1
|
Kopmar NE, Othus M, Quach K, Rasmussen A, Schonhoff K, Becker PS, Walter RB, Halpern AB, Salit R, Cassaday RD, Shustov A, Stewart FM, Oehler VG, Scott BL, Sandmaier BM, Lee SJ, Estey EH, Percival MEM. Intensive Reinduction Chemotherapy Followed by Early Allogeneic Hematopoietic Cell Transplantation for Relapsed/Refractory High-Grade Myeloid Neoplasms. Transplant Cell Ther 2024; 30:727.e1-727.e8. [PMID: 38710302 PMCID: PMC11223948 DOI: 10.1016/j.jtct.2024.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 03/01/2024] [Accepted: 05/03/2024] [Indexed: 05/08/2024]
Abstract
Outcomes for adults with relapsed/refractory (R/R) high-grade myeloid neoplasms remain poor, with allogeneic hematopoietic cell transplantation (HCT) the sole therapy likely to result in cure. We conducted the present study to determine the feasibility of early HCT-within 60 days of beginning reinduction chemotherapy-to see whether getting patients to HCT in an expeditious manner would expand the number of patients being offered this curative option. In this proof-of-principle feasibility study, we included adults age 18 to 75 years with R/R myeloid malignancies with ≥10% blood/marrow blasts at diagnosis who were eligible for a reduced-intensity HCT. Subjects received reinduction chemotherapy with cladribine, cytarabine, mitoxantrone, and filgrastim (CLAG-M) and proceeded to HCT with reduced-intensity conditioning (fludarabine/ melphalan). We enrolled 30 subjects, all of whom received CLAG-M reinduction, although only 9 underwent HCT within 60 days (<15, the predetermined threshold for feasibility "success"), with a median time to HCT of 48 days (range, 42 to 60 days). Eleven additional subjects received HCT beyond the target 60 days (off-study), with a median time to transplantation of 83 days (range, 53 to 367 days). Barriers to early HCT included infection, physician preference, lack of an HLA-matched donor, logistical delays, and disease progression, all of which may limit the real-world uptake of such early-to-transplantation protocols.
Collapse
Affiliation(s)
- Noam E Kopmar
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Megan Othus
- Public Health Sciences, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Kim Quach
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Allegra Rasmussen
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Kelda Schonhoff
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | | | - Roland B Walter
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington; Translational Science and Therapeutics Division, Fred Hutchinson Cancer Center, Seattle, Washington; Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington; Department of Epidemiology, University of Washington, Seattle, Washington
| | - Anna B Halpern
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Rachel Salit
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Ryan D Cassaday
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | | | | | - Vivian G Oehler
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington; Translational Science and Therapeutics Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Bart L Scott
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Brenda M Sandmaier
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington; Translational Science and Therapeutics Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Stephanie J Lee
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Elihu H Estey
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Mary-Elizabeth M Percival
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington.
| |
Collapse
|
2
|
Stelljes M, Middeke JM, Bug G, Wagner-Drouet EM, Müller LP, Schmid C, Krause SW, Bethge W, Jost E, Platzbecker U, Klein SA, Schubert J, Niederland J, Kaufmann M, Schäfer-Eckart K, Schaich M, Baldauf H, Stölzel F, Petzold C, Röllig C, Alakel N, Steffen B, Hauptrock B, Schliemann C, Sockel K, Lang F, Kriege O, Schaffrath J, Reicherts C, Berdel WE, Serve H, Ehninger G, Schmidt AH, Bornhäuser M, Mikesch JH, Schetelig J. Remission induction versus immediate allogeneic haematopoietic stem cell transplantation for patients with relapsed or poor responsive acute myeloid leukaemia (ASAP): a randomised, open-label, phase 3, non-inferiority trial. Lancet Haematol 2024; 11:e324-e335. [PMID: 38583455 DOI: 10.1016/s2352-3026(24)00065-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 02/16/2024] [Accepted: 02/16/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Whether high-dose cytarabine-based salvage chemotherapy, administered to induce complete remission in patients with poor responsive or relapsed acute myeloid leukaemia scheduled for allogeneic haematopoietic stem-cell transplantation (HSCT) after intensive conditioning confers a survival advantage, is unclear. METHODS To test salvage chemotherapy before allogeneic HSCT, patients aged between 18 and 75 years with non-favourable-risk acute myeloid leukaemia not in complete remission after first induction or untreated first relapse were randomly assigned 1:1 to remission induction with high-dose cytarabine (3 g/m2 intravenously, 1 g/m2 intravenously for patients >60 years or with a substantial comorbidity) twice daily on days 1-3 plus mitoxantrone (10 mg/m2 intravenously) on days 3-5 or immediate allogeneic HSCT for the disease control group. Block randomisation with variable block lengths was used and patients were stratified by age, acute myeloid leukaemia risk, and disease status. The study was open label. The primary endpoint was treatment success, defined as complete remission on day 56 after allogeneic HSCT, with the aim to show non-inferiority for disease control compared with remission induction with a non-inferiority-margin of 5% and one-sided type 1 error of 2·5%. The primary endpoint was analysed in both the intention-to-treat (ITT) population and in the per-protocol population. The trial is completed and was registered at ClinicalTrials.gov, NCT02461537. FINDINGS 281 patients were enrolled between Sept 17, 2015, and Jan 12, 2022. Of 140 patients randomly assigned to disease control, 135 (96%) proceeded