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Risueño A, See WL, Bluemmert I, de Botton S, DiNardo CD, Fathi AT, Schuh AC, Montesinos P, Vyas P, Prebet T, Gandhi A, Hasan M. Somatic gene mutation patterns and burden influence outcomes with enasidenib in relapsed/refractory IDH2-mutated AML. Leuk Res 2024; 140:107497. [PMID: 38564986 DOI: 10.1016/j.leukres.2024.107497] [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: 09/21/2023] [Revised: 02/23/2024] [Accepted: 03/23/2024] [Indexed: 04/04/2024]
Abstract
Limited treatment options are available for patients with relapsed/refractory acute myeloid leukemia (R/R AML). We recently reported results from the phase 3 IDHENTIFY trial (NCT02577406) showing improved response rates and event-free survival with enasidenib monotherapy compared with conventional care regimens (CCR) in heavily pretreated, older patients with late-stage R/R AML bearing IDH2 mutations. Here we investigated the prognostic impact of mutational burden and different co-mutation patterns at study entry within the predominant IDH2 variant subclasses, IDH2-R140 and IDH2-R172. The prognostic relevance of these variants is well documented in newly diagnosed AML, but data are lacking in R/R AML. In this large R/R AML patient cohort, targeted next-generation sequencing at baseline (screening) revealed distinct co-mutation patterns and mutational burden between subgroups bearing different IDH2 variants: variant IDH2-R140 was associated with greater mutational burden and was enriched predominantly with poor-risk mutations, including FLT3, RUNX1, and NRAS, while variant IDH2-R172 was associated with lower mutational burden and was preferentially co-mutated with DNMT3A. In multivariable analyses, RAS and RTK pathway mutations were significantly associated with decreased overall survival, after adjusting for treatment arm, IDH2 variant, and mutational burden. Importantly, enasidenib-mediated survival benefit was more pronounced in patients with IDH2-R172 variants.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Female
- Humans
- Male
- Middle Aged
- Aminopyridines/therapeutic use
- Drug Resistance, Neoplasm/genetics
- Isocitrate Dehydrogenase/genetics
- Leukemia, Myeloid, Acute/genetics
- Leukemia, Myeloid, Acute/drug therapy
- Leukemia, Myeloid, Acute/mortality
- Mutation
- Neoplasm Recurrence, Local/drug therapy
- Neoplasm Recurrence, Local/genetics
- Neoplasm Recurrence, Local/pathology
- Prognosis
- Triazines/therapeutic use
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Affiliation(s)
- Alberto Risueño
- Bristol Myers Squibb, Lawrenceville, 3401 Princeton Pike, Lawrence Township, NJ 08648, United States
| | - Wendy L See
- Bristol Myers Squibb, Summit, 86 Morris Avenue, Summit, NJ 07901, United States
| | - Iryna Bluemmert
- Celgene International Sàrl, a Bristol-Myers Squibb Company, Route de Perreux 1, Boudry 2017, Switzerland
| | - Stéphane de Botton
- Institut Gustave Roussy, 114 Rue Edouard Vaillant, Villejuif 94805, France
| | - Courtney D DiNardo
- The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, United States
| | - Amir T Fathi
- Massachusetts General Hospital Cancer Center, 55 Fruit Street, Boston, MA 02114, United States
| | - Andre C Schuh
- Princess Margaret Cancer Centre, 610 University Avenue, Toronto, ON M5G 2C4, Canada
| | - Pau Montesinos
- Hospital Universitario y Politécnico La Fe, Avinguda de Fernando Abril Martorell, 106, Valencia 46026, Spain
| | - Paresh Vyas
- MRC Molecular Haematology Unit and Oxford Biomedical Research Centre, University of Oxford and Oxford University Hospitals, Headley Way, Headington, Oxford OX3 9DS, United Kingdom
| | - Thomas Prebet
- Bristol Myers Squibb, Summit, 86 Morris Avenue, Summit, NJ 07901, United States
| | - Anita Gandhi
- Bristol Myers Squibb, Summit, 86 Morris Avenue, Summit, NJ 07901, United States
| | - Maroof Hasan
- Bristol Myers Squibb, Summit, 86 Morris Avenue, Summit, NJ 07901, United States.
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Rahmé R, Braun T. Venetoclax Combined with Intensive Chemotherapy: A New Hope for Refractory and/or Relapsed Acute Myeloid Leukemia? J Clin Med 2024; 13:549. [PMID: 38256681 PMCID: PMC10816428 DOI: 10.3390/jcm13020549] [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: 12/16/2023] [Revised: 01/08/2024] [Accepted: 01/16/2024] [Indexed: 01/24/2024] Open
Abstract
Background. Primary resistance of acute myeloid leukemia (AML) to the conventional 3 + 7 intensive chemotherapy and relapses after first-line chemotherapy are two highly challenging clinical scenarios. In these cases, when allogeneic stem cell transplantation is feasible, patients are usually retreated with other chemotherapeutic regimens, as transplantation is still considered, nowadays, the only curative option. Methods. We discuss the mechanisms behind resistance to chemotherapy and offer a comprehensive review on current treatments of refractory/relapsed AML with a focus on novel approaches incorporating the BCL-2 inhibitor venetoclax. Results. Alas, complete remission rates after salvage chemotherapy remain relatively low, between 30 and 60% at best. More recently, the BCL-2 inhibitor venetoclax was combined either with hypomethylating agents or chemotherapy in refractory/relapsed patients. In particular, its combination with chemotherapy offered promising results by achieving higher rates of remission and bridging a substantial number of patients to transplantation. Conclusions. Venetoclax-based approaches might become, in the near future, the new standard of care for refractory/relapsed AML.
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Affiliation(s)
- Ramy Rahmé
- Hematology Department, Avicenne Hospital, Assistance Publique-Hôpitaux de Paris, 93000 Bobigny, France
- Faculty of Medicine, Université Sorbonne Paris Nord, 93017 Bobigny, France;
| | - Thorsten Braun
- Hematology Department, Avicenne Hospital, Assistance Publique-Hôpitaux de Paris, 93000 Bobigny, France
- Faculty of Medicine, Université Sorbonne Paris Nord, 93017 Bobigny, France;
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Zhang C, Gao D, Wang X, Sun X, Yan Y, Yang Y, Zhang J, Yan J. Effectiveness of chemotherapy using bortezomib combined with homoharringtonine and cytarabine in refractory or relapsed acute myeloid leukemia: a phase II, multicenter, prospective clinical trial. Front Oncol 2023; 13:1142449. [PMID: 37664023 PMCID: PMC10472935 DOI: 10.3389/fonc.2023.1142449] [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: 01/11/2023] [Accepted: 06/28/2023] [Indexed: 09/05/2023] Open
Abstract
Background Refractory/relapsed acute myeloid leukemia (R/R AML) has unsatisfactory outcomes even after allogeneic hematopoietic stem cell transplantation. Long-term survival is mainly influenced by complete remission (CR) rates after induction therapies. Objectives To investigate CR/CR with incomplete hematologic recovery (CRi) rates and adverse events with a new induction therapy (bortezomib, homoharringtonine, and cytarabine [BHA]) for patients with R/R AML. Methods We enrolled 21 patients with R/R AML (median age, 42 [range, 30-62] years), who received BHA for remission induction (bortezomib, 1.3 mg/m2/day on days 1 and 4; homoharringtonine, 4 mg/m2/day for 5 days, and cytarabine, 1.5 g/m2/day for 5 days). CR and adverse events were assessed. Results After one course of BHA, the CR/CRi and partial remission rates were 38.1% and 14.3%, respectively, with an overall response rate (ORR) of 52.4% in 21 patients. 9 of 21 patients harbored FLT3-ITD or FLT3-TKD mutations, and achieved either CR/CRi or ORR of 66.7% (P=0.03) by comparison with that in R/R AML without FLT3 mutation. After induction therapy, consolidation chemotherapy or allogeneic hematopoietic stem cell transplantation led to a one-year overall survival of 27.8% in all patients. One-year relapse-free survival was 50% in 8 patients who had achieved CR/CRi after one course of BHA. During induction, non-hematologic adverse events (grade 3/4) commonly were infection (90.5%), hypokalemia (14.4%), hypocalcemia (14.3%), and mucositis (9.5%). In patients achieving CR, the median time to neutrophil count >0.5×109/L and time to platelet count >20×109/L were 15 (13-17) days and 13 (13-18) days, respectively. Conclusion BHA chemotherapy regimen was safe and tolerable to serve as an induction therapy for R/R AML, particularly with FLT3 mutation. The higher CR/CRi rate will give a clue to determine a potentialeffectiveness of BHA for AML patients carrying FLT3 mutation in a further investigation. Clinical trial registration https://www.chictr.org.cn/, identifier ChiCTR2000029841.
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Affiliation(s)
- Chengtao Zhang
- Department of Hematology, Liaoning Key Laboratory of Hematopoietic Stem Cell Transplantation and Translational Medicine, Liaoning Medical Center for Hematopoietic Stem Cell Transplantation, The Second Hospital of Dalian Medical University, Dalian, China
| | - Da Gao
- Department of Hematology, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Xiaohong Wang
- Department of Hematology, The ChaoYang Central Hospital, Liaoning, China
| | - Xiuli Sun
- Department of Hematology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yan Yan
- Department of Hematology, Bayannur Hospital, Bayannur, Inner Mongolia, China
| | - Yan Yang
- Department of Hematology, Liaoning Key Laboratory of Hematopoietic Stem Cell Transplantation and Translational Medicine, Liaoning Medical Center for Hematopoietic Stem Cell Transplantation, The Second Hospital of Dalian Medical University, Dalian, China
| | - Jingjing Zhang
- Department of Hematology, Liaoning Key Laboratory of Hematopoietic Stem Cell Transplantation and Translational Medicine, Liaoning Medical Center for Hematopoietic Stem Cell Transplantation, The Second Hospital of Dalian Medical University, Dalian, China
| | - Jinsong Yan
- Department of Hematology, Liaoning Key Laboratory of Hematopoietic Stem Cell Transplantation and Translational Medicine, Liaoning Medical Center for Hematopoietic Stem Cell Transplantation, The Second Hospital of Dalian Medical University, Dalian, China
- Blood Stem Cell Transplantation Institute of Dalian Medical University, Dalian, China
- Pediatric Oncology and Hematology Center of the Second Hospital of Dalian Medical University, Dalian, China
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Chen X, Zhao Y, Li Q, Fan S. Single-Center Retrospective Clinical Evaluation of Venetoclax Combined with HMAs and Half-Dose CAG for Unfit or Refractory/Relapsed AML. Onco Targets Ther 2023; 16:409-419. [PMID: 37334144 PMCID: PMC10276600 DOI: 10.2147/ott.s405611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 05/18/2023] [Indexed: 06/20/2023] Open
Abstract
Purpose The prognosis of patients with unfit or relapsed/refractory (R/R) AML remains poor. Venetoclax (VEN) has been shown to exhibit anti-leukemia stem cell activity; however, few studies have been published on the efficacy and safety of VEN combined with both hypomethylating agents (HMAs) and low-dose chemotherapy for patients with unfit or R/R AML. Methods This study retrospectively analyzed the clinical characteristics, treatment details, safety profile and clinical outcomes of patients with unfit or R/R AML treated with VEN+ HMAs+ half-dose CAG (LDAC, aclarubicin and granulocyte colony-stimulating factor). Results A total of 24 AML patients were involved in the study, of whom 13 (54.2%) were in the unfit group, and 11 (45.8%) were in the R/R group. FLT3 and IDH (8/24, 33.3%) were the most common gene aberrations. Patients in the R/R group were found to be more likely to carry KIT (5/11, 45.5%) compared with the unfit group (0/13, 0%) (P = 0.006). The ORR observed during the study was 83.3% (20/24; 14 CR, 2CRi, 4PR). In the unfit group, 11/13 (84.6%) patients achieved cCR (10 CR and 1 CRi); while 5/11 (45.5%) R/R patients achieved response (4 CR and 1 CRi). CR was observed in all AML patients with TP53 (5/5), GATA2 (3/3), CEBPA (3/3) and ASXL1 (3/3). The most common adverse events (AEs) during VEN+ HMAs+ half-dose CAG therapy were persistent cytopenias and infections. Conclusion The results of this study confirm that VEN+ HMAs+ half-dose CAG is associated with promising efficacy (even high-risk molecular patterns) and tolerable safety profile in patients with unfit or R/R AML. Yet, the study involves only a small sample size, which should not be overlooked. As such, further studies on the efficacy of VEN combined with HMAs and half-dose CAG regimen in AML patients are essential.
