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Short NJ, Jabbour E, Jamison T, Paul S, Cuglievan B, McCall D, Gibson A, Jain N, Haddad FG, Nasr LF, Marx KR, Rausch C, Savoy JM, Garris R, Ravandi F, Kantarjian H. Dose-Dense Mini-Hyper-CVD, Inotuzumab Ozogamicin and Blinatumomab Achieves Rapid MRD-Negativity in Philadelphia Chromosome-Negative B-cell Acute Lymphoblastic Leukemia. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2024; 24:e168-e173. [PMID: 38212207 DOI: 10.1016/j.clml.2023.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 12/21/2023] [Accepted: 12/28/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND The combination of low-intensity chemotherapy and inotuzumab ozogamicin (INO), with sequential blinatumomab, is highly effective in older adults with newly diagnosed B-cell acute lymphoblastic leukemia (ALL) and in relapsed or refractory B-cell ALL. Earlier, "dose-dense" administration of blinatumomab could lead to earlier and deeper measurable residual disease (MRD) responses and better outcomes. PATIENTS AND METHODS We performed a retrospective analysis of the safety and efficacy of a dose-dense regimen of mini-hyper-CVD (mini-hyperfractionated cyclophosphamide, vincristine, and dexamethasone alternating with mini-methotrexate and cytarabine), INO, and blinatumomab in patients with B-cell ALL. RESULTS Twenty-one patients were treated (frontline, n = 9; MRD consolidation, n = 4; relapsed/refractory, n = 8). In the frontline cohort, all patients achieved CR/CRi and MRD negativity by flow cytometry at the end of cycle 1. Across the frontline and MRD consolidation cohorts, 10/11 patients (91%) achieved next-generation sequencing MRD negativity at a sensitivity of 10-6, including 6/10 evaluable patients (60%) who achieved next-generation sequencing MRD negativity after cycle 1. The CR/CRi rate in the relapsed/refractory cohort was 63%, and all responders achieved MRD negativity by flow cytometry at the end of cycle 1. The 1-year overall survival rate for the combined cohort of the frontline and MRD-positive patients was 83%. No new safety signals were observed with the dose-dense mini-hyper-CVD, INO, and blinatumomab regimen. CONCLUSION Dose-dense delivery of mini-hyper-CVD, INO, and blinatumomab was safe and resulted in rapid and deep MRD negativity in patients with B-cell ALL. This regimen is now being prospectively evaluated in both the frontline and relapsed/refractory settings.
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Affiliation(s)
- Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Trevor Jamison
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Shilpa Paul
- Department of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Branko Cuglievan
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - David McCall
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Amber Gibson
- Department of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Fadi G Haddad
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lewis F Nasr
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kayleigh R Marx
- Department of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Caitlin Rausch
- Department of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - J Michael Savoy
- Department of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Rebecca Garris
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
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Huang XT, Wang CJ, Gao C, Xue TL, Zhao ZJ, Wang TY, Wu MY, Cui L, Zhang RD, Li ZG. Relationship between subtype-specific minimal residual disease level and long-term prognosis in children with acute lymphoblastic leukemia. Ann Hematol 2024:10.1007/s00277-024-05687-y. [PMID: 38494553 DOI: 10.1007/s00277-024-05687-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 02/29/2024] [Indexed: 03/19/2024]
Abstract
Minimal residual disease (MRD) based risk stratification criteria for specific genetic subtypes remained unclear in childhood acute lymphoblastic leukemia (ALL). Among 723 children with newly diagnosed ALL treated with the Chinese Children Leukemia Group CCLG-2008 protocol, MRD was assessed at time point 1 (TP1, at the end of induction) and TP2 (before consolidation treatment) and the MRD levels significantly differed in patients with different fusion genes or immunophenotypes (P all < 0.001). Moreover, the prognostic impact of MRD varied by distinct molecular subtypes. We stratified patients in each molecular subtype into two MRD groups based on the results. For patients carrying BCR::ABL1 or KMT2A rearrangements, we classified patients with MRD < 10-2 at both TP1 and TP2 as the low MRD group and the others as the high MRD group. ETV6::RUNX1+ patients with TP1 MRD < 10-3 and TP2 MRD-negative were classified as the low MRD group and the others as the high MRD group. For T-ALL, We defined children with TP1 MRD ≥ 10-3 as the high MRD group and the others as the low MRD group. The 10-year relapse-free survival of low MRD group was significantly better than that of high MRD group. We verified the prognostic impact of the subtype-specific MRD-based stratification in patients treated with the BCH-ALL2003 protocol. In conclusion, the subtype-specific MRD risk stratification may contribute to the precise treatment of childhood ALL.
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Affiliation(s)
- Xiao-Tong Huang
- Hematologic Diseases Laboratory, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
- National Key Discipline of Pediatrics, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Pediatric Hematology-Oncology, Hematology Center, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Chan-Juan Wang
- National Key Discipline of Pediatrics, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Pediatric Hematology-Oncology, Hematology Center, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Chao Gao
- Hematologic Diseases Laboratory, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
- National Key Discipline of Pediatrics, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Pediatric Hematology-Oncology, Hematology Center, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Tian-Lin Xue
- Hematologic Diseases Laboratory, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
- National Key Discipline of Pediatrics, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Pediatric Hematology-Oncology, Hematology Center, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Zi-Jing Zhao
- Hematologic Diseases Laboratory, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
- National Key Discipline of Pediatrics, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Pediatric Hematology-Oncology, Hematology Center, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Tian-You Wang
- National Key Discipline of Pediatrics, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Pediatric Hematology-Oncology, Hematology Center, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Min-Yuan Wu
- National Key Discipline of Pediatrics, Capital Medical University, Beijing, China
- Beijing Key Laboratory of Pediatric Hematology-Oncology, Hematology Center, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Lei Cui
- Hematologic Diseases Laboratory, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China.
