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Pasic I, Moya TA, Remberger M, Chen C, Gerbitz A, Kim DDH, Kumar R, Lam W, Law AD, Lipton JH, Michelis FV, Novitzky-Basso I, Viswabandya A, Mattsson J. Treosulfan- Versus Busulfan-based Conditioning in Allogeneic Hematopoietic Cell Transplantation for Myelodysplastic Syndrome: A Single-center Retrospective Propensity Score-matched Cohort Study. Transplant Cell Ther 2024; 30:681.e1-681.e11. [PMID: 38648898 DOI: 10.1016/j.jtct.2024.04.014] [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: 01/30/2024] [Revised: 04/02/2024] [Accepted: 04/18/2024] [Indexed: 04/25/2024]
Abstract
Treosulfan has shown promise in allogeneic hematopoietic cell transplantation (HCT) for its myeloablative properties and low toxicity. In this single-center retrospective propensity score-matched cohort study we compared treosulfan- and busulfan-based conditioning in allogeneic HCT for patients with myelodysplastic syndrome (MDS). This study included 138 adults who underwent allogeneic HCT for MDS or chronic myelomonocytic leukemia at Princess Margaret Hospital, Toronto, from 2015 to 2022. Using propensity score matching, we compared transplant outcomes between 2 well-matched cohorts who received conditioning with either fludarabine-treosulfan (FT) (n = 46) or fludarabine-busulfan with total body irradiation (FBT200) (n = 92). A scoring system based on patient age, Karnofsky performance score, and hematopoietic cell transplant comorbidity index was used to assign patients based on fitness to low-dose (30 g/m2) or high-dose (42 g/m2) treosulfan: 32 (69.6%) received high-dose treosulfan. The racial composition of the 2 groups was similar, with 27.2% and 21.7% of FBT200 and FT recipients, respectively, identifying as non-Caucasian (P = .61). Primary outcomes were analyzed at a median follow-up of 747 days. Of all participants, 116 (84.0%) received graft-versus-host disease (GVHD) prophylaxis with post-transplant cyclophosphamide (PTCY) and antithymocyte globulin (ATG). Patients who received FT had a superior 2-year overall survival (OS) compared to those who received FBT200: 66.9% (95% confidence interval (CI): 46.1 to 81.2) versus 44.5% (95% CI: 34 to 54.4), hazard ratio (HR): 0.43, 95% CI: 0.22 to 0.84 (P = .013). In multivariate analysis (MVA), only the use of fresh grafts (P = .02) and FT (P = .01) were associated with improved OS. FT was associated with superior 2-year relapse-free survival (RFS) compared to FBT200: 63.1% (95% CI: 42.6 to 77.9) versus 39.1% (95% CI: 29.1 to 49.1), HR: 0.44 (95% CI: 0.24 to 0.81), P = .008. In MVA, the use of fresh grafts (P = .03) and FT (P = .009) were associated with improved RFS. Recipients of FT demonstrated superior 2-year graft-versus-host disease relapse-free survival (GRFS) compared to those who received FBT200: 57.4% (95% CI: 37.8 to 72.8) versus 35.1% (95% CI: 25.5 to 45). In MVA, only FT was associated with superior GRFS (P = .02). FT recipients exhibited markedly superior 1-year event-free survival compared to recipients of FBT200 in univariate analysis (40.3% (95% CI: 25.9 to 54.2) versus 9.2% (95% CI: 4.4 to 16.3), HR: 0.47 (95% CI: 0.30 to 0.72), P < .001) and MVA (P = .004). FT was associated with lower 1-year nonrelapse mortality compared to FBT200 in univariate analysis (9.9% (95% CI: 3.0 to 21.8) versus 29.7% (95% CI: 20.6 to 39.3), HR: 0.41 (95% CI: 0.17 to 0.96), P = .04) and MVA (P = .04). Our study utilized propensity score matching to demonstrate superiority of treosulfan- over busulfan-based conditioning in stem cell transplantation of patients with MDS and is the first to evaluate the performance of treosulfan-based conditioning in combination with ATG and PTCY. As such, it contributes to the increasing body of evidence supporting the safety of treosulfan, even at the dose of 42 g/m2.
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Affiliation(s)
- Ivan Pasic
- Division of Medical Oncology and Hematology, Princess Margaret Hospital, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada.
| | - Tommy Alfaro Moya
- Division of Medical Oncology and Hematology, Princess Margaret Hospital, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada
| | - Mats Remberger
- Department of Medical Sciences, Uppsala University and KFUE, Uppsala University Hospital, Uppsala, Sweden
| | - Carol Chen
- Division of Medical Oncology and Hematology, Princess Margaret Hospital, Toronto, Canada
| | - Armin Gerbitz
- Division of Medical Oncology and Hematology, Princess Margaret Hospital, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada
| | - Dennis Dong Hwan Kim
- Division of Medical Oncology and Hematology, Princess Margaret Hospital, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada
| | - Rajat Kumar
- Division of Medical Oncology and Hematology, Princess Margaret Hospital, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada
| | - Wilson Lam
- Division of Medical Oncology and Hematology, Princess Margaret Hospital, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada
| | - Arjun Datt Law
- Division of Medical Oncology and Hematology, Princess Margaret Hospital, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada
| | - Jeffrey H Lipton
- Division of Medical Oncology and Hematology, Princess Margaret Hospital, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada
| | - Fotios V Michelis
- Division of Medical Oncology and Hematology, Princess Margaret Hospital, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada
| | - Igor Novitzky-Basso
- Division of Medical Oncology and Hematology, Princess Margaret Hospital, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada
| | - Auro Viswabandya
- Division of Medical Oncology and Hematology, Princess Margaret Hospital, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada
| | - Jonas Mattsson
- Division of Medical Oncology and Hematology, Princess Margaret Hospital, Toronto, Canada; Department of Medicine, University of Toronto, Toronto, Canada
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2
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Saraceni F, Labopin M, Raiola AM, Blaise D, Reményi P, Sorà F, Pavlu J, Bramanti S, Busca A, Berceanu A, Battipaglia G, Visani G, Sociè G, Bug G, Micò C, La Nasa G, Musso M, Olivieri A, Spyridonidis A, Savani B, Ciceri F, Nagler A, Mohty M. Thiotepa-busulfan-fludarabine Compared to Treosulfan-based Conditioning for Haploidentical Transplant With Posttransplant Cyclophosphamide in Patients With Acute Myeloid Leukemia in Remission: A Study From the Acute Leukemia Working Party of the EBMT. Hemasphere 2023; 7:e952. [PMID: 37746158 PMCID: PMC10513143 DOI: 10.1097/hs9.0000000000000952] [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: 02/14/2023] [Accepted: 07/31/2023] [Indexed: 09/26/2023] Open
Abstract
We conducted a registry analysis including adult acute myeloid leukemia (AML) patients in remission who had received thiotepa, busulfan, and fludarabine (TBF) or treosulfan-based (Treo) conditioning for haplo-hematopoietic stem cell transplant (HSCT) with posttransplant cyclophosphamide (PTCy) between 2010 and 2020. A total of 1123 patients met the inclusion criteria (968 received TBF and 155 received Treo). A 1:1 matched-pair analysis was performed on 142 TBF and 142 Treo patients. In the Treo group, 68% of patients received treosulfan at a dose ≥36 g/m2 and 54% of patients received a second alkylator (thiotepa or melphalan). We observed a trend toward increased incidence of grade II-IV acute (a) graft-versus-host disease (GVHD) at 180 days in the TBF group compared with Treo (29% versus 20%; P = 0.08), while incidence of grade III-IV aGVHD was not statistically different. Similarly, the incidence of chronic (c) GVHD was not statistically different in the 2 groups. Incidence of nonrelapse mortality at 2 years was 19% in TBF and 14% in Treo (P = 0.4). Relapse incidence at 2 years was not statistically different in the 2 groups (16% and 18% in TBF and Treo, respectively; P = 0.9). Leukemia-free survival, overall survival, and GVHD-free, relapse-free survival was 65% versus 68% (P = 0.6), 73% versus 76% (P = 0.5), and 54% versus 53% (P = 0.8) in TBF versus Treo, respectively. In conclusion, we did not find a significant difference between the 2 conditioning in the present study; Treo and TBF represent 2 valid alternative regimens for haplo-HSCT with PTCy for AML in remission.
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Affiliation(s)
- Francesco Saraceni
- Ematologia, Trapianto e Terapia Cellulare, Azienda Ospedaliero-Universitaria delle Marche, Ancona, Italy
| | - Myriam Labopin
- SorbonneUniversité, INSERM UMR-S 938, CRSA, EBMT Statistical Unit, Paris, France
| | - Anna M. Raiola
- Ematoloia e Terapia Cellulare, IRCCS Ospedale Policlinico San Martino Genova, Italy
| | - Didier Blaise
- Programme de Transplantation and TherapieCellulaire, Centre de RechercheenCancérologie de Marseille, Institut Paoli Calmettes, Marseille, France
| | - Péter Reményi
- Department of Hematology and Stem Cell Transplant, Budapest, Hungary
| | - Federica Sorà
- UniversitaCattolica S. Cuore, Istituto di Ematologia, Rome, Italy
| | - Jiri Pavlu
- Department of Hematology, Imperial College, Hammersmith Hospital, London, United Kingdom
| | - Stefania Bramanti
- Department of Oncology and Hematology, IstitutoClinicoHumanitas, Transplantation Unit, Milano, Italy
| | - Alessandro Busca
- S.S.C.V.D Trapianto di Cellule Staminali, A.O.U Cittadella Salute e dellaScienza di Torino, Italy
| | - Ana Berceanu
- Hopital Jean Minjoz, Service d`Hématologie, Besançon, France
| | - Giorgia Battipaglia
- Division of Hematology, Federico II` Medical School, University of Napoli, Italy
| | - Giuseppe Visani
- Hematology and Transplant Center, AORMN Hospital, Pesaro, Italy
| | - Gerard Sociè
- Department of Hematology, Hopital St. Louis, BMT, Paris, France
| | - Gesine Bug
- Goethe-Universitaet, MedizinischeKlinik II, Hämatologie, MedizinischeOnkologie, Frankfurt_Main, Germany
| | - Caterina Micò
- Hematology and Bone Marrow Transplant Unit, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Giorgio La Nasa
- Centro TrapiantiUnico Di CSE Adulti e Pediatrico A. O Brotzu, Cagliari, Italy
| | - Maurizio Musso
- Department of Oncologico, Ospedale La Maddalena, Palermo, Italy
| | - Attilio Olivieri
- Ematologia, Trapianto e Terapia Cellulare, Azienda Ospedaliero-Universitaria delle Marche, Ancona, Italy
| | - Alexandros Spyridonidis
- Bone Marrow Transplantation Unit and Institute of Cell Therapy, University of Patras, Greece
| | - Bipin Savani
- Long Term Transplant Clinic, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Fabio Ciceri
- Ospedale San Raffaele s.r.l., Hematology and BMT, Milano, Italy
| | - Arnon Nagler
- Hematology Division, ChaimShebaMedical Center, Tel-Hashomer, Israel
| | - Mohamad Mohty
- SorbonneUniversité, INSERM UMR-S 938, CRSA, Service d’hématologie et thérapie cellulaire, AP-HP, Hôpital Saint-Antoine, Paris, France
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3
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Gavriilaki E, Labopin M, Sakellari I, Salmenniemi U, Yakoub-Agha I, Potter V, Berceanu A, Rambaldi A, Hilgendorf I, Kröger N, Mielke S, Zuckerman T, Sanz J, Busca A, Ozdogu H, Anagnostopoulos A, Savani B, Giebel S, Bazarbachi A, Spyridonidis A, Nagler A, Mohty M. Comparative study of treosulfan plus Fludarabine (FT14) with busulfan plus Fludarabine (FB4) for acute myeloid leukemia in first or second complete remission: An analysis from the European Society for Blood and Marrow Transplantation (EBMT) Acute Leukemia Working Party (ALWP). Bone Marrow Transplant 2022; 57:1803-1809. [PMID: 36138068 DOI: 10.1038/s41409-022-01830-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 08/26/2022] [Accepted: 09/08/2022] [Indexed: 11/10/2022]
Abstract
Different doses of treosulfan plus fludarabine have shown advantage over reduced intensity regimens. However, data comparing higher doses of treosulfan to myeloablative busulfan are limited. Thus, we compared outcomes between FT14 (fludarabine 150/160 mg/m2 and treosulfan 42 g/m2, or FT14) over FB4 (fludarabine 150/160 mg/m2 and busulfan 12.8 mg/kg). We retrospectively studied patients from European Society for Blood and Marrow Transplantation registry: a) adults diagnosed with acute myeloid leukemia (AML), b) recipients of first allogeneic hematopoietic stem cell transplantation (HSCT) from unrelated or sibling donor (2010-2020), c) HSCT at first or second complete remission, d) conditioning with FT14 or FB4. FT14 recipients (n = 678) were older, with higher rates of secondary AML, unrelated donors, peripheral blood grafts, and adverse cytogenetics, but lower percentage of female donor to male recipient compared to FB4 (n = 2025). Analysis was stratified on age. In patients aged < 55 years, FT14 was associated with higher relapse incidence (RI) and lower Leukemia-Free Survival (LFS). In patients aged≥55 years, acute GVHD CI was higher in FB4, without significant differences in other outcomes. Although FT14 has been used for higher-risk HSCT patients, our large real-world multicenter study suggests that FB4 is associated with better outcomes compared to FT14 in younger patients.