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Affiliation(s)
- Xiaotong Chen
- Department of Hematology, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, People’s Republic of China
| | - Yanqiu Zhao
- Department of Hematology, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, People’s Republic of China
| | - Qi Li
- Department of Hematology, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, People’s Republic of China
| | - Shengjin Fan
- Department of Hematology, The First Affiliated Hospital of Harbin Medical University, Harbin, 150001, People’s Republic of China
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Martínez-Cuadrón D, Serrano J, Mariz J, Gil C, Tormo M, Martínez-Sánchez P, Rodríguez-Arbolí E, García-Boyero R, Rodríguez-Medina C, Martínez-Chamorro C, Polo M, Bergua J, Aguiar E, Amigo ML, Herrera P, Alonso-Domínguez JM, Bernal T, Espadana A, Sayas MJ, Algarra L, Vidriales MB, Vasconcelos G, Vives S, Pérez-Encinas MM, López A, Noriega V, García-Fortes M, Chillón MC, Rodríguez-Gutiérrez JI, Calasanz MJ, Labrador J, López JA, Boluda B, Rodríguez-Veiga R, Martínez-López J, Barragán E, Sanz MA, Montesinos P. Characteristics and Outcomes of Adult Patients in the PETHEMA Registry with Relapsed or Refractory FLT3-ITD Mutation-Positive Acute Myeloid Leukemia. Cancers (Basel) 2022; 14:cancers14112817. [PMID: 35681796 PMCID: PMC9179309 DOI: 10.3390/cancers14112817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/26/2022] [Accepted: 05/31/2022] [Indexed: 02/01/2023] Open
Abstract
This retrospective study investigated outcomes of 404 patients with relapsed/refractory (R/R) FMS-like tyrosine kinase 3 (FLT3)-internal tandem duplication (ITD) acute myeloid leukemia (AML) enrolled in the PETHEMA registry, pre-approval of tyrosine kinase inhibitors. Most patients (63%) had received first-line intensive therapy with 3 + 7. Subsequently, patients received salvage with intensive therapy (n = 261), non-intensive therapy (n = 63) or supportive care only (n = 80). Active salvage therapy (i.e., intensive or non-intensive therapy) resulted in a complete remission (CR) or CR without hematological recovery (CRi) rate of 42%. More patients achieved a CR/CRi with intensive (48%) compared with non-intensive (19%) salvage therapy (p < 0.001). In the overall population, median overall survival (OS) was 5.5 months; 1- and 5-year OS rates were 25% and 7%. OS was significantly (p < 0.001) prolonged with intensive or non-intensive salvage therapy compared with supportive therapy, and in those achieving CR/CRi versus no responders. Of 280 evaluable patients, 61 (22%) had an allogeneic stem-cell transplant after they had achieved CR/CRi. In conclusion, in this large cohort study, salvage treatment approaches for patients with FLT3-ITD mutated R/R AML were heterogeneous. Median OS was poor with both non-intensive and intensive salvage therapy, with best long-term outcomes obtained in patients who achieved CR/CRi and subsequently underwent allogeneic stem-cell transplant.
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Affiliation(s)
- David Martínez-Cuadrón
- Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain; (B.B.); (R.R.-V.); (E.B.); (M.A.S.); (P.M.)
- Correspondence: ; Tel.: +34-96-1244925
| | - Josefina Serrano
- Hospital Universitario Reina Sofía and Instituto Maimónides de Investigación Biomédica Córdoba (IMIBIC), 14004 Córdoba, Spain;
| | - José Mariz
- IPO (Istituto Portugues Oncologia), 4200-072 Porto, Portugal;
| | - Cristina Gil
- Hospital General Universitario de Alicante, 03010 Alicante, Spain;
| | - Mar Tormo
- Hospital Clínico Universitario, INCLIVA Biomedical Research Institute, 46010 Valencia, Spain;
| | - Pilar Martínez-Sánchez
- Hospital Universitario 12 de Octubre, Complutense University, i+12, CNIO, 28041 Madrid, Spain; (P.M.-S.); (J.M.-L.)
| | | | | | | | | | - Marta Polo
- Hospital Clínico San Carlos, 28040 Madrid, Spain;
| | - Juan Bergua
- Hospital San Pedro Alcántara, 10003 Cáceres, Spain;
| | | | - María L. Amigo
- Hospital General Universitario Morales Meseguer, 30008 Murcia, Spain;
| | - Pilar Herrera
- Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain;
| | | | - Teresa Bernal
- Hospital Universitario Central de Asturias, 33011 Asturias, Spain;
| | - Ana Espadana
- Hospital de Coimbra, 3400-091 Coimbra, Portugal;
| | - María J. Sayas
- Hospital Universitario Doctor Peset, 46017 Valencia, Spain;
| | - Lorenzo Algarra
- Hospital General Universitario de Albacete, 02006 Albacete, Spain;
| | - María B. Vidriales
- Department of Hematology, University Hospital of Salamanca (HUS/IBSAL), CIBERONC and Cancer Research Institute of Salamanca-IBMCC (USAL-CSIC), 37007 Salamanca, Spain; (M.B.V.); (M.C.C.)
| | | | - Susana Vives
- ICO-Hospital Germans Trias i Pujol, Badalona, José Carreras Leukemia Research Institute, Universitat Autònoma de Barcelona, 08916 Barcelona, Spain;
| | | | | | - Víctor Noriega
- Complejo Hospitalario Universitario A Coruña, 15006 La Coruna, Spain;
| | | | - María C. Chillón
- Department of Hematology, University Hospital of Salamanca (HUS/IBSAL), CIBERONC and Cancer Research Institute of Salamanca-IBMCC (USAL-CSIC), 37007 Salamanca, Spain; (M.B.V.); (M.C.C.)
| | | | | | | | - Juan A. López
- Complejo Hospitalario Ciudad de Jaén, 23007 Jaén, Spain;
| | - Blanca Boluda
- Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain; (B.B.); (R.R.-V.); (E.B.); (M.A.S.); (P.M.)
| | - Rebeca Rodríguez-Veiga
- Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain; (B.B.); (R.R.-V.); (E.B.); (M.A.S.); (P.M.)
| | - Joaquín Martínez-López
- Hospital Universitario 12 de Octubre, Complutense University, i+12, CNIO, 28041 Madrid, Spain; (P.M.-S.); (J.M.-L.)
| | - Eva Barragán
- Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain; (B.B.); (R.R.-V.); (E.B.); (M.A.S.); (P.M.)
| | - Miguel A. Sanz
- Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain; (B.B.); (R.R.-V.); (E.B.); (M.A.S.); (P.M.)
| | - Pau Montesinos
- Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain; (B.B.); (R.R.-V.); (E.B.); (M.A.S.); (P.M.)
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Park S, Kwag D, Kim TY, Lee JH, Lee JY, Min GJ, Park SS, Yahng SA, Jeon YW, Shin SH, Yoon JH, Lee SE, Cho BS, Eom KS, Kim YJ, Lee S, Min CK, Cho SG, Lee JW, Kim HJ. A retrospective comparison of salvage intensive chemotherapy versus venetoclax-combined regimen in patients with relapsed/refractory acute myeloid leukemia (AML). Ther Adv Hematol 2022; 13:20406207221081637. [PMID: 35340720 PMCID: PMC8949776 DOI: 10.1177/20406207221081637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 01/31/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Evidence that a venetoclax (VEN)-combined regimen is effective in relapsed/refractory acute myeloid leukemia (R/R AML) is emerging. However, it is unknown how VEN-combined low intensity treatment compares to intensive chemotherapy (IC) in medically fit patients with R/R AML. Methods: We compared AML patients who received IC (n = 89) to those who received a VEN in combination with hypomethylating agents or low dose cytarabine (VEN combination) (n = 54) as their first- or second-line salvage after failing anthracycline-containing intensive chemotherapy. Results: The median age was 49 years, and significantly more patients in the VEN combination group were in their second salvage and had received prior stem cell transplantation (SCT). Overall response rates including CR, CRi, and MLFS were comparable (44.0% for IC vs. 59.3% for VEN combination, p = 0.081), but VEN combination group compared to IC group tended to show lower treatment related mortality. The rate of bridging to SCT was the same (68.5%), but the percentage of SCT at blast clearance was significantly higher in the VEN-combined group (62.3% vs. 86.5%, p = 0.010). After median follow-up periods of 22.5 (IC) and 11.3 months (VEN combination), the median overall survival was 8.9 (95% CI, 5.4-12.4) and 12.4 months (95% CI, 9.5-15.2) (p = 0.724), respectively. Conclusion: VEN combination provides a comparable anti-leukemic response and survival to salvage IC, and provide a bridge to SCT with better disease control in medically-fit patients with R/R AML.
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Affiliation(s)
- Silvia Park
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Daehun Kwag
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Tong Yoon Kim
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Jong Hyuk Lee
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Joon Yeop Lee
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Gi June Min
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Sung Soo Park
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Seung-Ah Yahng
- Department of Hematology, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, South Korea
| | - Young-Woo Jeon
- Department of Hematology, Yeoido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Seung-Hwan Shin
- Department of Hematology, Catholic Hematology Hospital, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Jae-Ho Yoon
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Sung-Eun Lee
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Byung Sik Cho
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Ki-Seong Eom
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Yoo-Jin Kim
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Seok Lee
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Chang-Ki Min
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Seok-Goo Cho
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Jong Wook Lee
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Hee-Je Kim
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
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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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8
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Zeidner JF, Vincent BG, Ivanova A, Moore D, McKinnon KP, Wilkinson AD, Mukhopadhyay R, Mazziotta F, Knaus HA, Foster MC, Coombs CC, Jamieson K, Van Deventer H, Webster JA, Prince GT, DeZern AE, Smith BD, Levis MJ, Montgomery ND, Luznik L, Serody JS, Gojo I. Phase II Trial of Pembrolizumab after High-Dose Cytarabine in Relapsed/Refractory Acute Myeloid Leukemia. Blood Cancer Discov 2021; 2:616-629. [PMID: 34778801 DOI: 10.1158/2643-3230.bcd-21-0070] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 07/12/2021] [Accepted: 08/25/2021] [Indexed: 12/17/2022] Open
Abstract
Immune suppression, exhaustion, and senescence are frequently seen throughout disease progression in acute myeloid leukemia (AML). We conducted a phase II study of high-dose cytarabine followed by pembrolizumab 200 mg i.v. on day 14 to examine whether PD-1 inhibition improves clinical responses in relapsed/refractory (R/R) AML. Overall responders could receive pembrolizumab maintenance up to 2 years. Among 37 patients enrolled, the overall response rate, composite complete remission (CRc) rate (primary endpoint), and median overall survival (OS) were 46%, 38%, and 11.1 months, respectively. Patients with refractory/early relapse and those receiving treatment as first salvage had encouraging outcomes (median OS, 13.2 and 11.3 months, respectively). Grade ≥3 immune-related adverse events were rare (14%) and self-limiting. Patients who achieved CRc had a higher frequency of progenitor exhausted CD8+ T cells expressing TCF-1 in the bone marrow prior to treatment. A multifaceted correlative approach of genomic, transcriptomic, and immunophenotypic profiling offers insights on molecular correlates of response and resistance to pembrolizumab. Significance Immune-checkpoint blockade with pembrolizumab was tolerable and feasible after high-dose cytarabine in R/R AML, with encouraging clinical activity, particularly in refractory AML and those receiving treatment as first salvage regimen. Further study of pembrolizumab and other immune-checkpoint blockade strategies after cytotoxic chemotherapy is warranted in AML.See related commentary by Wei et al., p. 551. This article is highlighted in the In This Issue feature, p. 549.
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Affiliation(s)
- Joshua F Zeidner
- University of North Carolina School of Medicine, Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina.,Division of Hematology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Benjamin G Vincent
- University of North Carolina School of Medicine, Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina.,Division of Hematology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina.,University of North Carolina, Department of Microbiology and Immunology, Chapel Hill, North Carolina.,Program in Computational Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Anastasia Ivanova
- University of North Carolina School of Medicine, Department of Biostatistics, Chapel Hill, North Carolina
| | - Dominic Moore
- University of North Carolina School of Medicine, Department of Biostatistics, Chapel Hill, North Carolina
| | - Karen P McKinnon
- University of North Carolina School of Medicine, Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina.,University of North Carolina, Department of Microbiology and Immunology, Chapel Hill, North Carolina
| | - Alec D Wilkinson
- University of North Carolina School of Medicine, Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
| | - Rupkatha Mukhopadhyay
- Johns Hopkins School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland
| | - Francesco Mazziotta
- Johns Hopkins School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland.,University of Siena, Department of Medical Biotechnologies, Siena, Italy
| | - Hanna A Knaus
- Johns Hopkins School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland
| | - Matthew C Foster
- University of North Carolina School of Medicine, Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina.,Division of Hematology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Catherine C Coombs
- University of North Carolina School of Medicine, Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina.,Division of Hematology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Katarzyna Jamieson
- University of North Carolina School of Medicine, Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina.,Division of Hematology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Hendrik Van Deventer
- University of North Carolina School of Medicine, Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina.,Division of Hematology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Jonathan A Webster
- Johns Hopkins School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland.,Department of Oncology, Division of Hematological Malignancies, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Gabrielle T Prince
- Johns Hopkins School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland.,Department of Oncology, Division of Hematological Malignancies, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Amy E DeZern
- Johns Hopkins School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland.,Department of Oncology, Division of Hematological Malignancies, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - B Douglas Smith
- Johns Hopkins School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland.,Department of Oncology, Division of Hematological Malignancies, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Mark J Levis
- Johns Hopkins School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland.,Department of Oncology, Division of Hematological Malignancies, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Nathan D Montgomery
- University of North Carolina School of Medicine, Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina.,Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Leo Luznik
- Johns Hopkins School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland.,Department of Oncology, Division of Hematological Malignancies, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jonathan S Serody
- University of North Carolina School of Medicine, Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina.,Division of Hematology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina.,University of North Carolina, Department of Microbiology and Immunology, Chapel Hill, North Carolina.,Program in Computational Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ivana Gojo
- Johns Hopkins School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland.,University of Siena, Department of Medical Biotechnologies, Siena, Italy
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9
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Pandya BJ, Yang H, Schmeichel C, Qi CZ, Shah MV. A budget impact analysis of gilteritinib for the treatment of relapsed or refractory FLT3 mut+ acute myeloid leukemia in a US health plan. J Med Econ 2021; 24:19-28. [PMID: 33280474 DOI: 10.1080/13696998.2020.1851698] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
AIMS To estimate the economic impact of the introduction of gilteritinib for the treatment of relapsed/refractory (R/R) FLT3 mutation-positive (FLT3 mut+) acute myeloid leukemia (AML) from a US payer's perspective. METHODS A budget impact model (BIM) was developed to evaluate the 3-year total budgetary impact of treating adults with R/R FLT3 mut+ AML eligible for gilteritinib in a hypothetical US health plan. Total costs (drugs/administration, hospitalization, monitoring, adverse events, transfusions, subsequent hematopoietic stem cell transplantation, post-progression, and FLT3 testing) were estimated before and after gilteritinib entry. The budget impact was the total cost difference between the two scenarios. The target population size and cost inputs were based on public data or published literature, drug market share was informed by market research data, and the model included recommended treatments for R/R FLT3 mut+ AML per clinical guidelines. Deterministic sensitivity analyses (DSAs) and scenario analyses varying key model inputs and assumptions were conducted to test for robustness. RESULTS In a hypothetical health plan with 1 million members, 20.9 adults with R/R FLT3 mut+ AML were estimated to be eligible for gilteritinib. Of these, it was assumed 30.0% would be treated with gilteritinib in Year 1 following gilteritinib entry, increasing the total plan budget by $663,795 and the per-member-per-month (PMPM) cost by $0.055. In Years 2-3, the market share of gilteritinib increased to 45.0%, increasing the total plan budget impact by $1,078,371 and $1,087,230, and the PMPM cost by $0.090 and $0.091, respectively. The model results remained robust in DSAs and scenario analyses, with the largest impact observed when the projected uptake of gilteritinib was changed. LIMITATIONS The results of this BIM are contingent upon the model's assumptions and inputs. CONCLUSIONS Adding gilteritinib to the formulary for the treatment of adults with R/R FLT3 mut+ AML had a minimal budget impact from a US payer's perspective.