- National Key Discipline of Pediatrics, Capital Medical University, Beijing, China.
- Beijing Key Laboratory of Pediatric Hematology-Oncology, Hematology Center, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China.
| | - Rui-Dong Zhang
- National Key Discipline of Pediatrics, Capital Medical University, Beijing, China.
- Beijing Key Laboratory of Pediatric Hematology-Oncology, Hematology Center, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China.
| | - Zhi-Gang Li
- Hematologic Diseases Laboratory, Beijing Pediatric Research Institute, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China.
- National Key Discipline of Pediatrics, Capital Medical University, Beijing, China.
- Beijing Key Laboratory of Pediatric Hematology-Oncology, Hematology Center, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China.
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3
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Lee BJ, Griffin SP, Doh J, Chan A, Ciurea SO, Jeyakumar D, Fleischman AG, Naqvi K, Pannunzio NR, O'Brien S, Kongtim P. HyperCVAD versus pegaspargase-containing regimens for Hispanic adults with newly diagnosed B-cell acute lymphoblastic leukemia. Eur J Haematol 2024; 112:392-401. [PMID: 37933194 DOI: 10.1111/ejh.14125] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 10/15/2023] [Accepted: 10/16/2023] [Indexed: 11/08/2023]
Abstract
OBJECTIVE There are significant disparities in outcomes among Hispanic patients with acute lymphoblastic leukemia (ALL). Recent studies have demonstrated favorable outcomes of pegaspargase-containing ALL regimens (PEG-CAR) in young adults however, outcomes in Hispanic ethnicity continue to be underreported. METHODS We evaluated outcomes of newly diagnosed, adult B-cell ALL Hispanic and non-Hispanic patients consecutively treated with a PEG-CAR or HyperCVAD between January 2011 and November 2022. The primary endpoint was event-free survival (EFS) while secondary endpoints included cumulative incidence of relapse and overall survival (OS). RESULTS Among 105 included patients, 48 (45.7%) were treated with a PEG-CAR and 57 (54.3%) with HyperCVAD. Median age was 38 years (range, 18-75 years), 61% were Hispanic, and 35.2% had poor-genetic risk. Hispanic patients demonstrated significantly worse 5-year EFS with a PEG-CAR compared to that seen with HyperCVAD (HR, 2.58; 95% CI, 1.32-5.04; p = .006) whereas non-Hispanic patients had better outcomes with PIR (52.4% vs. 42.0%). Hispanic ethnicity (p = .015) and male sex (p = .019) were independent predictors for poor OS. CONCLUSIONS Hispanic patients with B-cell ALL had worse EFS with a PEG-CAR as compared with HyperCVAD. Future studies will aim to confirm these findings and establish a tailored treatment approach for this high-risk population.
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Affiliation(s)
- Benjamin J Lee
- Department of Pharmacy, Chao Family Comprehensive Cancer Center, University of California Irvine Health, Orange, California, USA
- Department of Clinical Pharmacy Practice, School of Pharmacy & Pharmaceutical Sciences, University of California, Irvine, California, USA
| | - Shawn P Griffin
- Department of Pharmacy, Chao Family Comprehensive Cancer Center, University of California Irvine Health, Orange, California, USA
- Department of Clinical Pharmacy Practice, School of Pharmacy & Pharmaceutical Sciences, University of California, Irvine, California, USA
| | - Jean Doh
- Department of Pharmacy, Chao Family Comprehensive Cancer Center, University of California Irvine Health, Orange, California, USA
| | - Alexandre Chan
- Department of Pharmacy, Chao Family Comprehensive Cancer Center, University of California Irvine Health, Orange, California, USA
- Department of Clinical Pharmacy Practice, School of Pharmacy & Pharmaceutical Sciences, University of California, Irvine, California, USA
- Department of Medicine, Division of Hematology Oncology, Chao Family Comprehensive Cancer Center, University of California Irvine Health, Orange, California, USA
| | - Stefan O Ciurea
- Department of Medicine, Division of Hematology Oncology, Chao Family Comprehensive Cancer Center, University of California Irvine Health, Orange, California, USA
| | - Deepa Jeyakumar
- Department of Medicine, Division of Hematology Oncology, Chao Family Comprehensive Cancer Center, University of California Irvine Health, Orange, California, USA
| | - Angela G Fleischman
- Department of Medicine, Division of Hematology Oncology, Chao Family Comprehensive Cancer Center, University of California Irvine Health, Orange, California, USA
| | - Kiran Naqvi
- Department of Medicine, Division of Hematology Oncology, Chao Family Comprehensive Cancer Center, University of California Irvine Health, Orange, California, USA
| | - Nicholas R Pannunzio
- Department of Medicine, Division of Hematology Oncology, Chao Family Comprehensive Cancer Center, University of California Irvine Health, Orange, California, USA
| | - Susan O'Brien
- Department of Medicine, Division of Hematology Oncology, Chao Family Comprehensive Cancer Center, University of California Irvine Health, Orange, California, USA
| | - Piyanuch Kongtim
- Department of Medicine, Division of Hematology Oncology, Chao Family Comprehensive Cancer Center, University of California Irvine Health, Orange, California, USA
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4
