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Graff Z, Wachter F, Eapen M, Lehmann L, Cooper T. Navigating Treatment Options and Communication in Relapsed Pediatric AML. Am Soc Clin Oncol Educ Book 2024; 44:e438690. [PMID: 38862135 DOI: 10.1200/edbk_438690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2024]
Abstract
Despite improved outcomes in newly diagnosed pediatric AML, relapsed disease remains a therapeutic challenge. Factors contributing to slow progress in improving outcomes include inherent challenges in pediatric clinical trial accrual and the scarcity of novel targeted/immunotherapy agents available for pediatric development. This paradigm is changing, however, as international collaboration grows in parallel with the development of promising targeted agents. In this review, we discuss the therapeutic landscape of relapsed pediatric AML, including conventional chemotherapy, targeted therapies, and the challenges of drug approvals in this patient population. We highlight current efforts to improve communication among academia, industry, and regulatory authorities and discuss the importance of international collaboration to improve access to new therapies. Among the therapeutic options, we highlight the approach to second hematopoietic stem cell transplant (HSCT) and discuss which patients are most likely to benefit from this potentially curative intervention. Importantly, we acknowledge the challenges in providing these high-risk interventions to our patients and their families and the importance of shared communication and decision making when considering early-phase clinical trials and second HSCT.
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Affiliation(s)
- Zachary Graff
- Department of Pediatrics, Division of Hematology, Oncology, and BMT, Medical College of Wisconsin, Milwaukee, WI
| | - Franziska Wachter
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Division of Hematology/Oncology, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Mary Eapen
- Department of Medicine, Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - Leslie Lehmann
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Division of Hematology/Oncology, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Todd Cooper
- Department of Pediatrics, Division of Hematology and Oncology, Seattle Children's Hospital, Seattle, WA
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2
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Verma A, Chi YY, Malvar J, Lamble A, Chaudhury S, Agarwal A, Li HT, Liang G, Leong R, Brown PA, Kaplan J, Schafer ES, Slone T, Pauly M, Chang BH, Stieglitz E, Wayne AS, Hijiya N, Bhojwani D. Nivolumab Plus 5-Azacitidine in Pediatric Relapsed/Refractory Acute Myeloid Leukemia (AML): Phase I/II Trial Results from the Therapeutic Advances in Childhood Leukemia and Lymphoma (TACL) Consortium. Cancers (Basel) 2024; 16:496. [PMID: 38339248 PMCID: PMC10854518 DOI: 10.3390/cancers16030496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/11/2024] [Accepted: 01/19/2024] [Indexed: 02/12/2024] Open
Abstract
Improvements in survival have been made over the past two decades for childhood acute myeloid leukemia (AML), but the approximately 40% of patients who relapse continue to have poor outcomes. A combination of checkpoint-inhibitor nivolumab and azacitidine has demonstrated improvements in median survival in adults with AML. This phase I/II study with nivolumab and azacitidine in children with relapsed/refractory AML (NCT03825367) was conducted through the Therapeutic Advances in Childhood Leukemia & Lymphoma consortium. Thirteen patients, median age 13.7 years, were enrolled. Patients had refractory disease with multiple reinduction attempts. Twelve evaluable patients were treated at the recommended phase II dose (established at dose level 1, 3 mg/kg/dose). Four patients (33%) maintained stable disease. This combination was well tolerated, with no dose-limiting toxicities observed. Grade 3-4 adverse events (AEs) were primarily hematological. Febrile neutropenia was the most common AE ≥ grade 3. A trend to improved quality of life was noted. Increases in CD8+ T cells and reductions in CD4+/CD8+ T cells and demethylation were observed. The combination was well tolerated and had an acceptable safety profile in pediatric patients with relapsed/refractory AML. Future studies might explore this combination for the maintenance of remission in children with AML at high risk of relapse.
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Affiliation(s)
- Anupam Verma
- Center for Cancer and Blood Disorders, Pediatric Hematology Oncology Branch, Children’s National Hospital, Washington, DC 20010, USA
- Division of Pediatric Hematology Oncology, Primary Children’s Hospital, University of Utah, Salt Lake City, UT 84113, USA
| | - Yueh-Yun Chi
- Division of Hematology-Oncology, Cancer and Blood Disease Institute, Children’s Hospital Los Angeles, Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, CA 90027, USA; (Y.-Y.C.); (A.S.W.); (D.B.)
| | - Jemily Malvar
- Division of Hematology-Oncology, Cancer and Blood Disease Institute, Children’s Hospital Los Angeles, Los Angeles, CA 90027, USA; (J.M.)
| | - Adam Lamble
- Department of Pediatric Hematology Oncology, Seattle Children’s Hospital, Seattle, WA 98105, USA;
| | - Sonali Chaudhury
- Department of Pediatric Hematology Oncology, Ann and Robert Lurie Children’s Hospital of Chicago, Chicago, IL 60611, USA;
| | - Archana Agarwal
- Department of Pathology, University of Utah and ARUP Laboratories, Salt Lake City, UT 84108, USA;
| | - Hong-Tao Li
- Department of Urology, University of Southern California, Los Angeles, CA 90033, USA; (H.-T.L.); (G.L.)
| | - Gangning Liang
- Department of Urology, University of Southern California, Los Angeles, CA 90033, USA; (H.-T.L.); (G.L.)
| | - Roy Leong
- Division of Hematology-Oncology, Cancer and Blood Disease Institute, Children’s Hospital Los Angeles, Los Angeles, CA 90027, USA; (J.M.)
| | | | - Joel Kaplan
- Department of Pediatric Hematology Oncology, Atrium Health Levine Children’s Hospital, Wake Forrest University, Charlotte, NC 28203, USA;
| | - Eric S. Schafer
- Division of Pediatric Hematology/Oncology, Baylor College of Medicine, Texas Children’s Cancer and Hematology Center, Houston, TX 77030, USA;
| | - Tamra Slone
- Department of Pediatric Hematology Oncology, UT Southwestern, Dallas, TX 75235, USA;
| | - Melinda Pauly
- Department of Pediatric Hematology Oncology, Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA;
| | - Bill H. Chang
- Division of Pediatric Hematology Oncology, Oregon Health and Science University, Portland, OR 97239, USA;
| | - Elliot Stieglitz
- Department of Pediatric Oncology, University of California, San Francisco Benioff Children’s Hospitals, San Francisco, CA 94158, USA;
| | - Alan S. Wayne
- Division of Hematology-Oncology, Cancer and Blood Disease Institute, Children’s Hospital Los Angeles, Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, CA 90027, USA; (Y.-Y.C.); (A.S.W.); (D.B.)
| | - Nobuko Hijiya
- Division of Pediatric Hematology Oncology and Stem Cell Transplant, Columbia University Medical Center, New York, NY 10032, USA;
| | - Deepa Bhojwani
- Division of Hematology-Oncology, Cancer and Blood Disease Institute, Children’s Hospital Los Angeles, Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, CA 90027, USA; (Y.-Y.C.); (A.S.W.); (D.B.)
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3
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Pawinska-Wasikowska K, Czogala M, Skoczen S, Surman M, Rygielska M, Ksiazek T, Pac A, Wieczorek A, Skalska-Sadowska J, Samborska M, Wachowiak J, Chaber R, Tomaszewska R, Szczepanski T, Zielezinska K, Urasinski T, Moj-Hackemer M, Kalwak K, Kozlowska M, Irga-Jaworska N, Balwierz W, Bukowska-Strakova K. Gemtuzumab ozogamicin for relapsed or primary refractory acute myeloid leukemia in children-the Polish Pediatric Leukemia and Lymphoma Study Group experience. Front Immunol 2023; 14:1268993. [PMID: 38187390 PMCID: PMC10766767 DOI: 10.3389/fimmu.2023.1268993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 12/07/2023] [Indexed: 01/09/2024] Open
Abstract
Background Gemtuzumab ozogamicin (GO), one of the first targeted drugs used in oncology, consists of an anti-cluster of differentiation 33 (CD33) monoclonal antibody bound to a derivative of cytotoxic calicheamicin. After the drug withdrawn in 2010 due to a significantly higher rate of early deaths, GO regained approval in 2017 for the treatment of newly diagnosed, refractory, or relapsed acute myeloid leukemia (AML) in adults and children over 15 years of age. The objective of the study was a retrospective analysis of clinical characteristics, treatment outcomes, and GO toxicity profile in children with primary refractory or relapsed (R/R) AML treated in Poland from 2008 to 2022. Methods Data were collected through the Polish Registry of Acute Myeloid Leukemia. From January 2008 to December 2022, 35 children with R/R AML were treated with GO in seven centers of the Polish Pediatric Leukemia and Lymphoma Study Group. Results Most of the children (30 of 35) received only one GO cycle in combination with various chemotherapy cycles (IDA-FLA, DOXO-FLA, FLA, FLAG, and others). Eighteen children (51%) achieved complete remission (CR), 14 did not respond to treatment, and three progressed. GO therapy was followed by allogeneic hematopoietic stem cell transplantation (allo-HSCT) in 18 children in CR. The 5-year overall survival (OS) after GO therapy was 37.1% ± 8.7% for the total cohort. There was a trend toward a superior outcome in patients with strong expression of CD33 expression (over 50% positive cells) compared with that in patients with lower expression of CD33 (OS, 41.2% ± 11.9% versus 27.8% ± 13.2%; p = 0.5; 5-year event-free survival, 35.4% ± 11.6% versus 25.7% ± 12.3%; p = 0.5, respectively). Children under 15 years have better outcome (OS, 34.9% ± 10.4% versus 30% ± 14.5%, p = 0.3). The most common adverse events were bone marrow aplasia, fever of unknown origin, infections, and elevated liver enzyme elevation. Sinusoidal obstruction syndrome occurred in two children. Conclusions The use of GO in severely pretreated children, including those under 15 years of age, with previous failure of AML treatment is a feasible and effective bridging therapy to allo-HSCT with an acceptable toxicity profile.
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Affiliation(s)
- Katarzyna Pawinska-Wasikowska
- Department of Pediatric Oncology and Hematology, Institute of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
- Department of Pediatric Oncology and Hematology, University Children Hospital of Krakow, Krakow, Poland
| | - Malgorzata Czogala
- Department of Pediatric Oncology and Hematology, Institute of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
- Department of Pediatric Oncology and Hematology, University Children Hospital of Krakow, Krakow, Poland
| | - Szymon Skoczen
- Department of Pediatric Oncology and Hematology, Institute of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
- Department of Pediatric Oncology and Hematology, University Children Hospital of Krakow, Krakow, Poland
| | - Marta Surman
- Laboratory of Clinical Immunology, University Children’s Hospital of Krakow, Krakow, Poland
| | - Monika Rygielska
- Department of Pediatric Oncology and Hematology, Hematology Laboratory, University Children’s Hospital, Krakow, Poland
| | - Teofila Ksiazek
- Department of Medical Genetics, Institute of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
| | - Agnieszka Pac
- Department of Epidemiology and Preventive Medicine, Faculty of Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Aleksandra Wieczorek
- Department of Pediatric Oncology and Hematology, Institute of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
- Department of Pediatric Oncology and Hematology, University Children Hospital of Krakow, Krakow, Poland
| | - Jolanta Skalska-Sadowska
- Department of Pediatric Oncology, Hematology and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Magdalena Samborska
- Department of Pediatric Oncology, Hematology and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Jacek Wachowiak
- Department of Pediatric Oncology, Hematology and Transplantology, Poznan University of Medical Sciences, Poznan, Poland
| | - Radoslaw Chaber
- Department of Pediatric Oncohematology, Clinical Province Hospital of Rzeszow, Rzeszow, Poland
- Department of Pediatrics, Institute of Medical Sciences, Medical College, University of Rzeszow, Rzeszow, Poland
| | - Renata Tomaszewska
- Department of Pediatric Hematology and Oncology, Zabrze, Medical University of Silesia, Katowice, Poland
| | - Tomasz Szczepanski
- Department of Pediatric Hematology and Oncology, Zabrze, Medical University of Silesia, Katowice, Poland
| | - Karolina Zielezinska
- Department of Pediatrics, Hemato-Oncology and Gastroenterology, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | - Tomasz Urasinski
- Department of Pediatrics, Hemato-Oncology and Gastroenterology, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | - Malgorzata Moj-Hackemer
- Clinical Department of Pediatric Bone Marrow Transplantation, Oncology and Hematology, Wroclaw Medical University, Wroclaw, Poland
| | - Krzysztof Kalwak
- Clinical Department of Pediatric Bone Marrow Transplantation, Oncology and Hematology, Wroclaw Medical University, Wroclaw, Poland
| | - Marta Kozlowska
- Department of Pediatrics, Hematology and Oncology, Medical University of Gdansk, Gdansk, Poland
| | - Ninela Irga-Jaworska
- Department of Pediatrics, Hematology and Oncology, Medical University of Gdansk, Gdansk, Poland
| | - Walentyna Balwierz
- Department of Pediatric Oncology and Hematology, Institute of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
- Department of Pediatric Oncology and Hematology, University Children Hospital of Krakow, Krakow, Poland
| | - Karolina Bukowska-Strakova
- Department of Clinical Immunology, Institute of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
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Branella GM, Lee JY, Okalova J, Parwani KK, Alexander JS, Arthuzo RF, Fedanov A, Yu B, McCarty D, Brown HC, Chandrakasan S, Petrich BG, Doering CB, Spencer HT. Ligand-based targeting of c-kit using engineered γδ T cells as a strategy for treating acute myeloid leukemia. Front Immunol 2023; 14:1294555. [PMID: 38022523 PMCID: PMC10679681 DOI: 10.3389/fimmu.2023.1294555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 10/26/2023] [Indexed: 12/01/2023] Open
Abstract
The application of immunotherapies such as chimeric antigen receptor (CAR) T therapy or bi-specific T cell engager (BiTE) therapy to manage myeloid malignancies has proven more challenging than for B-cell malignancies. This is attributed to a shortage of leukemia-specific cell-surface antigens that distinguish healthy from malignant myeloid populations, and the inability to manage myeloid depletion unlike B-cell aplasia. Therefore, the development of targeted therapeutics for myeloid malignancies, such as acute myeloid leukemia (AML), requires new approaches. Herein, we developed a ligand-based CAR and secreted bi-specific T cell engager (sBite) to target c-kit using its cognate ligand, stem cell factor (SCF). c-kit is highly expressed on AML blasts and correlates with resistance to chemotherapy and poor prognosis, making it an ideal candidate for which to develop targeted therapeutics. We utilize γδ T cells as a cytotoxic alternative to αβ T cells and a transient transfection system as both a safety precaution and switch to remove alloreactive modified cells that may hinder successful transplant. Additionally, the use of γδ T cells permits its use as an allogeneic, off-the-shelf therapeutic. To this end, we show mSCF CAR- and hSCF sBite-modified γδ T cells are proficient in killing c-kit+ AML cell lines and sca-1+ murine bone marrow cells in vitro. In vivo, hSCF sBite-modified γδ T cells moderately extend survival of NSG mice engrafted with disseminated AML, but therapeutic efficacy is limited by lack of γδ T-cell homing to murine bone marrow. Together, these data demonstrate preclinical efficacy and support further investigation of SCF-based γδ T-cell therapeutics for the treatment of myeloid malignancies.