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Affiliation(s)
- Bhavik J Pandya
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
| | | | | | | | - Manasee V Shah
- Astellas Pharma Global Development, Inc, Northbrook, IL, USA
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10
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Canaani J, Danylesko I, Shemtov N, Zlotnick M, Lozinsky K, Benjamini O, Yerushalmi R, Nagar M, Dor C, Shimoni A, Avigdor A, Nagler A. A phase II study of bisantrene in patients with relapsed/refractory acute myeloid leukemia. Eur J Haematol 2020; 106:260-266. [PMID: 33159365 DOI: 10.1111/ejh.13544] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 11/01/2020] [Accepted: 11/02/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To determine the current role of bisantrene, an anthracene with anthracycline-like activity which was shown in earlier studies to be effective therapy in relapsed/refractory acute myeloid leukemia with no discernible cardiotoxicity, in the treatment of patients with R/R AML. METHODS This phase 2, single-center study (NCT03820908) enrolled adult R/R AML to receive bisantrene (250 mg/m2 daily for 7 days) which was administered via an intravenous infusion over 2 hours on days 1-7. Disease assessment included routine blood work and bone marrow studies. RESULTS In all, 10 patients were enrolled with a median of 3 lines of prior therapy including seven patients who had relapsed following allogeneic stem cell transplantation. The most frequently reported grade ≥3 treatment-attributed hematologic AE was thrombocytopenia, whereas the most frequently reported grade ≥3 treatment-attributed non-hematologic AE was mucositis. Of the 10 patients, one (10%) achieved a complete remission and three patients achieved a partial remission resulting in an overall response rate of 40%. Next-generation sequencing of patient samples identified a wide array of mutations associated with activated signaling, splicing, and epigenetic modification. CONCLUSIONS In view of the observed low toxicity, a follow-up study combining bisantrene with complementary anti-leukemic therapy is planned.
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Affiliation(s)
- Jonathan Canaani
- Hematology Division, Chaim Sheba Medical Center, Tel-Hashomer, Tel Aviv University, Tel Aviv, Israel
| | - Ivetta Danylesko
- Hematology Division, Chaim Sheba Medical Center, Tel-Hashomer, Tel Aviv University, Tel Aviv, Israel
| | - Noga Shemtov
- Hematology Division, Chaim Sheba Medical Center, Tel-Hashomer, Tel Aviv University, Tel Aviv, Israel
| | - Maya Zlotnick
- Hematology Division, Chaim Sheba Medical Center, Tel-Hashomer, Tel Aviv University, Tel Aviv, Israel
| | - Kira Lozinsky
- Hematology Division, Chaim Sheba Medical Center, Tel-Hashomer, Tel Aviv University, Tel Aviv, Israel
| | - Ohad Benjamini
- Hematology Division, Chaim Sheba Medical Center, Tel-Hashomer, Tel Aviv University, Tel Aviv, Israel
| | - Ronit Yerushalmi
- Hematology Division, Chaim Sheba Medical Center, Tel-Hashomer, Tel Aviv University, Tel Aviv, Israel
| | - Meital Nagar
- Hematology Division, Chaim Sheba Medical Center, Tel-Hashomer, Tel Aviv University, Tel Aviv, Israel
| | - Chen Dor
- Hematology Division, Chaim Sheba Medical Center, Tel-Hashomer, Tel Aviv University, Tel Aviv, Israel
| | - Avichai Shimoni
- Hematology Division, Chaim Sheba Medical Center, Tel-Hashomer, Tel Aviv University, Tel Aviv, Israel
| | - Abraham Avigdor
- Hematology Division, Chaim Sheba Medical Center, Tel-Hashomer, Tel Aviv University, Tel Aviv, Israel
| | - Arnon Nagler
- Hematology Division, Chaim Sheba Medical Center, Tel-Hashomer, Tel Aviv University, Tel Aviv, Israel
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11
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DeWolf S, Tallman MS. How I treat relapsed or refractory AML. Blood 2020; 136:1023-1032. [PMID: 32518943 PMCID: PMC7453152 DOI: 10.1182/blood.2019001982] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 04/28/2020] [Indexed: 12/15/2022] Open
Abstract
Treatment of relapsed or refractory acute myeloid leukemia (AML) has presented challenges for hematologists for decades. Despite numerous clinical studies, outcomes are consistently disappointing with 5-year overall survival rates of ∼10%. Allogeneic hematopoietic cell transplantation at the time of second complete remission remains the only reliable option with curative potential. However, recent approval of several new agents has transformed treatment paradigms that had been in place for almost half a century in AML. This new therapeutic landscape provides the opportunity to revisit the approach to relapsed or refractory AML. Through illustrative cases, we describe our approach, which increasingly relies on specific disease biology. We focus on treatment outside of the context of clinical trials because such trials are not available in most parts of the world. Primarily, we consider age, fitness to tolerate intensive chemotherapy, remission duration, and presence of a targetable mutation to guide treatment. The coming years will inevitably bring new targets and agents that may prove most effective when combined with each other and/or chemotherapy. Future studies are needed to determine how best to implement this evolving armamentarium of treatment options, to elucidate mechanisms of resistance, and to continue the pursuit of novel drug discovery.
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Affiliation(s)
- Susan DeWolf
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY; and
| | - Martin S Tallman
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY; and
- Leukemia Service, Department of Medicine, Weill Cornell Medical College, New York, NY
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12
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Canaani J, Nagar M, Heering G, Gefen C, Yerushalmi R, Shem-Tov N, Volchek Y, Merkel D, Avigdor A, Shimoni A, Amariglio N, Rechavi G, Nagler A. Reassessing the role of high dose cytarabine and mitoxantrone in relapsed/refractory acute myeloid leukemia. Oncotarget 2020; 11:2233-2245. [PMID: 32577167 PMCID: PMC7289527 DOI: 10.18632/oncotarget.27618] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 05/14/2020] [Indexed: 01/04/2023] Open
Abstract
A substantial segment of patients with acute myeloid leukemia (AML) will relapse following an initial response to induction therapy or will prove to be primary refractory. High-dose cytarabine and mitoxantrone (HiDAC/MITO) is an established salvage therapy for these patients. We studied all adult patients with relapsed/refractory (R/R) AML who were treated with HiDAC/MITO in our center between the years 2008-2017. To determine whether responding patients harbored a unique molecular signature, we performed targeted next-generation sequencing (NGS) on a subset of patients. The study cohort consisted of 172 patients with a median age of 54 years (range 18–77). The composite complete remission rate was 58%; 11 patients (6%) died during salvage therapy. Median survival was 11.4 months with a 1-year survival rate of 48%. In multivariate analysis favorable risk cytogenetics [Odds ratio (OR)=0.34, confidence interval (CI) 95%, 0.17–0.68; P = 0.002], and de-novo AML (OR = 0.4, CI 95%, 0.16–0.98; P = 0.047) were independently associated with a favorable response. Patients who attained a complete remission had a median survival of 43.7 months compared with 5.2 months for refractory patients (p < 0.0001). Neither the FLT3-ITD and NPM1 mutational status nor the indication for salvage therapy significantly impacted on the response to HiDAC/MITO salvage. NGS analysis identified 20 different mutations across the myeloid gene spectrum with a distinct TP53 signature detected in non-responding patients. HiDAC/MITO is an effective salvage regimen in R/R AML, however patients with adverse cytogenetics or secondary disease may not benefit as much from this approach.
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Affiliation(s)
- Jonathan Canaani
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Meital Nagar
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Gabriel Heering
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Chen Gefen
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Ronit Yerushalmi
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Noga Shem-Tov
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Yulia Volchek
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Drorit Merkel
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Abraham Avigdor
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Avichai Shimoni
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Ninette Amariglio
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Gidi Rechavi
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Arnon Nagler
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
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13
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Mayer K, Hahn-Ast C, Schwab K, Schmidt-Wolf IGH, Brossart P, Glasmacher A, von Lilienfeld-Toal M. Long-term follow-up of Cladribine, high-dose Cytarabine, and Idarubicin as salvage treatment for relapsed acute myeloid leukemia and literature review. Eur J Haematol 2020; 104:538-545. [PMID: 32049382 DOI: 10.1111/ejh.13395] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 02/07/2020] [Accepted: 02/07/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE Outcome for relapsed acute myeloid leukemia (AML) is poor. Cladribine has activity in AML, and an enhancing effect on other cytostatic drugs thus may help overcome resistance. Here, we present the final analysis of our phase II trial evaluating safety and efficacy of cladribine, cytarabine, and idarubicin (CAI) in relapsed AML. METHODS Patients with relapsed AML after at least 6 months remission received two courses of CAI. After 9 patients, prolonged neutropenia prompted protocol change (omission of idarubicin in 2nd course and dose-reduction of cytarabine). Primary endpoints were remission rate and safety. RESULTS Twenty patients received treatment, fourteen one, and six two courses CAI/CA. After first course, complete remission (CR/CRi) was achieved in 60%. Most frequent toxicity was infection. Median OS was 8.8 months in all patients and 21.1 months in those with CR. Nine patients (48%) proceeded to allogeneic stem cell transplantation (allo-SCT), four of those are still alive and in CR, accounting for a 5-year survival rate of 55% of transplanted patients. CONCLUSION Cladribine, cytarabine, and idarubicin in relapsed AML is feasible and induces good response rates. As expected, infections are the most important complication. However, combined with allo-SCT, long-term survival can be achieved in a substantial number of patients.
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Affiliation(s)
- Karin Mayer
- Medizinische Klinik III, Hämatologie/Onkologie/Rheumatologie, Universitätsklinikum Bonn, Bonn, Germany
| | - Corinna Hahn-Ast
- Medizinische Klinik III, Hämatologie/Onkologie/Rheumatologie, Universitätsklinikum Bonn, Bonn, Germany
| | - Katjana Schwab
- Medizinische Klinik III, Hämatologie/Onkologie/Rheumatologie, Universitätsklinikum Bonn, Bonn, Germany
| | | | - Peter Brossart
- Medizinische Klinik III, Hämatologie/Onkologie/Rheumatologie, Universitätsklinikum Bonn, Bonn, Germany
| | - Axel Glasmacher
- Medizinische Klinik III, Hämatologie/Onkologie/Rheumatologie, Universitätsklinikum Bonn, Bonn, Germany
| | - Marie von Lilienfeld-Toal
- Klinik für Innere Medizin II, Abteilung für Hämatologie und Onkologie, Universitätsklinikum Jena, Jena, Germany.,Leibniz-Institut für Naturstoff-Forschung und Infektionsbiologie, Hans-Knöll Institut, Jena, Germany.,Center for Sepsis Control and Care (CSCC), Universitätsklinikum Jena, Jena, Germany
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14
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Cahill KE, Karimi YH, Karrison TG, Jain N, Green M, Weiner H, Fulton N, Kadri S, Godley LA, Artz AS, Liu H, Thirman MJ, Le Beau MM, McNerney ME, Segal J, Larson RA, Stock W, Odenike O. A phase 1 study of azacitidine with high-dose cytarabine and mitoxantrone in high-risk acute myeloid leukemia. Blood Adv 2020; 4:599-606. [PMID: 32074275 PMCID: PMC7042987 DOI: 10.1182/bloodadvances.2019000795] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 12/24/2019] [Indexed: 12/18/2022] Open
Abstract
In this phase 1 study, azacitidine (AZA) was given before high-dose cytarabine (HiDAC) and mitoxantrone (mito) based on the hypothesis that epigenetic priming with a hypomethylating agent before cytotoxic chemotherapy would improve response rates in patients with high-risk acute myeloid leukemia (AML), including relapsed/refractory disease. The primary objective was to establish the recommended phase 2 dose of AZA given before standard HiDAC/mito. In a dose escalation scheme, 46 patients (median age, 66 years) received AZA at 37.5, 50, or 75 mg/m2 subcutaneously or IV once daily on days 1 to 5 followed by HiDAC (3000 mg/m2) and mitoxantrone (30 mg/m2) once each on days 6 and 10 (the HiDAC/mito dose was reduced 33% in elderly subjects). Two dose-limiting toxicities occurred (both in the same patient): acute liver failure and kidney injury at the 50 mg/m2 dose. The 30-day induction death rate was 2.2% (1 of 46). The overall response rate, including complete remission and complete remission with incomplete count recovery, was 61% (28 of 46). Previously untreated patients aged ≥60 years with therapy-related AML and de novo AML were more likely to respond than untreated patients with AML progressing from an antecedent hematologic disorder (myelodysplastic syndrome and chronic myelomonocytic leukemia). Patients with favorable European Leukemia Network risk (P = .008), NPM1 mutations (P = .007), or IDH2 mutations (P = .03) were more likely to respond, and those with TP53 mutations (P = .03) were less likely to respond. The recommended phase 2 dose of AZA is 75 mg/m2 per day on days 1 to 5 followed by HiDAC (3000 mg/m2) and mitoxantrone (30 mg/m2) once each on days 6 and 10. This trial was registered at www.clinicaltrials.gov as #NCT01839240.
