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Fraccaroli A, Stauffer E, Haebe S, Prevalsek D, Weiss L, Dorman K, Drolle H, von Bergwelt-Baildon M, Stemmler HJ, Herold T, Tischer J. Treosulfan-Versus Melphalan-Based Reduced Intensity Conditioning in HLA-Haploidentical Transplantation for Patients ≥ 50 Years with Advanced MDS/AML. Cancers (Basel) 2024; 16:2859. [PMID: 39199629 PMCID: PMC11353158 DOI: 10.3390/cancers16162859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2024] [Revised: 08/11/2024] [Accepted: 08/14/2024] [Indexed: 09/01/2024] Open
Abstract
Relapse and regimen-related toxicities remain major challenges in achieving long-term survival, particularly among older patients with high-risk myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML) undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT). Previous studies have demonstrated the feasibility of treosulfan-based conditioning, noting stable engraftment and low non-relapse mortality (NRM) in patients undergoing HLA-matched allo-HSCT. However, data on treosulfan-based conditioning in the HLA-haploidentical transplantation (HaploT) setting are limited. We retrospectively compared conditioning with fludarabine-cyclophosphamide (FC)-melphalan (110 mg/m2) and FC-treosulfan (30 g/m2) prior to HaploT using post-transplantation cyclophosphamide (PTCy) in patients with high-risk MDS/AML patients ≥ 50 years, transplanted from 2009-2021 at our institution (n = 80). After balancing patient characteristics by a matched-pair analysis, we identified twenty-one matched pairs. Two-year OS and LFS were similar among the groups (OS 66% and LFS 66%, p = 0.8 and p = 0.57). However, FC-melphalan was associated with a significantly lower probability of relapse compared to FC-treosulfan (0% vs. 24%, p = 0.006), counterbalanced by a higher NRM (33% vs. 10%, p = 0.05). Time to engraftment and incidences of acute and chronic graft-versus-host disease (GvHD) did not differ significantly. In conclusion, HaploT using FC-treosulfan in combination with PTCy in patients aged ≥50 years with MDS/AML appears safe and effective, particularly in advanced disease stages. We confirm the favorable extramedullary toxicity profile, allowing for potential dose intensification to enhance antileukemic activity.
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Affiliation(s)
- Alessia Fraccaroli
- Hematopoietic Stem Cell Transplantation Unit, Department of Medicine III, LMU University Hospital, 81377 Munich, Germany; (A.F.); (E.S.); (S.H.); (D.P.); (L.W.); (K.D.); (H.D.); (M.v.B.-B.); (H.-J.S.); (T.H.)
| | - Elena Stauffer
- Hematopoietic Stem Cell Transplantation Unit, Department of Medicine III, LMU University Hospital, 81377 Munich, Germany; (A.F.); (E.S.); (S.H.); (D.P.); (L.W.); (K.D.); (H.D.); (M.v.B.-B.); (H.-J.S.); (T.H.)
| | - Sarah Haebe
- Hematopoietic Stem Cell Transplantation Unit, Department of Medicine III, LMU University Hospital, 81377 Munich, Germany; (A.F.); (E.S.); (S.H.); (D.P.); (L.W.); (K.D.); (H.D.); (M.v.B.-B.); (H.-J.S.); (T.H.)
| | - Dusan Prevalsek
- Hematopoietic Stem Cell Transplantation Unit, Department of Medicine III, LMU University Hospital, 81377 Munich, Germany; (A.F.); (E.S.); (S.H.); (D.P.); (L.W.); (K.D.); (H.D.); (M.v.B.-B.); (H.-J.S.); (T.H.)
| | - Lena Weiss
- Hematopoietic Stem Cell Transplantation Unit, Department of Medicine III, LMU University Hospital, 81377 Munich, Germany; (A.F.); (E.S.); (S.H.); (D.P.); (L.W.); (K.D.); (H.D.); (M.v.B.-B.); (H.-J.S.); (T.H.)
| | - Klara Dorman
- Hematopoietic Stem Cell Transplantation Unit, Department of Medicine III, LMU University Hospital, 81377 Munich, Germany; (A.F.); (E.S.); (S.H.); (D.P.); (L.W.); (K.D.); (H.D.); (M.v.B.-B.); (H.-J.S.); (T.H.)
| | - Heidrun Drolle
- Hematopoietic Stem Cell Transplantation Unit, Department of Medicine III, LMU University Hospital, 81377 Munich, Germany; (A.F.); (E.S.); (S.H.); (D.P.); (L.W.); (K.D.); (H.D.); (M.v.B.-B.); (H.-J.S.); (T.H.)
| | - Michael von Bergwelt-Baildon
- Hematopoietic Stem Cell Transplantation Unit, Department of Medicine III, LMU University Hospital, 81377 Munich, Germany; (A.F.); (E.S.); (S.H.); (D.P.); (L.W.); (K.D.); (H.D.); (M.v.B.-B.); (H.-J.S.); (T.H.)
- German Cancer Consortium (DKTK), Partner Site Munich, a Partnership between the DKFZ Heidelberg and the University Hospital of the LMU, 81377 Munich, Germany
| | - Hans-Joachim Stemmler
- Hematopoietic Stem Cell Transplantation Unit, Department of Medicine III, LMU University Hospital, 81377 Munich, Germany; (A.F.); (E.S.); (S.H.); (D.P.); (L.W.); (K.D.); (H.D.); (M.v.B.-B.); (H.-J.S.); (T.H.)
| | - Tobias Herold
- Hematopoietic Stem Cell Transplantation Unit, Department of Medicine III, LMU University Hospital, 81377 Munich, Germany; (A.F.); (E.S.); (S.H.); (D.P.); (L.W.); (K.D.); (H.D.); (M.v.B.-B.); (H.-J.S.); (T.H.)
| | - Johanna Tischer
- Hematopoietic Stem Cell Transplantation Unit, Department of Medicine III, LMU University Hospital, 81377 Munich, Germany; (A.F.); (E.S.); (S.H.); (D.P.); (L.W.); (K.D.); (H.D.); (M.v.B.-B.); (H.-J.S.); (T.H.)
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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.
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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.
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Bono R, Sapienza G, Tringali S, Rotolo C, Patti C, Mulè A, Calafiore V, Santoro A, Castagna L. Allogeneic Stem Cell Transplantation in Refractory Acute Myeloid Leukaemia. Cells 2024; 13:755. [PMID: 38727291 PMCID: PMC11083056 DOI: 10.3390/cells13090755] [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: 02/19/2024] [Revised: 04/19/2024] [Accepted: 04/24/2024] [Indexed: 05/13/2024] Open
Abstract
Refractory acute myeloid leukaemia is very difficult to treat and represents an unmet clinical need. In recent years, new drugs and combinations of drugs have been tested in this category, with encouraging results. However, all treated patients relapsed and died from the disease. The only curative option is allogeneic transplantation through a graft from a healthy donor immune system. Using myeloablative conditioning regimens, the median overall survival regimens is 19%. Several so-called sequential induction chemotherapies followed by allogeneic transplantation conditioned by reduced intensity regimens have been developed, improving the overall survival to 25-57%. In the allogeneic transplantation field, continuous improvements in practices, particularly regarding graft versus host disease prevention, infection prevention, and treatment, have allowed us to observe improvements in survival rates. This is true mainly for patients in complete remission before transplantation and less so for refractory patients. However, full myeloablative regimens are toxic and carry a high risk of treatment-related mortality. In this review, we describe the results obtained with the different modalities used in more recent retrospective and prospective studies. Based on these findings, we speculate how allogeneic stem cell transplantation could be modified to maximise its therapeutic effect on refractory acute myeloid leukaemia.