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Short NJ, Jabbour E, Jain N, Senapati J, Nasr L, Haddad FG, Li Z, Hsiao YC, Yang JJ, Pemmaraju N, Ohanian M, Wierda WG, Montalban-Bravo G, Borthakur G, Han L, Xiao L, Huang X, Abramova R, Zhao M, Garris R, Konopleva M, Ravandi F, Kantarjian H. A phase 1/2 study of mini-hyper-CVD plus venetoclax in patients with relapsed/refractory acute lymphoblastic leukemia. Blood Adv 2024; 8:909-915. [PMID: 38207208 PMCID: PMC10875259 DOI: 10.1182/bloodadvances.2023012231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 12/20/2023] [Accepted: 01/02/2024] [Indexed: 01/13/2024] Open
Abstract
ABSTRACT Preclinical studies suggest that Bcl-2 inhibition with venetoclax has antileukemic activity in acute lymphoblastic leukemia (ALL) and may synergize with conventional chemotherapy. We designed a phase 1/2 clinical trial to evaluate the safety and efficacy of low-intensity chemotherapy in combination with venetoclax in adults with relapsed or refractory ALL. Patients received the mini-hyper-CVD regimen (dose-attenuated hyperfractionated cyclophosphamide, vincristine, and dexamethasone alternating with methotrexate and cytarabine) in combination with venetoclax (200 mg or 400 mg daily) on days 1 to 14 in cycle 1 and on days 1 to 7 in consolidation cycles. Twenty-two patients were treated. The median number of prior therapies was 2 (range, 1-6). Thirteen patients (59%) had undergone prior allogeneic stem cell transplant (allo-SCT), and 7 of 18 patients (39%) with B-cell ALL had previously received both inotuzumab ozogamicin and blinatumomab. The recommended phase 2 dose of venetoclax in the combination regimen was 400 mg daily. The composite complete remission (CR) and CR with incomplete hematologic recovery (CRi) rate was 57% (CR, 43%; CRi, 14%), and 45% of responders achieved measurable residual disease negativity by multiparameter flow cytometry. Four patients proceeded to allo-SCT. The median duration of response was 6.3 months. The median overall survival was 7.1 months, and the 1-year overall survival rate was 29%. The most common grade ≥3 nonhematologic adverse events were infection in 17 patients (77%) and febrile neutropenia in 4 patients (18%). Overall, the combination of mini-hyper-CVD plus venetoclax was active in heavily pretreated relapsed/refractory ALL. Further development of venetoclax-based combinations in ALL is warranted. This trial is registered at www.clinicaltrials.gov as #NCT03808610.
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Affiliation(s)
- Nicholas J. Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jayastu Senapati
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lewis Nasr
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Fadi G. Haddad
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Zhenhua Li
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN
| | - Yu-Chih Hsiao
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN
| | - Jun J. Yang
- Department of Pharmacy and Pharmaceutical Sciences, St. Jude Children's Research Hospital, Memphis, TN
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Maro Ohanian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - William G. Wierda
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Gautam Borthakur
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lina Han
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lianchun Xiao
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Xuelin Huang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Regina Abramova
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Min Zhao
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Rebecca Garris
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Marina Konopleva
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
- Department of Oncology, Montefiore Einstein Cancer Center & Albert Einstein College of Medicine, New York, NY
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
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5
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Zarling LC, Stevenson PA, Soma LA, Martino CH, Percival MEM, Halpern AB, Ghiuzeli CM, Becker PS, Oehler VG, Cooper JP, Orozco JJ, Hendrie PC, Walter RB, Estey EH, Cassaday RD. Hyper-CVAD versus dose-adjusted EPOCH as initial treatment for adults with acute lymphoblastic leukemia. Eur J Haematol 2023; 111:863-871. [PMID: 37670560 DOI: 10.1111/ejh.14089] [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: 06/19/2023] [Revised: 08/10/2023] [Accepted: 08/16/2023] [Indexed: 09/07/2023]
Abstract
OBJECTIVES We recently performed a single-arm phase II trial of DA-EPOCH in adults with acute lymphoblastic leukemia (ALL). We sought to compare these results to those with standard Hyper-CVAD. METHODS We created a retrospective matched cohort of patients who received Hyper-CVAD (n = 69) at our center and otherwise met eligibility criteria for the DA-EPOCH trial (n = 53). RESULTS Our outcomes support the use of Hyper-CVAD over DA-EPOCH in Ph- disease for both overall survival (OS; HR 0.18, p = .004) and event-free survival (EFS; HR 0.51, p = .06). In contrast, outcomes were similar in Ph+ disease (OS HR 0.97, p = .96; EFS HR 0.65, p = .21). Rates of morphologic remission and measurable residual-disease negativity were similar between the regimens. Hyper-CVAD was associated with significantly more febrile neutropenia (OR 1.9, p = .03) and a greater incidence of Grade 4 or 5 adverse events (20% vs. 6%). Average transfusions per cycle of both red blood cells (p < .001) and platelets (p < .001) were five-fold higher with Hyper-CVAD. CONCLUSIONS Our findings support continued use of Hyper-CVAD for Ph- ALL but suggest that DA-EPOCH may be a reasonable alternative for Ph+ ALL. These data also highlight a potential role for DA-EPOCH in resource-limited settings or when more intense therapy is not feasible.