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Affiliation(s)
- Kirk E Cahill
- Department of Medicine, University of Chicago Medicine, Chicago, IL
| | - Yasmin H Karimi
- Department of Medicine, University of Chicago Medicine, Chicago, IL
| | - Theodore G Karrison
- Department of Public Health Sciences, University of Chicago, Chicago, IL; and
- Comprehensive Cancer Center
| | - Nitin Jain
- Section of Hematology/Oncology, Department of Medicine, and
| | - Margaret Green
- Section of Hematology/Oncology, Department of Medicine, and
| | - Howard Weiner
- Section of Hematology/Oncology, Department of Medicine, and
| | - Noreen Fulton
- Section of Hematology/Oncology, Department of Medicine, and
| | - Sabah Kadri
- Department of Pathology, University of Chicago Medicine, Chicago, IL
| | - Lucy A Godley
- Comprehensive Cancer Center
- Section of Hematology/Oncology, Department of Medicine, and
| | - Andrew S Artz
- Comprehensive Cancer Center
- Section of Hematology/Oncology, Department of Medicine, and
| | - Hongtao Liu
- Comprehensive Cancer Center
- Section of Hematology/Oncology, Department of Medicine, and
| | - Michael J Thirman
- Comprehensive Cancer Center
- Section of Hematology/Oncology, Department of Medicine, and
| | - Michelle M Le Beau
- Comprehensive Cancer Center
- Section of Hematology/Oncology, Department of Medicine, and
| | - Megan E McNerney
- Comprehensive Cancer Center
- Department of Pathology, University of Chicago Medicine, Chicago, IL
| | - Jeremy Segal
- Comprehensive Cancer Center
- Department of Pathology, University of Chicago Medicine, Chicago, IL
| | - Richard A Larson
- Comprehensive Cancer Center
- Section of Hematology/Oncology, Department of Medicine, and
| | - Wendy Stock
- Comprehensive Cancer Center
- Section of Hematology/Oncology, Department of Medicine, and
| | - Olatoyosi Odenike
- Comprehensive Cancer Center
- Section of Hematology/Oncology, Department of Medicine, and
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15
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Fractionated gemtuzumab ozogamicin in association with high dose chemotherapy: a bridge to allogeneic stem cell transplantation in refractory and relapsed acute myeloid leukemia. Bone Marrow Transplant 2019; 55:452-460. [PMID: 31554931 DOI: 10.1038/s41409-019-0690-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 09/05/2019] [Accepted: 09/06/2019] [Indexed: 12/16/2022]
Abstract
Optimization of the salvage regimen is required to improve prognosis in primary refractory or relapsed acute myeloid leukemia (AML). In fit patients, a bridge to allogeneic transplant is the primary purpose of salvage. We tested the combination of fractionated gemtuzumab ozogamicin with cytarabine and mitoxantrone (MYLODAM schema) with primary endpoint of efficacy and safety. We also attempted to define predictive factors for survival and response after salvage. We included 58 patients with a median age at salvage of 56 years. The overall response rate was 67%. Leukemia-free survival (LFS) and overall survival (OS) at 2 years was 36% (95% CI: 23-49) and 54% (95% CI: 39-68), respectively. Treatment-related mortality was 7%. Three veno-occlusive diseases (SOS/VOD) occurred during salvage. In the allogeneic group of 28 patients (48%), LFS and OS at 2 years was 57 % (95% CI: 36.3-77.5) and 69 % (95% CI: 49.3-88.7), respectively. Incidences of nonrelapse mortality, grade II-IV acute graft-versus-host disease (GVHD) and chronic GVHD were 16%, 40%, and 45%, respectively. A GO-based intensive regimen is a viable option for salvage therapy and a feasible schedule as a bridge to allogeneic transplant.
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16
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Stein EM, DiNardo CD, Fathi AT, Pollyea DA, Stone RM, Altman JK, Roboz GJ, Patel MR, Collins R, Flinn IW, Sekeres MA, Stein AS, Kantarjian HM, Levine RL, Vyas P, MacBeth KJ, Tosolini A, VanOostendorp J, Xu Q, Gupta I, Lila T, Risueno A, Yen KE, Wu B, Attar EC, Tallman MS, de Botton S. Molecular remission and response patterns in patients with mutant- IDH2 acute myeloid leukemia treated with enasidenib. Blood 2019; 133:676-687. [PMID: 30510081 PMCID: PMC6384189 DOI: 10.1182/blood-2018-08-869008] [Citation(s) in RCA: 245] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 11/19/2018] [Indexed: 12/14/2022] Open
Abstract
Approximately 8% to 19% of patients with acute myeloid leukemia (AML) have isocitrate dehydrogenase-2 (IDH2) mutations, which occur at active site arginine residues R140 and R172. IDH2 mutations produce an oncometabolite, 2-hydroxyglutarate (2-HG), which leads to DNA and histone hypermethylation and impaired hematopoietic differentiation. Enasidenib is an oral inhibitor of mutant-IDH2 proteins. This first-in-human phase 1/2 study evaluated enasidenib doses of 50 to 650 mg/d, administered in continuous 28-day cycles, in patients with mutant-IDH2 hematologic malignancies. Overall, 214 of 345 patients (62%) with relapsed or refractory (R/R) AML received enasidenib, 100 mg/d. Median age was 68 years. Forty-two patients (19.6%) attained complete remission (CR), 19 patients (10.3%) proceeded to an allogeneic bone marrow transplant, and the overall response rate was 38.8% (95% confidence interval [CI], 32.2-45.7). Median overall survival was 8.8 months (95% CI, 7.7-9.6). Response and survival were comparable among patients with IDH2-R140 or IDH2-R172 mutations. Response rates were similar among patients who, at study entry, were in relapse (37.7%) or were refractory to intensive (37.5%) or nonintensive (43.2%) therapies. Sixty-six (43.1%) red blood cell transfusion-dependent and 53 (40.2%) platelet transfusion-dependent patients achieved transfusion independence. The magnitude of 2-HG reduction on study was associated with CR in IDH2-R172 patients. Clearance of mutant-IDH2 clones was also associated with achievement of CR. Among all 345 patients, the most common grade 3 or 4 treatment-related adverse events were hyperbilirubinemia (10%), thrombocytopenia (7%), and IDH differentiation syndrome (6%). Enasidenib was well tolerated and induced molecular remissions and hematologic responses in patients with AML for whom prior treatments had failed. The study is registered at www.clinicaltrials.gov as #NCT01915498.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Aminopyridines/therapeutic use
- Biomarkers, Tumor
- Female
- Follow-Up Studies
- Humans
- Isocitrate Dehydrogenase/antagonists & inhibitors
- Isocitrate Dehydrogenase/genetics
- Leukemia, Myeloid, Acute/drug therapy
- Leukemia, Myeloid, Acute/genetics
- Leukemia, Myeloid, Acute/pathology
- Male
- Middle Aged
- Mutant Proteins/antagonists & inhibitors
- Mutant Proteins/genetics
- Mutation
- Neoplasm Recurrence, Local/drug therapy
- Neoplasm Recurrence, Local/genetics
- Neoplasm Recurrence, Local/pathology
- Prognosis
- Remission Induction
- Survival Rate
- Triazines/therapeutic use
- Young Adult
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Affiliation(s)
- Eytan M Stein
- Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Cornell Medical College, New York, NY
| | | | - Amir T Fathi
- Massachusetts General Hospital Cancer Center, Boston, MA
- Harvard Medical School, Boston, MA
| | | | | | - Jessica K Altman
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Gail J Roboz
- Weill Cornell Medical College, New York, NY
- New York Presbyterian Hospital, New York, NY
| | - Manish R Patel
- Florida Cancer Specialists and Sarah Cannon Research Institute, Sarasota, FL
| | - Robert Collins
- University of Texas Southwestern Medical Center, Dallas, TX
| | - Ian W Flinn
- Sarah Cannon Research Institute/Tennessee Oncology, Nashville, TN
| | | | - Anthony S Stein
- Gehr Family Center for Leukemia Research, City of Hope Comprehensive Cancer Center, Duarte, CA
| | | | - Ross L Levine
- Memorial Sloan Kettering Cancer Center, New York, NY
| | - Paresh Vyas
- MRC Molecular Haematology Unit and Oxford Biomedical Research Centre, University of Oxford and Oxford University Hospitals, Oxford, United Kingdom
| | | | | | | | | | | | | | - Alberto Risueno
- Celgene Institute for Translational Research Europe, Seville, Spain
| | | | - Bin Wu
- Agios Pharmaceuticals, Inc., Cambridge, MA
| | | | - Martin S Tallman
- Memorial Sloan Kettering Cancer Center, New York, NY
- Weill Cornell Medical College, New York, NY
| | - Stéphane de Botton
- Gustave Roussy, Département d'hématologie et Département d'innovation thérapeutique, Villejuif, France; and
- Université Paris Sud, Université Paris-Saclay, Le Kremlin-Bicêtre, France
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17
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Efficacy and Feasibility of Allogeneic Hematopoietic Stem-Cell Transplantation in the Treatment of Refractory Acute Myeloid Leukemia. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2019; 19:177-182. [PMID: 30616990 DOI: 10.1016/j.clml.2018.11.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 11/06/2018] [Accepted: 11/15/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND Refractory acute myeloid leukemia (AML) includes AML includes failure of disease to respond to standard induction chemotherapy, relapse within 6 months after first CR, and 2 or more relapses. The outcome of these patients is usually very poor; only a small proportion can be rescued by allogenic hematopoietic stem-cell transplantation (allo-HSCT). The aim of this study was to evaluate the efficacy and feasibility of allo-HSCT in patients with refractory AML. PATIENTS AND METHODS We retrospectively analyzed the clinical outcome of 91 patients who were diagnosed with treatment-refractory AML at Hacettepe University Hospital between January 2002 and June 2018. Patients' disease status included refractory AML, defined as failure to respond to standard induction chemotherapy and relapse within 6 months after first complete remission. RESULTS The median follow-up was 12 months (range, 0.5-184 months) for the entire group. Kaplan-Meier estimates of the 3-year overall survival for patients who underwent allo-HSCT and patients who received only salvage chemotherapy were 67% and 12%, respectively. Additionally, the Kaplan-Meier estimates of 5-year overall survival for patients who underwent allo-HSCT and patients who received only salvage chemotherapy were 44% and 4%, respectively (P < .001). Complete remission was obtained in 25 patients (83.3%) who underwent allo-HSCT; however, the disease of only 3 patients (3.8%) exhibited complete response after salvage chemotherapy. CONCLUSION Allo-HSCT is still the best-known treatment option with curative potential in patients with treatment-refractory AML. Therefore, all efforts should be made in an attempt to find a suitable matched donor in order to perform allo-HSCT.
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18
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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.
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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.
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19
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Westhus J, Noppeney R, Dührsen U, Hanoun M. FLAG salvage therapy combined with idarubicin in relapsed/refractory acute myeloid leukemia. Leuk Lymphoma 2018; 60:1014-1022. [PMID: 30277107 DOI: 10.1080/10428194.2018.1508670] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Acute myeloid leukemia (AML) is characterized by a high failure rate to achieve complete remission as well as high relapse rates that cause an emergent need for efficient and tolerable salvage therapies. The combination of FLAG with idarubicin (FLAG-Ida) is a widely used protocol. However, its efficacy has been analyzed in only a limited number of studies with majorly small patient cohorts. Here, we analyzed 132 patients with largely primary refractory or first-time relapsed AML treated according to the FLAG-Ida protocol. The overall complete remission rate (CR + CRi) was 56% with a median overall survival of 15 months (95% CI, 5.7-25.1). The median disease-free survival for CR/CRi-patients was not reached. The mortality rate on day 30 was 9% and increased on day 60 to 16%. Our results show in relapsed/refractory AML patients a high efficacy and compatibility for the FLAG-Ida regimen.
