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Cao J, Pei R, Lu Y, Zheng Z, Yuan Z, Li D, Zhang P, Liu X, Chen D, Du X, Chen L, Li S, Ye P, Wang T. Fludarabine and antithymocyte globulin-based conditioning regimen combined with post-transplantation cyclophosphamide for haploidentical allogeneic hematopoietic stem cell transplantation in patients with high-risk acute myeloid leukemia and myelodysplastic syndrome. Curr Res Transl Med 2023; 71:103360. [PMID: 36427418 DOI: 10.1016/j.retram.2022.103360] [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: 04/15/2022] [Revised: 07/10/2022] [Accepted: 07/22/2022] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Relapse and graft-versus-host disease (GVHD) are the important complications influencing mortality for patients with high-risk acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS) after allogeneic hematopoietic stem cell transplantation (allo-HSCT). GVHD prophylaxis based on post-transplant cyclophosphamide (PTCy) or antithymocyte globulin (ATG) is widely used in haploidentical HSCT (haplo-HSCT). OBJECTIVE We developed a modified intensified conditioning regimen including fludarabine (Flu) and investigated the effect of ATG-PTCy combination on transplant outcomes in high-risk AML and MDS compared with those patients who received only ATG as GVHD prophylaxis. METHODS A total of 80 patients with high-risk AML and MDS were divided into two groups and assigned to one-to-one pairing. RESULTS The modified ATG-PTCy group had more infused mononuclear cells, CD34-positive cells and CD3-positive cells than those in the ATG group (P < 0.05). The amount of platelet transfusion was higher in the ATG group than the modified ATG-PTCy group [2 (range, 1-6) U vs 2 (range, 1-5) U, P = 0.005]. The median of platelet recovery was better in the modified ATG-PTCy group than in the ATG group (12 days vs 13 days,P = 0.041). The infection rates of bacteria, fungi and virus at 100 days after transplantation were similar in both groups. Compared with the ATG group, individuals who received the modified ATG-PTCy regimen had higher 2-year GVHD- and relapse-free survival(GRFS) [60.0% (95%CI, 44.9-75.1%) vs 34.8% (95%CI, 19.9-49.7%), P = 0.028]; lower 180-day incidence of II-IV acute GVHD (aGVHD) [15.0% (95%CI, 4.0-26.0%) vs 39.8% (95%CI, 23.9-55.7%), P = 0.029]; lower 1-year incidence of moderate to severe chronic GVHD (cGVHD) [2.9% (95%CI, 2.0-3.8%) vs 19.6% (95%CI, 5.3-33.9%), P = 0.039]; and without an increase in the 2-year cumulative incidence of relapse (CIR) [19.5% (95%CI, 6.6-32.4%) vs 30.4% (95%CI, 15.3-45.5%), P = 0.291]. CONCLUSIONS High-dose stem cells can promote blood cell implantation. The modified ATG-PTCy combination was associated with decreased risk of aGVHD and cGVHD, no increased risk of recurrence, and improved GRFS. It represents an effective strategy for high risk AML and MDS.
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Affiliation(s)
- Junjie Cao
- Department of Hematology, The Affiliated People's Hospital of Ningbo University, Ningbo, Zhejiang Province, China.
| | - Renzhi Pei
- Department of Hematology, The Affiliated People's Hospital of Ningbo University, Ningbo, Zhejiang Province, China
| | - Ying Lu
- Department of Hematology, The Affiliated People's Hospital of Ningbo University, Ningbo, Zhejiang Province, China
| | | | - Zhiyang Yuan
- Shanghai Tissuebank Biotechnology Co., Ltd, Shanghai, China
| | - Daiyang Li
- Shanghai Tissuebank Biotechnology Co., Ltd, Shanghai, China
| | - Pisheng Zhang
- Department of Hematology, The Affiliated People's Hospital of Ningbo University, Ningbo, Zhejiang Province, China
| | - Xuhui Liu
- Department of Hematology, The Affiliated People's Hospital of Ningbo University, Ningbo, Zhejiang Province, China
| | - Dong Chen
- Department of Hematology, The Affiliated People's Hospital of Ningbo University, Ningbo, Zhejiang Province, China
| | - Xiaohong Du
- Department of Hematology, The Affiliated People's Hospital of Ningbo University, Ningbo, Zhejiang Province, China
| | - Lieguang Chen
- Department of Hematology, The Affiliated People's Hospital of Ningbo University, Ningbo, Zhejiang Province, China
| | - Shuangyue Li
- Department of Hematology, The Affiliated People's Hospital of Ningbo University, Ningbo, Zhejiang Province, China
| | - Peipei Ye
- Department of Hematology, The Affiliated People's Hospital of Ningbo University, Ningbo, Zhejiang Province, China
| | - Tiantian Wang
- Department of Hematology, The Affiliated People's Hospital of Ningbo University, Ningbo, Zhejiang Province, China
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Brown P, Inaba H, Annesley C, Beck J, Colace S, Dallas M, DeSantes K, Kelly K, Kitko C, Lacayo N, Larrier N, Maese L, Mahadeo K, Nanda R, Nardi V, Rodriguez V, Rossoff J, Schuettpelz L, Silverman L, Sun J, Sun W, Teachey D, Wong V, Yanik G, Johnson-Chilla A, Ogba N. Pediatric Acute Lymphoblastic Leukemia, Version 2.2020, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2021; 18:81-112. [PMID: 31910389 DOI: 10.6004/jnccn.2020.0001] [Citation(s) in RCA: 85] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Acute lymphoblastic leukemia (ALL) is the most common pediatric malignancy. Advancements in technology that enhance our understanding of the biology of the disease, risk-adapted therapy, and enhanced supportive care have contributed to improved survival rates. However, additional clinical management is needed to improve outcomes for patients classified as high risk at presentation (eg, T-ALL, infant ALL) and who experience relapse. The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for pediatric ALL provide recommendations on the workup, diagnostic evaluation, and treatment of the disease, including guidance on supportive care, hematopoietic stem cell transplantation, and pharmacogenomics. This portion of the NCCN Guidelines focuses on the frontline and relapsed/refractory management of pediatric ALL.
