probabilities were 65% (95% CI, 50%-79%). The pooled cumulative incidence of relapse-related mortality was 28% (95% CI, 22%-34%). The pooled estimated incidence of acute and chronic GVHD, respectively, were 28% (95% CI, 22%-34%) and 38% (95% CI, 27%-49%). CONCLUSION AZA administration is efficacious for relapse prevention after HSCT in myeloid malignancies.
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Affiliation(s)
- Tingting Pan
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, Jiangsu, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, Jiangsu, China
| | - Shiyu Han
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Meng Zhou
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, Jiangsu, China
| | - Jiaqian Qi
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, Jiangsu, China
| | - Hong Wang
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, Jiangsu, China
| | - Xiaoyan Xu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, Jiangsu, China
| | - Xueqian Li
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, Jiangsu, China
| | - Yifang Yao
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, Jiangsu, China
| | - Yue Han
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, Jiangsu, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, Jiangsu, China.,State Key Laboratory of Radiation Medicine and Protection, Soochow University, Suzhou, Jiangsu, China
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23
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Single-agent 5-azacytidine as post-transplant maintenance in high-risk myeloid malignancies undergoing allogeneic hematopoietic cell transplantation. Ann Hematol 2022; 101:1321-1331. [PMID: 35352216 DOI: 10.1007/s00277-022-04821-y] [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: 08/30/2021] [Accepted: 03/22/2022] [Indexed: 11/01/2022]
Abstract
Relapse is a major cause of treatment failure after allogeneic hematopoietic cell transplantation (allo-HCT) in myeloid malignancies. Additional strategies have been devised to further maximize the immunologic effect of allo-HCT, notably through maintenance therapy with hypomethylating agents such as 5-azacytidine (AZA). We conducted a single-center retrospective study to investigate the efficacy of AZA after allo-HCT for high-risk myeloid malignancies. All patients transplanted between Jan 2014 and Sept 2019 for high-risk acute myeloid leukemia (n = 123), myelodysplastic syndrome (n = 51), or chronic myelomonocytic leukemia (n = 11) were included. Patients who died, relapsed, or developed grade ≥ 2 acute graft-versus-host disease before day + 60 were excluded, as well as those who were eligible for anti-FMS-like tyrosine kinase 3 maintenance. Of the 185 included patients, 65 received AZA while 120 did not. Median age at transplant was 59 years; 51.9% of patients were males. The median follow-up was 24 months for both groups. Regarding main patient characteristics and transplantation modalities, the two groups were comparable. In multivariate analyses, there were no significant differences between the two groups in terms of 2-year cumulative incidence of relapse (HR = 1.19; 95% confidence interval (CI) 0.67-2.12; p = 0.55), overall survival (HR = 0.62; 95%CI 0.35-1.12; p = 0.12) and event-free survival (HR = 0.97; 95%CI 0.60-1.58; p = 0.91) rates. In conclusion, single-agent AZA does not appear to be an optimal drug for preventing post-transplant relapse in patients with high-risk myeloid malignancies. This study highlights the need for prospective studies of alternative therapies or combination approaches in the post-transplant setting.
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24
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Abou Dalle I, El Cheikh J, Bazarbachi A. Pharmacologic Strategies for Post-Transplant Maintenance in Acute Myeloid Leukemia: It Is Time to Consider! Cancers (Basel) 2022; 14:1490. [PMID: 35326641 PMCID: PMC8946578 DOI: 10.3390/cancers14061490] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/16/2022] [Accepted: 01/16/2022] [Indexed: 11/16/2022] Open
Abstract
Patients with high-risk acute myeloid leukemia are offered allogeneic hematopoietic cell transplantation (allo-HCT) in first remission to reduce risk of relapse. However, disease recurrence remains the major reason of allo-HCT failure, occurring in around 35-45% of patients, and leading to dismal outcomes. Strategies to reduce the risk of relapse are greatly needed, especially in the early post-transplant phase where the graft-versus-leukemia (GVL) effect is not yet activated. Some practices include the use of myeloablative conditioning regimens, close monitoring of measurable residual disease and donor chimerism, rapid tapering of immunosuppression, and implementation of pre-emptive strategies as the use of donor lymphocyte infusion. However, it's time to consider prophylactic pharmacologic interventions post allo-HCT that aim at maintaining leukemic clones under control by both direct cytotoxic activity and by enhancing the GVL effect. In this current review, available data on drugs targeting epigenetic pathways like azacitidine, or actionable mutations like FLT3 and IDH1/2 inhibitors used as maintenance post allo-HCT, will be discussed.
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Affiliation(s)
| | | | - Ali Bazarbachi
- Hematology-Oncology Division, Department of Internal Medicine, American University of Beirut Medical Center, Beirut 1107 2020, Lebanon; (I.A.D.); (J.E.C.)
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25
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Bewersdorf JP, Prebet T, Gowda L. Azacitidine maintenance in AML post induction and posttransplant. Curr Opin Hematol 2022; 29:84-91. [PMID: 35013047 DOI: 10.1097/moh.0000000000000700] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Disease relapse remains the most common cause of death among patients with acute myeloid leukemia (AML) following induction therapy and allogeneic hematopoietic cell transplant (allo-HCT). Prolonging the duration of remission with minimal nonrelapse mortality risk is an area of unmet need for AML patients. RECENT FINDINGS In QUAZAR AML-001 study, the oral azacitidine analogue CC-486 demonstrated an overall survival (OS) benefit when given as postremission therapy (PRT) for patients in CR1 that were ineligible to proceed to allo-HCT. Used as maintenance post allo-HCT, CC-486 has also shown safety with encouraging disease-free survival (DFS). Although a recent randomized trial of parenteral azacitidine vs. placebo post allo-HCT failed to show relapse reduction, a subsequent meta-analysis of maintenance studies posttransplant has shown good utility with this approach. Such conflicting results emphasize the need for robust study designs to identify subsets of patients that derive maximal benefits using latest tools to risk stratify relapse risk. SUMMARY PRT with hypomethylating agents is feasible and in select population, there is a survival advantage with CC-486. Better understanding of distinct epigenetic and immunomodulatory properties of azacitidine, holds significant promise to synergize pharmacologic and cellular drivers of disease control as PRT in future AML trials.
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Affiliation(s)
- Jan Philipp Bewersdorf
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Thomas Prebet
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Lohith Gowda
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, Yale University, New Haven, Connecticut, USA
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26
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Georgi JA, Stasik S, Bornhäuser M, Platzbecker U, Thiede C. Analysis of Subset Chimerism for MRD-Detection and Pre-Emptive Treatment in AML. Front Oncol 2022; 12:841608. [PMID: 35252010 PMCID: PMC8892234 DOI: 10.3389/fonc.2022.841608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 01/26/2022] [Indexed: 11/25/2022] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (alloHCT) represents the only potentially curative treatment in high-risk AML patients, but up to 40% of patients suffer from relapse after alloHCT. Treatment of overt relapse poses a major therapeutic challenge and long-term disease control is achieved only in a minority of patients. In order to avoid post-allograft relapse, maintenance as well as pre-emptive therapy strategies based on MRD-detection have been used. A prerequisite for the implementation of pre-emptive therapy is the accurate identification of patients at risk for imminent relapse. Detection of measurable residual disease (MRD) represents an effective tool for early relapse prediction in the post-transplant setting. However, using established MRD methods such as multicolor flow cytometry or quantitative PCR, sensitive MRD monitoring is only applicable in about half of the patients with AML and advanced MDS undergoing alloHCT. Donor chimerism analysis, in particular when performed on enriched leukemic stem and progenitor cells, e.g. CD34+ cells, is a sensitive method and has emerged as an alternative option in the post alloHCT setting. In this review, we will focus on the current strategies for lineage specific chimerism analysis, results of pre-emptive treatment using this technology as well as future developments in this field.