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Affiliation(s)
- Jonas Westhus
- a Department of Hematology , University Hospital, University of Duisburg-Essen , Essen , Germany
| | - Richard Noppeney
- a Department of Hematology , University Hospital, University of Duisburg-Essen , Essen , Germany
| | - Ulrich Dührsen
- a Department of Hematology , University Hospital, University of Duisburg-Essen , Essen , Germany
| | - Maher Hanoun
- a Department of Hematology , University Hospital, University of Duisburg-Essen , Essen , Germany
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20
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Boddu P, Borthakur G, Koneru M, Huang X, Naqvi K, Wierda W, Bose P, Jabbour E, Estrov Z, Burger J, Alvarado Y, Deshmukh A, Patel A, Cavazos A, Han L, Cortes JE, Kantarjian H, Andreeff M, Konopleva M. Initial Report of a Phase I Study of LY2510924, Idarubicin, and Cytarabine in Relapsed/Refractory Acute Myeloid Leukemia. Front Oncol 2018; 8:369. [PMID: 30319961 PMCID: PMC6167965 DOI: 10.3389/fonc.2018.00369] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 08/20/2018] [Indexed: 11/13/2022] Open
Abstract
Background: The CXCR4/SDF-1α axis plays a vital role in the retention of stem cells within the bone marrow and downstream activation of cell survival signaling pathways. LY2510924, a second generation CXCR4, showed significant anti-leukemia activity in a murine AML model. Methods: We conducted a phase I study to determine the safety and toxicity of LY2510924, idarubicin and cytarabine (IA) combination therapy in relapsed/refractory (R/R) AML. Eligible patients were 18–70 years of age receiving up to salvage 3 therapy. A peripheral blood absolute blast count of < 20,000/μL was required for inclusion. LY2510924 was administered daily for 7 days followed by IA from day 8. Two dose escalation levels (10 and 20 mg) were evaluated, with a plan to enroll up to 12 patients in the phase I portion. Results: The median age of the enrolled patients (n = 11) was 55 years (range, 19–70). Median number of prior therapies was 1 (1–3). Six and five patients were treated at dose-levels “0” (10 mg) and “1” (20 mg), respectively. Only one patient experiencing a dose limiting toxicity (grade 3 rash and myelosuppression). Three and one complete responses were observed at dose-levels “0” and “1,” respectively; the overall response rate (ORR) was 36% (4 of 11 patients). A ≥ 50% decrease in CXCR4 mean fluorescence intensity was observed in 4 of 9 patients by flow cytometry, indicating incomplete suppression of CXCR4-receptor occupancy. Conclusions: The combination of LY2510924 with IA is safe in R/R AML. Dose-escalation to a 30 mg LY2510924 dose is planned to achieve complete blockade of CXCR4 receptor occupancy, followed by expansion phase at the recommended phase 2 dose-level.
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Affiliation(s)
- Prajwal Boddu
- Department of Leukemia, University of Texas at MD Anderson Cancer Center, Houston, TX, United States
| | - Gautam Borthakur
- Department of Leukemia, University of Texas at MD Anderson Cancer Center, Houston, TX, United States
| | | | - Xuelin Huang
- Department of Leukemia, University of Texas at MD Anderson Cancer Center, Houston, TX, United States
| | - Kiran Naqvi
- Department of Leukemia, University of Texas at MD Anderson Cancer Center, Houston, TX, United States
| | - William Wierda
- Department of Leukemia, University of Texas at MD Anderson Cancer Center, Houston, TX, United States
| | - Prithviraj Bose
- Department of Leukemia, University of Texas at MD Anderson Cancer Center, Houston, TX, United States
| | - Elias Jabbour
- Department of Leukemia, University of Texas at MD Anderson Cancer Center, Houston, TX, United States
| | - Zeev Estrov
- Department of Leukemia, University of Texas at MD Anderson Cancer Center, Houston, TX, United States
| | - Jan Burger
- Department of Leukemia, University of Texas at MD Anderson Cancer Center, Houston, TX, United States
| | - Yesid Alvarado
- Department of Leukemia, University of Texas at MD Anderson Cancer Center, Houston, TX, United States
| | - April Deshmukh
- Department of Leukemia, University of Texas at MD Anderson Cancer Center, Houston, TX, United States
| | - Ami Patel
- Department of Leukemia, University of Texas at MD Anderson Cancer Center, Houston, TX, United States
| | - Antonio Cavazos
- Department of Leukemia, University of Texas at MD Anderson Cancer Center, Houston, TX, United States
| | - Lina Han
- Department of Leukemia, University of Texas at MD Anderson Cancer Center, Houston, TX, United States
| | - Jorge E Cortes
- Department of Leukemia, University of Texas at MD Anderson Cancer Center, Houston, TX, United States
| | - Hagop Kantarjian
- Department of Leukemia, University of Texas at MD Anderson Cancer Center, Houston, TX, United States
| | - Michael Andreeff
- Department of Leukemia, University of Texas at MD Anderson Cancer Center, Houston, TX, United States
| | - Marina Konopleva
- Department of Leukemia, University of Texas at MD Anderson Cancer Center, Houston, TX, United States
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21
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McMahon CM, Perl AE. Management of primary refractory acute myeloid leukemia in the era of targeted therapies. Leuk Lymphoma 2018; 60:583-597. [PMID: 30234399 DOI: 10.1080/10428194.2018.1504937] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Primary refractory acute myeloid leukemia (AML), or primary induction failure, represents a continued challenge in clinical management. This review presents an overview of primary refractory disease and a discussion of risk factors for induction failure, including current evidence regarding the impact of karyotype and molecular mutation status on responsiveness to chemotherapy. We review the evidence for various treatment options for refractory AML including salvage chemotherapy regimens, allogeneic hematopoietic stem cell transplantation, targeted agents, and non-intensive therapies such as hypomethylating agents. A therapeutic approach to this patient population is presented, and several new and emerging therapies are reviewed.
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Affiliation(s)
- Christine M McMahon
- a Department of Medicine, Division of Hematology and Oncology , Perelman School of Medicine at the University of Pennsylvania , Philadelphia , PA , USA
| | - Alexander E Perl
- a Department of Medicine, Division of Hematology and Oncology , Perelman School of Medicine at the University of Pennsylvania , Philadelphia , PA , USA
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22
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Megías-Vericat JE, Martínez-Cuadrón D, Sanz MÁ, Montesinos P. Salvage regimens using conventional chemotherapy agents for relapsed/refractory adult AML patients: a systematic literature review. Ann Hematol 2018; 97:1115-1153. [DOI: 10.1007/s00277-018-3304-y] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 03/12/2018] [Indexed: 12/26/2022]
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23
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Martínez-Cuadrón D, Boluda B, Martínez P, Bergua J, Rodríguez-Veiga R, Esteve J, Vives S, Serrano J, Vidriales B, Salamero O, Cordón L, Sempere A, Jiménez-Ubieto A, Prieto-Delgado J, Díaz-Beyá M, Garrido A, Benavente C, Pérez-Simón JA, Moscardó F, Sanz MA, Montesinos P. A phase I-II study of plerixafor in combination with fludarabine, idarubicin, cytarabine, and G-CSF (PLERIFLAG regimen) for the treatment of patients with the first early-relapsed or refractory acute myeloid leukemia. Ann Hematol 2018; 97:763-772. [PMID: 29392425 DOI: 10.1007/s00277-018-3229-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 12/28/2017] [Indexed: 12/01/2022]
Abstract
Clinical outcomes of patients with acute myeloid leukemia (AML) showing the first primary refractory or early-relapsed disease remain very poor. The Programa Español de Tratamientos en Hematología (PETHEMA) group designed a phase I-II trial using FLAG-Ida (fludarabine, idarubicin, cytarabine, and G-CSF) plus high-dose intravenous plerixafor, a molecule inducing mobilization of blasts through the SDF-1α-CXCR4 axis blockade and potentially leading to chemosensitization of the leukemic cells. We aimed to establish a recommended phase 2 dose (RP2D) of plerixafor plus FLAG-Ida, as well as the efficacy and safety of this combination for early-relapsed (first complete remission (CR/CRi) < 12 months) or primary refractory AML. Between 2012 and 2015, 57 patients were enrolled, and 41 received the RP2D (median age 52 years [range, 18-64]). Among these patients, 20 (49%) achieved CR/CRi, and 3 (7%) died during induction. CR/CRi rate was 50% (13/26) among primary refractory and 47% (7/15) among early relapse. Overall, 25 patients (61%) were allografted. Median overall and disease-free survivals were 9.9 and 13 months, respectively. In summary, the combination of plerixafor plus FLAG-Ida resulted in a relatively high CR/CRi rate in adult patients with primary refractory or early relapsed AML, with an acceptable toxicity profile and induction mortality rate, bridging the majority of patients to allogeneic stem cell transplantation. ClinicalTrials.gov Identifier: NCT01435343.
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Affiliation(s)
- David Martínez-Cuadrón
- Hematology Department, Hospital Universitari i Politècnic, La Fe, Avinguda Fernando Abril Martorell, 106, 46026, València, Spain.,CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Blanca Boluda
- Hematology Department, Hospital Universitari i Politècnic, La Fe, Avinguda Fernando Abril Martorell, 106, 46026, València, Spain
| | | | - Juan Bergua
- Hospital San Pedro de Alcántara, Cáceres, Spain
| | - Rebeca Rodríguez-Veiga
- Hematology Department, Hospital Universitari i Politècnic, La Fe, Avinguda Fernando Abril Martorell, 106, 46026, València, Spain
| | | | - Susana Vives
- Hospital ICO-Universitari Germans Trias i Pujol, José Carreras Leukemia Research Institute, Badalona, Spain
| | | | | | - Olga Salamero
- Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Lourdes Cordón
- Hematology Department, Hospital Universitari i Politècnic, La Fe, Avinguda Fernando Abril Martorell, 106, 46026, València, Spain.,CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Amparo Sempere
- Hematology Department, Hospital Universitari i Politècnic, La Fe, Avinguda Fernando Abril Martorell, 106, 46026, València, Spain.,CIBERONC, Instituto Carlos III, Madrid, Spain
| | | | | | | | - Ana Garrido
- Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | | | - Federico Moscardó
- Hematology Department, Hospital Universitari i Politècnic, La Fe, Avinguda Fernando Abril Martorell, 106, 46026, València, Spain
| | - Miguel A Sanz
- Hematology Department, Hospital Universitari i Politècnic, La Fe, Avinguda Fernando Abril Martorell, 106, 46026, València, Spain.,CIBERONC, Instituto Carlos III, Madrid, Spain.,Department of Medicine, University of Valencia, Valencia, Spain
| | - Pau Montesinos
- Hematology Department, Hospital Universitari i Politècnic, La Fe, Avinguda Fernando Abril Martorell, 106, 46026, València, Spain. .,CIBERONC, Instituto Carlos III, Madrid, Spain.
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24
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Roboz GJ, Kantarjian HM, Yee KWL, Kropf PL, O'Connell CL, Griffiths EA, Stock W, Daver NG, Jabbour E, Ritchie EK, Walsh KJ, Rizzieri D, Lunin SD, Curio T, Chung W, Hao Y, Lowder JN, Azab M, Issa JPJ. Dose, schedule, safety, and efficacy of guadecitabine in relapsed or refractory acute myeloid leukemia. Cancer 2017; 124:325-334. [PMID: 29211308 PMCID: PMC5814873 DOI: 10.1002/cncr.31138] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 08/16/2017] [Accepted: 08/23/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Outcomes for patients with relapsed or refractory acute myeloid leukemia (AML) are poor. Guadecitabine, a next‐generation hypomethylating agent, could be useful in treating such patients. METHODS In this multicenter, open‐label, phase 2 dose‐expansion study, AML patients from 10 North American medical centers were first randomized (1:1) to receive subcutaneous guadecitabine at 60 or 90 mg/m2 on 5 consecutive days in each 28‐day cycle (5‐day regimen). Subsequently, another cohort was treated for 10 days with 60 mg/m2 (10‐day regimen). RESULTS Between June 15, 2012, and August 19, 2013, 108 patients with previously treated AML consented to enroll in the study, and 103 of these patients were treated; 5 patients did not receive the study treatment. A total of 103 patients were included in the safety and efficacy analyses (24 and 26 patients who were randomly assigned to 60 and 90 mg/m2/d, respectively [5‐day regimen] and 53 patients who were assigned to 60 mg/m2/d [10‐day regimen]). The 90 mg/m2 dose showed no benefit in clinical outcomes in comparison with 60 mg/m2 in the randomized cohort. Composite complete response (CRc) and complete response (CR) rates were higher with the 10‐day regimen versus the 5‐day regimen (CRc, 30.2% vs 16.0%; P = .1061; CR, 18.9% vs 8%; P = .15). Adverse events (grade ≥ 3) were mainly hematologic, with a higher incidence on the 10‐day regimen. Early all‐cause mortality was low and similar between regimens. Twenty patients (8 on the 5‐day regimen and 12 on the 10‐day regimen) were bridged to hematopoietic cell transplantation. CONCLUSIONS Guadecitabine has promising clinical activity and an acceptable safety profile and thus warrants further development in this population. Cancer 2018;124:325‐34. © 2017 The Authors. Cancer published by Wiley Periodicals, Inc. on behalf of American Cancer Society. This is an open access article under the terms of the Creative Commons Attribution NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes. Outcomes for patients with relapsed or refractory acute myeloid leukemia are poor. Guadecitabine, a next‐generation hypomethylating agent, has promising clinical activity and an acceptable safety profile and warrants further development in this population. See also pages 242‐4.