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Affiliation(s)
- Roberto Bono
- BMT Unit, AOR Villa Sofia-Vincenzo Cervello, 90146 Palermo, Italy; (R.B.); (G.S.); (S.T.); (C.R.)
| | - Giuseppe Sapienza
- BMT Unit, AOR Villa Sofia-Vincenzo Cervello, 90146 Palermo, Italy; (R.B.); (G.S.); (S.T.); (C.R.)
| | - Stefania Tringali
- BMT Unit, AOR Villa Sofia-Vincenzo Cervello, 90146 Palermo, Italy; (R.B.); (G.S.); (S.T.); (C.R.)
| | - Cristina Rotolo
- BMT Unit, AOR Villa Sofia-Vincenzo Cervello, 90146 Palermo, Italy; (R.B.); (G.S.); (S.T.); (C.R.)
| | - Caterina Patti
- Onco-Hematology Unit, AOR Villa Sofia-Vincenzo Cervello, 90146 Palermo, Italy; (C.P.); (A.M.); (V.C.)
| | - Antonino Mulè
- Onco-Hematology Unit, AOR Villa Sofia-Vincenzo Cervello, 90146 Palermo, Italy; (C.P.); (A.M.); (V.C.)
| | - Valeria Calafiore
- Onco-Hematology Unit, AOR Villa Sofia-Vincenzo Cervello, 90146 Palermo, Italy; (C.P.); (A.M.); (V.C.)
| | - Alessandra Santoro
- Onco-Hematology and Cell Manipulation Laboratory Unit, AOR Villa Sofia-Vincenzo Cervello, 90146 Palermo, Italy;
| | - Luca Castagna
- BMT Unit, AOR Villa Sofia-Vincenzo Cervello, 90146 Palermo, Italy; (R.B.); (G.S.); (S.T.); (C.R.)
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Mina A, Greenberg PL, Deeg HJ. How I reduce and treat posttransplant relapse of MDS. Blood 2024; 143:1344-1354. [PMID: 38306658 DOI: 10.1182/blood.2023023005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 01/12/2024] [Accepted: 01/28/2024] [Indexed: 02/04/2024] Open
Abstract
ABSTRACT Allogeneic hematopoietic stem cell transplantation (HSCT) is the only potentially curative option for patients with high-risk myelodysplastic syndromes (MDS). Advances in conditioning regimens and supportive measures have reduced treatment-related mortality and increased the role of transplantation, leading to more patients undergoing HSCT. However, posttransplant relapse of MDS remains a leading cause of morbidity and mortality for this procedure, necessitating expert management and ongoing results analysis. In this article, we review treatment options and our institutional approaches to managing MDS relapse after HSCT, using illustrative clinical cases that exemplify different clinical manifestations and management of relapse. We address areas of controversy relating to conditioning regimen intensity, chemotherapeutic bridging, and donor selection. In addition, we discuss future directions for advancing the field, including (1) the need for prospective clinical trials separating MDS from acute myeloid leukemia and focusing on posttransplant relapse, as well as (2) the validation of measurable residual disease methodologies to guide timely interventions.
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Affiliation(s)
- Alain Mina
- Myeloid Malignancies Program, Center for Cancer Research, National Cancer Institute, Bethesda, MD
| | - Peter L Greenberg
- Department of Medicine, Division of Hematology, Stanford University School of Medicine, Stanford, CA
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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.
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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
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Naik S, Rakszawski K, Zheng H, Claxton D, Minagawa K, Mineishi S. Clofarabine Preconditioning followed by Allogeneic Transplant Using TBI and Post-Transplant Cyclophosphamide for Relapsed Refractory Leukemia. Int J Mol Sci 2024; 25:957. [PMID: 38256031 PMCID: PMC10815844 DOI: 10.3390/ijms25020957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 01/08/2024] [Accepted: 01/08/2024] [Indexed: 01/24/2024] Open
Abstract
Acute myeloid leukemia patients with induction failure or relapsed refractory disease have minimal chance of achieving remission with subsequent treatments. Several trials have shown the feasibility of clofarabine-based conditioning in allogeneic stem cell transplants (allo-HSCT) for non-remission AML patients. Pre-transplant conditioning with clofarabine followed by reduced-intensity allo-HSCT has also demonstrated a potential benefit in those patients with human leukocyte antigen (HLA)-identical donors, but it is not commonly used in haploidentical and mismatched transplants. In this case report, we describe our experience of seven cases of non-remission AML who received clofarabine preconditioning followed by an allo-HSCT with PTCy. The 2-year overall survival and disease-free survival was 83.3% (95% confidence interval (CI): 27.3-97.9%) and 85.7% (95% CI: 33.4-97.9%). Median days of neutrophil and platelet recovery were 16 (range of 13-23) and 28 (range of 17-75), respectively. The cumulative incidence of grade II-IV acute graft-versus-host disease (GVHD) at day 100 and chronic GVHD at 1-year showed 28.6% (95% CI: 8-74.2%) and 28.6% (95% CI: 3-63.9%), respectively. The two-year relapse rate was 14.3% (95% CI: 2.14-66.6%). One-year GVHD-free relapse-free survival (GFRS) at 1-year was 71.4% (95% CI: 25.8-92%). Our patients showed successful outcomes with clofarabine preconditioning to reduce the leukemic burden at the pre-transplant period followed by PTCy to reduce GVHD resulting in lower relapsed rate and better GFRS in these patients.
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Affiliation(s)
- Seema Naik
- Department of Medicine, Penn State Cancer Institute, 500 University Dr. Hershey, Hershey, PA 17033, USA; (K.R.); (H.Z.); (D.C.); (K.M.); (S.M.)
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7
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Geer M, Magenau J. Salvaging (with) CloBu4. Transplant Cell Ther 2023; 29:69-70. [PMID: 36759048 DOI: 10.1016/j.jtct.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Affiliation(s)
- Marcus Geer
- Blood and Marrow Transplant Program, Rogel Cancer Center, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-5932.
| | - John Magenau
- Blood and Marrow Transplant Program, Rogel Cancer Center, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-5932.