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Affiliation(s)
- Eleni Gavriilaki
- Hematology Department-BMT Unit, G Papanikolaou Hospital, Thessaloniki, Greece.
| | - Myriam Labopin
- Service d' Hématologie Clinique et Thérapie Cellulaire, Hospital Saint-Antoine, Sorbonne Université, Centre de Recherche Saint-Antoine (CRSA), Paris, France
| | - Ioanna Sakellari
- Hematology Department-BMT Unit, G Papanikolaou Hospital, Thessaloniki, Greece
| | - Urpu Salmenniemi
- HUCH Comprehensive Cancer Center, Stem Cell Transplantation Unit - Helsinki, Helsinki, Finland
| | | | - Victoria Potter
- Kings College Hospital, Dept. of Haematological Medicine, King's Denmark Hill Campus - London, London, UK
| | - Ana Berceanu
- Hopital Jean Minjoz, Service d'Hématologie - Besançon, Besançon, France
| | - Alessandro Rambaldi
- Department of Oncology and Hematology, University of Milan and Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Inken Hilgendorf
- Universitaetsklinikum Jena, Klinik für Innere Medizin II - Jena, Jena, Germany
| | - Nicolaus Kröger
- University Hospital Eppendorf, Bone Marrow Transplantation Centre - Hamburg, Hamburg, Germany
| | - Stephan Mielke
- Karolinska University Hospital, Dept. of Hematology - Stockholm, Stockholm, Sweden
| | - Tsila Zuckerman
- Rambam Medical Center, Dept. of Hematology & BMT - Haifa, Haifa, Israel
| | - Jaime Sanz
- University Hospital La Fe, Hematology Department - Valencia, Valencia, Spain
| | - Alessandro Busca
- S.S.C.V.D Trapianto di Cellule Staminali, A.O.U Citta della Salute e della Scienza di Torino, Torino, Italy
| | - Hakan Ozdogu
- Baskent University Hospital, Haematology Division, BMT Unit, Haematology Reserach Laboratory, Training & Medical - Adana, Adana, Turkey
| | | | - Bipin Savani
- Vanderbilt University Medical Center, Division of Hematology/ Oncology, Nashville, TN, USA
| | - Sebastian Giebel
- Maria Sklodowska-Curie Institute, Department of Bone Marrow Transplantation and Oncohematology, Oncology Center - Gliwice, Gliwice, Poland
| | - Ali Bazarbachi
- American University of Beirut, Medical Center, Department of Internal Medicine - Beirut, Beirut, Lebanon
| | - Alexandros Spyridonidis
- Department of Internal Medicine, Bone Marrow Transplantation Unit, University Hospital of Patras, Patras, Greece
| | - Arnon Nagler
- Chaim Sheba Medical Center, Dept. of Bone Marrow Transplantation - Tel-Hashomer, Tel-Hashomer, Israel
| | - Mohamad Mohty
- Service d' Hématologie Clinique et Thérapie Cellulaire, Hospital Saint-Antoine, Sorbonne Université, Centre de Recherche Saint-Antoine (CRSA), Paris, France
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4
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Braitsch K, Schwarz A, Koch K, Hubbuch M, Menzel H, Keller U, Götze KS, Bassermann F, Herhaus P, Verbeek M. Conditioning with fludarabine and treosulfan compared to FLAMSA-RIC in allogeneic stem cell transplantation for myeloid malignancies: a retrospective single-center analysis. Ann Hematol 2022; 101:1311-1319. [PMID: 35364726 PMCID: PMC9072466 DOI: 10.1007/s00277-022-04822-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 03/22/2022] [Indexed: 12/03/2022]
Abstract
Reduced intensity conditioning (RIC) and reduced toxicity conditioning (RTC) regimens enable allogeneic hematopoietic stem cell transplantation (alloSCT) to more patients due to reduction in transplant-related mortality (TRM). The conditioning regimens with fludarabine and treosulfan (Flu/Treo) or fludarabine, amsacrine, cytarabine (FLAMSA)-RIC have shown their efficacy and tolerability in various malignancies. So far, no prospective study comparing the two regimens is available. Two studies compared the regimens retrospectively, in which both provided similar outcome. In this retrospective, single-center analysis, these two regimens were compared with regard to outcome, rate of acute and chronic graft versus host disease (GvHD), and engraftment. 113 consecutive patients with myeloid malignancies who received Flu/Treo or FLAMSA-RIC conditioning prior to alloSCT between 2007 and 2019 were included. Except for age, previous therapies, and remission status before alloSCT, patient characteristics were well balanced. The median follow-up time within this analysis was 44 months. There was no significant difference in absolute neutrophil count (ANC) or platelet engraftment between the two conditioning regimens. Overall survival (OS), the relapse-free survival (RFS), and the TRM were not significantly different between the two cohorts. The rate of GvHD did not differ between the two groups. In summary, this retrospective analysis shows that there is no major difference regarding tolerability and survival between the Flu/Treo and FLAMSA-RIC regimens. Despite several limitations due to uneven distribution concerning age and remission status, we demonstrate that Flu/Treo and FLAMSA-RIC provide similar outcomes and are feasible in older and intensively pre-treated patients.
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Affiliation(s)
- Krischan Braitsch
- Internal Medicine III, Hematology and Medical Oncology, School of Medicine, Technische Universität München, Ismaninger Strasse 22, 81675, Munich, Germany.
| | - Alix Schwarz
- Internal Medicine III, Hematology and Medical Oncology, School of Medicine, Technische Universität München, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Katrin Koch
- Internal Medicine III, Hematology and Medical Oncology, School of Medicine, Technische Universität München, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Mara Hubbuch
- Internal Medicine III, Hematology and Medical Oncology, School of Medicine, Technische Universität München, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Helge Menzel
- Medical Department I, Malteser Krankenhaus St. Franziskus-Hospital, Waldstraße 17, 24939, Flensburg, Germany
| | - Ulrich Keller
- Internal Medicine III, Hematology and Medical Oncology, School of Medicine, Technische Universität München, Ismaninger Strasse 22, 81675, Munich, Germany.,German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Katharina S Götze
- Internal Medicine III, Hematology and Medical Oncology, School of Medicine, Technische Universität München, Ismaninger Strasse 22, 81675, Munich, Germany.,German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Florian Bassermann
- Internal Medicine III, Hematology and Medical Oncology, School of Medicine, Technische Universität München, Ismaninger Strasse 22, 81675, Munich, Germany.,German Cancer Consortium (DKTK) and German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Peter Herhaus
- Internal Medicine III, Hematology and Medical Oncology, School of Medicine, Technische Universität München, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Mareike Verbeek
- Internal Medicine III, Hematology and Medical Oncology, School of Medicine, Technische Universität München, Ismaninger Strasse 22, 81675, Munich, Germany
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5
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O'Hagan Henderson S, Frietsch JJ, Hilgendorf I, Hochhaus A, Köhne CH, Casper J. Combination of treosulfan, fludarabine and cytarabine as conditioning in patients with acute myeloid leukemia, myelodysplastic syndrome and myeloproliferative neoplasms. J Cancer Res Clin Oncol 2021; 148:2599-2609. [PMID: 34674031 PMCID: PMC9470667 DOI: 10.1007/s00432-021-03836-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 10/13/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Treosulfan and fludarabine (Treo/Flu) were successfully introduced into toxicity-reduced conditioning for SCT. However, the risk of post-SCT relapse remains a matter of concern. We report the results of a novel individual treatment approach with Treo/Flu and cytarabine (Treo/Flu/AraC) conditioning prior to allogeneic SCT in patients with acute myeloid leukemia (AML), myelodysplastic syndrome (MDS), or myeloproliferative neoplasms (MPN). METHODS Seventy-seven patients (median age 54 years) at high risk of disease relapse due to unfavorable cytogenetics or failure to achieve complete remission prior to SCT were included. Median follow-up was 3.2 years. RESULTS The 1-, 2- and 3-year RFS rates were 49.4%, 41.7%, and 37.6% and OS rates were 59.3%, 49.3%, and 45.4%, respectively. Cumulative incidence of NRM was 10% at 100 days, 18.8% at 1 year and 20.1% at 2 years. The cumulative incidence of relapse increased from 31% at 1 year to 38.5% after 3 years. The cumulative incidences of engraftment, chimerism, graft-versus-host disease (GvHD) and toxicities were acceptable and comparable with similar patients conditioned with Treo/Flu or FLAMSA-RIC. CONCLUSION In conclusion, Treo/Flu/AraC provides tolerable, feasible, and effective conditioning for patients with AML, MDS or MPN, even in advanced disease states. The incidence of NRM and relapse is acceptable in this heavily pre-treated population with high-risk disease. Future research will aim to confirm these initial findings and include a larger number of participants in a prospective trial.
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Affiliation(s)
- Samantha O'Hagan Henderson
- Onkologie und Hämatologie, Universitätsklinikum Oldenburg, Klinik Für Innere Medizin II, Oldenburg, Germany
| | - Jochen J Frietsch
- Abteilung Hämatologie und Internistische Onkologie, Universitätsklinikum Jena, Klinik Für Innere Medizin II, Am Klinikum 1, 07747, Jena, Germany.
| | - Inken Hilgendorf
- Abteilung Hämatologie und Internistische Onkologie, Universitätsklinikum Jena, Klinik Für Innere Medizin II, Am Klinikum 1, 07747, Jena, Germany
| | - Andreas Hochhaus
- Abteilung Hämatologie und Internistische Onkologie, Universitätsklinikum Jena, Klinik Für Innere Medizin II, Am Klinikum 1, 07747, Jena, Germany
| | - Claus-Henning Köhne
- Onkologie und Hämatologie, Universitätsklinikum Oldenburg, Klinik Für Innere Medizin II, Oldenburg, Germany
| | - Jochen Casper
- Onkologie und Hämatologie, Universitätsklinikum Oldenburg, Klinik Für Innere Medizin II, Oldenburg, Germany
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6
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Shimoni A, Robin M, Iacobelli S, Beelen D, Mufti GJ, Ciceri F, Bethge W, Volin L, Blaise D, Ganser A, Luft T, Chevallier P, Schwerdtfeger R, Koster L, de Witte T, Kröger N, Nagler A, Yakoub-Agha I. Allogeneic hematopoietic cell transplantation in patients with myelodysplastic syndrome using treosulfan based compared to other reduced-intensity or myeloablative conditioning regimens. A report of the chronic malignancies working party of the EBMT. Br J Haematol 2021; 195:417-428. [PMID: 34514596 DOI: 10.1111/bjh.17817] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/18/2021] [Accepted: 08/20/2021] [Indexed: 12/20/2022]
Abstract
Allogeneic haematopoietic-cell transplantation (allo-HCT) is a potentially curative therapy for high-risk myelodysplastic syndrome (MDS). Reduced-intensity conditioning (RIC) is usually associated with lower non-relapse mortality (NRM), higher relapse rate and similar overall-survival (OS) as myeloablative-conditioning (MAC). Fludarabine/treosulfan (FT) is a reduced-toxicity regimen with intense anti-leukaemia activity and a favourable toxicity profile. We investigated post-transplant outcomes in 1722 MDS patients following allo-HCT with FT (n = 367), RIC (n = 687) or MAC (n = 668). FT and RIC recipients were older than MAC recipients, median age 59, 59 and 51 years, respectively (P < 0·001) but other disease characteristics were similar. The median follow-up was 64 months (1-171). Five-year relapse rates were 25% (21-30), 38% (34-42) and 25% (22-29), after FT, RIC and MAC, respectively, (P < 0·001). NRM was 30% (25-35), 27% (23-30) and 34% (31-38, P = 0·008), respectively. Five-year OS was 50% (44-55), 43% (38-47), and 43% (39-47), respectively (P = 0·03). In multivariate analysis, FT was associated with a lower risk of relapse (HR 0·55, P < 0·001) and better OS (HR 0·72, P = 0·01). MAC was associated with higher NRM (HR 1·44, P = 0·001). In conclusion, FT is associated with similar low relapse rates as MAC and similar low NRM as RIC, resulting in improved OS. FT may be the preferred regimen for allo-HCT in MDS.
