1
|
Palmieri R, Billio A, Ferrara F, Galimberti S, Lemoli RM, Todisco E, Moretti F, Venditti A. Literature review and expert opinion on the treatment of high-risk acute myeloid leukemia in patients who are eligible for intensive chemotherapy. Front Oncol 2024; 14:1367393. [PMID: 38444680 PMCID: PMC10912626 DOI: 10.3389/fonc.2024.1367393] [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: 01/08/2024] [Accepted: 02/06/2024] [Indexed: 03/07/2024] Open
Abstract
In patients with Acute Myeloid Leukemia (AML), the assessment of disease risk plays a central role in the era of personalized medicine. Indeed, integrating baseline clinical and biological features on a case-by-case basis is not only essential to select which treatment would likely result in a higher probability of achieving complete remission, but also to dynamically customize any subsequent therapeutic intervention. For young high-risk patients with low comorbidities burden and in good general conditions (also called "fit" patients), intensive chemotherapy followed by allogeneic stem cell transplantation still represents the backbone of any therapeutic program. However, with the approval of novel promising agents in both the induction/consolidation and the maintenance setting, the algorithms for the management of AML patients considered eligible for intensive chemotherapy are in constant evolution. In this view, we selected burning issues regarding the identification and management of high-risk AML, aiming to provide practical advice to facilitate their daily clinical management in patients considered eligible for intensive chemotherapy.
Collapse
Affiliation(s)
- Raffaele Palmieri
- Hematology, Department of Biomedicine and Prevention, University Tor Vergata, Rome, Italy
| | - Atto Billio
- Division of Hematology and Bone Marrow Transplant (BMT), Hospital S. Maurizio, Bolzano, Italy
| | | | - Sara Galimberti
- Hematology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Roberto M. Lemoli
- Cattedra di Ematologia, Dipartimento di Medicina Interna (DiMI), Università di Genova, Genova, Italy
- Clinica Ematologica, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Martino, Genova, Italy
| | - Elisabetta Todisco
- Struttura Complessa (SC) Ematologia, Ospedale Busto Arsizio, Azienda Socio Sanitaria Territoriale (ASST) Valle Olona, Varese, Italy
| | - Federico Moretti
- Hematology, Department of Biomedicine and Prevention, University Tor Vergata, Rome, Italy
| | - Adriano Venditti
- Hematology, Department of Biomedicine and Prevention, University Tor Vergata, Rome, Italy
| |
Collapse
|
2
|
Fusillo TF, Millman S, Menghrajani K. Acute Myeloid Leukemia Presenting as Common Colds: An Uncommon Consideration. Cureus 2024; 16:e53217. [PMID: 38425594 PMCID: PMC10902726 DOI: 10.7759/cureus.53217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2024] [Indexed: 03/02/2024] Open
Abstract
Acute myeloid leukemia is the most common form of leukemia and can present with a wide variety of signs and symptoms. This article presents a case of a middle-aged male who presented with ongoing upper respiratory cold-like symptoms and was then found to be severely pancytopenic. A diagnosis of acute myeloid leukemia was made after a bone marrow biopsy, and the patient underwent induction chemotherapy. This article brings to light the uncommon diagnosis of acute myeloid leukemia, from a common presentation, a common cold. Additionally, it discusses the initial workup and diagnostic process of acute myeloid leukemia, risk stratification, and a basic treatment algorithm.
Collapse
Affiliation(s)
- Thomas F Fusillo
- Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Scott Millman
- Leukemia, Memorial Sloan Kettering Cancer Center, New York, USA
| | | |
Collapse
|
3
|
Dozzo A, Galvin A, Shin JW, Scalia S, O'Driscoll CM, Ryan KB. Modelling acute myeloid leukemia (AML): What's new? A transition from the classical to the modern. Drug Deliv Transl Res 2022:10.1007/s13346-022-01189-4. [PMID: 35930221 DOI: 10.1007/s13346-022-01189-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2022] [Indexed: 11/24/2022]
Abstract
Acute myeloid leukemia (AML) is a heterogeneous malignancy affecting myeloid cells in the bone marrow (BM) but can spread giving rise to impaired hematopoiesis. AML incidence increases with age and is associated with poor prognostic outcomes. There has been a disconnect between the success of novel drug compounds observed in preclinical studies of hematological malignancy and less than exceptional therapeutic responses in clinical trials. This review aims to provide a state-of-the-art overview on the different preclinical models of AML available to expand insights into disease pathology and as preclinical screening tools. Deciphering the complex physiological and pathological processes and developing predictive preclinical models are key to understanding disease progression and fundamental in the development and testing of new effective drug treatments. Standard scaffold-free suspension models fail to recapitulate the complex environment where AML occurs. To this end, we review advances in scaffold/matrix-based 3D models and outline the most recent advances in on-chip technology. We also provide an overview of clinically relevant animal models and review the expanding use of patient-derived samples, which offer the prospect to create more "patient specific" screening tools either in the guise of 3D matrix models, microphysiological "organ-on-chip" tools or xenograft models and discuss representative examples.
Collapse
Affiliation(s)
| | - Aoife Galvin
- School of Pharmacy, University College Cork, Cork, Ireland
| | - Jae-Won Shin
- Department of Pharmacology and Regenerative Medicine, University of Illinois at Chicago College of Medicine, 909 S. Wolcott Ave, Chicago, IL, 5091 COMRB, USA
| | - Santo Scalia
- Università degli Studi di Ferrara, Via Luigi Borsari 46, 44121, Ferrara, Italy
| | - Caitriona M O'Driscoll
- School of Pharmacy, University College Cork, Cork, Ireland.,SSPC Centre for Pharmaceutical Research, School of Pharmacy, University College Cork, Cork, Ireland
| | - Katie B Ryan
- School of Pharmacy, University College Cork, Cork, Ireland. .,SSPC Centre for Pharmaceutical Research, School of Pharmacy, University College Cork, Cork, Ireland.
| |
Collapse
|
4
|
Re-induction therapy in adult patients with acute myeloid leukemia with ≤20 % blasts: A retrospective cohort study. Leuk Res 2021; 111:106731. [PMID: 34695644 DOI: 10.1016/j.leukres.2021.106731] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 10/12/2021] [Accepted: 10/18/2021] [Indexed: 11/23/2022]
|
5
|
Abstract
Acute myeloid leukemia (AML) is an uncommon but potentially catastrophic diagnosis with historically high mortality rates. The standard of care treatment remained unchanged for decades; however, recent discoveries of molecular drivers of leukemogenesis and disease progression have led to novel therapies for AML. Ongoing research and clinical trials are actively seeking to personalize therapy by identifying molecular targets, discovering patient specific and disease specific risk factors, and identifying effective combinations of modalities and drugs. This review focuses on important updates in diagnostic and disease classifications that reflect new understanding of the biology of AML, its mutational heterogeneity, some important genetic and environmental risk factors, and new treatment options including cytotoxic chemotherapy, novel targeted agents, and cellular therapies.