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Affiliation(s)
- Patrick Brown
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | - Hiroto Inaba
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | - Colleen Annesley
- Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
| | | | - Susan Colace
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | - Mari Dallas
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | - Kara Kelly
- Roswell Park Comprehensive Cancer Center
| | | | | | | | - Luke Maese
- Huntsman Cancer Institute at the University of Utah
| | - Kris Mahadeo
- The University of Texas MD Anderson Cancer Center
| | | | | | | | - Jenna Rossoff
- Ann & Robert H. Lurie Children's Hospital of Chicago
| | - Laura Schuettpelz
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | | | | | - Weili Sun
- City of Hope National Medical Center
| | - David Teachey
- Abramson Cancer Center at the University of Pennsylvania
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Wang H, Bai J, Pei Z, Zhang B, Wang J, Lian X, Song Q. Venetoclax + hypomethylating agents combined with dose-adjusted HAG for relapsed/refractory acute myeloid leukemia: Two case reports. Medicine (Baltimore) 2020; 99:e23265. [PMID: 33217852 PMCID: PMC7676608 DOI: 10.1097/md.0000000000023265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
RATIONALE Some acute myeloid leukemia (AML) patients are unresponsive to treatment or have remission followed by worsening of disease (known as relapsed/refractory AML [R/RAML]) after standardized treatment. The CAG/HAG regimen is not often used clinically because heterogenous patient responses, resistance, and hematopoietic bone marrow dysfunction have been reported with its use. We present 2 cases of R/RAML treated with a new combined therapy (venetoclax+ hypomethylating agents [HMAs]) in which the HAG dose was adjusted and effective in the first course of treatment. PATIENT CHARACTERISTICS Case 1 involved a 23-year-old man who had suffered from AML for >4 years, and his FLT3 mutation status was positive at the initial diagnosis. After the first course of treatment with the standard-dose "Da" plan, the patient experienced complete remission. During the subsequent courses of treatment, the patient experienced 6 recurrences and was treated with the "ID Ara-C + MIT + sidaaniline" and "CAG + sidaaniline" regimens. However, the disease did not respond. Case 2 involved a 26-year-old man who received chemotherapy with the "Da," "ID Ara-C," "decitabine + half-dose CAG," and "HAE" regimens. In this patients, remission could not be achieved. Reintroduction of the "ia" scheme also failed after treatment in our hospital. DIAGNOSIS Two patients were diagnosed with R/RAML. INTERVENTIONS The patient in case 2 received chemotherapy interventions, whereas the patient in case 1 refused to receive medical services at our hospital. OUTCOMES The patient in case 1 was discharged after complete response treatment due to economic reasons and relapsed 2 months later. The patient ultimately died of infection and heart failure. The patient in case 2 is receiving a second cycle of chemotherapy. LESSONS We recommend the "venetoclax + HMAs combined with dose-adjusted CAH/HAG" regimen as an effective treatment for adult R/RAML.
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Affiliation(s)
- Hongxia Wang
- Department of Hematology, Jiaozuo People's Hospital
| | - Junjun Bai
- Department of Hematology, Jiaozuo People's Hospital
| | - Zhixin Pei
- Department of Hematology, Jiaozuo People's Hospital
| | - Bei Zhang
- Department of Hematology, Jiaozuo People's Hospital
| | - Junjie Wang
- Department of Hematology, Jiaozuo People's Hospital
| | - Xingli Lian
- Pharmacy Intravennous Admixture Service, Second People's Hospital of Jiaozuo, Jiaozuo, China
| | - Qinglin Song
- Department of Hematology, Jiaozuo People's Hospital
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Qian JJ, Hu X, Wang Y, Zhang Y, Du J, Yang M, Tong H, Qian WB, Wei J, Yu W, Lou YJ, Mao L, Tao Meng H, You LS, Wang L, Li X, Huang X, Cao LH, Zhao JZ, Yan Yan X, Chen YB, Chen Y, Zhang SJ, Jin J, Hu J, Zhu HH. CAG regimen for refractory or relapsed adult T-cell acute lymphoblastic leukemia: A retrospective, multicenter, cohort study. Cancer Med 2020; 9:5327-5334. [PMID: 32492289 PMCID: PMC7402818 DOI: 10.1002/cam4.3079] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 01/30/2020] [Accepted: 02/22/2020] [Indexed: 01/09/2023] Open
Abstract
Adult patients with relapsed or refractory T‐cell acute lymphoblastic leukemia (R/R‐T‐ALL) have extremely poor prognosis, representing an urgent unmet medical need. Finding an optimal salvage regimen to bridge transplantation is a priority. The CAG (cytarabine, aclarubicin, and G‐CSF) regimen was initially used by one group in China, showing unexpectedly promising results in 11 R/R‐T‐ALL patients. Here, we report the multicenter results of 41 patients who received the CAG regimen as salvage therapy. After one cycle of the CAG regimen, complete remission and partial remission were achieved in 33 (80.5%) and two (4.9%) patients, respectively. Failure to respond was observed in six patients (14.6%). Early T‐cell precursor (ETP) (n = 26) and non‐ETP (n = 15) patients had a similar CR rate (80.8% vs 80.0%, P = .95). Among 41 patients, allo‐HSCT was successfully performed in 27 (66%) patients (22 in CR and 5 in non‐CR). With a median follow‐up time of 12 months, the estimated 2‐year overall survival and event‐free survival were 68.8% (95% CI, 47.3%‐83.0%) and 56.5% (95% CI, 37.1%‐71.9%), respectively. The CAG regimen was well‐tolerated, and no early death occurred. Our multicenter results show that the CAG regimen is highly effective and safe, representing a novel choice for adult patients with R/R‐T‐ALL and providing a better bridge to transplantation.