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Affiliation(s)
- Gianna M. Branella
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
- Graduate Division of Biological and Biomedical Sciences, Laney Graduate School, Emory University, Atlanta, GA, United States
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA, United States
| | - Jasmine Y. Lee
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
- Graduate Division of Biological and Biomedical Sciences, Laney Graduate School, Emory University, Atlanta, GA, United States
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA, United States
| | - Jennifer Okalova
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA, United States
- Molecular Systems Pharmacology Program, Graduate Division of Biological and Biomedical Sciences, Laney Graduate School, Emory University, Atlanta, GA, United States
| | - Kiran K. Parwani
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
- Graduate Division of Biological and Biomedical Sciences, Laney Graduate School, Emory University, Atlanta, GA, United States
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA, United States
| | - Jordan S. Alexander
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA, United States
| | - Raquel F. Arthuzo
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
- Graduate Division of Biological and Biomedical Sciences, Laney Graduate School, Emory University, Atlanta, GA, United States
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA, United States
| | - Andrew Fedanov
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA, United States
| | - Bing Yu
- Expression Therapeutics, Inc., Tucker, GA, United States
| | - David McCarty
- Expression Therapeutics, Inc., Tucker, GA, United States
| | | | - Shanmuganathan Chandrakasan
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA, United States
| | | | - Christopher B. Doering
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA, United States
- Molecular Systems Pharmacology Program, Graduate Division of Biological and Biomedical Sciences, Laney Graduate School, Emory University, Atlanta, GA, United States
| | - H. Trent Spencer
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, United States
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA, United States
- Molecular Systems Pharmacology Program, Graduate Division of Biological and Biomedical Sciences, Laney Graduate School, Emory University, Atlanta, GA, United States
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5
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Marrero RJ, Cao X, Wu H, Elsayed AH, Klco JM, Ribeiro RC, Rubnitz JE, Ma X, Meshinchi S, Aplenc R, Kolb EA, Ries RE, Alonzo TA, Pounds SB, Lamba JK. SAMHD1 single nucleotide polymorphisms impact outcome in children with newly diagnosed acute myeloid leukemia. Blood Adv 2023; 7:2538-2550. [PMID: 36689724 PMCID: PMC10242642 DOI: 10.1182/bloodadvances.2022009088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 12/08/2022] [Accepted: 01/09/2023] [Indexed: 01/24/2023] Open
Abstract
Cytarabine arabinoside (Ara-C) has been the cornerstone of acute myeloid leukemia (AML) chemotherapy for decades. After cellular uptake, it is phosphorylated into its active triphosphate form (Ara-CTP), which primarily exerts its cytotoxic effects by inhibiting DNA synthesis in proliferating cells. Interpatient variation in the enzymes involved in the Ara-C metabolic pathway has been shown to affect intracellular abundance of Ara-CTP and, thus, its therapeutic benefit. Recently, SAMHD1 (SAM and HD domain-containing deoxynucleoside triphosphate triphosphohydrolase 1) has emerged to play a role in Ara-CTP inactivation, development of drug resistance, and, consequently, clinical response in AML. Despite this, the impact of genetic variations in SAMHD1 on outcome in AML has not been investigated in depth. In this study, we evaluated 25 single nucleotide polymorphisms (SNPs) within the SAMHD1 gene for association with clinical outcome in 400 pediatric patients with newly diagnosed AML from 2 clinical trials, AML02 and AML08. Three SNPs, rs1291128, rs1291141, and rs7265241 located in the 3' region of SAMHD1 were significantly associated with at least 1 clinical outcome: minimal residual disease after induction I, event-free survival (EFS), or overall survival (OS) in the 2 cohorts. In an independent cohort of patients from the COG-AAML1031 trial (n = 854), rs7265241 A>G remained significantly associated with EFS and OS. In multivariable analysis, all the SNPs remained independent predictors of clinical outcome. These results highlight the relevance of the SAMHD1 pharmacogenomics in context of response to Ara-C in AML and warrants the need for further validation in expanded patient cohorts.
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Affiliation(s)
- Richard J. Marrero
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL
| | - Xueyuan Cao
- Department of Health Promotion and Disease Prevention, University of Tennessee Health Science Center, Memphis, TN
| | - Huiyun Wu
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, TN
| | - Abdelrahman H. Elsayed
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL
| | - Jeffery M. Klco
- Department of Pathology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Raul C. Ribeiro
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Jeffrey E. Rubnitz
- Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Xiaotu Ma
- Department of Computational Biology, St. Jude Children’s Research Hospital, Memphis, TN
| | - Soheil Meshinchi
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Richard Aplenc
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - E. Anders Kolb
- Nemours Center for Cancer and Blood Disorders, Alfred I. DuPont Hospital for Children, Wilmington, DE
| | - Rhonda E. Ries
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Todd A. Alonzo
- Children's Oncology Group Statistics and Data Center, Monrovia, CA
- Biostatistics Division, University of Southern California, Los Angeles, CA
| | - Stanley B. Pounds
- Department of Biostatistics, St. Jude Children’s Research Hospital, Memphis, TN
| | - Jatinder K. Lamba
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL
- University of Florida Health Cancer Center, University of Florida, Gainesville, FL
- Center for Pharmacogenomics and Precision Medicine, College of Pharmacy, University of Florida, Gainesville, FL
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6
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Marinoff AE, Aaronson K, Agrawal AK, Braun BS, Golden C, Huang BJ, Michlitsch J, Southworth E, Thrall A, Vo KT, Stieglitz E. Venetoclax in combination with chemotherapy as treatment for pediatric advanced hematologic malignancies. Pediatr Blood Cancer 2023; 70:e30335. [PMID: 37036306 PMCID: PMC10133180 DOI: 10.1002/pbc.30335] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 03/06/2023] [Accepted: 03/13/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND Venetoclax is frequently used as salvage treatment in pediatric, adolescent, and young adult (AYA) patients with advanced hematologic malignancies. However, more data are needed from real-world studies to guide the safe and appropriate use of venetoclax in this population. PROCEDURE We retrospectively reviewed the medical records of all patients diagnosed with hematologic malignancies less than 30 years of age treated with venetoclax outside of clinical trials at the University of California San Francisco Benioff Children's Hospitals from 2016 to 2022. RESULTS We identified 13 patients (acute myeloid leukemia, n = 8; B-acute lymphoblastic leukemia, n = 3; myelodysplastic syndrome, n = 2) aged 4 months to 27 years. A median of 3 prior lines of therapy weregiven (range 0-5). All patients received venetoclax in combination with either a hypomethylating agent or conventional chemotherapy. Three (23%) patients achieved complete remission (CR); two (15%) achieved partial remission (PR); 3 (23%) had stable disease (SD), and five (42%) had progressive disease. Median survival and time to progression from venetoclax initiation was 9 months (range 2.5-52 months) and 3 months (range 2 weeks to 7.5 months), respectively. Six patients (46%) developed grade 3 or higher infections while receiving venetoclax, including bacteremia due to atypical organisms, invasive pulmonary infections with Aspergillus, cytomegalovirus (CMV) viremia, skin infections, and encephalitis with bacterial brain abscesses. CONCLUSIONS Venetoclax in combination with hypomethylating agents or cytotoxic chemotherapy was effective in a subset of pediatric/AYA patients with advanced hematologic malignancies, but multiple severe infections were observed, particularly among patients who received venetoclax in combination with chemotherapy. Prospective studies will be required to determine the optimal dose and duration of venetoclax in this population.
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Affiliation(s)
- Amanda E. Marinoff
- University of California, San Francisco Benioff Children’s Hospitals, Oakland and San Francisco, California
| | - Kathryn Aaronson
- University of California, San Francisco Benioff Children’s Hospitals, Oakland and San Francisco, California
| | - Anurag K. Agrawal
- University of California, San Francisco Benioff Children’s Hospitals, Oakland and San Francisco, California
| | - Benjamin S. Braun
- University of California, San Francisco Benioff Children’s Hospitals, Oakland and San Francisco, California
| | - Carla Golden
- University of California, San Francisco Benioff Children’s Hospitals, Oakland and San Francisco, California
| | - Benjamin J. Huang
- University of California, San Francisco Benioff Children’s Hospitals, Oakland and San Francisco, California
| | - Jennifer Michlitsch
- University of California, San Francisco Benioff Children’s Hospitals, Oakland and San Francisco, California
| | - Erica Southworth
- University of California, San Francisco Benioff Children’s Hospitals, Oakland and San Francisco, California
| | - Allyson Thrall
- University of California, San Francisco Benioff Children’s Hospitals, Oakland and San Francisco, California
| | - Kieuhoa T. Vo
- University of California, San Francisco Benioff Children’s Hospitals, Oakland and San Francisco, California
| | - Elliot Stieglitz
- University of California, San Francisco Benioff Children’s Hospitals, Oakland and San Francisco, California
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Parametric Models for Survival Analysis of Childhood Cancer Patients' Data. INTERNATIONAL JOURNAL OF CANCER MANAGEMENT 2022. [DOI: 10.5812/ijcm-127430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: The rate of childhood cancer death has dropped steadily over the past 50 years. The pediatric cancer risk has remained under investigation. Objectives: This study aims at investigating the associated factors with the survival of pediatric patients with retinoblastoma, sarcoma, brain tumor, and leukemia cancer. Methods: The cohort study of 1879 children with retinoblastoma, sarcoma, brain tumor, and leukemia aged < 1, 1 - 5, 6 - 10, 11 - 15, and > 15 years in Mahak Hospital and Rehabilitation Complex from 2007 to 2016 were enrolled in the study. Median survival time was reported for each cancer. Parametric survival models including Gompertz, Weibull, lognormal, and log‑logistic models were fitted. Then, the model with almost minimum Akaike information criterion (AIC) was chosen. The hazard ratio (HR) and the analysis were performed by R3.5.1. Results: Totally, 270 (14.37%) patients with Retinoblastoma, 667 (35.5%) with leukemia, 625 (33.26%) with a Brain tumor, and 317 (16.87%) with Sarcoma were included in this study; 815 (43.37%) patients were female. Gompertz's model was chosen to fit the data due to the minimum AIC. The associated factors with the survival of childhood cancers were as follows: age < 1 year, parental relation, loco-regional relapse and chemotherapy alone (HR: 7.63, 1.56, 4.61, 1.12) in leukemia, other nationalities, metastasis or metastasis and loco-regional relapse and chemotherapy alone (HR = 3.74, 5.75, 2.12) in retinoblastoma, loco-regional relapse and metastasis (HR = 2.40, 3.71) in brain tumor, other ages except for 5 - 10 years, parental relation, chemotherapy alone, and metastasis (HR = 33.3, 1.80, 3.57, 3.8) in sarcoma. Conclusions: Age, parental familial relationships, combination therapy, and metastasis of primary cancer were the risk factors for survival of children with 4 common cancers of leukemia, retinoblastoma, brain tumors, and sarcoma, using the Gompertz model.
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8
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Molecular Measurable Residual Disease Assessment before Hematopoietic Stem Cell Transplantation in Pediatric Acute Myeloid Leukemia Patients: A Retrospective Study by the I-BFM Study Group. Biomedicines 2022; 10:biomedicines10071530. [PMID: 35884834 PMCID: PMC9313005 DOI: 10.3390/biomedicines10071530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 06/14/2022] [Accepted: 06/24/2022] [Indexed: 11/16/2022] Open
Abstract
Hematopoietic stem cell transplantation (HSCT) is a curative post-remission treatment in patients with acute myeloid leukemia (AML), but relapse after transplant is still a challenging event. In recent year, several studies have investigated the molecular minimal residual disease (qPCR-MRD) as a predictor of relapse, but the lack of standardized protocols, cut-offs, and timepoints, especially in the pediatric setting, has prevented its use in several settings, including before HSCT. Here, we propose the first collaborative retrospective I-BFM-AML study assessing qPCR-MRD values in pretransplant bone marrow samples of 112 patients with a diagnosis of AML harboring t(8;21)(q22; q22)RUNX1::RUNX1T1, or inv(16)(p13q22)CBFB::MYH11, or t(9;11)(p21;q23)KMT2A::MLLT3, or FLT3-ITD genetic markers. We calculated an ROC cut-off of 2.1 × 10−4 that revealed significantly increased OS (83.7% versus 57.1%) and EFS (80.2% versus 52.9%) for those patients with lower qPCR-MRD values. Then, we partitioned patients into three qPCR-MRD groups by combining two different thresholds, 2.1 × 10−4 and one lower cut-off of 1 × 10−2, and stratified patients into low-, intermediate-, and high-risk groups. We found that the 5-year OS (83.7%, 68.6%, and 39.2%, respectively) and relapse-free survival (89.2%, 73.9%, and 67.9%, respectively) were significantly different independent of the genetic lesion, conditioning regimen, donor, and stem cell source. These data support the PCR-based approach playing a clinical relevance in AML transplant management.
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9
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Relapsed acute myeloid leukemia in children and adolescents: current treatment options and future strategies. Leukemia 2022; 36:1951-1960. [PMID: 35668109 DOI: 10.1038/s41375-022-01619-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/18/2022] [Accepted: 05/26/2022] [Indexed: 11/08/2022]
Abstract
Pediatric acute myeloid leukemia (AML) develops from clonal expansion of hematopoietic precursor cells and is characterized by morphologic and cytomolecular heterogeneity. Although the past 40 years have seen significant improvements in overall survival, the prevailing treatment challenges in pediatric AML are the prevention of relapse and the management of relapsed disease. Approximately 25% of children and adolescents with AML suffer disease relapse and face a poor prognosis. Our greater understanding of the genomic, epigenomic, metabolomic, and immunologic pathophysiology of relapsed AML allows for better therapeutic strategies that are being developed for pediatric clinical trials. The development of biologically rational agents is critical as conventional chemotherapeutic salvage regimens are not effective for all patients and pose risk of organ toxicity in heavily pretreated patients. Another major barrier to improvement in outcomes for relapsed pediatric AML is the historic lack of availability and participation in clinical trials. There are ongoing efforts to launch multinational clinical trials of emerging therapies. The purpose of this review is to summarize currently available and newly developed therapies for relapsed pediatric AML.
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10
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Bednarski JJ, Zimmerman C, Berrien-Elliott MM, Foltz JA, Becker-Hapak M, Neal CC, Foster M, Schappe T, McClain E, Pence PP, Desai S, Kersting-Schadek S, Wong P, Russler-Germain DA, Fisk B, Lie WR, Eisele J, Hyde S, Bhatt ST, Griffith OL, Griffith M, Petti AA, Cashen AF, Fehniger TA. Donor memory-like NK cells persist and induce remissions in pediatric patients with relapsed AML after transplant. Blood 2022; 139:1670-1683. [PMID: 34871371 PMCID: PMC8931511 DOI: 10.1182/blood.2021013972] [Citation(s) in RCA: 55] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 11/18/2021] [Indexed: 11/20/2022] Open
Abstract
Pediatric and young adult (YA) patients with acute myeloid leukemia (AML) who relapse after allogeneic hematopoietic cell transplantation (HCT) have an extremely poor prognosis. Standard salvage chemotherapy and donor lymphocyte infusions (DLIs) have little curative potential. Previous studies showed that natural killer (NK) cells can be stimulated ex vivo with interleukin-12 (IL-12), -15, and -18 to generate memory-like (ML) NK cells with enhanced antileukemia responses. We treated 9 pediatric/YA patients with post-HCT relapsed AML with donor ML NK cells in a phase 1 trial. Patients received fludarabine, cytarabine, and filgrastim followed 2 weeks later by infusion of donor lymphocytes and ML NK cells from the original HCT donor. ML NK cells were successfully generated from haploidentical and matched-related and -unrelated donors. After infusion, donor-derived ML NK cells expanded and maintained an ML multidimensional mass cytometry phenotype for >3 months. Furthermore, ML NK cells exhibited persistent functional responses as evidenced by leukemia-triggered interferon-γ production. After DLI and ML NK cell adoptive transfer, 4 of 8 evaluable patients achieved complete remission at day 28. Two patients maintained a durable remission for >3 months, with 1 patient in remission for >2 years. No significant toxicity was experienced. This study demonstrates that, in a compatible post-HCT immune environment, donor ML NK cells robustly expand and persist with potent antileukemic activity in the absence of exogenous cytokines. ML NK cells in combination with DLI present a novel immunotherapy platform for AML that has relapsed after allogeneic HCT. This trial was registered at https://clinicaltrials.gov as #NCT03068819.
