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Yoon JH, Lee S. Diagnostic and therapeutic advances in adults with acute lymphoblastic leukemia in the era of gene analysis and targeted immunotherapy. Korean J Intern Med 2024; 39:34-56. [PMID: 38225824 PMCID: PMC10790045 DOI: 10.3904/kjim.2023.407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 12/03/2023] [Accepted: 12/23/2023] [Indexed: 01/17/2024] Open
Abstract
Acute lymphoblastic leukemia (ALL) is one of the most rapidly changing hematological malignancies with advanced understanding of the genetic landscape, detection methods of minimal residual disease (MRD), and the development of immunotherapeutic agents with good clinical outcomes. The annual incidence of adult ALL in Korea is 300-350 patients per year. The WHO classification of ALL was revised in 2022 to reflect the molecular cytogenetic features and suggest new adverse- risk subgroups, such as Ph-like ALL and ETP-ALL. We continue to use traditional adverse-risk features and cytogenetics, with MRD-directed post-remission therapy including allogeneic hematopoietic cell transplantation. However, with the introduction of novel agents, such as ponatinib, blinatumomab, and inotuzumab ozogamicin incorporated into frontline therapy, good MRD responses have been achieved, and overall survival outcomes are improving. Accordingly, some clinical trials have suggested a possible era of chemotherapy-free or transplantation-free approaches in the near future. Nevertheless, relapse of refractory ALL still occurs, and some poor ALL subtypes, such as Ph-like ALL and ETP-ALL, are unsolved problems for which novel agents and treatment strategies are needed. In this review, we summarize the currently applied diagnostic and therapeutic practices in the era of advanced genetic analysis and targeted immunotherapies in United States and Europe and introduce real-world Korean data.
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Affiliation(s)
- Jae-Ho Yoon
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seok Lee
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Prockop S, Wachter F. The current landscape: Allogeneic hematopoietic stem cell transplant for acute lymphoblastic leukemia. Best Pract Res Clin Haematol 2023; 36:101485. [PMID: 37611999 DOI: 10.1016/j.beha.2023.101485] [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: 05/26/2023] [Accepted: 05/31/2023] [Indexed: 08/25/2023]
Abstract
One of the consistent features in development of hematopoietic stem cell transplant (HCT) for Acute Lymphoblastic Leukemia (ALL) is the rapidity with which discoveries in the laboratory are translated into innovations in clinical care. Just a few years after murine studies demonstrated that rescue from radiation induced marrow failure is mediated by cellular not humoral factors, E. Donnall Thomas reported on the transfer of bone marrow cells into irradiated leukemia patients. This was followed quickly by the first descriptions of Graft versus Leukemia (GvL) effect and Graft versus Host Disease (GvHD). Despite the pivotal nature of these findings, early human transplants were uniformly unsuccessful and identified the challenges that continue to thwart transplanters today - leukemic relapse, regimen related toxicity, and GvHD. While originally only an option for young, fit patients with a matched family donor, expansion of the donor pool to include unrelated donors, umbilical cord blood units, and more recently the growing use of haploidentical donors have all made transplant a more accessible therapy for patients with ALL. Novel agents for conditioning, prevention and treatment of GvHD have improved outcomes and investigators continue to develop novel treatment strategies that balance regimen related toxicity with disease control. Our evolving understanding of how to prevent and treat GvHD and how to prevent relapse are incorporated into novel clinical trials that are expected to further improve outcomes. Here we review current considerations and future directions for both adult and pediatric patients undergoing HCT for ALL, including indication for transplant, donor selection, cytoreductive regimens, and outcomes.
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Affiliation(s)
- Susan Prockop
- Pediatric Stem Cell Transplant Program, DFCI/BCH Center for Cancer and Blood Disorders, Pediatrics, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, United States.
| | - Franziska Wachter
- Pediatric Stem Cell Transplant Program, DFCI/BCH Center for Cancer and Blood Disorders, Pediatrics, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, United States.
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Modi D, Alkassis S, Kim S, Kin A, Deol A, Ayash L, Ratanatharathorn V, Uberti JP. Allogeneic stem cell transplant outcomes between TBI-containing reduced intensity and myeloablative conditioning regimens for ALL in complete remission. Leuk Lymphoma 2023; 64:1285-1294. [PMID: 37154379 DOI: 10.1080/10428194.2023.2206181] [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: 11/28/2022] [Revised: 04/11/2023] [Accepted: 04/14/2023] [Indexed: 05/10/2023]
Abstract
Total-body irradiation (TBI)-based conditioning regimen is preferred in acute lymphoblastic leukemia (ALL). We retrospectively evaluated allogeneic stem cell transplant (alloSCT) outcomes of 86 adult ALL patients in complete remission (CR) who received TBI-containing reduced intensity (RIC) (Flu/Mel/TBI = 31) and myeloablative conditioning (MAC) (VP16/TBI = 47; CY/TBI = 8) between January 2005 and December 2019. All patients received peripheral blood allografts. Patients in the RIC group were older than the MAC group (61 years old versus 36 years, p < .001). Donor was 8/8 HLA-matched in 83% and unrelated in 65% of patients. Three-year survival was 56.04% for RIC and 69.9% for MAC (HR 0.64; p = .19). Propensity score-based multivariable Cox analyses (PSCA) did not demonstrate any difference in grade III-IV acute graft versus host disease (GVHD) (SHR 1.23, p = .91), chronic GVHD (SHR 0.92, p = .88), survival (HR 0.94, p = .92), and relapse-free survival (HR 0.66, p = .47) between both groups, while relapse rate was lower (SHR 0.21, p = .02) for MAC compared to RIC. Our study did not demonstrate any difference in survival for TBI-containing RIC and MAC alloSCT for adult ALL in CR.
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Affiliation(s)
- Dipenkumar Modi
- Department of Oncology, Barbara Ann Karmanos Cancer Institute, Wayne State University, Detroit, MI, USA
| | - Samer Alkassis
- Department of Oncology, Barbara Ann Karmanos Cancer Institute, Wayne State University, Detroit, MI, USA
| | - Seongho Kim
- Biostatistics Core, Barbara Ann Karmanos Cancer Institute, Department of Oncology, Wayne State University, Detroit, MI, USA
| | - Andrew Kin
- Department of Oncology, Barbara Ann Karmanos Cancer Institute, Wayne State University, Detroit, MI, USA
| | - Abhinav Deol
- Department of Oncology, Barbara Ann Karmanos Cancer Institute, Wayne State University, Detroit, MI, USA
| | - Lois Ayash
- Department of Oncology, Barbara Ann Karmanos Cancer Institute, Wayne State University, Detroit, MI, USA
| | - Voravit Ratanatharathorn
- Department of Oncology, Barbara Ann Karmanos Cancer Institute, Wayne State University, Detroit, MI, USA
| | - Joseph P Uberti
- Department of Oncology, Blood & Marrow Stem Cell Transplant Program, Barbara Ann Karmanos Cancer Institute, Wayne State University, Detroit, MI, USA
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Yoon JH, Kim HS, Min GJ, Park SS, Park S, Lee SE, Cho BS, Eom KS, Kim YJ, Kim HJ, Min CK, Cho SG, Lee JW, Kim M, Kim Y, Lee S. Cytogenetic and molecular characteristics and outcomes of adult patients with early T-cell precursor acute lymphoblastic leukemia. Eur J Haematol 2023; 110:137-148. [PMID: 36217591 DOI: 10.1111/ejh.13883] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 10/04/2022] [Accepted: 10/06/2022] [Indexed: 01/19/2023]
Abstract
Early T-cell precursor acute lymphoblastic leukemia (ETP-ALL) is a recently identified high-risk subgroup of T-cell ALL in children. However, there have been conflicting reports and limited data have been reported in adult patients. We retrospectively analyzed the cytogenetic and molecular characteristics and long-term survival outcomes of adult patients with ETP-ALL versus non-ETP-ALL. We analyzed 58 patients (median age, 35 years [range, 18-76 years]) with newly diagnosed T-cell ALL who received a uniform remission induction and consolidation chemotherapy with suitable samples for genetic analyses. If a donor was available, all patients were recommended allogeneic hematopoietic cell transplantation (allo-HCT) for post-remission therapy. Out of 58 patients, 21 (36.2%) had ETP-ALL. Patients with ETP-ALL were older and had a higher proportion of complex karyotype than non-ETP-ALL. Additionally, more DNMT3A mutations were detected in ETP-ALL, whereas FBXW7 mutations and CDKN2A/CDKN2B deletions were found nearly exclusively in non-ETP-ALL. The overall complete remission (CR) rates were not different between ETP-ALL (95.2%) and non-ETP-ALL (81.1%) and subsequent allo-HCT proceeding rates in CR1 were 61.9% for ETP-ALL and 43.2% for non-ETP-ALL, respectively. The overall prognosis of patients with T-ALL was poor that estimated 5-year overall survival (OS) was 33.3% for ETP-ALL and 29.5% for non-ETP-ALL. In a subgroup analysis of patients treated with allo-HCT in CR1 (n = 29), 5-year OS was 53.8% for ETP-ALL and 55.4% for non-ETP-ALL. Our data showed molecular characteristics of ETP-ALL and non-ETP-ALL and revealed that intensive chemotherapy followed by allo-HCT for post-remission therapy can contribute to preserved survival outcome of adult patients with ETP-ALL.
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Affiliation(s)
- Jae-Ho Yoon
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hoon Seok Kim
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Gi June Min
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sung-Soo Park
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Silvia Park
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sung-Eun Lee
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Byung-Sik Cho
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ki-Seong Eom
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yoo-Jin Kim
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hee-Je Kim
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chang-Ki Min
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seok-Goo Cho
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jong Wook Lee
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Myungshin Kim
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yonggoo Kim
- Department of Laboratory Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seok Lee
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Yoon JH, Kwag D, Lee JH, Min GJ, Park SS, Park S, Lee SE, Cho BS, Eom KS, Kim YJ, Kim HJ, Min CK, Cho SG, Wook Lee J, Lee S. Superior survival outcome of blinatumomab compared with conventional chemotherapy for adult patients with relapsed or refractory B-cell precursor acute lymphoblastic leukemia: a propensity score-matched cohort analysis. Ther Adv Hematol 2023; 14:20406207231154713. [PMID: 36895914 PMCID: PMC9989437 DOI: 10.1177/20406207231154713] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 01/17/2023] [Indexed: 03/08/2023] Open
Abstract
Background Blinatumomab showed a higher complete remission (CR) rate and a safe bridging to allogeneic hematopoietic cell transplantation (allo-HCT) in adults with relapsed or refractory B-cell precursor acute lymphoblastic leukemia (R/R BCP-ALL). Objectives We tried to analyze the outcome of blinatumomab compared with the real-world historical data. We expected superior outcome of blinatumomab compared with historical conventional chemotherapy. Design We conducted a retrospective study using real-world data in the Catholic Hematology Hospital. Methods Total 197 consecutive cases of R/R BCP-ALL were treated with conventional chemotherapy (n = 113) or blinatumomab, which was available since late 2016 (n = 84). Patients who achieved CR underwent allo-HCT if donor was available. We conducted a propensity score-matched cohort analysis using 5 criteria of age, CR duration, cytogenetics, previous allo-HCT, and salvage lines between historical group and blinatumomab. Results Each cohort consisted of 52 patients. In blinatumomab group, CR rate was higher (80.8% versus 53.8%, p = 0.006) and more patients proceeded to allo-HCT (80.8% versus 46.2%, p < 0.001). Among the CR patients with available minimal residual disease (MRD) results, 68.6% in blinatumomab group and 40.0% in conventional chemotherapy group were MRD-negative. Regimen-related mortality during the chemotherapy cycles was significantly higher in the conventional chemotherapy group (40.4% versus 1.9%, p < 0.001). Estimated 3-year overall survival (OS) was 33.2% (median, 26.3 months) after blinatumomab, and 15.4% (median, 8.2 months) after conventional chemotherapy (p < 0.001). Estimated 3-year non-relapse mortality were 30.3% and 51.9% (p = 0.004), respectively. In multivariate analysis, CR duration < 12 months showed more relapses and poor OS, and conventional chemotherapy showed higher non-relapse mortality and poor OS. Conclusions Matched cohort analysis showed superior outcomes of blinatumomab compared with conventional chemotherapy. However, large numbers of relapses and non-relapse mortalities continue to occur even after blinatumomab followed by allo-HCT. Novel therapeutic strategies are still needed for R/R BCP-ALL.