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Affiliation(s)
- Jie-Jing Qian
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Zhejiang, China.,Institute of Hematology, Zhejiang University, Zhejiang, China.,Zhejiang Province Key Laboratory of Hematology Oncology Diagnosis and Treatment, Hangzhou, China
| | - Xiaoxia Hu
- Department of Hematology, Institute of Hematology, Changhai Hospital, Shanghai, China
| | - Ying Wang
- Department of Hematology, Shanghai Jiaotong University School of Medicine Affiliated Ruijin Hospital North, Shanghai, China
| | - Yi Zhang
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Zhejiang, China.,Institute of Hematology, Zhejiang University, Zhejiang, China.,Zhejiang Province Key Laboratory of Hematology Oncology Diagnosis and Treatment, Hangzhou, China
| | - Juan Du
- Department of Hematology, Shanghai Changzheng Hospital, The Second Military Medical University, Shanghai, China
| | - Min Yang
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Zhejiang, China.,Institute of Hematology, Zhejiang University, Zhejiang, China.,Zhejiang Province Key Laboratory of Hematology Oncology Diagnosis and Treatment, Hangzhou, China
| | - Hongyan Tong
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Zhejiang, China.,Institute of Hematology, Zhejiang University, Zhejiang, China.,Zhejiang Province Key Laboratory of Hematology Oncology Diagnosis and Treatment, Hangzhou, China
| | - Wen-Bin Qian
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Zhejiang, China.,Institute of Hematology, Zhejiang University, Zhejiang, China.,Zhejiang Province Key Laboratory of Hematology Oncology Diagnosis and Treatment, Hangzhou, China
| | - Juying Wei
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Zhejiang, China.,Institute of Hematology, Zhejiang University, Zhejiang, China.,Zhejiang Province Key Laboratory of Hematology Oncology Diagnosis and Treatment, Hangzhou, China
| | - Wenjun Yu
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Zhejiang, China.,Institute of Hematology, Zhejiang University, Zhejiang, China.,Zhejiang Province Key Laboratory of Hematology Oncology Diagnosis and Treatment, Hangzhou, China
| | - Yin-Jun Lou
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Zhejiang, China.,Institute of Hematology, Zhejiang University, Zhejiang, China.,Zhejiang Province Key Laboratory of Hematology Oncology Diagnosis and Treatment, Hangzhou, China
| | - Liping Mao
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Zhejiang, China.,Institute of Hematology, Zhejiang University, Zhejiang, China.,Zhejiang Province Key Laboratory of Hematology Oncology Diagnosis and Treatment, Hangzhou, China
| | - Hai Tao Meng
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Zhejiang, China.,Institute of Hematology, Zhejiang University, Zhejiang, China.,Zhejiang Province Key Laboratory of Hematology Oncology Diagnosis and Treatment, Hangzhou, China
| | - Liang-Shun You
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Zhejiang, China.,Institute of Hematology, Zhejiang University, Zhejiang, China.,Zhejiang Province Key Laboratory of Hematology Oncology Diagnosis and Treatment, Hangzhou, China
| | - Libing Wang
- Department of Hematology, Institute of Hematology, Changhai Hospital, Shanghai, China
| | - Xia Li
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Zhejiang, China.,Institute of Hematology, Zhejiang University, Zhejiang, China.,Zhejiang Province Key Laboratory of Hematology Oncology Diagnosis and Treatment, Hangzhou, China
| | - Xin Huang
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Zhejiang, China.,Institute of Hematology, Zhejiang University, Zhejiang, China.,Zhejiang Province Key Laboratory of Hematology Oncology Diagnosis and Treatment, Hangzhou, China
| | - Li-Hong Cao
- Department of Hematology, Shulan (Hangzhou) Hospital, Hangzhou, China
| | - Jian-Zhi Zhao
- Department of hematology, Shaoxing Central Hospital, Shaoxing, China
| | - Xiao Yan Yan
- Department of Biostatistics, Peking University Clinical Research Institute, Beijing, China
| | - Yu-Bao Chen
- Department of Hematology, Shanghai Jiaotong University School of Medicine Affiliated Ruijin Hospital North, Shanghai, China
| | - Yu Chen
- Department of Hematology, Shanghai Jiaotong University School of Medicine Affiliated Ruijin Hospital North, Shanghai, China
| | - Su-Jiang Zhang
- Department of Hematology, Shanghai Jiaotong University School of Medicine Affiliated Ruijin Hospital North, Shanghai, China
| | - Jie Jin
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Zhejiang, China.,Institute of Hematology, Zhejiang University, Zhejiang, China.,Zhejiang Province Key Laboratory of Hematology Oncology Diagnosis and Treatment, Hangzhou, China
| | - Jiong Hu
- Shanghai Institute of Hematology, Department of Hematology, Blood and Marrow Transplantation Center, Collaborative Innovation Center of Hematology, RuiJin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hong-Hu Zhu
- Department of Hematology, the First Affiliated Hospital, College of Medicine, Zhejiang University, Zhejiang, China.,Institute of Hematology, Zhejiang University, Zhejiang, China.,Zhejiang Province Key Laboratory of Hematology Oncology Diagnosis and Treatment, Hangzhou, China
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Mustafa O, Abdalla K, AlAzmi AA, Elimam N, Abrar MB, Jastaniah W. FLAG/FLAG-IDA regimen for children with relapsed/refractory acute leukemia in the era of targeted novel therapies. J Oncol Pharm Pract 2018; 25:1831-1838. [PMID: 30518307 DOI: 10.1177/1078155218817816] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Outcomes of relapsed/refractory childhood acute leukemia remain poor. We analyzed the safety/efficacy of fludarabine, cytarabine, and granulocyte colony stimulating factor, with/without idarubicin (FLAG ± IDA) as salvage therapy compared with recent published results of novel therapies. METHODS This retrospective study included children aged 1 to 15 years with relapsed/refractory acute leukemia who received FLAG ± IDA salvage therapy from January 2000 to December 2014. Patients with infant leukemia, mixed lineage leukemia, Philadelphia-positive acute leukemia, or secondary leukemia were excluded. RESULT Fifty patients were identified: 25 with acute lymphoblastic leukemia and 25 with acute myeloid leukemia. The median age at initiation of FLAG ± IDA was seven years. Site of relapse was the bone marrow in 29, isolated central nervous system in 11, and combined in 10 patients. FLAG ± IDA was used after first relapse in 68% and after multiple relapses in 32%. Complete remission was achieved in 34 (68%) patients. No variables predictive of complete remission were identified. Grade 3 or greater toxicity was observed in 96% and 6% died from toxicity. Toxicities included hematologic toxicity (96%), infection (52%), and enterocolitis (28%). Twenty-four of 50 (48%) patients achieved a sustained complete remission and survived to bone marrow transplantation. The five-year overall survival was 23.9% ± 6.9%. Patients achieving second complete remission and patients proceeding to bone marrow transplantation following second complete remission demonstrated significantly improved overall survival (p = 0.001). CONCLUSION Despite a 68% complete remission rate using FLAG ± IDA, only 48% of patients survived to bone marrow transplantation. The regimen was associated with 96% toxicity and only one in four patients was alive at five years. This underscores the need to find more effective lower toxicity salvage regimens.