Collapse
Affiliation(s)
- Laura F Newell
- Knight Cancer Institute, Hematology and Medical Oncology, Oregon Health & Science University, Portland, OR, USA
| | - Rachel J Cook
- Knight Cancer Institute, Hematology and Medical Oncology, Oregon Health & Science University, Portland, OR, USA
| |
Collapse
|
6
|
Mirgh S. (F)utility of day 14 bone marrow in acute myeloid leukemia on 3 + 7 induction – Is it time to bid adieu to day 14 bone marrow? CANCER RESEARCH, STATISTICS, AND TREATMENT 2021. [DOI: 10.4103/crst.crst_283_21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
7
|
Nair C, Manuprasad A, Raghavan V, Shenoy P, Krishnan A. The utility of day 14 bone marrow response assessment in patients undergoing acute myeloid leukemia induction: A single institution retrospective experience. CANCER RESEARCH, STATISTICS, AND TREATMENT 2021. [DOI: 10.4103/crst.crst_90_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
8
|
England JT, Saini L, Hogge D, Forrest D, Narayanan S, Power M, Nevill T, Kuchenbauer F, Hudoba M, Szkotak A, Brandwein J, Sanford D. Day 14 Bone Marrow Evaluation During Acute Myeloid Leukemia Induction in a Real-world Canadian Cohort. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 20:e427-e436. [PMID: 32201130 DOI: 10.1016/j.clml.2020.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 02/17/2020] [Accepted: 02/18/2020] [Indexed: 11/18/2022]
Abstract
INTRODUCTION The 2017 National Comprehensive Cancer Network guidelines for acute myeloid leukemia have recommended performing bone marrow (BM) aspiration and BM trephine biopsy (BMTB) 14 to 21 days after starting induction therapy (commonly referred to as "day 14 [D14] marrow"). Those who do not achieve a hypoplastic marrow, with cellularity < 20% and blasts < 5%, are recommended to undergo 2-cycle induction (2CI). We performed a retrospective analysis to determine the impact of D14 BM characteristics in predicting for remission, association with overall survival (OS), and the effect of 2CI according to the D14 BM results. PATIENTS AND METHODS Patients aged 18 to 70 years undergoing induction therapy with standard "7 + 3" regimens were included. D14 cellularity was determined from BMTB samples and the blast percentage was assessed by morphology on BM aspiration and BMTB samples. The outcomes evaluated included the rates of complete remission (CR) and OS. RESULTS A total of 486 patients with results from D14 BM evaluation were included in the present study. On multivariate analysis, cytogenetic risk and D14 blasts < 5% were predictive of CR/CR with incomplete count recovery (P < .001). Cytogenetic risk (P < .001), age < 60 years (P = .001), and D14 blasts < 5% (P = .045) predicted for OS. 2CI was performed in 131 patients (27%). Patients with hypocellular D14 BM but residual blasts (n = 106) underwent 2CI in 46% of cases, with improved remission rates (43.9% vs. 72.0%; P = .004) but no difference in OS. CONCLUSIONS The results from D14 BM evaluations are predictive of subsequent remission and OS. Our findings did not show a survival benefit with D14 BM-driven 2CI.
Collapse
Affiliation(s)
- James T England
- Leukemia/Bone Marrow Transplant Program of British Columbia, Division of Hematology, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Lalit Saini
- Division of Hematology, Department of Medicine, Western University, London, ON, Canada
| | - Donna Hogge
- Leukemia/Bone Marrow Transplant Program of British Columbia, Division of Hematology, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Donna Forrest
- Leukemia/Bone Marrow Transplant Program of British Columbia, Division of Hematology, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Sujaatha Narayanan
- Leukemia/Bone Marrow Transplant Program of British Columbia, Division of Hematology, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Maryse Power
- Leukemia/Bone Marrow Transplant Program of British Columbia, Division of Hematology, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Thomas Nevill
- Leukemia/Bone Marrow Transplant Program of British Columbia, Division of Hematology, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Florian Kuchenbauer
- Leukemia/Bone Marrow Transplant Program of British Columbia, Division of Hematology, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Monika Hudoba
- Division of Hematopathology, Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Artur Szkotak
- Division of Hematology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Joseph Brandwein
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB, Canada
| | - David Sanford
- Leukemia/Bone Marrow Transplant Program of British Columbia, Division of Hematology, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.
| |
Collapse
|
9
|
Jamy O, Bodine C, Sampat D, Sarmad R, Chadha A, Vachhani P, Papadantonakis N, Di Stasi A. Observation Versus Immediate Reinduction for Acute Myeloid Leukemia Patients With Indeterminate Day 14 Bone Marrow Results. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2019; 20:31-38. [PMID: 31757719 DOI: 10.1016/j.clml.2019.09.613] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 09/10/2019] [Accepted: 09/20/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION The benefit of immediate reinduction chemotherapy for patients with indeterminate day 14 bone marrow results (≤ 20% cellularity and 5%-20% blasts) remains unclear. We report our experience with patients with acute myeloid leukemia (AML) with indeterminate day 14 bone marrow biopsy results treated with reinduction chemotherapy versus observation alone. MATERIALS AND METHODS We performed a retrospective study to assess the outcomes of adult patients with newly diagnosed AML treated with or without reinduction chemotherapy for indeterminate day 14 bone marrow results. RESULTS We identified 50 patients with indeterminate day 14 bone marrow results. Of the 50 patients, 25 (50%) had received reinduction therapy and 25 (50%) had not. Of the 50 patients, 24 (48%) had poor risk disease, 12 in the reinduction arm (10 with an abnormal karyotype and 2 with a normal karyotype with molecular abnormalities) and 12 in the observation arm (6 with an abnormal karyotype and 6 with a normal karyotype with molecular abnormalities). The overall response rate (complete remission plus complete remission with incomplete count recovery) was similar in both treatment arms (80% vs. 80%). No statistically significant difference was found in the median overall survival (13 months vs. 21 months; P = .88) or relapse-free survival (13 months vs. 33 months; P = .53) between the 2 treatment arms. CONCLUSION Our study did not find a statistically significant difference in the overall response rates or survival outcome measures for patients with AML and indeterminate day 14 bone marrow in the 2 treatment groups. Our findings question the utility of immediate reinduction chemotherapy and raise concern regarding overtreatment in this patient population. Larger studies investigating similar outcomes are warranted to validate our clinical findings.