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Affiliation(s)
- Avichai Shimoni
- Chaim Sheba Medical Center, Tel-Aviv University, Tel-Hashomer, Israel
| | - Marie Robin
- Hematology/Transplantation, Saint Louis Hospital, Paris, France
| | - Simona Iacobelli
- Interdipartimentale di Biostatistica e Bioinformatica, Universita tor Vergata, Rome, Italy
| | - Dietrich Beelen
- Clinic for Bone Marrow Transplantation, University Hospital, Essen, Germany
| | - Ghulam J Mufti
- Haematological Medicine, King's College Hospital, London, United Kingdom
| | - Fabio Ciceri
- Hematology and Bone Marrow Transplantation Unit, Division of Regenerative Medicine, Stem Cells and Gene Therapy, San Raffaele Scientific Institute, Milano, Italy
| | - Wolfgang Bethge
- Department of Hematology, Oncology, Immunology, University of Tübingen, Tübingen, Germany
| | - Liisa Volin
- Department of Medicine, Helsinki University Central Hospital, Helsinki, Finland
| | - Didier Blaise
- Department of Hematology, Institut Paoli Calmettes, Marseille, France
| | - Arnold Ganser
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Thomas Luft
- Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| | | | - Rainer Schwerdtfeger
- Centre for Hematopoietic Cell Transplantation, German Diagnostic Clinic, Wiesbaden, Germany
| | - Linda Koster
- EBMT Data Office, University Medical Centre, Leiden, Netherlands
| | - Theo de Witte
- University Medical Centre St. Radboud, Nijmegen, Netherlands
| | - Nicolaus Kröger
- Department for Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Arnon Nagler
- Chaim Sheba Medical Center, Tel-Aviv University, Tel-Hashomer, Israel
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7
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Sakellari I, Gavriilaki E, Mallouri D, Batsis I, Varelas C, Tagara S, Bousiou Z, Papathanasiou M, Vardi A, Papalexandri A, Vadikoliou C, Athanasiadou A, Lalayanni C, Fylaktou A, Antoniadis K, Anagnostopoulos A. Survival Advantage of Treosulfan Plus Fludarabine Before Allogeneic Hematopoietic Cell Transplantation for Older or Comorbid Patients With Myeloid Malignancies. Transplant Cell Ther 2021; 27:916.e1-916.e6. [PMID: 34320443 DOI: 10.1016/j.jtct.2021.07.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/24/2021] [Accepted: 07/19/2021] [Indexed: 11/29/2022]
Abstract
We have previously shown an advantage of a myeloablative conditioning regimen with reduced toxicity (Fludarabine 150 mg/m2, Treosulfan 42 g/m2, FluTreo) compared to a reduced-intensity regimen. We aimed to determine long-term safety and efficacy of FluTreo. We prospectively studied consecutive patients who received FluTreo in our center (2014-2019) on the basis of age (≥50 years), hematopoietic cell transplantation comorbidity index (HCT-CI) ≥2, or both. FluTreo recipients were then compared to a historical control group. We studied 68 FluTreo recipients, with a median age of 58.5 years and HCT-CI of 3. We calculated cumulative incidence (CI) of acute (grade 2-4) and moderate/severe chronic graft-versus-host disease (GVHD) (29.9% and 25%, respectively). The 3-year CI of treatment-related mortality was 19.1%, associated only with acute GVHD (P < .001). With a median follow-up of 27.3 (range 5.7-84.5) months in surviving patients, the 3-year overall survival (OS) was 56.6%, and disease-free survival (DFS) was 54.9%. Median survival has not yet been reached. Among pretransplantation and transplantation factors, only HCT-CI was associated with DFS and OS (P = .022 and P = .043, respectively). FluTreo recipients aged ≥50 with HCT-CI ≤ 2 had favorable DFS and OS compared with patients aged ≥50 with HCT-CI ≤2 after myeloablative conditioning. Our real-world study confirms that HCT with FluTreo expands the transplant population with favorable outcomes compared to previously used conditions. The choice of HCT in patients of a rather older age and comorbidity index needs to be revisited.
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Affiliation(s)
- Ioanna Sakellari
- Hematology Department - BMT Unit, G Papanicolaou Hospital, Thessaloniki, Greece
| | - Eleni Gavriilaki
- Hematology Department - BMT Unit, G Papanicolaou Hospital, Thessaloniki, Greece.
| | - Despina Mallouri
- Hematology Department - BMT Unit, G Papanicolaou Hospital, Thessaloniki, Greece
| | - Ioannis Batsis
- Hematology Department - BMT Unit, G Papanicolaou Hospital, Thessaloniki, Greece
| | - Christos Varelas
- Hematology Department - BMT Unit, G Papanicolaou Hospital, Thessaloniki, Greece
| | - Sofia Tagara
- Hematology Department - BMT Unit, G Papanicolaou Hospital, Thessaloniki, Greece
| | - Zoi Bousiou
- Hematology Department - BMT Unit, G Papanicolaou Hospital, Thessaloniki, Greece
| | - Maria Papathanasiou
- Hematology Department - BMT Unit, G Papanicolaou Hospital, Thessaloniki, Greece
| | - Anna Vardi
- Hematology Department - BMT Unit, G Papanicolaou Hospital, Thessaloniki, Greece
| | | | | | | | - Chrysavgi Lalayanni
- Hematology Department - BMT Unit, G Papanicolaou Hospital, Thessaloniki, Greece
| | - Asimina Fylaktou
- National Peripheral Histocompatibility Center, Department of Immunology, Hippokration General Hospital, Thessaloniki, Greece
| | - Konstantinos Antoniadis
- Aristotle University of Thessaloniki, School of Health Sciences, School of Dentistry, Thessaloniki, Greece
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8
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Gagelmann N, Kröger N. Dose intensity for conditioning in allogeneic hematopoietic cell transplantation: can we recommend "when and for whom" in 2021? Haematologica 2021; 106:1794-1804. [PMID: 33730842 PMCID: PMC8252938 DOI: 10.3324/haematol.2020.268839] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Indexed: 12/12/2022] Open
Abstract
Allogeneic hematopoietic stem-cell transplantation is a potentially curative therapy for various hematologic diseases. An essential component of this procedure is the pre-transplant conditioning regimen, which should facilitate engraftment and reduce or eliminate tumor cells. The recognition of the substantial association of a graft-versus- tumor effect and the high toxicity of the commonly used conditioning regimen led to the introduction of more differentiated intensity strategies, with the aim of making hematopoietic stem-cell transplantation less toxic and safer, and thus more applicable to broader populations such as older or unfit patients. In general, prospective and retrospective studies suggest a correlation between increasing intensity and nonrelapse mortality and an inverse correlation with relapse incidence. In this review, we will summarize traditional and updated definitions for conditioning intensity strategies and the landscape of comparative prospective and retrospective studies, which may help to find the balance between the risk of non-relapse mortality and relapse. We will try to underscore the caveats regarding these definitions and analyses, by missing complex differences between intensity and toxicity as well as the broad influences of other factors in the transplantation procedure. We will summarize evidence regarding several confounders which may influence decisions when selecting the intensity of the conditioning regimen for any given patient, according to the individual risk of relapse and non-relapse mortality.
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Affiliation(s)
- Nico Gagelmann
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg.
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9
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Zhu S, Liu G, Liu J, Chen Q, Wang Z. Long-Term Outcomes of Treosulfan- vs. Busulfan-Based Conditioning Regimen for Patients With Myelodysplastic Syndrome and Acute Myeloid Leukemia Before Hematopoietic Cell Transplantation: A Systematic Review and Meta-Analysis. Front Oncol 2020; 10:591363. [PMID: 33425740 PMCID: PMC7793760 DOI: 10.3389/fonc.2020.591363] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 10/05/2020] [Indexed: 12/17/2022] Open
Abstract
Background Many studies aimed to evaluate the efficacy and safety of treosulfan-based conditioning regimens for allogeneic hematopoietic cell transplantation (allo-HCT) compared with other regimens, but different outcomes were reported across studies. Aim To determine the long-term survival outcomes of treosulfan-based vs. busulfan-based conditioning regimens in myelodysplastic syndrome (MDS)/acute myeloid leukemia (AML) patients. Methods PubMed, Embase, and Cochrane library were searched for studies published prior to December 6, 2019. The fixed-effects model was applied for overall survival (OS), leukemia-free survival (LFS), non-relapse mortality (NRM), acute and chronic graft versus host disease (GvHD). Relapse incidence (RI) was pooled by the use of the random-effects model. Results Six studies were included (3,982 patients; range, 57-1,956). The pooled HR for OS favored treosulfan (HR=0.80, 95%CI: 0.71-0.90). There was no significant difference in NRM between the two regimens (HR=0.84, 95%CI=0.71-1.01). There was no significant difference in LFS between the two regimens (HR=0.98, 95%CI=0.87-1.12). Treosulfan-based regimens showed a lower risk of aGvHD (HR=0.70, 95%CI=0.59-0.82), but there was no difference for cGvHD (HR=0.94, 95%CI=0.81-1.09). There was no significant difference in RI between the two regimens (HR=0.96, 95%CI=0.71-1.31). There was no publication bias among these studies. Conclusion The current meta-analysis determined that treosulfan-based conditioning regimens could improve the OS in patients with MDS and AML, with lower acute graft-versus-host disease incidence, compared with busulfan-based regimens.
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Affiliation(s)
- Sheng Zhu
- Department of Radiology, The First Affiliated Hospital of Jinan University, Guangzhou, China.,Department of Radiology, Affiliated Hospital of Xiangnan University, Chenzhou, China
| | - Gang Liu
- Department of Pediatrics, Affiliated Hospital of Xiangnan University, Chenzhou, China
| | - Jing Liu
- Department of Radiology, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Qiuying Chen
- Department of Radiology, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Zhiqiang Wang
- Department of Radiology, The First Affiliated Hospital of Jinan University, Guangzhou, China
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Treosulfan-Based Conditioning Regimen for Second Allograft in Patients with Myelofibrosis. Cancers (Basel) 2020; 12:cancers12113098. [PMID: 33114179 PMCID: PMC7690833 DOI: 10.3390/cancers12113098] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 10/15/2020] [Accepted: 10/21/2020] [Indexed: 11/17/2022] Open
Abstract
Simple Summary Currently, the only curative therapy in myelofibrosis is allogeneic hematopoietic stem cell transplantation. Donor lymphocyte infusion and second stem cell transplantation are the two main treatment options for myelofibrosis patients who relapse after the first transplantation. The optimal conditioning regimen for the second transplantation in myelofibrosis patients is not well defined. Our study aimed to address this question and showed that treosulfan-based conditioning for second allograft in relapsed myelofibrosis patients resulted in longtime freedom from disease in about 50% of the patients. This data supports the second allogeneic hematopoietic stem cell transplantation with a less toxic treosulfan-based conditioning regimen that is effective in relapsed, donor lymphocyte infusion resistant myelofibrosis patients with long term low transplant-related mortality and relapse rates. Abstract Relapse after allogeneic hematopoietic stem cell transplantation (AHSCT) in myelofibrosis (MF) patients remains as a significant issue despite advances in transplantation procedures and significant prolongation in survival. Second AHSCT is a potential treatment option but associated with high treatment-related mortality and novel less toxic conditioning regimens are needed. In 33 MF patients with relapse after AHSCT and failure to donor lymphocyte infusion (DLI) we investigated treosulfan (36–42 g/m2) in combination with fludarabine and anti-thymocyte globulin (ATG) as conditioning regimen for a second AHSCT with matched related (n = 2), unrelated (n = 23), or mismatched unrelated (n = 8) donors. All patients achieved leukocyte engraftment after a median of 11 days, and 56 ± 13% experienced acute GVHD grade II–IV at day 100. The therapy-related mortality at day 100 and at 3 years was 16% and 31%, respectively. The cumulative incidence of relapse at 5 years was 16%, resulting in a 5-year disease-free and overall survival of 45% and 47%, respectively. Treosulfan-based conditioning for second allograft in relapsed MF patients resulted in about 50% of the patients in long-term freedom from disease.