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Affiliation(s)
- Gail J Roboz
- Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, New York
| | | | - Karen W L Yee
- Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | | | - Casey L O'Connell
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | | | | | - Naval G Daver
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Elias Jabbour
- The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Ellen K Ritchie
- Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, New York
| | | | | | - Scott D Lunin
- Florida Cancer Specialist and Research Institute, Fort Myers, Florida
| | - Tania Curio
- Weill Cornell Medicine, NewYork-Presbyterian Hospital, New York, New York
| | - Woonbok Chung
- Fels Institute for Cancer Research and Molecular Biology, Temple University, Philadelphia, Pennsylvania
| | - Yong Hao
- Astex Pharmaceuticals, Pleasanton, California
| | | | | | - Jean-Pierre J Issa
- Fels Institute for Cancer Research and Molecular Biology, Temple University, Philadelphia, Pennsylvania
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25
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Randomized phase II trial of cytosine arabinoside with and without the CHK1 inhibitor MK-8776 in relapsed and refractory acute myeloid leukemia. Leuk Res 2017; 61:108-116. [PMID: 28957699 DOI: 10.1016/j.leukres.2017.09.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 09/08/2017] [Accepted: 09/10/2017] [Indexed: 11/23/2022]
Abstract
PURPOSE Cytosine arabinoside (AraC) remains the backbone of most treatment regimens for acute myeloid leukemia (AML). Incorporation of AraC into DNA activates checkpoint kinase 1 (Chk1), leading to cell-cycle arrest and diminished AraC cytotoxicity, which can be reversed by the selective Chk1 inhibitor MK-8776. Building on a Phase I trial, we conducted a phase II trial comparing timed sequential AraC with or without MK-8776. METHODS Patients with relapsed or primary refractory AML were randomized 1:1 to receive either AraC with MK-8776 (Arm A); or AraC alone (Arm B). RESULTS 32 patients were treated: 14 assigned to Arm A and 18 to Arm B. There were 5 (36%) complete responses (CR/CRi) and 1 (7%) partial response (PR) in Arm A, and 8 (44%) CR/CRis and 1 (6%) PR in Arm B. Median survival did not differ significantly between the two groups (5.9months in Arm A vs. 4.5 months in Arm B). MK-8776 led to a robust increase in DNA damage in circulating leukemic blasts as measured by increased γ-H2AX (16.9%±6.1% prior and 36.4%±6.8% at one hour after MK-8776 infusion, p=0.016). CONCLUSION Response rates and survival were similar between the two groups in spite of evidence that MK-8776 augmented DNA damage in circulating leukemic blasts. Better than expected results in the control arm using timed sequential AraC and truncated patient enrollment may have limited the ability to detect clinical benefit from the combination.
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26
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Short NJ, Kantarjian H, Ravandi F, Huang X, Xiao L, Garcia-Manero G, Plunkett W, Gandhi V, Sasaki K, Pemmaraju N, Daver NG, Borthakur G, Jain N, Konopleva M, Estrov Z, Kadia TM, Wierda WG, DiNardo CD, Brandt M, O'Brien SM, Cortes JE, Jabbour E. A phase I/II randomized trial of clofarabine or fludarabine added to idarubicin and cytarabine for adults with relapsed or refractory acute myeloid leukemia. Leuk Lymphoma 2017; 59:813-820. [PMID: 28718728 DOI: 10.1080/10428194.2017.1349907] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The purine nucleoside analogues clofarabine and fludarabine are active in acute myeloid leukemia (AML). We conducted a phase I/II randomized study of idarubicin and cytarabine with either clofarabine (CIA) or fludarabine (FIA) for relapsed or refractory AML. Clofarabine 15 mg/m2 was identified as the recommended phase II dose. Eighty-one patients were assigned using adaptive randomization to CIA (n = 48) or FIA (n = 33). The complete response (CR)/CR without platelet recovery rate did not differ between CIA and FIA (38% versus 30%, respectively; p = .50). In both arms, more than half of patients who had received only one prior line of therapy achieved remission. The median event-free survival for CIA and FIA was 2.0 and 1.9 months (p = .48), and the median overall survival was 6.3 and 4.7 months, respectively (p = .28). No significant differences in adverse events or early mortality rates were observed. Overall, CIA and FIA resulted in similar response rates and survival in patients with relapsed/refractory AML.
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Affiliation(s)
- Nicholas J Short
- a Department of Leukemia , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Hagop Kantarjian
- a Department of Leukemia , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Farhad Ravandi
- a Department of Leukemia , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Xuelin Huang
- b Department of Biostatistics , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Lianchun Xiao
- b Department of Biostatistics , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Guillermo Garcia-Manero
- a Department of Leukemia , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - William Plunkett
- c Department of Experimental Therapeutics , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Varsha Gandhi
- c Department of Experimental Therapeutics , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Koji Sasaki
- d Division of Cancer Medicine , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Naveen Pemmaraju
- a Department of Leukemia , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Naval G Daver
- a Department of Leukemia , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Gautam Borthakur
- a Department of Leukemia , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Nitin Jain
- a Department of Leukemia , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Marina Konopleva
- a Department of Leukemia , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Zeev Estrov
- a Department of Leukemia , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Tapan M Kadia
- a Department of Leukemia , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - William G Wierda
- a Department of Leukemia , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Courtney D DiNardo
- a Department of Leukemia , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Mark Brandt
- a Department of Leukemia , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Susan M O'Brien
- c Department of Experimental Therapeutics , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Jorge E Cortes
- a Department of Leukemia , The University of Texas MD Anderson Cancer Center , Houston , TX , USA
| | - Elias Jabbour
- a Department of Leukemia , The University of Texas MD Anderson Cancer Center , Houston , TX , USA.,e Chao Family Comprehensive Cancer Center , University of California Irvine , Orange , CA , USA
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Outcomes of Six-Dose High-Dose Cytarabine as a Salvage Regimen for Patients with Relapsed/Refractory Acute Myeloid Leukemia. Adv Hematol 2017; 2017:6464972. [PMID: 28588617 PMCID: PMC5446853 DOI: 10.1155/2017/6464972] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 04/27/2017] [Indexed: 01/13/2023] Open
Abstract
Relapsed/refractory acute myeloid leukemia (RR-AML) is associated with poor prognosis and long-term disease-free survival requires allogeneic hematopoietic cell transplantation (allo-HCT). Limited data exists, regarding the optimal regimen to obtain remission prior to allo-HCT. Single agent high-dose cytarabine (10-12 doses administered every 12 hours) has been previously used as induction therapy. Six-dose high-dose cytarabine (HiDAC-6), commonly used as a consolidation regimen, has never been evaluated as induction therapy. We present a retrospective review of 26 consecutive patients with RR-AML receiving single agent cytarabine 3 g/m2 intravenously every 12 hours on days 1, 3, and 5 for a total of six doses (HiDAC-6). Median follow-up for surviving patients was 10.4 months (range 1.6-112.2 months). Complete remission was obtained in 62% (54% CR and 8% CRi) of the patients. The median relapse-free survival (RFS) was 22.3 months (range 0.7-112 months), event-free survival (EFS) was 4.7 months (range 0.5-112 months), and the overall survival (OS) was 9.6 months (range 1-112 months). Thirty-five percent of patients were able to subsequently proceed to allo-HCT. Treatment-related toxicities included neutropenic fever (38%), infection (35%), neurotoxicity (8%), and skin toxicity (8%). This is the first study to demonstrate HiDAC-6 as an active treatment option for younger patients with RR-AML which can effectively serve as a bridge to allo-HCT without significant toxicity.
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Khan N, Hantel A, Knoebel RW, Artz A, Larson RA, Godley LA, Thirman MJ, Liu H, Churpek JE, King D, Odenike O, Stock W. Efficacy of single-agent decitabine in relapsed and refractory acute myeloid leukemia. Leuk Lymphoma 2017; 58:1-7. [PMID: 28278716 DOI: 10.1080/10428194.2017.1289524] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Improving therapy for relapsed/refractory AML remains a challenge. We performed a retrospective analysis of outcomes following decitabine treatment in 34 patients with relapsed/refractory AML (median age, 62; median Charlson comorbidity score, 6). Decitabine, 20 mg/m2 daily, was given in 5- (25%) or 10-day (75%) cycles. Overall response rate (OR) was 30% with 21% complete remission and 9% partial remission rate. Patients with therapy-related myeloid neoplasm (t-MN) and secondary AML had a significantly higher OR compared to those with de novo AML (70 vs. 30%; p = .02). Median overall survival of all patients was 8.5 months. Median survival in patients with t-MN or secondary AML was 12.4 months compared to 8 months in those with de novo AML (p = .20). Fifteen (44%) patients proceeded to hematopoietic stem cell transplant. These data support using 10-day treatment cycles of decitabine in patients with relapsed/refractory AML, particularly for those with secondary or therapy-related AML.
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Affiliation(s)
- Niloufer Khan
- a Departments of Medicine and Pediatrics , The University of Chicago Medicine , Chicago , IL , USA
| | - Andrew Hantel
- b Department of Medicine , Section of Hematology/Oncology, The University of Chicago Medicine , Chicago , IL , USA
| | - Randall W Knoebel
- c Department of Pharmacy , The University of Chicago Medicine , Chicago , IL , USA
| | - Andrew Artz
- b Department of Medicine , Section of Hematology/Oncology, The University of Chicago Medicine , Chicago , IL , USA
| | - Richard A Larson
- b Department of Medicine , Section of Hematology/Oncology, The University of Chicago Medicine , Chicago , IL , USA
| | - Lucy A Godley
- b Department of Medicine , Section of Hematology/Oncology, The University of Chicago Medicine , Chicago , IL , USA
| | - Michael J Thirman
- b Department of Medicine , Section of Hematology/Oncology, The University of Chicago Medicine , Chicago , IL , USA
| | - Hongtao Liu
- b Department of Medicine , Section of Hematology/Oncology, The University of Chicago Medicine , Chicago , IL , USA
| | - Jane E Churpek
- b Department of Medicine , Section of Hematology/Oncology, The University of Chicago Medicine , Chicago , IL , USA
| | - Darren King
- d Department of Medicine , Section of Hematology/Oncology, The University of Michigan , Ann Arbor , MI , USA
| | - Olatoyosi Odenike
- b Department of Medicine , Section of Hematology/Oncology, The University of Chicago Medicine , Chicago , IL , USA
| | - Wendy Stock
- b Department of Medicine , Section of Hematology/Oncology, The University of Chicago Medicine , Chicago , IL , USA
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Relapsed Acute Myeloid Leukemia: Need for Innovative Treatment Strategies to Improve Outcome. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2016; 15 Suppl:S104-8. [PMID: 26297261 DOI: 10.1016/j.clml.2015.03.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 03/18/2015] [Indexed: 12/27/2022]
Abstract
Relapse continues to be a major hurdle in achieving cure in patients with acute myeloid leukemia (AML). The outcome after relapse is not uniform in all patients with AML and is dependent on several prognostic variables, including age, cytogenetics at initial diagnosis, duration of first complete remission, whether an allogeneic stem cell transplant was performed during first complete remission, and the presence of a number of molecular aberrations. Despite extensive research over the past several decades, there is no standard of care for treating patients with relapsed AML. This is possibly due to the accrual of patients with widely different disease profiles in most trials for relapsed AML. With increasing insights into the disease biology based on identification of pathogenic and aberrant molecular and cellular pathways, novel therapeutic strategies are emerging. Hopefully in the near future, we can improve the outcome of patients with relapsed AML with treatment strategies based on identification of specific targets and methods to overcome these aberrant processes.
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Kell J. Considerations and challenges for patients with refractory and relapsed acute myeloid leukaemia. Leuk Res 2016; 47:149-60. [PMID: 27371910 DOI: 10.1016/j.leukres.2016.05.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 05/30/2016] [Indexed: 12/29/2022]
Abstract
Despite advances in understanding the complexities of acute myeloid leukaemia (AML), the treatment of refractory or relapsed AML (rrAML) remains a daunting clinical challenge. Numerous clinical trials have failed to identify new treatments or combinations of existing therapies that substantially improve outcomes and survival. This may be due, at least in part, to heterogeneity among study patients with respect to multiple inter-related factors that have been shown to affect treatment outcomes for patients with rrAML; such factors include age, cytogenetics, immunophenotypic changes, and (in the case of relapsed AML) duration of first complete remission, or if the patient has had a previous blood and marrow transplant (BMT). A clear understanding of disease characteristics and patient-related factors that influence treatment response, as well as expected outcomes with existing and emerging therapies, can aid clinicians in helping their patients navigate through this complex disease state.
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Affiliation(s)
- Jonathan Kell
- University Hospital of Wales, Department of Haematology, Heath Park, Cardiff, GB, United Kingdom.