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Affiliation(s)
- Lucas C Zarling
- Department of Medicine, University of Washington, Seattle, Washington, DC, USA
| | - Philip A Stevenson
- Clinical Statistics Division, Fred Hutchinson Cancer Center, Seattle, Washington, DC, USA
| | - Lorinda A Soma
- Department of Pathology, City of Hope National Medical Center, Duarte, California, USA
| | - Christen H Martino
- Department of Medicine, University of Washington, Seattle, Washington, DC, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, DC, USA
| | - Mary-Elizabeth M Percival
- Department of Medicine, University of Washington, Seattle, Washington, DC, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, DC, USA
| | - Anna B Halpern
- Department of Medicine, University of Washington, Seattle, Washington, DC, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, DC, USA
| | - Cristina M Ghiuzeli
- Department of Medicine, University of Washington, Seattle, Washington, DC, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, DC, USA
| | - Pamela S Becker
- Department of Medicine, University of Washington, Seattle, Washington, DC, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, DC, USA
- Department of Hematology & Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California, USA
| | - Vivian G Oehler
- Department of Medicine, University of Washington, Seattle, Washington, DC, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, DC, USA
| | - Jason P Cooper
- Department of Medicine, University of Washington, Seattle, Washington, DC, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, DC, USA
| | - Johnnie J Orozco
- Department of Medicine, University of Washington, Seattle, Washington, DC, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, DC, USA
| | - Paul C Hendrie
- Department of Medicine, University of Washington, Seattle, Washington, DC, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, DC, USA
| | - Roland B Walter
- Department of Medicine, University of Washington, Seattle, Washington, DC, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, DC, USA
| | - Elihu H Estey
- Department of Medicine, University of Washington, Seattle, Washington, DC, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, DC, USA
| | - Ryan D Cassaday
- Department of Medicine, University of Washington, Seattle, Washington, DC, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, DC, USA
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6
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Gupta DG, Varma N, Sharma P, Truica MI, Abdulkadir SA, Singh P, Singh Sachdeva MU, Naseem S, Siddiqui MR, Bose P, Binota J, Malhotra P, Khadwal A, Trehan A, Varma S. Hematological, clinical, immunophenotypic characterization, and treatment outcomes of prognostically significant genetic subtypes of B-lineage acute lymphoblastic leukemia: A report of 1021 patients from India. Cancer 2023; 129:3390-3404. [PMID: 37498973 DOI: 10.1002/cncr.34957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 05/25/2023] [Accepted: 05/26/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND The published literature on hematological, clinical, flowcytometric-immunophenotyping, and minimal residual disease outcomes of the prognostically important genetic subtypes of acute lymphoblastic leukemia (ALL) is scarce from low-income countries. For newer classifications such as BCR::ABL1-like ALLs, the scarcity of patient-level data is even more pronounced. METHODS The authors performed comprehensive detection of recurrent gene fusions and BCR::ABL1-like ALL cases followed by immunophenotypic profiling and obtained clinical outcome parameters for a large cohort (n = 1021) of patients from India. This cohort included a significant number of patients with BCR::ABL1-like ALL subtype and other genetic subtypes of ALL. RESULTS Patients with BCR::ABL1-positive and BCR::ABL1-like ALL were significantly older, had male preponderance, and expressed a higher white blood cell count than BCR::ABL1-negative cases (p < .05). Logistic regression modeling of B-lineage-ALL (B-ALL) subtypes revealed that cluster of differentiation (CD)36 is a strong statistically significant predictive marker of BCR::ABL1-like ALL (p < .05). Furthermore, patients with BCR::ABL1-like ALLs show a significantly higher frequency of CD36 expression compared to BCR::ABL1-negative ALLs (p < .05). In terms of clinical symptoms, lymphadenopathy is a strong statistically significant predictive marker in BCR::ABL1-like ALLs compared to BCR::ABL1-negative ALL cases (p < .05). In terms of treatment outcomes, minimal residual disease (MRD) positivity in BCR::ABL1-positive ALL cases were statistically significant (p < .05), and BCR::ABL1-like ALL cases had high MRD-positivity as compared to BCR::ABL1-negative ALL cases but did not show statistical significance. CONCLUSIONS The findings evince the use of novel therapies and personalized treatment regimens to improve the overall survival of the newer incorporated entities in B-ALLs. This is the first report characterizing the hematological, clinical, flowcytometric-immunophenotyping, and minimal residual disease outcomes of the prognostically significant subtypes of ALLs in patients from India. PLAIN LANGUAGE SUMMARY Characterizing the hematological, clinical, flowcytometric-immunophenotyping, and minimal residual disease outcomes of the prognostically significant subtypes (n = 1021) of acute lymphoblastic leukemia (ALLs) in patients from India. We have made two independent logistic regression models of cluster of differentiation (CD) markers and clinical symptoms to differentiate prognostically significant subtypes of ALLs. Logistic regression analysis of CD markers revealed CD36 as a strong predictor in BCR::ABL1-like ALL cases compared to BCR::ABL1-negative ALL cases. Logistic regression analysis of clinical symptoms revealed lymphadenopathy significantly predicts BCR::ABL1-like ALLs (p < .05). In terms of treatment outcomes, BCR::ABL1-positive ALL had statistically significant minimal residual disease (MRD) (p < .05), and BCR::ABL1-like ALL cases had high MRD-positivity but did not show statistical significance as compared to BCR::ABL1-negative ALLs.
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Affiliation(s)
- Dikshat Gopal Gupta
- Department of Urology and Pathology, The Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Neelam Varma
- Department of Hematology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Praveen Sharma
- Department of Hematology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Mihai I Truica
- Department of Urology and Pathology, The Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Sarki A Abdulkadir
- Department of Urology and Pathology, The Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Parmod Singh
- Department of Anatomy, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Man Updesh Singh Sachdeva
- Department of Hematology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shano Naseem
- Department of Hematology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Mohammad Rizwan Siddiqui
- Department of Pediatrics, Northwestern University Feinberg School of Medicine and Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Parveen Bose
- Department of Hematology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Jogeshwar Binota
- Department of Hematology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Malhotra
- Department of Clinical Hematology and Medical Oncology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Alka Khadwal
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Amita Trehan
- Pediatric Hematology Oncology Unit, Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Subhash Varma
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Hodroj MH, Abou Dalle I, Moukalled N, El Cheikh J, Mohty M, Bazarbachi A. Novel strategies to prevent and overcome relapse after allogeneic hematopoietic cell transplantation in acute lymphoblastic leukemia. Front Immunol 2023; 14:1191912. [PMID: 37359547 PMCID: PMC10285443 DOI: 10.3389/fimmu.2023.1191912] [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: 03/22/2023] [Accepted: 05/26/2023] [Indexed: 06/28/2023] Open
Abstract
The outcome of B-cell acute lymphoblastic leukemia (B-ALL) has improved over time with the incorporation of multi-agent chemotherapy in the treatment landscape as well as the recent approval of immunotherapeutic agents allowing a larger proportion of patients to undergo allogeneic hematopoietic cell transplantation (allo-HCT) which is still considered a potential curative approach. However, relapse post-transplant is still occurring and constitutes a common cause of treatment failure in B-ALL. The present review aims to discuss the novel strategies and therapies used to prevent and overcome relapse post allo-HCT in patients with ALL, focusing on the role of tyrosine kinase inhibitors in Philadelphia chromosome positive B-ALL, the role of innovative agents such as blinatumomab and inotuzumab ozogamicin, and finally the role of cellular therapy.