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11
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Treosulfan-Based Conditioning Regimen in Haematopoietic Stem Cell Transplantation with TCRαβ/CD19 Depletion in Nijmegen Breakage Syndrome. J Clin Immunol 2020; 40:861-871. [PMID: 32602054 DOI: 10.1007/s10875-020-00811-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 06/18/2020] [Indexed: 01/05/2023]
Abstract
Nijmegen breakage syndrome (NBS) is a DNA repair disorder characterized by combined immunodeficiency and a high predisposition to malignancies. HSCT appears to cure immunodeficiency, but remains challenging due to limited experience in long-term risks of transplant-associated toxicity and malignancies. Twenty NBS patients received 22 allogeneic HSCTs with TCRαβ/CD19+ graft depletion with fludarabine 150 mg/m2, cyclophosphamide 20-40 mg/kg and thymoglobulin 5 mg/kg based conditioning regimens (CRs). Twelve patients additionally received low-dose busulfan 4 mg/kg (Bu group) and 10 patients (including 2 recipients of a second HSCT) treosulfan (Treo group) 30 g/m2. Overall and event-free survival were 0.75 vs 1 (p = 0.16) and 0.47 vs 0.89 (p = 0.1) in the Bu and Treo groups, respectively. In the Bu group, four patients developed graft rejection, and three died: two died of de novo and relapsed lymphomas and one died of adenoviral hepatitis. The four living patients exhibited split chimerism with predominantly recipient myeloid cells and predominantly donor T and B lymphocytes. In Treo group, one patient developed rhabdomyosarcoma. There was no difference in the incidence of GVHD, viral reactivation, or early toxicity between either group. Low-dose Bu-containing CR in NBS leads to increased graft failure and low donor myeloid chimerism. Treo-CR followed by TCRαβ/CD19-depleted HSCT demonstrates a low level of early transplant-associated toxicity and enhanced graft function with stable donor chimerism.
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12
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Shouval R, Kouniavski E, Fein J, Danylesko I, Shem‐Tov N, Geva M, Yerushalmi R, Shimoni A, Nagler A. Risk factors and implications of oral mucositis in recipients of allogeneic hematopoietic stem cell transplantation. Eur J Haematol 2019; 103:402-409. [DOI: 10.1111/ejh.13299] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 07/11/2019] [Accepted: 07/12/2019] [Indexed: 12/24/2022]
Affiliation(s)
- Roni Shouval
- Hematology and Bone Marrow Transplantation Division, Chaim Sheba Medical Center, Tel‐HaShomer, Sackler School of Medicine Tel Aviv University Ramat‐Gan Israel
- Dr. Pinchas Bornstein Talpiot Medical Leadership Program Chaim Sheba Medical Center Ramat‐Gan Israel
| | - Elizaveta Kouniavski
- Hematology and Bone Marrow Transplantation Division, Chaim Sheba Medical Center, Tel‐HaShomer, Sackler School of Medicine Tel Aviv University Ramat‐Gan Israel
| | - Joshua Fein
- Hematology and Bone Marrow Transplantation Division, Chaim Sheba Medical Center, Tel‐HaShomer, Sackler School of Medicine Tel Aviv University Ramat‐Gan Israel
| | - Ivetta Danylesko
- Hematology and Bone Marrow Transplantation Division, Chaim Sheba Medical Center, Tel‐HaShomer, Sackler School of Medicine Tel Aviv University Ramat‐Gan Israel
| | - Noga Shem‐Tov
- Hematology and Bone Marrow Transplantation Division, Chaim Sheba Medical Center, Tel‐HaShomer, Sackler School of Medicine Tel Aviv University Ramat‐Gan Israel
| | - Mika Geva
- Hematology and Bone Marrow Transplantation Division, Chaim Sheba Medical Center, Tel‐HaShomer, Sackler School of Medicine Tel Aviv University Ramat‐Gan Israel
| | - Ronit Yerushalmi
- Hematology and Bone Marrow Transplantation Division, Chaim Sheba Medical Center, Tel‐HaShomer, Sackler School of Medicine Tel Aviv University Ramat‐Gan Israel
| | - Avichai Shimoni
- Hematology and Bone Marrow Transplantation Division, Chaim Sheba Medical Center, Tel‐HaShomer, Sackler School of Medicine Tel Aviv University Ramat‐Gan Israel
| | - Arnon Nagler
- Hematology and Bone Marrow Transplantation Division, Chaim Sheba Medical Center, Tel‐HaShomer, Sackler School of Medicine Tel Aviv University Ramat‐Gan Israel
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13
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Fludarabine-treosulfan compared to thiotepa-busulfan-fludarabine or FLAMSA as conditioning regimen for patients with primary refractory or relapsed acute myeloid leukemia: a study from the Acute Leukemia Working Party of the European Society for Blood and Marrow Transplantation (EBMT). J Hematol Oncol 2019; 12:44. [PMID: 31023346 PMCID: PMC6482556 DOI: 10.1186/s13045-019-0727-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Accepted: 03/31/2019] [Indexed: 12/18/2022] Open
Abstract
Background Limited data is available to guide the choice of the conditioning regimen for patients with acute myeloid leukemia (AML) undergoing transplant with persistent disease. Methods We retrospectively compared outcome of fludarabine-treosulfan (FT), thiotepa-busulfan-fludarabine (TBF), and sequential fludarabine, intermediate dose Ara-C, amsacrine, total body irradiation/busulfan, cyclophosphamide (FLAMSA) conditioning in patients with refractory or relapsed AML. Results Complete remission rates at day 100 were 92%, 80%, and 88% for FT, TBF, and FLAMSA, respectively (p = 0.13). Non-relapse mortality, incidence of relapse, acute (a) and chronic (c) graft-versus-host disease (GVHD) rates did not differ between the three groups. Overall survival at 2 years was 37% for FT, 24% for TBF, and 34% for FLAMSA (p = 0.10). Independent prognostic factors for survival were Karnofsky performance score and patient CMV serology (p = 0.01; p = 0.02), while survival was not affected by age at transplant. The use of anti-thymocyte globulin (ATG) was associated with reduced risk of grade III–IV aGVHD (p = 0.02) and cGVHD (p = 0.006), with no influence on relapse. Conclusions In conclusion, FT, TBF, and FLAMSA regimens provided similar outcome in patients undergoing transplant with active AML. Survival was determined by patient characteristics as Karnofsky performance score and CMV serology, however was not affected by age at transplant. ATG appears able to reduce the incidence of acute and chronic GVHD without influencing relapse risk. Electronic supplementary material The online version of this article (10.1186/s13045-019-0727-4) contains supplementary material, which is available to authorized users.
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14
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Sheth V, Labopin M, Canaani J, Volin L, Brecht A, Ganser A, Mayer J, Labussière-Wallet H, Bittenbring J, Shouval R, Savani B, Mohty M, Nagler A. Comparison of FLAMSA-based reduced intensity conditioning with treosulfan/fludarabine conditioning for patients with acute myeloid leukemia: an ALWP/EBMT analysis. Bone Marrow Transplant 2018; 54:531-539. [DOI: 10.1038/s41409-018-0288-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 06/23/2018] [Accepted: 06/26/2018] [Indexed: 11/09/2022]
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15
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Kobbe G, Schroeder T, Haas R, Germing U. The current and future role of stem cells in myelodysplastic syndrome therapies. Expert Rev Hematol 2018; 11:411-422. [DOI: 10.1080/17474086.2018.1452611] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Guido Kobbe
- Medical Faculty, Department of Hematology, Oncology and Clinical Immunology, Heinrich Heine University, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Thomas Schroeder
- Medical Faculty, Department of Hematology, Oncology and Clinical Immunology, Heinrich Heine University, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Rainer Haas
- Medical Faculty, Department of Hematology, Oncology and Clinical Immunology, Heinrich Heine University, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Ulrich Germing
- Medical Faculty, Department of Hematology, Oncology and Clinical Immunology, Heinrich Heine University, University Hospital Düsseldorf, Düsseldorf, Germany
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16
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Intravenous Busulfan Compared with Treosulfan-Based Conditioning for Allogeneic Stem Cell Transplantation in Acute Myeloid Leukemia: A Study on Behalf of the Acute Leukemia Working Party of European Society for Blood and Marrow Transplantation. Biol Blood Marrow Transplant 2017; 24:751-757. [PMID: 29247780 DOI: 10.1016/j.bbmt.2017.12.776] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Accepted: 12/07/2017] [Indexed: 12/22/2022]
Abstract
Dose intensity of the conditioning regimen has significant impact on the outcomes after stem cell transplantation (SCT) for acute myeloid leukemia. Most studies have shown more relapse, less nonrelapse mortality (NRM), and similar overall survival after reduced-intensity and myeloablative conditioning. There are limited data on the dose equivalence and expected outcomes of treosulfan-based compared with busulfan-based conditioning. We compared SCT outcomes after fludarabine with either intravenous busulfan at a myeloablative dose (FB4, 12.8 mg/kg, n = 1265) or a reduced dose (FB2, 6.4 mg/kg, n = 1456) or treosulfan at 42 g/m2 (FT14, n = 403) or 36 g/m2 (FT12, n = 168). Median patient age was 48, 60, 57, and 60 years in the FB4, FB2, FT14, and FT12 groups, respectively (P < .0001). Two-year overall survival was 58%, 53%, 53%, and 51%, respectively (P = .25). Multivariate analysis identified advanced age, advanced disease status, and secondary leukemia to be associated with worse survival. Relapse rate was 30%, 35%, 34%, and 40%, respectively. Relapse was more common after FB2, advanced age and disease status, secondary leukemia, and sibling donors. NRM was 17%, 18%, 21%, and 16%, respectively. NRM was least common after FT12 and more common with advanced age and disease status and unrelated donors. Treosulfan-based regimens were associated with lower rates of graft-versus-host disease. There was no difference in any outcome among patients in first complete remission at transplantation. However, there was better survival with treosulfan-based conditioning in advanced leukemia. In conclusion, survival is determined mostly by disease biology and is similar after various regimens. Treosulfan-based conditioning is more similar to myeloablative than to reduced-intensity conditioning but can be administered safely in older patients, with lower rates of graft-versus-host disease and possibly better outcomes in patients with active leukemia.
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17
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Shimoni A, Vago L, Bernardi M, Yerushalmi R, Peccatori J, Greco R, Shem-Tov N, Lo Russo A, Danylesko I, Apel A, Bonini C, Lupo Stanghellini MT, Nagler A, Ciceri F. Missing HLA C group 1 ligand in patients with AML and MDS is associated with reduced risk of relapse and better survival after allogeneic stem cell transplantation with fludarabine and treosulfan reduced toxicity conditioning. Am J Hematol 2017. [PMID: 28631269 DOI: 10.1002/ajh.24827] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Reduced-toxicity conditioning with fludarabine and treosulfan is a dose-intensive regimen with enhanced anti-leukemia effect and acceptable toxicity in AML/MDS. HLA-C regulates natural-killer (NK) cell function by inhibiting Killer immunoglobulin-like receptors (KIR) and is divided into C1 and C2 epitopes. The missing-ligand theory suggests that missing recipient KIR ligands drives NK-alloreactivity after SCT, in the absence of HLA-mismatch by activating unlicensed donor NK cells. We analyzed SCT outcomes in 203 patients with AML/MDS, median age 58 years, given SCT from matched-siblings (n = 97) or matched-unrelated donors (n = 106), using two treosulfan doses (total 36 or 42 g/m2 ). 34% expressed one HLA-C group 1 allele (C1C1), 19% one HLA-C group 2 allele (C2C2), and 48% both KIR ligands (C1C2). Median follow-up was 48 months. 5-year relapse, nonrelapse mortality (NRM) and leukemia-free survival (LFS) rates were 38%, 27%, and 36%, respectively. Relapse rates were 43%, 45%, and 26% in patients expressing C1C1, C1C2, and C2C2 ligands, respectively (P = .03). Multivariate-analysis identified chemo-refractory disease (HR 3.1, P = .003), poor cytogenetics (HR 1.7, P = .08), female donor to male recipient (HR 0.4, P = .01) and C2C2 ligands (HR 0.4, P = .04) as independent factors predicting relapse. HLA-C ligands were not associated with GVHD or NRM. LFS was 33%, 30%, and 46%, respectively (P = .07). Chemorefractory disease (HR 3.1, P = .0004) and C2C2 group ligand (HR 0.6, P = .06) independently predicted LFS. Treosulfan dose did not predict any SCT outcome. In conclusion, missing HLA-C group 1 ligand is associated with reduced relapse risk, similar NRM and improved LFS, after HLA-matched SCT with treosulfan conditioning in AML/MDS.