Collapse
Affiliation(s)
- Omer Jamy
- Division of Hematology/Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL.
| | - Charles Bodine
- Division of Hematology/Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Devi Sampat
- Division of Hematology/Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Rehan Sarmad
- Division of Hematology/Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Awal Chadha
- Division of Hematology/Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Pankit Vachhani
- Division of Hematology/Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Nikolaos Papadantonakis
- Division of Hematology/Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Antonio Di Stasi
- Division of Hematology/Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| |
Collapse
|
10
|
Refaei M, Radhwi O, Sandhu I, Brandwein J, Sun HWL, Saini L. A strategy of Day14 bone marrows and early intervention is not superior to a strategy of noDay14 bone marrows and delayed intervention in patients with acute myeloid leukemia. Leuk Lymphoma 2019; 60:1749-1757. [PMID: 31043109 DOI: 10.1080/10428194.2018.1543878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
We conducted a retrospective study of 364 acute myeloid leukemia patients treated using a Day14 or a noDay14 strategy. Under the Day14 strategy, patients received an interim marrow at 7-10 days following chemotherapy and, in case of residual disease, received immediate reinduction chemotherapy. Under the noDay14 strategy patients were only evaluated at end-of-induction (EOI). Overall induction mortality was higher in the Day14 cohort (8.3 vs. 3.6%, p = .12) but rates of remission (75.4 vs. 83%, p = .13) and refractory disease (14.3 vs. 13.4%, p = .87) at EOI were similar in the Day14 and noDay14 cohorts as were relapse rates (37.9% vs. 34.3%, p = .616), median relapse-free survival (14.8 vs. 15 months, p = .658) and median overall survival (25.3 vs. 37.2 months, p = .264). In multivariate analysis, the use of a Day14 strategy did not impact outcomes suggesting that a Day14 strategy is not superior to a noDay14 strategy.
Collapse
Affiliation(s)
- Mohammad Refaei
- a Department of Medicine , University of Alberta , Edmonton , Canada
| | - Osman Radhwi
- a Department of Medicine , University of Alberta , Edmonton , Canada
| | - Irwindeep Sandhu
- a Department of Medicine , University of Alberta , Edmonton , Canada
| | - Joseph Brandwein
- a Department of Medicine , University of Alberta , Edmonton , Canada
| | - Hao Wei Linda Sun
- a Department of Medicine , University of Alberta , Edmonton , Canada
| | - Lalit Saini
- a Department of Medicine , University of Alberta , Edmonton , Canada
| |
Collapse
|
11
|
Mika T, Ladigan S, Schork K, Turewicz M, Eisenacher M, Schmiegel W, Schroers R, Baraniskin A. Monocytes-neutrophils-ratio as predictive marker for failure of first induction therapy in AML. Blood Cells Mol Dis 2019; 77:103-108. [PMID: 31029023 DOI: 10.1016/j.bcmd.2019.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 04/17/2019] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Acute myeloid leukemia (AML) is, if untreated, a fatal hematologic neoplasia. Failure of the first induction chemotherapy is a hallmark for a poor prognosis. Early recognition of therapy failure is crucial for planning further therapies. Therefore, international guidelines recommend a bone marrow biopsy around day 14 after the beginning of induction therapy. Hypocellular bone marrow on day 14 is still gold standard for therapy assessment and further therapy strategy. Despite this, non-invasive ways for the evaluation of induction therapy were looked for in the past years. METHODS We collected peripheral blood cell counts and routine laboratory values of patients treated with "7 + 3" induction therapy. Ratios of absolute cell counts of monocytes and neutrophils (MNR) were calculated daily, and the values were compared in patients with failure of the first induction therapy and patients with therapy response. RESULTS 54 patients were included, 12 of which had failure of first induction therapy. The MNR following therapy was highly correlated with the bone marrow results. With the right cut-off, the MNR provides a valid and reliable tool for identification of patients with failure of first induction therapy with a sensitivity of 83.3% and a specificity of 87.8% on day 18. CONCLUSIONS We propose a novel and non-invasive method for detection of failure of first induction therapy in patients with de novo AML and "7 + 3" induction therapy. The MNR is free of cost since the required cell counts are performed routinely for each patient undergoing intensive chemotherapy.
Collapse
Affiliation(s)
- Thomas Mika
- Department of Medicine, Knappschaftskrankenhaus Bochum-Langendreer, Ruhr University Bochum, Germany; Center of Clinical Research, Department of Molecular GI-Oncology, Ruhr University Bochum, Germany.
| | - Swetlana Ladigan
- Department of Medicine, Knappschaftskrankenhaus Bochum-Langendreer, Ruhr University Bochum, Germany; Center of Clinical Research, Department of Molecular GI-Oncology, Ruhr University Bochum, Germany
| | - Karin Schork
- Medizinisches Proteom-Center, Ruhr University Bochum, Germany
| | | | | | - Wolff Schmiegel
- Department of Medicine, Knappschaftskrankenhaus Bochum-Langendreer, Ruhr University Bochum, Germany
| | - Roland Schroers
- Department of Medicine, Knappschaftskrankenhaus Bochum-Langendreer, Ruhr University Bochum, Germany
| | - Alexander Baraniskin
- Department of Medicine, Knappschaftskrankenhaus Bochum-Langendreer, Ruhr University Bochum, Germany
| |
Collapse
|
12
|
Banck JC, Görlich D. In-silico comparison of two induction regimens (7 + 3 vs 7 + 3 plus additional bone marrow evaluation) in acute myeloid leukemia treatment. BMC SYSTEMS BIOLOGY 2019; 13:18. [PMID: 30704476 PMCID: PMC6357450 DOI: 10.1186/s12918-019-0684-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 01/16/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND Clinical integration of systems biology approaches is gaining in importance in the course of digital revolution in modern medicine. We present our results of the analysis of an extended mathematical model describing abnormal human hematopoiesis. The model is able to describe the course of an acute myeloid leukemia including its treatment. In first-line treatment of acute myeloid leukemia, the induction chemotherapy aims for a rapid leukemic cell reduction. We consider combinations of cytarabine and anthracycline-like chemotherapy. Both substances are widely used as standard treatment to achieve first remission. In particular, we compare two scenarios: a single-induction course with 7 days cytarabine and 3 day of anthracycline-like treatment (7 + 3) with a 7 + 3 course and a bone marrow evaluation that leads, in case of insufficient leukemic cell reduction, to the provision of a second chemotherapy course. Three scenarios, based on the leukemias growth kinetics (slow, intermediate, fast), were analyzed. We simulated different intensity combinations for both therapy schemata (7 + 3 and 7 + 3 + evaluation). RESULTS Our model shows that within the 7 + 3 regimen a wider range of intensity combinations result in a complete remission (CR), compared to 7 + 3 + evaluation (fast: 64.3% vs 46.4%; intermediate: 63.7% vs 46.7%; slow: 0% vs 0%). Additionally, the number of simulations resulting in a prolonged CR was higher within the standard regimen (fast: 59.8% vs 40.1%; intermediate: 48.6% vs 31.0%; slow: 0% vs 0%). On the contrary, the 7 + 3 + evaluation regimen allows CR and prolonged CR by lower chemotherapy intensities compared to 7 + 3. Leukemic pace has a strong impact on treatment response and especially on specific effective doses. As a result, faster leukemias are characterized by superior treatment outcomes and can be treated effectively with lower treatment intensities. CONCLUSIONS We could show that 7 + 3 treatment has considerable more chemotherapy combinations leading to a first CR. However, the 7 + 3 + evaluation regimen leads to CR for lower therapy intensity and presumably less side effects. An additional evaluation can be considered beneficial to control therapy success, especially in low dose settings. The treatment success is dependent on leukemia growth dynamics. The determination of leukemic pace should be a relevant part of a personalized medicine.