to allogeneic HSCT, 97 (69%) after watchful waiting only. Of 141 patients randomly assigned to remission induction, 134 (95%) received salvage chemotherapy and 128 (91%) patients subsequently proceeded to allogeneic HSCT. In the ITT population, treatment success was observed in 116 (83%) of 140 patients in the disease control group versus 112 (79%) of 141 patients with remission induction (test for non-inferiority, p=0·036). Among per-protocol treated patients, treatment success was observed in 116 (84%) of 138 patients with disease control versus 109 (81%) of 134 patients in the remission induction group (test for non-inferiority, p=0·047). The difference in treatment success between disease control and remission induction was estimated as 3·4% (95% CI -5·8 to 12·6) for the ITT population and 2·7% (-6·3 to 11·8) for the per-protocol population. Fewer patients with disease control compared with remission induction had non-haematological adverse events grade 3 or worse (30 [21%] of 140 patients vs 86 [61%] of 141 patients, χ2 test p<0·0001). Between randomisation and the start of conditioning, with disease control two patients died from progressive acute myeloid leukaemia and zero from treatment-related complications, and with remission induction two patients died from progressive acute myeloid leukaemia and two from treatment-related complications. Between randomisation and allogeneic HSCT, patients with disease control spent a median of 27 days less in hospital than those with remission induction, ie, the median time in hospital was 15 days (range 7-64) versus 42 days (27-121, U test p<0·0001), respectively. INTERPRETATION Non-inferiority of disease control could not be shown at the 2·5% significance level. The rate of treatment success was also not statistically better for patients with remission induction. Watchful waiting and immediate transplantation could be an alternative for fit patients with poor response or relapsed acute myeloid leukaemia who have a stem cell donor available. More randomised controlled intention-to-transplant trials are needed to define the optimal treatment before transplantation for patients with active acute myeloid leukaemia. FUNDING DKMS and the Gert and Susanna Mayer Stiftung Foundation.
Collapse
Affiliation(s)
| | | | - Gesine Bug
- Goethe University Frankfurt, Frankfurt am Main, Germany
| | | | - Lutz P Müller
- University Hospital, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Christoph Schmid
- Faculty of Medicine, Augsburg University Hospital, Augsburg, Germany
| | | | | | - Edgar Jost
- University Hospital Aachen & Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf, Aachen, Germany
| | | | | | | | - Judith Niederland
- Helios Klinikum Berlin-Buch, Klinik für Hämatologie und Zelltherapie, Berlin, Germany
| | | | | | | | | | - Friedrich Stölzel
- University Hospital TU Dresden, Dresden, Germany; University Hospital Schleswig-Holstein, Kiel, Germany
| | | | | | - Nael Alakel
- University Hospital TU Dresden, Dresden, Germany
| | - Björn Steffen
- Goethe University Frankfurt, Frankfurt am Main, Germany
| | | | | | - Katja Sockel
- University Hospital TU Dresden, Dresden, Germany
| | - Fabian Lang
- Goethe University Frankfurt, Frankfurt am Main, Germany
| | | | - Judith Schaffrath
- University Hospital, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | | | | | - Hubert Serve
- Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Gerhard Ehninger
- University Hospital TU Dresden, Dresden, Germany; Cellex Cell Professionals, Cologne, Germany
| | | | - Martin Bornhäuser
- University Hospital TU Dresden, Dresden, Germany; National Center for Tumor Diseases, Dresden, Germany
| | | | - Johannes Schetelig
- University Hospital TU Dresden, Dresden, Germany; DKMS gemeinnützige GmbH, Tübingen und Dresden, Germany.
| |
Collapse
|
3
|
Orozco JJ, Vo PT, Gooley TA, Haaf RL, Lundberg SJ, Hamlin DK, Wilbur DS, Matesan MC, Fisher DR, Gopal AK, Green DJ, Pagel JM, Sandmaier BM. Targeted Radiation Delivery before Haploidentical HCT for High-risk Leukemia or MDS Patients Yields Long-term Survivors. Clin Cancer Res 2024; 30:274-282. [PMID: 37939122 PMCID: PMC10843688 DOI: 10.1158/1078-0432.ccr-23-1200] [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: 05/02/2023] [Revised: 08/23/2023] [Accepted: 11/02/2023] [Indexed: 11/10/2023]
Abstract
PURPOSE Hematopoietic cell transplantation (HCT) has curative potential for myeloid malignancies, though many patients cannot tolerate myeloablative conditioning with high-dose chemotherapy alone or with total-body irradiation (TBI). Here we report long-term outcomes from a phase I/II study using iodine-131 (131I)-anti-CD45 antibody BC8 combined with nonmyeloablative conditioning prior to HLA-haploidentical HCT in adults with high-risk relapsed/ refractory acute myeloid or lymphoid leukemia (AML or ALL), or myelodysplastic syndrome (MDS; ClinicalTrials.gov, NCT00589316). PATIENTS AND METHODS Patients received a tracer diagnostic dose before a therapeutic infusion of 131I-anti-CD45 to deliver escalating doses (12-26 Gy) to the dose-limiting organ. Patients subsequently received fludarabine, cyclophosphamide (CY), and 2 Gy TBI conditioning before haploidentical marrow HCT. GVHD prophylaxis was posttransplant CY plus tacrolimus and mycophenolate mofetil. RESULTS Twenty-five patients (20 with AML, 4 ALL and 1 high-risk MDS) were treated; 8 had ≥ 5% blasts by morphology (range 9%-20%), and 7 had previously failed HCT. All 25 patients achieved a morphologic remission 28 days after HCT, with only 2 patients showing minimal residual disease (0.002-1.8%) by flow cytometry. Median time to engraftment was 15 days for neutrophils and 23 days for platelets. Point estimates for overall survival and progression-free survival were 40% and 32% at 1 year, and 24% at 2 years, respectively. Point estimates of relapse and nonrelapse mortality at 1 year were 56% and 12%, respectively. CONCLUSIONS 131I-anti-CD45 radioimmunotherapy prior to haploidentical HCT is feasible and can be curative in some patients, including those with disease, without additional toxicity.