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Affiliation(s)
- Omima Mustafa
- Princess Noorah Oncology Center, King Abdulaziz Medical City, King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia
| | - Khalid Abdalla
- Princess Noorah Oncology Center, King Abdulaziz Medical City, King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia
| | - Aeshah A AlAzmi
- Department of Pharmaceutical Care, Clinical Pharmacy, King Abdulaziz Medical City, King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia
| | - Naglla Elimam
- Princess Noorah Oncology Center, King Abdulaziz Medical City, King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia
| | - Mohammed Burhan Abrar
- Princess Noorah Oncology Center, King Abdulaziz Medical City, King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia
| | - Wasil Jastaniah
- Princess Noorah Oncology Center, King Abdulaziz Medical City, King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia.,Department of Pediatrics, Faculty of Medicine, Umm AlQura University, Makkah, Saudi Arabia
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6
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Westhus J, Noppeney R, Dührsen U, Hanoun M. FLAG salvage therapy combined with idarubicin in relapsed/refractory acute myeloid leukemia. Leuk Lymphoma 2018; 60:1014-1022. [PMID: 30277107 DOI: 10.1080/10428194.2018.1508670] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Acute myeloid leukemia (AML) is characterized by a high failure rate to achieve complete remission as well as high relapse rates that cause an emergent need for efficient and tolerable salvage therapies. The combination of FLAG with idarubicin (FLAG-Ida) is a widely used protocol. However, its efficacy has been analyzed in only a limited number of studies with majorly small patient cohorts. Here, we analyzed 132 patients with largely primary refractory or first-time relapsed AML treated according to the FLAG-Ida protocol. The overall complete remission rate (CR + CRi) was 56% with a median overall survival of 15 months (95% CI, 5.7-25.1). The median disease-free survival for CR/CRi-patients was not reached. The mortality rate on day 30 was 9% and increased on day 60 to 16%. Our results show in relapsed/refractory AML patients a high efficacy and compatibility for the FLAG-Ida regimen.
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Affiliation(s)
- Jonas Westhus
- a Department of Hematology , University Hospital, University of Duisburg-Essen , Essen , Germany
| | - Richard Noppeney
- a Department of Hematology , University Hospital, University of Duisburg-Essen , Essen , Germany
| | - Ulrich Dührsen
- a Department of Hematology , University Hospital, University of Duisburg-Essen , Essen , Germany
| | - Maher Hanoun
- a Department of Hematology , University Hospital, University of Duisburg-Essen , Essen , Germany
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McMahon CM, Perl AE. Management of primary refractory acute myeloid leukemia in the era of targeted therapies. Leuk Lymphoma 2018; 60:583-597. [PMID: 30234399 DOI: 10.1080/10428194.2018.1504937] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Primary refractory acute myeloid leukemia (AML), or primary induction failure, represents a continued challenge in clinical management. This review presents an overview of primary refractory disease and a discussion of risk factors for induction failure, including current evidence regarding the impact of karyotype and molecular mutation status on responsiveness to chemotherapy. We review the evidence for various treatment options for refractory AML including salvage chemotherapy regimens, allogeneic hematopoietic stem cell transplantation, targeted agents, and non-intensive therapies such as hypomethylating agents. A therapeutic approach to this patient population is presented, and several new and emerging therapies are reviewed.
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Affiliation(s)
- Christine M McMahon
- a Department of Medicine, Division of Hematology and Oncology , Perelman School of Medicine at the University of Pennsylvania , Philadelphia , PA , USA
| | - Alexander E Perl
- a Department of Medicine, Division of Hematology and Oncology , Perelman School of Medicine at the University of Pennsylvania , Philadelphia , PA , USA
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Hassan IB, Kristensen J, Al Qawasmeh K, Alam A. Re-induction chemotherapy using FLAG-mitoxantrone for adult patients with relapsed acute leukemia: a single-center experience from United Arab Emirates. Int J Hematol 2018; 108:390-401. [PMID: 29951735 DOI: 10.1007/s12185-018-2478-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 06/04/2018] [Accepted: 06/14/2018] [Indexed: 10/28/2022]
Abstract
We studied the outcome of 47 adult patients with relapsed acute leukaemia (AML = 25 and ALL = 22) treated with FLAG-mitoxantrone regimen. Median time to relapse was 10.7 months (range 1.9-27.7). Complete remission (CR2) was 60.1% which was significantly more frequent in ALL compared to AML (P = 0.049). WBC count < 100 × 109/L at initial diagnosis and time to relapse > 1 year were significantly predictor for CR2 in AML (P = 0.005 for both). Induction death was significantly higher in ALL compared to AML (P = 0.039). Median follow-up was 4.0 months (0.9-119.8) for AML and 2.1 months (range 0.6-118.1) for ALL. Nine patients underwent allogeneic stem-cell transplantation (allo-SCT). Estimated overall survival (OS) at 12 and 18 months was 60.5 and 34.6%, respectively, for AML, and 39.9 and 29.9%, respectively, for ALL. For AML patients failure to achieve CR, WBC count at initial diagnosis > 5 × 109/L and poor cytogenetic risk group was significant predictors of poor OS (P = 0.010, P = 0.025, and P = 0.015, respectively). For ALL patients failure to achieve of CR, WBC count at relapse < 5 × 109/L (CR patients) and lack of any type of consolidation therapy were significant predictor of poor OS (P < 0.001, P = 0.008, P = 0.008, respectively).