Collapse
Affiliation(s)
- Jan Christoph Banck
- Institute of Biostatistics and Clinical Research, Westfälische Wilhelms-Universität Münster, Münster, Germany.,Department of Medicine III, University Hospital, Ludwig-Maximilians-Universität Munich, Munich, Germany
| | - Dennis Görlich
- Institute of Biostatistics and Clinical Research, Westfälische Wilhelms-Universität Münster, Münster, Germany.
| |
Collapse
|
13
|
Wong HY, Sung AD, Lindblad KE, Sheela S, Roloff GW, Rizzieri D, Goswami M, Mulé MP, Ramos NR, Tang J, Thompson J, DeStefano CB, Romero K, Dillon LW, Kim DY, Lai C, Hourigan CS. Molecular Measurable Residual Disease Testing of Blood During AML Cytotoxic Therapy for Early Prediction of Clinical Response. Front Oncol 2019; 8:669. [PMID: 30697529 PMCID: PMC6341003 DOI: 10.3389/fonc.2018.00669] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 12/18/2018] [Indexed: 12/18/2022] Open
Abstract
Measurable residual disease (MRD) testing after initial chemotherapy treatment can predict relapse and survival in acute myeloid leukemia (AML). However, it has not been established if repeat molecular or genetic testing during chemotherapy can offer information regarding the chemotherapy sensitivity of the leukemic clone. Blood from 45 adult AML patients at day 1 and 4 of induction (n = 35) or salvage (n = 10) cytotoxic chemotherapy was collected for both quantitative real-time PCR (qPCR) assessment (WT1) and next generation sequencing (>500 × depth) of 49 gene regions recurrently mutated in MDS/AML. The median age of subjects was 62 (23–78); 42% achieved a complete response. WT1 was overexpressed in most patients tested but was uninformative for very early MRD assessment. A median of 4 non-synonymous variants (range 0–7) were detected by DNA sequencing of blood on day 1 of therapy [median variant allele frequency (VAF): 29%]. Only two patients had no variants detectable. All mutations remained detectable in blood on day 4 of intensive chemotherapy and remarkably the ratio of mutated to wild-type sequence was often maintained. This phenomenon was not limited to variants in DNMT3A, TET2, and ASXL1. The kinetics of NPM1 and TP53 variant burden early during chemotherapy appeared to be exceptions and exhibited consistent trends in this cohort. In summary, molecular testing of blood on day 4 of chemotherapy is not predictive of clinical response to cytotoxic induction therapy in AML. The observed stability in variant allele frequency suggests that cytotoxic therapy may have a limited therapeutic index for clones circulating in blood containing these mutations. Further validation is required to confirm the utility of monitoring NPM1 and TP53 kinetics in blood during cytotoxic therapy.
Collapse
Affiliation(s)
- Hong Yuen Wong
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung and Blood Institute, Bethesda, MD, United States
| | - Anthony D Sung
- Duke University School of Medicine, Durham, NC, United States
| | - Katherine E Lindblad
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung and Blood Institute, Bethesda, MD, United States
| | - Sheenu Sheela
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung and Blood Institute, Bethesda, MD, United States
| | - Gregory W Roloff
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung and Blood Institute, Bethesda, MD, United States
| | - David Rizzieri
- Duke University School of Medicine, Durham, NC, United States
| | - Meghali Goswami
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung and Blood Institute, Bethesda, MD, United States
| | - Matthew P Mulé
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung and Blood Institute, Bethesda, MD, United States
| | - Nestor R Ramos
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung and Blood Institute, Bethesda, MD, United States
| | - Jingrong Tang
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung and Blood Institute, Bethesda, MD, United States
| | - Julie Thompson
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung and Blood Institute, Bethesda, MD, United States
| | - Christin B DeStefano
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung and Blood Institute, Bethesda, MD, United States
| | - Kristi Romero
- Duke University School of Medicine, Durham, NC, United States
| | - Laura W Dillon
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung and Blood Institute, Bethesda, MD, United States
| | - Dong-Yun Kim
- Office of Biostatistics Research, Division of Cardiovascular Sciences, National Heart, Lung and Blood Institute, Bethesda, MD, United States
| | - Catherine Lai
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung and Blood Institute, Bethesda, MD, United States
| | - Christopher S Hourigan
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung and Blood Institute, Bethesda, MD, United States
| |
Collapse
|
14
|
Comparison of Peripheral Blast Clearance and Day 14 Bone Marrow Biopsy in Predicting Remission Status and Survival After 7+3 Induction in Acute Myeloid Leukemia. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2018; 19:73-82. [PMID: 30528848 DOI: 10.1016/j.clml.2018.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 10/31/2018] [Accepted: 11/02/2018] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Induction chemotherapy with cytarabine and an anthracycline (7+3) remains the standard of care for acute myeloid leukemia (AML). PATIENTS AND METHODS We retrospectively analyzed 183 newly diagnosed AML patients to compare the utility of rapid peripheral blast clearance (PBC), day of peripheral blast disappearance, residual blasts, and cellularity at day 14 bone marrow biopsy (D14BM) in predicting clinical response to 7+3 induction, overall survival (OS), and relapse-free survival (RFS). RESULTS In multivariable logistic regression analysis, day 2 PBC > 85% [P = .0016] was the only predictor of remission status, with sensitivity and specificity of 75%. Peripheral blast disappearance within 5 days after induction and < 10% cellularity in D14BM predicted superior OS and RFS in multivariate analysis. Median follow-up of patients was 28 months since diagnosis. Two-year OS and RFS for patients with ≤ 10% versus > 10% cellularity at D14BM was 60.6% [95% confidence interval (CI), 50.8%-72.2%] versus 32.5% [95% CI, 23.0%-45.8%], and 51.9% [95% CI, 41.9%-64.3%] versus 28.8% [95% CI, 19.1%-43.4%], respectively [P = .0003 for OS and .002 for RFS]. CONCLUSION Rapid PBC after 7+3 induction showed a significant improvement in specificity compared with D14BM, with similar sensitivity. Neither of these methods were reliably specific tools for the decision of early reinduction, despite their prognostic value. Our findings indicate that morphological cellularity in D14BM is an independent prognostic factor for OS and RFS, regardless of blast percentage, and that ≤ 10% cellularity defines D14BM hypoplasia.