Collapse
Affiliation(s)
- Johnnie J Orozco
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
- Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Phuong T Vo
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
- Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Ted A Gooley
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Robyn L Haaf
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Sally J Lundberg
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Donald K Hamlin
- Radiation Oncology, University of Washington School of Medicine, Seattle, Washington
| | - D Scott Wilbur
- Radiation Oncology, University of Washington School of Medicine, Seattle, Washington
| | - Manuela C Matesan
- Nuclear Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Darrell R Fisher
- Versant Medical Physics and Radiation Safety, Richland, Washington
| | - Ajay K Gopal
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
- Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Damian J Green
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
- Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - John M Pagel
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Brenda M Sandmaier
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
- Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| |
Collapse
|
4
|
Park S, Kwag D, Kim TY, Lee JH, Lee JY, Min GJ, Park SS, Yahng SA, Jeon YW, Shin SH, Yoon JH, Lee SE, Cho BS, Eom KS, Kim YJ, Lee S, Min CK, Cho SG, Lee JW, Kim HJ. A retrospective comparison of salvage intensive chemotherapy versus venetoclax-combined regimen in patients with relapsed/refractory acute myeloid leukemia (AML). Ther Adv Hematol 2022; 13:20406207221081637. [PMID: 35340720 PMCID: PMC8949776 DOI: 10.1177/20406207221081637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 01/31/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Evidence that a venetoclax (VEN)-combined regimen is effective in relapsed/refractory acute myeloid leukemia (R/R AML) is emerging. However, it is unknown how VEN-combined low intensity treatment compares to intensive chemotherapy (IC) in medically fit patients with R/R AML. Methods: We compared AML patients who received IC (n = 89) to those who received a VEN in combination with hypomethylating agents or low dose cytarabine (VEN combination) (n = 54) as their first- or second-line salvage after failing anthracycline-containing intensive chemotherapy. Results: The median age was 49 years, and significantly more patients in the VEN combination group were in their second salvage and had received prior stem cell transplantation (SCT). Overall response rates including CR, CRi, and MLFS were comparable (44.0% for IC vs. 59.3% for VEN combination, p = 0.081), but VEN combination group compared to IC group tended to show lower treatment related mortality. The rate of bridging to SCT was the same (68.5%), but the percentage of SCT at blast clearance was significantly higher in the VEN-combined group (62.3% vs. 86.5%, p = 0.010). After median follow-up periods of 22.5 (IC) and 11.3 months (VEN combination), the median overall survival was 8.9 (95% CI, 5.4-12.4) and 12.4 months (95% CI, 9.5-15.2) (p = 0.724), respectively. Conclusion: VEN combination provides a comparable anti-leukemic response and survival to salvage IC, and provide a bridge to SCT with better disease control in medically-fit patients with R/R AML.
Collapse
Affiliation(s)
- Silvia Park
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Daehun Kwag
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Tong Yoon Kim
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Jong Hyuk Lee
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Joon Yeop Lee
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Gi June Min
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Sung Soo Park
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Seung-Ah Yahng
- Department of Hematology, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, South Korea
| | - Young-Woo Jeon
- Department of Hematology, Yeoido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Seung-Hwan Shin
- Department of Hematology, Catholic Hematology Hospital, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Jae-Ho Yoon
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Sung-Eun Lee
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Byung Sik Cho
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Ki-Seong Eom
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Yoo-Jin Kim
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Seok Lee
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Chang-Ki Min
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Seok-Goo Cho
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Jong Wook Lee
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Hee-Je Kim
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| |
Collapse
|
5
|
Sockel K, Stölzel F, Hönl F, Baldauf H, Röllig C, Wermke M, von Bonin M, Teipel R, Link-Rachner C, Brandt K, Kroschinsky F, Hänel M, Morgner A, Klesse C, Ehninger G, Platzbecker U, Bornhäuser M, Schetelig J, Middeke JM. Allogeneic Stem Cell Transplantation with Sequential Melphalan-Based Conditioning in AML: Residual Morphological Blast Count Determines the Risk of Relapse. Cancer Manag Res 2022; 14:547-559. [PMID: 35210852 PMCID: PMC8857952 DOI: 10.2147/cmar.s339846] [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: 09/19/2021] [Accepted: 12/23/2021] [Indexed: 11/29/2022] Open
Abstract
Introduction Allogeneic hematopoietic cell transplantation (HCT) during chemotherapy-induced aplasia may offer long-term survival in acute myeloid leukemia (AML) with otherwise poor prognosis including ELN adverse risk, relapsed or refractory disease. However, the value of residual morphologic disease prior HCT in this context has not been conclusively settled until yet. Therefore, we aimed to investigate variables predicting outcome in this unique setting of sequential conditioning therapy, with a focus on pretreatment morphologic blast count. In contrast to the most popular FLAMSA-RIC protocol, we used a melphalan-based conditioning regimen during aplasia. Methods We retrospectively analyzed data from 173 AML patients who underwent a sequential melphalan-based conditioning therapy between 2003 and 2015 at our centre. All patients participated either in the prospective Phase 2 BRIDGE trial (NCT01295307), the Phase 3 AML2003 study (NCT00180102) or were treated according to this protocol and underwent allogeneic HCT after melphalan-based conditioning in treatment-induced aplasia. Results Median bone marrow blast count prior to conditioning was 10% (range, 0–96%). Four year probabilities of EFS and OS were 34% (95% CI, 28–43%) and 43% (95% CI, 36–52%), respectively. In multivariate analysis, blast count >20% was associated with worse EFS (HR = 1.93; p = 0.009) and OS (HR = 1.80; p = 0.026). This effect was not significant anymore for HCT during 1st line therapy. Conclusion Allogeneic HCT in aplasia with a melphalan-based conditioning regimen has the potential to cure a subset of adverse risk AML patients, even with persistent morphological disease prior HCT. However, a high pre-transplant blast count still indicates patients with a dismal prognosis, especially in the relapsed patient group, for whom post-transplant strategies should be considered to further optimize post HCT outcome.