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Affiliation(s)
- Julia-Annabell Georgi
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Carl Gustav Carus der Technischen Universität, Dresden, Germany
| | - Sebastian Stasik
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Carl Gustav Carus der Technischen Universität, Dresden, Germany
| | - Martin Bornhäuser
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Carl Gustav Carus der Technischen Universität, Dresden, Germany
- National Center for Tumor Diseases (NCT), Dresden, Germany
- *Correspondence: Martin Bornhäuser ,
| | - Uwe Platzbecker
- Klinik und Poliklinik für Hämatologie, Zelltherapie und Hämostaseologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Christian Thiede
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Carl Gustav Carus der Technischen Universität, Dresden, Germany
- AgenDix GmbH, Dresden, Germany
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27
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Leotta S, Condorelli A, Sciortino R, Milone GA, Bellofiore C, Garibaldi B, Schininà G, Spadaro A, Cupri A, Milone G. Prevention and Treatment of Acute Myeloid Leukemia Relapse after Hematopoietic Stem Cell Transplantation: The State of the Art and Future Perspectives. J Clin Med 2022; 11:253. [PMID: 35011994 PMCID: PMC8745746 DOI: 10.3390/jcm11010253] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 12/24/2021] [Accepted: 12/28/2021] [Indexed: 12/19/2022] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) for high-risk acute myeloid leukemia (AML) represents the only curative option. Progress has been made in the last two decades in the pre-transplant induction therapies, supportive care, selection of donors and conditioning regimens that allowed to extend the HSCT to a larger number of patients, including those aged over 65 years and/or lacking an HLA-identical donor. Furthermore, improvements in the prophylaxis of the graft-versus-host disease and of infection have dramatically reduced transplant-related mortality. The relapse of AML remains the major reason for transplant failure affecting almost 40-50% of the patients. From 10 to 15 years ago to date, treatment options for AML relapsing after HSCT were limited to conventional cytotoxic chemotherapy and donor leukocyte infusions (DLI). Nowadays, novel agents and targeted therapies have enriched the therapeutic landscape. Moreover, very recently, the therapeutic landscape has been enriched by manipulated cellular products (CAR-T, CAR-CIK, CAR-NK). In light of these new perspectives, careful monitoring of minimal-residual disease (MRD) and prompt application of pre-emptive strategies in the post-transplant setting have become imperative. Herein, we review the current state of the art on monitoring, prevention and treatment of relapse of AML after HSCT with particular attention on novel agents and future directions.
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Affiliation(s)
| | - Annalisa Condorelli
- Division of Hematology, AOU “Policlinico G. Rodolico-San Marco”, Via Santa Sofia 78, 95124 Catania, Italy; (S.L.); (R.S.); (G.A.M.); (C.B.); (B.G.); (G.S.); (A.S.); (A.C.); (G.M.)
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28
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Webster JA, Luznik L, Gojo I. Treatment of AML Relapse After Allo-HCT. Front Oncol 2022; 11:812207. [PMID: 34976845 PMCID: PMC8716583 DOI: 10.3389/fonc.2021.812207] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 11/25/2021] [Indexed: 01/02/2023] Open
Abstract
With advances in allogeneic hematopoietic stem cell transplant (allo-HCT), disease relapse has replaced transplant-related mortality as the primary cause of treatment failure for patients with acute myeloid leukemia (AML). The efficacy of allo-HCT in AML is a consequence of a graft-versus-leukemia (GVL) effect that is mediated by T lymphocytes, and unique mechanisms of immune evasion underlying post-allo-HCT AML relapses have recently been characterized. Relapsed AML following allo-HCT presents a particularly vexing clinical challenge because transplant-related toxicities, such as graft-versus-host (GVHD) and infections, increase the risk of treatment-related morbidity and mortality. In general, the prognosis of relapsed AML following allo-HCT is poor with most patients failing to achieve a subsequent remission and 2-year survival consistently <15%. The two factors that have been found to predict a better prognosis are a longer duration of post-transplant remission prior to relapse and a lower disease burden at the time of relapse. When considered in combination with a patient's age; co-morbidities; and performance status, these factors can help to inform the appropriate therapy for the treatment of post-transplant relapse. This review discusses the options for the treatment of post-transplant AML relapse with a focus on the options to achieve a subsequent remission and consolidation with cellular immunotherapy, such as a second transplant or donor lymphocyte infusion (DLI). While intensive reinduction therapy and less intensive approaches with hypomethylating agents have long represented the two primary options for the initial treatment of post-transplant relapse, molecularly targeted therapies and immunotherapy are emerging as potential alternative options to achieve remission. Herein, we highlight response and survival outcomes achieved specifically in the post-transplant setting using each of these approaches and discuss how some therapies may overcome the immunologic mechanisms that have been implicated in post-transplant relapse. As long-term survival in post-transplant relapse necessarily involves consolidation with cellular immunotherapy, we present data on the efficacy and toxicity of both DLI and second allo-HCT including when such therapies are integrated with reinduction. Finally, we provide our general approach to the treatment of post-transplant relapse, integrating both novel therapies and our improved understanding of the mechanisms underlying post-transplant relapse.
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Affiliation(s)
- Jonathan A Webster
- Hematologic Malignancies and Bone Marrow Transplantation Program, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Leo Luznik
- Hematologic Malignancies and Bone Marrow Transplantation Program, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Ivana Gojo
- Hematologic Malignancies and Bone Marrow Transplantation Program, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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29
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What Are the Prospects for Treating TP53 Mutated Myelodysplastic Syndromes and Acute Myeloid Leukemia? Cancer J 2022; 28:51-61. [DOI: 10.1097/ppo.0000000000000569] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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30
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The Evolving Role of Allogeneic Stem Cell Transplant in the Era of Molecularly Targeted Agents. Cancer J 2022; 28:78-84. [DOI: 10.1097/ppo.0000000000000575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Poiré X, Graux C, Ory A, Herman J, Baron F, Schoemans H, Lewalle P, De Becker A, Deeren D, Berneman Z, Kerre T, Zachée P, Selleslag D, Beguin Y. Sequential administration of low dose 5-azacytidine (AZA) and donor lymphocyte infusion (DLI) for patients with acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS) in relapse after allogeneic stem cell transplantation (SCT): a prospective study from the Belgian Hematology Society (BHS). Bone Marrow Transplant 2022; 57:116-118. [PMID: 34611291 DOI: 10.1038/s41409-021-01464-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 08/08/2021] [Accepted: 09/07/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Xavier Poiré
- Section of Hematology, Cliniques Universitaires St-Luc, Université Catholique de Louvain, Brussels, Belgium.