Collapse
|
15
|
Jamy O, Bae S, Costa LJ, Erba HP, Papadantonakis N. Outcomes of fludarabine, high dose cytarabine and granulocyte-colony stimulating factor (FLAG) as re-induction for residual acute myeloid leukemia on day 14 bone marrow. Leuk Res 2018; 74:64-67. [PMID: 30300822 DOI: 10.1016/j.leukres.2018.09.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 09/20/2018] [Accepted: 09/24/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND Patients with acute myeloid leukemia (AML) treated with intensive chemotherapy may require re-induction based on the evaluation of day 14 bone marrow biopsy. METHODS A retrospective chart review was performed to evaluate adult patients with AML who received re-induction with fludarabine, high dose cytarabine and granulocyte colony stimulating factor (FLAG) regimen for residual disease (≥ 5% blasts by morphology) on day 14 bone marrow examination between September 2012 and July 2017 at our institution. RESULTS We identified 27 patients who received FLAG therapy for treatment of residual disease on day 14 marrow examination following initial induction. The median age at diagnosis was 61 years and the majority of patients had poor risk AML. The overall response rate was 78% and 15 patients proceeded to allogeneic hematopoietic stem cell transplantation. CONCLUSION The regimen was well tolerated and is a viable re-induction option for patients with residual disease on a day 14 bone marrow.
Collapse
Affiliation(s)
- Omer Jamy
- Division of Hematology/Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sejong Bae
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA; Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Luciano J Costa
- Division of Hematology/Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA; Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Harry P Erba
- Division of Hematology/Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA; Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Nikolaos Papadantonakis
- Division of Hematology/Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA; Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA.
| |
Collapse
|
16
|
Ollila TA, Olszewski AJ, Butera JN, Quesenberry MI, Quesenberry PJ, Reagan JL. Marrow Hypocellularity, But Not Residual Blast Count or Receipt of Reinduction Chemotherapy, Is Prognostic on Day-14 Assessment in Acute Myeloid Leukemia Patients With Morphologic Residual Disease. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2018; 18:204-209. [DOI: 10.1016/j.clml.2018.01.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 01/24/2018] [Indexed: 11/28/2022]
|
17
|
Alsaleh K, Aleem A, Almomen A, Anjum F, S Alotaibi G. Impact of Day 14 Bone Marrow Biopsy on Re-Induction
Decisions and Prediction of a Complete Response in Acute
Myeloid Leukemia Cases. Asian Pac J Cancer Prev 2018; 19:421-425. [PMID: 29479992 PMCID: PMC5980929 DOI: 10.22034/apjcp.2018.19.2.421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background: With acute myeloid leukemia (AML), there are limited data about the accuracy of day 14 bone
marrow (BM) biopsies for predicting complete remission as compared to day 28 BM biopsy results. We here aimed
to estimate the correlation between, and the diagnostic accuracy of, both approaches. Materials and Methods: We
reviewed 84 patients with AML treated with standard induction chemotherapy to evaluate the remission rate and
treatment decisions based on day 14 BM biopsy from 2000-2012. Results: Sixty five patients (77%) demonstrated
remission (CR) with less than 5% blasts on their day 14 BM. Thirteen patients (16%) had residual disease (RD), and
6 (7%) were classified as indeterminate response (IR) i.e., blasts 5-20%. Two patients with RD on day 14 underwent
re-induction. Out of the 17 remaining cases with RD+IR, 14 (all 6 with IR and 8 out of 11 with residual disease with
no re-induction) demonstrated a morphologic complete remission (CR) on day 28 BM. The percentages for complete
remissions on days 28 and 14 were significantly different [94% versus 79.3%, respectively; p=0.004, (OR= 0.143, 95%
CI: 0.032-0.63)]. Day 14 BM had 82% sensitivity in predicting CR on Day 28; however, it had insufficient specificity
(60%) in predicting failure of CR. Conclusions: Induction treatment response assessment based on day 14 BM does
not accurately predict the response rate on day 28 and the use of day 14 BM as a sole marker of response to therapy
might expose patients to unnecessary interventions.
Collapse
|
18
|
Nachar VR, Perissinotti AJ, Scappaticci GB, Bixby DL, Marini BL. Predictors for requiring re-induction chemotherapy in acute myeloid leukemia patients with residual disease on day 14 bone marrow assessment. Leuk Res 2017; 63:56-61. [DOI: 10.1016/j.leukres.2017.10.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 10/05/2017] [Accepted: 10/28/2017] [Indexed: 11/30/2022]
|
19
|
Terry CM, Shallis RM, Estey E, Lim SH. Day 14 bone marrow examination in the management of acute myeloid leukemia. Am J Hematol 2017; 92:1079-1084. [PMID: 28612456 DOI: 10.1002/ajh.24818] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 06/04/2017] [Accepted: 06/05/2017] [Indexed: 12/26/2022]
Abstract
The National Comprehensive Cancer Network (NCCN) recommends that a repeat bone marrow evaluation is carried out seven to ten days following completion of induction therapy so that if a patient's day 14 bone marrow shows residual blast cell counts of >10%, the patient would proceed early to a second cycle of induction therapy. Although blast cell counts of <5% on day 14 bone marrow is sensitive in predicting remission on day 28, various studies have found that day 14 bone marrow is highly nonspecific because a large proportion of patients with blast cell counts of >5% on day 14 bone marrow would still attain a complete remission of the disease without any further chemotherapy. Clinical decision based on day 14 bone marrow will result in some of these patients being given a second induction therapy unnecessarily. A second cycle of chemotherapy is associated with not only higher risk for treatment-related mortality but also increased use of hospital resources such as increased intravenous antimicrobials use, longer hospital stay, and higher demand for blood products. In this article, we examined the utility, discussed the shortfalls, and re-appraised the values of day 14 bone marrow in the management of patients with AML. On the basis of our review, we suggest that the practice of day 14 bone marrow examination should be re-evaluated and should probably only be carried out in the setting of clinical trials with clear questions to address its role in predicting outcome of the therapeutic intervention.
Collapse
Affiliation(s)
- Christopher M. Terry
- Division of Hematology and Oncology; Rhode Island Hospital/Brown University Warren Alpert Medical School; Providence Rhode Island
| | - Rory M. Shallis
- Division of Hematology and Oncology; Rhode Island Hospital/Brown University Warren Alpert Medical School; Providence Rhode Island
| | - Elihu Estey
- Clinical Research Division, Fred Hutchinson Cancer Research Center; Seattle Washington
- Division of Medical Oncology; Department of Medicine, University of Washington; Seattle Washington
- Division of Hematology; Department of Medicine, University of Washington; Seattle Washington
| | - Seah H. Lim
- Division of Hematology and Oncology; Rhode Island Hospital/Brown University Warren Alpert Medical School; Providence Rhode Island
| |
Collapse
|
20
|
Early assessment of response to induction therapy in acute myeloid leukemia using 18F-FLT PET/CT. EJNMMI Res 2017; 7:75. [PMID: 28916904 PMCID: PMC5602811 DOI: 10.1186/s13550-017-0326-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 09/07/2017] [Indexed: 12/24/2022] Open
Abstract
Background We evaluated the suitability of 18F-fluorodeoxythymidine (18F-FLT) positron emission tomography (PET)/computed tomography (CT) for assessment of the early response to induction therapy and its value for predicting clinical outcome in patients with acute myeloid leukemia (AML). Adult patients who had histologically confirmed AML and received induction therapy were enrolled. All patients underwent 18F-FLT PET/CT after completion of induction. PET/CT images were visually and quantitatively assessed. Cases with intensely increased bone marrow uptake in more than one third of the long bones and throughout the central skeleton were interpreted as PET-positive for resistant disease (RD). PET results were compared to the clinical response and outcome. Results In visual PET analysis of 10 eligible patients (7 male, 3 female; median age 58 years), 5 patients were interpreted as being PET-positive and 5 as PET-negative. Standardized uptake values were significantly different between PET-positive and PET-negative groups. Eight of 10 patients achieved clinical complete remission (CR)/CR with incomplete blood count recovery (CRi). Five CR/CRi patients had PET-negative findings, but 3 CR patients had PET-positive findings. Both of the RD patients had PET-positive findings. During follow-up, 2 CR patients with PET-positive findings relapsed, or were strongly suspected of relapse, 4 months after consolidation. Conclusion 18F-FLT PET/CT after induction therapy showed good sensitivity and negative-predictive value for evaluating RD in patients with AML. This preliminary study suggests that 18F-FLT PET/CT may be valuable as a noninvasive tool for early assessment of the response to treatment and may provide prognostic value for survival in patients with AML.