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Affiliation(s)
- Mohammad Hassan Hodroj
- Division of Hematology & Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Iman Abou Dalle
- Division of Hematology & Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
- Bone Marrow Transplantation Program, American University of Beirut Medical Center, Beirut, Lebanon
| | - Nour Moukalled
- Division of Hematology & Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
- Bone Marrow Transplantation Program, American University of Beirut Medical Center, Beirut, Lebanon
| | - Jean El Cheikh
- Division of Hematology & Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
- Bone Marrow Transplantation Program, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mohamad Mohty
- Sorbonne University, Saint-Antoine Hospital, AP-HP, INSERM UMRs 938, Paris, France
| | - Ali Bazarbachi
- Division of Hematology & Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
- Bone Marrow Transplantation Program, American University of Beirut Medical Center, Beirut, Lebanon
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8
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Jabbour E, Short NJ, Senapati J, Jain N, Huang X, Daver N, DiNardo CD, Pemmaraju N, Wierda W, Garcia-Manero G, Montalban Bravo G, Sasaki K, Kadia TM, Khoury J, Wang SA, Haddad FG, Jacob J, Garris R, Ravandi F, Kantarjian HM. Mini-hyper-CVD plus inotuzumab ozogamicin, with or without blinatumomab, in the subgroup of older patients with newly diagnosed Philadelphia chromosome-negative B-cell acute lymphocytic leukaemia: long-term results of an open-label phase 2 trial. Lancet Haematol 2023; 10:e433-e444. [PMID: 37187201 DOI: 10.1016/s2352-3026(23)00073-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 03/08/2023] [Accepted: 03/10/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND The outcome of older patients with B-cell acute lymphocytic leukaemia is inferior to that in younger patients due to the adverse disease biology and their inability to tolerate intensive therapy. We aimed to study the long-term outcomes of inotuzumab ozogamicin with or without blinatumomab in combination with low-intensity chemotherapy in these patients. METHODS For this open-label phase 2 trial, patients aged 60 years or older with newly diagnosed, Philadelphia-chromosome negative, B-cell acute lymphocytic leukaemia, and an ECOG performance status of 3 or lower were eligible. This study was conducted at the University of Texas MD Anderson Cancer Center. The induction chemotherapy consisted of mini-hyper-CVD and has been published before; inotuzumab ozogamicin was administered intravenously on day 3 of the first four cycles at a dose of 1·3-1·8 mg/m2 in cycle 1, followed by 1·0-1·3 mg/m2 in subsequent cycles (cycles 2-4). Maintenance therapy with dose-reduced POMP (6-mercaptopurine, vincristine, methotrexate, and prednisone) was given for 3 years. From patient 50 onwards, the study protocol was amended to fractionate inotuzumab ozogamicin to a maximum cumulative dose of 2·7 mg/m2 (0·9 mg/m2 during cycle 1 fractionated into 0·6 mg/m2 on day 2 and 0·3 mg/m2 on day 8 of cycle 1, and 0·6 mg/m2 in cycles 2-4 fractionated into 0·3 mg/m2 on day 2 and 0·3 mg/m2 on day 8) followed by blinatumomab for four cycles (cycles 5-8). POMP maintenance was shortened to 12 cycles with one cycle of blinatumomab administered by continuous infusion after every three cycles of POMP. The primary endpoint was progression-free survival and was analysed on an intention-to-treat basis. This trial is registered with ClinicalTrials.gov (NCT01371630) and the present data is from the newly diagnosed, older subgroup of patients treated on the phase 2 portion of this trial; the trial is still enrolling patients. RESULTS Between Nov 11, 2011, and March 31, 2022, 80 patients were enrolled and treated (32 female and 48 male patients; median age 68 years [IQR 63-72]), 31 of whom were treated after the protocol amendment. With a median follow-up of 92·8 months (IQR 8·8-67·4), the 2-year progression-free survival was 58·2% (95% CI 46·7-68·2) and 5-year progression-free survival was 44·0% (31·2-54·3). At a median follow-up of 104·4 months (IQR 6·6-89·2) for the patients treated before the protocol amendment and 29·7 months (8·8-41·0) for those treated after the protocol amendment, median progression-free survival did not differ significantly between the two groups (34·7 months [95% CI 15·0-68·3] vs 56·4 months [11·3-69·7]; p=0·77). The most common grade 3-4 events were thrombocytopenia in 62 (78%) patients and febrile neutropenia in 26 (32%) patients. Six (8%) patients developed hepatic sinusoidal obstruction syndrome. There were eight (10%) deaths due to infectious complications, nine (11%) from complications related to secondary myeloid malignancy, and four (5%) from sinusoidal obstruction syndrome. INTERPRETATION Inotuzumab ozogamicin with or without blinatumomab added to low-intensity chemotherapy showed promising activity in terms of progression-free survival in older patients with B-cell acute lymphocytic leukaemia. Further attenuation of the chemotherapy regimen might improve tolerability while maintaining efficacy in older patients. FUNDING Pfizer and Amgen.