Collapse
Affiliation(s)
- Katja Sockel
- Medical Clinic and Policlinic I, University Hospital Carl Gustav Carus and Medical Faculty of the TU Dresden, Dresden, Germany
| | - Friedrich Stölzel
- Medical Clinic and Policlinic I, University Hospital Carl Gustav Carus and Medical Faculty of the TU Dresden, Dresden, Germany
| | - Franziska Hönl
- Medical Clinic and Policlinic I, University Hospital Carl Gustav Carus and Medical Faculty of the TU Dresden, Dresden, Germany
| | | | - Christoph Röllig
- Medical Clinic and Policlinic I, University Hospital Carl Gustav Carus and Medical Faculty of the TU Dresden, Dresden, Germany
| | - Martin Wermke
- Medical Clinic and Policlinic I, University Hospital Carl Gustav Carus and Medical Faculty of the TU Dresden, Dresden, Germany
| | - Malte von Bonin
- Medical Clinic and Policlinic I, University Hospital Carl Gustav Carus and Medical Faculty of the TU Dresden, Dresden, Germany
| | - Raphael Teipel
- Medical Clinic and Policlinic I, University Hospital Carl Gustav Carus and Medical Faculty of the TU Dresden, Dresden, Germany
| | - Cornelia Link-Rachner
- Medical Clinic and Policlinic I, University Hospital Carl Gustav Carus and Medical Faculty of the TU Dresden, Dresden, Germany
| | - Kalina Brandt
- Medical Clinic and Policlinic I, University Hospital Carl Gustav Carus and Medical Faculty of the TU Dresden, Dresden, Germany
| | - Frank Kroschinsky
- Medical Clinic and Policlinic I, University Hospital Carl Gustav Carus and Medical Faculty of the TU Dresden, Dresden, Germany
| | - Mathias Hänel
- Department of Medicine III, Chemnitz Hospital, Chemnitz, Germany
| | - Anke Morgner
- Department of Medicine III, Chemnitz Hospital, Chemnitz, Germany
| | | | - Gerhard Ehninger
- Medical Clinic and Policlinic I, University Hospital Carl Gustav Carus and Medical Faculty of the TU Dresden, Dresden, Germany
| | - Uwe Platzbecker
- Department of Hematology, Cellular Therapy and Hemostaseology, Leipzig University Hospital, Leipzig, Germany
| | - Martin Bornhäuser
- Medical Clinic and Policlinic I, University Hospital Carl Gustav Carus and Medical Faculty of the TU Dresden, Dresden, Germany
| | - Johannes Schetelig
- Medical Clinic and Policlinic I, University Hospital Carl Gustav Carus and Medical Faculty of the TU Dresden, Dresden, Germany
- Clinical Trials Unit, DKMS, Dresden, Germany
| | - Jan Moritz Middeke
- Medical Clinic and Policlinic I, University Hospital Carl Gustav Carus and Medical Faculty of the TU Dresden, Dresden, Germany
- Correspondence: Jan Moritz Middeke, Medical Clinic and Policlinic I, University Hospital Carl Gustav Carus and Medical Faculty of the TU Dresden, Fetscherstr. 74, Dresden, 01307, Germany, Tel +49-0351-458-15603, Fax +49-0351-458-4373, Email
| |
Collapse
|
6
|
Real-world experience of CPX-351 as first-line treatment for patients with acute myeloid leukemia. Blood Cancer J 2021; 11:164. [PMID: 34608129 PMCID: PMC8490353 DOI: 10.1038/s41408-021-00558-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 09/07/2021] [Accepted: 09/17/2021] [Indexed: 01/22/2023] Open
Abstract
To investigate the efficacy and toxicities of CPX-351 outside a clinical trial, we analyzed 188 patients (median age 65 years, range 26–80) treated for therapy-related acute myeloid leukemia (t-AML, 29%) or AML with myelodysplasia-related changes (AML-MRC, 70%). Eighty-six percent received one, 14% two induction cycles, and 10% received consolidation (representing 22% of patients with CR/CRi) with CPX-351. Following induction, CR/CRi rate was 47% including 64% of patients with available information achieving measurable residual disease (MRD) negativity (<10−3) as measured by flow cytometry. After a median follow-up of 9.3 months, median overall survival (OS) was 21 months and 1-year OS rate 64%. In multivariate analysis, complex karyotype predicted lower response (p = 0.0001), while pretreatment with hypomethylating agents (p = 0.02) and adverse European LeukemiaNet 2017 genetic risk (p < 0.0001) were associated with lower OS. Allogeneic hematopoietic cell transplantation (allo-HCT) was performed in 116 patients (62%) resulting in promising outcome (median survival not reached, 1-year OS 73%), especially in MRD-negative patients (p = 0.048). With 69% of patients developing grade III/IV non-hematologic toxicity following induction and a day 30-mortality of 8% the safety profile was consistent with previous findings. These real-world data confirm CPX-351 as efficient treatment for these high-risk AML patients facilitating allo-HCT in many patients with promising outcome after transplantation.