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Affiliation(s)
| | - Clare Zimmerman
- Division of Hematology and Oncology, Department of Pediatrics, and
| | - Melissa M Berrien-Elliott
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Jennifer A Foltz
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Michelle Becker-Hapak
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Carly C Neal
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Mark Foster
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Timothy Schappe
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Ethan McClain
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Patrick P Pence
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Sweta Desai
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Samantha Kersting-Schadek
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Pamela Wong
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - David A Russler-Germain
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Bryan Fisk
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | | | - Jeremy Eisele
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Stephanie Hyde
- Division of Hematology and Oncology, Department of Pediatrics, and
| | - Sima T Bhatt
- Division of Hematology and Oncology, Department of Pediatrics, and
| | - Obi L Griffith
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Malachi Griffith
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Allegra A Petti
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO
| | - Amanda F Cashen
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Todd A Fehniger
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
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11
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UMAP Based Anomaly Detection for Minimal Residual Disease Quantification within Acute Myeloid Leukemia. Cancers (Basel) 2022; 14:cancers14040898. [PMID: 35205645 PMCID: PMC8870142 DOI: 10.3390/cancers14040898] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 01/28/2022] [Accepted: 02/02/2022] [Indexed: 11/22/2022] Open
Abstract
Simple Summary Acute myeloid leukemia (AML) is the second most frequent leukemia entity in children and adolescents, and definitely the most aggressive variant. Multiparameter flow-cytometry is one of the methodologies most useful to monitor the number of remaining leukemic cells in bone marrow (minimal residual disease, MRD) in AML patients, because it is widely available and applicable to most patients. However, AML flow cytometry data show very complex patterns and identifying leukemic cells in the data is subjective, time-consuming and requires experienced operators who are not available world-wide. In this paper, we approach automatic assessment of AML flow cytometry samples with a novel semi-supervised machine learning model, leveraging implicit expert knowledge stored in a collection of manually assessed samples. Because AML data exhibit a high degree of variability in the patterns of blast cell populations that is difficult to model, the model detects anomalies starting from the appearance of normal cell populations. Abstract Leukemia is the most frequent malignancy in children and adolescents, with acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML) as the most common subtypes. Minimal residual disease (MRD) measured by flow cytometry (FCM) has proven to be a strong prognostic factor in ALL as well as in AML. Machine learning techniques have been emerging in the field of automated MRD quantification with the objective of superseding subjective and time-consuming manual analysis of FCM-MRD data. In contrast to ALL, where supervised multi-class classification methods have been successfully deployed for MRD detection, AML poses new challenges: AML is rarer (with fewer available training data) than ALL and much more heterogeneous in its immunophenotypic appearance, where one-class classification (anomaly detection) methods seem more suitable. In this work, a new semi-supervised approach based on the UMAP algorithm for MRD detection utilizing only labels of blast free FCM samples is presented. The method is tested on a newly gathered set of AML FCM samples and results are compared to state-of-the-art methods. We reach a median F1-score of 0.794, while providing a transparent classification pipeline with explainable results that facilitates inter-disciplinary work between medical and technical experts. This work shows that despite several issues yet to overcome, the merits of automated MRD quantification can be fully exploited also in AML.
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12
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Wang L, Li C, Xu F, Cao F, Zhang B, Wang J, Wang S, Chen L, Li N, Liao C, Liu H. Analysis of efficacy, safety and prognostic factors of DAC-HAA treatment in Chinese pediatric patients with refractory or relapsed acute myeloid leukemia. Mol Clin Oncol 2021; 15:269. [PMID: 34790353 PMCID: PMC8591692 DOI: 10.3892/mco.2021.2431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 08/19/2021] [Indexed: 11/06/2022] Open
Abstract
Hematopoietic stem cell transplantation (HSCT) is generally considered as the only effective treatment for children with relapsed/refractory (R/R) acute myeloid leukemia (AML). Achieving remission prior to HSCT affects the efficacy of the procedure and patient survival; therefore, induction therapy in children with R/R AML prior to HSCT is very important. The aim of the present study was to evaluate the clinical efficacy, prognosis and safety of 5-aza-2-deoxycytidine (DAC) combined with homoharringtonine + cytarabine + aclarubicin (HAA regimen) in the treatment of pediatric R/R AML. A total of 53 pediatric patients with R/R AML, aged 1-14 years, were treated with DAC-HAA. The overall response rate was 83.1%, with a complete remission rate of 77.4% and a partial remission rate of 5.7%. In conclusion, DAC-HAA therapy for children with R/R AML was found to be associated with a high remission rate, a short period of bone marrow suppression and a good safety profile. Therefore, DAC-HAA may be of value as a transitional regimen prior to HSCT and is worthy of clinical consideration.
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Affiliation(s)
- Liang Wang
- Children's Hematology Oncology, Anhui Provincial Cancer Hospital, Hefei, Anhui 230031, P.R. China
| | - Chun Li
- Department of Pediatrics, The First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui 230001, P.R. China
| | - Fang Xu
- Children's Hematology Oncology, Anhui Provincial Cancer Hospital, Hefei, Anhui 230031, P.R. China
| | - Fang Cao
- Children's Hematology Oncology, Anhui Provincial Cancer Hospital, Hefei, Anhui 230031, P.R. China
| | - Bo Zhang
- Children's Hematology Oncology, Anhui Provincial Cancer Hospital, Hefei, Anhui 230031, P.R. China
| | - Jing Wang
- Children's Hematology Oncology, Anhui Provincial Cancer Hospital, Hefei, Anhui 230031, P.R. China
| | - Shen Wang
- Children's Hematology Oncology, Anhui Provincial Cancer Hospital, Hefei, Anhui 230031, P.R. China
| | - Li Chen
- Children's Hematology Oncology, Anhui Provincial Cancer Hospital, Hefei, Anhui 230031, P.R. China
| | - Na Li
- Children's Hematology Oncology, Anhui Provincial Cancer Hospital, Hefei, Anhui 230031, P.R. China
| | - Chenglin Liao
- Children's Hematology Oncology, Anhui Provincial Cancer Hospital, Hefei, Anhui 230031, P.R. China
| | - Hongjun Liu
- Department of Pediatrics, The First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui 230001, P.R. China
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13
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Cieniewicz B, Uyeda MJ, Chen PP, Sayitoglu EC, Liu JMH, Andolfi G, Greenthal K, Bertaina A, Gregori S, Bacchetta R, Lacayo NJ, Cepika AM, Roncarolo MG. Engineered type 1 regulatory T cells designed for clinical use kill primary pediatric acute myeloid leukemia cells. Haematologica 2021; 106:2588-2597. [PMID: 33054128 PMCID: PMC8485690 DOI: 10.3324/haematol.2020.263129] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Indexed: 12/02/2022] Open
Abstract
Type 1 regulatory (Tr1) T cells induced by enforced expression of interleukin-10 (LV-10) are being developed as a novel treatment for chemotherapy-resistant myeloid leukemias. In vivo, LV-10 cells do not cause graft-versus-host disease while mediating graft-versus-leukemia effect against adult acute myeloid leukemia (AML). Since pediatric AML (pAML) and adult AML are different on a genetic and epigenetic level, we investigate herein whether LV-10 cells also efficiently kill pAML cells. We show that the majority of primary pAML are killed by LV-10 cells, with different levels of sensitivity to killing. Transcriptionally, pAML sensitive to LV-10 killing expressed a myeloid maturation signature. Overlaying the signatures of sensitive and resistant pAML onto the public NCI TARGET pAML dataset revealed that sensitive pAML clustered with M5 monocytic pAML and pAML with MLL rearrangement. Resistant pAML clustered with myelomonocytic leukemias and those bearing the core binding factor translocations inv(16) or t(8;21)(RUNX1- RUNX1T1). Furthermore, resistant pAML upregulated the membrane glycoprotein CD200, which binds to the inhibitory receptor CD200R1 on LV-10 cells. In order to examine if CD200 expression on target cells can impair LV-10 cell function, we overexpressed CD200 in myeloid leukemia cell lines ordinarily sensitive to LV-10 killing. Indeed, LV-10 cells degranulated less and killed fewer CD200-overexpressing cells compared to controls, indicating that pAML can utilize CD200 expression for immune evasion. Altogether, the majority of pAML are killed by LV-10 cells in vitro, supporting further LV-10 cell development as an innovative cell therapy for pAML.
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Affiliation(s)
- Brandon Cieniewicz
- Department of Pediatrics, Division of Stem Cell Biology and Regenerative Medicine, Stanford School of Medicine, Stanford
| | - Molly Javier Uyeda
- Department of Pediatrics, Division of Stem Cell Biology and Regenerative Medicine, Stanford School of Medicine, Stanford, CA; Stanford Institute for Stem Cell Biology and Regenerative Medicine, Stanford School of Medicine, Stanford
| | - Ping Pauline Chen
- Department of Pediatrics, Division of Stem Cell Biology and Regenerative Medicine, Stanford School of Medicine, Stanford
| | - Ece Canan Sayitoglu
- Department of Pediatrics, Division of Stem Cell Biology and Regenerative Medicine, Stanford School of Medicine, Stanford
| | - Jeffrey Mao-Hwa Liu
- Department of Pediatrics, Division of Stem Cell Biology and Regenerative Medicine, Stanford School of Medicine, Stanford
| | | | - Katharine Greenthal
- Department of Pediatrics, Division of Stem Cell Biology and Regenerative Medicine, Stanford School of Medicine, Stanford
| | - Alice Bertaina
- Department of Pediatrics, Division of Stem Cell Biology and Regenerative Medicine, Stanford School of Medicine, Stanford
| | | | - Rosa Bacchetta
- Department of Pediatrics, Division of Stem Cell Biology and Regenerative Medicine, Stanford School of Medicine, Stanford
| | - Norman James Lacayo
- Department of Pediatrics, Division of Stem Cell Biology and Regenerative Medicine, Stanford School of Medicine, Stanford
| | - Alma-Martina Cepika
- Department of Pediatrics, Division of Stem Cell Biology and Regenerative Medicine, Stanford School of Medicine, Stanford
| | - Maria Grazia Roncarolo
- Department of Pediatrics, Division of Stem Cell Biology and Regenerative Medicine, Stanford School of Medicine, Stanford, CA; Stanford Institute for Stem Cell Biology and Regenerative Medicine, Stanford School of Medicine, Stanford.
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Abstract
Minimal or measurable residual disease (MRD) after therapy is the most important independent prognostic factor in acute myeloid leukemia. MRD measured by multiparametric flow cytometry and real-time quantitative polymerase chain reaction has been integrated into risk stratification and used to guide future treatment strategies. Recent technological advances have allowed the application of the novel molecular method, high-throughput sequencing, in MRD detection in clinical practice to improve sensitivity and specificity. Randomized studies are needed to address outstanding issues, including the optimal methods and timing of MRD testing and interlaboratory standardization to facilitate comparisons, to further improve MRD-directed interventions.
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Affiliation(s)
- Xueyan Chen
- Hematopathology, SCCA G7800, 825 Eastlake Ave E., Seattle, WA 98109, USA
| | - Sindhu Cherian
- Hematopathology, SCCA G7800, 825 Eastlake Ave E., Seattle, WA 98109, USA.
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15
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Survival Following Relapse in Children with Acute Myeloid Leukemia: A Report from AML-BFM and COG. Cancers (Basel) 2021; 13:cancers13102336. [PMID: 34066095 PMCID: PMC8151466 DOI: 10.3390/cancers13102336] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 05/05/2021] [Accepted: 05/07/2021] [Indexed: 02/06/2023] Open
Abstract
Simple Summary Acute myeloid leukemia in children remains a difficult disease to cure despite intensive therapies that push the limits of tolerability. Though the intent of initial therapy should be the prevention of relapse, about 30% of all patients experience a relapse. Hence, relapse therapy remains critically important for survival. This retrospective analysis of two large international study groups (COG and BFM) was undertaken to describe the current survival, response rates and clinical features that predict outcomes. We demonstrate that children with relapsed AML may be cured with cytotoxic therapy followed by HSCT. High-risk features at initial diagnosis and early relapse remain prognostic for post-relapse survival. Current response criteria are not aligned with the standards of care for children, nor are the count recovery thresholds meaningful for prognosis in children with relapsed AML. Our data provide a new baseline for future treatment planning and will allow an updated stratification in upcoming studies. Abstract Post-relapse therapy remains critical for survival in children with acute myeloid leukemia (AML). We evaluated survival, response and prognostic variables following relapse in independent cooperative group studies conducted by COG and the population-based AML-BFM study group. BFM included 197 patients who relapsed after closure of the last I-BFM relapse trial until 2017, while COG included 852 patients who relapsed on the last Phase 3 trials (AAML0531, AAML1031). Overall survival at 5 years (OS) was 42 ± 4% (BFM) and 35 ± 2% (COG). Initial high-risk features (BFM 32 ± 6%, COG 26 ± 4%) and short time to relapse (BFM 29 ± 4%, COG 25 ± 2%) predicted diminished survival. In the BFM dataset, there was no difference in OS for patients who had a complete remission with full hematopoietic recovery (CR) following post-relapse re-induction compared to those with partial neutrophil and platelet recovery (CRp and CRi) only (52 ± 7% vs. 63 ± 10%, p = 0.39). Among 90 patients alive at last follow-up, 87 had received a post-relapse hematopoietic stem cell transplant (HSCT). OS for patients with post-relapse HSCT was 54 ± 4%. In conclusion, initial high-risk features and early relapse remain prognostic. Response assessment with full hematopoietic recovery following initial relapse therapy does not predict survival. These data indicate the need for post-relapse risk stratification in future studies of relapse therapies.
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16
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Arora S, Pushpam D, Tiwari A, Choudhary P, Chopra A, Gupta R, Kumar R, Bakhshi S. Allogeneic hematopoietic stem cell transplant in pediatric acute myeloid leukemia: Lessons learnt from a tertiary care center in India. Pediatr Transplant 2021; 25:e13918. [PMID: 33142026 DOI: 10.1111/petr.13918] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 09/09/2020] [Accepted: 10/18/2020] [Indexed: 01/10/2023]
Abstract
There is paucity of data on outcomes of MSD-HSCT in children with relapsed or high-risk AML from developing countries, which have unique challenges including adverse host factors and resource constraints. We retrospectively reviewed records of children (age ≤ 18 years) who underwent MSD-HSCT for AML at our center from 2009 to 2019 to evaluate clinical outcome and its predictors using Cox proportional hazards model. There were 46 children (36 boys and 10 girls) with mean age 10.7 ± 4.8 years. Indication for HSCT was relapsed AML in CR2 (n = 37), primary refractory (n = 3), or relapsed refractory disease (n = 3); high-risk (n = 1) or secondary (n = 2) AML in CR1. Five-year EFS and OS were 33.3 ± 7.2% and 36.3 ± 7.6%, respectively. On multivariate analysis, CR1 duration less than 12 months, presence of active disease at transplant, and use of bone marrow stem cell graft were associated with poorer EFS and OS. There was one (2.2%) TRM, while disease relapse occurred in 20/40 patients who underwent HSCT in remission. Though the 5-year EFS and OS were inferior to results reported from high-income countries, relapse (and not TRM) was the major cause of treatment failure. A well-sustained CR1, achievement of disease remission, and use of peripheral blood allograft seem imperative to a successful transplant. Targeted therapy along with HSCT may be the option for those with early relapse.