Collapse
|
21
|
Griffin PT, Komrokji RS, Sweet K, Al Ali NH, Padron E, Kubal TE, List AF, Lancet JE. Bone marrow cellularity at day 14 is the most important predictive factor for response in patients with AML who require double-induction chemotherapy: Analysis from a large, single institution experience. Am J Hematol 2017; 92:232-237. [PMID: 28006850 DOI: 10.1002/ajh.24627] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 12/13/2016] [Accepted: 12/14/2016] [Indexed: 02/06/2023]
Abstract
In patients with acute myeloid leukemia (AML), the presence of residual disease at day 14 after primary induction therapy warrants consideration of a second induction cycle. However, data to guide retreatment decisions in such patients are presently limited. Here, we retrospectively reviewed data from 176 patients with AML treated at our institution with a second induction chemotherapy regimen because of day 14 residual disease. Clinical variables and nadir bone marrow features were assessed for correlations with complete remission (CR) and overall survival (OS). In our patient group, 59% achieved CR after a second induction course. Median OS for the entire group was 12.40 months (95% CI, 9.90-14.90) but 19.07 months (95% CI, 13.13-25.01) for those who attained a CR. Nadir marrow hypocellularity (P < 0.001) at day 14, absolute blast reduction of >50% (P = 0.030), and de novo disease status (P = 0.018) were significantly correlated with CR achievement after re-induction. Marrow hypocellularity at day 14 was the most significant predictor of CR on multivariate analysis (P < 0.001). Nadir marrow features did not independently correlate with OS when accounting for CR status. Re-induction was successful in achieving CR in most patients. Study patients who did not achieve CR were more likely to have nonhypocellular marrows.
Collapse
Affiliation(s)
| | - Rami S. Komrokji
- H. Lee Moffitt Cancer Center and Research InstituteTampa Florida USA
| | - Kendra Sweet
- H. Lee Moffitt Cancer Center and Research InstituteTampa Florida USA
| | - Najla H. Al Ali
- H. Lee Moffitt Cancer Center and Research InstituteTampa Florida USA
| | - Eric Padron
- H. Lee Moffitt Cancer Center and Research InstituteTampa Florida USA
| | - Timothy E. Kubal
- H. Lee Moffitt Cancer Center and Research InstituteTampa Florida USA
| | - Alan F. List
- H. Lee Moffitt Cancer Center and Research InstituteTampa Florida USA
| | - Jeffrey E. Lancet
- H. Lee Moffitt Cancer Center and Research InstituteTampa Florida USA
| |
Collapse
|
22
|
Percival ME, Lai C, Estey E, Hourigan CS. Bone marrow evaluation for diagnosis and monitoring of acute myeloid leukemia. Blood Rev 2017; 31:185-192. [PMID: 28190619 DOI: 10.1016/j.blre.2017.01.003] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 01/31/2017] [Indexed: 12/20/2022]
Abstract
The diagnosis of acute myeloid leukemia (AML) can be made based on peripheral blood or bone marrow blasts. In this review, we will discuss the role of bone marrow evaluation and peripheral blood monitoring in the diagnosis, management, and follow up of AML patients. For patients with circulating blasts, it is reasonable to perform the necessary studies needed for diagnosis and risk stratification, including multiparametric flow cytometry, cytogenetics, and molecular analysis, on a peripheral blood specimen. The day 14 marrow is used to document hypocellularity in response to induction chemotherapy, but it is unclear if that assessment is necessary as it often does not affect immediate management. Currently, response assessments performed at count recovery for evaluation of remission and measurable residual disease rely on bone marrow sampling. For monitoring of relapse, peripheral blood evaluation may be adequate, but the sensitivity of bone marrow testing is in some cases superior. While bone marrow evaluation can certainly be avoided in particular situations, this cumbersome and uncomfortable procedure currently remains the de facto standard for response assessment.
Collapse
Affiliation(s)
- Mary-Elizabeth Percival
- Department of Medicine, University of Washington, Seattle, WA, USA; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
| | - Catherine Lai
- Myeloid Malignancies Section, Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Elihu Estey
- Department of Medicine, University of Washington, Seattle, WA, USA; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Christopher S Hourigan
- Myeloid Malignancies Section, Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| |
Collapse
|
23
|
Norkin M, Chang M, An Q, Leather H, Katragadda L, Li Y, Moreb JS, May WS, Brown RA, Hsu JW, Hiemenz JW, Wingard JR, Cogle CR. A new model to predict remission status in AML patients based on day 14 bone marrow biopsy. Leuk Res 2016; 46:69-73. [DOI: 10.1016/j.leukres.2016.04.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Revised: 03/26/2016] [Accepted: 04/15/2016] [Indexed: 10/21/2022]
|
24
|
Campuzano-Zuluaga G, Deutsch Y, Salzberg M, Gomez A, Vargas F, Elias R, Kwon D, Goodman M, Ikpatt OF, Chapman JR, Watts J, Vega F, Swords R. Routine interim disease assessment in patients undergoing induction chemotherapy for acute myeloid leukemia: Can we do better? Am J Hematol 2016; 91:277-82. [PMID: 26663264 DOI: 10.1002/ajh.24271] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 12/01/2015] [Accepted: 12/03/2015] [Indexed: 11/06/2022]
Abstract
The presence of >5% blasts at "day 14" (D14), in patients undergoing induction chemotherapy for acute myeloid leukemia (AML) is problematic. It is unclear if a second course of chemotherapy for early persistent disease will alter outcome in these patients. We conducted a retrospective study of AML patients undergoing induction chemotherapy where diagnostic, interim (around day 14), and recovery (days 21-42) bone marrow (BM) evaluations were available for review. Of the 113 patients included in the final analysis, 99 (87.6%) achieved CR at hematologic recovery. At D14, 90 patients (79.6%) had <5% blasts and of these, 87 (96.7%) ultimately achieved CR. At D14, Twenty-three (20.4%) patients had residual leukemia (>5% blasts). Of these, 11 (47.8%) received a second course of chemotherapy (double induction [DI]) and 12 (52.2%) were observed until count recovery (single induction [SI]). No significant difference in CR rates was observed between these two groups (58.3% DI group vs. 45.5% SI group, P value = 0.684). In our analysis, D14 BM evaluation did not uniformly identify patients with primary induction failure. To unequivocally determine the value of a D14 marrow assessment in AML, prospective studies in the context of large cooperative group trials are required. Considering our findings and similar reports from others, we propose that D14 marrow assessment should be individualized, and that other factors, such as cytogenetics and early peripheral blood blast clearance should be considered, to identify patients most likely to benefit from interim disease assessment during AML induction therapy.