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Affiliation(s)
- Jae-Ho Yoon
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Daehun Kwag
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jong-Hyuk Lee
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Gi June Min
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sung-Soo Park
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Silvia Park
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sung-Eun Lee
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Byung-Sik Cho
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ki-Seong Eom
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yoo-Jin Kim
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hee-Je Kim
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chang-Ki Min
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seok-Goo Cho
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jong Wook Lee
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Seok Lee
- Department of Hematology, Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222, Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea
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Saraceni F, Scortechini I, Fiorentini A, Dubbini MV, Mancini G, Federici I, Colaneri FR, Lotito AF, Guerzoni S, Puglisi B, Olivieri A. Conditioning Regimens for Frail Patients with Acute Leukemia Undergoing Allogeneic Stem Cell Transplant: How to Strike Gently. Clin Hematol Int 2021; 3:153-160. [PMID: 34938987 PMCID: PMC8690700 DOI: 10.2991/chi.k.210731.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 07/25/2021] [Indexed: 01/06/2023] Open
Abstract
Despite the recent dramatic progress in acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL) therapy, allogeneic transplant remains a mainstay of treatment for patients with acute leukemia. The availability of novel compounds and low intensity chemotherapy regimens made it possible for a significant proportion of elderly and comorbid patients with AML or ALL to undergo curative treatment protocols. In addition, the expansion of donor availability and the recent dramatic progress in haploidentical stem cell transplant, allow the identification of an available donor for nearly every patient. Therefore, an increasing number of transplants are currently performed in elderly and frail patients with AML or ALL. However, allo-Hematopoietic stem cell transplant (HSCT) in this delicate setting represents an important challenge, especially regarding the selection of the conditioning protocol. Ideally, conditioning intensity should be reduced as much as possible; however, in patients with acute leukemia relapse remains the major cause of transplant failure. In this article we present modern tools to assess the patient health status before transplant, review the available data on the outcome of frail AML an ALL patients undergoing allo-HSCT, and discuss how preparatory regimens can be optimized in this setting.
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Affiliation(s)
- Francesco Saraceni
- Hematology and Stem Cell Transplant, Ospedali Riuniti Ancona, Via Conca 71, Ancona, Italy
| | - Ilaria Scortechini
- Hematology and Stem Cell Transplant, Ospedali Riuniti Ancona, Via Conca 71, Ancona, Italy
| | - Alessandro Fiorentini
- Hematology and Stem Cell Transplant, Ospedali Riuniti Ancona, Via Conca 71, Ancona, Italy
| | - Maria Vittoria Dubbini
- Hematology and Stem Cell Transplant, Ospedali Riuniti Ancona, Via Conca 71, Ancona, Italy
| | - Giorgia Mancini
- Hematology and Stem Cell Transplant, Ospedali Riuniti Ancona, Via Conca 71, Ancona, Italy
| | - Irene Federici
- Hematology and Stem Cell Transplant, Ospedali Riuniti Ancona, Via Conca 71, Ancona, Italy
| | | | | | - Selene Guerzoni
- Hematology and Stem Cell Transplant, Ospedali Riuniti Ancona, Via Conca 71, Ancona, Italy
| | - Bruna Puglisi
- Hematology and Stem Cell Transplant, Ospedali Riuniti Ancona, Via Conca 71, Ancona, Italy
| | - Attilio Olivieri
- Hematology and Stem Cell Transplant, Ospedali Riuniti Ancona, Via Conca 71, Ancona, Italy
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Cao LQ, Zhou Y, Liu YR, Xu LP, Zhang XH, Wang Y, Chen H, Chen YH, Wang FR, Han W, Sun YQ, Yan CH, Tang FF, Mo XD, Liu KY, Fan QZ, Chang YJ, Huang XJ. A risk score system for stratifying the risk of relapse in B cell acute lymphocytic leukemia patients after allogenic stem cell transplantation. Chin Med J (Engl) 2021; 134:1199-1208. [PMID: 33734137 PMCID: PMC8143760 DOI: 10.1097/cm9.0000000000001402] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND For patients with B cell acute lymphocytic leukemia (B-ALL) who underwent allogeneic stem cell transplantation (allo-SCT), many variables have been demonstrated to be associated with leukemia relapse. In this study, we attempted to establish a risk score system to predict transplant outcomes more precisely in patients with B-ALL after allo-SCT. METHODS A total of 477 patients with B-ALL who underwent allo-SCT at Peking University People's Hospital from December 2010 to December 2015 were enrolled in this retrospective study. We aimed to evaluate the factors associated with transplant outcomes after allo-SCT, and establish a risk score to identify patients with different probabilities of relapse. The univariate and multivariate analyses were performed with the Cox proportional hazards model with time-dependent variables. RESULTS All patients achieved neutrophil engraftment, and 95.4% of patients achieved platelet engraftment. The 5-year cumulative incidence of relapse (CIR), overall survival (OS), leukemia-free survival (LFS), and non-relapse mortality were 20.7%, 70.4%, 65.6%, and 13.9%, respectively. Multivariate analysis showed that patients with positive post-transplantation minimal residual disease (MRD), transplanted beyond the first complete remission (≥CR2), and without chronic graft-versus-host disease (cGVHD) had higher CIR (P < 0.001, P = 0.004, and P < 0.001, respectively) and worse LFS (P < 0.001, P = 0.017, and P < 0.001, respectively), and OS (P < 0.001, P = 0.009, and P < 0.001, respectively) than patients without MRD after transplantation, transplanted in CR1, and with cGVHD. A risk score for predicting relapse was formulated with the three above variables. The 5-year relapse rates were 6.3%, 16.6%, 55.9%, and 81.8% for patients with scores of 0, 1, 2, and 3 (P < 0.001), respectively, while the 5-year LFS and OS values decreased with increasing risk score. CONCLUSION This new risk score system might stratify patients with different risks of relapse, which could guide treatment.
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Affiliation(s)
- Le-Qing Cao
- Peking University People's Hospital & Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Yang Zhou
- Peking University People's Hospital & Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Yan-Rong Liu
- Peking University People's Hospital & Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Lan-Ping Xu
- Peking University People's Hospital & Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Xiao-Hui Zhang
- Peking University People's Hospital & Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Yu Wang
- Peking University People's Hospital & Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Huan Chen
- Peking University People's Hospital & Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Yu-Hong Chen
- Peking University People's Hospital & Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Feng-Rong Wang
- Peking University People's Hospital & Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Wei Han
- Peking University People's Hospital & Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Yu-Qian Sun
- Peking University People's Hospital & Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Chen-Hua Yan
- Peking University People's Hospital & Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Fei-Fei Tang
- Peking University People's Hospital & Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Xiao-Dong Mo
- Peking University People's Hospital & Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Kai-Yan Liu
- Peking University People's Hospital & Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Qiao-Zhen Fan
- Peking University People's Hospital & Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Ying-Jun Chang
- Peking University People's Hospital & Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Xiao-Jun Huang
- Peking University People's Hospital & Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
- Peking-Tsinghua Center for Life Sciences, Peking University, Beijing 100871, China
- Research Unit of Key Technique for Diagnosis and Treatments of Hematologic Malignancies, Chinese Academy of Medical Sciences, 2019RU029, Beijing, China
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Peric Z, Labopin M, Peczynski C, Polge E, Cornelissen J, Carpenter B, Potter M, Malladi R, Byrne J, Schouten H, Fegueux N, Socié G, Rovira M, Kuball J, Gilleece M, Giebel S, Nagler A, Mohty M. Comparison of reduced-intensity conditioning regimens in patients with acute lymphoblastic leukemia >45 years undergoing allogeneic stem cell transplantation—a retrospective study by the Acute Leukemia Working Party of EBMT. Bone Marrow Transplant 2020; 55:1560-1569. [DOI: 10.1038/s41409-020-0878-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 03/14/2020] [Accepted: 03/18/2020] [Indexed: 01/08/2023]
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9
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Yahng SA, Min GJ, Park SS, Park S, Jeon YW, Yoon JH, Shin SH, Lee SE, Cho BS, Eom KS, Lee S, Min CK, Kim HJ, Lee JW, Kim YJ. Role of pretransplant anti-thymocyte globulin in matched sibling donor stem cell transplantation after reduced intensity conditioning for myelodysplastic syndrome. Eur J Haematol 2020; 104:459-468. [PMID: 31957068 DOI: 10.1111/ejh.13386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 01/13/2020] [Accepted: 01/14/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We investigated the role of anti-thymocyte globulin (ATG; Thymoglobulin) in matched sibling donor hematopoietic stem cell transplantation (MSD-HSCT) after reduced intensity conditioning (RIC) in myelodysplastic syndrome (MDS). METHODS Forty-seven patients with 10 mg/kg ATG (ATG group; median age 53 years) and 33 without ATG (no-ATG group; median age 43, P < .0001) were compared. RESULTS Median time to engraftment was similar. Two-year cumulative incidence of moderate-to-severe chronic graft-versus-host disease (GVHD) was significantly lower in the ATG group (15% vs 55%, P < .0001), while that of acute GVHD was similar compared with the no-ATG group. After a median follow-up of 60 months (range, 14-184), the 3-year cumulative incidences of non-relapse mortality and relapse were 9% and 21% for ATG group and 15% and 19% for no-ATG group (P = .408 and P = .717), respectively, leading to a significantly better 3-year GVHD-free and relapse-free survival (GRFS) in the ATG group (55% vs 19%, P = .006): The 3-year overall and disease-free survival were similar. Infectious complication occurred with similar frequencies in both groups. CONCLUSION These findings suggest that ATG can be safely used to decrease moderate-to-severe chronic GVHD with improved GRFS for patients with MDS receiving MSD-HSCT in RIC setting.
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Affiliation(s)
- Seung-Ah Yahng
- Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Gi-June Min
- Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung-Soo Park
- Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Silvia Park
- Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young-Woo Jeon
- Yeoido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae-Ho Yoon
- Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seung-Hwan Shin
- Eunpyung St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung-Eun Lee
- Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Byung-Sik Cho
- Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ki-Seong Eom
- Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seok Lee
- Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chang-Ki Min
- Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hee-Je Kim
- Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jong-Wook Lee
- Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yoo-Jin Kim
- Catholic Hematology Hospital and Leukemia Research Institute, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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10
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Experience of blinatumomab salvage for patients with acute lymphoblastic leukemia presenting with isolated extramedullary relapse after previous allogeneic hematopoietic cell transplantation. Bone Marrow Transplant 2019; 55:1469-1472. [DOI: 10.1038/s41409-019-0708-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 08/03/2019] [Indexed: 11/08/2022]
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11
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Perspectives on the Use of a Medium-Dose Etoposide, Cyclophosphamide, and Total Body Irradiation Conditioning Regimen in Allogeneic Hematopoietic Stem Cell Transplantation: The Japanese Experience from 1993 to Present. J Clin Med 2019; 8:jcm8050569. [PMID: 31027384 PMCID: PMC6572563 DOI: 10.3390/jcm8050569] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 04/18/2019] [Accepted: 04/24/2019] [Indexed: 02/07/2023] Open
Abstract
The outcome for adults with acute lymphoblastic leukemia (ALL) treated with chemotherapy or autologous hematopoietic stem cell transplantation (HSCT) is poor. Therefore, allogeneic HSCT (allo HSCT) for adults aged less than 50 years with ALL is performed with myeloablative conditioning (MAC) regimens. Among the several MAC regimens, a conditioning regimen of 120 mg/kg (60mg/kg for two days) cyclophosphamide (CY) and 12 gray fractionated (12 gray in six fractions for three days) total body irradiation (TBI) is commonly used, resulting in a long term survival rate of approximately 50% when transplanted at the first complete remission. The addition of 30 mg/kg (15 mg/kg for two days) etoposide (ETP) to the CY/TBI regimen revealed an excellent outcome (a long-term survival rate of approximately 80%) in adults with ALL, showing lower relapse and non-relapse mortality rates. It is preferable to perform allo HSCT with a medium-dose ETP/CY/TBI conditioning regimen at the first complete remission in high-risk ALL patients and at the second complete remission (in addition to the first complete remission) in standard-risk ALL patients. The ETP dose and administration schedule are important factors for reducing the relapse and non-relapse mortality rates, preserving a better outcome. The pharmacological study suggests that the prolonged administration of ETP at a reduced dose is a promising treatment.