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8
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Connor MP, Loren AW, Hexner EO, Martin ME, Gill SI, Luger SM, Mangan JK, Perl AE, McCurdy SR, Pratz KW, Timlin C, Freyer CW, Carulli A, Catania C, Smith J, Hollander L, Zebrowski AM, Stadtmauer EA, Porter DL, Frey NV. Clofarabine and Busulfan Myeloablative Conditioning in Allogeneic Hematopoietic Cell Transplantation for Patients With Active Myeloid Malignancies. Transplant Cell Ther 2023; 29:113-118. [PMID: 36336258 DOI: 10.1016/j.jtct.2022.10.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 10/19/2022] [Accepted: 10/28/2022] [Indexed: 11/06/2022]
Abstract
Patients with refractory or relapsed and refractory myeloid malignancies have a poor prognosis. Allogeneic hematopoietic cell transplantation (HCT) with myeloablative conditioning (MAC) in patients with active, chemotherapy-refractory myeloid disease is historically associated with high rates of relapse and nonrelapse mortality (NRM). A MAC regimen combining clofarabine with busulfan (Clo/Bu4) has been reported to exhibit antileukemic activity with acceptable toxicity in patients age ≤70 years. Here we describe the clinical outcomes of a real-world population of patients with active myeloid malignancies undergoing allogeneic HCT with Clo/Bu4 MAC. In a single-center retrospective descriptive analysis, we identified patients who underwent HCT for myeloid malignancies not in remission using Clo/Bu4 MAC between 2012 and 2020. We report event-free survival (EFS) and overall survival (OS), cumulative incidences of relapse and NRM, and the incidence and severity of acute and chronic graft-versus-host disease (GVHD). We identified 69 patients with a median age of 60 years (range, 22 to 70 years). Most patients had relapsed/refractory or primary refractory acute myelogenous leukemia (AML; n = 55) or refractory myelodysplastic syndrome (MDS; n = 12); 1 patient had chronic myelogenous leukemia, and 1 patient had a blastic plasmacytoid dendritic cell neoplasm. Fifty patients (72.5%) had complete remission at day 100 post-transplantation. Two-year EFS and OS were 30% (95% confidence interval [CI], 20% to 44%) and 40% (95% CI, 29% to 54%), respectively. Patients with AML had a 2-year EFS and OS of 28% (95% CI, 18% to 44%) and 38% (95% CI, 27% to 54%), respectively; those with MDS had a 2-year EFS and OS of 47% (95% CI, 25% to 88%) and 56% (95% CI, 33% to 94%), respectively. The cumulative incidence of relapse at 2 years was 39% (95% CI, 27% to 51%) for all patients, including 45% (95% CI, 31% to 58%) in the patients with AML and 18% (95% CI, 2% to 45%) in those with MDS. NRM at 2 years was 31% (95% CI, 20% to 42%), including 27% (95% CI, 15% to 39%) in patients with AML and 35% (95% CI, 10% to 63%) in those with MDS. The total incidence of acute GVHD (aGVHD) of any severity was 80%, and the incidence of grade III-IV aGVHD was 22%. In patients who achieved remission, those who required systemic immunosuppression for aGVHD (58%) had poorer 2-year EFS (29% versus 54%; P = .05) and 2-year OS (39% versus 70%; P = .04) compared to those who did not. The 2-year cumulative incidence of chronic GVHD was 44% (95% CI, 28% to 58%). Clo/Bu4 MAC followed by allogeneic HCT for patients with active myeloid malignancies is an effective transplantation strategy for patients up to age 70, particularly those with advanced MDS. The high incidence of and poor outcomes associated with aGVHD highlight the importance of optimizing preventative strategies.
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Affiliation(s)
- Matthew P Connor
- Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Alison W Loren
- Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elizabeth O Hexner
- Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mary Ellen Martin
- Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Saar I Gill
- Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Selina M Luger
- Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - James K Mangan
- Moores Cancer Center at the University of California, San Diego, California
| | - Alexander E Perl
- Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Shannon R McCurdy
- Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Keith W Pratz
- Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Colleen Timlin
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Craig W Freyer
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alison Carulli
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christopher Catania
- Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jacqueline Smith
- Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lauren Hollander
- Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alexis M Zebrowski
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Edward A Stadtmauer
- Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David L Porter
- Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Noelle V Frey
- Abramson Cancer Center, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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9
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Park S, Kwag D, Kim TY, Lee JH, Lee JY, Min GJ, Park SS, Yahng SA, Jeon YW, Shin SH, Yoon JH, Lee SE, Cho BS, Eom KS, Kim YJ, Lee S, Min CK, Cho SG, Lee JW, Kim HJ. A retrospective comparison of salvage intensive chemotherapy versus venetoclax-combined regimen in patients with relapsed/refractory acute myeloid leukemia (AML). Ther Adv Hematol 2022; 13:20406207221081637. [PMID: 35340720 PMCID: PMC8949776 DOI: 10.1177/20406207221081637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 01/31/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Evidence that a venetoclax (VEN)-combined regimen is effective in relapsed/refractory acute myeloid leukemia (R/R AML) is emerging. However, it is unknown how VEN-combined low intensity treatment compares to intensive chemotherapy (IC) in medically fit patients with R/R AML. Methods: We compared AML patients who received IC (n = 89) to those who received a VEN in combination with hypomethylating agents or low dose cytarabine (VEN combination) (n = 54) as their first- or second-line salvage after failing anthracycline-containing intensive chemotherapy. Results: The median age was 49 years, and significantly more patients in the VEN combination group were in their second salvage and had received prior stem cell transplantation (SCT). Overall response rates including CR, CRi, and MLFS were comparable (44.0% for IC vs. 59.3% for VEN combination, p = 0.081), but VEN combination group compared to IC group tended to show lower treatment related mortality. The rate of bridging to SCT was the same (68.5%), but the percentage of SCT at blast clearance was significantly higher in the VEN-combined group (62.3% vs. 86.5%, p = 0.010). After median follow-up periods of 22.5 (IC) and 11.3 months (VEN combination), the median overall survival was 8.9 (95% CI, 5.4-12.4) and 12.4 months (95% CI, 9.5-15.2) (p = 0.724), respectively. Conclusion: VEN combination provides a comparable anti-leukemic response and survival to salvage IC, and provide a bridge to SCT with better disease control in medically-fit patients with R/R AML.
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Affiliation(s)
- Silvia Park
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Daehun Kwag
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Tong Yoon Kim
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Jong Hyuk Lee
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Joon Yeop Lee
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Gi June Min
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Sung Soo Park
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Seung-Ah Yahng
- Department of Hematology, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, South Korea
| | - Young-Woo Jeon
- Department of Hematology, Yeoido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Seung-Hwan Shin
- Department of Hematology, Catholic Hematology Hospital, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Jae-Ho Yoon
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Sung-Eun Lee
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Byung Sik Cho
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Ki-Seong Eom
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Yoo-Jin Kim
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Seok Lee
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Chang-Ki Min
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Seok-Goo Cho
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Jong Wook Lee
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Hee-Je Kim
- Department of Hematology, Catholic Hematology Hospital, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
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10
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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.
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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
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11
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Bakunina K, Putter H, Versluis J, Koster EAS, van der Holt B, Manz MG, Breems DA, Gjertsen BT, Cloos J, Valk PJM, Passweg J, Pabst T, Ossenkoppele GJ, Löwenberg B, Cornelissen JJ, de Wreede LC. The added value of multi-state modelling in a randomized controlled trial: The HOVON 102 study re-analyzed. Cancer Med 2021; 11:630-640. [PMID: 34953042 PMCID: PMC8817075 DOI: 10.1002/cam4.4392] [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: 06/14/2021] [Revised: 09/20/2021] [Accepted: 09/23/2021] [Indexed: 11/07/2022] Open
Abstract
Clofarabine is an active antileukemic drug for subgroups of patients with acute myeloid leukemia (AML). Multi-state models can provide additional insights to supplement the original intention-to-treat analysis of randomized controlled trials (RCT). We re-analyzed the HOVON102/SAKK30/09 phase III RCT for newly diagnosed AML patients, which randomized between standard induction chemotherapy with or without clofarabine. Using multi-state models, we evaluated the effects of induction chemotherapy outcomes (complete remission [CR], measurable residual disease [MRD]), and post-remission therapy with allogeneic stem cell transplantation [alloSCT] on relapse and death. Through the latter a consistent reduction in the hazard of relapse in the clofarabine arm compared to the standard arm was found, which occurred irrespective of MRD status or post-remission treatment with alloSCT, demonstrating a strong and persistent antileukemic effect of clofarabine. During the time period between achieving CR and possible post-remission treatment with alloSCT, non-relapse mortality was higher in patients receiving clofarabine. An overall net benefit of treatment with clofarabine was identified using the composite endpoint current leukemia-free survival (CLFS). In conclusion, these results enforce and extend the earlier reported beneficial effect of clofarabine in AML and show that multi-state models further detail the effect of treatment on competing and series of events.