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Affiliation(s)
- Inaam Bashir Hassan
- Department of Internal Medicine, Faculty of Medicine and Health Sciences, United Arab Emirates University, P.O. Box 17666, Al Ain, United Arab Emirates. .,Department of Hematology, Oncology Tawam Hospital, Al Ain, United Arab Emirates.
| | | | - Khalid Al Qawasmeh
- Department of Hematology, Oncology Tawam Hospital, Al Ain, United Arab Emirates
| | - Arif Alam
- Department of Hematology, Oncology Tawam Hospital, Al Ain, United Arab Emirates
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9
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Megías-Vericat JE, Martínez-Cuadrón D, Sanz MÁ, Montesinos P. Salvage regimens using conventional chemotherapy agents for relapsed/refractory adult AML patients: a systematic literature review. Ann Hematol 2018; 97:1115-1153. [DOI: 10.1007/s00277-018-3304-y] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 03/12/2018] [Indexed: 12/26/2022]
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10
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Feng X, Lan H, Ruan Y, Li C. Impact on acute myeloid leukemia relapse in granulocyte colony-stimulating factor application: a meta-analysis. ACTA ACUST UNITED AC 2018. [PMID: 29516766 DOI: 10.1080/10245332.2018.1446811] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES This meta-analysis evaluated the impact of granulocyte colony-stimulating factor (G-CSF) added to chemotherapy on treatment outcomes including survival and disease recurrence in patients with acute myeloid leukemia (AML). METHODS Medline, Cochrane, EMBASE, and Google Scholar databases were searched until 19 September 2016 using search terms. Studies that investigated patients with AML who underwent stem-cell transplantation were included. RESULTS The overall analysis revealed a significant improvement in overall survival (OS) (P = .019) and disease-free survival (DFS) (P = .002) for patients receiving G-CSF with chemotherapy. Among patients without prior AML treatment, there was a significant improvement in DFS (P = .014) and reduction in incidence of relapse (P = .015) for those who received G-CSF. However, subgroup analyses found no significant difference between G-CSF (+) and G-CSF (-) treatments in rates of OS (P = .104) and complete remission (CR) (P = .572) for patients without prior AML treatment. Among patients with relapsed/refractory AML, there was no significant difference found between G-CSF (+) and G-CSF (-) groups for OS (P = .225), DFS (P = .209), and CR (P = .208). DISCUSSION Treatment with chemotherapy plus G-CSF appears to provide better survival and treatment responses compared with chemotherapy alone, particularly for patients with previously untreated AML. ABBREVIATIONS AML, acute myeloid leukemia; CI, confidence interval; CR, complete remission; DFS, disease-free survival; G-CSF, granulocyte colony-stimulating factor; GM-CSF, granulocyte macrophage colony-stimulating factor; HR, hazard ratio; MDS, myelodysplastic syndrome; OR, odds ratio; OS, overall survival; RCTs, randomized control trials; RR, relative risk.
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Affiliation(s)
- Xiaoqin Feng
- a Department of Pediatrics , Nanfang Hospital , Guangzhou City , People's Republic of China
| | - He Lan
- a Department of Pediatrics , Nanfang Hospital , Guangzhou City , People's Republic of China
| | - Yongsheng Ruan
- a Department of Pediatrics , Nanfang Hospital , Guangzhou City , People's Republic of China
| | - Chunfu Li
- a Department of Pediatrics , Nanfang Hospital , Guangzhou City , People's Republic of China
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11
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Yılmaz Bengoa Ş, Ataseven E, Kızmazoğlu D, Demir Yenigürbüz F, Erdem M, Ören H. FLAG Regimen with or without Idarubicin in Children with Relapsed/Refractory Acute Leukemia: Experience from a Turkish Pediatric Hematology Center. Turk J Haematol 2017; 34:46-51. [PMID: 27095144 PMCID: PMC5451688 DOI: 10.4274/tjh.2015.0411] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Objective: The optimal therapy to achieve higher rates of survival in pediatric relapsed/refractory acute leukemia (AL) is still unknown. In developing countries, it is difficult to obtain some of the recent drugs for optimal therapy and mostly well-known drugs proven to be effective are used. We assessed the efficacy of the combination of fludarabine, high-dose cytarabine, and granulocyte colony-stimulating factor (FLAG regimen) with or without idarubicin (IDA) in children with relapsed/refractory acute lymphoblastic leukemia and acute myeloid leukemia. Materials and Methods: Between September 2007 and May 2015, 18 children with refractory/relapsed AL attending our center, treated with a FLAG regimen with or without IDA, were included. The primary end point was the remission status of the bone marrow sampled after the first/second course of chemotherapy. The second end point was the duration of survival after hematopoietic stem cell transplantation (HSCT). Results: Complete remission (CR) was achieved in 7 patients (38.8%) after the first cycle, and at the end of the second cycle the total number of patients in CR was 8 (42.1%). All patients in CR underwent HSCT. The CR rate in patients who had IDA in combination therapy was 28.6%, and it was 50% in patients treated without IDA (p=0.36). Mean survival duration in transplanted patients was 24.7±20.8 months (minimum-maximum: 2-70, median: 25 months), and it was 2.7±1.64 months (minimum-maximum: 0-5, median: 3 months) in nontransplanted patients. Five of them (27.7%) were still alive at the end of the study and in CR. The median time of follow-up for these patients was 33 months (minimum-maximum: 25-70 months). Conclusion: FLAG regimens with or without IDA produced a CR of >24 months in 27.7% of children with relapsed/refractory AL and can be recommended as therapeutic options prior to HSCT in developing countries.