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31
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Bergua JM, Montesinos P, Martinez-Cuadrón D, Fernández-Abellán P, Serrano J, Sayas MJ, Prieto-Fernandez J, García R, García-Huerta AJ, Barrios M, Benavente C, Pérez-Encinas M, Simiele A, Rodríguez-Macias G, Herrera-Puente P, Rodríguez-Veiga R, Martínez-Sánchez MP, Amador-Barciela ML, Riaza-Grau R, Sanz MA. A prognostic model for survival after salvage treatment with FLAG-Ida +/− gemtuzumab-ozogamicine in adult patients with refractory/relapsed acute myeloid leukaemia. Br J Haematol 2016; 174:700-10. [DOI: 10.1111/bjh.14107] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Accepted: 02/29/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Juan M. Bergua
- Department of Haematology; Hospital San Pedro de Alcántara; Cáceres Spain
| | - Pau Montesinos
- Department of Haematology; University Hospital La Fe; Valencia Spain
| | | | | | | | - María J. Sayas
- Department of Haematology; Hospital Doctor Peset; Valencia Spain
| | | | - Raimundo García
- Department of Haematology; General Hospital Castellón; Castellón Spain
| | | | - Manuel Barrios
- Department of Haematology; Hospital Carlos Haya; Málaga Spain
| | | | | | | | | | | | | | | | | | | | - Miguel A. Sanz
- Department of Haematology; University Hospital La Fe; Valencia Spain
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32
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A phase I study of intermediate dose cytarabine in combination with lenalidomide in relapsed/refractory acute myeloid leukemia. Leuk Res 2016; 43:44-8. [DOI: 10.1016/j.leukres.2016.02.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 01/29/2016] [Accepted: 02/14/2016] [Indexed: 11/22/2022]
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33
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Qu Q, Liu L, Zhang Y, Li X, Wu D. Increasing aclarubicin dosage of the conventional CAG (low-dose cytarabine and aclarubicin in combination with granulocyte colony-stimulating factor) regimen is more efficacious as a salvage therapy than CAG for relapsed/refractory acute myeloid leukemia. Leuk Res 2015; 39:1353-9. [DOI: 10.1016/j.leukres.2015.09.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Revised: 08/10/2015] [Accepted: 09/13/2015] [Indexed: 10/23/2022]
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34
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How I treat refractory and early relapsed acute myeloid leukemia. Blood 2015; 126:319-27. [DOI: 10.1182/blood-2014-10-551911] [Citation(s) in RCA: 196] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 04/02/2015] [Indexed: 12/19/2022] Open
Abstract
AbstractBetween 10% and 40% of newly diagnosed patients with acute myeloid leukemia (AML) do not achieve complete remission with intensive induction therapy and are therefore categorized as primary refractory or resistant. Few of these patients can be cured with conventional salvage therapy. They need to be evaluated regarding eligibility for allogeneic hematopoietic stem cell transplantation (HSCT) as this is currently the treatment with the highest probability of cure. To reduce the leukemia burden prior to transplantation, salvage chemotherapy regimens need to be employed. Whenever possible, refractory/relapsed patients should be enrolled in clinical trials as we do not have highly effective and standardized treatments for this situation. Novel therapies include tyrosine kinase inhibitors, small-molecule inhibitors (eg, for Polo-like kinase 1 and aminopeptidase), inhibitors of mutated isocitrate dehydrogenase (IDH) 1 and IDH2, antibody-based therapies, and cell-based therapies. Although the majority of these therapies are still under evaluation, they are likely to enter clinical practice rapidly as a bridge to transplant and/or in older, unfit patients who are not candidates for allogeneic HSCT. In this review, we describe our approach to refractory/early relapsed AML, and we discuss treatment options for patients with regard to different clinical conditions and molecular profiles.
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35
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Ahmed T, Holwerda S, Klepin HD, Isom S, Ellis LR, Lyerly S, Manuel M, Dralle S, Berenzon D, Powell BL, Pardee TS. High dose cytarabine, mitoxantrone and l-asparaginase (HAMA) salvage for relapsed or refractory acute myeloid leukemia (AML) in the elderly. Leuk Res 2015; 39:945-9. [PMID: 26154683 DOI: 10.1016/j.leukres.2015.05.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 05/13/2015] [Accepted: 05/28/2015] [Indexed: 10/23/2022]
Abstract
Acute myeloid leukemia (AML) is an aggressive malignancy that affects older patients. The role of salvage therapy in the elderly is controversial and there is little data on efficacy. Outcomes for 94 relapsed or refractory AML patients who received salvage HAMA therapy were analyzed. Of the 94 patients 66 were ≥60, including 26 patients ≥70, and 28 were <60 years old. Early mortality (30-day) was 14% (4%<60, 18%≥60 years old). Overall, 27% of patients died during hospitalization or were discharged to hospice (11%<60, 33%≥60 years old). CR/CRi was achieved in 41% of patients (61%<60, 33%≥60 years old). Median survival was 6.1 months (15.7<60, 5.2≥60). Patients ≥60 who achieved a CR/CRi had a median survival of 11.7 months. At 12 months 56% of patients <60 were alive versus 24% of patients ≥60. At 24 months these numbers fell to 40% and 2% respectively. In those <60 years old, 50% went on to allogeneic hematopoietic stem cell transplant (HSCT) whereas 14% of patients in the ≥60 cohort did so. In conclusion, HAMA salvage therapy results in a 33% response rate in patients ≥60 years old with acceptable toxicity.
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Affiliation(s)
- Tamjeed Ahmed
- Internal Medicine, Wake Forest Baptist Health, Winston-Salem, NC, United States
| | - Scott Holwerda
- Internal Medicine, Wake Forest Baptist Health, Winston-Salem, NC, United States
| | - Heidi D Klepin
- Internal Medicine, Section on Hematology and Oncology, Wake Forest Baptist Health, Winston-Salem, NC, United States
| | - Scott Isom
- Internal Medicine, Section on Hematology and Oncology, Wake Forest Baptist Health, Winston-Salem, NC, United States
| | - Leslie R Ellis
- Internal Medicine, Section on Hematology and Oncology, Wake Forest Baptist Health, Winston-Salem, NC, United States
| | - Susan Lyerly
- Internal Medicine, Section on Hematology and Oncology, Wake Forest Baptist Health, Winston-Salem, NC, United States
| | - Megan Manuel
- Internal Medicine, Section on Hematology and Oncology, Wake Forest Baptist Health, Winston-Salem, NC, United States
| | - Sarah Dralle
- Internal Medicine, Section on Hematology and Oncology, Wake Forest Baptist Health, Winston-Salem, NC, United States
| | - Dmitriy Berenzon
- Internal Medicine, Section on Hematology and Oncology, Wake Forest Baptist Health, Winston-Salem, NC, United States
| | - Bayard L Powell
- Internal Medicine, Section on Hematology and Oncology, Wake Forest Baptist Health, Winston-Salem, NC, United States
| | - Timothy S Pardee
- Internal Medicine, Section on Hematology and Oncology, Wake Forest Baptist Health, Winston-Salem, NC, United States; Cancer Biology, Comprehensive Cancer Center of Wake Forest University, Winston-Salem, NC, United States.
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36
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Ramos NR, Mo CC, Karp JE, Hourigan CS. Current Approaches in the Treatment of Relapsed and Refractory Acute Myeloid Leukemia. J Clin Med 2015; 4:665-95. [PMID: 25932335 PMCID: PMC4412468 DOI: 10.3390/jcm4040665] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 03/20/2015] [Indexed: 01/07/2023] Open
Abstract
The limited sensitivity of the historical treatment response criteria for acute myeloid leukemia (AML) has resulted in a different paradigm for treatment compared with most other cancers presenting with widely disseminated disease. Initial cytotoxic induction chemotherapy is often able to reduce tumor burden to a level sufficient to meet the current criteria for "complete" remission. Nevertheless, most AML patients ultimately die from their disease, most commonly as clinically evident relapsed AML. Despite a variety of available salvage therapy options, prognosis in patients with relapsed or refractory AML is generally poor. In this review, we outline the commonly utilized salvage cytotoxic therapy interventions and then highlight novel investigational efforts currently in clinical trials using both pathway-targeted agents and immunotherapy based approaches. We conclude that there is no current standard of care for adult relapsed or refractory AML other than offering referral to an appropriate clinical trial.
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Affiliation(s)
- Nestor R. Ramos
- Myeloid Malignancies Section, Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD 20892-1583, USA; E-Mail:
- Department of Hematology-Oncology, John P. Murtha Cancer Center, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA; E-Mail:
| | - Clifton C. Mo
- Department of Hematology-Oncology, John P. Murtha Cancer Center, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA; E-Mail:
| | - Judith E. Karp
- Division of Hematologic Malignancies, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA; E-Mail:
| | - Christopher S. Hourigan
- Myeloid Malignancies Section, Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD 20892-1583, USA; E-Mail:
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37
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Lee YG, Kwon JH, Kim I, Yoon SS, Lee JS, Park S. Effective salvage therapy for high-risk relapsed or refractory acute myeloid leukaemia with cisplatin in combination with high-dose cytarabine and etoposide. Eur J Haematol 2014; 92:478-84. [DOI: 10.1111/ejh.12274] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Yun-Gyoo Lee
- Department of Internal Medicine; Seoul National University College of Medicine; Seoul National University Bundang Hospital; Seongnam Korea
| | - Ji-hyun Kwon
- Department of Internal Medicine; Seoul National University College of Medicine; Seoul National University Hospital; Seoul Korea
| | - Inho Kim
- Department of Internal Medicine; Seoul National University College of Medicine; Seoul National University Hospital; Seoul Korea
| | - Sung Soo Yoon
- Department of Internal Medicine; Seoul National University College of Medicine; Seoul National University Hospital; Seoul Korea
| | - Jong-Seok Lee
- Department of Internal Medicine; Seoul National University College of Medicine; Seoul National University Bundang Hospital; Seongnam Korea
| | - Seongyang Park
- Department of Internal Medicine; Seoul National University College of Medicine; Seoul National University Hospital; Seoul Korea
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38
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Abstract
PURPOSE OF REVIEW Acute myeloid leukemia (AML) is a devastating disease, in which the majority of afflicted patients eventually experience relapse and die from their disease. RECENT FINDINGS Clinical and molecular characterization of the disease have greatly aided in prognostication in both primary and relapsed settings, which may broadly guide therapy, but truly effective standards of care for relapsed AML remain lacking. Traditional chemotherapeutic drugs have modest but limited efficacy in relapsed AML, whereas more novel and potent cytotoxic chemotherapeutic agents hold promise and are entering the advanced phases of testing. Targeted therapies for AML have demonstrated activity, often as single agents, generating enthusiasm for further development in subgroups of patients with appropriate molecular anomalies. Finally, allogeneic stem cell transplantation continues to evolve as an effective and potentially curative therapy for limited numbers of patients with relapsed AML. SUMMARY The complexity of relapsed AML will dictate the need for continued development of novel chemotherapeutic and targeted therapies that suit the molecular and clinical profiling of individual patients.
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Yu W, Mao L, Qian J, Qian W, Meng H, Mai W, Tong H, Tong Y, Jin J. Homoharringtonine in combination with cytarabine and aclarubicin in the treatment of refractory/relapsed acute myeloid leukemia: a single-center experience. Ann Hematol 2013; 92:1091-100. [PMID: 23595277 DOI: 10.1007/s00277-013-1758-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Accepted: 04/05/2013] [Indexed: 10/27/2022]
Abstract
To assess the efficacy and toxicity of HAA regimen (Homoharringtonine 4 mg/m(2)/day, days 1-3; cytarabine 150 mg/m(2)/day, days 1-7; aclarubicin 12 mg/m(2)/day, days 1-7) as a salvage therapy in the treatment of refractory and/or relapsed acute myeloid leukemia (AML), 46 patients with refractory and/or relapsed AML, median age 37 (16-65) years, participated in this clinical study. The median follow-up was 41 (10-86) months. Eighty percent of patients achieved complete remission (CR), and the first single course of re-induction HAA regimen resulted in CR rate of 76.1 %. The study protocol allowed two courses of induction. The CR rates of patients with favorable, intermediate and unfavorable cytogenetics were 90 %, 88.9 %, and 37.5 %, respectively. For all patients, the estimated 3-year overall survival (OS) rate was 42 %, and the estimated relapse free survival (RFS) at 3 years for the 36 CR cases was 49 %. The toxicities associated with HAA regimen were acceptable. HAA is a good choice in cases with refractory/relapsing AML for salvage chemotherapy, preferably with a high-efficacy and low-toxicity profile.