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Affiliation(s)
- Katerina Bakunina
- Department of Hematology, HOVON Data Center, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Hein Putter
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Jurjen Versluis
- Department of Hematology, Erasmus University Medical Center Cancer Institute, Rotterdam, The Netherlands
| | - Eva A S Koster
- Department of Hematology, Leiden University Medical Center, Leiden, The Netherlands
| | - Bronno van der Holt
- Department of Hematology, HOVON Data Center, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Markus G Manz
- Department of Medical Oncology and Hematology, University Hospital Zurich, Zurich, Switzerland
| | - Dimitri A Breems
- Department of Hematology, Hospital Network Antwerp Stuivenberg/Middelheim, Antwerp, Belgium
| | - Bjorn T Gjertsen
- Department of Internal Medicine, Hematology section, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Jacqueline Cloos
- Department of Hematology, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Peter J M Valk
- Department of Hematology, Erasmus University Medical Center Cancer Institute, Rotterdam, The Netherlands
| | - Jakob Passweg
- Department of Hematology, University Hospital Basel, Basel, Switzerland
| | - Thomas Pabst
- Department of Medical Oncology, University Hospital/Inselspital, Bern, Switzerland
| | - Gert J Ossenkoppele
- Department of Hematology, Amsterdam UMC, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bob Löwenberg
- Department of Hematology, Erasmus University Medical Center Cancer Institute, Rotterdam, The Netherlands
| | - Jan J Cornelissen
- Department of Hematology, Erasmus University Medical Center Cancer Institute, Rotterdam, The Netherlands
| | - Liesbeth C de Wreede
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
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12
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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.
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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
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13
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Heinicke T, Labopin M, Polge E, Stelljes M, Ganser A, Tischer J, Brecht A, Kröger N, Beelen DW, Scheid C, Bethge W, Dreger P, Bunjes D, Wagner E, Platzbecker U, Savani BN, Nagler A, Mohty M. Evaluation of six different types of sequential conditioning regimens for allogeneic stem cell transplantation in relapsed/refractory acute myelogenous leukemia - a study of the Acute Leukemia Working Party of the EBMT. Leuk Lymphoma 2020; 62:399-409. [PMID: 33040622 DOI: 10.1080/10428194.2020.1827248] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The Acute Leukemia Working Party (ALWP) of the EBMT assessed the outcome of allogeneic stem cell transplantation (alloSCT) in patients with relapsed/refractory AML (r/rAML) evaluating six sequential conditioning regimens (SR) groups. A total of 2132 patients were included. LFS at 2 years was 28.9%, 33.6%, 35.3%, 20.6%, 24.4%, and 27% for the FLAMSA-TBI4, FLAMSA-Chemo, Mel-Flu-TBI8, Mel-Treo-Flu, Thio-ETO-Cy-Bu2-Flu, and Clo-ARAC-(Bu2/TBI4)-Cy groups, respectively. In patients <55 years of age Mel-Flu-TBI8 had the best LFS, which was statistically significant only in comparison to the Mel-Treo-Flu group, while in patients ≥55 years LFS was best with FLAMSA-Chemo without significant differences compared to FLAMSA-TBI4 and Mel-Flu-TBI8. Furthermore, best NRM rates were obtained with the two FLAMSA regimens groups. Our study suggests that in younger (<55 years) patients a more intense regimen might be used whereas in older (≥55 years) patients the focus might be more on tolerability.
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Affiliation(s)
- Thomas Heinicke
- Department of Hematology and Oncology, Otto-von-Guericke University, Magdeburg, Germany
| | - Myriam Labopin
- Department of Hematology and Cell Therapy, Hopital Saint-Antoine, Paris, France.,Acute Leukemia Working Party of EBMT Office, Hopital St. Antoine, Paris, France
| | - Emmanuelle Polge
- Acute Leukemia Working Party of EBMT Office, Hopital St. Antoine, Paris, France
| | - Matthias Stelljes
- Department of Internal Medicine A, University of Muenster, Muenster, Germany
| | - Arnold Ganser
- Department of Haematology, Hemostasis, Oncology, Hannover Medical School, Hannover, Germany
| | - Johanna Tischer
- Department of Internal Medicine III, Hematopoietic Stem Cell Transplantation, University Hospital of Munich-Campus Grosshadern, LMU, Munich, Germany
| | - Arne Brecht
- DKD Helios-Klinikum, KMT-Abteilung, Wiesbaden, Germany
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Hospital Eppendorf, Hamburg, Germany
| | - Dietrich W Beelen
- Department of Bone Marrow Transplantation, University Hospital Essen, Essen, Germany
| | - Christof Scheid
- I Department of Medicine, University of Cologne, Cologne, Germany
| | - Wolfgang Bethge
- Medizinische Klinik II, University Tübingen, Tübingen, Germany
| | - Peter Dreger
- Medizinische Klinik u. Poliklinik V, University of Heidelberg, Heidelberg, Germany
| | - Donald Bunjes
- Klinik fuer Innere Medzin III, University Hospital Ulm, Ulm, Germany
| | - Eva Wagner
- Department of Hematology, Oncology and Pneumology, University Medical Center Mainz, Mainz, Germany
| | - Uwe Platzbecker
- Medical Clinic and Policlinic 1, University Hospital Leipzig, Leipzig, Germany
| | - Bipin N Savani
- Division of Hematology-Oncology, Vanderbilt University Medical Center, Brentwood, TN, USA
| | - Arnon Nagler
- Acute Leukemia Working Party of EBMT Office, Hopital St. Antoine, Paris, France.,Hematology Division and Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel-Hashomer and Tel Aviv University, Tel HaShomer, Israel
| | - Mohamad Mohty
- Department of Hematology and Cell Therapy, Hopital Saint-Antoine, Paris, France.,Acute Leukemia Working Party of EBMT Office, Hopital St. Antoine, Paris, France
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14
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A Rare Case of Coexisting Breast Cancer and Refractory Acute Myeloid Leukemia. Case Rep Hematol 2020; 2020:8893185. [PMID: 32908731 PMCID: PMC7468610 DOI: 10.1155/2020/8893185] [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: 05/01/2020] [Revised: 07/18/2020] [Accepted: 08/10/2020] [Indexed: 11/17/2022] Open
Abstract
The occurrence of acute myeloid leukemia (AML) within six months from a diagnosis of breast cancer (BC) is rarely reported in the literature, and it is associated with a poor prognosis. We report herein the case of a 40-year-old woman referred to our centre affected by BC and simultaneous AML. The patient proved refractory to first line therapy and achieved complete remission (CR) with a clofarabine-based regimen followed by allogeneic stem cell transplantation (ASCT). Both during salvage chemotherapy and after ASCT, the patient presented severe infectious complications ( acute cholecistytis and Nocardia pneumonia, respectively) treated with surgery, and currently she is alive in CR for both diseases after 29 months of follow-up. The case highlights the importance of a diagnostic assessment of any unexplained cytopenia in association with solid neoplasia under treatment, underlining the feasibility and priority of a timely treatment of the haematological neoplasm in order to achieve long-term survival.