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Affiliation(s)
- Şebnem Yılmaz Bengoa
- Dokuz Eylül University Faculty of Medicine, Department of Pediatric Hematology, İzmir, Turkey Phone: +90 505 5252163 E-mail:
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12
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Bergua JM, Montesinos P, Martinez-Cuadrón D, Fernández-Abellán P, Serrano J, Sayas MJ, Prieto-Fernandez J, García R, García-Huerta AJ, Barrios M, Benavente C, Pérez-Encinas M, Simiele A, Rodríguez-Macias G, Herrera-Puente P, Rodríguez-Veiga R, Martínez-Sánchez MP, Amador-Barciela ML, Riaza-Grau R, Sanz MA. A prognostic model for survival after salvage treatment with FLAG-Ida +/− gemtuzumab-ozogamicine in adult patients with refractory/relapsed acute myeloid leukaemia. Br J Haematol 2016; 174:700-10. [DOI: 10.1111/bjh.14107] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Accepted: 02/29/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Juan M. Bergua
- Department of Haematology; Hospital San Pedro de Alcántara; Cáceres Spain
| | - Pau Montesinos
- Department of Haematology; University Hospital La Fe; Valencia Spain
| | | | | | | | - María J. Sayas
- Department of Haematology; Hospital Doctor Peset; Valencia Spain
| | | | - Raimundo García
- Department of Haematology; General Hospital Castellón; Castellón Spain
| | | | - Manuel Barrios
- Department of Haematology; Hospital Carlos Haya; Málaga Spain
| | | | | | | | | | | | | | | | | | | | - Miguel A. Sanz
- Department of Haematology; University Hospital La Fe; Valencia Spain
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13
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How I treat adults with relapsed or refractory Philadelphia chromosome-negative acute lymphoblastic leukemia. Blood 2015; 126:589-96. [PMID: 25966988 DOI: 10.1182/blood-2014-09-551937] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 04/02/2015] [Indexed: 12/17/2022] Open
Abstract
The long-term prognosis of adult patients with relapsed Philadelphia chromosome-negative acute lymphoblastic lymphoma (ALL) is poor. Allogeneic stem cell transplant in second remission is the only curative approach and is the goal when feasible. There is no standard chemotherapy regimen for relapsed disease, although a few agents are approved for use in this setting. The bispecific CD19-directed CD3 T-cell engager, blinatumomab, has recently been granted accelerated approval by the US Food and Drug Administration for relapsed or refractory disease of B-cell lineage. For patients with relapsed T-cell ALL, nelarabine is available. Liposomal vincristine is also approved for relapsed disease. When selecting combination chemotherapy salvage options, evaluation of the prior treatment and timing of relapse informs treatment decisions. Monoclonal and cellular investigational therapies are quite promising and should be explored in the appropriate patient.
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14
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Chemomodulation of sequential high-dose cytarabine by fludarabine in relapsed or refractory acute myeloid leukemia: a randomized trial of the AMLCG. Leukemia 2013; 28:1001-7. [DOI: 10.1038/leu.2013.297] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Revised: 09/27/2013] [Accepted: 10/03/2013] [Indexed: 11/08/2022]
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15
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Yu W, Mao L, Qian J, Qian W, Meng H, Mai W, Tong H, Tong Y, Jin J. Homoharringtonine in combination with cytarabine and aclarubicin in the treatment of refractory/relapsed acute myeloid leukemia: a single-center experience. Ann Hematol 2013; 92:1091-100. [PMID: 23595277 DOI: 10.1007/s00277-013-1758-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2011] [Accepted: 04/05/2013] [Indexed: 10/27/2022]
Abstract
To assess the efficacy and toxicity of HAA regimen (Homoharringtonine 4 mg/m(2)/day, days 1-3; cytarabine 150 mg/m(2)/day, days 1-7; aclarubicin 12 mg/m(2)/day, days 1-7) as a salvage therapy in the treatment of refractory and/or relapsed acute myeloid leukemia (AML), 46 patients with refractory and/or relapsed AML, median age 37 (16-65) years, participated in this clinical study. The median follow-up was 41 (10-86) months. Eighty percent of patients achieved complete remission (CR), and the first single course of re-induction HAA regimen resulted in CR rate of 76.1 %. The study protocol allowed two courses of induction. The CR rates of patients with favorable, intermediate and unfavorable cytogenetics were 90 %, 88.9 %, and 37.5 %, respectively. For all patients, the estimated 3-year overall survival (OS) rate was 42 %, and the estimated relapse free survival (RFS) at 3 years for the 36 CR cases was 49 %. The toxicities associated with HAA regimen were acceptable. HAA is a good choice in cases with refractory/relapsing AML for salvage chemotherapy, preferably with a high-efficacy and low-toxicity profile.
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Affiliation(s)
- Wenjuan Yu
- Department of Hematology, the First Affiliated Hospital, Zhejiang University College of Medicine, No. 79 Qingchun Road, Hangzhou, Zhejiang, People's Republic of China
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16
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Alwan AF, Matti BF, Naji AS, Jawad AM. The Efficacy of Fludarabine, High Dose Cytosine Arabinoside with Granulocyte Colony Stimulating Factor (FLAG) Protocol as Salvage Therapy for Refractory/Relapsed Acute Leukemias in Adult Iraqi Patients. Indian J Hematol Blood Transfus 2013; 30:231-5. [PMID: 25435719 DOI: 10.1007/s12288-013-0244-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Accepted: 02/11/2013] [Indexed: 10/27/2022] Open
Abstract
Refractory/relapsed acute leukemia has always been a challenging problem for hematologist. Over the past decade emphasis has been made in the development of regimens containing fludarabine, combined with cytosine arabinoside for the treatment of refractory/relapsed acute leukemias. The aim of this study is to evaluate the efficacy and toxicity of the combination of fludarabine, high dose cytarabine, and granulocyte colony stimulating factor in refractory relapsed cases of acute leukaemia, a prospective study is being conducted at the National Center of Hematology and hematology unit/Baghdad teaching hospital from July 2008 to July 2010. Twenty Patients with refractory/relapsed acute leukemia were treated with fludarabine 30 mg/m(2) and cytosine arabinoside (Ara-C) 2 g/m(2) for 5 days, and granulocyte colony stimulating factor G-CSF 300 µg/day from day 0 till neutrophil recovery (ANC > 1.0 × 10(9)/L). Response was evaluated by bone marrow examination on day 30 post chemotherapy. Patients included were refractory acute lymphoblastic leukemia (ALL) (five patients), relapsed ALL (four patients), refractory acute myeloid leukemia (AML) (eight patients), relapsed AML (three patients). Complete remission (CR) was achieved in nine (45 %) patients, while three (15 %) patients got partial remission. Three (15 %) patients died because of post chemotherapy complications and five (25 %) patient failed to achieve remission. Major complications encountered were: anemia, fever, bleeding, mucositis and bacterial infections. FLAG protocol is well tolerated and effective regimen in relapsed/refractory acute leukemias. The toxicity is acceptable, enabling most patients to receive further treatment, including transplantation procedures.