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12
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Yoon JH, Min GJ, Park SS, Jeon YW, Lee SE, Cho BS, Eom KS, Kim YJ, Kim HJ, Min CK, Cho SG, Kim DW, Lee JW, Lee S. Minimal residual disease-based long-term efficacy of reduced-intensity conditioning versus myeloablative conditioning for adult Philadelphia-positive acute lymphoblastic leukemia. Cancer 2018; 125:873-883. [PMID: 30521062 DOI: 10.1002/cncr.31874] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 09/15/2018] [Accepted: 10/12/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND The sensitivity of Philadelphia chromosome (Ph)-positive acute lymphoblastic leukemia (ALL) to reduced-intensity conditioning (RIC) allogeneic hematopoietic cell transplantation (HCT) versus myeloablative conditioning (MAC) allogeneic HCT by minimal residual disease (MRD) kinetics is not well established. METHODS This study compared long-term outcomes based on MRD kinetics for 79 patients with RIC transplants and 116 patients with MAC transplants in first complete remission (CR1) after tyrosine kinase inhibitor-based chemotherapy (median follow-up, 67.1 months). MRD monitoring was centrally evaluated by real-time quantitative polymerase chain reaction for all patients. RESULTS RIC showed a cumulative incidence of relapse (CIR; 30.6% vs 31.7%), nonrelapse mortality (17.5% vs 14.9%), disease-free survival (DFS; 51.9% vs 53.4%), and overall survival (61.1% vs 61.4%) comparable to those associated with MAC. In all MRD kinetics-based subgroups, no differences in CIR (early complete molecular response [CMR], 19.3% vs 4.8%; early major molecular response [MMR], 17.0% vs 26.8%; late CMR, 20.0% vs 14.3%; late MMR, 28.3% vs 31.0%; poor molecular response [PMR], 57.9% vs 62.4%) or DFS (early CMR, 71.6% vs 76.2%; early MMR, 66.9% vs 52.1%; late CMR, 50.0% vs 64.3%; late MMR, 50.7% vs 53.7%; PMR, 31.6% vs 34.1%) were observed between RIC and MAC. In a multivariate analysis, the conditioning intensity had no significant impact on transplantation outcomes. CONCLUSIONS RIC is a valid alternative choice for long-term disease control and is worthy of further investigation in prospective trials for adult Ph-positive ALL in CR1.
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Affiliation(s)
- Jae-Ho Yoon
- Department of Hematology, Catholic Hematology Hospital, College of Medicine, Catholic University of Korea, Seoul, Korea.,Leukemia Research Institute, College of Medicine, Catholic University of Korea, Seoul, Korea
| | - Gi June Min
- Department of Hematology, Catholic Hematology Hospital, College of Medicine, Catholic University of Korea, Seoul, Korea
| | - Sung-Soo Park
- Department of Hematology, Catholic Hematology Hospital, College of Medicine, Catholic University of Korea, Seoul, Korea
| | - Young-Woo Jeon
- Department of Hematology, Catholic Hematology Hospital, College of Medicine, Catholic University of Korea, Seoul, Korea
| | - Sung-Eun Lee
- Department of Hematology, Catholic Hematology Hospital, College of Medicine, Catholic University of Korea, Seoul, Korea.,Leukemia Research Institute, College of Medicine, Catholic University of Korea, Seoul, Korea
| | - Byung-Sik Cho
- Department of Hematology, Catholic Hematology Hospital, College of Medicine, Catholic University of Korea, Seoul, Korea.,Leukemia Research Institute, College of Medicine, Catholic University of Korea, Seoul, Korea
| | - Ki-Seong Eom
- Department of Hematology, Catholic Hematology Hospital, College of Medicine, Catholic University of Korea, Seoul, Korea.,Leukemia Research Institute, College of Medicine, Catholic University of Korea, Seoul, Korea
| | - Yoo-Jin Kim
- Department of Hematology, Catholic Hematology Hospital, College of Medicine, Catholic University of Korea, Seoul, Korea.,Leukemia Research Institute, College of Medicine, Catholic University of Korea, Seoul, Korea
| | - Hee-Je Kim
- Department of Hematology, Catholic Hematology Hospital, College of Medicine, Catholic University of Korea, Seoul, Korea.,Leukemia Research Institute, College of Medicine, Catholic University of Korea, Seoul, Korea
| | - Chang-Ki Min
- Department of Hematology, Catholic Hematology Hospital, College of Medicine, Catholic University of Korea, Seoul, Korea.,Leukemia Research Institute, College of Medicine, Catholic University of Korea, Seoul, Korea
| | - Seok-Goo Cho
- Department of Hematology, Catholic Hematology Hospital, College of Medicine, Catholic University of Korea, Seoul, Korea.,Leukemia Research Institute, College of Medicine, Catholic University of Korea, Seoul, Korea
| | - Dong-Wook Kim
- Department of Hematology, Catholic Hematology Hospital, College of Medicine, Catholic University of Korea, Seoul, Korea.,Leukemia Research Institute, College of Medicine, Catholic University of Korea, Seoul, Korea
| | - Jong Wook Lee
- Department of Hematology, Catholic Hematology Hospital, College of Medicine, Catholic University of Korea, Seoul, Korea.,Leukemia Research Institute, College of Medicine, Catholic University of Korea, Seoul, Korea
| | - Seok Lee
- Department of Hematology, Catholic Hematology Hospital, College of Medicine, Catholic University of Korea, Seoul, Korea.,Leukemia Research Institute, College of Medicine, Catholic University of Korea, Seoul, Korea
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13
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Leonard JT, Hayes-Lattin B. Reduced Intensity Conditioning Allogeneic Hematopoietic Stem Cell Transplantation for Acute Lymphoblastic Leukemia; Current Evidence, and Improving Outcomes Going Forward. Curr Hematol Malig Rep 2018; 13:329-340. [PMID: 30008035 PMCID: PMC6097057 DOI: 10.1007/s11899-018-0462-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
PURPOSE OF REVIEW Outcomes for older adults with acute lymphoblastic leukemia (ALL) remain poor, and allogeneic hematopoietic stem cell transplant (HSCT) remains a potentially curative modality. However, benefits are offset by high rates of non-relapse mortality (NRM) in patients undergoing myeloablative conditioning (MAC) regimens. Reduced intensity conditioning (RIC) regimens can extend this therapy to adults who are unfit for MAC, although at the cost of higher relapse rates. In this review, we discuss evidence to support the usage of RIC regimens, controversies, and potential strategies to improve transplant outcomes going forward. RECENT FINDINGS Several novel therapies have recently been approved for the treatment of relapsed ALL and may play an important role in bridging adults with residual disease to RIC transplant. Assessing response to initial therapy via minimal residual disease (MRD) monitoring may determine which patients will derive the most benefit from allogeneic HSCT. Reduced intensity allogeneic HSCT remains a potentially curative therapy that can be offered to older adults however challenges remain. Going forward, MRD testing and novel therapies may help better select which patients should proceed to transplant and assist in getting those patients to transplant with optimally controlled disease.
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Affiliation(s)
- Jessica T Leonard
- Center for Hematologic Malignancies, Knight Cancer Institute, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Mail Code L586, Portland, OR, 97239, USA.
| | - Brandon Hayes-Lattin
- Center for Hematologic Malignancies, Knight Cancer Institute, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Mail Code L586, Portland, OR, 97239, USA
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14
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Roth-Guepin G, Canaani J, Ruggeri A, Labopin M, Finke J, Cornelissen JJ, Delage J, Stuhler G, Rovira M, Potter M, Stadler M, Veelken H, Cahn JY, Collin M, Beguin Y, Giebel S, Nagler A, Mohty M. Allogeneic stem cell transplantation in acute lymphoblastic leukemia patients older than 60 years: a survey from the acute leukemia working party of EBMT. Oncotarget 2017; 8:112972-112979. [PMID: 29348881 PMCID: PMC5762566 DOI: 10.18632/oncotarget.22934] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 11/05/2017] [Indexed: 01/13/2023] Open
Abstract
Hematopoietic stem cell transplantation (HSCT) is being increasingly explored as a treatment modality for older patients with acute lymphoblastic leukemia (ALL). Yet, concerns regarding the long term outcome of transplantation in older patients limit the wide spread applicability of this approach. In this analysis we set out to determine the outcome of ALL patients over the age of 60 who underwent reduced intensity HSCT. Herein, we present the experience of the acute leukemia working party (ALWP) of the EBMT in this age group. We analyzed a cohort of 142 patients transplanted in first remission with a median age of 62 (range 60–76 years) and a median follow-up period of 36 months post-transplant. At 3 years, overall survival (OS) and leukemia-free survival were 42% and 35%, respectively. Multivariate analyses identified cytomegalovirus (CMV) donor-recipient matching (CMV D+/R+) to be significantly associated with inferior OS. Patients transplanted from unrelated donors experienced increased grade II-IV acute graft versus host disease compared to those receiving grafts from matched related donors [Hazard ratio (HR) of 3.7, 95% confidence interval (CI), 1.75–7.8; p = 0.0005). Outcome was not impacted by Philadelphia chromosome status. A select subset of older ALL patients will benefit from extended survival and a disease free state following HSCT.