Collapse
Affiliation(s)
- Germán Campuzano-Zuluaga
- Division of Hematopathology; Department of Pathology and Laboratory Medicine; University of Miami and Sylvester Comprehensive Cancer Center, and Jackson Memorial Hospital; Miami Florida
| | - Yehuda Deutsch
- Division of Hematology and Oncology; Department of Medicine; University of Miami and Sylvester Comprehensive Cancer Center, and Jackson Memorial Hospital; Miami Florida
| | - Matthew Salzberg
- Division of Hematology and Oncology; Department of Medicine; University of Miami and Sylvester Comprehensive Cancer Center, and Jackson Memorial Hospital; Miami Florida
| | - Alexandra Gomez
- Division of Hematology and Oncology; Department of Medicine; University of Miami and Sylvester Comprehensive Cancer Center, and Jackson Memorial Hospital; Miami Florida
| | - Fernando Vargas
- Division of Hematology and Oncology; Department of Medicine; University of Miami and Sylvester Comprehensive Cancer Center, and Jackson Memorial Hospital; Miami Florida
| | - Roy Elias
- Division of Hematology and Oncology; Department of Medicine; University of Miami and Sylvester Comprehensive Cancer Center, and Jackson Memorial Hospital; Miami Florida
| | - Deukwoo Kwon
- Sylvester Comprehensive Cancer Center, University of Miami; Miami Florida
| | - Mark Goodman
- Division of Hematology and Oncology; Department of Medicine; University of Miami and Sylvester Comprehensive Cancer Center, and Jackson Memorial Hospital; Miami Florida
| | - Offiong F. Ikpatt
- Division of Hematopathology; Department of Pathology and Laboratory Medicine; University of Miami and Sylvester Comprehensive Cancer Center, and Jackson Memorial Hospital; Miami Florida
| | - Jennifer R. Chapman
- Division of Hematopathology; Department of Pathology and Laboratory Medicine; University of Miami and Sylvester Comprehensive Cancer Center, and Jackson Memorial Hospital; Miami Florida
| | - Justin Watts
- Division of Hematology and Oncology; Department of Medicine; University of Miami and Sylvester Comprehensive Cancer Center, and Jackson Memorial Hospital; Miami Florida
| | - Francisco Vega
- Division of Hematopathology; Department of Pathology and Laboratory Medicine; University of Miami and Sylvester Comprehensive Cancer Center, and Jackson Memorial Hospital; Miami Florida
| | - Ronan Swords
- Division of Hematology and Oncology; Department of Medicine; University of Miami and Sylvester Comprehensive Cancer Center, and Jackson Memorial Hospital; Miami Florida
| |
Collapse
|
25
|
Ofran Y, Leiba R, Ganzel C, Saban R, Gatt M, Ram R, Arad A, Bulvik S, Hellmann I, Gino-Moor S, Zuckerman T, Hoffman R, Horowitz N, Lavi N, Ringelstein S, Henig I, Hayun M, Rowe JM. Prospective comparison of early bone marrow evaluation on day 5 versus day 14 of the "3 + 7" induction regimen for acute myeloid leukemia. Am J Hematol 2015; 90:1159-64. [PMID: 26435038 DOI: 10.1002/ajh.24207] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Revised: 09/29/2015] [Accepted: 09/29/2015] [Indexed: 01/07/2023]
Abstract
Evaluation of early response during induction therapy for acute myeloid leukemia (AML) is used for prognostication and re-induction strategy, yet the optimal evaluation time point is unknown. Clearance of bone marrow (BM) blasts by day 14 of therapy does not ensure remission; thus, some patients requiring re-induction are neglected. This study aimed to examine the role of earlier BM evaluation during induction for predicting remission and overall survival. Results of BM testing on the 5th and 14th day of intensive induction were prospectively compared in 127 adult patients with AML. Re-induction was given, based on Day 14 results, to 25 patients. Reduction of the BM blast count to <5% as early as by the fifth day of induction was more specifically associated with the achievement of remission compared to Day 14 (88.2% vs. 60%, respectively). Rapid responders have a better 3-year overall survival (OS). Day 5 results are a stronger predictor of OS by multivariate analysis and better segregate long-term survivors than the Day 14th BM count (66% vs. 30%, P = 0.0001 and 48% vs. 37%, respectively, P = 0.04). The Day 5 evaluation of BM carries significant clinical information. The benefit of prescribing re-induction based on such early evaluation should be prospectively studied.