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Affiliation(s)
- Shalabh Arora
- Department of Medical Oncology, Dr. BRAIRCH, AIIMS, New Delhi, India
| | - Deepam Pushpam
- Department of Medical Oncology, Dr. BRAIRCH, AIIMS, New Delhi, India
| | - Akash Tiwari
- Department of Medical Oncology, Dr. BRAIRCH, AIIMS, New Delhi, India
| | | | - Anita Chopra
- Unit of Laboratory Oncology, Dr. BRAIRCH, AIIMS, New Delhi, India
| | - Ritu Gupta
- Unit of Laboratory Oncology, Dr. BRAIRCH, AIIMS, New Delhi, India
| | - Rajive Kumar
- Unit of Laboratory Oncology, Dr. BRAIRCH, AIIMS, New Delhi, India
| | - Sameer Bakhshi
- Department of Medical Oncology, Dr. BRAIRCH, AIIMS, New Delhi, India
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17
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Second Relapse of Pediatric Patients with Acute Myeloid Leukemia: A Report on Current Treatment Strategies and Outcome of the AML-BFM Study Group. Cancers (Basel) 2021; 13:cancers13040789. [PMID: 33672815 PMCID: PMC7918758 DOI: 10.3390/cancers13040789] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/09/2021] [Accepted: 02/11/2021] [Indexed: 01/27/2023] Open
Abstract
Simple Summary Children with acute myeloid leukemia (AML) experience high relapse rates of about 30%; still, survival rates following the first relapse are encouraging. Hence, it is critically important to examine the consequences of a second relapse; however, little is known about this subgroup of patients. This retrospective population-based analysis intends to describe response, survival and prognostic factors relevant for the survival of children with second relapse of AML. Treatment approaches include many different therapeutic regimens, including palliation and intensive treatment with curative intent (63% of the patients). Survival is poor; however, patients who respond to reinduction attempts can be rescued with subsequent hematopoietic stem cell transplantation. We deciphered risk factors, such as short time interval from first to second relapse below one year as being associated with a poor outcome. This analysis will help to improve future international treatment planning and patient care of children with advanced AML. Abstract Successful management of relapse is critical to improve outcomes of children with acute myeloid leukemia (AML). We evaluated response, survival and prognostic factors after a second relapse of AML. Among 1222 pediatric patients of the population-based AML-Berlin–Frankfurt–Munster (BFM) study group (2004 until 2017), 73 patients met the quality parameters for inclusion in this study. Central review of source documentation warranted the accuracy of reported data. Treatment approaches included palliation in 17 patients (23%), intensive therapy with curative intent (n = 46, 63%) and other regimens (n = 10). Twenty-five patients (35%) received hematopoietic stem cell transplantation (HSCT), 21 of whom (88%) had a prior HSCT. Survival was poor, with a five-year probability of overall survival (pOS) of 15 ± 4% and 31 ± 9% following HSCT (n = 25). Early second relapse (within one year after first relapse) was associated with dismal outcome (pOS 2 ± 2%, n = 44 vs. 33 ± 9%, n = 29; p < 0.0001). A third complete remission (CR) is required for survival: 31% (n = 14) of patients with intensive treatment achieved a third CR with a pOS of 36 ± 13%, while 28 patients (62%) were non-responders (pOS 7 ± 5%). In conclusion, survival is poor but possible, particularly after a late second relapse and an intensive chemotherapy followed by HSCT. This analysis provides a baseline for future treatment planning.
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18
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Salaverria C, Plenert E, Vasquez R, Fuentes-Alabi S, Tomlinson GA, Sung L. Paediatric relapsed acute leukaemia: curative intent chemotherapy improves quality of life. BMJ Support Palliat Care 2021:bmjspcare-2020-002722. [PMID: 33455915 DOI: 10.1136/bmjspcare-2020-002722] [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: 10/02/2020] [Revised: 12/18/2020] [Accepted: 01/03/2021] [Indexed: 01/25/2023]
Abstract
OBJECTIVES Paediatric patients with leukaemia with relapse or induction failure have poor prognosis. Anticipated quality of life (QoL) is important in treatment decision making. The objective was to determine if curative intent at relapse or induction failure, when compared with palliative intent, was associated with child's physical health, pain or general fatigue and parents' QoL over time among patients with paediatric leukaemia in El Salvador. METHODS This was a prospective observational cohort study. Children 2-18 years with acute leukaemia at first relapse or induction failure were eligible. Assessments occurred every 2 months for up to 2 years using validated proxy report and self-report scales, where guardians were the primary respondents. Initial curative or palliative intent was categorised at enrolment by physicians. The impact of initial intent on QoL was assessed using linear mixed effects models and interaction between QoL and time. RESULTS Of the 60 families enrolled, initial treatment intent was curative in 31 (51.7%) and palliative in 29 (48.3%). During the 2-year observation period, 44 children died. Initial curative intent significantly improved child's physical health (estimate=8.4, 95% CI 5.1 to 11.6), pain (estimate=5.4, 95% CI 1.5 to 9.2) and fatigue (estimate=6.6, 95% CI 3.2 to 9.9) compared with palliative intent, but not parents' QoL (estimate=1.0, 95% CI -0.8 to 2.8). CONCLUSIONS Among paediatric patients with acute leukaemia at relapse or induction failure, initial curative intent treatment plan was associated with better physical health, pain and fatigue when compared with palliative intent. A curative approach may be a reasonable option for patients with acute leukaemia even when prognosis is poor.
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Affiliation(s)
- Carmen Salaverria
- Division of Hematology and Oncology, Hospital Nacional De Ninos Benjamin Bloom, San Salvador, El Salvador
| | - Erin Plenert
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Roberto Vasquez
- Division of Hematology and Oncology, Hospital Nacional De Ninos Benjamin Bloom, San Salvador, El Salvador
| | - Soad Fuentes-Alabi
- Division of Hematology and Oncology, Hospital Nacional De Ninos Benjamin Bloom, San Salvador, El Salvador
| | - George A Tomlinson
- Department of Medicine, Toronto General Hospital, Toronto, Ontario, Canada
| | - Lillian Sung
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
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19
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Moritake H, Tanaka S, Miyamura T, Nakayama H, Shiba N, Shimada A, Terui K, Yuza Y, Koh K, Goto H, Kakuda H, Saito A, Hasegawa D, Iwamoto S, Taga T, Adachi S, Tomizawa D. The outcomes of relapsed acute myeloid leukemia in children: Results from the Japanese Pediatric Leukemia/Lymphoma Study Group AML-05R study. Pediatr Blood Cancer 2021; 68:e28736. [PMID: 32991072 DOI: 10.1002/pbc.28736] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/04/2020] [Accepted: 09/06/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND The prognosis of children with acute myeloid leukemia (AML) has improved with the efficacy of hematopoietic cell transplantation (HCT) as a second-line therapy and improvements in supportive care following anthracycline- and cytarabine-based chemotherapy; however, the outcomes of children with relapsed AML still remain unsatisfactory. PROCEDURE In order to identify prognostic factors and improve their prognosis, we analyzed 111 patients who relapsed after treatment with the Japanese Pediatric Leukemia/Lymphoma Study Group (JPLSG) AML-05 protocol and who were registered in the retrospective JPLSG AML-05R study. RESULTS The 5-year overall survival rate was 36.1%. The major determinant of survival was duration from the diagnosis to relapse. The mean duration in the nonsurviving group (10.1 ± 4.1 months) was shorter than that in the surviving group (16.3 ± 8.3 months) (P < .01). Moreover, achieving a second complete remission (CR2) prior to HCT was associated with a good prognosis (P < .01). Etoposide, cytarabine, and mitoxantrone (ECM)- or fludarabine, cytarabine, and granulocyte colony-stimulating factor (FLAG)-based regimens were therefore recommended for reinduction therapy (P < .01). A genetic analysis also revealed the prognostic significance of FMS-like tyrosine kinase 3 (FLT3)-internal tandem duplication as a poor prognostic marker (P = .04) and core binding factor-AML, t(8;21), and inv(16) as good prognostic markers (P < .01). CONCLUSIONS Achieving a CR2 prior to HCT is important in order to improve the prognosis of relapsed pediatric AML. Recent molecular targeted therapies, such as FLT3 inhibitors, may contribute to overcome their prognoses. Larger prospective investigations are necessary to establish individualized treatment strategies for patients with relapsed childhood AML.
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Affiliation(s)
- Hiroshi Moritake
- Division of Pediatrics, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Shiro Tanaka
- Department of Clinical Biostatistics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takako Miyamura
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hideki Nakayama
- Department of Pediatrics, National Hospital Organization Kyushu Cancer Center, Fukuoka, Japan
| | - Norio Shiba
- Department of Pediatrics, Yokohama City University Hospital, Yokohama, Japan
| | - Akira Shimada
- Department of Pediatrics, Okayama University, Okayama, Japan
| | - Kiminori Terui
- Department of Pediatrics, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yuki Yuza
- Department of Hematology/Oncology, Tokyo Metropolitan Children's Medical Center, Fuchu, Japan
| | - Katsuyoshi Koh
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Hiroaki Goto
- Division of Hemato-oncology/Regenerative Medicine, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Harumi Kakuda
- Department of Hematology/Oncology, Chiba Children's Hospital, Chiba, Japan
| | - Akiko Saito
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Daisuke Hasegawa
- Department of Pediatrics, St. Luke's International Hospital, Tokyo, Japan
| | - Shotaro Iwamoto
- Department of Pediatrics, Mie University Graduate School of Medicine, Tsu, Japan
| | - Takashi Taga
- Department of Pediatrics, Shiga University of Medical Science, Otsu, Japan
| | - Souichi Adachi
- Department of Human Health Sciences, Kyoto University, Kyoto, Japan
| | - Daisuke Tomizawa
- Division of Leukemia and Lymphoma, Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
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20
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Hoffman AE, Schoonmade LJ, Kaspers GJ. Pediatric relapsed acute myeloid leukemia: a systematic review. Expert Rev Anticancer Ther 2020; 21:45-52. [PMID: 33111585 DOI: 10.1080/14737140.2021.1841640] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Introduction: Pediatric relapsed acute myeloid leukemia (AML) remains lethal in the majority of cases, despite intensive therapy. Randomized trials are largely lacking, and the main issues of optimal therapy and prognostic factors remain unclear. Area covered: This systematic review includes all literature evaluating treatment outcome after first relapse. We searched databases PubMed and Embase.com. Twelve out of six thousand articles were ultimately included, based on age of the population (<21 years), relapsed AML, and information on clinical outcome (second complete remission (CR2), disease-free survival (DFS), event-free survival (EFS) and overall survival (OS)). There was only one randomized clinical trial reported. This review shows that there is no standard treatment for relapsed AML in children, and that outcome varies for CR2 and (2- to 10-year) OS rates, mean 64% (range, 50-75%), and 31% (16-43%), respectively. Children treated with chemotherapy only in first complete remission (CR1) tend to have better outcome after relapse than children receiving allo-SCT in CR1. Allo-SCT seems to be the most effective consolidation therapy in children achieving CR2, after relapse. Duration of CR1 was the most frequently reported statistically significant prognostic factor. Through randomized clinical trials, better knowledge of prognostic factors enabling risk-stratified treatment, and of more effective and less toxic therapies, should contribute to better clinical outcome for children with relapsed AML. Expert opinion: Outcome of pediatric relapsed AML has improved to OS rates up to 40%. However, there is a lack of knowledge on (independent) prognostic factors, optimal reinduction chemotherapy, timing of allo-SCT, and late effects. International collaboration should enable large, randomized clinical trials addressing these issues.
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Affiliation(s)
- Anne E Hoffman
- Emma Children's Hospital, Amsterdam UMC, Pediatric Oncology, Vrije Universiteit Amsterdam , Amsterdam
| | - Linda J Schoonmade
- Medical Library, Vrije Universiteit Amsterdam , Amsterdam, The Netherlands
| | - Gertjan Jl Kaspers
- Emma Children's Hospital, Amsterdam UMC, Pediatric Oncology, Vrije Universiteit Amsterdam , Amsterdam.,Princess Máxima Center For Pediatric Oncolocy , The Netherlands, Utrecht
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21
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Garg A, Ganguly S, Vishnubhatla S, Chopra A, Bakhshi S. Outpatient ADE (cytarabine, daunorubicin, and etoposide) is feasible and effective for the first relapse of pediatric acute myeloid leukemia: A prospective, phase II study. Pediatr Blood Cancer 2020; 67:e28404. [PMID: 32672904 DOI: 10.1002/pbc.28404] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 04/26/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND Approximately 40% children with acute myeloid leukemia (AML) invariably relapse, after attaining the first complete remission (CR), with dismal long-term outcome. There is little consensus regarding choice of optimal induction chemotherapy regimen for relapsed pediatric AML. PROCEDURE A prospective single arm phase II study (CTRI/2017/02/007757) was carried out at our center to evaluate the safety and efficacy of outpatient cytarabine, daunorubicin, and etoposide (ADE) regimen in pediatric AML (≤18 years) at the first relapse. Response evaluation was done by bone marrow aspiration morphology along with minimal residual disease (MRD) assessment. All adverse events including need and duration of hospitalization, transfusion support, and antimicrobial use were recorded. RESULTS Total 45 patients were included with median age of 12 years. The CR rate of the cohort was 66% and 54% of patients were MRD negative. The estimated 2-year event-free survival (EFS) and overall survival (OS) were 29% (±7%) and 34% (±7%), respectively. The presence of fever at relapse was associated with inferior CR rate (P = .001), positive MRD (P = .01), and inferior EFS (P = .02), while not achieving nadir absolute neutrophil count of zero during induction was associated with inferior CR rate (P = .03) and inferior OS (P = .04). Approximately all patients developed ≥Grade 3 cytopenia and febrile neutropenia. Twenty-six (59%) patients required hospitalization for management of toxicity and there were four (9%) deaths attributed to infection. CONCLUSION ADE is an effective induction regimen for pediatric AML patients at the first relapse with reasonable toxicity profile. Outpatient administration of the regimen is feasible in the presence of proper support structure and rigorous follow up.
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Affiliation(s)
- Arun Garg
- Department of Medical Oncology, Dr. B.R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Shuvadeep Ganguly
- Department of Medical Oncology, Dr. B.R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | | | - Anita Chopra
- Department of Laboratory Oncology, Dr. B.R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Sameer Bakhshi
- Department of Medical Oncology, Dr. B.R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
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22
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Kim H. Treatments for children and adolescents with AML. Blood Res 2020; 55:S5-S13. [PMID: 32719170 PMCID: PMC7386885 DOI: 10.5045/br.2020.s002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 01/30/2020] [Accepted: 02/14/2020] [Indexed: 12/12/2022] Open
Abstract
In recent decades, survival rates for childhood acute myeloid leukemia have remarkably improved, owing to chemotherapy intensification, allogeneic hematopoietic stem cell transplantation, and improved supportive care. Furthermore, treatment protocols have evolved and are currently better matched to prognostic factors and treatment responses. Recently, new molecular prognostic factors were discovered via leukemia genomic studies. Moreover, new tumor subtypes with independent gene expression profiles have been characterized. To broaden the therapeutic options for patients with poor prognoses, therapies that target specific candidate mutations are being identified. Additionally, new drugs are undergoing clinical trials, and immunotherapy is attracting significant interest as a treatment option for recurrent or refractory childhood acute myeloid leukemia.