Collapse
|
7
|
Kunadt D, Stölzel F. Effective Immunosurveillance After Allogeneic Hematopoietic Stem Cell Transplantation in Acute Myeloid Leukemia. Cancer Manag Res 2021; 13:7411-7427. [PMID: 34594134 PMCID: PMC8478160 DOI: 10.2147/cmar.s261721] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 09/15/2021] [Indexed: 12/25/2022] Open
Abstract
The number of patients receiving allogeneic hematopoietic stem cell transplantation (alloHCT) has increased constantly over the last years due to advances in transplant technology development, supportive care, transplant safety, and donor availability. Currently, acute myeloid leukemia (AML) is the most frequent indication for alloHCT. However, disease relapse remains the main cause of therapy failure. Therefore, concepts of maintaining and, if necessary, reinforcing a strong graft-versus-leukemia (GvL) effect is crucial for the prognosis and long-term survival of the patients. Over the last decades, it has become evident that effective immunosurveillance after alloHCT is an entangled complex of donor-specific characteristics, leukemia-associated geno- and phenotypes, and acquired resistance mechanisms. Furthermore, adoption of effector cells such as natural killer (NK) cells, alloreactive and regulatory T-cells with their accompanying receptor repertoire, and cell–cell interactions driven by messenger molecules within the stem cell and the bone marrow niche have important impact. In this review of pre- and posttransplant elements and mechanisms of immunosurveillance, we highlight the most important mechanisms after alloHCT.
Collapse
Affiliation(s)
- Desiree Kunadt
- Department of Internal Medicine I, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany
| | - Friedrich Stölzel
- Department of Internal Medicine I, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany
| |
Collapse
|
8
|
Pabon CM, Li Z, Hennig T, de Castro C, Neff JL, Horwitz ME, LeBlanc TW, Long GD, Lopez RD, Sung AD, Chao N, Gasparetto C, Sarantopoulos S, Adams DB, Erba H, Rizzieri DA. Morphologic leukemia-free state in acute myeloid leukemia is sufficient for successful allogeneic hematopoietic stem cell transplant. Blood Cancer J 2021; 11:92. [PMID: 33994546 PMCID: PMC8126559 DOI: 10.1038/s41408-021-00481-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 04/05/2021] [Accepted: 04/26/2021] [Indexed: 01/03/2023] Open
Affiliation(s)
- Cindy M Pabon
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, NC, USA.
| | - Zhiguo Li
- Department of Biostatistics and Bioinfomatics, Duke University, Durham, NC, USA
| | - Therese Hennig
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Carlos de Castro
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Jadee L Neff
- Department of Pathology, Divisions of Hematopathology and Molecular Pathology, Genetics and Genomics, Durham, NC, USA
| | - Mitchell E Horwitz
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Thomas W LeBlanc
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Gwynn D Long
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Richard D Lopez
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Anthony D Sung
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Nelson Chao
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Cristina Gasparetto
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | | | - Donna B Adams
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Harry Erba
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - David A Rizzieri
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| |
Collapse
|
9
|
Kussman A, Shyr D, Hale G, Oshrine B, Petrovic A. Allogeneic hematopoietic cell transplantation in chemotherapy-induced aplasia in children with high-risk acute myeloid leukemia or myelodysplasia. Pediatr Blood Cancer 2019; 66:e27481. [PMID: 30318867 DOI: 10.1002/pbc.27481] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 09/06/2018] [Accepted: 09/13/2018] [Indexed: 12/12/2022]
Abstract
Relapse remains the most common cause of treatment failure after hematopoietic cell transplantation for acute myeloid leukemia. Inability to achieve hematologic complete remission has been a barrier to transplant for patients with refractory disease. We describe six children with refractory myeloid disease undergoing transplant in chemotherapy-induced aplasia, as a strategy to facilitate curative therapy in refractory patients. Clofarabine- or high-dose cytarabine-based chemotherapy regimens were used to achieve marrow aplasia, followed by reduced-intensity conditioning and allogeneic transplant before hematologic recovery. Long-term disease control was achieved in five, with one transplant-related mortality, suggesting the feasibility of this approach.
Collapse
Affiliation(s)
| | - David Shyr
- Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Gregory Hale
- Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | | | | |
Collapse
|
10
|
Davies JK, Hassan S, Sarker SJ, Besley C, Oakervee H, Smith M, Taussig D, Gribben JG, Cavenagh JD. Durable graft-versus-leukaemia effects without donor lymphocyte infusions - results of a phase II study of sequential T-replete allogeneic transplantation for high-risk acute myeloid leukaemia and myelodysplasia. Br J Haematol 2017; 180:346-355. [PMID: 29076145 DOI: 10.1111/bjh.14980] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 09/01/2017] [Indexed: 01/13/2023]
Abstract
Allogeneic haematopoietic stem-cell transplantation remains the only curative treatment for relapsed/refractory acute myeloid leukaemia (AML) and high-risk myelodysplasia but has previously been limited to patients who achieve remission before transplant. New sequential approaches employing T-cell depleted transplantation directly after chemotherapy show promise but are burdened by viral infection and require donor lymphocyte infusions (DLI) to augment donor chimerism and graft-versus-leukaemia effects. T-replete transplantation in sequential approaches could reduce both viral infection and DLI usage. We therefore performed a single-arm prospective Phase II clinical trial of sequential chemotherapy and T-replete transplantation using reduced-intensity conditioning without planned DLI. The primary endpoint was overall survival. Forty-seven patients with relapsed/refractory AML or high-risk myelodysplasia were enrolled; 43 proceeded to transplantation. High levels of donor chimerism were achieved spontaneously with no DLI. Overall survival of transplanted patients was 45% and 33% at 1 and 3 years. Only one patient developed cytomegalovirus disease. Cumulative incidences of treatment-related mortality and relapse were 35% and 20% at 1 year. Patients with relapsed AML and myelodysplasia had the most favourable outcomes. Late-onset graft-versus-host disease protected against relapse. In conclusion, a T-replete sequential transplantation using reduced-intensity conditioning is feasible for relapsed/refractory AML and myelodysplasia and can deliver graft-versus-leukaemia effects without DLI.