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Affiliation(s)
- Avichai Shimoni
- Division of Hematology; Chaim Sheba Medical Center, Tel-Hashoer; Israel
- Sackler Medical School, Tel-Aviv University; Tel-Aviv Israel
| | - Luca Vago
- IRCCS San Raffaele Hospital; Hematology and Bone Marrow Transplantation Unit; Milan Italy
| | - Massimo Bernardi
- IRCCS San Raffaele Hospital; Hematology and Bone Marrow Transplantation Unit; Milan Italy
| | - Ronit Yerushalmi
- Division of Hematology; Chaim Sheba Medical Center, Tel-Hashoer; Israel
| | - Jacopo Peccatori
- IRCCS San Raffaele Hospital; Hematology and Bone Marrow Transplantation Unit; Milan Italy
| | - Raffaella Greco
- IRCCS San Raffaele Hospital; Hematology and Bone Marrow Transplantation Unit; Milan Italy
| | - Noga Shem-Tov
- Division of Hematology; Chaim Sheba Medical Center, Tel-Hashoer; Israel
| | - Alessandro Lo Russo
- IRCCS San Raffaele Hospital; Hematology and Bone Marrow Transplantation Unit; Milan Italy
| | - Ivetta Danylesko
- Division of Hematology; Chaim Sheba Medical Center, Tel-Hashoer; Israel
| | - Arie Apel
- Division of Hematology; Chaim Sheba Medical Center, Tel-Hashoer; Israel
| | - Chiara Bonini
- IRCCS San Raffaele Hospital; Hematology and Bone Marrow Transplantation Unit; Milan Italy
- University Vita-Salute San Raffaele; Milan Italy
| | | | - Arnon Nagler
- Division of Hematology; Chaim Sheba Medical Center, Tel-Hashoer; Israel
- Sackler Medical School, Tel-Aviv University; Tel-Aviv Israel
| | - Fabio Ciceri
- IRCCS San Raffaele Hospital; Hematology and Bone Marrow Transplantation Unit; Milan Italy
- University Vita-Salute San Raffaele; Milan Italy
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18
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Nagler A, Labopin M, Beelen D, Ciceri F, Volin L, Shimoni A, Foá R, Milpied N, Peccatori J, Polge E, Mailhol A, Mohty M, Savani BN. Long-term outcome after a treosulfan-based conditioning regimen for patients with acute myeloid leukemia: A report from the Acute Leukemia Working Party of the European Society for Blood and Marrow Transplantation. Cancer 2017; 123:2671-2679. [DOI: 10.1002/cncr.30646] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Arnon Nagler
- Acute Leukemia Working Party; European Society for Blood and Marrow Transplantation Paris Study Office/European Center for Biostatistical and Epidemiological Evaluation in Hematopoietic Cell Therapy (CEREST-TC); Paris France
- Hematology Division; Chaim Sheba Medical Center; Tel Hashomer Israel
| | - Myriam Labopin
- Acute Leukemia Working Party; European Society for Blood and Marrow Transplantation Paris Study Office/European Center for Biostatistical and Epidemiological Evaluation in Hematopoietic Cell Therapy (CEREST-TC); Paris France
- Department of Hematology; St. Antoine Hospital; Paris France
- INSERM UMR 938; Paris France
- Pierre and Marie Curie University; Paris France
| | - Dietrich Beelen
- Department of Bone Marrow Transplantation; University Hospital; Essen Germany
| | - Fabio Ciceri
- Hematology and Bone Marrow Transplantation Unit; San Raffaele Scientific Institute; Milano Italy
| | - Liisa Volin
- Stem Cell Transplantation Unit, Comprehensive Cancer Center; Helsinki University Central Hospital; Helsinki Finland
| | - Avichai Shimoni
- Hematology Division; Chaim Sheba Medical Center; Tel Hashomer Israel
| | - Roberto Foá
- Department of Cellular Biotechnology and Hematology; University La Sapienza; Rome Italy
| | - Noel Milpied
- CHU Bordeaux, Hôpital Haut-Leveque; Pessac France
| | - Jacopo Peccatori
- Hematology and Bone Marrow Transplantation Unit; San Raffaele Scientific Institute; Milano Italy
| | - Emmanuelle Polge
- Acute Leukemia Working Party; European Society for Blood and Marrow Transplantation Paris Study Office/European Center for Biostatistical and Epidemiological Evaluation in Hematopoietic Cell Therapy (CEREST-TC); Paris France
| | - Audrey Mailhol
- Acute Leukemia Working Party; European Society for Blood and Marrow Transplantation Paris Study Office/European Center for Biostatistical and Epidemiological Evaluation in Hematopoietic Cell Therapy (CEREST-TC); Paris France
| | - Mohamad Mohty
- Acute Leukemia Working Party; European Society for Blood and Marrow Transplantation Paris Study Office/European Center for Biostatistical and Epidemiological Evaluation in Hematopoietic Cell Therapy (CEREST-TC); Paris France
- Department of Hematology; St. Antoine Hospital; Paris France
- INSERM UMR 938; Paris France
- Pierre and Marie Curie University; Paris France
| | - Bipin N. Savani
- Acute Leukemia Working Party; European Society for Blood and Marrow Transplantation Paris Study Office/European Center for Biostatistical and Epidemiological Evaluation in Hematopoietic Cell Therapy (CEREST-TC); Paris France
- Long-Term Transplantation Clinic; Vanderbilt University Medical Center; Nashville Tennessee
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19
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Conditioning regimens for allogeneic hematopoietic stem cell transplants in acute myeloid leukemia. Bone Marrow Transplant 2017; 52:1504-1511. [DOI: 10.1038/bmt.2017.83] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 02/06/2017] [Accepted: 02/24/2017] [Indexed: 12/24/2022]
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20
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Zhang ZH, Lian XY, Yao DM, He PF, Ma JC, Xu ZJ, Guo H, Zhang W, Lin J, Qian J. Reduced intensity conditioning of allogeneic hematopoietic stem cell transplantation for myelodysplastic syndrome and acute myeloid leukemia in patients older than 50 years of age: a systematic review and meta-analysis. J Cancer Res Clin Oncol 2017; 143:1853-1864. [PMID: 28470473 DOI: 10.1007/s00432-017-2429-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 04/18/2017] [Indexed: 01/02/2023]
Abstract
PURPOSE A systematic review and meta-analysis were performed to explore the efficacy and safety of allogeneic hematopoietic stem cell transplantation with a reduced intensity conditioning regimen in elderly patients with myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML). METHODS Overall survival (OS) and event-free survival (EFS) were established as the primary endpoints for directly assessing the efficacy, and non-relapse mortality (NRM) for safety. The eligible patients were at or above 50 years of age, and the outcomes of the typical elderly patients (≥60 years) were analyzed individually. RESULTS The pooled estimates (95% confidence interval (CI)) for 1-year OS, EFS and NRM were 65 (55-74) %, 50 (44-55) % and 26 (21-30) %, respectively; as for the patients ≥60 years of age, these were 63 (53-72) %, 46 (41-50) % and 28 (23-32) %, respectively. No significantly statistical difference achieved between MDS and AML patients in 1-year EFS and NRM [relative risk (RR) 0.91, 95% CI 0.80-1.04; P = 0.172 and RR 1.18, 95% CI 0.82-1.69; P = 0.365]. The patients with lower diseases risk had the possibility of higher OS rate at ≥ 3 years than those with higher diseases risk (RR 1.37, 95% CI 0.95-1.97; P = 0.088). The patients had significantly higher 2-year OS and EFS rates in complete remission (CR, CR1 and CR2) at transplantation compared to those with advanced diseases (P < 0.05). CONCLUSIONS RIC-alloHSCT is a feasible treatment option for the patients older than 50 year of age with MDS and AML. Advanced diseases status and higher diseases risk may be the poor factors for prognosis.
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Affiliation(s)
- Zhi-Hui Zhang
- Department of Hematology, Affiliated People's Hospital of Jiangsu University, 8 Dianli Rd., Zhenjiang, 212002, Jiangsu, People's Republic of China.,The Key Lab of Precision Diagnosis and Treatment of Zhenjiang City, Zhenjiang, Jiangsu, People's Republic of China
| | - Xin-Yue Lian
- Department of Hematology, Affiliated People's Hospital of Jiangsu University, 8 Dianli Rd., Zhenjiang, 212002, Jiangsu, People's Republic of China.,The Key Lab of Precision Diagnosis and Treatment of Zhenjiang City, Zhenjiang, Jiangsu, People's Republic of China
| | - Dong-Ming Yao
- Laboratory Center, Affiliated People's Hospital of Jiangsu University, 8 Dianli Rd., Zhenjiang, 212002, Jiangsu, People's Republic of China.,The Key Lab of Precision Diagnosis and Treatment of Zhenjiang City, Zhenjiang, Jiangsu, People's Republic of China
| | - Pin-Fang He
- Laboratory Center, Affiliated People's Hospital of Jiangsu University, 8 Dianli Rd., Zhenjiang, 212002, Jiangsu, People's Republic of China.,The Key Lab of Precision Diagnosis and Treatment of Zhenjiang City, Zhenjiang, Jiangsu, People's Republic of China
| | - Ji-Chun Ma
- Laboratory Center, Affiliated People's Hospital of Jiangsu University, 8 Dianli Rd., Zhenjiang, 212002, Jiangsu, People's Republic of China.,The Key Lab of Precision Diagnosis and Treatment of Zhenjiang City, Zhenjiang, Jiangsu, People's Republic of China
| | - Zi-Jun Xu
- Laboratory Center, Affiliated People's Hospital of Jiangsu University, 8 Dianli Rd., Zhenjiang, 212002, Jiangsu, People's Republic of China.,The Key Lab of Precision Diagnosis and Treatment of Zhenjiang City, Zhenjiang, Jiangsu, People's Republic of China
| | - Hong Guo
- Laboratory Center, Affiliated People's Hospital of Jiangsu University, 8 Dianli Rd., Zhenjiang, 212002, Jiangsu, People's Republic of China.,The Key Lab of Precision Diagnosis and Treatment of Zhenjiang City, Zhenjiang, Jiangsu, People's Republic of China
| | - Wei Zhang
- Department of Hematology, Affiliated People's Hospital of Jiangsu University, 8 Dianli Rd., Zhenjiang, 212002, Jiangsu, People's Republic of China.,The Key Lab of Precision Diagnosis and Treatment of Zhenjiang City, Zhenjiang, Jiangsu, People's Republic of China
| | - Jiang Lin
- Laboratory Center, Affiliated People's Hospital of Jiangsu University, 8 Dianli Rd., Zhenjiang, 212002, Jiangsu, People's Republic of China. .,The Key Lab of Precision Diagnosis and Treatment of Zhenjiang City, Zhenjiang, Jiangsu, People's Republic of China.
| | - Jun Qian
- Department of Hematology, Affiliated People's Hospital of Jiangsu University, 8 Dianli Rd., Zhenjiang, 212002, Jiangsu, People's Republic of China. .,The Key Lab of Precision Diagnosis and Treatment of Zhenjiang City, Zhenjiang, Jiangsu, People's Republic of China.
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21
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Sakellari I, Mallouri D, Gavriilaki E, Batsis I, Kaliou M, Constantinou V, Papalexandri A, Lalayanni C, Vadikolia C, Athanasiadou A, Yannaki E, Sotiropoulos D, Smias C, Anagnostopoulos A. Survival Advantage and Comparable Toxicity in Reduced-Toxicity Treosulfan-Based versus Reduced-Intensity Busulfan-Based Conditioning Regimen in Myelodysplastic Syndrome and Acute Myeloid Leukemia Patients after Allogeneic Hematopoietic Cell Transplantation. Biol Blood Marrow Transplant 2017; 23:445-451. [DOI: 10.1016/j.bbmt.2016.11.023] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 11/29/2016] [Indexed: 12/28/2022]
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22
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Kayser S, Benner A, Thiede C, Martens U, Huber J, Stadtherr P, Janssen JWG, Röllig C, Uppenkamp MJ, Bochtler T, Hegenbart U, Ehninger G, Ho AD, Dreger P, Krämer A. Pretransplant NPM1 MRD levels predict outcome after allogeneic hematopoietic stem cell transplantation in patients with acute myeloid leukemia. Blood Cancer J 2016; 6:e449. [PMID: 27471865 PMCID: PMC5030374 DOI: 10.1038/bcj.2016.46] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Accepted: 05/19/2016] [Indexed: 12/19/2022] Open
Abstract
The objective was to evaluate the prognostic impact of pre-transplant minimal residual disease (MRD) as determined by real-time quantitative polymerase chain reaction in 67 adult NPM1-mutated acute myeloid leukemia patients receiving allogeneic hematopoietic stem cell transplantation (HSCT). Twenty-eight of the 67 patients had a FLT3-ITD (42%). Median age at transplantation was 54.7 years, median follow-up for survival from time of allografting was 4.9 years. At transplantation, 31 patients were in first, 20 in second complete remission (CR) and 16 had refractory disease (RD). Pre-transplant NPM1 MRD levels were measured in 39 CR patients. Overall survival (OS) for patients transplanted in CR was significantly longer as compared to patients with RD (P=0.004), irrespective of whether the patients were transplanted in first or second CR (P=0.74). There was a highly significant difference in OS after allogeneic HSCT between pre-transplant MRD-positive and MRD-negative patients (estimated 5-year OS rates of 40 vs 89% P=0.007). Multivariable analyses on time to relapse and OS revealed pre-transplant NPM1 MRD levels >1% as an independent prognostic factor for poor survival after allogeneic HSCT, whereas FLT3-ITD had no impact. Notably, outcome of patients with pre-transplant NPM1 MRD positivity >1% was as poor as that of patients transplanted with RD.