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Affiliation(s)
- Alaa Fadhil Alwan
- The National Center of Hematology, Almustansiriya University, Baghdad, Iraq
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17
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Luo S, Cai F, Jiang L, Zhang S, Shen Z, Sun L, Gao S. Clinical study of Mito-FLAG regimen in treatment of relapsed acute myeloid leukemia. Exp Ther Med 2013; 5:982-986. [PMID: 23407597 PMCID: PMC3570250 DOI: 10.3892/etm.2013.917] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2012] [Accepted: 01/18/2013] [Indexed: 11/21/2022] Open
Abstract
Patients with relapsed acute myeloid leukemia (AML) have unfavorable prognosis and require innovative therapeutic approaches. In this study we used fludarabine combined with a middle dose of cytosine arabinoside (Ara-C), mitoxantrone and granulocyte-colony stimulating factor (G-CSF) as a salvage therapy for patients with relapsed AML in China. Forty-five patients with relapsed AML were treated with the Mito-FLAG regimen consisting of mitoxantrone (7 mg/m2, day 1, 3 and 5), fludarabine (30 mg/m2, days 1–5), Ara-C (1 g/m2, over 3 h every 12 h, days 1–5) and G-CSF [5 μg/kg/day subcutaneously from day 0 until the white blood count (WBC) was >20×109/l]. Patients with a partial response (PR) received another course of the same regimen. Patients with a suitable donor and aged <50 years received allogeneic stem cell transplantation (allo-SCT). Twenty-three patients (51%) and 3 patients (7%) achieved complete remission (CR) and PR, respectively, following one or two courses of Mito-FLAG, and the overall response (OR) rate was 58%. Nine patients (20%) received allo-SCT and 4 patients (9%) succumbed early. Hematological toxicity and infections were the most prominent toxicities of this regimen. Other toxicities included nausea, vomiting, bleeding, hyperbilirubinemia, renal toxicity and arrhythmia. The probability of overall survival (OS) at 4 years was 19% (95% CI, 11–26%) and the probability of 4-year disease-free survival (DFS) was 29% for all 23 patients in CR (95% CI, 18–41%). Our data suggest that Mito-FLAG is a highly effective and well-tolerated salvage regimen for relapsed AML.
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Affiliation(s)
- Sheng Luo
- Department of Hematology, The First Affiliated Hospital of Wenzhou Medical College, Wenzhou, Zhejiang 325000, P.R. China
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18
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Fong CY, Grigoriadis G, Hocking J, Coutsouvelis J, Muirhead J, Campbell P, Paul E, Walker P, Avery S, Patil S, Spencer A, Schwarer A, Wei A. Fludarabine, cytarabine, granulocyte-colony stimulating factor and amsacrine: an effective salvage therapy option for acute myeloid leukemia at first relapse. Leuk Lymphoma 2012; 54:336-41. [PMID: 22812445 DOI: 10.3109/10428194.2012.713479] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Improved therapeutic options for relapsing patients with acute myeloid leukemia (AML) are urgently needed. Poor outcomes following salvage therapy have been reported in those with short initial remission duration, adverse risk karyotype, prior allograft, older age, FLT3-internal tandem duplication (ITD) AML and prior high-dose cytarabine (HiDAC) induction therapy. We present a cohort of 58 patients (aged 18-70) treated with fludarabine, cytarabine, granulocyte-colony stimulating factor (G-CSF) and amsacrine (FLAG-amsacrine) as salvage chemotherapy for AML at first relapse. 83% had received prior HiDAC-based therapy. The overall complete remission (CR/CR with incomplete blood count recovery [CRi]) rate was 59%, with median event-free survival (EFS) and overall survival (OS) of 6.9 and 10.6 months, respectively. FLAG-amsacrine was an effective bridge to allogeneic transplant with 38% successfully transplanted with excellent outcomes (median OS not reached). FLAG-amsacrine was also effective in elderly patients (≥ 60 years), with 61% achieving second remission. The regimen was well tolerated, with 30- and 42-day treatment-related mortality of 3.4% and 13.8%, respectively. Outcomes remained poor in those with short initial remission duration (<6 months). We conclude that FLAG-amsacrine is a useful salvage option for AML at first relapse.
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Affiliation(s)
- Chun Yew Fong
- Department of Clinical Hematology, The Alfred Hospital, Melbourne, Australia
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19
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Chemotherapy with hybrid liposomes for acute lymphatic leukemia leading to apoptosis in vivo. Int J Pharm 2011; 406:173-8. [DOI: 10.1016/j.ijpharm.2010.12.041] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2010] [Revised: 12/15/2010] [Accepted: 12/31/2010] [Indexed: 11/18/2022]
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20
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Management of relapse after allo-SCT for AML and the role of second transplantation. Bone Marrow Transplant 2009; 44:769-77. [PMID: 19855439 DOI: 10.1038/bmt.2009.300] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Relapse after allo-SCT for AML carries very poor prognosis. Second allo-SCT, although curative, is not an appropriate treatment option for a large number of relapsing patients (only 2-20% patients receive a second allo-SCT), and efforts to increase the number of patients who may benefit from a second allo-SCT are ongoing. In addition, understanding the varied biological processes that are operative in disease relapse has encouraged the development of novel therapies, and could be beneficial to patients who are currently managed conservatively with supportive care for relapsed disease. Incorporating novel combinations of drugs with immunomodulation, although theoretically attractive, should be tested in the setting of clinical trials. In this review, we discuss the currently available approaches for relapsed AML after allo-SCT.
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Litzow MR, Othus M, Cripe LD, Gore SD, Lazarus HM, Lee SJ, Bennett JM, Paietta EM, Dewald GW, Rowe JM, Tallman MS. Failure of three novel regimens to improve outcome for patients with relapsed or refractory acute myeloid leukaemia: a report from the Eastern Cooperative Oncology Group. Br J Haematol 2009; 148:217-25. [PMID: 19804455 DOI: 10.1111/j.1365-2141.2009.07917.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The treatment of relapsed acute myeloid leukaemia (AML) remains unsatisfactory. We conducted a phase II randomized trial where patients received intermediate-dose cytarabine for 4 d followed by gemtuzumab ozogamicin on day 5 (Arm A), or combined with liposomal daunorubicin for 3 d (Arm B), or cytarabine given for 5 d combined with cyclophosphamide for 3 d and topotecan by continuous infusion for 5 d (Arm C). Eligible patients had primary refractory AML, a first relapse after a remission of <1 year, or a second or greater relapse. The primary objective of this trial was attainment of a conventional complete remission (CR) or a CR without platelet recovery (CRp) in at least 40% of patients. The CR/CRp rates for the 82 eligible patients were 3/26 (12%) in Arm A, 2/29 (7%) in Arm B, and 1/27 (4%) in Arm C. No patients who had relapsed within 6 months of initial CR or who had suffered multiple relapses responded. More than 95% of patients subsequently died of AML. No unexpected toxicities were encountered. We conclude that none of these three regimens were effective enough in the treatment of high-risk relapsed or refractory AML to warrant further study. This trial was registered at http://www.clinicaltrials.gov as #NCT00005962.