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Affiliation(s)
| | - Jonathan Canaani
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel-Aviv, Israel
| | - Annalisa Ruggeri
- Acute Leukemia Working Party-EBMT and Department of Hematology and Cell Therapy, HÔpital Saint-Antoine, Paris, France
| | - Myriam Labopin
- Acute Leukemia Working Party-EBMT and Department of Hematology and Cell Therapy, HÔpital Saint-Antoine, Paris, France.,INSERM UMR 938, Paris, France.,Université Pierre et Marie Curie, Paris, France
| | - Juergen Finke
- Department of Hematology and Oncology, University Medical Center Freiburg, Freiburg, Germany
| | - Jan J Cornelissen
- Erasmus MC Cancer Institute, University Medical Center Rotterdam, Department of Hematology, Rotterdam, The Netherlands
| | - Jeremy Delage
- Service d'Hématologie et d'Oncologie, Hospital Lapeyronie CHU , University Montpellier, Montpellier, France
| | - Gernot Stuhler
- Deutsche Klinik für Diagnostik, KMT Zentrum, Wiesbaden, Germany
| | - Monserrat Rovira
- Hospital Clinic Barcelona, Institute of Hematology and Oncology, Department of Hematology, Barcelona, Spain
| | - Mike Potter
- Institute of Hematology and Oncology, Department of Hematology, London, UK
| | - Michael Stadler
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover, Medical School, Hannover, Germany
| | - Hendrik Veelken
- Department of Hematology, Leiden University Medical Center, Leiden, Netherlands
| | - Jean Yves Cahn
- Department of Hematology, University Hospital, Grenoble, France
| | - Matthew Collin
- Newcastle University, Adult HSCT unit, Northern Centre for Bone Marrow Transplantation, Freeman Hospital, Newcastle upon Tyne, UK
| | - Yves Beguin
- University of Liege, Department of Hematology, CHU of Liège, Liège, Belgium
| | - Sebastian Giebel
- Department of Bone Marrow Transplantation and Oncohematology, Maria Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice, Poland
| | - Arnon Nagler
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel-Aviv, Israel.,Acute Leukemia Working Party-EBMT and Department of Hematology and Cell Therapy, HÔpital Saint-Antoine, Paris, France
| | - Mohamad Mohty
- Acute Leukemia Working Party-EBMT and Department of Hematology and Cell Therapy, HÔpital Saint-Antoine, Paris, France.,INSERM UMR 938, Paris, France.,Université Pierre et Marie Curie, Paris, France
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15
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Byrne M, Savani BN, Mohty M, Nagler A. Peripheral blood stem cell versus bone marrow transplantation: A perspective from the Acute Leukemia Working Party of the European Society for Blood and Marrow Transplantation. Exp Hematol 2016; 44:567-73. [DOI: 10.1016/j.exphem.2016.04.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Accepted: 04/05/2016] [Indexed: 12/31/2022]
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16
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Kim DY, Park HS, Choi EJ, Lee JH, Lee JH, Jeon M, Kang YA, Lee YS, Seol M, Cho YU, Jang S, Chi HS, Lee KH, Park CJ. Immunophenotypic markers in adult acute lymphoblastic leukemia: the prognostic significance of CD20 and TdT expression. Blood Res 2015; 50:227-34. [PMID: 26770950 PMCID: PMC4705048 DOI: 10.5045/br.2015.50.4.227] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 11/19/2015] [Accepted: 11/25/2015] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Efforts to overcome poor outcomes in patients with adult acute lymphoblastic leukemia (ALL) have focused on combining new therapeutic agents targeting immunophenotypic markers (IPMs) with classical cytotoxic agents; therefore, it is important to evaluate the clinical significance of IPMs. METHODS Baseline characteristics and clinical outcomes of patients with adult ALL were retrospectively analyzed. The percentage of blasts expressing IPMs at diagnosis was measured by multicolor flow cytometry analysis. Samples in which ≥20% of blasts expressed an IPM were considered positive. RESULTS Among the total patient population (N=230), almost all (92%) were in first or second hematological complete remission (HCR) and 54% received allogeneic hematopoietic cell transplant (allo-HCT). Five-year hematologic relapse-free survival (HRFS) and overall survival (OS) rates were 36% and 39%, respectively, and 45.6% and 80.5% of patients were positive for the IPMs CD20 and terminal deoxynucleotidyl transferase (TdT), respectively. Expression of CD20, CD13, CD34, and TdT was associated with HRFS rate, and expression of CD20 and CD13 was associated with OS rate, as was the performance of allo-HCT. In multivariate analysis, positivity for CD20 (HRFS: hazard ratio [HR], 2.21, P<0.001; OS: HR, 1.63, P=0.015) and negativity for TdT (HRFS: HR, 2.30, P=0.001) were both significantly associated with outcomes. When patients were categorized into three subgroups according to positivity for CD20 and TdT, there were significant differences in HRFS and OS among the subgroups. CONCLUSION Positivity for CD20 and TdT expression and clinical risk group were prognostic factors in adult ALL.
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Affiliation(s)
- Dae-Young Kim
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Han-Seung Park
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun-Ji Choi
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung-Hee Lee
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Je-Hwan Lee
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Mijin Jeon
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young-Ah Kang
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young-Shin Lee
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Miee Seol
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young-Uk Cho
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seongsoo Jang
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyun-Sook Chi
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyoo-Hyung Lee
- Department of Hematology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chan-Jeoung Park
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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17
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Pingali SR, Champlin RE. Pushing the envelope-nonmyeloablative and reduced intensity preparative regimens for allogeneic hematopoietic transplantation. Bone Marrow Transplant 2015; 50:1157-67. [PMID: 25985053 PMCID: PMC4809137 DOI: 10.1038/bmt.2015.61] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Accepted: 11/17/2014] [Indexed: 12/30/2022]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) was originally developed to allow delivery of myeloablative doses of chemotherapy and radiotherapy. With better understanding of disease pathophysiology, the graft vs malignancy (GVM) effect of allogeneic hematopoietic transplantation and toxicities associated with myeloablative conditioning (MAC) regimens, the focus shifted to developing less toxic conditioning regimens to reduce treatment-related morbidity without compromising survival. Although HCT with MAC is preferred to reduced intensity conditioning (RIC) for most patients ⩽60 years with AML/myelodysplastic syndrome and ALL, RIC and nonmyeloablative (NMA) regimens allow HCT for many otherwise ineligible patients. Reduced intensity preparative regimens have produced high rates of PFS for diagnoses, which are highly sensitive to GVM. Relapse of the malignancy is the major cause of treatment failure with RIC/NMA HCT. Incorporation of novel agents like bortezomib or lenalidomide, addition of cellular immunotherapy and use of targeted radiation therapies could further improve outcome. In this review, we discuss commonly used RIC/NMA regimens and promising novel regimens.
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Affiliation(s)
- S R Pingali
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - R E Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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18
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Imamura M, Shigematsu A. Allogeneic hematopoietic stem cell transplantation in adult acute lymphoblastic leukemia: potential benefit of medium-dose etoposide conditioning. Exp Hematol Oncol 2015; 4:20. [PMID: 26322249 PMCID: PMC4552453 DOI: 10.1186/s40164-015-0015-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 07/07/2015] [Indexed: 12/03/2022] Open
Abstract
The outcomes of adult acute lymphoblastic leukemia (ALL) patients with chemotherapy or autologous hematopoietic stem cell transplantation (HSCT) are unsatisfactory. Therefore, allogeneic (allo) HSCT has been applied to those patients in first complete remission (CR1), and has shown a long-term survival rate of approximately 50 %. In terms of myeloablative conditioning (MAC) regimen, higher dose of cyclophosphamide (CY) and total body irradiation (TBI) (the standard CY + TBI) has been generally applied to allo HSCT. Other MAC regimens such as busulfan-based or etoposide-based regimens have also been used. Among those, medium-dose etoposide (ETP) in addition to the standard CY + TBI conditioning regimen appears to be promising for allo HSCT in adult ALL when transplanted in ALL patients aged under 50 years in CR1 and also in CR2, showing an excellent outcome without increasing relapse or transplant-related mortality (TRM) rates. By contrast, reduced-intensity conditioning (RIC) regimens have also been applied to adult ALL patients and favorable outcomes have been obtained; however, relapse and TRM rates remain high. Therefore, an allo HSCT conditioning regimen which deserves further study for adult ALL patients aged under 50 years in CR1 and CR2 appears to be medium-dose ETP + CY + TBI and RIC is suitable for patients aged over 50 years or for younger patients with comorbid conditions. On the contrary, new therapeutic strategies for adult ALL patients are increasingly utilized with better outcomes; namely, various tyrosine kinase inhibitors for Philadelphia chromosome (Ph)-positive ALL, human leukocyte antigen-haploidentical HSCT, and pediatric-inspired regimens for Ph-negative ALL. Therefore, the optimal treatment modality should be selected considering patient’s age, Ph-positivity, donor availability, risk classification, efficacy, and safety.
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Affiliation(s)
- Masahiro Imamura
- Department of Hematology, Sapporo Hokuyu Hospital, Higashi-Sapporo 6-6-5-1, 003-0006 Shiroishi-ku, Sapporo Japan
| | - Akio Shigematsu
- Department of Hematology, Sapporo Hokuyu Hospital, Higashi-Sapporo 6-6-5-1, 003-0006 Shiroishi-ku, Sapporo Japan
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19
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Impact of IKZF1 deletions on long-term outcomes of allo-SCT following imatinib-based chemotherapy in adult Philadelphia chromosome-positive ALL. Bone Marrow Transplant 2014; 50:354-62. [DOI: 10.1038/bmt.2014.281] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 10/29/2014] [Accepted: 11/03/2014] [Indexed: 11/08/2022]
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20
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Role of allogeneic hematopoietic stem cell transplantation in adult patients with acute lymphoblastic leukemia. Mediterr J Hematol Infect Dis 2014; 6:e2014065. [PMID: 25408851 PMCID: PMC4235484 DOI: 10.4084/mjhid.2014.065] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 09/11/2014] [Indexed: 12/15/2022] Open
Abstract
Adult acute lymphoblastic leukemia (ALL) is a heterogeneous disease, due to the expression of different biological and clinical risk factors, for which allogeneic stem cell transplantation (alloHSCT) is an effective consolidation therapy. The non-relapse mortality of alloHSCT remains significantly higher compared with that of conventional chemotherapy. Therefore, one of the main challenges in the care of ALL is to establish a more precise prognostic definition to select patients who could take advantage from an alloHSCT. Currently, the use of minimal residual disease following induction and early consolidation therapy has improved the prognostic accuracy in defining ALL risk class. In Philadelphia-positive ALL, the introduction of tyrosine kinase inhibitors pre and post alloHSCT appears to improve outcomes significantly and, in the absence of specially designed clinical trials, alloHSCT remains the most effective post-remission therapy. Nowadays, alloHSCT can be performed according to various modalities encompassing the use of different conditioning regimens, as well as distinct donors and stem cell source, with a significant accessibility to transplant.
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Chevallier P, Labopin M, Socié G, Tabrizi R, Furst S, Lioure B, Guillaume T, Delaunay J, de La Tour RP, Vigouroux S, El-Cheikh J, Blaise D, Michallet M, Bilger K, Milpied N, Moreau P, Mohty M. Results from a clofarabine-busulfan-containing, reduced-toxicity conditioning regimen prior to allogeneic stem cell transplantation: the phase 2 prospective CLORIC trial. Haematologica 2014; 99:1486-91. [PMID: 24951467 PMCID: PMC4562538 DOI: 10.3324/haematol.2014.108563] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 06/16/2014] [Indexed: 01/30/2023] Open
Abstract
We prospectively evaluated the safety and efficacy of a clofarabine, intravenous busulfan and antithymocyte globulin-based reduced-toxicity conditioning (CloB2A2) regimen before allogeneic stem cell transplantation. Thirty high-risk patients (median age: 59 years; acute myeloid leukemia n=11, acute lymphoblastic leukemia n=13; myelodysplastic syndrome n=5, bi-phenotypic leukemia n=1) were included in this phase 2 study. At time of their transplant, 20 and seven patients were in first and second complete remission, respectively, while three patients with myelodysplastic syndrome were responding to chemotherapy or who had not been previously treated. The CloB2A2 regimen consisted of clofarabine 30 mg/m(2)/day for 4 days, busulfan 3.2 mg/kg/day for 2 days and antithymocyte globulin 2.5 mg/kg/day for 2 days. The median follow-up was 23 months. Engraftment occurred in all patients. The 1-year overall survival, leukemia-free survival, relapse incidence and non-relapse mortality rates were 63±9%, 57±9%, 40±9%, and 3.3±3%, respectively. Comparing patients with acute myeloid leukemia/myelodysplastic syndrome versus those with acute lymphoblastic leukemia/bi-phenotypic leukemia, the 1-year overall and leukemia-free survival rates were 75±10% versus 50±13%, respectively (P=0.07) and 69±12% versus 43±13%, respectively (P=0.08), while the 1-year relapse incidence was 25±11% versus 57±14%, respectively (P=0.05). The CloB2A2 regimen prior to allogeneic stem cell transplantation is feasible, allowing for full engraftment and low toxicity. Disease control appears to be satisfactory, especially in patients with acute myeloid leukemia/myelodysplastic syndrome. The trial was registered at www.clinicaltrials.gov no. NCT00863148.