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Affiliation(s)
- S Kayser
- Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany.,Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ) and Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| | - A Benner
- Division of Biostatistics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - C Thiede
- Department of Medicine I, University Hospital Carl-Gustav-Carus, Dresden, Germany
| | - U Martens
- Cancer Center Heilbronn-Franken, Heilbronn, Germany
| | - J Huber
- Cancer Center Heilbronn-Franken, Heilbronn, Germany
| | - P Stadtherr
- Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| | - J W G Janssen
- Institute of Human Genetics, University of Heidelberg, Heidelberg, Germany
| | - C Röllig
- Department of Medicine I, University Hospital Carl-Gustav-Carus, Dresden, Germany
| | - M J Uppenkamp
- Department of Oncology, Hospital of Ludwigshafen, Ludwigshafen, Germany
| | - T Bochtler
- Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany.,Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ) and Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| | - U Hegenbart
- Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| | - G Ehninger
- Department of Medicine I, University Hospital Carl-Gustav-Carus, Dresden, Germany
| | - A D Ho
- Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| | - P Dreger
- Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| | - A Krämer
- Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany.,Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ) and Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
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23
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Does quality of life impact the decision to pursue stem cell transplantation for elderly patients with advanced MDS? Bone Marrow Transplant 2016; 51:1121-6. [DOI: 10.1038/bmt.2016.40] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 01/19/2016] [Accepted: 02/02/2016] [Indexed: 12/20/2022]
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24
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Allogeneic stem cell transplantation after conditioning with treosulfan, etoposide and cyclophosphamide for patients with ALL: a phase II-study on behalf of the German Cooperative Transplant Study Group and ALL Study Group (GMALL). Bone Marrow Transplant 2015; 50:1503-7. [PMID: 26367236 DOI: 10.1038/bmt.2015.202] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 06/26/2015] [Accepted: 07/02/2015] [Indexed: 01/27/2023]
Abstract
TBI-based preparative regimens are considered as standard conditioning therapy for allogeneic stem cell transplantation (AHSC) in patients with ALL. We investigated toxicity and efficacy of a non-TBI-based regimen consisting of treosulfan, etoposide and cyclophosphamide for ALL within a prospective study. Major inclusion criteria were CR and non-eligibility for TBI. Fifty patients with a median age of 46.5 years (range, 18-64) were included. Donors were HLA-identical sibling (n=8), matched (n=42) or mismatched (n=10) unrelated. The toxicity was moderate, resulting in a cumulative incidence of non-relapse mortality (NRM) at 1 year of 8% (90% confidence interval: 2-15%). Acute GvHD grade II-IV and grade III/IV was noted in 53% and 14%, respectively. Chronic GvHD at one year was seen in 41%. After a median follow-up of 24 months the cumulative incidence of relapse was 36% (90% confidence interval: 24-48) and 51% (90% confidence interval: 37-65) at 1 and 2 years, respectively. The estimated 2-year disease-free and overall survivals were 36 and 48%, respectively. Treosulfan, etoposide and cyclophosphamide followed by AHSC has a favorable toxicity profile with low NRM and therefore represents a potential alternative regimen for ALL in 1. CR (NCT00682305).
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25
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Oran B. Which Patients Should Undergo Allogeneic Stem Cell Transplantation for Myelodysplastic Syndromes, and When Should We Do It? CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2015; 15 Suppl:S43-9. [DOI: 10.1016/j.clml.2015.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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26
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Romański M, Teżyk A, Zaba C, Główka FK. Rapid and sensitive liquid chromatography-tandem mass spectrometry method for determination of protein-free pro-drug treosulfan and its biologically active monoepoxy-transformer in plasma and brain tissue. Talanta 2014; 127:123-32. [PMID: 24913866 DOI: 10.1016/j.talanta.2014.03.067] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2013] [Revised: 03/26/2014] [Accepted: 03/28/2014] [Indexed: 11/29/2022]
Abstract
For the first time a high performance liquid chromatography method with tandem mass spectrometry detection (HPLC-MS/MS) was developed for simultaneous determination of a pro-drug treosulfan (TREO) and its active monoepoxide (S,S-EBDM) in biological matrices. Small volumes of rat plasma (50 μL) and the brain homogenate supernatant (100 μL), equivalent to 0.02 g of brain tissue, were required for the analysis. Protein-free TREO, S,S-EBDM and acetaminophen, internal standard (IS), were isolated from the samples by ultrafiltration. Complete resolution of the analytes and the IS was accomplished on Zorbax Eclipse column using an isocratic elution with a mobile phase composed of ammonium formate - formic acid buffer pH 4.0 and acetonitrile. Detection was performed on a triple-quadrupole MS via multiple-reaction-monitoring following electrospray ionization. The developed method was fully validated according to the current guidelines of the European Medicines Agency. Calibration curves were linear in ranges: TREO 0.2-5720 μM and S,S-EBDM 0.9-175 μM for plasma, and TREO 0.2-29 μM and S,S-EBDM 0.4-44 μM for the brain homogenate supernatant. The limits of quantitation of TREO and S,S-EBDM in the studied matrices were much lower in comparison to the previously used bioanalytical methods. The HPLC-MS/MS method was adequately precise (coefficient of variation≤12.2%), accurate (relative error≤8.6%), and provided no carry-over, acceptable matrix effect as well as dilution integrity. The analytes were stable in acidified plasma and the brain homogenate supernatant samples for 4 h at room temperature, for 4 months at-80°C as well as within two cycles of freezing and thawing, and demonstrated 18-24h autosampler stability. The validated method enabled determination of low concentrations of TREO and S,S-EBDM in incurred brain samples of the rats treated with TREO, which constitutes a novel bioanalytical application.
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Affiliation(s)
- Michał Romański
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, 6 Święcickiego Street, 60-781 Poznań, Poland
| | - Artur Teżyk
- Department of Forensic Medicine, Poznan University of Medical Sciences, 6 Święcickiego Street, 60-781 Poznań, Poland
| | - Czesław Zaba
- Department of Forensic Medicine, Poznan University of Medical Sciences, 6 Święcickiego Street, 60-781 Poznań, Poland
| | - Franciszek K Główka
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, 6 Święcickiego Street, 60-781 Poznań, Poland.
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27
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Abstract
Acute myeloid leukemia carries a dismal prognosis in patients over 60 years of age and, despite many clinical trials of both novel and conventional agents, there has been no significant improvement in overall survival during the last 30 years. Combinations of anthracyclines and cytarabine remain the cornerstone of therapy and produce complete remission in 45-55% of older patients, with a median survival of only 8-12 months. These statistics become even worse in patients over 70 years and those with unfavorable cytogenetics and/or poor performance status. Deciding which older acute myeloid leukemia patients would benefit from intensive chemotherapy is difficult and efforts are underway to improve existing risk-assessment tools. Many new agents are under development, including signal transduction inhibitors, farnesyl transferase inhibitors, antibodies and novel chemotherapeutics. To date, small-molecule inhibitors and targeted therapies have had limited single-agent efficacy and have required combination with chemotherapy. The role of hematopoietic stem cell transplantation in older patients is under investigation. All patients over 60 years of age with acute myeloid leukemia should be encouraged to participate in a clinical trial if possible.
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Affiliation(s)
- Gail J Roboz
- Weill Medical College of Cornell University and The New York Presbyterian Hospital, 520 East 70th Street, Starr 340A, New York, NY 10021, USA.
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28
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Risk-adapted, treosulfan-based therapy with auto- and allo-SCT for relapsed/refractory aggressive NHL: a prospective phase-II trial. Bone Marrow Transplant 2013; 49:410-5. [PMID: 24362366 DOI: 10.1038/bmt.2013.199] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2013] [Revised: 10/16/2013] [Accepted: 10/25/2013] [Indexed: 11/09/2022]
Abstract
Since the outcome of relapsed/refractory aggressive non-Hodgkin's lymphoma (NHL) is highly variable, a risk-adapted treatment approach was evaluated. After two cycles of DHAP, patients received high-dose treosulfan/etoposide/carboplatinum (TEC) and autologous stem cell rescue. After TEC, low-risk patients with late relapse (>1 year after first CR who achieved CR after DHAP received no further treatment. Patients with late relapse who achieved CR or PR only after TEC underwent a second cycle of TEC. High-risk patients with early relapse/refractory disease received treosulfan/fludarabine followed by allogeneic transplantation. Rituximab was added in patients with B-cell lymphoma (86%). At entry, 36% of all 57 patients had refractory disease, 32% early and 32% late relapse. During DHAP treatment, progression occurred in 32% of patients. Of 33 patients who received TEC, 5 received second TEC and 15 allogeneic transplantation. Main toxicity after TEC was oral mucositis (CTC grades 3 and 4 in 50% and 13%, respectively). In total, 42% patients achieved CR. Median OS was 21.4 months for all patients and 32.6 for those who underwent allogeneic transplantation. International prognostic index (IPI) at study entry was highly discriminative at predicting OS (P<0.0001). Risk-adapted, treosulfan-based therapy with auto- and allo-SCT is feasible. Long-term survival is possible with allogeneic transplantation.
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29
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Brand R, Putter H, van Biezen A, Niederwieser D, Martino R, Mufti G, Onida F, Symeonidis A, Schmid C, Garderet L, Robin M, van Gelder M, Finke J, Bornhäuser M, Kobbe G, Germing U, de Witte T, Kröger N. Comparison of allogeneic stem cell transplantation and non-transplant approaches in elderly patients with advanced myelodysplastic syndrome: optimal statistical approaches and a critical appraisal of clinical results using non-randomized data. PLoS One 2013; 8:e74368. [PMID: 24116002 PMCID: PMC3792099 DOI: 10.1371/journal.pone.0074368] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Accepted: 08/06/2013] [Indexed: 11/18/2022] Open
Abstract
Allogeneic stem cell transplantation (ASCT) from related or unrelated donors may cure patients with myelodysplastic syndromes (MDS), a heterogeneous group of clonal stem cell disorders. We analysed 384 elderly patients (55-69 years) with advanced MDS who received either ASCT (n=247) and were reported to The European Group for Blood and Marrow Transplantation (EBMT) or a non –transplant approach (n=137) reported to the Düsseldorf registry. Besides an attempt to answer the question of „comparison“, the purpose of this work is to explain the difficulties in comparing a non-transplant with a transplant cohort, when death before transplant is likely but unknown and the selection of patients for transplant is based on assumptions. It shows which methods are almost always biased and that even the most sophisticated approaches crucially rely on clinical assumptions. Using the most appropriate model for our data, we derive an overall univariate non-significant survival disadvantage for the transplant cohort (HR: 1.29, p = 0.11). We show that such an “average” hazard ratio is however misleading due to non-proportionality of the hazards reflecting early treatment related mortality, the occurring of which is logically correlated with the interval between diagnosis and transplant creating a disproportional drop in the (reconstructed) survival curve of the transplanted patients. Also in multivariate analysis (correcting for age > 60 (HR: 1.4, p = 0.02) and abnormal cytogenetics (HR: 1.46, p = 0.01)), transplantation seems to be worse (HR: 1.39, p = 0.05) but only in the (incorrect but commonly applied) model without time varying covariates. The long term (time depending) hazard ratio is shown to be virtually 1 and overall survival is virtually identical in both groups. Nonetheless no conclusion can be reached from a clinical point of view without assumptions which are by their very nature untestable unless all patients would be followed from diagnosis.