| | - Carlos Graux
- Section of Hematology, CHU UCL Namur-Godinne, Université Catholique de Louvain, Yvoir, Belgium
| | - Aurélie Ory
- Data Management Office, Belgian Hematology Society, Liège, Belgium
| | - Julie Herman
- Data Management Office, Belgian Hematology Society, Liège, Belgium
| | - Frédéric Baron
- Section of Hematology, Centre Hospitalier Universitaire de Liège, Université de Liège, Liège, Belgium
| | - Hélène Schoemans
- Department of Hematology, University Hospitals of Leuven and KU Leuven, Leuven, Belgium
| | - Philippe Lewalle
- Section of Hematology, Institut Jules Bordet, Université libre de Bruxelles, Brussels, Belgium
| | - Ann De Becker
- Department Clinical Hematology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Dries Deeren
- Department of Hematology, AZ Delta, Roeselare, Belgium
| | - Zwi Berneman
- Department of Hematology, Antwerp University Hospital, Edegem, Belgium
| | - Tessa Kerre
- Department of Hematology, Ghent University Hospital, Ghent, Belgium
| | - Pierre Zachée
- Department of Hematology, ZNA Stuivenberg, Antwerp, Belgium
| | | | - Yves Beguin
- Section of Hematology, Centre Hospitalier Universitaire de Liège, Université de Liège, Liège, Belgium
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Bewersdorf JP, Allen C, Mirza AS, Grimshaw AA, Giri S, Podoltsev NA, Gowda L, Cho C, Tallman MS, Zeidan AM, Stahl M. Hypomethylating Agents and FLT3 Inhibitors As Maintenance Treatment for Acute Myeloid Leukemia and Myelodysplastic Syndrome After Allogeneic Hematopoietic Stem Cell Transplantation-A Systematic Review and Meta-Analysis. Transplant Cell Ther 2021; 27:997.e1-997.e11. [PMID: 34551341 PMCID: PMC9533376 DOI: 10.1016/j.jtct.2021.09.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 08/19/2021] [Accepted: 09/08/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Disease relapse remains the major cause of death among patients with acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS) who receive an allogeneic hematopoietic cell transplant (allo-HCT). Maintenance treatment with FLT3 inhibitors and hypomethylating agents (HMA) has been studied in various clinical trials with mixed results. OBJECTIVE To synthesize the current evidence on the efficacy and safety of FLT3 inhibitors and HMA for maintenance therapy after allo-HCT in AML and MDS. METHODS For this systematic review and meta-analysis Cochrane Library, Google Scholar, Ovid Medline, Ovid Embase, PubMed, Scopus, and Web of Science Core Collection were searched from inception to March 2021 for studies on maintenance therapies after allo-HCT in AML and MDS. Studies were excluded if they were reviews, commentaries, case series with <5 patients, or basic research articles, not published in English, not on post-allo-HCT maintenance with FLT3 inhibitors or HMA in AML or MDS, or if they were clinical trials without published results or duplicate publications from the same patient cohort. Studies with insufficient reporting of the primary endpoint (2-year overall survival [OS]) and studies using FLT3 inhibitors or HMA for pre-emptive treatment of imminent relapse based on positive measurable residual disease testing were excluded. Random-effects models were used to pool response rates for the primary outcome of 2-year OS. Hazard ratios (HR) for death and relapse were calculated for studies that included a control group. Rates of relapse-free survival (RFS), non-relapse mortality, and acute and chronic graft-versus-host-disease (GVHD) were studied as secondary endpoints. Downs and Black checklist and risk of bias assessments were used to gauge the quality of individual studies. The study protocol has been registered on PROSPERO (CRD42020187298). RESULTS Our search strategy identified 5559 studies. Twenty-one studies with a total of 809 patients were included in the meta-analysis. The 2-year OS rates were 81.7% (95% confidence interval [CI], 73.8%-87.7%) and 65.7% (95% CI, 55.1%-74.9%) among patients treated with FLT3 inhibitors and HMA, respectively. In sensitivity analyses restricted to studies that included a control group, maintenance therapy with FLT3 inhibitors (HR for death = 0.41; 95% CI, 0.26-0.62) or HMA (HR = 0.45; 95% CI, 0.31-0.66) appeared superior to no maintenance therapy. The 2-year RFS rates were 79.8% (95% CI, 75.0%-83.9%) and 62.4% (95% CI, 50.6%-72.9%) among patients treated with FLT3 inhibitors and HMA, respectively. Rates of any grade acute and chronic GVHD were 33.1% (95% CI, 25.4%-41.8%; grade 3/4: 16.5%) and 42.5% (95% CI, 26.3%-60.4%) among FLT3 inhibitor and 42.7% (95% CI, 33.5%-52.4%; grade 3/4: 8.1%) and 41.5% (95% CI, 32.0%-51.6%) among HMA-treated patients, respectively. CONCLUSION Maintenance therapy with either FLT3 inhibitors or HMA after allo-HCT can lead to prolonged and improved OS and RFS with a favorable safety profile. Additional studies are needed to define the optimal duration of treatment, the role of measurable residual disease status, and transplant characteristics in patient selection.
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Affiliation(s)
- Jan Philipp Bewersdorf
- Department of Internal Medicine, Section of Hematology, Yale School of Medicine, New Haven, Connecticut; Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, New York; Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut
| | - Cecily Allen
- Department of Internal Medicine, Section of Hematology, Yale School of Medicine, New Haven, Connecticut
| | - Abu-Sayeef Mirza
- Department of Internal Medicine, Section of Hematology, Yale School of Medicine, New Haven, Connecticut
| | - Alyssa A Grimshaw
- Harvey Cushing/John Hay Whitney Medical Library, Yale University, New Haven, Connecticut
| | - Smith Giri
- Division of Hematology and Oncology, University of Alabama School of Medicine, Birmingham, Alabama
| | - Nikolai A Podoltsev
- Department of Internal Medicine, Section of Hematology, Yale School of Medicine, New Haven, Connecticut; Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut
| | - Lohith Gowda
- Department of Internal Medicine, Section of Hematology, Yale School of Medicine, New Haven, Connecticut
| | - Christina Cho
- Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Martin S Tallman
- Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Amer M Zeidan
- Department of Internal Medicine, Section of Hematology, Yale School of Medicine, New Haven, Connecticut; Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University, New Haven, Connecticut
| | - Maximilian Stahl
- Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medical Oncology, Adult Leukemia Program, Dana-Farber Cancer Institute, Boston, Massachusetts.
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Malladi R, Ahmed I, McIlroy G, Dignan FL, Protheroe R, Jackson A, Moss P, Nunnick J, Siddique S, Bishop R, Elhaneid M, Hodgkinson A, Craddock C. Azacitidine for the treatment of steroid-refractory chronic graft-versus-host disease: the results of the phase II AZTEC clinical trial. Bone Marrow Transplant 2021; 56:2948-2955. [PMID: 34446853 DOI: 10.1038/s41409-021-01439-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 07/13/2021] [Accepted: 08/17/2021] [Indexed: 11/08/2022]
Abstract
Chronic graft-versus-host disease (cGvHD) is a major cause of non-relapse morbidity and mortality following allogeneic stem cell transplant. Over half of patients with moderate or severe cGvHD fail to respond adequately to first-line treatment with systemic steroids, and although a range of second-line options have been employed, a lack of prospective evidence means there is no standard of care. The AZTEC trial is a prospective, single-arm, phase II study investigating the safety and activity of azacitidine for the treatment of cGvHD in patients who are resistant to, or intolerant of, systemic steroid therapy. The co-primary outcomes were treatment tolerability, and activity measured as objective response according to modified National Institutes of Health criteria. Fourteen patients were recruited to the first stage of the trial, of whom seven completed the planned six cycles of azacitidine 36 mg/m2 days 1-5 per 28-day cycle. Azacitidine was tolerated by 13/14 patients, and 7/14 showed an objective response. Clinical responses were mirrored by improvements in patient-reported cGvHD symptoms and quality of life. AZTEC demonstrates that azacitidine is a safe and promising option for the treatment of cGvHD, and continued evaluation in the second stage of this phase II efficacy study is supported.
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Affiliation(s)
- Ram Malladi
- Centre for Clinical Haematology, Queen Elizabeth Hospital Birmingham, Birmingham, UK.