Collapse
Affiliation(s)
- Yishai Ofran
- Department of Hematology and Bone Marrow Transplantation; Rambam Health Care Campus; Haifa Israel
- Bruce Rappaport Faculty of Medicine; Technion, Haifa, Israel, Israel Institute of Technology
| | - Ronit Leiba
- Quality of Care Unit; Rambam Health Care Campus; Haifa Israel
| | - Chezi Ganzel
- Department of Hematology; Shaare Zedek Medical Center; Jerusalem Israel
| | - Revital Saban
- Department of Hematology; Shaare Zedek Medical Center; Jerusalem Israel
| | - Moshe Gatt
- Hematology Department; Hadassah Hebrew University Medical Center; Jerusalem Israel
| | - Ron Ram
- Department of Hematology and bone marrow transplantation; Sourasky Medical Center, Tel Aviv University; Tel Aviv Israel
| | - Ariela Arad
- Department of Hematology; Sanz Medical Center - Laniado Hospital; Netanya Israel
| | - Shlomo Bulvik
- Department of Hematology; Sanz Medical Center - Laniado Hospital; Netanya Israel
| | - Ilana Hellmann
- Hematology department; Meir Medical Center; Kfar Saba Israel
| | | | - Tsila Zuckerman
- Department of Hematology and Bone Marrow Transplantation; Rambam Health Care Campus; Haifa Israel
- Bruce Rappaport Faculty of Medicine; Technion, Haifa, Israel, Israel Institute of Technology
| | - Ron Hoffman
- Department of Hematology and Bone Marrow Transplantation; Rambam Health Care Campus; Haifa Israel
- Bruce Rappaport Faculty of Medicine; Technion, Haifa, Israel, Israel Institute of Technology
| | - Netanel Horowitz
- Department of Hematology and Bone Marrow Transplantation; Rambam Health Care Campus; Haifa Israel
- Bruce Rappaport Faculty of Medicine; Technion, Haifa, Israel, Israel Institute of Technology
| | - Noa Lavi
- Department of Hematology and Bone Marrow Transplantation; Rambam Health Care Campus; Haifa Israel
- Bruce Rappaport Faculty of Medicine; Technion, Haifa, Israel, Israel Institute of Technology
| | - Shimrit Ringelstein
- Department of Hematology and Bone Marrow Transplantation; Rambam Health Care Campus; Haifa Israel
- Bruce Rappaport Faculty of Medicine; Technion, Haifa, Israel, Israel Institute of Technology
| | - Israel Henig
- Department of Hematology and Bone Marrow Transplantation; Rambam Health Care Campus; Haifa Israel
| | - Michal Hayun
- Department of Hematology and Bone Marrow Transplantation; Rambam Health Care Campus; Haifa Israel
| | - Jacob M. Rowe
- Department of Hematology and Bone Marrow Transplantation; Rambam Health Care Campus; Haifa Israel
- Bruce Rappaport Faculty of Medicine; Technion, Haifa, Israel, Israel Institute of Technology
- Department of Hematology; Shaare Zedek Medical Center; Jerusalem Israel
| |
Collapse
|
26
|
Jain S, Mahapatra M, Pati HP. CD34 immunohistochemistry in bone marrow biopsies for early response assessment in acute myeloid leukemia. Int J Lab Hematol 2015; 37:746-51. [DOI: 10.1111/ijlh.12406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 06/05/2015] [Indexed: 11/30/2022]
Affiliation(s)
- S. Jain
- Department of Hematology; All India Institute of Medical Sciences; New Delhi India
| | - M. Mahapatra
- Department of Hematology; All India Institute of Medical Sciences; New Delhi India
| | - H. P. Pati
- Department of Hematology; All India Institute of Medical Sciences; New Delhi India
| |
Collapse
|
27
|
Zeidner JF, Foster MC, Blackford AL, Litzow MR, Morris LE, Strickland SA, Lancet JE, Bose P, Levy MY, Tibes R, Gojo I, Gocke CD, Rosner GL, Little RF, Wright JJ, Doyle LA, Smith BD, Karp JE. Randomized multicenter phase II study of flavopiridol (alvocidib), cytarabine, and mitoxantrone (FLAM) versus cytarabine/daunorubicin (7+3) in newly diagnosed acute myeloid leukemia. Haematologica 2015; 100:1172-9. [PMID: 26022709 DOI: 10.3324/haematol.2015.125849] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 05/21/2015] [Indexed: 11/09/2022] Open
Abstract
Serial studies have demonstrated that induction therapy with FLAM [flavopiridol (alvocidib) 50 mg/m(2) days 1-3, cytarabine 667 mg/m(2)/day continuous infusion days 6-8, and mitoxantrone (FLAM) 40 mg/m(2) day 9] yields complete remission rates of nearly 70% in newly diagnosed poor-risk acute myeloid leukemia. Between May 2011-July 2013, 165 newly diagnosed acute myeloid leukemia patients (age 18-70 years) with intermediate/adverse-risk cytogenetics were randomized 2:1 to receive FLAM or 7+3 (cytarabine 100 mg/m(2)/day continuous infusion days 1-7 and daunorubicin 90 mg/m(2) days 1-3), across 10 institutions. Some patients on 7+3 with residual leukemia on day 14 received 5+2 (cytarabine 100 mg/m(2)/day continuous infusion days 1-5 and daunorubicin 45 mg/m(2) days 1-2), whereas patients on FLAM were not re-treated based on day 14 bone marrow findings. The primary objective was to compare complete remission rates between one cycle of FLAM and one cycle of 7+3. Secondary end points included safety, overall survival and event-free survival. FLAM led to higher complete remission rates than 7+3 alone (70% vs. 46%; P=0.003) without an increase in toxicity, and this improvement persisted after 7+3+/-5+2 (70% vs. 57%; P=0.08). There were no significant differences in overall survival and event-free survival in both arms but post-induction strategies were not standardized. These results substantiate the efficacy of FLAM induction in newly diagnosed AML. A phase III study is currently in development. This study is registered with clinicaltrials.gov identifier: 01349972.
Collapse
Affiliation(s)
- Joshua F Zeidner
- The Johns Hopkins Hospital, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA University of North Carolina, Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | - Matthew C Foster
- University of North Carolina, Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | - Amanda L Blackford
- The Johns Hopkins Hospital, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | | | - Lawrence E Morris
- The Blood and Marrow Transplant Program at Northside Hospital, Bone Marrow Transplant Group of Georgia, Atlanta, GA, USA
| | | | - Jeffrey E Lancet
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Prithviraj Bose
- Virginia Commonwealth University, Massey Cancer Center, Richmond, VA, USA
| | - M Yair Levy
- Texas Oncology, Baylor Charles A. Simmons Cancer Center, Dallas, TX, USA
| | | | - Ivana Gojo
- The Johns Hopkins Hospital, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA University of Maryland Medical Center, Stewart Greenebaum Cancer Center, Baltimore, MD, USA
| | - Christopher D Gocke
- The Johns Hopkins Hospital, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Gary L Rosner
- The Johns Hopkins Hospital, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | | | | | | | - B Douglas Smith
- The Johns Hopkins Hospital, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Judith E Karp
- The Johns Hopkins Hospital, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| |
Collapse
|
28
|
Abstract
PURPOSE OF REVIEW Patients with acute myeloid leukemia typically are monitored with bone marrow biopsy 7-10 days after completion of induction therapy. However, this test has relatively poor sensitivity and specificity for classifying patients likely to have long-term cure or even patients who will need additional therapy to achieve complete remission. Several new methods of assessing response are being studied and are summarized in this review. RECENT FINDINGS Many new methods are being used to evaluate response assessment. Emerging data suggest that various types of clinical, chemical, and imaging biomarkers, as well as more sensitive techniques to measure minimal residual disease, can all help provide more accurate response assessment and prognostic information. SUMMARY New techniques will improve the way we assess response to acute myeloid leukemia therapy. Larger confirmatory studies utilizing these novel markers of response to change treatment and to improve clinical outcomes are urgently needed.
Collapse
|
29
|
Yezefski T, Xie H, Walter R, Pagel J, Becker PS, Hendrie P, Sandhu V, Shannon-Dorcy K, Abkowitz J, Appelbaum FR, Estey E. Value of routine 'day 14' marrow exam in newly diagnosed AML. Leukemia 2014; 29:247-9. [PMID: 25204570 DOI: 10.1038/leu.2014.268] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- T Yezefski
- University of Washington School of Medicine, Seattle, WA, USA
| | - H Xie
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - R Walter
- 1] Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA [2] Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA, USA [3] Division of Hematology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - J Pagel
- 1] Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA [2] Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - P S Becker
- 1] Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA [2] Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA, USA [3] Division of Hematology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - P Hendrie
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - V Sandhu
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - K Shannon-Dorcy
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - J Abkowitz
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - F R Appelbaum
- 1] Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA [2] Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - E Estey
- 1] Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA [2] Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA, USA [3] Division of Hematology, Department of Medicine, University of Washington, Seattle, WA, USA
| |
Collapse
|