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Affiliation(s)
- Ronald Brand
- Department of Statistics, University Medical Center, Leiden, The Netherlands
| | - Hein Putter
- Department of Statistics, University Medical Center, Leiden, The Netherlands
| | - Anja van Biezen
- Department of Statistics, University Medical Center, Leiden, The Netherlands
| | | | | | | | - Francesco Onida
- Fondazione IRCCS Ospedale Maggiore, University Medical Center, Milan, Italy
| | | | | | | | - Marie Robin
- Department of BMT, Hopital St Louis, Paris, France
| | - Michel van Gelder
- Department of Hematology, University Maastricht, Maastricht, The Netherlands
| | - Jürgen Finke
- Department of Hematology/Oncology, University Medical Center, Freiburg, Germany
| | - Martin Bornhäuser
- Department of Hematology/Oncology, University Mediacal Center, Dresden, Germany
| | - Guido Kobbe
- Department of Hematology and Oncology, University Hospital, Düsseldorf, Germany
| | - Ulrich Germing
- Department of Hematology and Oncology, University Hospital, Düsseldorf, Germany
| | - Theo de Witte
- Nijmegen Center for Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nicolaus Kröger
- Department for Stem Cell Transplantation, University Medical Center, Hamburg, Germany
- * E-mail:
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30
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Oran B, Popat U, Andersson B, Champlin R. Allogeneic hematopoietic stem cell transplantation for myelodysplastic syndromes. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2013; 13 Suppl 2:S282-8. [PMID: 24290213 DOI: 10.1016/j.clml.2013.07.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 07/29/2013] [Accepted: 07/29/2013] [Indexed: 02/03/2023]
Abstract
Allogeneic stem cell transplantation (SCT) is the only treatment with curative potential for myelodysplastic syndrome (MDS). The availability of SCT has been expanded with the introduction of reduced intensity conditioning for older patients and the use of alternative donors. Treatment-related mortality and relapse have remained major barriers to uniform success and there is a significant need for innovative approaches to improve these outcomes. Encouraging results have been reported for patients who lack a human leukocyte antigen-identical donor with the use of cord blood and haploidentical donors. Improved approaches for patient selection and optimization of the timing of SCT are needed. New prognostic classification schemas identify risk groups for disease outcomes and facilitate decisions with regard to SCT. Patients with intermediate-2 and high-risk disease and those with therapy-related MDS have a poor prognosis with alternative therapies; improved results have been reported with hematopoietic transplantation. The optimum timing for SCT is controversial in the era of hypomethylating agents. Initial conservative management is indicated for patients with low-risk disease. Hematopoietic transplantation remains the only curative treatment for patients with MDS and should be used before patients overtly progress to advanced disease. Failure to respond to hypomethylating agents does not adversely affect the outcome of SCT; these patients might achieve durable remissions with hematopoietic transplantation. Refined prognostic markers are needed to identify poor prognosis patients to guide patient selection for SCT, and novel transplantation approaches are required to reduce the risk of disease relapse and complications of the procedure.
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Affiliation(s)
- Betul Oran
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas, M.D. Anderson Cancer Center, Houston, TX
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31
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Abstract
Abstract
Allogeneic hematopoietic stem cell transplantation (SCT) is well accepted as a curative treatment approach for younger patients with myelodysplastic syndrome (MDS) and has become one of the most frequent indications for allogeneic SCT as reported to the Center for International Blood and Marrow Transplant Research. However, MDS patients are usually elderly with a median age of approximately 75 years at diagnosis. Large register studies have confirmed the feasibility of the procedure in elderly MDS patients; and in the register of the European Group for Blood and Marrow Transplantation, one-third of the allogeneic transplant procedures for MDS were performed in 2010 in patients older than 60 years. Despite its curative potential, its role in the treatment of elderly MDS patients is less defined. Because of the inherent complications of the transplantation leading to treatment-related mortality and the risk of relapse, a careful calculation of the benefit for each patient is mandatory, taking into account comorbidities, disease status, donor selection, and effective nontransplant therapies. Prospective multicenter studies are needed to define optimal intensity of the conditioning regimen, timing of transplantation within a treatment algorithm, including drug-based therapies, and posttransplant strategies to reduce the risk of relapse.
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32
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Sockel K, Ehninger G, Hofbauer LC, Platzbecker U. Optimizing management of myelodysplastic syndromes post-allogeneic transplantation. Expert Rev Hematol 2012; 4:669-80. [PMID: 22077530 DOI: 10.1586/ehm.11.58] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Allogeneic hematopoietic stem cell transplantation is still the only potentially curative treatment for patients with myelodysplastic syndromes. Improvements in donor selection, supportive care and the introduction of reduced-intensity conditioning have led to a decrease in early transplant mortality. However, relapse rates have not changed significantly in recent years. Furthermore, treatment options for patients relapsing after hematopoietic stem cell transplantation are limited and often short-lived. Thus, optimizing the post-transplant outcome by maintenance approaches or minimal residual disease-directed preemptive therapy is an important goal of current clinical research. Further strategies aiming at an improved prevention of graft-versus-host disease are currently under investigation.
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Affiliation(s)
- Katja Sockel
- Medizinische Klinik und Poliklinik I, Universitätsklinikum 'Carl Gustav Carus' Dresden, 01307 Dresden, Germany
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Michallet M, Sobh M, Milpied N, Bay JO, Fürst S, Harousseau JL, Mohty M, Nicolini FE, Labussière H, Tedone N, Morisset S, Vigouroux S, Baumgart J, Tabrizi R, Blaise D. Phase II prospective study of treosulfan-based reduced-intensity conditioning in allogeneic HSCT for hematological malignancies from 10/10 HLA-identical unrelated donor. Ann Hematol 2012; 91:1289-97. [PMID: 22362122 DOI: 10.1007/s00277-012-1429-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Accepted: 02/07/2012] [Indexed: 10/28/2022]
Abstract
Different RIC regimens were evaluated prior to allo-HSCT in different hematological malignancies. We conducted this prospective study in adult patients with various hematological malignancies in order to evaluate the toxicity and efficacy of treosulfan-based conditioning, followed by allo-HSCT from 10/10 HLA-identical unrelated donors. Conditioning included treosulfan 12 g/m(2)/day i.v. (day -6 to day -4), fludarabine 30 mg/m(2)/day i.v. (day -6 to day -2), and ATG 2.5 mg/kg/day (day -2 to day -1). PBSC were used as HSC source. We included 56 patients (29 AML, 9 MM, 8 MDS, 6 CLL, 3 ALL, and 1 CML) with a median age of 57 years (18-65.5). Fifty-four (96%) patients engrafted; the cumulative incidence of aGVHD grade ≥II at 3 months reached 31%. The cumulative incidence of cGVHD at 18 months was 34% limited and 8% extensive. The median overall survival (OS) was not reached with a 3-year probability of 52%. The cumulative incidence of relapse at 3 years was 25%, and the cumulative incidence of transplant-related mortality (TRM) at 12 and 24 months was 20% and 23%, respectively. Treosulfan appears to be a good alternative for conditioning of MUD transplant patients with promising results in terms of OS, relapse, and TRM.
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Affiliation(s)
- Mauricette Michallet
- Hematology, Blood and Marrow Transplant Unit, Centre Hospitalier Lyon Sud, CHU et Université de Lyon, Lyon, France.
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34
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Shimoni A, Shem-Tov N, Volchek Y, Danylesko I, Yerushalmi R, Nagler A. Allo-SCT for AML and MDS with treosulfan compared with BU-based regimens: reduced toxicity vs reduced intensity. Bone Marrow Transplant 2012; 47:1274-82. [DOI: 10.1038/bmt.2012.4] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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35
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Casper J, Holowiecki J, Trenschel R, Wandt H, Schaefer-Eckart K, Ruutu T, Volin L, Einsele H, Stuhler G, Uharek L, Blau I, Bornhaeuser M, Zander AR, Larsson K, Markiewicz M, Giebel S, Kruzel T, Mylius HA, Baumgart J, Pichlmeier U, Freund M, Beelen DW. Allogeneic hematopoietic SCT in patients with AML following treosulfan/fludarabine conditioning. Bone Marrow Transplant 2011; 47:1171-7. [PMID: 22158386 DOI: 10.1038/bmt.2011.242] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
An alternative reduced-toxicity conditioning regimen for allogeneic transplantation, based on treosulfan and fludarabine, has recently been identified. The safety and efficacy of this new conditioning regimen has been investigated prospectively in patients with AML. A total number of 75 patients with AML in CR were treated with 3 × 14 g/m(2) treosulfan and 5 × 30 mg/m(2) fludarabine, followed by matched sibling or unrelated SCT. Patients were evaluated for engraftment, adverse events, GVHD, and for non-relapse mortality, relapse incidence, overall and disease-free survival (DFS). All patients showed primary engraftment of neutrophils after a median of 20 days. Non-hematological adverse events grade III-IV in severity included mainly infections (59%) and gastrointestinal symptoms (7%). Acute GVHD grade II-IV occurred in 21% and extensive chronic GVHD occurred in 16% of the patients. After a median follow-up of 715 days, the 2-year overall and DFS estimates were 61% and 55%, respectively. The 2-year incidences of relapse and non-relapse mortality reached 34% and 11%, respectively. In summary, our data confirm promising safety and efficacy of the treosulfan-based conditioning therapy in AML patients, ClinicalTrials.gov Identifier: NCT01063660.
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Affiliation(s)
- J Casper
- Division of Hematology and Oncology, University of Rostock, Rostock, Germany.
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Zinke-Cerwenka W, Valentin A, Posch U, Beham-Schmid C, Groselj-Strele A, Linkesch W, Wölfler A, Sill H. Reduced-intensity allografting in patients with therapy-related myeloid neoplasms and active primary malignancies. Bone Marrow Transplant 2011; 46:1540-4. [PMID: 21860429 DOI: 10.1038/bmt.2011.165] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Therapy-related myeloid neoplasms (t-MNs) are severe long-term consequences of cytotoxic treatments for a primary, often, malignant disorder. So far, the majority of patients eligible for transplantation have undergone myeloablative allo haematopoietic SCT (HSCT) as a potentially curative treatment, but it has been associated with high transplantation-related mortality (TRM) rates. In this retrospective study, we analysed the outcome of patients with t-MNs undergoing HSCT with reduced-intensity conditioning (RIC). Of 55 patients, seen at a single centre over a 10-year period, 17 underwent RIC HSCT with related or unrelated donors. The estimated overall survival was 53% at 1 year and 47% at 3 years, and disease-free survival was 47% at 1 year. At 1 year, the cumulative incidence of relapse and TRM were 24% and 30%, respectively. Of five patients with active primary neoplasms who underwent transplantation, two are alive beyond 1 year and show CR of both t-MNs and the primary malignancy. These data indicate that RIC HSCT is an encouraging approach for patients with t-MNs. The issue of primary malignancies not being in remission at the time of transplantation should be explored in further studies.
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Affiliation(s)
- W Zinke-Cerwenka
- Division of Haematology, Medical University of Graz, Graz, Austria
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37
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Abstract
Most of patients with hematological malignancies are elderly (more than 60 years). Allogeneic stem cell transplantation is an important and effective treatment for most of these diseases. However, the toxicity and the supposed frailty of elderly patients, have limited the applicability of allogeneic transplantation for these patients. Elderly patients are at high risk to develop life-threatening complications, if allogeneic transplantation is performed with myeloablative conditioning regimens and using bone marrow stem source. Since more than 10 years, reduced intensity conditioning regimen have been developed, allowing to overcome the age as contra-indication for allogeneic transplantation. On the other hand, it is the presence of comorbidities which identify frail patients. For these subjects, allogeneic transplantation should be not indicated. Furthermore, advances in the supportive care and the development of new molecules could allow to reduce the toxicity of myeloablative conditioning regimens and thus to offer more intensive regimens before transplantation also in elderly population.
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38
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Ruutu T, Volin L, Beelen DW, Trenschel R, Finke J, Schnitzler M, Holowiecki J, Giebel S, Markiewicz M, Uharek L, Blau IW, Kienast J, Stelljes M, Larsson K, Zander AR, Gramatzki M, Repp R, Einsele H, Stuhler G, Baumgart J, Mylius HA, Pichlmeier U, Freund M, Casper J. Reduced-toxicity conditioning with treosulfan and fludarabine in allogeneic hematopoietic stem cell transplantation for myelodysplastic syndromes: final results of an international prospective phase II trial. Haematologica 2011; 96:1344-50. [PMID: 21659356 DOI: 10.3324/haematol.2011.043810] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND An alternative reduced-toxicity conditioning regimen for allogeneic transplantation, based on treosulfan and fludarabine, has recently been identified. The rationale for this study was to investigate the efficacy and safety of this regimen prospectively in patients with a primary myelodysplastic syndrome. DESIGN AND METHODS A total of 45 patients with primary myelodysplastic syndromes were conditioned with 3×14 g/m(2) treosulfan and 5×30 mg/m(2) fludarabine followed by allogeneic hematopoietic stem cell transplantation. Subtypes of myelodysplastic syndromes were refractory anemia with excess blasts-2 (44%), refractory cytopenia with multilineage dysplasia (27%), refractory anemia (9%), refractory anemia with ringed sideroblasts (4%), refractory cytopenia with multilineage dysplasia and ringed sideroblasts (4%), refractory anemia with excess blasts-1 (2%), and myelodysplastic syndrome with isolated del (5q) (2%). The myelodysplastic syndrome was unclassified in 7% of the patients. Forty-seven percent of the patients had a favorable karyotype, 29% an unfavorable one, and 18% an intermediate karyotype. Patients were evaluated for engraftment, adverse events, graft-versus-host disease, non-relapse mortality, relapse incidence, overall survival and disease-free survival. RESULTS All but one patient showed primary engraftment of neutrophils after a median of 17 days. Non-hematologic adverse events of grade III-IV in severity included mainly infections and gastrointestinal symptoms (80% and 22% of the patients, respectively). Acute graft-versus-host disease grade II-IV developed in 24%, and extensive chronic graft-versus-host disease in 28% of the patients. After a median follow-up of 780 days, the 2-year overall and disease-free survival estimates were 71% and 67%, respectively. The 2-year cumulative incidences of non-relapse mortality and relapse were 17% and 16%, respectively. CONCLUSIONS Our safety and efficacy data suggest that treosulfan-based conditioning therapy is a promising treatment option for patients with myelodysplastic syndromes. clinicaltrials.gov identifier: NCT01062490.