- Department of Haematology, Addenbrooke's Hospital, Cambridge, UK.
| | - Ikhlaaq Ahmed
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Graham McIlroy
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Fiona L Dignan
- Department of Clinical Haematology, Manchester University NHS Foundation Trust, Manchester, UK
| | - Rachel Protheroe
- Department of Haematology, University Hospitals Bristol, Bristol, UK
| | - Aimee Jackson
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Paul Moss
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Jane Nunnick
- Centre for Clinical Haematology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Shamyla Siddique
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Rebecca Bishop
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Mohamed Elhaneid
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Andrea Hodgkinson
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Charles Craddock
- Centre for Clinical Haematology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, UK
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Austin AE, Byrne M. Detecting and preventing post-hematopoietic cell transplant relapse in AML. Curr Opin Hematol 2021; 28:380-388. [PMID: 34534984 DOI: 10.1097/moh.0000000000000686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Relapsed disease is the primary cause of mortality for acute myeloid leukemia (AML) patients after allogeneic hematopoietic cell transplantation (HCT). This review outlines the most recent advances in the detection and prevention of AML relapse following allogeneic HCT. RECENT FINDINGS Conventional methods for predicting post-HCT relapse rely on the molecular and cytogenetics features present at diagnosis. These methods are slow to reflect a growing understanding of the molecular heterogeneity of AML and impact of new therapies on post-HCT outcomes. The use of measurable residual disease (MRD) techniques, including multiparameter flow cytometry and molecular testing, may improve the prognostic ability of these models and should be incorporated into post-HCT surveillance whenever possible.In the post-HCT setting, FLT3 inhibitor maintenance data indicate that effective therapies can improve post-HCT outcomes. Maintenance data with DNA methyltransferase inhibitor monotherapy is less compelling and outcomes may improve with combinations. Early interventions directed at preemptive management of MRD may further improve post-HCT outcomes. SUMMARY Post-HCT AML relapse prevention has evolved to include more sensitive measures of disease detection and novel therapies that may improve outcomes of poor-risk AML patients. Additional work is needed to maintain this progress.
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Affiliation(s)
| | - Michael Byrne
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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35
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Garcia-Manero G, Döhner H, Wei AH, La Torre I, Skikne B, Beach CL, Santini V. Oral Azacitidine (CC-486) for the Treatment of Myeloid Malignancies. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 22:236-250. [PMID: 34758945 DOI: 10.1016/j.clml.2021.09.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 09/22/2021] [Accepted: 09/27/2021] [Indexed: 02/07/2023]
Abstract
Epigenetic dysregulation leads to aberrant DNA hypermethylation and is common in acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS). A large number of clinical trials in AML, MDS, and other hematologic malignancies have assessed hypomethylating agents (HMAs), used alone or in combination with other drugs, in the frontline, maintenance, relapsed/refractory, and peritransplant settings. Effective maintenance therapy has long been a goal for patients with AML in remission. Previous large, randomized clinical trials of maintenance with HMAs or other agents had not shown meaningful improvement in overall survival. Oral azacitidine (Oral-AZA [CC-486]) is approved in the United States, Canada, and European Union for treatment of adult patients with AML in first complete remission (CR) or CR with incomplete blood count recovery (CRi) following intensive induction chemotherapy who are ineligible for hematopoietic cell transplant. Regulatory approvals of Oral-AZA were based on outcomes from the randomized, phase III QUAZAR AML-001 trial, which showed a median overall survival advantage of 9.9 months with Oral-AZA versus placebo. Oral-AZA allows convenient extended AZA dosing for 14 days per 28-day treatment cycle, which is not feasible with injectable AZA. Focusing on AML and MDS, this report reviews the rationale for the use of orally bioavailable AZA and its potential use in all-oral combination therapy regimens; the unique pharmacokinetic and pharmacodynamic profile of Oral-AZA compared with injectable AZA; the clinical safety and efficacy of Oral-AZA maintenance therapy in patients with AML in first remission and for treatment of patients with active MDS; and ongoing Oral-AZA clinical trials.
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Affiliation(s)
| | - Hartmut Döhner
- Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany
| | - Andrew H Wei
- Department of Clinical Haematology, The Alfred Hospital, Melbourne, Australia; Monash University, Australian Centre for Blood Diseases, Melbourne, Australia
| | | | - Barry Skikne
- Bristol-Myers Squibb Company, Princeton, NJ; Department of Hematology, University of Kansas Medical Center, Kansas City, KS
| | - C L Beach
- Bristol-Myers Squibb Company, Princeton, NJ
| | - Valeria Santini
- MDS Unit, Hematology, AOU Careggi, University of Florence, Florence, Italy
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Xi Y, Jingying D, Chenglong L, Hong Z, Rong Z, Xiaodong W, Chunsen W, Xiaobing H. Epigenetic Therapy Promotes the Ratio of Th1/Th17 Lineage to Reverse Immune Evasion and Treat Leukemia Relapse Post-allogeneic Stem Cell Transplantation in Non-APL AML Patients. Front Mol Biosci 2021; 7:595395. [PMID: 34504867 PMCID: PMC8421566 DOI: 10.3389/fmolb.2020.595395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 11/30/2020] [Indexed: 11/21/2022] Open
Abstract
To reverse the early-stage relapse post-hematopoietic stem cell transplantation, we investigated the safety and efficacy of a new epigenetic regimen (chidamide and decitabine plus thymalfasin simultaneously) on acute myeloid leukemia patients (excluding acute promyelocytic leukemia). Twenty-four patients were enrolled in this observational study during April 2015 to May 2018. The most common adverse event was reversible CTCAE grade 2 thrombocytopenia (20/24). Strikingly, all 24 patients had response to this epigenetic regimen accompanied with decreased measurable residual disease. The overall survival rate is 79.2% (19/24), with a relapse-free survival rate of 79.2% (19/24). During this regimen treatment, Th1 cells and CD3+CD4-CD8+T cells increased, and Th17 cells decreased gradually. The status of high Th1 and low Th17 cells was still observed on the 3rd month after discontinuation of this regimen. Interestingly, the significantly elevated ratio of Th1/Th17 seemed to reflect the treatment-related immune effect, which may be a valuable marker to be monitored in the early-relapse stage for evaluating the efficacy and prognosis.
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Affiliation(s)
- Yang Xi
- Sichuan Provincial People's Hospital, Affiliated Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Dai Jingying
- Sichuan Provincial People's Hospital, Affiliated Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Li Chenglong
- Sichuan Provincial People's Hospital, Affiliated Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Zheng Hong
- Sichuan Provincial People's Hospital, Affiliated Hospital of University of Electronic Science and Technology of China, Chengdu, China.,Penn State Cancer Institute, Penn State University College of Medicine, Hershey, PA, United States
| | - Zhang Rong
- Sichuan Provincial People's Hospital, Affiliated Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Wang Xiaodong
- Sichuan Provincial People's Hospital, Affiliated Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Wang Chunsen
- Sichuan Provincial People's Hospital, Affiliated Hospital of University of Electronic Science and Technology of China, Chengdu, China
| | - Huang Xiaobing
- Sichuan Provincial People's Hospital, Affiliated Hospital of University of Electronic Science and Technology of China, Chengdu, China
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Liu J, Jiang ZX, Xie XS, Wan DM, Cao WJ, Wang M, Liu ZZ, Dong ZK, Wang HQ, Lu RQ, Zhang YY, Cheng QQ, Fan JX, Li W, He F, Guo R. Maintenance Treatment With Low-Dose Decitabine After Allogeneic Hematopoietic Cell Transplantation in Patients With Adult Acute Lymphoblastic Leukemia. Front Oncol 2021; 11:710545. [PMID: 34485147 PMCID: PMC8415411 DOI: 10.3389/fonc.2021.710545] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 07/28/2021] [Indexed: 12/14/2022] Open
Abstract
Background Post-transplant relapse remains a principal leading cause of failure after allogeneic hematopoietic stem cell transplantation (allo-HSCT) in patients with adult acute lymphoblastic leukemia (ALL). The aim of this study was to investigate the efficacy and safety of low-dose decitabine on the prevention of adult ALL relapse after allo-HSCT. Methods In this prospective study, we enrolled 34 patients with ALL who underwent allo-HSCT from August 2016 to April 2020 and received low-dose decitabine maintenance treatment after transplantation. The primary objectives were cumulative incidence of relapse rate (CIR), overall survival (OS), and disease-free survival (DFS). The secondary objectives were graft-versus-host disease (GVHD) and safety. Results Among the enrolled 34 patients, 6 patients relapsed and 6 patients died. The 2-year CIR, OS, and DFS were 20.2, 77.5, and 73.6%, respectively. Subgroup analysis revealed the 2-year CIR, OS, and DFS rates of 12 patients with T-ALL/lymphoblastic lymphoma (LBL) were 8.3, 90, and 81.5%, respectively. None of the seven patients with T-ALL relapsed. During maintenance treatment, only one patient (2.9%) developed grade IV acute GVHD and four (11.8%) patients had severe chronic GVHD. Thirty-two patients (94.1%) developed only grade I to II myelosuppression, and two patients (5.8%) developed grade III to IV granulocytopenia. Conclusions Maintenance treatment with low-dose decitabine after allo-HSCT may be used as a therapeutic option to reduce relapse in patients with adult ALL, especially in patients with T-ALL. Our findings require confirmation in larger-scale controlled trials. Clinical Trial Registration Chinese Clinical Trials Registry, identifier ChiCTR1800014888.