Collapse
Affiliation(s)
- Jeff K Davies
- Centre for Haemato-Oncology, Barts Cancer Institute, Queen Mary University of London, London, UK.,Department of Haemato-Oncology, Barts Cancer Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Sandra Hassan
- Centre for Haemato-Oncology, Barts Cancer Institute, Queen Mary University of London, London, UK
| | - Shah-Jalal Sarker
- Centre for Experimental Cancer Medicine, Barts Cancer Institute, Queen Mary University of London, London, UK
| | - Caroline Besley
- Centre for Haemato-Oncology, Barts Cancer Institute, Queen Mary University of London, London, UK
| | - Heather Oakervee
- Department of Haemato-Oncology, Barts Cancer Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Matthew Smith
- Department of Haemato-Oncology, Barts Cancer Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - David Taussig
- Centre for Haemato-Oncology, Barts Cancer Institute, Queen Mary University of London, London, UK.,Department of Haemato-Oncology, Barts Cancer Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - John G Gribben
- Centre for Haemato-Oncology, Barts Cancer Institute, Queen Mary University of London, London, UK.,Department of Haemato-Oncology, Barts Cancer Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Jamie D Cavenagh
- Centre for Haemato-Oncology, Barts Cancer Institute, Queen Mary University of London, London, UK.,Department of Haemato-Oncology, Barts Cancer Centre, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| |
Collapse
|
11
|
Progressive Dispersion of Azole Resistance in Aspergillus fumigatus: Fatal Invasive Aspergillosis in a Patient with Acute Myeloid Leukemia Infected with an A. fumigatus Strain with a cyp51A TR 46 Y121F M172I T289A Allele. Antimicrob Agents Chemother 2017; 61:61/8/e00270-17. [PMID: 28743702 DOI: 10.1128/aac.00270-17] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Patients with hematologic malignancies as well as allogeneic hematopoietic stem cell transplantation (HSCT) patients are at high risk for invasive aspergillosis. Here, we report a culture- and autopsy-proven fatal invasive aspergillosis in an allogeneic HSTC patient which he developed despite posaconazole prophylaxis. The agent was determined to be an azole-resistant Aspergillus fumigatus strain bearing the cyp51A mutation combination TR46 Y121F M172I T289A. At increasing frequency, the azole resistance of A. fumigatus is being reported globally, limiting treatment options and complicating regimens.
Collapse
|
12
|
Long-Term Follow-Up and Impact of Comorbidity before Allogeneic Hematopoietic Stem Cell Transplantation in Patients with Relapsed or Refractory Acute Myeloid Leukemia-Lessons Learned from the Prospective BRIDGE Trial. Biol Blood Marrow Transplant 2017; 23:1491-1497. [PMID: 28527985 DOI: 10.1016/j.bbmt.2017.05.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 05/14/2017] [Indexed: 11/22/2022]
Abstract
In patients with relapsed or refractory (r/r) acute myeloid leukemia (AML), allogeneic hematopoietic stem cell transplantation (HSCT) is considered to be the only treatment providing long-term disease control. The BRIDGE trial studied the safety and efficacy of a clofarabine-based salvage therapy before HSCT in patients with r/r AML. Here, we report the long-term follow-up of this phase II multicenter trial and exploratory analyses on the impact of comorbidity on outcome. Eighty-four patients with a median age of 61 years (range, 40 to 75) were enrolled. Patients were scheduled for at least 1 cycle of salvage therapy with CLARA (clofarabine 30 mg/m2; cytarabine 1 g/m2, days 1 to 5). Chemo-responsive patients with a donor received HSCT after first CLARA. The conditioning regimen consisted of clofarabine 30 mg/m2, day -6 to -3, and melphalan 140 mg/m2 day -2. The Eastern Cooperative Oncology Group (ECOG) score, the hematopoietic cell transplantation-specific comorbidity index (HCT-CI), and the Cumulative Illness Rating Scale were obtained at study enrollment as well as before HSCT. Sixty-seven percent of the patients received HSCT within the trial. After a median follow up of 40 months, the estimated 3-year overall survival (OS) for all enrolled patients and those with HSCT within the trial was 40% and 55%, respectively. Relapse-free survival for patients who underwent transplantation with a complete remission afterwards (n = 50) was 48%, calculated from the day of transplantation. In multivariate analysis, both the HCT-CI and ECOG score had a statistically significant impact on OS with a hazard ratio of 1.22 (P = .025)and 1.72 (P = .001), respectively. Using a clofarabine-based salvage therapy combined with early allogeneic HSCT, we were able to achieve good long-term results for patients with r/r AML. In this cohort, both the HCT-CI and the ECOG scores gave prognostic information on OS, showing the feasibility and clinical relevance of comorbidity evaluation at the time of diagnosis of r/r AML patients.