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MESH Headings
- Adenine Nucleotides/therapeutic use
- Adult
- Aged
- Antilymphocyte Serum/therapeutic use
- Arabinonucleosides/therapeutic use
- Busulfan/therapeutic use
- Clofarabine
- Drug Administration Schedule
- Female
- Graft Survival/immunology
- Hematopoietic Stem Cell Transplantation
- Humans
- Leukemia, Biphenotypic, Acute/immunology
- Leukemia, Biphenotypic, Acute/mortality
- Leukemia, Biphenotypic, Acute/pathology
- Leukemia, Biphenotypic, Acute/therapy
- Leukemia, Myeloid, Acute/immunology
- Leukemia, Myeloid, Acute/mortality
- Leukemia, Myeloid, Acute/pathology
- Leukemia, Myeloid, Acute/therapy
- Male
- Middle Aged
- Myeloablative Agonists/therapeutic use
- Myelodysplastic Syndromes/immunology
- Myelodysplastic Syndromes/mortality
- Myelodysplastic Syndromes/pathology
- Myelodysplastic Syndromes/therapy
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/immunology
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/mortality
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/pathology
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/therapy
- Recurrence
- Survival Analysis
- Transplantation Conditioning/methods
- Transplantation, Homologous
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Affiliation(s)
| | - Myriam Labopin
- Université Pierre & Marie Curie, Paris INSERM, UMRs 938, Paris Hôpital Saint-Antoine, AP-HP, Paris
| | - Gérard Socié
- Hematology Department, Hopital Saint-Louis, Paris
| | | | - Sabine Furst
- Hematology Department, Institut Paoli-Calmette, Marseille
| | | | | | | | | | | | - Jean El-Cheikh
- Hematology Department, Institut Paoli-Calmette, Marseille
| | - Didier Blaise
- Hematology Department, Institut Paoli-Calmette, Marseille
| | | | | | | | | | - Mohamad Mohty
- Hematology Department, CHU Hotel-Dieu, Nantes Université Pierre & Marie Curie, Paris INSERM, UMRs 938, Paris Hôpital Saint-Antoine, AP-HP, Paris
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22
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Hwang YY, Mohty M, Chim CS. Allogeneic hematopoietic stem cell transplantation in Philadelphia-negative adult ALL: Myeloablative, non-myeloablative, and beyond. Hematology 2014; 20:61-71. [DOI: 10.1179/1607845414y.0000000175] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Affiliation(s)
- Y. Y. Hwang
- University Department of Medicine Queen Mary Hospital, University of Hong Kong, Hong Kong
| | - M. Mohty
- Centre Hospitalier et Universitaire (CHU) de Nantes, Hématologie Clinique, Nantes, and Acute Leukemia Working Party of EBMT, Paris, France
| | - C. S. Chim
- University Department of Medicine Queen Mary Hospital, University of Hong Kong, Hong Kong
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23
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PBSC vs BM grafts with myeloablative conditioning for unrelated donor transplantation in adults with high-risk ALL. Bone Marrow Transplant 2014; 49:773-9. [PMID: 24662418 DOI: 10.1038/bmt.2014.54] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 12/22/2013] [Accepted: 01/31/2014] [Indexed: 12/22/2022]
Abstract
Few studies are available that compare PBSC and BM from unrelated donors, especially in adult high-risk ALL. To determine which graft source is superior in adult high-risk ALL, we analyzed the long-term outcomes of 106 consecutive transplants from 8/8-matched or 7/8-matched unrelated donors (38 PBSC vs 68 BM). All patients received a uniform strategy of pre-transplant therapy, myeloablative conditioning and GVHD prophylaxis. At 5 years, PBSC transplants showed higher incidence of chronic GVHD than did BM transplants (74.3% vs 46.7%, P=0.001). PBSC transplants showed outcomes comparable to those of BM transplants for relapse (23.7% vs 28.1%), non-relapse mortality (18.4% vs 25.0%), disease-free survival (57.9% vs 46.9%) and OS (57.9% vs 50.0%). In a separate comparison of outcomes between the two graft sources according to the presence of a Ph chromosome, no significant advantage of PBSC over BM was found in both subgroups of patients. Our data suggest that the outcomes of unrelated donor transplantation are similar between PBSC and BM in adult high-risk ALL. Whether PBSC should be the preferred graft source for a specific subgroup of adult ALL needs to be further investigated.
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24
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Bachanova V, Marks DI, Zhang MJ, Wang H, de Lima M, Aljurf MD, Arellano M, Artz AS, Bacher U, Cahn JY, Chen YB, Copelan EA, Drobyski WR, Gale RP, Greer JP, Gupta V, Hale GA, Kebriaei P, Lazarus HM, Lewis ID, Lewis VA, Liesveld JL, Litzow MR, Loren AW, Miller AM, Norkin M, Oran B, Pidala J, Rowe JM, Savani BN, Saber W, Vij R, Waller EK, Wiernik PH, Weisdorf DJ. Ph+ ALL patients in first complete remission have similar survival after reduced intensity and myeloablative allogeneic transplantation: impact of tyrosine kinase inhibitor and minimal residual disease. Leukemia 2014; 28:658-65. [PMID: 23989431 PMCID: PMC3951192 DOI: 10.1038/leu.2013.253] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Revised: 08/12/2013] [Accepted: 08/22/2013] [Indexed: 01/21/2023]
Abstract
The efficacy of reduced intensity conditioning (RIC) allogeneic hematopoietic cell transplantation (HCT) for Philadelphia chromosome positive (Ph+) acute lymphoblastic leukemia (ALL) is uncertain. We analyzed 197 adults with Ph+ ALL in first complete remission; 67 patients receiving RIC were matched with 130 receiving myeloablative conditioning (MAC) for age, donor type and HCT year. Over 75% received pre-HCT tyrosine kinase inhibitors (TKIs), mostly imatinib; 39% (RIC) and 49% (MAC) were minimal residual disease (MRD)(neg) pre-HCT. At a median 4.5 years follow-up, 1-year transplant-related mortality (TRM) was lower in RIC (13%) than MAC (36%; P=0.001) while the 3-year relapse rate was 49% in RIC and 28% in MAC (P=0.058). Overall survival (OS) was similar (RIC 39% (95% confidence interval (CI) 27-52) vs 35% (95% CI 27-44); P=0.62). Patients MRD(pos) pre-HCT had higher risk of relapse with RIC vs MAC (hazard ratio (HR) 1.97; P=0.026). However, patients receiving pre-HCT TKI in combination with MRD negativity pre-RIC HCT had superior OS (55%) compared with a similar MRD population after MAC (33%; P=0.0042). In multivariate analysis, RIC lowered TRM (HR 0.6; P=0.057), but absence of pre-HCT TKI (HR 1.88; P=0.018), RIC (HR 1.891; P=0.054) and pre-HCT MRD(pos) (HR 1.6; P=0.070) increased relapse risk. RIC is a valid alternative strategy for Ph+ ALL patients ineligible for MAC and MRD(neg) status is preferred pre-HCT.
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Affiliation(s)
- Veronika Bachanova
- Blood and Marrow Transplant Program, University of Minnesota Medical Center, Minneapolis, MN
| | - David I. Marks
- Bristol Adult BMT Unit, Bristol Children’s Hospital, Bristol, UNITED KINGDOM
| | - Mei-Jie Zhang
- Center for International Blood and Marrow Transplant Research (CIBMTR), Medical College of Wisconsin, Milwaukee, WI
| | - Hailin Wang
- Center for International Blood and Marrow Transplant Research (CIBMTR), Medical College of Wisconsin, Milwaukee, WI
| | - Marcos de Lima
- Seidman Cancer Center, University Hospitals Case Medical Center, Cleveland, OH
| | - Mahmoud D. Aljurf
- King Faisal Specialist Hospital and Research Center, Riyadh, SAUDI ARABIA
| | | | | | - Ulrike Bacher
- Klinik und Poliklinik fur Stammzelltransplantation, Universitatsklinikum Hamburg-Eppendorf, Hamburg, GERMANY
| | - Jean-Yves Cahn
- Department of Hematology, University Hospital, Grenoble, FRANCE
| | | | | | | | - Robert Peter Gale
- Imperial College, Section of Hematology, Division of Experimental Medicine, Department of Medicine, London, UNITED KINGDOM
| | - John P Greer
- Vanderbilt University Medical Center, Nashville, TN
| | - Vikas Gupta
- Princess Margaret Hospital, Toronto, ON, CANADA
| | | | - Partow Kebriaei
- Stem Cell Transplantation and Cellular Therapy, MD Anderson Cancer Center, Houston, TX
| | - Hillard M. Lazarus
- Seidman Cancer Center, University Hospitals Case Medical Center, Cleveland, OH
| | - Ian D. Lewis
- Haematology and Bone Marrow Transplant Unit, Royal Adelaide Hospital/SA Pathology, Adelaide, AUSTRALIA
| | | | - Jane L. Liesveld
- Strong Memorial Hospital, University of Rochester Medical Center; Rochester, NY
| | - Mark R. Litzow
- Hematology and Internal Medicine, Mayo Clinic Rochester, Rochester, MN
| | - Alison W. Loren
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | | | - Maxim Norkin
- Shands HealthCare and University of Florida, Gainesville, FL
| | - Betul Oran
- Stem Cell Transplantation and Cellular Therapy, MD Anderson Cancer Center, Houston, TX
| | - Joseph Pidala
- Blood and Marrow Transplantation, Moffitt Cancer Center, Tampa, FL
| | - Jacob M. Rowe
- Department of Hematology, Rambam Medical Center, Haifa, ISRAEL
| | | | - Wael Saber
- Center for International Blood and Marrow Transplant Research (CIBMTR), Medical College of Wisconsin, Milwaukee, WI
| | - Ravi Vij
- Barnes Jewish Hospital, Washington University School of Medicine, St. Louis, MO
| | - Edmund K. Waller
- Bone Marrow and Stem Cell Transplant Center, Emory University Hospital, Atlanta, GA
| | | | - Daniel J. Weisdorf
- Blood and Marrow Transplant Program, University of Minnesota Medical Center, Minneapolis, MN
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25
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Kanamori H, Mizuta S, Kako S, Kato H, Nishiwaki S, Imai K, Shigematsu A, Nakamae H, Tanaka M, Ikegame K, Yujiri T, Fukuda T, Minagawa K, Eto T, Nagamura-Inoue T, Morishima Y, Suzuki R, Sakamaki H, Tanaka J. Reduced-intensity allogeneic stem cell transplantation for patients aged 50 years or older with B-cell ALL in remission: a retrospective study by the Adult ALL Working Group of the Japan Society for Hematopoietic Cell Transplantation. Bone Marrow Transplant 2013; 48:1513-8. [DOI: 10.1038/bmt.2013.140] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2013] [Revised: 07/18/2013] [Accepted: 07/29/2013] [Indexed: 11/12/2022]
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26
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Wu X, He G, Fa Y, Ma X, Wu D, Ai H, Huang X, Han Y, Xu Y, Sun A, Wu Q, Tang X, Fu Z. Comparable outcomes of partially matched related and matched related allogeneic hematopoietic cell transplantation following reduced-intensity conditioning in adult patients with Philadelphia chromosome-negative acute lymphoblastic leukemia. Int J Hematol 2013; 98:456-62. [DOI: 10.1007/s12185-013-1412-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Revised: 07/31/2013] [Accepted: 08/06/2013] [Indexed: 12/23/2022]
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27
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Eom KS, Shin SH, Yoon JH, Yahng SA, Lee SE, Cho BS, Kim YJ, Kim HJ, Min CK, Kim DW, Lee JW, Min WS, Park CW, Lee S. Comparable long-term outcomes after reduced-intensity conditioning versus myeloablative conditioning allogeneic stem cell transplantation for adult high-risk acute lymphoblastic leukemia in complete remission. Am J Hematol 2013; 88:634-41. [PMID: 23620000 DOI: 10.1002/ajh.23465] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Revised: 04/13/2013] [Accepted: 04/16/2013] [Indexed: 11/12/2022]
Abstract
The role of reduced-intensity conditioning (RIC) in adult acute lymphoblastic leukemia (ALL) remains unclear because of the small sample size, short follow-up duration, various regimens for conditioning and graft-versus-host disease (GVHD) prophylaxis, and the heterogeneity of selection criteria for transplantation. We compared long-term outcomes of 60 consecutive RIC transplants (fludarabine plus melphalan) with 120 myeloablative conditioning (MAC) transplants (total body irradiation plus cyclophosphamide) for adult high-risk ALL in first or second complete remission. All transplants received a uniform strategy of pretransplant chemotherapy and GVHD prophylaxis. Compared to MAC transplants, RIC transplants had older age (46 years vs. 33 years, P < 0.001) and higher proportions of transplantation using peripheral blood (93.3% vs. 13.3%; P < 0.001) but otherwise showed similar characteristics. After a median follow-up of 67 months, RIC transplants showed comparable nonrelapse mortality (21.2% vs. 24.3%) and disease-free survival (50.8% vs. 54.9%) to MAC transplants, although relapse risk was higher (34.2% vs. 26.4%; HR, 2.07; P = 0.019) in multivariate analysis. Other independent factors associated with better outcomes were the presence of chronic GVHD and transplantation in first complete remission. Interestingly, the negative impact of RIC on relapse risk was seen only for Philadelphia-positive ALL transplants (32.7% vs. 19.6%; HR, 3.46; P = 0.020), while no difference was found between RIC and MAC for Philadelphia-negative ALL transplants (35.0% vs. 32.1%; HR, 1.39; P = 0.429). RIC can be considered as a reasonable choice for providing a sufficient long-term graft-versus-leukemia effect for adult high-risk ALL patients ineligible for MAC.