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Affiliation(s)
- Jia Liu
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Hematopoietic Stem Cell Transplantation Center, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Zhong-Xing Jiang
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xin-Sheng Xie
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ding-Ming Wan
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Wei-Jie Cao
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Meng Wang
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhen-Zhen Liu
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhen-Kun Dong
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hai-Qiong Wang
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Run-Qing Lu
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yin-Yin Zhang
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Qian-Qian Cheng
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ji-Xin Fan
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Wei Li
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Fei He
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Rong Guo
- Department of Hematology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Can the New and Old Drugs Exert an Immunomodulatory Effect in Acute Myeloid Leukemia? Cancers (Basel) 2021; 13:cancers13164121. [PMID: 34439275 PMCID: PMC8393879 DOI: 10.3390/cancers13164121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 08/11/2021] [Accepted: 08/14/2021] [Indexed: 12/30/2022] Open
Abstract
Simple Summary The advent of novel immunotherapeutic strategies has revealed the importance of immune dysregulation and of a tolerogenic microenvironment for acute myeloid leukemia (AML) fitness. We reviewed the “off-target” effects on the immune system of different drugs used in the treatment of AML to explore the advantages of this unexpected interaction. Abstract Acute myeloid leukemia (AML) is considered an immune-suppressive neoplasm capable of evading immune surveillance through cellular and environmental players. Increasing knowledge of the immune system (IS) status at diagnosis seems to suggest ever more attention of the crosstalk between the leukemic clone and its immunologic counterpart. During the last years, the advent of novel immunotherapeutic strategies has revealed the importance of immune dysregulation and suppression for leukemia fitness. Considering all these premises, we reviewed the “off-target” effects on the IS of different drugs used in the treatment of AML, focusing on the main advantages of this interaction. The data reported support the idea that a successful therapeutic strategy should consider tailored approaches for performing leukemia eradication by both direct blasts killing and the engagement of the IS.
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39
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Loo S, Wei AH. Post-transplant maintenance therapy for MDS and AML: a bridge too far or the beginning of a new era? Leuk Lymphoma 2021; 62:3073-3077. [PMID: 34348073 DOI: 10.1080/10428194.2021.1961243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Sun Loo
- Department of Clinical Hematology, Alfred Hospital, Melbourne, VIC, Australia
| | - Andrew H Wei
- Australian Centre for Blood Diseases, Monash University, Melbourne, VIC, Australia
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40
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Improved outcome in AML relapse after allogeneic transplant with high-intensity chemotherapy followed by 2nd allogeneic stem cell transplant or donor lymphocyte infusion. Ann Hematol 2021; 100:2585-2592. [PMID: 34322774 DOI: 10.1007/s00277-021-04616-7] [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: 01/25/2021] [Accepted: 07/16/2021] [Indexed: 10/20/2022]
Abstract
Acute myeloid leukemia (AML) relapse after allogeneic stem cell transplant (alloSCT) remains a major therapeutic challenge. While patients with longer remission after initial alloSCT are recommended to receive cell therapy (CT) such as 2ndalloSCT or donor lymphocyte infusion (DLI), survival for patients who relapse within 6 months of alloSCT has been dismal. We evaluated the outcomes of AML relapse after alloSCT to assess the impact of different treatments on long-term survival. One hundred and seventy-two patients with AML underwent alloSCT at the Penn State Cancer Institute from January 2014 to August 2019. Sixty-nine patients relapsed (median age, 60 years; range, 10-75). Of these, 4 patients underwent 2ndalloSCT, and 26 received DLI. One-year overall survival (OS) in all cases was 20.3% (95% CI: 11.8-30.4%). Patients with ECOG performance status (PS) 0-2 at relapse showed a better 1-year OS than those with PS 3-4. Median OS for patients who received chemotherapy only or chemotherapy with CT was 74 or 173.5 days, respectively (p < 0.001). Relapsed patients receiving conventional re-induction chemotherapy were categorized as the high-intensity chemotherapy (H) group, while those receiving treatments such as hypomethylating agents or targeted agents were categorized as the low-intensity chemotherapy (L) group. The H group showed a better 1-year OS compared with the L group. Patients who received H + CT showed a better 1-year OS of 52.9% than the other 3 groups (p < 0.001). Even for patients with post-alloSCT remission duration of less than 6 months, the statistical significance was preserved. Factors including age, donor source at 1stalloSCT, time to relapse, blast counts, PS at relapse, and treatment type after post-alloSCT relapse were used for a multivariate analysis, and matched or mismatched related donor and H + CT after alloSCT were identified as independent factors associated with OS. These findings support the use of H + CT as the treatment option of choice for AML patients who relapse after alloSCT when feasible.
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41
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Jondreville L, Roos-Weil D, Uzunov M, Boussen I, Grenier A, Norol F, Morel V, Nguyen S, Souchet L. FLAMSA-Busulfan-Melphalan as a Sequential Conditioning Regimen in HLA-Matched or Haploidentical Hematopoietic Stem Cell Transplantation for High-Risk Myeloid Diseases. Transplant Cell Ther 2021; 27:915.e1-915.e8. [PMID: 34329755 DOI: 10.1016/j.jtct.2021.07.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 06/14/2021] [Accepted: 07/19/2021] [Indexed: 11/17/2022]
Abstract
Given the poor prognosis of relapsed/refractory myeloid malignancies, the concept of sequential conditioning before allogeneic hematopoietic stem cell transplantation (allo-HSCT) has proven to be an effective approach. We sought to evaluate a sequential scheme combining fludarabine, amsacrine, and cytarabine (FLAMSA) for cytoreduction, followed by reduced-intensity conditioning with busulfan and melphalan (FLAMSA-BuMel), which was designed to be suitable for both HLA-matched and haploidentical HSCT. This single-center retrospective study included 36 adult patients with high-risk myeloid malignancies who underwent allo-HSCT from HLA-matched (n = 19) or haploidentical (n = 17) donors. Along with the standard prophylaxis for graft-versus-host disease (GVHD), patients with a haploidentical donor received post-transplantation high-dose cyclophosphamide. A post-transplantation consolidation treatment with low-dose 5-azacytidine and prophylactic donor lymphocyte infusions was provided whenever possible. Thirty patients (83%) achieved complete remission on day +30. With a median follow-up of 30.0 months, the 2-year overall survival was 89% in the HLA-matched group versus 34% in the haploidentical group (P = .0018). The 2-year disease-free survival in these 2 groups was 68% and 34%, respectively (P = .013). At 2 years, the probability of relapse was 32% and 20%, respectively, and nonrelapse mortality was 0% and 58%, respectively (P = .0003). The leading cause of death was relapse in the HLA-matched group (3 of 19) and hemorrhagic events (5 of 17) in the haploidentical group, favored by significantly delayed platelet reconstitution and a severe GVHD context. These data confirm the feasibility of FLAMSA-BuMel as a sequential conditioning in allo-HSCT for high-risk myeloid malignancies. The use of bone marrow as the preferred graft source might reduce the incidence of acute GVHD and nonrelapse mortality in the haploidentical transplantation setting.