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Affiliation(s)
- Elias Jabbour
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Nicholas J Short
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jayastu Senapati
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nitin Jain
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Xuelin Huang
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naval Daver
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Courtney D DiNardo
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naveen Pemmaraju
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William Wierda
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | | | - Koji Sasaki
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tapan M Kadia
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph Khoury
- Department of Hematopathology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sa A Wang
- Department of Hematopathology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Fadi G Haddad
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jovitta Jacob
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rebecca Garris
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Farhad Ravandi
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hagop M Kantarjian
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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9
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Kantarjian H, Haddad FG, Jain N, Sasaki K, Short NJ, Loghavi S, Kanagal-Shamanna R, Jorgensen J, Khouri I, Kebriaei P, Alvarado Y, Kadia T, Paul S, Garcia-Manero G, Dabaja B, Yilmaz M, Jacob J, Garris R, O'Brien S, Ravandi F, Jabbour E. Results of salvage therapy with mini-hyper-CVD and inotuzumab ozogamicin with or without blinatumomab in pre-B acute lymphoblastic leukemia. J Hematol Oncol 2023; 16:44. [PMID: 37131217 PMCID: PMC10155451 DOI: 10.1186/s13045-023-01444-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 04/21/2023] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND Historically, adults with relapsed-refractory acute lymphoblastic leukemia (ALL) experienced poor outcomes with intensive chemotherapy. This mature analysis explores the benefit of the addition of sequential blinatumomab to low-intensity mini-Hyper-CVD chemotherapy with inotuzumab ozogamicin in this setting. METHODS Mini-Hyper-CVD (cyclophosphamide and dexamethasone at 50% dose reduction, no anthracycline, methotrexate at 75% dose reduction, cytarabine at 83% dose reduction) was combined with inotuzumab during the first 4 courses. From Patient #68 and onwards, inotuzumab was given in reduced and fractionated doses, and blinatumomab was added sequentially for 4 courses. Maintenance therapy with prednisone, vincristine, 6-mercaptopurine and methotrexate was given for 12 courses, and blinatumomab for 4 additional courses. RESULTS Among 110 patients (median age, 37 years) treated, 91 (83%) responded (complete response, 69 patients, 63%). Measurable residual disease negativity was documented in 75 patients (82% of responders). Fifty-three patients (48%) received allogeneic stem cell transplantation (SCT). Hepatic sinusoidal obstruction syndrome occurred in 9/67 patients (13%) on the original inotuzumab schedule and in 1/43 (2%) on the modified schedule. With a median follow-up of 48 months, the median overall survival (OS) was 17 months, and the 3 year OS was 40%. The 3 year OS was 34% with mini-Hyper-CVD plus inotuzumab and 52% with additional blinatumomab (P = 0.16). By landmark analysis at 4 months, the 3 year OS was 54%, similar between patients who did or did not receive allogeneic SCT. CONCLUSION Low-intensity mini-Hyper-CVD plus inotuzumab with or without blinatumomab showed efficacy in patients with relapsed-refractory ALL, with better survival after the addition of blinatumomab. Trial registration The trial was registered on clinicaltrials.gov with the identifier NCT01371630.
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Affiliation(s)
- Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Box 428, Houston, TX, 77030, USA.
| | - Fadi G Haddad
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Box 428, Houston, TX, 77030, USA
| | - Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Box 428, Houston, TX, 77030, USA
| | - Koji Sasaki
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Box 428, Houston, TX, 77030, USA
| | - Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Box 428, Houston, TX, 77030, USA
| | - Sanam Loghavi
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Rashmi Kanagal-Shamanna
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Jeffrey Jorgensen
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Issa Khouri
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Partow Kebriaei
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Yesid Alvarado
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Box 428, Houston, TX, 77030, USA
| | - Tapan Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Box 428, Houston, TX, 77030, USA
| | - Shilpa Paul
- Department of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Guillermo Garcia-Manero
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Box 428, Houston, TX, 77030, USA
| | - Bouthaina Dabaja
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, 77030, USA
| | - Musa Yilmaz
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Box 428, Houston, TX, 77030, USA
| | - Jovitta Jacob
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Box 428, Houston, TX, 77030, USA
| | - Rebecca Garris
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Box 428, Houston, TX, 77030, USA
| | - Susan O'Brien
- Chao Family Comprehensive Cancer Center, University of California Irvine, Orange, CA, USA
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Box 428, Houston, TX, 77030, USA
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Box 428, Houston, TX, 77030, USA
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10
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Jabbour E, Short NJ, Jain N, Haddad FG, Welch MA, Ravandi F, Kantarjian H. The evolution of acute lymphoblastic leukemia research and therapy at MD Anderson over four decades. J Hematol Oncol 2023; 16:22. [PMID: 36927623 PMCID: PMC10018889 DOI: 10.1186/s13045-023-01409-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 02/09/2023] [Indexed: 03/18/2023] Open
Abstract
Progress in the research and therapy of adult acute lymphoblastic leukemia (ALL) is accelerating. This analysis summarizes the data derived from the clinical trials conducted at MD Anderson between 1985 and 2022 across ALL subtypes. In Philadelphia chromosome-positive ALL, the addition of BCR::ABL1 tyrosine kinase inhibitors (TKIs) to intensive chemotherapy since 2000, improved outcomes. More recently, a chemotherapy-free regimen with blinatumomab and ponatinib resulted in a complete molecular remission rate of 85% and an estimated 3-year survival rate of 90%, potentially reducing the role of, and need for allogeneic stem cell transplantation (SCT) in remission. In younger patients with pre-B Philadelphia chromosome-negative ALL, the integration of blinatumomab and inotuzumab into the frontline therapy has improved the estimated 3-year survival rate to 85% across all risk categories. Our future strategy is to evaluate the early integration of both immunotherapy agents, inotuzumab and blinatumomab, with low-dose chemotherapy (dose-dense mini-Hyper-CVD-inotuzumab-blinatumomab) into the frontline setting followed by CAR T cells consolidation in high-risk patients, without any further maintenance therapy. In older patients, using less intensive chemotherapy (mini-Hyper-CVD) in combination with inotuzumab and blinatumomab has improved the 5-year survival rate to 50%. Among patients ≥ 65-70 years, the mortality in complete remission (CR) is still high and is multifactorial (old age, death in CR with infections, development of myelodysplastic syndrome or acute myeloid leukemia). A chemotherapy-free regimen with inotuzumab and blinatumomab is being investigated. The assessment of measurable residual disease (MRD) by next-generation sequencing (NGS) is superior to conventional assays, with early MRD negativity by NGS being associated with the best survival. We anticipate that the future therapy in B-ALL will involve less intensive and shorter chemotherapy regimens in combination with agents targeting CD19 (blinatumomab), CD20, and CD22 (inotuzumab). The optimal timing and use of CAR T cells therapy may be in the setting of minimal disease, and future trials will assess the role of CAR T cells as a consolidation among high-risk patients to replace allogeneic SCT. In summary, the management of ALL has witnessed significant progress during the past four decades. Novel combination regimens including newer-generation BCR::ABL1 TKIs and novel antibodies are questioning the need and duration of intensive chemotherapy and allogeneic SCT.