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Affiliation(s)
- Hyery Kim
- Department of Pediatrics, University of Ulsan College of Medicine, Asan Medical Center Children’s Hospital, Seoul, Korea
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23
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Ghukasyan LG, Krasnov GS, Muravenko OV, Ikonnikova AY, Yurasov RA, Baidun LV, Ibragimova SZ, Nasedkina TV. Driver Mutations in Acute Myeloid Leukemia with Inversion of Chromosome 16. Mol Biol 2020. [DOI: 10.1134/s0026893320030073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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24
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[Efficacy and prognostic factors in children with non-core binding factor acute myeloid leukemia]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2020; 22. [PMID: 32434642 PMCID: PMC7389398 DOI: 10.7499/j.issn.1008-8830.2002021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To compare the efficacy of the CAMS-2005 and CAMS-2009 regimens in treating children with non-core binding factor acute myeloid leukemia (non-CBF AML) and to study the prognosis factors. METHODS A total of 161 children who were initially diagnosed with non-CBF AML from April 2005 to December 2015 were enrolled as study subjects, and were divided into a CAMS-2005 regimen group (n=52) and a CAMS-2009 regimen group (n=109) according to the chemotherapy regimen provided. The efficacy was retrospectively compared between the two groups. RESULTS The complete remission (CR) rate at the first course of treatment was higher in the CAMS-2009 regimen group than that in the CMAS-2005 regimen group (63.3% vs 46.2%; P<0.05). There were no significant differences between the two groups in treatment-related mortality rate (11.9% vs 17.3%), recurrence rate (27.5% vs 28.8%), and three-year overall survival (OS) rate (44%±5% vs 28%±6%) (P>0.05). Children who achieved CR at the first course of treatment had significantly higher OS and event-free survival rates than those who did not achieved CR (P<0.01). CONCLUSIONS The CAMS-2009 regimen is superior to the CAMS-2005 regimen in improving the CR rate in children with non-CBF AML after induction treatment. Whether CR is achieved at the first course of treatment can affect the OS rate of children with non-CBF AML.
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25
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Successful Treatment of Pediatric Refractory/Relapsed AML with KIR-Ligand-Mismatched Cord Blood Transplant after FLAG-IDA Reinduction Therapy with or without the GO Regimen. Case Rep Hematol 2020; 2020:1378056. [PMID: 32099697 PMCID: PMC7037524 DOI: 10.1155/2020/1378056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 01/11/2020] [Accepted: 01/25/2020] [Indexed: 11/17/2022] Open
Abstract
Prognosis in pediatric patients with refractory/relapsed acute myeloid leukemia (AML) is grim, and there is no standard treatment for such patients. Combined treatment with intensive chemotherapy and gemtuzumab ozogamicin (GO), a monoclonal anti-CD33 antibody conjugated with calicheamicin, is useful as reinduction therapy in refractory/relapsed AML. Here, we describe three cases of pediatric refractory/relapsed AML that were successfully managed with FLAG-IDA (fludarabine, cytarabine, granulocyte colony-stimulating factor, and idarubicin), with or without GO, as reinduction therapy before a KIR-ligand-mismatched cord blood transplant. This strategy relies on the fact that killer cell immunoglobulin-like receptors (KIR) on cord blood natural killer (NK) cells recognize human leukocyte antigen (HLA) class I alleles, and that donor KIR-ligand incompatibility may be associated with lower incidence of relapse and improved survival in AML, as cells that lack these inhibitory HLA ligands can activate NK cells. All three patients are currently alive and have been disease-free for 24-65 months, although one patient developed severe sinusoidal obstructive syndrome (SOS). Thus, our strategy can result in excellent outcomes in pediatric patients with refractory/relapsed AML.
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26
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Lamble AJ, Tasian SK. Opportunities for immunotherapy in childhood acute myeloid leukemia. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:218-225. [PMID: 31808843 PMCID: PMC6913480 DOI: 10.1182/hematology.2019000357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Clinical outcomes for children with acute myeloid leukemia (AML) have improved minimally during the past 4 decades despite maximally intensive chemotherapy, hematopoietic stem cell transplantation, and optimized supportive care. Chemoresistance and relapse remain major sources of childhood cancer-associated mortality and highlight the need for alternative treatment approaches. The remarkable recent success of humoral and cellular immunotherapies in children and adults with relapsed/refractory B-acute lymphoblastic leukemia has inspired hope for similar accomplishments in patients with AML. However, unique challenges exist, including the biologic and immunophenotypic heterogeneity of childhood AML and the significant potential for on-target/off-tumor immunotherapeutic toxicity due to target antigen expression on nonmalignant cells. This article reviews the current landscape of antibody-based and cellular immunotherapies under current clinical evaluation with an emphasis on active or soon-to-open phase 1 trials for children with relapsed/refractory AML.
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Affiliation(s)
- Adam J Lamble
- Division of Hematology-Oncology, Seattle Children's Hospital, Seattle, WA
- University of Washington School of Medicine, Seattle, WA
| | - Sarah K Tasian
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, PA; and
- Department of Pediatrics and Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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27
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Lamble AJ, Tasian SK. Opportunities for immunotherapy in childhood acute myeloid leukemia. Blood Adv 2019; 3:3750-3758. [PMID: 31770440 PMCID: PMC6880897 DOI: 10.1182/bloodadvances.2019000357] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 08/04/2019] [Indexed: 12/26/2022] Open
Abstract
Clinical outcomes for children with acute myeloid leukemia (AML) have improved minimally during the past 4 decades despite maximally intensive chemotherapy, hematopoietic stem cell transplantation, and optimized supportive care. Chemoresistance and relapse remain major sources of childhood cancer-associated mortality and highlight the need for alternative treatment approaches. The remarkable recent success of humoral and cellular immunotherapies in children and adults with relapsed/refractory B-acute lymphoblastic leukemia has inspired hope for similar accomplishments in patients with AML. However, unique challenges exist, including the biologic and immunophenotypic heterogeneity of childhood AML and the significant potential for on-target/off-tumor immunotherapeutic toxicity due to target antigen expression on nonmalignant cells. This article reviews the current landscape of antibody-based and cellular immunotherapies under current clinical evaluation with an emphasis on active or soon-to-open phase 1 trials for children with relapsed/refractory AML.
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MESH Headings
- Antineoplastic Agents, Immunological/administration & dosage
- Antineoplastic Agents, Immunological/adverse effects
- Antineoplastic Agents, Immunological/therapeutic use
- Biomarkers, Tumor
- Cell Cycle Checkpoints/drug effects
- Child
- Child, Preschool
- Disease Susceptibility
- Drug Resistance, Neoplasm/genetics
- Female
- Genetic Predisposition to Disease
- Genetic Testing
- Humans
- Immunomodulation/drug effects
- Infant
- Leukemia, Myeloid, Acute/diagnosis
- Leukemia, Myeloid, Acute/drug therapy
- Leukemia, Myeloid, Acute/etiology
- Leukemia, Myeloid, Acute/mortality
- Male
- Molecular Targeted Therapy/adverse effects
- Molecular Targeted Therapy/methods
- Recurrence
- T-Lymphocytes/drug effects
- T-Lymphocytes/immunology
- T-Lymphocytes/metabolism
- Treatment Outcome
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Affiliation(s)
- Adam J Lamble
- Division of Hematology-Oncology, Seattle Children's Hospital, Seattle, WA
- University of Washington School of Medicine, Seattle, WA
| | - Sarah K Tasian
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, PA; and
- Department of Pediatrics and Abramson Cancer Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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28
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Ye C, Ma S, Xia B, Zheng C. Weighted Gene Coexpression Network Analysis Identifies Cysteine-Rich Intestinal Protein 1 (CRIP1) as a Prognostic Gene Associated with Relapse in Patients with Acute Myeloid Leukemia. Med Sci Monit 2019; 25:7396-7406. [PMID: 31577790 PMCID: PMC6790098 DOI: 10.12659/msm.918092] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Acute myeloid leukemia (AML) is associated with a high relapse rate and poor prognosis. This study aimed to use weighted gene coexpression network analysis (WGCNA) of gene coexpression networks to identify candidate prognostic biomarker genes in patients with AML and to investigate the expression of these genes in the human U937 cell line in vitro. MATERIAL AND METHODS RNA-seq data were retrieved from the Cancer Genome Atlas (TCGA) and included bone marrow samples and survival data of patients with AML (N=151), patients who did not relapse after treatment (N=119), and patients with relapse (N=40). Differentially expressed genes were identified, WGCNA was used to detect functional modules, and survival analysis was performed. The Cell Counting Kit-8 (CCK-8) assay investigated the proliferation of U937 cells transfected with short hairpin RNAs (shRNAs), shCRIP1, shHIST1H1C, and shHIST1H1E. RNA-seq analysis identified gene expression following CRIP1 knockdown. RESULTS Eighty-two genes were associated with both relapse and prognosis in patients with AML. There were two prognosis-related gene modules in the coexpression network. In the coexpression network, the histone cluster 1 H1 family member gene, HIST1H1C had the maximum relapse fold change, HIST1H1E had the lowest survival p-value, and the cysteine-rich intestinal protein 1 (CRIP1) gene had the most edge numbers and was significantly associated with poor prognosis (P=0.0165786). RNA-seq data showed that there was a significant difference in gene expression after CRIP1 knockdown in U937 cells. CONCLUSIONS WGCNA of gene coexpression networks identified CRIP1 as a potential prognostic biomarker gene in patients with AML.
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Affiliation(s)
- Chengyu Ye
- First Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China (mainland).,Department of Radiotherapy, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China (mainland).,Department of Blood Chemotherapy, Wenzhou Central Hospital, Wenzhou, Zhejiang, China (mainland)
| | - Shenglin Ma
- Department of Radiotherapy, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China (mainland)
| | - Bing Xia
- Department of Radiotherapy, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China (mainland)
| | - Cuiping Zheng
- Department of Blood Chemotherapy, Wenzhou Central Hospital, Wenzhou, Zhejiang, China (mainland)
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29
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Mutated WT1, FLT3-ITD, and NUP98-NSD1 Fusion in Various Combinations Define a Poor Prognostic Group in Pediatric Acute Myeloid Leukemia. JOURNAL OF ONCOLOGY 2019; 2019:1609128. [PMID: 31467532 PMCID: PMC6699323 DOI: 10.1155/2019/1609128] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 06/24/2019] [Indexed: 12/17/2022]
Abstract
Acute myeloid leukemia is a life-threatening malignancy in children and adolescents treated predominantly by risk-adapted intensive chemotherapy that is partly supported by allogeneic stem cell transplantation. Mutations in the WT1 gene and NUP98-NSD1 fusion are predictors of poor survival outcome/prognosis that frequently occur in combination with internal tandem duplications of the juxta-membrane domain of FLT3 (FLT3-ITD). To re-evaluate the effect of these factors in contemporary protocols, 353 patients (<18 years) treated in Germany with AML-BFM treatment protocols between 2004 and 2017 were included. Presence of mutated WT1 and FLT3-ITD in blasts (n=19) resulted in low 3-year event-free survival of 29% and overall survival of 33% compared to rates of 45-63% and 67-87% in patients with only one (only FLT3-ITD; n=33, only WT1 mutation; n=29) or none of these mutations (n=272). Including NUP98-NSD1 and high allelic ratio (AR) of FLT3-ITD (AR ≥0.4) in the analysis revealed very poor outcomes for patients with co-occurrence of all three factors or any of double combinations. All these patients (n=15) experienced events and the probability of overall survival was low (27%). We conclude that co-occurrence of WT1 mutation, NUP98-NSD1, and FLT3-ITD with an AR ≥0.4 as triple or double mutations still predicts dismal response to contemporary first- and second-line treatment for pediatric acute myeloid leukemia.
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30
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Løvvik Juul-Dam K, Guldborg Nyvold C, Vålerhaugen H, Zeller B, Lausen B, Hasle H, Beier Ommen H. Measurable residual disease monitoring using Wilms tumor gene 1 expression in childhood acute myeloid leukemia based on child-specific reference values. Pediatr Blood Cancer 2019; 66:e27671. [PMID: 30900388 DOI: 10.1002/pbc.27671] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Revised: 01/16/2019] [Accepted: 01/30/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND Measurable/minimal residual disease (MRD) monitoring can predict imminent hematological relapse in acute myeloid leukemia (AML). The majority of childhood AML patients do not harbor fusion genes or mutations applicable as MRD markers and overexpression of Wilms tumor gene 1 (WT1) may constitute a useful monitoring target. However, age-specific reference values in healthy hematopoiesis and standardization of WT1 assessment are prerequisites for clinical utility. PROCEDURE We investigated WT1 expression across age in hematologically healthy controls (n = 109), during suspected infection (n = 90) and bone marrow (BM) regeneration (n = 13). WT1 expression in AML at diagnosis (n = 91) and during follow-up (n = 30) was compared with age-specific reference values. RESULTS WT1 expression correlated with age and showed higher levels in both BM and peripheral blood (PB) in children compared with adults (P < 0.001 and P = 0.01). WT1 expression from healthy hematopoiesis was lower in PB compared with BM (WT1BM /WT1PB = 8.6, 95% CI: 5.3-13.7) and not influenced by infection nor BM regeneration. At AML diagnosis, 66% had more than 20-fold WT1 overexpression in PB or BM (PB 74%; BM 45%). WT1 was quantified in 279 PB samples during follow-up. All 11 patients with PB sampling within 4 months of disease recurrence displayed WT1 overexpression by a median of 1.9 months (range, 0.7-9.7) before hematological relapse. CONCLUSIONS This study defines child-specific reference values for WT1 expression in healthy hematopoiesis and demonstrates that WT1 expression in PB is a useful post-treatment monitoring tool in childhood AML. Based on these observations, we propose definitions for childhood AML molecular relapse using WT1 overexpression.
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Affiliation(s)
| | - Charlotte Guldborg Nyvold
- Department of Hematology, Aarhus University Hospital, Aarhus, Denmark.,Hematology-Pathology Research Laboratory, Department of Hematology, Odense University Hospital, Odense, Denmark
| | - Helen Vålerhaugen
- Department of Pathology, The Norwegian Radium Hospital, Oslo, Norway
| | - Bernward Zeller
- Division of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Birgitte Lausen
- Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Hasle
- Department of Pediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Hans Beier Ommen
- Department of Hematology, Aarhus University Hospital, Aarhus, Denmark
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31
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Mustafa O, Abdalla K, AlAzmi AA, Elimam N, Abrar MB, Jastaniah W. FLAG/FLAG-IDA regimen for children with relapsed/refractory acute leukemia in the era of targeted novel therapies. J Oncol Pharm Pract 2018; 25:1831-1838. [PMID: 30518307 DOI: 10.1177/1078155218817816] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Outcomes of relapsed/refractory childhood acute leukemia remain poor. We analyzed the safety/efficacy of fludarabine, cytarabine, and granulocyte colony stimulating factor, with/without idarubicin (FLAG ± IDA) as salvage therapy compared with recent published results of novel therapies. METHODS This retrospective study included children aged 1 to 15 years with relapsed/refractory acute leukemia who received FLAG ± IDA salvage therapy from January 2000 to December 2014. Patients with infant leukemia, mixed lineage leukemia, Philadelphia-positive acute leukemia, or secondary leukemia were excluded. RESULT Fifty patients were identified: 25 with acute lymphoblastic leukemia and 25 with acute myeloid leukemia. The median age at initiation of FLAG ± IDA was seven years. Site of relapse was the bone marrow in 29, isolated central nervous system in 11, and combined in 10 patients. FLAG ± IDA was used after first relapse in 68% and after multiple relapses in 32%. Complete remission was achieved in 34 (68%) patients. No variables predictive of complete remission were identified. Grade 3 or greater toxicity was observed in 96% and 6% died from toxicity. Toxicities included hematologic toxicity (96%), infection (52%), and enterocolitis (28%). Twenty-four of 50 (48%) patients achieved a sustained complete remission and survived to bone marrow transplantation. The five-year overall survival was 23.9% ± 6.9%. Patients achieving second complete remission and patients proceeding to bone marrow transplantation following second complete remission demonstrated significantly improved overall survival (p = 0.001). CONCLUSION Despite a 68% complete remission rate using FLAG ± IDA, only 48% of patients survived to bone marrow transplantation. The regimen was associated with 96% toxicity and only one in four patients was alive at five years. This underscores the need to find more effective lower toxicity salvage regimens.