Collapse
|
13
|
Fujiwara H, Fuji S, Wake A, Kato K, Takatsuka Y, Fukuda T, Taguchi J, Uchida N, Miyamoto T, Hidaka M, Miyazaki Y, Tomoyose T, Onizuka M, Takanashi M, Ichinohe T, Atsuta Y, Utsunomiya A. Dismal outcome of allogeneic hematopoietic stem cell transplantation for relapsed adult T-cell leukemia/lymphoma, a Japanese nation-wide study. Bone Marrow Transplant 2017; 52:484-488. [DOI: 10.1038/bmt.2016.313] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|
14
|
Fuji S, Fujiwara H, Nakano N, Wake A, Inoue Y, Fukuda T, Hidaka M, Moriuchi Y, Miyamoto T, Uike N, Taguchi J, Eto T, Tomoyose T, Kondo T, Yamanoha A, Ichinohe T, Atsuta Y, Utsunomiya A. Early application of related SCT might improve clinical outcome in adult T-cell leukemia/lymphoma. Bone Marrow Transplant 2015; 51:205-11. [PMID: 26524263 DOI: 10.1038/bmt.2015.265] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Revised: 08/31/2015] [Accepted: 09/14/2015] [Indexed: 02/08/2023]
Abstract
Allogeneic hematopoietic SCT (allo-HSCT) is a curative treatment for aggressive adult T-cell leukemia/lymphoma (ATLL). Considering the dismal prognosis associated with conventional chemotherapies, early application of allo-HSCT might be beneficial for patients with ATLL. However, no previous study has addressed the optimal timing of allo-HSCT from related donors. Hence, to evaluate the impact of timing of allo-HSCT for patients with ATLL, we retrospectively analyzed data from patients with ATLL who received an allo-HSCT from a related donor. The median age was 52 years. Patients were grouped according to the interval from diagnosis to allo-HSCT: early transplant group, <100 days, n=72; late transplant group, ⩾100 days, n=428. The corresponding constituents of disease status were not statistically different between the two groups (P=0.11). The probability of OS in the early transplant group was significantly higher than that in the late transplant group (4-year OS, 49.3% vs 31.2%). Multivariate analysis revealed that late allo-HSCT was an unfavorable prognostic factor for OS (hazard ratio, 1.46; 95% confidence interval (CI), 1.01-2.11; P=0.04). Despite the limitations of a retrospective study, it might be acceptable to consider early application of allo-HSCT for ATLL.
Collapse
Affiliation(s)
- S Fuji
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - H Fujiwara
- First Department of Internal Medicine, Ehime University Hospital, Ehime, Japan
| | - N Nakano
- Department of Hematology, Imamura Bun-in Hospital, Kagoshima, Japan
| | - A Wake
- Department of Hematology, Toranomon Hospital Kajigaya, Kanagawa, Japan
| | - Y Inoue
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - T Fukuda
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - M Hidaka
- Department of Hematology, National Hospital Organization Kumamoto Medical Center, Kumamoto, Japan
| | - Y Moriuchi
- Department of Hematology, Sasebo City General Hospital, Nagasaki, Japan
| | - T Miyamoto
- Department of Hematology and Oncology, Kyushu University Hospital, Fukuoka, Japan
| | - N Uike
- Department of Hematology, National Kyushu Cancer Center, Fukuoka, Japan
| | - J Taguchi
- Department of Hematology, Atomic Bomb Disease and Hibakusha Medicine Unit, Nagasaki University Hospital, Nagasaki, Japan
| | - T Eto
- Department of Hematology, Hamanomachi Hospital, Fukuoka, Japan
| | - T Tomoyose
- Second Department of Internal Medicine, Endocrinology, Diabetes and Metabolism, Hematology and Rheumatology, University Hospital, University of the Ryukyus, Okinawa, Japan
| | - T Kondo
- Department of Hematology/Oncology, Kyoto University Hospital, Kyoto, Japan
| | - A Yamanoha
- Department of Haematology, Heart-Life Hospital, Okinawa, Japan
| | - T Ichinohe
- Department of Hematology and Oncology, Hiroshima University Hospital, Hiroshima, Japan
| | - Y Atsuta
- Japanese Data Center for Hematopoietic Cell Transplantation, Nagoya, Japan.,Department of Healthcare Administration, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - A Utsunomiya
- Department of Hematology, Imamura Bun-in Hospital, Kagoshima, Japan
| | | |
Collapse
|
15
|
Clofarabine salvage therapy before allogeneic hematopoietic stem cell transplantation in patients with relapsed or refractory AML: results of the BRIDGE trial. Leukemia 2015; 30:261-7. [PMID: 26283567 DOI: 10.1038/leu.2015.226] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 08/04/2015] [Accepted: 08/06/2015] [Indexed: 12/29/2022]
Abstract
In patients with relapsed or refractory (r/r) acute myeloid leukemia (AML), long-term disease control can only be achieved by allogeneic hematopoietic stem cell transplantation (HSCT). We studied the safety and efficacy of clofarabine-based salvage therapy. The study was designed as phase II, multicenter, intent-to-transplant (ITT) study. A total of 84 patients with r/r AML were enrolled. All patients received at least one cycle of CLARA (clofarabine 30 mg/m(2) and cytarabine 1 g/m(2), days 1-5). Chemo-responsive patients with a donor received HSCT in aplasia after first CLARA. Generally, HSCT was performed as soon as possible. The conditioning regimen consisted of clofarabine (4 × 30 mg/m(2)) and melphalan (140 mg/m(2)). The median patient age was 61 years (range 40-75). On day 15 after start of CLARA, 26% of patients were in a morphologically leukemia-free state and 79% exposed a reduction in bone marrow blasts. Overall, 67% of the patients received HSCT within the trial. The primary end point, defined as complete remission after HSCT, was achieved by 60% of the patients. According to the ITT, overall survival at 2 years was 43% (95% confidence interval (CI), 32-54%). The 2-year disease-free survival for transplanted patients was 52% (95% CI, 40-69%). Clofarabine-based salvage therapy combined with allogeneic HSCT in aplasia shows promising results in patients with r/r AML.