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Affiliation(s)
- Ludovic Jondreville
- Service d'Hématologie Clinique, Hôpital Pitié-Salpêtrière, APHP, Sorbonne Université, Paris, France.
| | - Damien Roos-Weil
- Service d'Hématologie Clinique, Hôpital Pitié-Salpêtrière, APHP, Sorbonne Université, Paris, France
| | - Madalina Uzunov
- Service d'Hématologie Clinique, Hôpital Pitié-Salpêtrière, APHP, Sorbonne Université, Paris, France
| | - Inès Boussen
- Service d'Hématologie Clinique, Hôpital Pitié-Salpêtrière, APHP, Sorbonne Université, Paris, France
| | - Adrien Grenier
- Service d'Hématologie Clinique, Hôpital Pitié-Salpêtrière, APHP, Sorbonne Université, Paris, France
| | - Françoise Norol
- Service d'Hématologie Clinique, Hôpital Pitié-Salpêtrière, APHP, Sorbonne Université, Paris, France
| | - Véronique Morel
- Service d'Hématologie Clinique, Hôpital Pitié-Salpêtrière, APHP, Sorbonne Université, Paris, France
| | - Stéphanie Nguyen
- Service d'Hématologie Clinique, Hôpital Pitié-Salpêtrière, APHP, Sorbonne Université, Paris, France
| | - Laetitia Souchet
- Service d'Hématologie Clinique, Hôpital Pitié-Salpêtrière, APHP, Sorbonne Université, Paris, France
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42
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Guolo F, Di Grazia C, Minetto P, Raiola AM, Clavio M, Miglino M, Tedone E, Contini P, Mangerini R, Kunkl A, Colombo N, Pugliese G, Carminati E, Marcolin R, Passannante M, Bagnasco S, Galaverna F, Lamparelli T, Ballerini F, Cagnetta A, Cea M, Gobbi M, Bacigalupo A, Lemoli RM, Angelucci E. Pre-transplant minimal residual disease assessment and transplant-related factors predict the outcome of acute myeloid leukemia patients undergoing allogeneic stem cell transplantation. Eur J Haematol 2021; 107:573-582. [PMID: 34297437 DOI: 10.1111/ejh.13694] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 07/18/2021] [Accepted: 07/20/2021] [Indexed: 12/27/2022]
Abstract
We studied pretransplant minimal residual disease (MRD) in 224 patients (median age 44 years; range 17-65) with acute myeloid leukemia (AML) undergoing allogeneic stem cell transplant (HSCT) in complete remission. MRD was evaluated on marrow samples using multicolor flow cytometry and assessment of WT1 gene expression. Both methods showed a strong prognostic value and their combination allowed the identification of three groups of patients with different risk of relapse. In multivariate analysis, combined MRD was the only predictor of cumulative incidence of relapse, regardless of donor type, conditioning regimen, first or second CR at HSCT, HSCT year, and ELN risk group. Multivariate regression model showed that only negative combined MRD status (P < .001) and myeloablative conditioning (P = .004) were independently associated with better OS. Among MRD-positive patients, a reduced incidence of relapse was observed in patients receiving haplo transplant (P < .05) and in patients who showed grade II-IV aGVHD (P < .03). In patients with negative combined MRD, the intensity of conditioning regimen did not affect the overall favorable outcome. We suggest that pretransplant MRD evaluation combined with transplant-related factors can identify AML patients at higher risk for relapse and might help in defining the overall transplant strategy.
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Affiliation(s)
- Fabio Guolo
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, Genoa, Italy
| | | | - Paola Minetto
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, Genoa, Italy
| | | | - Marino Clavio
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, Genoa, Italy
| | - Maurizio Miglino
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, Genoa, Italy
| | | | - Paola Contini
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | | | | | | | - Girolamo Pugliese
- Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, Genoa, Italy
| | - Enrico Carminati
- Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, Genoa, Italy
| | - Riccardo Marcolin
- Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, Genoa, Italy
| | - Monica Passannante
- Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, Genoa, Italy
| | - Samuele Bagnasco
- Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, Genoa, Italy
| | - Federica Galaverna
- Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, Genoa, Italy
| | | | - Filippo Ballerini
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, Genoa, Italy
| | - Antonia Cagnetta
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, Genoa, Italy
| | - Michele Cea
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, Genoa, Italy
| | - Marco Gobbi
- Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, Genoa, Italy
| | | | - Roberto Massimo Lemoli
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy.,Clinic of Hematology, Department of Internal Medicine (DiMI), University of Genoa, Genoa, Italy
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43
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Webster JA, Yogarajah M, Zahurak M, Symons H, Dezern AE, Gojo I, Prince GT, Morrow J, Jones RJ, Smith BD, Showel M. A phase II study of azacitidine in combination with granulocyte-macrophage colony-stimulating factor as maintenance treatment, after allogeneic blood or marrow transplantation in patients with poor-risk acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS). Leuk Lymphoma 2021; 62:3181-3191. [PMID: 34284701 DOI: 10.1080/10428194.2021.1948029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Relapse is the most common cause of treatment failure following allogeneic blood or marrow transplantation (alloBMT) for AML or MDS. Post-transplant maintenance therapies may prevent relapse. We conducted a phase II trial combining azacitidine (AZA) with GM-CSF in non-relapsed, post-transplant patients with AML or MDS. Patients received escalating doses of AZA to a maximum of 75 mg/m2 for 5 days per cycle for up to 12 cycles. GM-CSF was given on days 1-10 of each cycle. Eighteen patients were treated following non-myeloablative (17) and myeloablative (1) alloBMT for AML (61.1%), MDS (27.7%), or therapy-related myeloid neoplasm (11.1%). The majority of patients (72%) received their graft from an HLA-haploidentical donor. The treatment was well-tolerated with rare grade 3-4 hematologic toxicities. One patient suffered an exacerbation of GVHD. The 24-month relapse-free and overall survivals were 47 and 57%, respectively, with a median of 18.6 and 29 months.