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Affiliation(s)
- Omima Mustafa
- Princess Noorah Oncology Center, King Abdulaziz Medical City, King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia
| | - Khalid Abdalla
- Princess Noorah Oncology Center, King Abdulaziz Medical City, King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia
| | - Aeshah A AlAzmi
- Department of Pharmaceutical Care, Clinical Pharmacy, King Abdulaziz Medical City, King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia
| | - Naglla Elimam
- Princess Noorah Oncology Center, King Abdulaziz Medical City, King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia
| | - Mohammed Burhan Abrar
- Princess Noorah Oncology Center, King Abdulaziz Medical City, King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia
| | - Wasil Jastaniah
- Princess Noorah Oncology Center, King Abdulaziz Medical City, King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia.,Department of Pediatrics, Faculty of Medicine, Umm AlQura University, Makkah, Saudi Arabia
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32
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Identifying Prognostic Factors That Influence Outcome of Childhood Acute Myeloid Leukemia in First Relapse in Saudi Arabia: Results of the Multicenter SAPHOS Study. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2018; 18:773-780. [DOI: 10.1016/j.clml.2018.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 08/28/2018] [Accepted: 09/04/2018] [Indexed: 01/17/2023]
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Bager N, Juul-Dam KL, Sandahl JD, Abrahamsson J, Beverloo B, de Bont ESJM, Ha SY, Jahnukainen K, Jónsson ÓG, Kaspers GL, Kovalova Z, Lausen B, De Moerloose B, Noren-Nyström U, Palle J, Saks K, Zeller B, Kjeldsen E, Hasle H. Complex and monosomal karyotype are distinct cytogenetic entities with an adverse prognostic impact in paediatric acute myeloid leukaemia. A NOPHO-DBH-AML study. Br J Haematol 2018; 183:618-628. [PMID: 30406946 DOI: 10.1111/bjh.15587] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 07/19/2018] [Indexed: 12/17/2022]
Abstract
Data on occurrence, genetic characteristics and prognostic impact of complex and monosomal karyotype (CK/MK) in children with acute myeloid leukaemia (AML) are scarce. We studied CK and MK in a large unselected cohort of childhood AML patients diagnosed and treated according to Nordic Society for Paediatric Haematology and Oncology (NOPHO)-AML protocols 1993-2015. In total, 800 patients with de novo AML were included. CK was found in 122 (15%) and MK in 41 (5%) patients. CK and MK patients were young (median age 2·1 and 3·3 years, respectively) and frequently had FAB M7 morphology (24% and 22%, respectively). Refractory disease was more common in MK patients (15% vs. 4%) and stem cell transplantation in first complete remission was more frequent (32% vs. 19%) compared with non-CK/non-MK patients. CK showed no association with refractory disease but was an independent predictor of an inferior event-free survival (EFS; hazard ratio [HR] 1·43, P = 0·03) and overall survival (OS; HR 1·48, P = 0·01). MK was associated with a poor EFS (HR 1·57, P = 0·03) but did not show an inferior OS compared to non-MK patients (HR 1·14, P = 0·62). In a large paediatric cohort, we characterized AML with non-recurrent abnormal karyotype and unravelled the adverse impact of CK and MK on prognosis.
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Affiliation(s)
- Ninna Bager
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Kristian L Juul-Dam
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Julie D Sandahl
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Jonas Abrahamsson
- Institution for Clinical Sciences, Department of Paediatrics, Queen Silvia Children's Hospital, Gothenburg, Sweden
| | - Berna Beverloo
- Department of Cytogenetics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Eveline S J M de Bont
- Department of Paediatrics, University Medical Centre Groningen, Groningen, the Netherlands
| | - Shau-Yin Ha
- Hong Kong Paediatric Haematology & Oncology Study Group, Department of Paediatrics, Queen Mary Hospital, Hong Kong, China
| | - Kirsi Jahnukainen
- Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | - Gertjan L Kaspers
- Paediatric Oncology/Haematology, VU University Medical Centre, Amsterdam, Academy of Princess Maxima Centre for Paediatric Oncology, Utrecht, The Netherlands
| | - Zhanna Kovalova
- Department of Paediatrics, Children's Clinical University Hospital, Riga, Latvia
| | - Birgitte Lausen
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | - Ulrika Noren-Nyström
- Department of Medical Biosciences, Genetics, Umeå University Hospital, Umeå, Sweden
| | - Josefine Palle
- Department of Woman's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Kadri Saks
- Department of Paediatrics, SA Tallinna Lastehaigla, Tallinn, Estonia
| | - Bernward Zeller
- Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Eigil Kjeldsen
- Department of Cytogenetics, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Hasle
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
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Increased Survival for Children With Acute Myeloid Leukemia Results From Improved Postrelapse Treatment. J Pediatr Hematol Oncol 2018; 40:541-547. [PMID: 29794644 DOI: 10.1097/mph.0000000000001215] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The treatment for pediatric acute myeloid leukemia (AML) has not changed significantly over the past 3 decades, yet outcomes have improved with cure rates increasing from 30% to over 60% of all newly diagnosed children over this period. This improvement in survival has been attributed to both treatment intensification and improved supportive care over the decades, although the precise impact of each remains unknown. PATIENTS AND METHODS We retrospectively analyzed a unique cohort of 276 patients with de novo AML diagnosed in childhood, all treated with the same chemotherapy protocol over a 25-year period from 1986 to 2012. RESULTS The contemporary cohort (2000-2012), compared with the historical cohort (1986-1999) had significantly improved overall survival (75% vs. 50%; hazard ratio, 2.17; 95% confidence interval, 1.15-2.93), lower disease-related mortality (38% vs. 19%, P=0.02) and were significantly more likely to receive an allogeneic transplant after relapse (stem cell transplantation [SCT], 73% vs. 12%; P<0.0001). Allogeneic transplant postrelapse was associated with a significantly improved survival across the entire cohort (overall survival 50% for allogeneic SCT vs. 12% for autologous or none, P<0.0001). There was no significant difference between the contemporary and historical cohorts in treatment-related mortality (13% vs. 7%, P=0.42) or relapse rates after induction (50% in older cohort vs. 40% in recent era, P=0.25), suggesting consistency of induction treatment efficacy and toxicity across the 2 periods. CONCLUSIONS This data suggests improved survival in pediatric AML in the modern era has predominantly resulted from changes in treatment after relapse, including increased use of allogeneic SCT.
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Complete Remission of a Refractory Acute Myeloid Leukemia with Myelodysplastic- and Monosomy 7-Related Changes after a Combined Conditioning Regimen of Plerixafor, Cytarabine and Melphalan in a 4-Year-Old Boy: A Case Report and Review of Literature. Cancers (Basel) 2018; 10:cancers10090291. [PMID: 30150522 PMCID: PMC6162695 DOI: 10.3390/cancers10090291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 08/13/2018] [Accepted: 08/23/2018] [Indexed: 11/16/2022] Open
Abstract
Acute myeloid leukemia with myelodysplastic changes and monosomy 7 is a rare form of pediatric leukemia associated with very poor disease-free survival. The refractoriness of the disease is due to the protection offered by the bone marrow niche, making leukemic stem cells impervious to whatever chemotherapy or myeloablative regimen is chosen. Using a mobilizing agent for haematopoietic stem cells, Plerixafor, could sensitise leukemic cells to the myeloablative therapy. This approach was not previously used in a pediatric population, and in adult populations, was used in combination with busulphan with no difference in overall survival. We describe the case of a 4-year-old boy affected by refractory acute myeloid leukemia with myelodysplastic changes and monosomy 7. The child had never achieved a remission. We proposed a combined time-scheduled scheme of therapy with plerixafor and melphalan. Combining pharmacokinetics of plerixafor with pharmacokinetics and rapid and elevated myeloablative potential of melphalan in high dosage (200 mg/m2), we succeeded in mobilizing more than 85% of stem blasts immediately before infusion of Melphalan. The count of residual blasts after 8 h from melphalan infusion was only 1.3 cells/μL. The child achieved an engraftment at day +32 with full donor chimerism. Sixteen months after haematopoietic stem cell transplantation (HSCT), he is well and in complete remission. Our case suggests that the use of plerixafor before a conditioning therapy with melphalan could induce remission in acute myeloid leukemia refractory to the usual conditioning therapy in pediatric patients. This work adds strength to the body of knowledge regarding the “personalized” conditioning regimen for high-risk leukemic patients.
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36
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Anti-thymocyte globulin’s activity against acute myeloid leukemia stem cells. Bone Marrow Transplant 2018; 54:549-559. [DOI: 10.1038/s41409-018-0296-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 07/19/2018] [Accepted: 07/21/2018] [Indexed: 01/22/2023]
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37
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Niktoreh N, Lerius B, Zimmermann M, Gruhn B, Escherich G, Bourquin JP, Dworzak M, Sramkova L, Rossig C, Creutzig U, Reinhardt D, Rasche M. Gemtuzumab ozogamicin in children with relapsed or refractory acute myeloid leukemia: a report by Berlin-Frankfurt-Münster study group. Haematologica 2018; 104:120-127. [PMID: 30093401 PMCID: PMC6312035 DOI: 10.3324/haematol.2018.191841] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 08/03/2018] [Indexed: 12/13/2022] Open
Abstract
Despite intensified salvage treatments, children with relapsed/refractory acute myeloid leukemia (AML) have poor survival. We evaluated gemtuzumab ozogamicin (CD33-targeted drug) used on a compassionate basis in patients diagnosed from 1995 until 2014 within Acute Myeloid Leukemia Berlin-Frankfurt-Münster studies, and identified 76 patients (<18 years) with highly-advanced and pre-treated AML [refractory de novo acute myeloid leukemia (n=10), de novo AML refractory to relapse (1st early: n=41; 1st late: n=10; 2nd or more: n=10), and secondary AML (n=5)]. At doses of 2.5–10 mg/m2, gemtuzumab ozogamicin was administered in 1-4 cycles as single agent (47%), combined with cytarabine (47%), or others (6%). Most common grade 3/4 adverse events were infections or febrile neutropenia (78% of severe adverse events), infusion-related immunological reactions (6%), and gastrointestinal symptoms (5%). Three patients experienced veno-occlusive disease (one fatal due to exacerbation of a pre-existing cardiomyopathy). Sixty-four percent received subsequent hematopoietic stem cell transplantation. Probability of 4-year overall survival was 18±5% in all, 27±7% in patients with and 0% in patients without hematopoietic stem cell transplantation (P<0.0001). Administration of gemtuzumab ozogamicin on a patient-specific, compassionate use basis was frequently considered in our study group and proved to be effective for bridging children with very advanced AML to hematopoietic stem cell transplantation. Uniform prospective studies for these patients are urgently needed.
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Affiliation(s)
- Naghmeh Niktoreh
- Department of Pediatric Hematology and Oncology, University Hospital Essen, Germany
| | - Beate Lerius
- Department of Pediatric Hematology and Oncology, University Hospital Essen, Germany
| | - Martin Zimmermann
- Department of Pediatric Hematology and Oncology, Hannover Medical School, Germany
| | - Bernd Gruhn
- Department of Pediatrics, Jena University Hospital, Germany
| | - Gabriele Escherich
- Department of Pediatric Hematology and Oncology, Eppendorf University Hospital, Hamburg, Germany
| | - Jean-Pierre Bourquin
- Division of Pediatric Hematology/Oncology, University Children's Hospital Zurich, Switzerland
| | - Michael Dworzak
- St. Anna Children's Hospital and Children's Cancer Research Institute, Department of Pediatrics, Medical University of Vienna, Austria
| | - Lucie Sramkova
- Department of Pediatric Hematology and Oncology, 2 Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czech Republic
| | - Claudia Rossig
- University Children's Hospital Münster, Pediatric Hematology and Oncology, Germany
| | - Ursula Creutzig
- Department of Pediatric Hematology and Oncology, Hannover Medical School, Germany
| | - Dirk Reinhardt
- Department of Pediatric Hematology and Oncology, University Hospital Essen, Germany
| | - Mareike Rasche
- Department of Pediatric Hematology and Oncology, University Hospital Essen, Germany
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38
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van Eijkelenburg NKA, Rasche M, Ghazaly E, Dworzak MN, Klingebiel T, Rossig C, Leverger G, Stary J, De Bont ESJM, Chitu DA, Bertrand Y, Brethon B, Strahm B, van der Sluis IM, Kaspers GJL, Reinhardt D, Zwaan CM. Clofarabine, high-dose cytarabine and liposomal daunorubicin in pediatric relapsed/refractory acute myeloid leukemia: a phase IB study. Haematologica 2018; 103:1484-1492. [PMID: 29773602 PMCID: PMC6119144 DOI: 10.3324/haematol.2017.187153] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2017] [Accepted: 05/16/2018] [Indexed: 12/29/2022] Open
Abstract
Survival in children with relapsed/refractory acute myeloid leukemia is unsatisfactory. Treatment consists of one course of fludarabine, cytarabine and liposomal daunorubicin, followed by fludarabine and cytarabine and stem-cell transplantation. Study ITCC 020/I-BFM 2009-02 aimed to identify the recommended phase II dose of clofarabine replacing fludarabine in the abovementioned combination regimen (3+3 design). Escalating dose levels of clofarabine (20-40 mg/m2/day × 5 days) and liposomal daunorubicin (40-80 mg/m2/day) were administered with cytarabine (2 g/m2/day × 5 days). Liposomal DNR was given on day 1, 3 and 5 only. The cohort at the recommended phase II dose was expanded to make a preliminary assessment of anti-leukemic activity. Thirty-four children were enrolled: refractory 1st (n=11), early 1st (n=15), ≥2nd relapse (n=8). Dose level 3 (30 mg/m2clofarabine; 60 mg/m2liposomal daunorubicin) appeared to be safe only in patients without subclinical fungal infections. Infectious complications were dose-limiting. The recommended phase II dose was 40 mg/m2 clofarabine with 60 mg/m2 liposomal daunorubicin. Side-effects mainly consisted of infections. The overall response rate was 68% in 31 response evaluable patients, and 80% at the recommended phase II dose (n=10); 22 patients proceeded to stem cell transplantation. The 2-year probability of event-free survival (pEFS) was 26.5±7.6 and probability of survival (pOS) 32.4±8.0%. In the 21 responding patients, the 2-year pEFS was 42.9±10.8 and pOS 47.6±10.9%. Clofarabine exposure in plasma was not significantly different from that in single-agent studies. In conclusion, clofarabine was well tolerated and showed high response rates in relapsed/refractory pediatric acute myeloid leukemia. Patients with (sub) clinical fungal infections should be treated with caution. Clofarabine has been taken forward in the Berlin-Frankfurt-Münster study for newly diagnosed acute myeloid leukemia. The Study ITCC-020 was registered as EUDRA-CT 2009-009457-13; Dutch Trial Registry number 1880.