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Affiliation(s)
- Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 428, Houston, TX, 77030, USA.
| | - Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 428, Houston, TX, 77030, USA
| | - Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 428, Houston, TX, 77030, USA
| | - Fadi G Haddad
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 428, Houston, TX, 77030, USA
| | - Mary Alma Welch
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 428, Houston, TX, 77030, USA
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 428, Houston, TX, 77030, USA
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 428, Houston, TX, 77030, USA
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11
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Kantarjian H, Short NJ, Jain N, Sasaki K, Huang X, Haddad FG, Khouri I, DiNardo CD, Pemmaraju N, Wierda W, Garcia-Manero G, Kebriaei P, Garris R, Loghavi S, Jorgensen J, Kwari M, O'Brien S, Ravandi F, Jabbour E. Frontline combination of ponatinib and hyper-CVAD in Philadelphia chromosome-positive acute lymphoblastic leukemia: 80-months follow-up results. Am J Hematol 2023; 98:493-501. [PMID: 36600670 DOI: 10.1002/ajh.26816] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 11/23/2022] [Accepted: 12/14/2022] [Indexed: 01/06/2023]
Abstract
The combination of ponatinib, a third-generation BCR::ABL1 tyrosine kinase inhibitor, with hyper-CVAD chemotherapy resulted in high rates of complete molecular remissions and survival, without the need for stem cell transplantation (SCT) in most patients with Philadelphia chromosome(Ph)-positive acute lymphocytic leukemia (ALL). Confirming these results in a large cohort of patients with longer follow-up would establish this regimen as a new standard of care. Adults with newly diagnosed Ph-positive ALL were treated with the hyper-CVAD regimen. Ponatinib was added as 45 mg daily × 14 during induction, then 45 mg daily continuously (first 37 patients) or 30 mg daily continuously, with dose reduction to 15 mg daily upon achievement of a complete molecular response (CMR; absence of a detectable BCR::ABL1 transcript by quantitative reverse transcription polymerase-chain reaction at a sensitivity of 0.01%). Maintenance therapy consisted of daily ponatinib and vincristine-prednisone monthly for 2 years, followed by daily ponatinib indefinitely. Twelve intrathecal injections of cytarabine alternating with methotrexate were given as central nervous system prophylaxis. The trial is registered on clinicaltrials.gov with the identifier NCT01424982. Eighty-six patients were treated. Their median age was 46 years (range, 21-80). All 68 patients with active disease at the initiation of therapy achieved complete response (CR) The cumulative CMR rate was 86%. Twenty- patients (23%) underwent allogeneic SCT. With a median follow-up of 80 months (range, 16-129 months), the estimated 6-year event-free survival rate was 65% and the overall survival rate was 75%. There was no difference in outcome by performance of allogeneic SCT in first CR. Common grade 3-5 adverse events included infection (n = 80, 93%), increased liver transaminases (n = 26, 31%) and total bilirubin (n = 13, 15%), hypertension (n = 15, 17%), pancreatitis (n = 13, 15%), hemorrhage (n = 12, 13%), and skin rash (n = 9, 10%). Two ponatinib-related deaths from myocardial infarction (3%; at months 2.6 and 4.3, respectively; both in CR) in the first 37 patients treated led to the ponatinib dose-modifications mentioned earlier, with no further ponatinib-related deaths observed. The long-term results of ponatinib and hyper-CVAD continue to demonstrate excellent outcome results and acceptable safety data, indicating that this strategy is another standard of care approach in frontline Ph-positive ALL.
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Affiliation(s)
- Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Koji Sasaki
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Xuelin Huang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Fadi G Haddad
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Issa Khouri
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Courtney D DiNardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - William Wierda
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Guillermo Garcia-Manero
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Partow Kebriaei
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Rebecca Garris
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sanam Loghavi
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jeffrey Jorgensen
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Monica Kwari
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Susan O'Brien
- Chao Family Comprehensive Cancer Center, University of California Irvine, Orange, California, USA
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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12
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Nedumannil R, Ritchie D, Bajel A, Ng AP, Harrison SJ, Westerman D. Real-world utility of early measurable residual disease assessments by multi-parametric flow cytometry in adult patients with B-lymphoblastic leukemia receiving Hyper-CVAD induction chemotherapy. Eur J Haematol Suppl 2023; 110:168-176. [PMID: 36321745 DOI: 10.1111/ejh.13890] [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: 08/24/2022] [Revised: 10/22/2022] [Accepted: 10/26/2022] [Indexed: 11/05/2022]
Abstract
Multi-parametric flow cytometry (MFC) has a well-established role in measurable residual disease (MRD) monitoring in patients with B-lymphoblastic leukemia (B-ALL). However, the optimal time-point (TP) for early MRD testing and associated prognostic impact remain undefined in adult B-ALL patients receiving Hyper-CVAD induction chemotherapy. To evaluate the utility of MRD analysis after one cycle (TP1) in comparison to MRD analysis after two cycles (TP2) of induction treatment with Hyper-CVAD chemotherapy, we studied 49 adult B-ALL patients over a 10-year period (2010-2020) who had available bone marrow samples for morphological and MFC MRD assessments at the two separate TPs. Median times to TP1 and TP2 relative to start of treatment were 21 and 45 days, respectively. When censored at transplant, achievement of MRD negativity at TP1 was not associated with a statistically significant improvement in either event-free survival (EFS) (p = .426) or overall survival (OS) (p = .335) when compared to patients with MRD positivity. In contrast, achieving MRD negativity at TP2 was associated with a statistically significant improvement in both EFS (p = ·005) and OS (p = .047) over patients who remained MRD positive. Multivariate analysis demonstrated that KMT2A-rearrangement and MRD positivity at TP2 were the only significant predictors of outcome, correlating with worse EFS and OS. Therefore, in the absence of residual morphologic disease, MRD analysis after one cycle of Hyper-CVAD induction chemotherapy did not provide additional benefit with regard to risk stratification or correlation with survival outcomes when compared to MRD testing after two cycles of Hyper-CVAD in adult B-ALL patients.