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Lee SR, Yang DH, Ahn JS, Kim YK, Lee JJ, Choi YJ, Shin HJ, Chung JS, Cho YY, Chae YS, Kim JG, Sohn SK, Kim HJ. The clinical outcome of FLAG chemotherapy without idarubicin in patients with relapsed or refractory acute myeloid leukemia. J Korean Med Sci 2009; 24:498-503. [PMID: 19543516 PMCID: PMC2698199 DOI: 10.3346/jkms.2009.24.3.498] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2008] [Accepted: 07/01/2008] [Indexed: 11/20/2022] Open
Abstract
A refractory and resistant disease to conventional induction chemotherapy and relapsed disease are considered as the most important adverse prognostic factors for acute myeloid leukemia (AML). Sixty-one patients (median age, 33.6 yr) with relapsed or refractory AML were treated with the FLAG regimen that consisted of fludarabine (30 mg/m(2), days 1-5), cytarabine (2.0 g/m(2), days 1-5) and granulocyte colony-stimulating factor. Of the treated patients 29 patients (47.5%) achieved complete remission (CR). Higher CR rates were observed for patients with a first or second relapse as compared to patients with a primary refractory response or relapse after stem cell transplantation (HSCT). There was a significant difference in the response rates according to the duration of leukemia-free survival (pre-LFS) before chemotherapy (P=0.05). The recovery time of both neutrophils (> or =500/microL) and platelets (> or =20,000/microL) required a median of 21 and 18 days, respectively. Treatment-related mortality (TRM) occurred in seven patients (11.4%), of which 71.4% of TRM was caused by an invasive aspergillosis infection. After achieving CR, 18 patients underwent consolidation chemotherapy and six patients underwent allogeneic HSCT. In conclusion, FLAG chemotherapy without idarubicin is a relatively effective and well-tolerated regimen for relapsed or refractory AML and the use of FLAG chemotherapy has allowed intensive post-remission therapy including HSCT.
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Affiliation(s)
- Se Ryeon Lee
- Blood and Marrow Transplant Center, Hwasun, Korea
- Genome Research Center for Hematopoietic Diseases, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Deok Hwan Yang
- Blood and Marrow Transplant Center, Hwasun, Korea
- Genome Research Center for Hematopoietic Diseases, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Jae Sook Ahn
- Blood and Marrow Transplant Center, Hwasun, Korea
- Genome Research Center for Hematopoietic Diseases, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Yeo Kyeoung Kim
- Blood and Marrow Transplant Center, Hwasun, Korea
- Genome Research Center for Hematopoietic Diseases, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Je Jung Lee
- Blood and Marrow Transplant Center, Hwasun, Korea
- Genome Research Center for Hematopoietic Diseases, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Young Jin Choi
- Department of Hematology/Oncology, Pusan National University Hospital, Busan, Korea
| | - Ho Jin Shin
- Department of Hematology/Oncology, Pusan National University Hospital, Busan, Korea
| | - Joo Seop Chung
- Department of Hematology/Oncology, Pusan National University Hospital, Busan, Korea
| | - Yoon Young Cho
- Department of Oncology/Hematology, KyungPook National University Hospital, Daegu, Korea
| | - Yee Soo Chae
- Department of Oncology/Hematology, KyungPook National University Hospital, Daegu, Korea
| | - Jong Gwang Kim
- Department of Oncology/Hematology, KyungPook National University Hospital, Daegu, Korea
| | - Sang Kyun Sohn
- Department of Oncology/Hematology, KyungPook National University Hospital, Daegu, Korea
| | - Hyeoung Joon Kim
- Blood and Marrow Transplant Center, Hwasun, Korea
- Genome Research Center for Hematopoietic Diseases, Chonnam National University Hwasun Hospital, Hwasun, Korea
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The novel histone deacetylase inhibitor, LBH589, induces expression of DNA damage response genes and apoptosis in Ph- acute lymphoblastic leukemia cells. Blood 2008; 111:5093-100. [PMID: 18349321 DOI: 10.1182/blood-2007-10-117762] [Citation(s) in RCA: 117] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We investigated the mechanism of action of LBH589, a novel broad-spectrum HDAC inhibitor belonging to the hydroxamate class, in Philadelphia chromosome-negative (Ph(-)) acute lymphoblastic leukemia (ALL). Two model human Ph(-) ALL cell lines (T-cell MOLT-4 and pre-B-cell Reh) were treated with LBH589 and evaluated for biologic and gene expression responses. Low nanomolar concentrations (IC(50): 5-20 nM) of LBH589 induced cell-cycle arrest, apoptosis, and histone (H3K9 and H4K8) hyperacetylation. LBH589 treatment increased mRNA levels of proapoptosis, growth arrest, and DNA damage repair genes including FANCG, FOXO3A, GADD45A, GADD45B, and GADD45G. The most dramatically expressed gene (up to 45-fold induction) observed after treatment with LBH589 is GADD45G. LBH589 treatment was associated with increased histone acetylation at the GADD45G promoter and phosphorylation of histone H2A.X. Furthermore, treatment with LBH589 was active against cultured primary Ph(-) ALL cells, including those from a relapsed patient, inducing loss of cell viability (up to 70%) and induction of GADD45G mRNA expression (up to 35-fold). Thus, LBH589 possesses potent growth inhibitory activity against including Ph(-) ALL cells associated with up-regulation of genes critical for DNA damage response and growth arrest. These findings provide a rationale for exploring the clinical activity of LBH589 in the treatment of patients with Ph(-) ALL.
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