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15
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Peccatori J, Mastaglio S, Giglio F, Greco R, Crocchiolo R, Patriarca F, Forno B, Deola S, Assanelli A, Lupo Stanghellini MT, Marcatti M, Zecca M, Cortelazzo S, Fanin R, Fagioli F, Locatelli F, Ciceri F. Clofarabine and Treosulfan as Conditioning for Matched Related and Unrelated Hematopoietic Stem Cell Transplantation: Results from the Clo3o Phase II Trial. Biol Blood Marrow Transplant 2019; 26:316-322. [PMID: 31605823 DOI: 10.1016/j.bbmt.2019.09.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 09/17/2019] [Accepted: 09/30/2019] [Indexed: 10/25/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) can be curative for patients with hematologic malignancies. The ideal conditioning regimen before allo-HSCT has not been established. We conducted a Phase II study to evaluate the tolerability and efficacy of clofarabine and treosulfan as conditioning regimen before allo-HSCT. The primary objective was to evaluate the cumulative incidence of nonrelapse mortality (NRM) on day +100. Forty-four patients (36 with acute myelogenous leukemia, 5 with acute lymphoblastic leukemia, 3 with myelodysplastic syndromes) were enrolled. The median patient age was 47 years, and the median duration of follow-up was 27 months. The conditioning regimen was based on clofarabine 40 mg/m2 (days -6 to -2) and treosulfan 14 g/m2 (days -6 to -4). Allogeneic hematopoietic stem cells were derived from a sibling (n = 22) or a well-matched unrelated donor (n = 22). Graft-versus-host disease (GVHD) prophylaxis consisted of antithymocyte globulin, rituximab, cyclosporine, and a short-course of methotrexate. The regimen allowed for rapid engraftment and a 100-day NRM of 18%, due mainly to bacterial infections. The incidences of grade II-IV acute GVHD and chronic GVHD were 16% and 19%, respectively. The rates of overall survival (OS), progression-free survival, and relapse at 2 years were 51%, 31%, and 50%, respectively. Significantly different outcomes were observed between patients with low-intermediate and patients with high-very high Disease Risk Index (DRI) scores (1-year OS, 78% and 24%, respectively). Our findings show that the use of treosulfan and clofarabine as a conditioning regimen for allo-HSCT is feasible, with a 78% 1-year OS in patients with a low-intermediate DRI score. However, 1-year NRM was 18%, and despite the intensified conditioning regimen, relapse incidence remains a major issue in patients with poor prognostic risk factors.
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Affiliation(s)
- Jacopo Peccatori
- Hematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sara Mastaglio
- Hematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fabio Giglio
- Hematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Raffaella Greco
- Hematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Francesca Patriarca
- Carlo Melzi Hematology and Cellular Therapy Unit, Azienda Sanitaria Universitaria Integrata di Udine, Undine, Italy
| | - Barbara Forno
- Hematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sara Deola
- Department of Hematology, Ospedale Regionale, Bolzano, Italy
| | - Andrea Assanelli
- Hematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Magda Marcatti
- Hematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marco Zecca
- Pediatric Hematology/Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Renato Fanin
- Carlo Melzi Hematology and Cellular Therapy Unit, Azienda Sanitaria Universitaria Integrata di Udine, Undine, Italy
| | - Franca Fagioli
- Pediatric Onco-Hematology, University of Torino, Torino, Italy
| | - Franco Locatelli
- Department of Pediatric Hematology and Oncology, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Fabio Ciceri
- Hematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.
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16
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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.
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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
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17
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Clinical outcome of FLAG-IDA chemotherapy sequential with Flu-Bu3 conditioning regimen in patients with refractory AML: a parallel study from Shanghai Institute of Hematology and Institut Paoli-Calmettes. Bone Marrow Transplant 2018; 54:458-464. [PMID: 30082853 PMCID: PMC6462832 DOI: 10.1038/s41409-018-0283-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 06/28/2018] [Accepted: 06/30/2018] [Indexed: 01/26/2023]
Abstract
The purpose of the study was to evaluate the feasibility of conditioning regimen with sequential chemotherapy (FLAG-IDA), followed by Fludarabine (5 days) + Busulfan (3 days) by parallel analysis of patients with refractory acute myeloid leukemia (AML) from two transplantation centers in China and France. A total of 47 refractory AML with median bone marrow blast of 35% (1–90%) and median age at 42 years (16–62) were enrolled. Thirteen patients received peripheral stem cell transplantation (HSCT) from HLA-matched sibling donor, while 18 and 16 from unrelated or haplo-identical donors, respectively. With a median follow-up of 24.3 months (1–70), 13 patients relapsed at a median time of 5.1 months (2.2–18.0) and 24 patients died due to relapse (n = 12) or non-relapsed mortality (NRM, n = 12). The estimated 3-year RR and NRM were 33.5 ± 5.7% and 25.7 ± 4.2%, respectively. The estimated 3-year overall survival (OS) and event-free survival (EFS) were 43.8 ± 7.8% and 42.3 ± 7.8%. In multivariate analysis, age (<40) and low bone marrow blast were associated with better EFS, while no difference was observed between the two centers. The patients enrolled in study were unselected, representing typical patients' population of refractory AML, and primary data demonstrated the feasibility of sequential conditioning regimen.
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18
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Xiao H, Li L, Pang Y, Wu Y, Jiang Z, Liu Z, Wu J, Xiao Y, Huang F, Liu Q, Zhang H, Luo Y, Huang H. Sequential treatment combining cladribine-based re-induction, myeloablative allogeneic HSCT, and prophylactic donor lymphocyte infusion: a promising treatment for refractory acute myeloid leukemia. Ann Hematol 2018; 97:2479-2490. [PMID: 30078144 DOI: 10.1007/s00277-018-3453-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 07/19/2018] [Indexed: 11/26/2022]
Abstract
We describe the first multicenter prospective study to assess the efficacy, safety, and immune reconstitution of a novel sequential transplant approach in 24 patients with primary induction failure/relapsed acute myeloid leukemia (AML). The sequential regimen consisted of cladribine 5 mg/m2/day and cytarabine 2 g/m2/day for 5 days and mitoxantrone 7 mg/m2/day for 3 days, followed by myeloablative allogeneic hematopoietic stem cell transplantation (allo-HSCT) using intravenous busulfan (3.2 mg/kg/day) for 4 days and cyclophosphamide (60 mg/kg/day) for 2 days. Patients in CR without acute graft-versus-host disease at day + 90 received prophylactic donor lymphocyte infusion (pDLI). At the time of transplantation, a marrow blast infiltration > 20% or any level of circulating blasts was found in 62.5% of patients. The cumulative incidence of relapse at 2 years was 29.8%. Overall survival (OS) was 74.5% at 1 year and 56.5% at 2 years. Leukemia-free survival (LFS) at 1 and 2 years was 62.5 and 50.5%, respectively. Multivariate analysis demonstrated that haploidentical related donor, pDLI, and experiencing chronic graft-versus-host disease (cGVHD) were protective from relapse. Total T cells and T cell subsets in peripheral blood recovered at 3 months post-HSCT. The expressions of immune checkpoints (cytotoxic T lymphocyte antigen 4 and programmed death 1) were extremely low in T cells over the first 1 year post-transplantation.
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Affiliation(s)
- Haowen Xiao
- Department of Hematology, Guangzhou General Hospital of Guangzhou Military Command, No. 111 Liuhua Rd., Guangzhou, 510010, Guangdong Province, People's Republic of China.
- Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, People's Republic of China.
| | - Li Li
- Center of Cell-Biological Therapy and Research, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, Guangdong Province, People's Republic of China
| | - Yan Pang
- Department of Hematology, Guangzhou General Hospital of Guangzhou Military Command, No. 111 Liuhua Rd., Guangzhou, 510010, Guangdong Province, People's Republic of China
| | - Yuanbin Wu
- Department of Hematology, Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong Province, People's Republic of China
| | - Zujun Jiang
- Department of Hematology, Guangzhou General Hospital of Guangzhou Military Command, No. 111 Liuhua Rd., Guangzhou, 510010, Guangdong Province, People's Republic of China
| | - Zenghui Liu
- Department of Hematology, Guangzhou General Hospital of Guangzhou Military Command, No. 111 Liuhua Rd., Guangzhou, 510010, Guangdong Province, People's Republic of China
| | - Jiulong Wu
- Center of Cell-Biological Therapy and Research, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, Guangdong Province, People's Republic of China
| | - Yang Xiao
- Department of Hematology, Guangzhou General Hospital of Guangzhou Military Command, No. 111 Liuhua Rd., Guangzhou, 510010, Guangdong Province, People's Republic of China
| | - Fen Huang
- Department of Hematology, Nanfang Hospital of Southern Medical University, Guangzhou, Guangdong Province, People's Republic of China
| | - Qifa Liu
- Department of Hematology, Nanfang Hospital of Southern Medical University, Guangzhou, Guangdong Province, People's Republic of China
| | - Hang Zhang
- Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, People's Republic of China
| | - Yi Luo
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, People's Republic of China
| | - He Huang
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, People's Republic of China
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19
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Decroocq J, Itzykson R, Vigouroux S, Michallet M, Yakoub-Agha I, Huynh A, Beckerich F, Suarez F, Chevallier P, Nguyen-Quoc S, Ledoux MP, Clement L, Hicheri Y, Guillerm G, Cornillon J, Contentin N, Carre M, Maillard N, Mercier M, Mohty M, Beguin Y, Bourhis JH, Charbonnier A, Dauriac C, Bay JO, Blaise D, Deconinck E, Jubert C, Raus N, Peffault de Latour R, Dhedin N. Similar outcome of allogeneic stem cell transplantation after myeloablative and sequential conditioning regimen in patients with refractory or relapsed acute myeloid leukemia: A study from the Société Francophone de Greffe de Moelle et de Thérapie Cellulaire. Am J Hematol 2018; 93:416-423. [PMID: 29226497 DOI: 10.1002/ajh.25004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Revised: 12/05/2017] [Accepted: 12/07/2017] [Indexed: 01/22/2023]
Abstract
Patients with acute myeloid leukemia (AML) in relapse or refractory to induction therapy have a dismal prognosis. Allogeneic hematopoietic stem cell transplantation is the only curative option. In these patients, we aimed to compare the results of a myeloablative transplant versus a sequential approach consisting in a cytoreductive chemotherapy followed by a reduced intensity conditioning regimen and prophylactic donor lymphocytes infusions. We retrospectively analyzed 99 patients aged 18-50 years, transplanted for a refractory (52%) or a relapsed AML not in remission (48%). Fifty-eight patients received a sequential approach and 41 patients a myeloablative conditioning regimen. Only 6 patients received prophylactic donor lymphocytes infusions. With a median follow-up of 48 months, 2-year overall survival was 39%, 95% confidence interval (CI) (24-53) in the myeloablative group versus 33%, 95% CI (21-45) in the sequential groups (P = .39), and 2-year cumulative incidence of relapse (CIR) was 57% versus 50% respectively (P = .99). Nonrelapse mortality was not higher in the myeloablative group (17% versus 15%, P = .44). In multivariate analysis, overall survival, CIR and nonrelapse mortality remained similar between the two groups. However, in multivariate analysis, sequential conditioning led to fewer acute grade II-IV graft versus host disease (GVHD) (HR for sequential approach = 0.37; 95% CI: 0.21-0.65; P < .001) without a significant impact on chronic GVHD (all grades and extensive). In young patients with refractory or relapsed AML, myeloablative transplant and sequential approach offer similar outcomes except for a lower incidence of acute GvHD after a sequential transplant.
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Affiliation(s)
| | | | | | | | - Ibrahim Yakoub-Agha
- Hematology department; CHU de Lille, LIRIC INSERM U995, Université Lille 2, Lille; France
| | - Anne Huynh
- Hematology department; IUCT Oncopole; Toulouse France
| | | | - Felipe Suarez
- Hematology department; Hôpital Necker Enfants malades; Paris France
| | | | | | | | | | - Yosr Hicheri
- Hematology department; CHU Lapeyronie; Montpellier France
| | | | | | | | - Martin Carre
- Hematology department; CHU Grenoble; Grenoble France
| | | | | | - Mohamad Mohty
- Hematology department; Hôpital Saint Antoine; Paris France
| | - Yves Beguin
- Hematology department; CHU Liège; Liège Belgium
| | | | | | | | | | - Didier Blaise
- Hematology department; Institut Paoli Calmettes; Marseille France
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20
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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.
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21
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Büttner B, Knoth H, Kramer M, Oertel R, Seeling A, Sockel K, von Bonin M, Stölzel F, Alakel N, Platzbecker U, Röllig C, Ehninger G, Bornhäuser M, Schetelig J, Middeke JM. Impact of pharmacokinetics on the toxicity and efficacy of clofarabine in patients with relapsed or refractory acute myeloid leukemia. Leuk Lymphoma 2017; 58:2865-2874. [PMID: 28509593 DOI: 10.1080/10428194.2017.1319051] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Common side effects of clofarabine (CFB) are liver toxicity, particularly a transient elevation of transaminases and skin toxicity. We studied the correlation of pharmacokinetic (PK) parameters with these toxicities and the efficacy of CFB in patients with relapsed or refractory acute myeloid leukemia. Clofarabine PK parameters showed large inter-individual variability. A higher CFB area under the curve was significantly associated with higher transaminase levels (p = .011 for aspartate aminotransferase (AST), adjusted for age, sex, cumulated CFB dosage, baseline AST, and glomerular filtration rate (GFR)). No significant association could be found between maximum concentration and the liver toxicity parameters. The occurrence of skin toxicity and the response to re-induction chemotherapy evaluated at day 15 were also not associated with PK. In conclusion, a higher individual CFB exposure is associated with increased liver toxicity reflected by elevated liver enzymes, without having an impact on anti-leukemic efficacy.