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Affiliation(s)
- Ki-Seong Eom
- Department of Hematology; Catholic BMT Center, College of Medicine, The Catholic University of Korea; Seoul; Republic of Korea (South Korea)
| | - Seung-Hwan Shin
- Department of Hematology; Catholic BMT Center, College of Medicine, The Catholic University of Korea; Seoul; Republic of Korea (South Korea)
| | - Jae-Ho Yoon
- Department of Hematology; Catholic BMT Center, College of Medicine, The Catholic University of Korea; Seoul; Republic of Korea (South Korea)
| | - Seung-Ah Yahng
- Department of Hematology; Catholic BMT Center, College of Medicine, The Catholic University of Korea; Seoul; Republic of Korea (South Korea)
| | - Sung-Eun Lee
- Department of Hematology; Catholic BMT Center, College of Medicine, The Catholic University of Korea; Seoul; Republic of Korea (South Korea)
| | - Byung-Sik Cho
- Department of Hematology; Catholic BMT Center, College of Medicine, The Catholic University of Korea; Seoul; Republic of Korea (South Korea)
| | - Yoo-Jin Kim
- Department of Hematology; Catholic BMT Center, College of Medicine, The Catholic University of Korea; Seoul; Republic of Korea (South Korea)
| | - Hee-Je Kim
- Department of Hematology; Catholic BMT Center, College of Medicine, The Catholic University of Korea; Seoul; Republic of Korea (South Korea)
| | - Chang-Ki Min
- Department of Hematology; Catholic BMT Center, College of Medicine, The Catholic University of Korea; Seoul; Republic of Korea (South Korea)
| | - Dong-Wook Kim
- Department of Hematology; Catholic BMT Center, College of Medicine, The Catholic University of Korea; Seoul; Republic of Korea (South Korea)
| | - Jong-Wook Lee
- Department of Hematology; Catholic BMT Center, College of Medicine, The Catholic University of Korea; Seoul; Republic of Korea (South Korea)
| | - Woo-Sung Min
- Department of Hematology; Catholic BMT Center, College of Medicine, The Catholic University of Korea; Seoul; Republic of Korea (South Korea)
| | - Chong-Won Park
- Department of Hematology; Catholic BMT Center, College of Medicine, The Catholic University of Korea; Seoul; Republic of Korea (South Korea)
| | - Seok Lee
- Department of Hematology; Catholic BMT Center, College of Medicine, The Catholic University of Korea; Seoul; Republic of Korea (South Korea)
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28
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Leung AY, Tse E, Hwang YY, Chan TS, Gill H, Chim CS, Lie AK, Kwong YL. Primary treatment of leukemia relapses after allogeneic hematopoietic stem cell transplantation with reduced-intensity conditioning second transplantation from the original donor. Am J Hematol 2013; 88:485-91. [PMID: 23512868 DOI: 10.1002/ajh.23439] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Revised: 03/11/2013] [Accepted: 03/13/2013] [Indexed: 01/25/2023]
Abstract
Acute leukemia relapsing after allogeneic hematopoietic stem cell transplantation (HSCT) has dismal outcome. Consecutive consenting patients (acute myeloid leukemia: N = 71; acute lymphoblastic leukemia: N = 37), at a median age of 37 (16-57) years, who had relapsed 7.9 (1.3-132) months post-HSCT, were treated with three cytarabine-based intensive regimens as reduced-intensity conditioning (RIC), followed by infusion of mobilized HSC from the original donors. There were four treatment-related mortalities (TRMs). Of 104 evaluable cases, 72 patients (67%) achieved complete remission (CR)/CR with incomplete hematologic recovery (CRi). The median overall survival (OS) of the entire cohort was 11.6 months. The OS of patients achieving CR/CRi after the first RIC/HSCT was 18.8 months, as compared with 3.9 months for those not (P < 0.01). For 32 patients with nonremission, 11 received a repeat RIC-HSCT, leading to CR/CRi in three cases. Therefore, 75/108 (69%) of patients achieved CR/CRi after one or two courses of RIC-HSCT. Among CR/CRi patients, 48 cases relapsed again after 6.1 (1.0-64.4) months. Thirty cases received a repeat RIC-HSCT, leading to CR/CRi in 22 patients. Multivariate analyses showed a significant impact of remission duration after initial HSCT (P = 0.026) and the presence of acute graft-versus-host disease after RIC-HSCT (P = 0.011) on CR/CRi. RIC-HSCT as primary treatment for acute leukemic relapses post-HSCT induced a high CR rate with low TRM. Optimal postremission treatment remains to be defined.
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Affiliation(s)
| | - Eric Tse
- Department of Medicine; Queen Mary Hospital; Hong Kong
| | - Yu-Yan Hwang
- Department of Medicine; Queen Mary Hospital; Hong Kong
| | | | - Harinder Gill
- Department of Medicine; Queen Mary Hospital; Hong Kong
| | | | | | - Yok-Lam Kwong
- Department of Medicine; Queen Mary Hospital; Hong Kong
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29
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Tanaka J, Kanamori H, Nishiwaki S, Ohashi K, Taniguchi S, Eto T, Nakamae H, Minagawa K, Miyamura K, Sakamaki H, Morishima Y, Kato K, Suzuki R, Nishimoto N, Oba K, Masauzi N. Reduced-intensity vs myeloablative conditioning allogeneic hematopoietic SCT for patients aged over 45 years with ALL in remission: a study from the Adult ALL Working Group of the Japan Society for Hematopoietic Cell Transplantation (JSHCT). Bone Marrow Transplant 2013; 48:1389-94. [PMID: 23665820 DOI: 10.1038/bmt.2013.68] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2012] [Revised: 03/05/2013] [Accepted: 04/08/2013] [Indexed: 11/09/2022]
Abstract
In this study, outcomes for 575 adult ALL patients aged ≥45 years who underwent first allo-SCT in CR were analyzed according to the type of conditioning regimen (myeloablative conditioning (MAC) for 369 patients vs reduced-intensity conditioning (RIC) for 206 patients). Patients in the RIC group were older (median age, 58 vs 51 years, P<0.0001). There were no statistically significant differences in 3-year OS, disease-free survival (DFS) and non-relapse mortality (NRM): 51% vs 53%, 47% vs 39% and 38% vs 36%, respectively. Multivariate analysis showed that CR2 and HLA mismatching were associated with poor OS (P=0.002 and P=0.019, respectively). HLA mismatching was associated with lower rate of relapse (P=0.016), but was associated with higher rate of NRM (P=0.001). RIC was associated with good OS and DFS in patients who received HLA-mismatch transplantation and were aged ≥55 years compared with MAC by multivariate analysis for each event with interaction (hazard ratio (HR) and 95% confidence interval 0.35 and 0.15-0.81, P=0.014 for OS and 0.36 and 0.16-0.81, P=0.013 for DFS). Therefore, patients ≥55 years of age with HLA-mismatch transplantation should be candidates for RIC rather than MAC.
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Affiliation(s)
- J Tanaka
- Department of Hematology and Oncology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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30
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Promising role of reduced-toxicity hematopoietic stem cell transplantation (PART-I). Stem Cell Rev Rep 2013; 8:1254-64. [PMID: 22836809 DOI: 10.1007/s12015-012-9401-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) remains a potential curative option for many patients with hematological malignancies (HM). However, the high rate of transplantation-related mortality (TRM) restricted the use of standard myeloablative HSCT to a minority of young and fit patients. Over the past few years, it has become evident that the alloreactivity of the immunocompetent donor cells mediated anti-malignancy effects independent of the action of high dose chemoradiotherapy. The use of reduced intensity conditioning (RIC) regimens has allowed a graft-versus-malignancy (GvM) effect to be exploited in patients who were previously ineligible for HSCT on the grounds of age and comorbidity. Retrospective analysis showed that RIC has been associated with lower TRM but a higher relapse rate leading to similar intermediate term overall and progression-free survivals when compared to standard myeloablative HSCT. However, the long term antitumor effect of this approach is less well established. Prospective studies are ongoing to define which patients might most benefit from reduced toxicity stem cell transplant (RT-SCT) and which transplant protocols are suitable for the different types of HM. The advent of RT-SCT permits the delivery of a potentially curative GvM effect to the majority of patients with HM whose outcome with conventional chemotherapy would be dismal. Remaining challenges include development of effective strategies to reduce relapse rates by augmenting GvM effects without increasing toxicity.
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31
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Indications and outcomes of reduced-toxicity hematopoietic stem cell transplantation in adult patients with hematological malignancies. Int J Hematol 2013; 97:581-98. [PMID: 23585244 DOI: 10.1007/s12185-013-1313-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Revised: 03/12/2013] [Accepted: 03/12/2013] [Indexed: 02/05/2023]
Abstract
Hematopoietic stem cell transplantation (HCT) utilizing non-myeloablative (NMA) and reduced-intensity conditioning (RIC) regimens (collectively referred to as reduced-toxicity HCT, RT-HCT) has become a viable therapeutic option for patients with hematological malignancies who are ineligible for standard myeloablative conditioning transplantation (MA-HCT). RT-HCT has been shown to induce stable engraftment with low toxicity, and to produce similar overall and progression-free survival (PFS) when compared to MA-HCT in acute myeloid leukemia and myelodysplastic syndrome. The best results for RT-HCT have been reported for patients with disease that is in remission, indolent and chemosensitive, and with a strong graft-versus-malignancy effect. Chronic graft-versus-host disease seems to correlate with a lower relapse rate and better PFS. RT-HCT is inferior when performed in poor risk or advanced disease, due to high relapse rates. A search for novel strategies that includes the most appropriate conditioning regimens and post-transplant immunomodulation protocols with more intensive anti-malignancy activity but limited toxicity is in progress. This review provides an update on the results of clinical studies of RT-HCT, and discusses possible indications and investigative strategies for improving the clinical outcomes of RT-HCT for the major hematological malignancies.
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32
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Allogeneic hematopoietic cell transplantation from alternative sources for adult Philadelphia chromosome-negative ALL: what should we choose when no HLA-matched related donor is available? Bone Marrow Transplant 2013; 48:1369-76. [DOI: 10.1038/bmt.2013.20] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Accepted: 01/30/2013] [Indexed: 02/06/2023]
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Medd PG, Peniket AJ, Littlewood TJ, Pearce R, Perry J, Kirkland KE, Shaw BE, Potter MN, Craddock CF, Milligan DW, Fielding AK, Marks DI, Cook G. Evidence for a GVL effect following reduced-intensity allo-SCT in ALL: a British Society of Blood and Marrow Transplantation study. Bone Marrow Transplant 2013; 48:982-7. [PMID: 23318533 DOI: 10.1038/bmt.2012.261] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Revised: 10/26/2012] [Accepted: 11/20/2012] [Indexed: 11/09/2022]
Abstract
Myeloablative allo-SCT decreases relapse incidence (RI) in ALL. Reduced intensity conditioning (RIC) may extend allo-SCT to older and less fit patients. Sixty-nine ALL patients reported to the BSBMT underwent fludarabine-based RIC allo-SCT, 38 from unrelated donors (UD). Forty-four patients received alemtuzumab. ALL was in CR in 64 patients (93%). This was a second or third SCT in 23 patients. Two-year OS and PFS were 36% and 32%, respectively. In multivariate analysis male recipients demonstrated better OS and PFS (hazard ratio (HR) = 0.42, P = 0.008 and HR = 0.45, P = 0.012, respectively). Two-year TRM was 29%: higher with younger age (HR = 0.97/year, P = 0.041), female recipient (HR = 2.55, P = 0.049) and increasing grade of acute GVHD (HR = 1.87, P = 0.001). Two-year RI was 38% and was lower in patients with acute and chronic GVHD (HR = 0.62 per increasing grade, P = 0.035 and HR = 0.52, P = 0.025, respectively). Long-term ALL-free survival is achievable following fludarabine-based RIC allo-SCT. The association between GVHD and decreased RI suggests the presence of a GVL effect.