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Affiliation(s)
- Wenjuan Yu
- Department of Hematology, the First Affiliated Hospital, Zhejiang University College of Medicine, No. 79 Qingchun Road, Hangzhou, Zhejiang, People's Republic of China
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40
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Al Ustwani O, Wetzler M. Homoharringtonine and granulocyte colony-stimulating factor priming for acute myeloid leukemia: is it ready for prime time? Leuk Lymphoma 2013; 54:2100-2. [PMID: 23410101 DOI: 10.3109/10428194.2013.776169] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Omar Al Ustwani
- Leukemia Section, Department of Medicine, Roswell Park Cancer Institute , Buffalo, NY , USA
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41
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Jamieson K, Odenike O. Late-phase investigational approaches for the treatment of relapsed/refractory acute myeloid leukemia. Expert Opin Pharmacother 2012; 13:2171-87. [DOI: 10.1517/14656566.2012.724061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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42
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Song LX, Xu L, Li X, Chang CK, Zhang Y, Wu LY, He Q, Zhang QX, Li X. Clinical outcome of treatment with a combined regimen of decitabine and aclacinomycin/cytarabine for patients with refractory acute myeloid leukemia. Ann Hematol 2012; 91:1879-86. [DOI: 10.1007/s00277-012-1550-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Accepted: 07/31/2012] [Indexed: 11/29/2022]
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43
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Faderl S, Wetzler M, Rizzieri D, Schiller G, Jagasia M, Stuart R, Ganguly S, Avigan D, Craig M, Collins R, Maris M, Kovacsovics T, Goldberg S, Seiter K, Hari P, Greiner J, Vey N, Recher C, Ravandi F, Wang ES, Vasconcelles M, Huebner D, Kantarjian HM. Clofarabine plus cytarabine compared with cytarabine alone in older patients with relapsed or refractory acute myelogenous leukemia: results from the CLASSIC I Trial. J Clin Oncol 2012; 30:2492-9. [PMID: 22585697 DOI: 10.1200/jco.2011.37.9743] [Citation(s) in RCA: 149] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To compare the receipt of clofarabine plus cytarabine (Clo+Ara-C arm) with cytarabine (Ara-C arm) in patients ≥ 55 years old with refractory or relapsed acute myelogenous leukemia (AML). PATIENTS AND METHODS Patients were randomly assigned to receive either clofarabine (Clo) 40 mg/m(2) or a placebo followed by Ara-C 1 g/m(2) for five consecutive days. The primary end point was overall survival (OS). Secondary end points included event-free survival (EFS), 4-month EFS, overall remission rate (ORR; complete remission [CR] plus CR with incomplete peripheral blood count recovery), disease-free survival (DFS), duration of remission (DOR), and safety. RESULTS Among 320 patients with confirmed AML (median age, 67 years), the median OS was 6.6 months in the Clo+Ara-C arm and 6.3 months in the Ara-C arm (hazard ratio [HR], 1.00; 95% CI, 0.78 to 1.28; P = 1.00). The ORR was 46.9% in the Clo+Ara-C arm (35.2% CR) versus 22.9% in the Ara-C arm (17.8% CR; P < .01). EFS (HR: 0.63; 95% CI, 0.49 to 0.80; P < .01) and 4-month EFS (37.7% v 16.6%; P < .01) favored the Clo+Ara-C arm compared with Ara-C arm, respectively. DFS and DOR were similar in both arms. Overall 30-day mortality was 16% and 5% for CLO+Ara-C and Ara-C arms, respectively. In the Clo+Ara-C and Ara-C arms, the most common grade 3 to 4 toxicities were febrile neutropenia (47% v 35%, respectively), hypokalemia (18% v 11%, respectively), thrombocytopenia (16% v 17%, respectively), pneumonia (14% v 10%, respectively), anemia (13% v 0%, respectively), neutropenia (11% v 9%, respectively), increased AST (11% v 2%, respectively), and increased ALT (10% v 3%, respectively). CONCLUSION Although the primary end point of OS did not differ between arms, Clo+Ara-C significantly improved response rates and EFS. Study follow-up continues, and the role of clofarabine in the treatment of adult patients with AML continues to be investigated.
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Affiliation(s)
- Stefan Faderl
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Hardesty BM, Cripe LD. Cytarabine in relapsed acute myeloid leukemia. Leuk Res 2012; 36:387-8. [DOI: 10.1016/j.leukres.2011.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Revised: 11/30/2011] [Accepted: 12/01/2011] [Indexed: 11/25/2022]
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Domínguez Senín L, Rodríguez Rodríguez JN, Garrido Martínez MT, Sánchez Argáiz M, Martín Chacón E. [Effectiveness and safety of the FLAG-IDA regimen in acute refractory or recurrent leukaemia]. FARMACIA HOSPITALARIA 2011; 36:261-7. [PMID: 22137611 DOI: 10.1016/j.farma.2011.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2010] [Revised: 04/18/2011] [Accepted: 05/17/2011] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To evaluate the effectiveness and safety of the FLAG-IDA regimen in patients with acute refractory and/or recurrent leukaemia. METHOD Descriptive, retrospective, observational study of the clinical histories of patients with the FLAG-IDA regimen during the period of 2005-2010. Effectiveness was measured using objective response, progression-free interval, and global survival. Safety was measured using the NCI classification system of common toxicity criteria for adverse events. RESULTS We registered 12 patients (52.17±8.26 years in women, and 54.83±7.22 years in men), 11 cases were acute myeloid leukaemia (5 refractory, 3 in recurrence, 1 secondary to chronic refractory myeloid leukaemia (CML) and 2 secondary to myelodysplastic syndrome (MDS), one of which was refractory and the other had not been previously treated) and one case was acute refractory lymphoblastic leukaemia (ALL). Six patients (50%) reached a complete response (CR). One patient reached a partial response (PR), which was followed by another protocol that produced a CR, two died due to disease progression, and three due to secondary complications from treatment. The progression-free interval for patients that reached a CR was 24.38 weeks (6 months). Median global survival was 8.4 weeks. Mean time needed for the recovery of neutropenia was 23 and 37 days in the first and second cycle, respectively. The mean time required for recuperation of thrombocytopenia was 24 and 35 days in each cycle. CONCLUSIONS The FLAG-IDA induction regimen for the treatment of high-risk leukaemia patients is an established protocol, with good tolerance and acceptable toxicity levels that offers an opportunity for facilitating the transplantation of haematopoietic progenitors.
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Affiliation(s)
- L Domínguez Senín
- Servicio de Farmacia Hospitalaria, Hospital Juan Ramón Jiménez, Huelva, España.
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Ravandi F. New treatments and strategies in acute myeloid leukemia. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2011; 11 Suppl 1:S60-4. [PMID: 22035750 PMCID: PMC4096137 DOI: 10.1016/j.clml.2011.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Revised: 02/09/2011] [Accepted: 02/22/2011] [Indexed: 10/18/2022]
Abstract
Despite considerable progress in the treatment of acute myeloid leukemia in the past several decades, the prognosis of the majority of patients with this disease remains guarded. Advances in supportive care and better characterization of disease subsets through cytogenetics and molecular analysis have led to significant success in treating specific subsets of patients, such as those with acute promyelocytic leukemia and core binding factor leukemias, particularly among the younger patients who are able to better tolerate the effects of cytotoxic chemotherapy. However, overall, only about 40% of younger patients and <10% of older patients with this disease are alive at 5 years. Current research is focusing on the identification of new cellular targets amenable to specific inhibitors, designing the best strategies for combining these novel agents with traditional chemotherapy regimens, and determining prognostic indicators that may allow us to better stratify therapy.
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Affiliation(s)
- Farhad Ravandi
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
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Abstract
More than one quarter of a million adults throughout the world are diagnosed annually with acute myeloid leukemia (AML). Despite considerable progress during the past 3 decades in the therapy of AML, two-thirds of young adults and 90% of older adults still die of their disease. The reported median age has increased over the past few decades, mostly because of a greater willingness of physicians to diagnose and treat older patients, and now is 72 years. The greatest challenge is in this age group. However, much improvement in therapy is needed for all adults with AML. Recent advances in allogeneic transplantation, a better understanding of prognostic factors, and development of targeted agents have only modestly improved overall outcome when large populations of patients are considered. Although an explosion in knowledge about the molecular pathogenesis of AML has outpaced treatment advances, such insights hold promise for the development of new therapies directed at specific molecular abnormalities that perturb malignant cell survival pathways. The current approach in 2010 to the management of this disease is presented through a discussion of illustrative cases.
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Robak T, Wierzbowska A. Current and emerging therapies for acute myeloid leukemia. Clin Ther 2010; 31 Pt 2:2349-70. [PMID: 20110045 DOI: 10.1016/j.clinthera.2009.11.017] [Citation(s) in RCA: 106] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2009] [Indexed: 02/01/2023]
Abstract
BACKGROUND Acute myeloid leukemia (AML) is a clonal disease characterized by the proliferation and accumulation of myeloid progenitor cells in the bone marrow, which ultimately leads to hematopoietic failure. The incidence of AML increases with age, and older patients typically have worse treatment outcomes than do younger patients. OBJECTIVE This review is focused on current and emerging treatment strategies for nonpromyelocytic AML in patients aged <60 years. METHODS A literature review was conducted of the PubMed database for articles published in English. Publications from 1990 through March 2009 were scrutinized, and the search was updated on August 26, 2009. The search terms used were: acute myeloid leukemia in conjunction with treatment, chemotherapy, stem cell transplantation, and immunotherapy. Clinical trials including adults with AML aged > or =19 years were selected for analysis. Conference proceedings from the previous 5 years of The American Society of Hematology, The European Hematology Association, and The American Society for Blood and Marrow Transplantation were searched manually. Additional relevant publications were obtained by reviewing the references from the chosen articles. RESULTS Cytarabine (AraC) is the cornerstone of induction therapy and consolidation therapy for AML. A standard form of induction therapy consists of AraC (100-200 mg/m(2)), administered by a continuous infusion for 7 days, combined with an anthracycline, administered intravenously for 3 days. Consolidation therapy comprises treatment with additional courses of intensive chemotherapy after the patient has achieved a complete remission (CR), usually with higher doses of the same drugs as were used during the induction period. High-dose AraC (2-3 g/m(2)) is now a standard consolidation therapy for patients aged <60 years. Despite substantial progress in the treatment of newly diagnosed AML, 20% to 40% of patients do not achieve remission with the standard induction chemotherapy, and 50% to 70% of first CR patients are expected to relapse within 3 years. The optimum strategy at the time of relapse, or for patients with the resistant disease, remains uncertain. Allogeneic stem cell transplantation has been established as the most effective form of antileukemic therapy in patients with AML in first or subsequent remission. New drugs are being evaluated in clinical studies, including immunotoxins, monoclonal antibodies, nucleoside analogues, hypomethylating agents, farnesyltransferase inhibitors, alkylating agents, FMS-like tyrosine kinase 3 inhibitors, and multidrug-resistant modulators. However, determining the success of these treatment strategies ultimately requires well-designed clinical trials, based on stratification of the patient risk, knowledge of the individual disease, and the drug's performance status. CONCLUSIONS Combinations of AraC and anthracyclines are still the mainstay of induction therapy, and use of high-dose AraC is now a standard consolidation therapy in AML patients aged <60 years. Although several new agents have shown promise in treating AML, it is unlikely that these agents will be curative when administered as monotherapy; it is more likely that they will be used in combination with other new agents or with conventional therapy.
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Affiliation(s)
- Tadeusz Robak
- Department of Hematology, Medical University of Lodz, Copernicus Memorial Hospital, Lodz, Poland.
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Perl AE, Kasner MT, Tsai DE, Vogl DT, Loren AW, Schuster SJ, Porter DL, Stadtmauer EA, Goldstein SC, Frey NV, Nasta SD, Hexner EO, Dierov JK, Swider CR, Bagg A, Gewirtz AM, Carroll M, Luger SM. A phase I study of the mammalian target of rapamycin inhibitor sirolimus and MEC chemotherapy in relapsed and refractory acute myelogenous leukemia. Clin Cancer Res 2009; 15:6732-9. [PMID: 19843663 DOI: 10.1158/1078-0432.ccr-09-0842] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Inhibiting mammalian target of rapamycin (mTOR) signaling in acute myelogenous leukemia (AML) blasts and leukemic stem cells may enhance their sensitivity to cytotoxic agents. We sought to determine the safety and describe the toxicity of this approach by adding the mTOR inhibitor, sirolimus (rapamycin), to intensive AML induction chemotherapy. EXPERIMENTAL DESIGN We performed a phase I dose escalation study of sirolimus with the chemotherapy regimen MEC (mitoxantrone, etoposide, and cytarabine) in patients with relapsed, refractory, or untreated secondary AML. RESULTS Twenty-nine subjects received sirolimus and MEC across five dose levels. Dose-limiting toxicities were irreversible marrow aplasia and multiorgan failure. The maximum tolerated dose (MTD) of sirolimus was determined to be a 12 mg loading dose on day 1 followed by 4 mg/d on days 2 to 7, concurrent with MEC chemotherapy. Complete or partial remissions occurred in 6 (22%) of the 27 subjects who completed chemotherapy, including 3 (25%) of the 12 subjects treated at the MTD. At the MTD, measured rapamycin trough levels were within the therapeutic range for solid organ transplantation. However, direct measurement of the mTOR target p70 S6 kinase phosphorylation in marrow blasts from these subjects only showed definite target inhibition in one of five evaluable samples. CONCLUSIONS Sirolimus and MEC is an active and feasible regimen. However, as administered in this study, the synergy between MEC and sirolimus was not confirmed. Future studies are planned with different schedules to clarify the clinical and biochemical effects of sirolimus in AML and to determine whether target inhibition predicts chemotherapy response.
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Affiliation(s)
- Alexander E Perl
- Hematologic Malignancies Program, Abramson Cancer Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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Abstract
PURPOSE OF REVIEW Treatment for relapsed or refractory acute myeloid leukemia remains a major challenge for the leukemia community. Although several approaches have been tested in phase II study designs, few comparative data exist to guide treatment choices. We searched the recent literature in Medline, EMBASE and BIOSIS, and abstracts from the American Society of Hematology and American Society of Clinical Oncology published between 2005 and 2007. We reviewed each report to identify studies that used a phase II or III design and that included a majority of adults with non-M3 acute myeloid leukemia described as 'relapsed' or 'refractory'. RECENT FINDINGS Several studies utilized novel cytotoxic chemotherapies, immunotherapies, epigenetic agents, and small molecule inhibitors. It is not possible to identify a single regimen or approach as the standard of care in relapsed and refractory acute myeloid leukemia. New and promising approaches are being explored, however. SUMMARY Outcomes in patients treated for relapsed or refractory acute myeloid leukemia remain inadequate. Striking a balance between the treatment-related mortality associated with salvage therapies, response rates of salvage regimens, and the likelihood of long-term disease-free survival are critical in planning a treatment approach for the individual patient with relapsed or refractory acute myeloid leukemia.
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