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Affiliation(s)
- Bozena Büttner
- a Klinikapotheke, Universitätsklinikum Carl Gustav Carus der TU Dresden , Dresden , Germany
| | - Holger Knoth
- a Klinikapotheke, Universitätsklinikum Carl Gustav Carus der TU Dresden , Dresden , Germany
| | - Michael Kramer
- b Universitätsklinikum Carl Gustav Carus der TU Dresden , Medizinische Klinik und Poliklinik I , Dresden , Germany
| | - Reinhard Oertel
- c Institut für Klinische Pharmakologie, Medizinische Fakultät Carl Gustav Carus der TU , Dresden , Germany
| | - Andreas Seeling
- d Institut für Pharmazie, Friedrich-Schiller-Universität Jena , Jena , Germany
| | - Katja Sockel
- b Universitätsklinikum Carl Gustav Carus der TU Dresden , Medizinische Klinik und Poliklinik I , Dresden , Germany
| | - Malte von Bonin
- b Universitätsklinikum Carl Gustav Carus der TU Dresden , Medizinische Klinik und Poliklinik I , Dresden , Germany.,e German Cancer Consortium (DKTK) , Heidelberg , Germany.,f Consortium for Translational Cancer Research, German Cancer Research Center (DKFZ) , Heidelberg , Germany
| | - Friedrich Stölzel
- b Universitätsklinikum Carl Gustav Carus der TU Dresden , Medizinische Klinik und Poliklinik I , Dresden , Germany
| | - Nael Alakel
- b Universitätsklinikum Carl Gustav Carus der TU Dresden , Medizinische Klinik und Poliklinik I , Dresden , Germany
| | - Uwe Platzbecker
- b Universitätsklinikum Carl Gustav Carus der TU Dresden , Medizinische Klinik und Poliklinik I , Dresden , Germany
| | - Christoph Röllig
- b Universitätsklinikum Carl Gustav Carus der TU Dresden , Medizinische Klinik und Poliklinik I , Dresden , Germany
| | - Gerhard Ehninger
- b Universitätsklinikum Carl Gustav Carus der TU Dresden , Medizinische Klinik und Poliklinik I , Dresden , Germany
| | - Martin Bornhäuser
- b Universitätsklinikum Carl Gustav Carus der TU Dresden , Medizinische Klinik und Poliklinik I , Dresden , Germany.,f Consortium for Translational Cancer Research, German Cancer Research Center (DKFZ) , Heidelberg , Germany.,g National Center for Tumor Diseases (NCT) , Heidelberg , Germany
| | - Johannes Schetelig
- b Universitätsklinikum Carl Gustav Carus der TU Dresden , Medizinische Klinik und Poliklinik I , Dresden , Germany.,h DKMS, German Bone Marrow Donor Center , Tübingen , Germany
| | - Jan Moritz Middeke
- b Universitätsklinikum Carl Gustav Carus der TU Dresden , Medizinische Klinik und Poliklinik I , Dresden , Germany
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22
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Sagawa M, Ohguchi H, Harada T, Samur MK, Tai YT, Munshi NC, Kizaki M, Hideshima T, Anderson KC. Ribonucleotide Reductase Catalytic Subunit M1 (RRM1) as a Novel Therapeutic Target in Multiple Myeloma. Clin Cancer Res 2017; 23:5225-5237. [PMID: 28442502 DOI: 10.1158/1078-0432.ccr-17-0263] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 03/17/2017] [Accepted: 04/18/2017] [Indexed: 11/16/2022]
Abstract
Purpose: To investigate the biological and clinical significance of ribonucleotide reductase (RR) in multiple myeloma.Experimental Design: We assessed the impact of RR expression on patient outcome in multiple myeloma. We then characterized the effect of genetic and pharmacologic inhibition of ribonucleotide reductase catalytic subunit M1 (RRM1) on multiple myeloma growth and survival using siRNA and clofarabine, respectively, in both in vitro and in vivo mouse xenograft models.Results: Newly diagnosed multiple myeloma patients with higher RRM1 expression have shortened survival. Knockdown of RRM1 triggered significant growth inhibition and apoptosis in multiple myeloma cells, even in the context of the bone marrow microenvironment. Gene expression profiling showed upregulation of DNA damage response genes and p53-regulated genes after RRM1 knockdown. Immunoblot and qRT-PCR analysis confirmed that γ-H2A.X, ATM, ATR, Chk1, Chk2, RAD51, 53BP1, BRCA1, and BRCA2 were upregulated/activated. Moreover, immunoblots showed that p53, p21, Noxa, and Puma were activated in p53 wild-type multiple myeloma cells. Clofarabine, a purine nucleoside analogue that inhibits RRM1, induced growth arrest and apoptosis in p53 wild-type cell lines. Although clofarabine did not induce cell death in p53-mutant cells, it did trigger synergistic toxicity in combination with DNA-damaging agent melphalan. Finally, we demonstrated that tumor growth of RRM1-knockdown multiple myeloma cells was significantly reduced in a murine human multiple myeloma cell xenograft model.Conclusions: Our results therefore demonstrate that RRM1 is a novel therapeutic target in multiple myeloma in the preclinical setting and provide the basis for clinical evaluation of RRM1 inhibitor, alone or in combination with DNA-damaging agents, to improve patient outcome in multiple myeloma. Clin Cancer Res; 23(17); 5225-37. ©2017 AACR.
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Affiliation(s)
- Morihiko Sagawa
- Jerome Lipper Multiple Myeloma Center, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.,Department of Hematology, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Hiroto Ohguchi
- Jerome Lipper Multiple Myeloma Center, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Takeshi Harada
- Jerome Lipper Multiple Myeloma Center, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Mehmet K Samur
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute and Harvard School of Public Health, Boston, Massachusetts
| | - Yu-Tzu Tai
- Jerome Lipper Multiple Myeloma Center, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Nikhil C Munshi
- Jerome Lipper Multiple Myeloma Center, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.,West Roxbury Division, VA Boston Healthcare System, West Roxbury, Massachusetts
| | - Masahiro Kizaki
- Department of Hematology, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Teru Hideshima
- Jerome Lipper Multiple Myeloma Center, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Kenneth C Anderson
- Jerome Lipper Multiple Myeloma Center, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts.
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23
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Molteni A, Riva M, Ravano E, Marbello L, Mancini V, Grillo G, Zucchetti E, Greco R, Cairoli R. Clofarabine-based chemotherapy as a bridge to transplant in the setting of refractory or relapsed acute myeloid leukemia, after at least one previous unsuccessful salvage treatment containing fludarabine: a single institution experience. Int J Hematol 2017; 105:769-776. [PMID: 28220349 DOI: 10.1007/s12185-017-2198-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Revised: 02/05/2017] [Accepted: 02/06/2017] [Indexed: 11/25/2022]
Abstract
For refractory or relapsed acute myeloid leukemia patients, allogeneic hematopoietic stem cell transplantation is the only curative treatment option, but the disease must be in remission before this can be attempted. "Salvage" therapy regimens containing high-dose cytarabine plus fludarabine or cladribine with or without anthracyclines or plus mitoxantrone and etoposide fail in 30-50% of cases. We report the outcome of 14 patients treated with a clofarabine-based treatment administered after at least one failed fludarabine-based "salvage" attempt in a "real life" (outside a clinical trial) context. No death related to the clofarabine-based treatment was observed. Four of the 14 patients (29%) reached complete remission and one (7%) achieved a reduction of marrow blasts to fewer than 10%. Three of these five patients were successfully transplanted and have shown a long-term survival. The small number of this group of patients does not permit the identification of clinical features clearly related to a favorable outcome, but we note that all the three long-term survivals were FLT3 wild type. Clofarabine-based "salvage therapy" in patients with very poor expectancy is feasible even after a fludarabine-based salvage attempt, albeit with success only in a small percentage of cases (3/14 = 21%).
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Affiliation(s)
- Alfredo Molteni
- Hematology, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy.