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Affiliation(s)
- Natasha K A van Eijkelenburg
- Department of Pediatric Oncology/Hematology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands.,Department of Pediatric Oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands.,European Consortium for Innovative Therapies for Children with Cancer (ITCC), Villejuif, France
| | - Mareike Rasche
- Department of Pediatric Oncology, University Children's Hospital, Essen, Germany
| | - Essam Ghazaly
- Centre for Haemato-Oncology, Barts Cancer Institute, Queen Mary University of London, UK
| | - Michael N Dworzak
- Children's Cancer Research Institute and St. Anna Children's Hospital, Department of Pediatrics, Medical University of Vienna, Austria
| | - Thomas Klingebiel
- Pediatric Hematology/Oncology, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Claudia Rossig
- Pediatric Hematology and Oncology, University Children's Hospital, Münster, Germany
| | - Guy Leverger
- Department of Pediatric Hematology and Oncology, AP-HP, GH HUEP, Trousseau Hospital, Paris, France
| | - Jan Stary
- Department of Pediatric Hematology and Oncology, 2Faculty of Medicine, Charles University Prague, University Hospital Motol, Czech Republic
| | - Eveline S J M De Bont
- Department of Pediatric Oncology, University Medical Center Groningen, University of Groningen, the Netherlands
| | - Dana A Chitu
- Clinical Trial Center, Department of Hematology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Yves Bertrand
- Pediatric Hematology Department, IHOP and Claude Bernard University, Lyon, France
| | - Benoit Brethon
- Department of Pediatric Hematology, Robert Debré Hospital, Paris, France
| | - Brigitte Strahm
- Division of Pediatric Hematology and Oncology, Department of Pediatrics and Adolescent Medicine, University of Freiburg, Germany
| | - Inge M van der Sluis
- Department of Pediatric Oncology/Hematology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands.,European Consortium for Innovative Therapies for Children with Cancer (ITCC), Villejuif, France
| | - Gertjan J L Kaspers
- Department of Pediatric Oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands.,Department of Pediatric Oncology, VU University Medical Center, Amsterdam, the Netherlands.,I-BFM-AML committee, Kiel, Germany
| | - Dirk Reinhardt
- European Consortium for Innovative Therapies for Children with Cancer (ITCC), Villejuif, France.,I-BFM-AML committee, Kiel, Germany
| | - C Michel Zwaan
- Department of Pediatric Oncology/Hematology, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands .,Department of Pediatric Oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands.,European Consortium for Innovative Therapies for Children with Cancer (ITCC), Villejuif, France
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Gemtuzumab Ozogamicin Containing Chemotherapy for Relapsed or Refractory Acute Myeloid Leukemia (AML) in Children. J Pediatr Hematol Oncol 2018; 40:163-168. [PMID: 29240026 DOI: 10.1097/mph.0000000000001010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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40
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Successes and challenges in the treatment of pediatric acute myeloid leukemia: a retrospective analysis of the AML-BFM trials from 1987 to 2012. Leukemia 2018; 32:2167-2177. [PMID: 29550834 PMCID: PMC6170392 DOI: 10.1038/s41375-018-0071-7] [Citation(s) in RCA: 133] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 01/18/2018] [Accepted: 01/24/2018] [Indexed: 12/25/2022]
Abstract
Overall survival (OS) of pediatric patients with acute myeloid leukemia (AML) increased in recent decades. However, it remained unknown whether advances in first-line treatment, supportive care, or second-line therapy mainly contributed to this improvement. Here, we retrospectively analyzed outcome and clinical data of 1940 pediatric AML patients (younger than 18 years of age), enrolled in the population-based AML-BFM trials between 1987 and 2012. While 5-year probability of OS (pOS) increased from 49 ± 3% (1987-1992) to 76 ± 4% (2010-2012; p < 0.0001), probability of event-free survival only improved from 41 ± 3% (1987-1992) to 50 ± 2% (1993-1998; p = 0.02) after introduction of high-dose cytarabine/mitoxantrone, but remained stable since then. Non-response and relapse rates stayed constant despite intensified first-line therapy (p = 0.08 and p = 0.17). Reduced fatal bleedings and leukostasis translated into fewer early deaths (8.1%vs. 2.2%; p = 0.001). Strikingly, pOS after non-response (13 ± 5% (1987-1992) vs. 43 ± 7% (2005-2010); p < 0.0001) or relapse (19 ± 4% vs. 45 ± 4%; p < 0.0001) improved. After 1999, more relapsed or refractory patients underwent hematopoietic stem cell transplantation (HSCT) with increased pOS after HSCT (29 ± 5% (1993-1998) vs. 50 ± 4% (2005-2010); p < 0.0001). Since efficacy of salvage therapy mainly contributed to better outcome in pediatric AML, our analysis indicates that a better allocation of patients, who cannot be cured with conventional chemotherapy, to an early "salvage-like" therapy is necessary.
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Masetti R, Castelli I, Astolfi A, Bertuccio SN, Indio V, Togni M, Belotti T, Serravalle S, Tarantino G, Zecca M, Pigazzi M, Basso G, Pession A, Locatelli F. Genomic complexity and dynamics of clonal evolution in childhood acute myeloid leukemia studied with whole-exome sequencing. Oncotarget 2018; 7:56746-56757. [PMID: 27462774 PMCID: PMC5302950 DOI: 10.18632/oncotarget.10778] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 07/10/2016] [Indexed: 11/25/2022] Open
Abstract
Despite significant improvement in treatment of childhood acute myeloid leukemia (AML), 30% of patients experience disease recurrence, which is still the major cause of treatment failure and death in these patients. To investigate molecular mechanisms underlying relapse, we performed whole-exome sequencing of diagnosis-relapse pairs and matched remission samples from 4 pediatric AML patients without recurrent cytogenetic alterations. Candidate driver mutations were selected for targeted deep sequencing at high coverage, suitable to detect small subclones (0.12%). BiCEBPα mutation was found to be stable and highly penetrant, representing a separate biological and clinical entity, unlike WT1 mutations, which were extremely unstable. Among the mutational patterns underlying relapse, we detected the acquisition of proliferative advantage by signaling activation (PTPN11 and FLT3-TKD mutations) and the increased resistance to apoptosis (hyperactivation of TYK2). We also found a previously undescribed feature of AML, consisting of a hypermutator phenotype caused by SETD2 inactivation. The consequent accumulation of new mutations promotes the adaptability of the leukemia, contributing to clonal selection. We report a novel ASXL3 mutation characterizing a very small subclone (<1%) present at diagnosis and undergoing expansion (60%) at relapse. Taken together, these findings provide molecular clues for designing optimal therapeutic strategies, in terms of target selection, adequate schedule design and reliable response-monitoring techniques.
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Affiliation(s)
- Riccardo Masetti
- Department of Pediatrics "Lalla Seràgnoli", Hematology-Oncology Unit, University of Bologna, Bologna, Italy
| | - Ilaria Castelli
- Department of Pediatrics "Lalla Seràgnoli", Hematology-Oncology Unit, University of Bologna, Bologna, Italy
| | - Annalisa Astolfi
- Interdepartmental Centre of Cancer Research "G. Prodi", University of Bologna, Bologna, Italy
| | - Salvatore Nicola Bertuccio
- Department of Pediatrics "Lalla Seràgnoli", Hematology-Oncology Unit, University of Bologna, Bologna, Italy
| | - Valentina Indio
- Interdepartmental Centre of Cancer Research "G. Prodi", University of Bologna, Bologna, Italy
| | - Marco Togni
- Department of Pediatrics "Lalla Seràgnoli", Hematology-Oncology Unit, University of Bologna, Bologna, Italy.,Current address: Stem Cell Group, University College London Cancer Institute, University College London, London, United Kingdom
| | - Tamara Belotti
- Department of Pediatrics "Lalla Seràgnoli", Hematology-Oncology Unit, University of Bologna, Bologna, Italy
| | - Salvatore Serravalle
- Department of Pediatrics "Lalla Seràgnoli", Hematology-Oncology Unit, University of Bologna, Bologna, Italy
| | - Giuseppe Tarantino
- Interdepartmental Centre of Cancer Research "G. Prodi", University of Bologna, Bologna, Italy
| | - Marco Zecca
- Department of Pediatric Hematology Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Martina Pigazzi
- Department of Woman and Child Health, Laboratory of Hematology-Oncology, University of Padova, Padova, Italy
| | - Giuseppe Basso
- Department of Woman and Child Health, Laboratory of Hematology-Oncology, University of Padova, Padova, Italy
| | - Andrea Pession
- Department of Pediatrics "Lalla Seràgnoli", Hematology-Oncology Unit, University of Bologna, Bologna, Italy
| | - Franco Locatelli
- Department of Pediatric Hematology-Oncology, IRCCS Ospedale Bambino Gesù, Rome, Italy.,University of Pavia, Pavia, Italy
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A phase 1 study of azacitidine combined with chemotherapy in childhood leukemia: a report from the TACL consortium. Blood 2018; 131:1145-1148. [PMID: 29339403 DOI: 10.1182/blood-2017-09-803809] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Wang J, Yuan L, Cheng H, Fei X, Yin Y, Gu J, Xue S, He J, Yang F, Wang X, Yang Y, Zhang W. Salvaged allogeneic hematopoietic stem cell transplantation for pediatric chemotherapy refractory acute leukemia. Oncotarget 2018; 9:3143-3159. [PMID: 29423036 PMCID: PMC5790453 DOI: 10.18632/oncotarget.22809] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 10/27/2017] [Indexed: 01/31/2023] Open
Abstract
There is an ongoing debate concerning the performance of salvaged allogeneic hematopoietic stem cell transplantation (allo-HSCT) in pediatric patients with acute refractory leukemia, in whom the prognosis is quite dismal. Few studies have ever been conducted on this subject. This may be partly due to missed opportunities by majority of the patients in such situations. To investigate the feasibility, evaluate the efficiency, and identify the prognostic factors of allo-HSCT in this sub-setting, the authors performed a single institution-based retrospective analysis. A total of 44 patients, of whom 28 had acute myeloid leukemia (AML), 13 had acute lymphocytic leukemia (ALL), and 3 had mixed phenotype leukemia (MPL), were enrolled in this study. With a median follow-up of 19 months, the estimated 2-year overall survival (OS) and progression free survival (PFS) were 34.3% (95% CI, 17.9–51.4%) and 33.6% (95% CI, 18.0–50.1%), respectively. The estimated 2-year incidence rates of relapse and non-relapse mortality (NRM) were 43.8% (95% CI 26.4–60.0%) and 19.6% (95% CI 9.1–32.9%), respectively. The estimated 100-day cumulative incidence of acute graft versus host disease (aGvHD) was 43.6% (95% CI 28.7–57.5%), and the 1-year cumulative incidence of chronic GvHD (cGvHD) was 45.5% (95% CI 30.5–59.3%). Compared with the previous studies, the multivariate analysis in this study additionally identified that female donors and cGvHD were associated with lower relapse and better PFS and OS. Male recipients, age younger than 10 years, a diagnosis of ALL, and the intermediate-adverse cytogenetic risk group were associated with increased relapse. On the contrary, extramedullary disease (EMD) and aGvHD were only linked to worse PFS. These data suggested that although only one-third of the patients would obtain PFS over 2 years, salvaged allo-HSCT is still the most reliable and best therapeutic strategy for refractory pediatric acute leukemia. If probable, choosing a female donor, better management of aGvHD, and induction of cGvHD promotes patient survival.
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Affiliation(s)
- Jingbo Wang
- Department of Hematology, China Aerospace Central Hospital, Beijing, China
| | - Lei Yuan
- Department of Hematology, China Aerospace Central Hospital, Beijing, China
| | - Haoyu Cheng
- Department of Hematology, China Aerospace Central Hospital, Beijing, China
| | - Xinhong Fei
- Department of Hematology, China Aerospace Central Hospital, Beijing, China
| | - Yumin Yin
- Department of Hematology, China Aerospace Central Hospital, Beijing, China
| | - Jiangying Gu
- Department of Hematology, China Aerospace Central Hospital, Beijing, China
| | - Song Xue
- Department of Hematology, China Aerospace Central Hospital, Beijing, China
| | - Junbao He
- Department of Hematology, China Aerospace Central Hospital, Beijing, China
| | - Fan Yang
- Department of Hematology, China Aerospace Central Hospital, Beijing, China
| | - Xiaocan Wang
- Department of Hematology, China Aerospace Central Hospital, Beijing, China
| | - Yixin Yang
- Department of Hematology, China Aerospace Central Hospital, Beijing, China
| | - Weijie Zhang
- Department of Hematology, China Aerospace Central Hospital, Beijing, China
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Nakayama H, Tomizawa D, Tanaka S, Iwamoto S, Shimada A, Saito AM, Yamashita Y, Moritake H, Terui K, Taga T, Matsuo H, Kosaka Y, Koh K, Hosoi H, Kurosawa H, Isoyama K, Horibe K, Mizutani S, Adachi S. Fludarabine, cytarabine, granulocyte colony-stimulating factor and idarubicin for relapsed childhood acute myeloid leukemia. Pediatr Int 2017; 59:1046-1052. [PMID: 28771903 DOI: 10.1111/ped.13378] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 06/21/2017] [Accepted: 07/05/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND The combination of fludarabine (Flu), high-dose cytarabine (Ara-C) and granulocyte colony-stimulating factor (G-CSF; FLAG), with anthracyclines has become standard chemotherapy for refractory acute myeloid leukemia (AML) in European children and adults. To clarify the efficacy and the safety of FLAG-idarubicin (IDA) for children prospectively, we planned a multicenter phase II study (AML-R11) by the Japanese Pediatric Leukemia/Lymphoma Study Group. METHODS Patients with AML aged between 2 and 20 years old, who had the first bone marrow (BM) relapse or induction failure, were enrolled. The FLAG-IDA regimen consisted of Flu 30 mg/m2 for 5 days, Ara-C 2 g/m2 for 5 days, G-CSF (lenograstim) 5 μg/kg for 6 days and IDA 10 mg/m2 for 3 days. The primary endpoint was remission rate after therapy. RESULTS Due to drug supply issues, the trial was suspended after the inclusion of seven eligible patients. There were six cases of early relapse within 1 year of the first remission. All seven patients completed the therapy and no early death was observed. Hematological toxicity was common, and one patient developed grade 4 non-hematological toxicity of bacterial meningitis. Although only one patient with late relapse achieved complete remission, minimal residual disease was positive on both flow cytometry and Wilms' tumor 1 mRNA. Two patients were alive in remission following hematopoietic stem cell transplantation, whereas the other five patients died of either the disease or treatment-related causes. CONCLUSION FLAG-IDA might be tolerable for children with refractory AML although the efficacy should be further investigated.