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Affiliation(s)
- P G Medd
- Department of Haematology, Oxford University Hospitals NHS Trust, Oxford, UK
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When, how, and what cell source for hematopoietic cell transplantation in first complete remission adult acute lymphoblastic leukemia? Hematology 2012. [DOI: 10.1182/asheducation.v2012.1.382.3798359] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Adult acute lymphoblastic leukemia (ALL) is a heterogeneous disease affected by many patient- and disease-related factors, including age, immunologic subtype, and clinical, genetic, and molecular features. Allogeneic hematopoietic cell transplantation (HCT) has occupied an increasing therapeutic role as a result of significant improvements in supportive care and histocompatibility testing. ALL Philadelphia chromosome–negative patients formerly excluded now are considered HCT candidates and survival rates with alternative donors may approach those obtained with matched-related donors. Reduced-intensity conditioning rather than myeloablative conditioning appears to provide comparable patient outcome results although these observations have not been validated in prospective studies. Improved tools can identify patients thought to be in remission based on morphology but who have active disease at the molecular or immunophenotypic level (minimal residual disease). Using B-cell antigen panels, clone-specific immunoglobulins, or T-cell receptor rearrangements to detect positivity at thresholds of at least 1 in 104 cells, such patients may be taken to HCT. The ongoing advances in conventional therapy intensity, however, now yield improved results and ongoing reassessment of the place of HCT needs to be continued; every effort should be made to enroll eligible patients in clinical trials.
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Daly A, Savoie ML, Geddes M, Chaudhry A, Stewart D, Duggan P, Bahlis N, Storek J, Brown C, Shafey M, Turner AR, Russell J. Fludarabine, Busulfan, Antithymocyte Globulin, and Total Body Irradiation for Pretransplantation Conditioning in Acute Lymphoblastic Leukemia: Excellent Outcomes in All but Older Patients with Comorbidities. Biol Blood Marrow Transplant 2012; 18:1921-6. [DOI: 10.1016/j.bbmt.2012.07.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Accepted: 07/19/2012] [Indexed: 10/28/2022]
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Bayraktar UD, Bashir Q, Qazilbash M, Champlin RE, Ciurea SO. Fifty years of melphalan use in hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 2012; 19:344-56. [PMID: 22922522 DOI: 10.1016/j.bbmt.2012.08.011] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Accepted: 08/17/2012] [Indexed: 12/22/2022]
Abstract
Melphalan remains the most widely used agent in preparative regimens for hematopoietic stem cell transplantation (SCT). From its initial discovery more than 50 years ago, it has been gradually incorporated in the conditioning regimens for both autologous and allogeneic transplantations because of its myeloablative properties and broad antitumor effects as a DNA alkylating agent. Melphalan remains the mainstay conditioning for multiple myeloma and lymphomas, and it has been used successfully in preparative regimens of a variety of other hematological and nonhematological malignancies. The addition of newer agents to conditioning, such as bortezomib or lenalidomide for myeloma or clofarabine for myeloid malignancies, may improve antitumor effects for transplantation, whereas melphalan in combination with alemtuzumab may represent a backbone for future cellular therapy because of reliable engraftment and low toxicity profile. This review summarizes the development and the current use of this remarkable drug in hematopoietic SCT.
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Affiliation(s)
- Ulas D Bayraktar
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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37
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The role of allogeneic hematopoietic stem cell transplantation in the therapy of patients with acute lymphoblastic leukemia. Curr Hematol Malig Rep 2012; 7:144-52. [PMID: 22410763 DOI: 10.1007/s11899-012-0116-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (alloHSCT) is an effective post-remission therapy in patients with acute lymphoblastic leukemia (ALL), but is associated with significant toxicity, so the optimal timing and use of this modality remains an issue of debate. Increased advances in reduced-intensity transplant preparative regimens and alternative donors has increased the accessibility of allogeneic transplantation. A risk adapted paradigm, using minimal residual disease analysis, may help in the selection of patients at highest risk for relapse, who may benefit most from alloHSCT. In this review, we summarize the indications for allogeneic transplantation within the risk-oriented paradigm, and also explore the latest literature on reduced intensity transplant regimens, as well as alternative donor transplantation for patients with ALL.
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Lee S, Kim DW, Cho BS, Yoon JH, Shin SH, Yahng SA, Lee SE, Eom KS, Kim YJ, Chung NG, Kim HJ, Min CK, Lee JW, Min WS, Park CW. Impact of minimal residual disease kinetics during imatinib-based treatment on transplantation outcome in Philadelphia chromosome-positive acute lymphoblastic leukemia. Leukemia 2012; 26:2367-74. [PMID: 22705993 DOI: 10.1038/leu.2012.164] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
We conducted a systemic evaluation to describe the effect of minimal residual disease (MRD) kinetics on long-term allogeneic transplantation outcome by analyzing 95 adult transplants with Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph-positive ALL) who received first-line two courses of imatinib-based chemotherapy (median follow-up 5 years). MRD monitoring was centrally evaluated by real-time quantitative PCR (4.5 log sensitivity). After the first course of imatinib-based chemotherapy, 33 patients (34.7%) achieved at least major molecular response. On the basis of MRD kinetics by the end of two courses of imatinib-based chemotherapy, we stratified entire patients into four subgroups: early-stable molecular responders (EMRs, n=33), late molecular responders (LMRs, n=35), intermediate molecular responders (IMRs, n=9) and poor molecular responders (PMRs, n=18). Multivariate analysis showed that the most powerful factor affecting long-term transplantation outcome was MRD kinetics. Compared with EMRs, IMRs or PMRs had significantly higher risk of treatment failure in terms of relapse and disease-free survival (DFS). LMRs had a tendency toward a lower DFS. Quantitative monitoring of MRD kinetics during the first-line imatinib-based chemotherapy course is useful in identifying subgroups of Ph-positive ALL transplants at a high risk of relapse.
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Affiliation(s)
- S Lee
- Department of Hematology, Catholic BMT Center, Research Institute of Molecular Genetics, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
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Nishiwaki S, Miyamura K. Allogeneic stem cell transplant for adult Philadelphia chromosome-negative acute lymphoblastic leukemia. Leuk Lymphoma 2012; 53:550-6. [DOI: 10.3109/10428194.2011.615424] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Saber W, Opie S, Rizzo JD, Zhang MJ, Horowitz MM, Schriber J. Outcomes after matched unrelated donor versus identical sibling hematopoietic cell transplantation in adults with acute myelogenous leukemia. Blood 2012; 119:3908-16. [PMID: 22327226 PMCID: PMC3350357 DOI: 10.1182/blood-2011-09-381699] [Citation(s) in RCA: 187] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2011] [Accepted: 02/08/2012] [Indexed: 11/20/2022] Open
Abstract
Approximately one-third of patients with an indication for hematopoietic cell transplantation (HCT) have an HLA-matched related donor (MRD) available to them. For the remaining patients, a matched unrelated donor (MUD) is an alternative. Prior studies comparing MRD and MUD HCT provide conflicting results, and the relative efficacy of MRD and MUD transplantation is an area of active investigation. To address this issue, we analyzed outcomes of 2223 adult acute myelogenous leukemia patients who underwent allogeneic HCT between 2002 and 2006 (MRD, n = 624; 8/8 HLA locus matched MUD, n = 1193; 7/8 MUD, n = 406). The 100-day cumulative incidence of grades B-D acute GVHD was significantly lower in MRD HCT recipients than in 8/8 MUD and 7/8 MUD HCT recipients (33%, 51%, and 53%, respectively; P < .001). In multivariate analysis, 8/8 MUD HCT recipients had a similar survival rate compared with MRD HCT recipients (relative risk [RR], 1.03; P = .62). 7/8 MUD HCT recipients had higher early mortality than MRD HCT recipients (RR, 1.40; P < .001), but beyond 6 months after HCT, their survival rates were similar (RR, 0.88; P = .30). These results suggest that transplantation from MUD and MRD donors results in similar survival times for patients with acute myelogenous leukemia.
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Affiliation(s)
- Wael Saber
- Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, 9200 W Wisconsin Ave., Milwaukee, WI 53226, USA.
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41
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Lee SE, Kim YJ, Yahng SA, Cho BS, Eom KS, Lee S, Min CK, Kim HJ, Cho SG, Kim DW, Lee JW, Min WS, Park CW. Survival benefits from reduced-intensity conditioning in allogeneic stem cell transplantation for young lower-risk MDS patients without significant comorbidities. Eur J Haematol 2011; 87:510-20. [PMID: 21883477 DOI: 10.1111/j.1600-0609.2011.01697.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The aim of this study was to determine the optimum conditioning intensity for allogeneic stem cell transplantation (SCT) in young (age ≤50), lower-risk (INT-1 by IPSS) Myelodysplastic syndrome (MDS) patients without significant comorbidities (hematopoietic cell transplantation-comorbidity index score ≤3). METHODS Transplant outcomes from 46 consecutive patients were retrospectively analyzed according to the conditioning intensity: reduced-intensity conditioning (RIC; n = 14), intensified RIC by adding low-dose total body irradiation (iRIC; n = 15), and myeloablative conditioning (MAC; n = 17). RESULTS After a median follow-up of 73.7 months, RIC had a better 4-yr overall survival (OS) (92.9%) compared with the iRIC (64.2%) or MAC (70.6%). Multivariate analysis showed that RIC was associated with improved OS compared with the MAC [relative risk (RR) of 0.08, P = 0.022] because of a lower transplant-related mortality (TRM) (RR, 0.08, P = 0.035). iRIC failed to show survival benefits over the MAC (RR of 0.77, P = 0.689) because of similarly high TRM (RR of 0.41, P = 0.480). Cumulative incidence of acute and chronic graft-versus-host disease (GVHD) after RIC was higher, but GVHD-specific survival was significantly better (RIC 100% vs. iRIC 45.7% vs. MAC, P = 0.018). Relapse rate was not different among the three groups, but in the RIC group, azacitidine was available and useful for inducing remission in two patients. CONCLUSION This study shows that RIC improved OS by directly lowering TRM and indirectly giving an additional chance for relapsed MDS in the era of hypomethylating treatment. RIC-SCT should be considered for relative healthy lower-risk MDS patients.
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Affiliation(s)
- Sung-Eun Lee
- Department of Hematology, Catholic Blood and Marrow Transplantation Center, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul
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Oliansky DM, Larson RA, Weisdorf D, Dillon H, Ratko TA, Wall D, McCarthy PL, Hahn T. The role of cytotoxic therapy with hematopoietic stem cell transplantation in the treatment of adult acute lymphoblastic leukemia: update of the 2006 evidence-based review. Biol Blood Marrow Transplant 2011; 18:18-36.e6. [PMID: 21803017 DOI: 10.1016/j.bbmt.2011.07.019] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2011] [Accepted: 07/25/2011] [Indexed: 11/26/2022]
Abstract
Clinical research published since the first evidence-based review on the role of hematopoietic stem cell transplantation (SCT) in the treatment of acute lymphoblastic leukemia (ALL) in adults is presented and critically evaluated in this update. Treatment recommendations changed or modified based on new evidence include: (1) myeloablative allogeneic SCT is an appropriate treatment for adult (<35 years) ALL in first complete remission for all disease risk groups; and (2) reduced-intensity conditioning may produce similar outcomes to myeloablative regimens. Treatment recommendations unchanged or strengthened by new evidence include: (1) allogeneic SCT is recommended over chemotherapy for ALL in second complete remission or greater; (2) allogeneic is superior to autologous SCT; and (3) there are similar survival outcomes after related and unrelated allogeneic SCT. New treatment recommendations based on new evidence include: (1) in the absence of a suitable allogeneic donor, autologous SCT may be an appropriate therapy, but results in a high relapse rate; (2) it is appropriate to consider cord blood transplantation for patients with no HLA well-matched donor; and (3) imatinib therapy before and/or after SCT (for Ph+ ALL) yields significantly superior survival outcomes. Areas of needed research in the treatment of adult ALL with SCT were identified and presented in the review.