| | - Marta Riva
- Hematology, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - Emanuele Ravano
- Hematology, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - Laura Marbello
- Hematology, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - Valentina Mancini
- Hematology, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - Giovanni Grillo
- Hematology, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - Elisa Zucchetti
- Hematology, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - Rosa Greco
- Hematology, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
| | - Roberto Cairoli
- Hematology, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy
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24
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Roboz GJ, Roboz J. The application of mass spectrometry to leukemia drug discovery. Expert Opin Drug Discov 2016; 11:1029-1032. [PMID: 27662537 DOI: 10.1080/17460441.2016.1233175] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Gail J Roboz
- a Department of Medicine, Division of Hematology and Medical Oncology , Weill Cornell Medicine and The New York Presbyterian Hospital , New York , NY , USA
| | - John Roboz
- b Department of Medicine, Division of Hematology/Oncology , Icahn School of Medicine of Mount Sinai , New York , NY , USA
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25
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Mohty M, Malard F, Blaise D, Milpied N, Socié G, Huynh A, Reman O, Yakoub-Agha I, Furst S, Guillaume T, Tabrizi R, Vigouroux S, Peterlin P, El-Cheikh J, Moreau P, Labopin M, Chevallier P. Sequential regimen of clofarabine, cytosine arabinoside and reduced-intensity conditioned transplantation for primary refractory acute myeloid leukemia. Haematologica 2016; 102:184-191. [PMID: 27561720 DOI: 10.3324/haematol.2016.150326] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 08/18/2016] [Indexed: 11/09/2022] Open
Abstract
The prognosis of patients with acute myeloid leukemia in whom primary treatment fails remains very poor. In order to improve such patients' outcome, we conducted a phase 2, prospective, multicenter trial to test the feasibility of a new sequential regimen, combining a short course of intensive chemotherapy and a reduced intensity-conditioning regimen, before allogeneic stem-cell transplantation. Twenty-four patients (median age, 47 years) with acute myeloid leukemia in primary treatment failure were included. Cytogenetic risk was poor in 15 patients (62%) and intermediate in nine (38%). The sequential regimen consisted of clofarabine (30 mg/m2/day) and cytosine arabinoside (1 g/m2/day) for 5 days, followed, after a 3-day rest, by reduced-intensity conditioning and allogeneic stem-cell transplantation combining cyclophosphamide (60 mg/kg), intravenous busulfan (3.2 mg/kg/day) for 2 days and anti-thymocyte globulin (2.5 mg/kg/day) for 2 days. Patients in complete remission at day +120 received prophylactic donor lymphocyte infusion. Eighteen patients (75%) achieved complete remission. With a median follow-up of 24.6 months, the Kaplan-Meier estimate of overall survival was 54% (95% CI: 33-71) at 1 year and 38% (95% CI: 18-46) at 2 years. The Kaplan-Meier estimate of leukemia-free survival was 46% (95% CI: 26-64) at 1 year and 29% (95% CI: 13-48) at 2 years. The cumulative incidence of non-relapse mortality was 8% (95% CI: 1-24) at 1 year and 12% (95% CI: 3-19) at 2 years. Results from this phase 2 prospective multicenter trial endorsed the safety and efficacy of a clofarabine-based sequential reduced-toxicity conditioning regimen, which warrants further investigation. This study was registered at www.clinicaltrials.gov, identifier number: NCT01188174.
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Affiliation(s)
- Mohamad Mohty
- Hematology Department, Centre Hospitalier et Universitaire (CHU) de Nantes, France .,Centre d'Investigation Clinique en Cancérologie (CI2C), CHU de Nantes, France.,Centre de Recherche Saint-Antoine, INSERM, UMRS 938, France.,Université Pierre et Marie Curie, Paris, France.,Hematology Department, AP-HP, Université Paris 6, Hôpital Saint Antoine, France
| | - Florent Malard
- Hematology Department, Centre Hospitalier et Universitaire (CHU) de Nantes, France.,Centre de Recherche Saint-Antoine, INSERM, UMRS 938, France.,Université Pierre et Marie Curie, Paris, France.,Hematology Department, AP-HP, Université Paris 6, Hôpital Saint Antoine, France
| | - Didier Blaise
- Unité de Transplantation et de Thérapie Cellulaire (U2T), Institut Paoli-Calmettes, Marseille, France
| | - Noel Milpied
- Hematology Department, CHU Haut-Lévêque, Bordeaux, France
| | - Gérard Socié
- Service de Greffe de Moelle, AP-HP, Université Paris 7, Hôpital Saint Louis, France
| | - Anne Huynh
- Hematology Department, IUCT Oncopole, Toulouse, France
| | - Oumédaly Reman
- Institut d'hématologie de Basse Normandie, CHU, Côte de Nacre 14000 Caen, France
| | | | - Sabine Furst
- Unité de Transplantation et de Thérapie Cellulaire (U2T), Institut Paoli-Calmettes, Marseille, France
| | - Thierry Guillaume
- Hematology Department, Centre Hospitalier et Universitaire (CHU) de Nantes, France
| | - Resa Tabrizi
- Hematology Department, CHU Haut-Lévêque, Bordeaux, France
| | | | - Pierre Peterlin
- Hematology Department, Centre Hospitalier et Universitaire (CHU) de Nantes, France
| | - Jean El-Cheikh
- Unité de Transplantation et de Thérapie Cellulaire (U2T), Institut Paoli-Calmettes, Marseille, France
| | - Philippe Moreau
- Hematology Department, Centre Hospitalier et Universitaire (CHU) de Nantes, France.,Centre d'Investigation Clinique en Cancérologie (CI2C), CHU de Nantes, France
| | - Myriam Labopin
- Hematology Department, AP-HP, Université Paris 6, Hôpital Saint Antoine, France
| | - Patrice Chevallier
- Hematology Department, Centre Hospitalier et Universitaire (CHU) de Nantes, France.,Centre d'Investigation Clinique en Cancérologie (CI2C), CHU de Nantes, France
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26
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Estey E. Acute myeloid leukemia: 2016 Update on risk-stratification and management. Am J Hematol 2016; 91:824-46. [PMID: 27417880 DOI: 10.1002/ajh.24439] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 05/26/2016] [Indexed: 11/09/2022]
Abstract
Evidence suggest 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. Am. J. Hematol. 91:825-846, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Elihu Estey
- Division of Hematology, University of Washington School of Medicine, Seattle, WA, Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
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27
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De Kouchkovsky I, Abdul-Hay M. 'Acute myeloid leukemia: a comprehensive review and 2016 update'. Blood Cancer J 2016; 6:e441. [PMID: 27367478 PMCID: PMC5030376 DOI: 10.1038/bcj.2016.50] [Citation(s) in RCA: 799] [Impact Index Per Article: 99.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 05/03/2016] [Accepted: 05/19/2016] [Indexed: 12/13/2022] Open
Abstract
Acute myeloid leukemia (AML) is the most common acute leukemia in adults, with an incidence of over 20 000 cases per year in the United States alone. Large chromosomal translocations as well as mutations in the genes involved in hematopoietic proliferation and differentiation result in the accumulation of poorly differentiated myeloid cells. AML is a highly heterogeneous disease; although cases can be stratified into favorable, intermediate and adverse-risk groups based on their cytogenetic profile, prognosis within these categories varies widely. The identification of recurrent genetic mutations, such as FLT3-ITD, NMP1 and CEBPA, has helped refine individual prognosis and guide management. Despite advances in supportive care, the backbone of therapy remains a combination of cytarabine- and anthracycline-based regimens with allogeneic stem cell transplantation for eligible candidates. Elderly patients are often unable to tolerate such regimens, and carry a particularly poor prognosis. Here, we review the major recent advances in the treatment of AML.
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Affiliation(s)
- I De Kouchkovsky
- Department of Medicine, New York University School of Medicine, New York, NY, USA
| | - M Abdul-Hay
- Department of Medicine, New York University School of Medicine, New York, NY, USA.,Department of Hematology/Oncology, New York University Perlmutter Cancer Center, New York, NY, USA
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28
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Thomas CM, Ippoliti C, Roboz GJ, Feldman E, Savva D, James S, van Besien K. Clofarabine as a bridge to hematopoietic stem cell transplant. Leuk Lymphoma 2016; 58:230-232. [PMID: 27240704 DOI: 10.1080/10428194.2016.1185784] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Christan M Thomas
- a Department of Pharmacy , St John's University College of Pharmacy , NY , USA.,b NewYork-Presbyterian Hospital , Weill Cornell Medical College , NY , USA
| | - Cindy Ippoliti
- b NewYork-Presbyterian Hospital , Weill Cornell Medical College , NY , USA
| | - Gail J Roboz
- b NewYork-Presbyterian Hospital , Weill Cornell Medical College , NY , USA
| | | | - Dimitrios Savva
- a Department of Pharmacy , St John's University College of Pharmacy , NY , USA
| | - Sara James
- a Department of Pharmacy , St John's University College of Pharmacy , NY , USA
| | - Koen van Besien
- d Department of Hematology/Oncology , University of Chicago , 5841 South Maryland , Chicago , IL , USA
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