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Affiliation(s)
- Jonathan A Webster
- Hematologic Malignancies and Bone Marrow Transplantation Program, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Marianna Zahurak
- Division of Biostatistics and Bioinformatics, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Heather Symons
- Hematologic Malignancies and Bone Marrow Transplantation Program, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Amy E Dezern
- Hematologic Malignancies and Bone Marrow Transplantation Program, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ivana Gojo
- Hematologic Malignancies and Bone Marrow Transplantation Program, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gabrielle T Prince
- Hematologic Malignancies and Bone Marrow Transplantation Program, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jillian Morrow
- Hematologic Malignancies and Bone Marrow Transplantation Program, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard J Jones
- Hematologic Malignancies and Bone Marrow Transplantation Program, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - B Douglas Smith
- Hematologic Malignancies and Bone Marrow Transplantation Program, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Margaret Showel
- Hematologic Malignancies and Bone Marrow Transplantation Program, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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44
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Mayerhofer C, Niemeyer CM, Flotho C. Current Treatment of Juvenile Myelomonocytic Leukemia. J Clin Med 2021; 10:3084. [PMID: 34300250 PMCID: PMC8305558 DOI: 10.3390/jcm10143084] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 07/09/2021] [Accepted: 07/10/2021] [Indexed: 02/06/2023] Open
Abstract
Juvenile myelomonocytic leukemia (JMML) is a rare pediatric leukemia characterized by mutations in five canonical RAS pathway genes. The diagnosis is made by typical clinical and hematological findings associated with a compatible mutation. Although this is sufficient for clinical decision-making in most JMML cases, more in-depth analysis can include DNA methylation class and panel sequencing analysis for secondary mutations. NRAS-initiated JMML is heterogeneous and adequate management ranges from watchful waiting to allogeneic hematopoietic stem cell transplantation (HSCT). Upfront azacitidine in KRAS patients can achieve long-term remissions without HSCT; if HSCT is required, a less toxic preparative regimen is recommended. Germline CBL patients often experience spontaneous resolution of the leukemia or exhibit stable mixed chimerism after HSCT. JMML driven by PTPN11 or NF1 is often rapidly progressive, requires swift HSCT and may benefit from pretransplant therapy with azacitidine. Because graft-versus-leukemia alloimmunity is central to cure high risk patients, the immunosuppressive regimen should be discontinued early after HSCT.
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Affiliation(s)
- Christina Mayerhofer
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany; (C.M.); (C.M.N.)
| | - Charlotte M. Niemeyer
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany; (C.M.); (C.M.N.)
- German Cancer Consortium (DKTK), 79106 Freiburg, Germany
| | - Christian Flotho
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, Medical Center, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany; (C.M.); (C.M.N.)
- German Cancer Consortium (DKTK), 79106 Freiburg, Germany
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45
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Guillaume T, Thépot S, Peterlin P, Ceballos P, Bourgeois AL, Garnier A, Orvain C, Giltat A, François S, Bris YL, Fronteau C, Planche L, Chevallier P. Prophylactic or Preemptive Low-Dose Azacitidine and Donor Lymphocyte Infusion to Prevent Disease Relapse following Allogeneic Transplantation in Patients with High-Risk Acute Myelogenous Leukemia or Myelodysplastic Syndrome. Transplant Cell Ther 2021; 27:839.e1-839.e6. [PMID: 34224913 DOI: 10.1016/j.jtct.2021.06.029] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 06/07/2021] [Accepted: 06/27/2021] [Indexed: 01/11/2023]
Abstract
Because of the persistently high rates of relapse of patients with high-risk acute myelogenous leukemia (AML) and myelodysplastic syndrome (MDS) following allogeneic hematopoietic stem cell transplantation (allo-HSCT), post-transplantation maintenance therapy has been proposed. We previously initiated a Phase II trial in which epigenetic therapy was combined with immunotherapy in an attempt to reduce disease relapse. In that study, low-dose azacitidine (AZA) and escalating doses of donor lymphocyte infusion (DLI) were given as post-allo-HSCT maintenance treatment. In the present study, we retrospectively analyze a larger cohort of patients receiving post-transplantation maintenance therapy and provide updates on some patients of the earlier study. The objectives of the present study were to analyze the cumulative incidence of relapse (CIR), overall survival (OS), and progression-free survival (PFS) and the incidence of acute and chronic graft-versus-host disease (GVHD) of patients with high-risk AML or MDS receiving post-transplantation maintenance treatment with AZA with or without DLI. We retrospectively analyzed 77 patients (54 with AML, 23 with MDS) considered at high risk based on either their genomic or clinical status at transplantation. Following allogeneic transplantation, they received at least 1 cycle of prophylactic or preemptive low-dose AZA with or without escalating doses of DLI to prevent disease relapse. Almost one-half of the patients (47%) were able to receive the full 12 cycles of scheduled AZA, and a majority (79%) received at least 1 DLI. With a median follow-up of 24 months, 19 patients (25%; 16 with AML, 3 with MDS) relapsed, at a median of 9.8 months (range, 4 to 58.6 months), giving a 22% CIR at 24 months. OS and PFS at 24 months were 70.8% and 68.3%, respectively. The cumulative incidences of grade II-IV acute GVHD and chronic GVHD were 27.4% and 45%, respectively. Only a minority of patients (11%) required delayed administration of AZA. These findings confirm that AZA-DLI maintenance is both tolerable and effective in reducing the risk of post-transplantation relapse.
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Affiliation(s)
- Thierry Guillaume
- Department of Hematology, Nantes University Hospital, Hôtel-Dieu, Nantes, France; Fédération Hospitalo-Universitaire Grand-Ouest Acute Leukemia, Nantes-Angers, France.
| | - Sylvain Thépot
- Fédération Hospitalo-Universitaire Grand-Ouest Acute Leukemia, Nantes-Angers, France; Department of Hematology, Angers University Hospital, Angers, France
| | - Pierre Peterlin
- Department of Hematology, Nantes University Hospital, Hôtel-Dieu, Nantes, France; Fédération Hospitalo-Universitaire Grand-Ouest Acute Leukemia, Nantes-Angers, France
| | - Patrice Ceballos
- Department of Hematology, Montpellier University Hospital, Saint-Eloi Hospital, Montpellier, France
| | - Amandine Le Bourgeois
- Department of Hematology, Nantes University Hospital, Hôtel-Dieu, Nantes, France; Fédération Hospitalo-Universitaire Grand-Ouest Acute Leukemia, Nantes-Angers, France
| | - Alice Garnier
- Department of Hematology, Nantes University Hospital, Hôtel-Dieu, Nantes, France; Fédération Hospitalo-Universitaire Grand-Ouest Acute Leukemia, Nantes-Angers, France
| | - Corentin Orvain
- Fédération Hospitalo-Universitaire Grand-Ouest Acute Leukemia, Nantes-Angers, France; Department of Hematology, Angers University Hospital, Angers, France
| | - Aurélien Giltat
- Fédération Hospitalo-Universitaire Grand-Ouest Acute Leukemia, Nantes-Angers, France; Department of Hematology, Angers University Hospital, Angers, France
| | - Sylvie François
- Fédération Hospitalo-Universitaire Grand-Ouest Acute Leukemia, Nantes-Angers, France; Department of Hematology, Angers University Hospital, Angers, France
| | - Yannick Le Bris
- Fédération Hospitalo-Universitaire Grand-Ouest Acute Leukemia, Nantes-Angers, France; Hematologic Biology Department, Nantes University Hospital, Hôtel-Dieu, Nantes, France
| | - Clémentine Fronteau
- Department of Pharmacy, Nantes University Hospital, Hôtel-Dieu, Nantes, France
| | - Lucie Planche
- Clinical Research Unit, Regional Hospital of Vendée, Les Oudairies, La Roche-Sur-Yon, France
| | - Patrice Chevallier
- Department of Hematology, Nantes University Hospital, Hôtel-Dieu, Nantes, France; Fédération Hospitalo-Universitaire Grand-Ouest Acute Leukemia, Nantes-Angers, France
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46
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Azacitidine maintenance after allogeneic hematopoietic cell transplantation for MDS and AML. Blood Adv 2021; 5:1757-1759. [PMID: 33755090 DOI: 10.1182/bloodadvances.2020003839] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 12/09/2020] [Indexed: 12/23/2022] Open
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47
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Loke J, Buka R, Craddock C. Allogeneic Stem Cell Transplantation for Acute Myeloid Leukemia: Who, When, and How? Front Immunol 2021; 12:659595. [PMID: 34012445 PMCID: PMC8126705 DOI: 10.3389/fimmu.2021.659595] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 03/23/2021] [Indexed: 12/28/2022] Open
Abstract
Although the majority of patients with acute myeloid leukemia (AML) treated with intensive chemotherapy achieve a complete remission (CR), many are destined to relapse if treated with intensive chemotherapy alone. Allogeneic stem cell transplant (allo-SCT) represents a pivotally important treatment strategy in fit adults with AML because of its augmented anti-leukemic activity consequent upon dose intensification and the genesis of a potent graft-versus-leukemia effect. Increased donor availability coupled with the advent of reduced intensity conditioning (RIC) regimens has dramatically increased transplant access and consequently allo-SCT is now a key component of the treatment algorithm in both patients with AML in first CR (CR1) and advanced disease. Although transplant related mortality has fallen steadily over recent decades there has been no real progress in reducing the risk of disease relapse which remains the major cause of transplant failure and represents a major area of unmet need. A number of therapeutic approaches with the potential to reduce disease relapse, including advances in induction chemotherapy, the development of novel conditioning regimens and the emergence of the concept of post-transplant maintenance, are currently under development. Furthermore, the use of genetics and measurable residual disease technology in disease assessment has improved the identification of patients who are likely to benefit from an allo-SCT which now represents an increasingly personalized therapy. Future progress in optimizing transplant outcome will be dependent on the successful delivery by the international transplant community of randomized prospective clinical trials which permit examination of current and future transplant therapies with the same degree of rigor as is routinely adopted for non-transplant therapies.