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43
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Reduced-intensity versus conventional myeloablative conditioning for patients with Philadelphia chromosome-negative acute lymphoblastic leukemia in complete remission. Blood 2011; 117:3698-9. [PMID: 21454468 DOI: 10.1182/blood-2011-01-329003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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44
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Santarone S, Pidala J, Di Nicola M, Field T, Alsina M, Ayala E, Janssen W, Kharfan-Dabaja MA, Ochoa L, Perez L, Perkins J, Raychaudhuri J, Fernandez H, Anasetti C. Fludarabine and pharmacokinetic-targeted busulfan before allografting for adults with acute lymphoid leukemia. Biol Blood Marrow Transplant 2011; 17:1505-11. [PMID: 21385623 DOI: 10.1016/j.bbmt.2011.02.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Accepted: 02/26/2011] [Indexed: 11/12/2022]
Abstract
We aimed to evaluate the safety and efficacy of fludarabine (FLU) and pharmacokinetic-targeted busulfan (BU) as conditioning regimen for hematopoietic cell transplantation (HCT) in adult patients with acute lymphoid leukemia (ALL). Forty-four patients with ALL (27 in first complete remission [CR1] and 17 in more advanced disease stage: 4 with primary induction failure [PIF], 12 in CR2, and 1 in CR3) received FLU and pharmacokinetic-targeted BU as preparative therapy for HCT. Grafts were T-replete, filgrastim-mobilized peripheral blood stem cells (PBSC). Graft-versus-host disease (GVHD) prophylaxis consisted of tacrolimus (TAC) and short-course methotrexate in 36 patients, TAC and sirolimus in 3, and TAC and mycophenolate mofetil in 5. Primary engraftment was achieved in all 44 patients. The cumulative incidence of transplant-related mortality (TRM) was 2% (95% confidence interval [CI] 0%-16%) at 100 days and 18% (95% CI 10%-34%) at 2 years. The 2-year cumulative incidence of relapse was 19% (95% CI 8%-41%) for those transplanted in CR1, and 48% (29%-80%) for those with more advanced disease. After a median follow-up of 32 months (range: 15-69 months), the 2-year overall survival (OS) was 54% (95% CI 39%-69%). Relapse-free survival (RFS) at 2 years was 63% (95% CI 45%-81%) for patients transplanted in CR1 and 34% (95% CI 11%-57%) for patients transplanted in more advanced disease. When compared to irradiation-containing regimens, FLU and PK-targeted BU appear safer and similarly effective in controlling ALL, providing a treatment option for adult patients with ALL.
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Affiliation(s)
- Stella Santarone
- Department of Biomedical Sciences, Chieti-Pescara University, Chieti, Italy
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45
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Reduced-intensity versus conventional myeloablative conditioning allogeneic stem cell transplantation for patients with acute lymphoblastic leukemia: a retrospective study from the European Group for Blood and Marrow Transplantation. Blood 2010; 116:4439-43. [DOI: 10.1182/blood-2010-02-266551] [Citation(s) in RCA: 193] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
This retrospective study assessed the outcome of 576 adult acute lymphoblastic leukemia patients aged ≥ 45 years, and who received a reduced-intensity conditioning (RIC; n = 127) or myeloablative conditioning (MAC; n = 449) allogeneic stem cell transplantation (allo-SCT) from a human leukocyte antigen-identical sibling while in complete remission. With a median follow-up of 16 months, at 2 years, the cumulative incidences of nonrelapse mortality and relapse incidence were 29% ± 2% (MAC) versus 21% ± 5% (RIC; P = .03), and 31% ± 2% (MAC) versus 47% ± 5% (RIC; P < .001), respectively. In a multivariate analysis, nonrelapse mortality was decreased in RIC recipients (P = .0001, hazard ratio [HR] = 1.98) whereas it was associated with higher relapse rate (P = .03, HR = 0.59). At 2 years, LFS was 38% ± 3% (MAC) versus 32% ± 6% (RIC; P = .07). In multivariate analysis, the type of conditioning regimen (RIC vs. MAC) was not significantly associated with leukemia-free survival (P = .23, HR = 0.84). Despite the need for randomized trials, we conclude that RIC allo-SCT from a human leukocyte antigen-identical donor is a potential therapeutic option for acute lymphoblastic leukemia patients aged ≥ 45 years in complete remission and not eligible for MAC allo-SCT.
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46
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Tajika K, Yamaguchi H, Mizuki T, Nakamura H, Nakayama K, Dan K. Stem cell transplantation using non-myeloablative conditioning regimen with fludarabine for hematological malignancies. J NIPPON MED SCH 2010; 77:254-9. [PMID: 21060236 DOI: 10.1272/jnms.77.254] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Stem cell transplantation (SCT) is a useful treatment for hematological malignancies, but it is limited to younger patients because of its high treatment-related mortality. Fludarabine (Flu), a novel anticancer agent with potent immunosuppressive activity, used as a conditioning regimen (reduced intensity transplantation; RIST), can decrease treatment-related mortality, as recently reported. However, the best drug combination and the best timing for RIST remain unknown. We herein report the SCT outcomes of 36 patients undergoing Flu treatment at our institution since December 2002 and retrospectively analyze the results. RIST conditioning with Flu was well-tolerated. No severe toxicity related conditioning regimens was observed in our patients, even though there were 10 patients with a history of autologous (n = 5) or allogeneic stem cell transplantation (n = 5). Hematological engraftment was found in 33 patients. The median times for reconstitution of WBCs, RBCs, and platelets were 16 days, 27.5 days and 34 days, respectively. Stable complete donor chimerism after SCT was present in all patients with WBC engraftment, and no patients experienced late rejection. Thirty-two patients were evaluated for acute graft versus host disease (aGVHD). Nine patients had no aGVHD. The incidence of grade I/II and III/IV aGVHD was 78% and 22%, respectively. Skin lesions were the major sites of involvement. Gut involvement was present in 9 patients. All 4 patients with grade IV GVHD had stage four hepatic GVHD. Twenty-two patients were analyzed for chronic GVHD (cGVHD). Twelve patients had no cGVHD, 6 had limited type and 4 had extended type. The overall survival (OS), relapse rate (RR), and non-relapse mortality (NRM) in all patients over 7 years were found to be 41.7%, 20.1%, and 34.6%, respectively. Induction failures were present in 5 cases of AML and 1 case of NHL. Disease progression was the primary cause of death, which occurred in 12 of 21 patients. Six patients died of grade IV GVHD (n = 2) or complicated fungal infection contracted during the GVHD treatment (n = 4). One patient died of secondary MSD, which originated from donor hematopoietic cells. Two patients died of cerebral bleeding and cardiac rapture, respectively. We found that the patients' state on SCT was the most important factor in long-term survival. The OS of standard risk and high risk patients with hematological malignancies were 75% and 30.3%. We concluded that stem cell transplantation using a non-myeloablative conditioning regimen with Flu was a useful therapeutic approach for patients with hematological malignancies.
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Affiliation(s)
- Kenji Tajika
- Department of Pathophysiological Management/Medical Oncology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan.
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47
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Lee S, Chung NG, Cho BS, Eom KS, Kim YJ, Kim HJ, Min CK, Cho SG, Kim DW, Lee JW, Min WS, Park CW, Kim CC. Donor-specific differences in long-term outcomes of myeloablative transplantation in adults with Philadelphia-negative acute lymphoblastic leukemia. Leukemia 2010; 24:2110-9. [PMID: 20882049 DOI: 10.1038/leu.2010.217] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
We analyzed long-term outcomes of myeloablative stem cell transplantation (SCT) in 292 adults with Philadelphia (Ph)-negative acute lymphoblastic leukemia (ALL). Donors were related (RD; n=132), unrelated (URD; n=68; 30 well-matched (WM), 19 partially matched (PM), 19 mismatched (MM)) and autologous (AUTO; n=92). After a median follow-up of 85 months, the risk of relapse was higher for AUTO-SCT than for RD-SCT (P<0.001). MM-URD-SCT yielded higher risk of non-relapse mortality than RD-SCT (P=0.010). As a result, disease-free survival (DFS) at 5 years was inferior using AUTO (46.1%; P=0.010) or MM-URD (26.3%; P=0.036), whereas DFS from other donor sources was approximately equivalent (53.5% for RD, 63.3% for WM-URD and 57.0% for PM-URD). Other factors associated with poorer DFS included SCT beyond first complete remission (CR), older age and adverse cytogenetics. In a pairwise comparison of outcomes between RD-SCT and AUTO-SCT for patients in first CR, the inferiority of AUTO-SCT was observed, particularly in high-risk patients. Conversely, in standard-risk patients, AUTO-SCT yielded comparable outcomes to RD-SCT. SCT using RD, WM-URD or PM-URD may be considered the best donor sources for adult high-risk Ph-negative ALL.
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Affiliation(s)
- S Lee
- Department of Hematology, Catholic Blood and Marrow Transplantation Center, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
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48
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Turner BE, Collin M, Rice AM. Reduced intensity conditioning for hematopoietic stem cell transplantation: has it achieved all it set out to? Cytotherapy 2010; 12:440-54. [DOI: 10.3109/14653241003709678] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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49
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Forman SJ. Role of reduced intensity transplant in adult patients with acute lymphoblastic leukemia: If and when? Best Pract Res Clin Haematol 2010; 22:557-66. [PMID: 19959108 DOI: 10.1016/j.beha.2009.10.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Although allogeneic transplantation is a potentially curative therapy for adults with acute lymphoblastic leukemia (ALL), the high risk of the ablative regimen limits its use, especially in older patients where the need for better therapy is greatest. Recent observations suggesting that a donor derived graft vs leukemia effect is important is facilitating cure after an allogeneic transplant has kindled interest in utilizing a reduced-intensity approach, which relies in large part on this effect to control and cure the disease. Several trials have now been reported that suggest that a reduced-intensity conditioning (RIC) approach might be very effective, especially in patients who are in the first remission of the disease from either related, unrelated, or cord blood transplant donors, with approximately 50% of patients alive and in remission two years after transplant. These studies suggest that prospective studies of RIC should be conducted in patients with ALL in first remission who are at high risk for relapse based on age or comorbidity to determine its role in the overall management of adult patients with this disease.
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Affiliation(s)
- Stephen J Forman
- Department of Hematology, City of Hope Comprehensive Cancer Center, Duarte, CA 91010, USA.
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50
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Verneris MR, Eapen M, Duerst R, Carpenter PA, Burke MJ, Afanasyev BV, Cowan MJ, He W, Krance R, Li CK, Tan PL, Wagner JE, Davies SM. Reduced-intensity conditioning regimens for allogeneic transplantation in children with acute lymphoblastic leukemia. Biol Blood Marrow Transplant 2010; 16:1237-44. [PMID: 20302960 DOI: 10.1016/j.bbmt.2010.03.009] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2010] [Accepted: 03/07/2010] [Indexed: 01/13/2023]
Abstract
Reduced-intensity conditioning regimens have been used extensively in adults with hematologic malignancies. To address whether this is a feasible approach for children with acute lymphoblastic leukemia, we evaluated transplant outcomes in 38 recipients transplanted from 1995-2005 for whom this was their first transplant. The median age at transplant was 12 years, and 47% had performance scores <90%. Disease status was first complete remission (CR) in 13%, > or =CR2 in 60% of patients, and 22% had active disease at transplantation. Matched related donors were available for a third of patients, about half of whom received bone marrow (BM) and the others, peripheral blood progenitor cells. Sixty percent of unrelated donor transplant recipients received peripheral blood progenitor cells. The day-100 probability of grade II-IV acute graft-versus-host disease was 37% and the 3-year probability of chronic graft-versus-host disease, 26%. At 3 years, the probability of treatment-related mortality was 40%, relapse 37%, and disease-free survival 30%. These data indicate long-term DFS can be achieved using reduced-intensity conditioning regimens in children with acute lymphoblastic leukemia. Given the relatively small cohort, these findings must be validated in a larger population.
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