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Affiliation(s)
- Hideki Nakayama
- Department of Pediatrics, National Hospital Organization Kyushu Cancer Center, Fukuoka, Japan.,Department of Pediatrics, National Hospital Organization Fukuoka-Higashi Medical Center, Fukuoka, Japan.,Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Daisuke Tomizawa
- Division of Leukemia and Lymphoma, Children's Cancer Center, National Center for Child Health and Development, Tokyo, Japan
| | - Shiro Tanaka
- Department of Clinical Biostatistics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shotaro Iwamoto
- Department of Pediatrics, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Akira Shimada
- Department of Pediatrics, Okayama University, Okayama, Japan
| | - Akiko M Saito
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Yuka Yamashita
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Hiroshi Moritake
- Department of Pediatrics, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Kiminori Terui
- Department of Pediatrics, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Takashi Taga
- Department of Pediatrics, Shiga University of Medical Science, Ohtsu, Japan
| | - Hidemasa Matsuo
- School of Human Health Science, Faculty of Medicine, Kyoto University, Kyoto, Japan
| | - Yoshiyuki Kosaka
- Department of Pediatric Hematology/Oncology, Hyougo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Katsuyoshi Koh
- Department of Hematology/Oncology, Saitama Children's Medical Center, Saitama, Japan
| | - Hajime Hosoi
- Department of Pediatrics, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | | | - Keiichi Isoyama
- Department of Pediatrics, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Keizo Horibe
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Shuki Mizutani
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Souichi Adachi
- School of Human Health Science, Faculty of Medicine, Kyoto University, Kyoto, Japan
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Abstract
Immune surveillance comprising of adaptive and innate immune systems is naturally designed to eliminate cancer development; overexpression of inhibitory receptors and their ligands prevent this check and lead to evasion and hence cancer progression and metastasis. The use of tumor-specific monoclonal antibodies (MAbs) targeting these checkpoint regulators is promising and has led to this novel field of cancer immunotherapy. The first antibody directed against cytotoxic T-lymphocyte associated protein 4 (CTLA-4), ipilimumab, showed promising results in clinical trials and was approved by the US Food and Drug Administration (FDA) for the treatment of metastatic melanoma in 2011. Since then, various other immune checkpoint inhibitors are being studied in preclinical and clinical trial phases, targeting programmed-death-1 (PD-1) and its ligand programmed death ligand 1 (PD-L1), T cell lymphocyte activation gene-3 (LAG-3), and others. Results from clinical trials are promising, and currently this approach has proven effective and safe in patients with solid tumors and some hematological malignancies in adults. In general, CTLA-4 and PD-1 inhibitors are well tolerated; however, the augmented immune response enabled by this class of agents is associated with a unique group of side effects called immune-related adverse events (irAEs). Experience in pediatrics using immune checkpoint inhibitors for hematological malignancies is limited to Hodgkin's disease and non-Hodgkin's lymphoma as in the ongoing Children's Oncology Group (COG) protocol ADVL1412. Therapeutic advances in childhood leukemia and lymphoma (TACL) consortium will initiate an early phase clinical trial with PD-1 inhibitor nivolumab in relapsed/refractory acute myeloid leukemia (AML) in the next few months.
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Affiliation(s)
- Kara L Davis
- a Bass Center for Childhood Cancer and Blood Disorders, Department of Pediatrics , Stanford University School of Medicine , Palo Alto , California
| | - Archana M Agarwal
- b Department of Pathology , University of Utah and ARUP Laboratories , Salt Lake City, Utah
| | - Anupam R Verma
- c Primary Children's Hospital, Pediatric Hematology Oncology, Department of Pediatrics , University of Utah , Salt Lake City, Utah
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Karlsson L, Forestier E, Hasle H, Jahnukainen K, Jónsson ÓG, Lausen B, Norén Nyström U, Palle J, Tierens A, Zeller B, Abrahamsson J. Outcome after intensive reinduction therapy and allogeneic stem cell transplant in paediatric relapsed acute myeloid leukaemia. Br J Haematol 2017; 178:592-602. [PMID: 28439893 DOI: 10.1111/bjh.14720] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 02/23/2017] [Indexed: 11/30/2022]
Abstract
Given that 30-40% of children with acute myeloid leukaemia (AML) relapse after primary therapy it is important to define prognostic factors and identify optimal therapy. From 1993 to 2012, 543 children from the Nordic countries were treated according to two consecutive protocols: 208 children relapsed. The influence of disease characteristics, first line treatment, relapse therapy and duration of first remission on outcome was analysed. Second complete remission (CR2) was achieved in 146 (70%) patients. Estimated 5-year overall survival (OS5y ) was 39 ± 4% for the whole group and 43 ± 4% for the 190 patients given re-induction therapy, of whom 76% received regimens that included fludarabine, cytarabine (FLA) ± anthracyclines, 18% received Nordic Society for Paediatric Haematology and Oncology (NOPHO) upfront blocks and 5% received other regimens. Late relapse ≥1 year from diagnosis, no allogeneic stem cell transplantation (SCT) in first remission and core binding factor AML were independent favourable prognostic factors for survival. For the 128 children (124 in CR2) that received SCT as consolidation therapy after relapse, OS5y was 61 ± 5%. Four of 19 children (21%) survived without receiving SCT as part of relapse therapy. Our data show that intensive re-induction followed by SCT can give cure rates of 40% in children with relapsed AML.
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Affiliation(s)
- Lene Karlsson
- Institution for Clinical Sciences, Department of Paediatrics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Erik Forestier
- Department of Clinical Sciences, Paediatrics, Umea University, Umea, Sweden
| | - Henrik Hasle
- Department of Paediatrics, Aarhus University Hospital Skejby, Aarhus, Denmark
| | - Kirsi Jahnukainen
- Division of Haematology-Oncology and Stem Cell Transplantation, Children's Hospital, Helsinki, Finland
| | - Ólafur G Jónsson
- Children's Hospital, Landspitali University Hospital, Hringbraut, Reykjavik, Iceland
| | - Birgitte Lausen
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | - Josefine Palle
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Anne Tierens
- Department of Pathobiology and Laboratory Medicine, University Health Network, Toronto General Hospital, Toronto, ON, Canada
| | - Bernward Zeller
- Department of Paediatrics, Oslo University Hospital, Oslo, Norway
| | - Jonas Abrahamsson
- Institution for Clinical Sciences, Department of Paediatrics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Yılmaz Bengoa Ş, Ataseven E, Kızmazoğlu D, Demir Yenigürbüz F, Erdem M, Ören H. FLAG Regimen with or without Idarubicin in Children with Relapsed/Refractory Acute Leukemia: Experience from a Turkish Pediatric Hematology Center. Turk J Haematol 2017; 34:46-51. [PMID: 27095144 PMCID: PMC5451688 DOI: 10.4274/tjh.2015.0411] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Objective: The optimal therapy to achieve higher rates of survival in pediatric relapsed/refractory acute leukemia (AL) is still unknown. In developing countries, it is difficult to obtain some of the recent drugs for optimal therapy and mostly well-known drugs proven to be effective are used. We assessed the efficacy of the combination of fludarabine, high-dose cytarabine, and granulocyte colony-stimulating factor (FLAG regimen) with or without idarubicin (IDA) in children with relapsed/refractory acute lymphoblastic leukemia and acute myeloid leukemia. Materials and Methods: Between September 2007 and May 2015, 18 children with refractory/relapsed AL attending our center, treated with a FLAG regimen with or without IDA, were included. The primary end point was the remission status of the bone marrow sampled after the first/second course of chemotherapy. The second end point was the duration of survival after hematopoietic stem cell transplantation (HSCT). Results: Complete remission (CR) was achieved in 7 patients (38.8%) after the first cycle, and at the end of the second cycle the total number of patients in CR was 8 (42.1%). All patients in CR underwent HSCT. The CR rate in patients who had IDA in combination therapy was 28.6%, and it was 50% in patients treated without IDA (p=0.36). Mean survival duration in transplanted patients was 24.7±20.8 months (minimum-maximum: 2-70, median: 25 months), and it was 2.7±1.64 months (minimum-maximum: 0-5, median: 3 months) in nontransplanted patients. Five of them (27.7%) were still alive at the end of the study and in CR. The median time of follow-up for these patients was 33 months (minimum-maximum: 25-70 months). Conclusion: FLAG regimens with or without IDA produced a CR of >24 months in 27.7% of children with relapsed/refractory AL and can be recommended as therapeutic options prior to HSCT in developing countries.
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Affiliation(s)
- Şebnem Yılmaz Bengoa
- Dokuz Eylül University Faculty of Medicine, Department of Pediatric Hematology, İzmir, Turkey Phone: +90 505 5252163 E-mail:
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Bista R, Lee DW, Pepper OB, Azorsa DO, Arceci RJ, Aleem E. Disulfiram overcomes bortezomib and cytarabine resistance in Down-syndrome-associated acute myeloid leukemia cells. JOURNAL OF EXPERIMENTAL & CLINICAL CANCER RESEARCH : CR 2017; 36:22. [PMID: 28143565 PMCID: PMC5286849 DOI: 10.1186/s13046-017-0493-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Accepted: 01/26/2017] [Indexed: 02/02/2023]
Abstract
Background Children with Down syndrome (DS) have increased risk for developing AML (DS-AMKL), and they usually experience severe therapy-related toxicities compared to non DS-AMKL. Refractory/relapsed disease has very poor outcome, and patients would benefit from novel, less toxic, therapeutic strategies that overcome resistance. Relapse/resistance are linked to cancer stem cells with high aldehyde dehydrogenase (ALDH) activity. The purpose of the present work was to study less toxic alternative therapeutic agents for relapsed/refractory DS-AMKL. Methods Fourteen AML cell lines including the DS-AMKL CMY and CMK from relapsed/refractory AML were used. Cytarabine (Ara-C), bortezomib (BTZ), disulfiram/copper (DSF/Cu2+) were evaluated for cytotoxicity, depletion of ALDH-positive cells, and resistance. BTZ-resistant CMY and CMK variants were generated by continuous BTZ treatment. Cell viability was assessed using CellTiter-Glo®, ALDH activity by ALDELUORTM, and proteasome inhibition by western blot of ubiquitinated proteins and the Proteasome-Glo™ Chymotrypsin-Like (CT-like) assay, apoptosis by Annexin V Fluos/Propidium iodide staining, and mutations were detected using PCR, cloning and sequencing. Results Ara-C-resistant AML cell lines were sensitive to BTZ and DSF/Cu2+. The Ara-C-resistant DS-AMKL CMY cells had a high percentage of ALDHbright “stem-like” populations that may underlie Ara-C resistance. One percent of these cells were still resistant to BTZ but sensitive to DSF/Cu2+. To understand the mechanism of BTZ resistance, BTZ resistant (CMY-BR) and (CMK-BR) were generated. A novel mutation PSMB5 Q62P underlied BTZ resistance, and was associated with an overexpression of the β5 proteasome subunit. BTZ-resistance conferred increased resistance to Ara-C due to G1 arrest in the CMY-BR cells, which protected the cells from S-phase damage by Ara-C. CMY-BR and CMK-BR cells were cross-resistant to CFZ and MG-132 but sensitive to DSF/Cu2+. In this setting, DSF/Cu2+ induced apoptosis and proteasome inhibition independent of CT-like activity inhibition. Conclusions We provide evidence that DSF/Cu2+ overcomes Ara-C and BTZ resistance in cell lines from DS-AMKL patients. A novel mutation underlying BTZ resistance was detected that may identify BTZ-resistant patients, who may not benefit from treatment with CFZ or Ara-C, but may be responsive to DSF/Cu2+. Our findings support the clinical development of DSF/Cu2+ as a less toxic efficacious treatment approach in patients with relapsed/refractory DS-AMKL. Electronic supplementary material The online version of this article (doi:10.1186/s13046-017-0493-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ranjan Bista
- Institute of Molecular Medicine at Phoenix Children's Hospital, Phoenix, AZ, USA
| | - David W Lee
- Institute of Molecular Medicine at Phoenix Children's Hospital, Phoenix, AZ, USA.,Department of Child Health, University of Arizona College of Medicine-Phoenix, Biosciences Partnership Building (BSPB), 5th floor, 475 N 5th Street, Phoenix, AZ, 85004, USA
| | - Oliver B Pepper
- Department of Child Health, University of Arizona College of Medicine-Phoenix, Biosciences Partnership Building (BSPB), 5th floor, 475 N 5th Street, Phoenix, AZ, 85004, USA.,Department of Biology and Biochemistry, University of Bath, Bath, UK
| | - David O Azorsa
- Institute of Molecular Medicine at Phoenix Children's Hospital, Phoenix, AZ, USA.,Department of Child Health, University of Arizona College of Medicine-Phoenix, Biosciences Partnership Building (BSPB), 5th floor, 475 N 5th Street, Phoenix, AZ, 85004, USA
| | - Robert J Arceci
- Institute of Molecular Medicine at Phoenix Children's Hospital, Phoenix, AZ, USA.,Department of Child Health, University of Arizona College of Medicine-Phoenix, Biosciences Partnership Building (BSPB), 5th floor, 475 N 5th Street, Phoenix, AZ, 85004, USA
| | - Eiman Aleem
- Institute of Molecular Medicine at Phoenix Children's Hospital, Phoenix, AZ, USA. .,Department of Child Health, University of Arizona College of Medicine-Phoenix, Biosciences Partnership Building (BSPB), 5th floor, 475 N 5th Street, Phoenix, AZ, 85004, USA. .,Department of Zoology, Faculty of Science, Alexandria University, Alexandria, Egypt.
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Unrelated Cord Blood Transplantation for Acute Leukemia Diagnosed in the First Year of Life: Outcomes and Risk Factor Analysis. Biol Blood Marrow Transplant 2017; 23:96-102. [DOI: 10.1016/j.bbmt.2016.10.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 10/15/2016] [Indexed: 11/20/2022]
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50
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Zhang Z, Wu B, Chai W, Cao L, Wang Y, Yu Y, Yang L. Knockdown of WAVE1 enhances apoptosis of leukemia cells by downregulating autophagy. Int J Oncol 2016; 48:2647-56. [PMID: 27035872 DOI: 10.3892/ijo.2016.3446] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Accepted: 02/20/2016] [Indexed: 11/05/2022] Open
Abstract
Chemoresistance of leukemia constitutes a great challenge for successful treatment of leukemia. Autophagy has recently attracted increasing attention for its role in conferring resistance to various conventional anti-neoplastic regiments. In the present study, the authors showed that WAVE1, a member of WASP family verprolin-homologous proteins, is a critical regulator of chemoresistance during autophagy. It is positively correlated with clinical status in pediatric acute myeloblastic leukemia (AML) and leukemia cell lines. The knockdown of WAVE1 expression decreased autophagy was accompanied by an upregulation of autophagic marker microtubule-associated protein light chain 3 (LC3)-Ⅱ, a degradation of SQSTM1/sequestosome 1 (p62) and the formation of autophagosomes. Moreover, a suppression of WAVE1 expression increased the sensitivity of leukemia cells to chemotherapy and apoptosis, and depletion of WAVE1 expression promoted the translocation of Bcl-2 from mitochondria into the cytoplasm. In addition, a knockdown of PI3K-Ⅲ expression significantly inhibited WAVE1-mediated autophagy. Furthermore, suppression of WAVE1 expression blocked the interactions between Beclin1 and PI3K-Ⅲ and the disassociation of Beclin1-Bcl-2 during enhanced autophagy. The above results suggested that WAVE1 is a critical pro-autophagic protein capable of enhancing cell survival and regulating chemoresistance in leukemia cells potentially through the Beclin1/Bcl-2 and Beclin1/PI3K-Ⅲ complex-dependent pathways.
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Affiliation(s)
- Zhaoxia Zhang
- Department of Pediatrics, Shenzhen People's Hospital, Shenzhen, Guangdong 518020, P.R. China
| | - Benqing Wu
- Department of Pediatrics, Shenzhen People's Hospital, Shenzhen, Guangdong 518020, P.R. China
| | - Wenwen Chai
- Department of Nuclear Medicine, Hu Nan Cancer Hospital and Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan 410008, P.R. China
| | - Lizhi Cao
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, Hunan 410008, P.R. China
| | - Yangping Wang
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, Hunan 410008, P.R. China
| | - Yan Yu
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, Hunan 410008, P.R. China
| | - Liangchun Yang
- Department of Pediatrics, Xiangya Hospital, Central South University, Changsha, Hunan 410008, P.R. China
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