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Affiliation(s)
- Justin Loke
- Centre for Clinical Haematology, Queen Elizabeth Hospital, Birmingham, United Kingdom
- CRUK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Richard Buka
- Centre for Clinical Haematology, Queen Elizabeth Hospital, Birmingham, United Kingdom
- CRUK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Charles Craddock
- Centre for Clinical Haematology, Queen Elizabeth Hospital, Birmingham, United Kingdom
- CRUK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
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48
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Loke J, Vyas H, Craddock C. Optimizing Transplant Approaches and Post-Transplant Strategies for Patients With Acute Myeloid Leukemia. Front Oncol 2021; 11:666091. [PMID: 33937080 PMCID: PMC8083129 DOI: 10.3389/fonc.2021.666091] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 03/23/2021] [Indexed: 11/13/2022] Open
Abstract
Acute Myeloid Leukemia (AML) is the commonest indication for allogeneic stem cell transplantation (allo-SCT) worldwide. The increasingly important role of allo-SCT in the management of AML has been underpinned by two important advances. Firstly, improvements in disease risk stratification utilizing genetic and Measurable Residual Disease (MRD) technologies permit ever more accurate identification of allo-mandatory patients who are at high risk of relapse if treated by chemotherapy alone. Secondly, increased donor availability coupled with the advent of reduced intensity conditioning (RIC) regimens has substantially expanded transplant access for patients with high risk AML In patients allografted for AML disease relapse continues to represent the commonest cause of transplant failure and the development of novel strategies with the potential to reduce disease recurrence represents a major unmet need.
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Affiliation(s)
- Justin Loke
- Centre for Clinical Haematology, Queen Elizabeth Hospital, Birmingham, United Kingdom.,Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Hrushikesh Vyas
- Centre for Clinical Haematology, Queen Elizabeth Hospital, Birmingham, United Kingdom.,Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
| | - Charles Craddock
- Centre for Clinical Haematology, Queen Elizabeth Hospital, Birmingham, United Kingdom.,Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
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49
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Mohty R, Massoud R, Chakhachiro Z, Mahfouz R, Nassif S, El-Cheikh J, Bazarbachi A, Abou Dalle I. Risk adapted therapeutic strategy in newly diagnosed acute myeloid leukemia: Refining the outcomes of ELN 2017 intermediate-risk patients. Leuk Res 2021; 105:106568. [PMID: 33857784 DOI: 10.1016/j.leukres.2021.106568] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 03/18/2021] [Accepted: 03/22/2021] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Despite advances in the treatment of acute myeloid leukemia (AML), cytotoxic chemotherapy remains the standard induction regimen. PATIENTS AND METHODS In this single center retrospective study, we assessed outcomes of 99 consecutive adult AML patients treated with a risk-adapted strategy with a median follow-up of 35.5 months. RESULTS We identified 24 (24 %), 55 (56 %) and 20 (20 %) patients classified as favorable-, intermediate-, and adverse- risk group respectively, according to the European LeukemiaNet (ELN) 2017 classification. Patients either received idarubicin and cytarabine induction chemotherapy with or without FLT3 inhibitors or hypomethylating agents based on age and comorbidity. The complete response (CR) rate was 76 % (82 % and 61 % in patients aged < 60 and ≥ 60, respectively). For the whole cohort, the 3-year overall survival (OS) was 53 %, being 62 % and 30 % in patients aged < 60 and ≥ 60, respectively. The 3-year leukemia-free survival (LFS) was 54 %, with 56 % and 45 % in patients aged < 60 and ≥ 60, respectively. The 3-year LFS were 58 %, 62 % and 25 % for patients within ELN favorable-, intermediate-, and adverse-risk groups respectively. Twenty-seven (36 %) out of 75 patients with intermediate- and adverse-risk disease underwent allogeneic hematopoietic cell transplantation (allo-HCT) in first CR with 92 % of them receiving post-transplant maintenance consisting of azacitidine in 19 (76 %) patients or sorafenib in 6 (24 %) patients. Of these patients younger than 60 years, the 3-year OS and LFS were 85 % and 69 %, respectively. CONCLUSION These results indicate an improved OS for AML patients especially in intermediate-risk category who were treated with a total therapy consisting of induction chemotherapy followed by allo-HCT and post-transplant maintenance.
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Affiliation(s)
- Razan Mohty
- Hematology-Oncology Division, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Radwan Massoud
- Hematology-Oncology Division, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Zaher Chakhachiro
- Hematopathology Division, Department of Pathology and Laboratory Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rami Mahfouz
- Hematopathology Division, Department of Pathology and Laboratory Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Samer Nassif
- Hematopathology Division, Department of Pathology and Laboratory Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Jean El-Cheikh
- Hematology-Oncology Division, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ali Bazarbachi
- Hematology-Oncology Division, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
| | - Iman Abou Dalle
- Hematology-Oncology Division, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
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50
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de Lima M, Roboz GJ, Platzbecker U, Craddock C, Ossenkoppele G. AML and the art of remission maintenance. Blood Rev 2021; 49:100829. [PMID: 33832807 DOI: 10.1016/j.blre.2021.100829] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 03/18/2021] [Accepted: 03/22/2021] [Indexed: 12/20/2022]
Abstract
Relapse in acute myeloid leukemia (AML) is common, especially in older patients, and there is currently no standard of care maintenance therapy for those who achieve complete remission. Finding effective, tolerable maintenance therapy to prolong remission has been a goal for decades, but early clinical trials testing a variety of agents demonstrated disappointing results with no overall survival benefit. CC-486, an oral hypomethylating agent, was recently approved in the United States for maintenance treatment in patients with AML in first remission following chemotherapy. A number of ongoing studies are assessing various therapeutics in the maintenance setting, including other hypomethylating agents, targeted small-molecule inhibitors, monoclonal antibodies, and immunomodulators. New strategies are needed to identify patients most likely to benefit from maintenance therapy, including those for whom a preemptive approach reliant on monitoring of measurable residual disease would be advantageous.
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Affiliation(s)
- Marcos de Lima
- The Ohio State University, Columbus, OH, United States of America.
| | - Gail J Roboz
- Weill Cornell Medicine, New York, NY, United States of America; New York Presbyterian Hospital, New York, NY, United States of America
| | | | - Charles Craddock
- Centre for Clinical Haematology, Queen Elizabeth Hospital, Birmingham, United Kingdom
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