Collapse
|
16
|
Low platelet count reduces subsequent complete remission rate despite marrow with <5% blasts after AML induction therapy. Leukemia 2015; 29:1779-80. [DOI: 10.1038/leu.2015.23] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
17
|
Estey EH. Acute myeloid leukemia: 2014 update on risk-stratification and management. Am J Hematol 2014; 89:1063-81. [PMID: 25318680 DOI: 10.1002/ajh.23834] [Citation(s) in RCA: 101] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Indexed: 12/11/2022]
Abstract
OVERVIEW Evidence suggests that even patients aged 70 or above benefit from specific AML therapy. The fundamental decision in AML then becomes whether to recommend standard or investigational treatment. This decision must rest on the likely outcome of standard treatment. Hence we review factors that predict treatment related mortality and resistance to therapy, the latter the principal cause of failure even in patients aged 70 or above. We emphasize the limitations of prediction of resistance based only on pre-treatment factors and stress the need to incorporate post-treatment factors, for example indicators of minimal residual disease. We review various newer therapeutic options and considerations that underlie the decision to recommend allogeneic hematopoietic cell transplant.
Collapse
Affiliation(s)
- Elihu H. Estey
- Division of Hematology; University of Washington and Member, Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| |
Collapse
|
18
|
|
19
|
Kharfan-Dabaja MA, Labopin M, Bazarbachi A, Hamladji RM, Blaise D, Socié G, Lioure B, Bermudez A, Lopez-Corral L, Or R, Arcese W, Fegueux N, Nagler A, Mohty M. Comparing i.v. BU dose intensity between two regimens (FB2 vs FB4) for allogeneic HCT for AML in CR1: a report from the Acute Leukemia Working Party of EBMT. Bone Marrow Transplant 2014; 49:1170-5. [PMID: 24978140 DOI: 10.1038/bmt.2014.133] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2014] [Revised: 05/07/2014] [Accepted: 05/12/2014] [Indexed: 01/20/2023]
Abstract
This retrospective analysis compared two regimens of fludarabine combined with i.v. BU 6.4 mg/kg (FB2) or BU 12.8 mg/kg (FB4) for allografting of AML in first CR. A total of 437 patients (median age: 50 years) were administered FB2 (n = 225, 51%) or FB4 (n = 212, 49%). Median follow-up time was 28 months. Use of FB2 resulted in a longer time to neutrophil engraftment (17 vs 15 days, P < 0.0001) but no difference in incidence of grade II-IV acute (P = 0.54) or chronic GVHD (P = 0.51). In patients < 50 years of age, FB2 was associated with a higher 2-year cumulative incidence of relapse (33 ± 6% vs 20 ± 4%, P = 0.04), but there was no difference in 2-year leukemia-free survival (LFS) (P = 0.45), OS (P = 0.53) or non-relapse mortality (P = 0.17). In recipients ⩾ 50 years of age, FB2 resulted in better 2-year LFS (63 ± 4% vs 42 ± 7%, P = 0.02) and OS (68 ± 4% vs 45 ± 7%, P = 0.006); a lower 2-year non-relapse mortality, albeit not statistically significant (15 ± 3% vs 29 ± 6%, P = 0.06), was observed with FB2. FB2 is an effective and well-tolerated regimen in patients ⩾ 50 years of age and does not compromise survival when used in patients <50 years undergoing allogeneic transplantation for AML in first CR.
Collapse
Affiliation(s)
- M A Kharfan-Dabaja
- 1] Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center/University of South Florida College of Medicine, Tampa, Florida, USA [2] Division of Hematology-Oncology and Bone Marrow Transplantation Program, American University of Beirut Medical Center, Beirut, Lebanon
| | - M Labopin
- Acute Leukemia Working Party of EBMT, Paris, France
| | - A Bazarbachi
- Division of Hematology-Oncology and Bone Marrow Transplantation Program, American University of Beirut Medical Center, Beirut, Lebanon
| | | | - D Blaise
- Unité de Transplantation et de Thérapie Cellulaire (U2T), Institut Paoli-Calmettes, Marseille, France
| | - G Socié
- Service d'Hématologie Greffe, Hôpital Saint Louis, Paris, France
| | - B Lioure
- CHU Hautepierre- Département d'Hématologie et Oncologie, Strasbourg, France
| | - A Bermudez
- Department of Hematology, Hospital Universitario Marqués de Valdecilla, Instituto de Formación e Investigación Marqués de Valdecilla, Santander, Spain
| | - L Lopez-Corral
- Servicio de Hematologia, Hospital Universitario de Salamanca, Salamanca, Spain
| | - R Or
- Department of Bone Marrow Transplantation and Cancer Immunotherapy, Hadassah University Hospital, Jerusalem, Israel
| | - W Arcese
- Rome Transplant Network, Department of Hematology, Stem Cell Transplant Unit, Tor Vergata University, Rome, Italy
| | - N Fegueux
- Service d'Hématologie, CHU, Montpellier, France
| | - A Nagler
- Hematology Division, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - M Mohty
- 1] Acute Leukemia Working Party of EBMT, Paris, France [2] Département d'Hématologie, Hopital Saint Antoine, Paris, France
| |
Collapse
|