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Affiliation(s)
- Tapani Ruutu
- Department of Medicine, Helsinki University Central Hospital, Helsinki, Finland.
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39
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Chemnitz JM, von Lilienfeld-Toal M, Holtick U, Theurich S, Shimabukuro-Vornhagen A, Krause A, Brossart P, Hallek M, Scheid C. Intermediate intensity conditioning regimen containing FLAMSA, treosulfan, cyclophosphamide, and ATG for allogeneic stem cell transplantation in elderly patients with relapsed or high-risk acute myeloid leukemia. Ann Hematol 2011; 91:47-55. [PMID: 21584670 DOI: 10.1007/s00277-011-1253-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2010] [Accepted: 05/03/2011] [Indexed: 10/18/2022]
Abstract
Lower dosage of total body irradiation (TBI) and chemotherapy in reduced-intensity conditioning (RIC) regimens prior to allogeneic stem cell transplantation have reduced the toxicity of the conditioning and non-relapse mortality. The FLAMSA-RIC protocol for high-risk patients with acute myeloid leukemia (AML) and myelodysplastic syndrome has shown promising results in refractory disease as well as in first complete remission. Still, the RIC protocol containing 4 Gy TBI/cyclophosphamide/anti-thymocyte globulin (ATG) implicates acute toxicity mainly due to TBI preventing its usage in patients with advanced age and/or severe co-morbidities. To increase feasibility and safety of the conditioning, we substituted TBI with treosulfan. Seventeen patients with relapsed or high-risk AML and either advanced age or concomitant disease were treated within a preparative regimen containing a 4-day course of chemotherapy (FLAMSA) followed by RIC comprising of treosulfan, cyclophosphamide, and ATG. After median follow-up of 12 months, the estimated incidences of relapse and non-relapse mortality were 25% and 20%, respectively. One-year overall survival was 62%. In conclusion, FLAMSA-treosulfan/cyclophosphamide/ATG is an intermediate intensity conditioning regimen with acceptable non-relapse mortality for patients with relapsed or high-risk AML. Substituting TBI with treosulfan provides an alternative to treat elderly patients or patients with severe co-morbidities when TBI appears not feasible due to the potential of increased toxicity.
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Affiliation(s)
- Jens Marcus Chemnitz
- BMT Program, Department I of Internal Medicine, University of Cologne, Kerpener Straße 62, 50924 Köln, Germany.
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40
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Danylesko I, Shimoni A, Nagler A. Treosulfan-based conditioning before hematopoietic SCT: more than a BU look-alike. Bone Marrow Transplant 2011; 47:5-14. [DOI: 10.1038/bmt.2011.88] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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41
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Treosulfan-based preparative regimens for allo-HSCT in childhood hematological malignancies: a retrospective study on behalf of the EBMT pediatric diseases working party. Bone Marrow Transplant 2011; 46:1510-8. [DOI: 10.1038/bmt.2010.343] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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42
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Vigouroux S, Tabrizi R, Melot C, Coiffard J, Lafarge X, Marit G, Bouabdallah K, Pigneux A, Leguay T, Dilhuydy MS, Schmitt A, Boiron JM, Milpied N. Methotrexate Reduces the Incidence of Severe Acute Graft-versus-Host Disease without Increasing the Risk of Relapse after Reduced-Intensity Allogeneic Stem Cell Transplantation from Unrelated Donors. Biol Blood Marrow Transplant 2011; 17:93-100. [DOI: 10.1016/j.bbmt.2010.06.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2010] [Accepted: 06/14/2010] [Indexed: 10/19/2022]
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43
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Santini V, Alessandrino PE, Angelucci E, Barosi G, Billio A, Di Maio M, Finelli C, Locatelli F, Marchetti M, Morra E, Musto P, Visani G, Tura S. Clinical management of myelodysplastic syndromes: update of SIE, SIES, GITMO practice guidelines. Leuk Res 2010; 34:1576-88. [PMID: 20149927 DOI: 10.1016/j.leukres.2010.01.018] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2010] [Revised: 01/11/2010] [Accepted: 01/17/2010] [Indexed: 12/13/2022]
Affiliation(s)
- V Santini
- Functional Unit of Haematology, AOU Careggi, University of Florence, Firenze, Italy.
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44
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Główka FK, Romański M, Wachowiak J. High-dose treosulfan in conditioning prior to hematopoietic stem cell transplantation. Expert Opin Investig Drugs 2010; 19:1275-95. [DOI: 10.1517/13543784.2010.517744] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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45
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Hilgendorf I, Wolff D, Gromke T, Trenschel R, Elmaagacli AH, Pichlmeier U, Junghanss C, Freund M, Beelen DW, Casper J. Retrospective analysis of treosulfan-based conditioning in comparison with standard conditioning in patients with myelodysplastic syndrome. Bone Marrow Transplant 2010; 46:502-9. [DOI: 10.1038/bmt.2010.153] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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46
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Nemecek ER, Guthrie KA, Sorror ML, Wood BL, Doney KC, Hilger RA, Scott BL, Kovacsovics TJ, Maziarz RT, Woolfrey AE, Bedalov A, Sanders JE, Pagel JM, Sickle EJ, Witherspoon R, Flowers ME, Appelbaum FR, Deeg HJ. Conditioning with treosulfan and fludarabine followed by allogeneic hematopoietic cell transplantation for high-risk hematologic malignancies. Biol Blood Marrow Transplant 2010; 17:341-50. [PMID: 20685259 DOI: 10.1016/j.bbmt.2010.05.007] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2010] [Accepted: 05/14/2010] [Indexed: 12/14/2022]
Abstract
In this prospective study 60 patients of median age 46 (range: 5-60 years), with acute myelogenous leukemia (AML; n = 44), acute lymphoblastic leukemia (ALL; n = 3), or myelodysplastic syndrome (MDS; n = 13) were conditioned for allogeneic hematopoietic cell transplantation with a treosulfan/fludarabine (Flu) combination. Most patients were considered at high risk for relapse or nonrelapse mortality (NRM). Patients received intravenous treosulfan, 12 g/m(2)/day (n = 5) or 14 g/m(2)/day (n = 55) on days -6 to -4, and Flu (30 mg/m(2)/day) on days -6 to -2, followed by infusion of marrow (n = 7) or peripheral blood stem cells (n = 53) from HLA-identical siblings (n = 30) or unrelated donors (n = 30). All patients engrafted. NRM was 5% at day 100, and 8% at 2 years. With a median follow-up of 22 months, the 2-year relapse-free survival (RFS) for all patients was 58% and 88% for patients without high-risk cytogenetics. The 2-year cumulative incidence of relapse was 33% (15% for patients with MDS, 34% for AML in first remission, 50% for AML or ALL beyond first remission and 63% for AML in refractory relapse). Thus, a treosulfan/Flu regimen was well tolerated and yielded encouraging survival and disease control with minimal NRM. Further trials are warranted to compare treosulfan/Flu to other widely used regimens, and to study the impact of using this regimen in more narrowly defined groups of patients.
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Affiliation(s)
- Eneida R Nemecek
- Oregon Health and Science University, Portland, Oregon 97239, USA.
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47
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Casper J, Wolff D, Knauf W, Blau IW, Ruutu T, Volin L, Wandt H, Schäfer-Eckart K, Holowiecki J, Giebel S, Aschan J, Zander AR, Kröger N, Hilgendorf I, Baumgart J, Mylius HA, Pichlmeier U, Freund M. Allogeneic hematopoietic stem-cell transplantation in patients with hematologic malignancies after dose-escalated treosulfan/fludarabine conditioning. J Clin Oncol 2010; 28:3344-51. [PMID: 20498405 DOI: 10.1200/jco.2009.23.3429] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Treosulfan was introduced recently as a conditioning agent for allogeneic blood stem-cell transplantation. The favorable nonhematologic toxicity profile at 3 x 10 g/m(2) was the basis for dose escalation in this prospective, multicenter trial. PATIENTS AND METHODS Fifty-six patients with various hematologic malignancies who were not eligible for standard conditioning were treated with one of three doses: 10 g/m(2), 12 g/m(2), or 14 g/m(2) of intravenous treosulfan, which was administered on days -6 to -4 combined with fludarabine 30 mg/m(2) on days -6 to -2. Patients in complete remission (CR; 42%) or non-CR (58%) received grafts from matched related (47%) or matched unrelated (51%) donors; one patient had a mismatched related donor (2%). RESULTS No engraftment failure occurred. Overall, extramedullary toxicity and the nonrelapse mortality rate at 2 years (20%) were low and did not increase with dose. Cumulative incidence of relapse/progression reached 31%. The overall survival and progression-free survival rates were 64% and 49%, respectively, in the total study population. An inverse dose dependency of relapse incidence was indicated in the subgroup receiving transplantations from matched related donors (P = .0568). CONCLUSION Treosulfan-based conditioning was feasible at all three doses. The 3 x 14 g/m(2) dose was selected for additional studies, because it combines desired characteristics of low toxicity and a low relapse rate.
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48
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KANAMORI H, ENAKA M, ITO S, MOTOHASHI K, HAGIHARA M, OSHIMA R, SAKAI R, FUJISAWA S, TANAKA M, FUJIMAKI K, FUJITA H, ISHIGATSUBO Y, MARUTA A. Myeloablative hematopoietic stem cell transplantation for myelodysplastic syndrome in patients younger than 55 years: impact of comorbidity and disease burden on the long-term outcome. Int J Lab Hematol 2010; 32:222-9. [DOI: 10.1111/j.1751-553x.2009.01175.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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49
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Ramakrishnan A, Sandmaier BM. Optimizing reduced-intensity conditioning regimens for myeloproliferative neoplasms. Expert Rev Hematol 2010; 3:23-33. [PMID: 20383269 PMCID: PMC2850074 DOI: 10.1586/ehm.09.73] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The myeloproliferative neoplasms (MPNs) are a group of clonal disorders that arise from a pluripotent hematopoietic stem cell and are characterized by excess cellular proliferation. These disorders tend to be chronic in nature and can terminate over time into a bone marrow failure syndrome characterized by marrow fibrosis or transform into a leukemic phase. MPNs are predominantly diseases of the elderly and this is one reason why until very recently the standard treatment was supportive care. The only curative modality for these disorders is allogeneic hematopoietic cell transplantation. The introduction of reduced-intensity conditioning regimens now allows this life-saving therapy to be offered to elderly patients who were previously considered ineligible for high-dose conditioning owing to age or comorbidity. In this review, we will summarize the current strategies and future directions regarding the use of reduced-intensity conditioning regimens in the treatment of MPNs.
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Affiliation(s)
- Aravind Ramakrishnan
- Associate in Clinical Research, Fred Hutchinson Cancer Research Center, Acting Instructor, University of Washington School of Medicine, 1100 Fairview Avenue N, D1-100, PO Box 19024, Seattle, WA 98109-1024, USA, Tel.: +1 206 667 2908, Fax: +1 206 667 6124,
| | - Brenda M Sandmaier
- Member, Clinical Research Division, Fred Hutchinson Cancer Research Center, Professor, University of Washington School of Medicine, 1100 Fairview Avenue N, D1-100, PO Box 19024, Seattle, WA 98109-1024, USA, Tel.: +1 206 667 4961, Fax: +1 206 667 6124
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50
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Giralt S. Advances in stem cell transplantation: making it better and safer. ACTA ACUST UNITED AC 2010; 9 Suppl 3:S293-5. [PMID: 19778855 DOI: 10.3816/clm.2009.s.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The development of reduced-intensity regimens has allowed physicians and patients to explore this option even in older patients. Current results underscore that age by itself should no longer be a contraindication for allogeneic transplantation in these patients, and long-term disease control with good quality of life is possible. Future trials combining novel antileukemic therapies and novel transplantation technologies are being explored. These trials should allow more patients with acute myeloid leukemia or myelodysplastic syndromes to achieve long and productive lives.
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Affiliation(s)
- Sergio Giralt
- Department of Stem Cell Transplantation, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA.
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