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Affiliation(s)
- Rithin Nedumannil
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Diagnostic Haematology, Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Clinical Haematology, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - David Ritchie
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Victoria, Australia
| | - Ashish Bajel
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Victoria, Australia
| | - Ashley P Ng
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Immunology Division, Walter and Eliza Hall Institute of Medical Research, Parkville, Australia
| | - Simon J Harrison
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Victoria, Australia
| | - David Westerman
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Department of Clinical Haematology, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Victoria, Australia
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13
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Tecchio C, Russignan A, Krampera M. Immunophenotypic measurable residual disease monitoring in adult acute lymphoblastic leukemia patients undergoing allogeneic hematopoietic stem cell transplantation. Front Oncol 2023; 13:1047554. [PMID: 36910638 PMCID: PMC9992536 DOI: 10.3389/fonc.2023.1047554] [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: 09/18/2022] [Accepted: 01/11/2023] [Indexed: 02/24/2023] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-HSCT) offers a survival benefit to adult patients affected by acute lymphoblastic leukemia (ALL). However, to avoid an overt disease relapse, patients with pre or post transplant persistence or occurrence of measurable residual disease (MRD) may require cellular or pharmacological interventions with eventual side effects. While the significance of multiparametric flow cytometry (MFC) in the guidance of ALL treatment in both adult and pediatric patients is undebated, fewer data are available regarding the impact of MRD monitoring, as assessed by MFC analysis, in the allo-HSCT settings. Aim of this article is to summarize and discuss currently available information on the role of MFC detection of MRD in adult ALL patients undergoing allo-HSCT. The significance of MFC-based MRD according to sensitivity level, timing, and in relation to molecular techniques of MRD and chimerism assessment will be also discussed.
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Affiliation(s)
- Cristina Tecchio
- Department of Medicine, Section of Hematology and Bone Marrow Transplant Unit, University of Verona, Verona, Italy
| | - Anna Russignan
- Department of Medicine, Section of Hematology and Bone Marrow Transplant Unit, University of Verona, Verona, Italy
| | - Mauro Krampera
- Department of Medicine, Section of Hematology and Bone Marrow Transplant Unit, University of Verona, Verona, Italy
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14
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Beelen DW, Arnold R, Stelljes M, Alakel N, Brecht A, Bug G, Bunjes D, Faul C, Finke J, Franke GN, Holler E, Kobbe G, Kröger N, Rösler W, Scheid C, Schönland S, Stadler M, Tischer J, Wagner-Drouet E, Wendelin K, Brüggemann M, Reiser L, Hoelzer D, Gökbuget N. Long-Term Results of Allogeneic Stem Cell Transplantation in Adult Ph- Negative High-Risk Acute Lymphoblastic Leukemia. Transplant Cell Ther 2022; 28:834-842. [PMID: 36031078 DOI: 10.1016/j.jtct.2022.08.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 08/19/2022] [Accepted: 08/22/2022] [Indexed: 12/24/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (HCT) is standard treatment for adult high-risk (HR) acute lymphoblastic leukemia (ALL) and contributed to the overall improved outcome. We report a consecutive cohort of prospectively defined HR patients treated on German Multicenter Acute Lymphoblastic Leukemia trials 06/99-07/03 with similar induction/consolidation therapy and HCT in first remission. A total of 542 patients (15-55 years) with BCR-ABL-negative ALL were analyzed. Sixty-seven percent received HCT from matched unrelated donors (MUD) and 32% from matched sibling donors (MSD). The incidence of non-relapse mortality (NRM) was 20% at 5 years. NRM occurred after median 6.6 months; the leading cause (46%) was infection. NRM after MUD decreased from 39% in trial 06/99 to 16% in trial 07/03 (P < .00001). Patient age was the strongest predictor of NRM. The 5-year relapse incidence was 23% using MSD and 25% using MUD. Minimal residual disease (MRD) was the strongest predictor of relapse (45% for molecular failure versus 6% for molecular CR; P < .0001). The median follow-up was 67 months, and the 5-year survival rate was 58%. Age, subtype/high risk feature, MRD status, trial and acute GvHD were significant prognostic factors. We provide a large reference analysis with long follow-up confirming a similar outcome of MSD and MUD HCT and improved NRM for MUD HCT over years. MRD has a strong impact on relapse risk, whereas age was the strongest predictor of NRM. New adapted conditioning strategies should be considered for older patients combined with the goal to reduce the MRD level before stem cell transplantation.
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Affiliation(s)
- Dietrich W Beelen
- Department of Bone Marrow Transplantation, West German Cancer Center, University of Duisburg-Essen, Duisburg, Germany
| | - Renate Arnold
- Hematology and Oncology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Stelljes
- Department of Medicine/Hematology and Oncology, University of Muenster, Münster, Germany
| | - Nael Alakel
- Department of Internal Medicine I, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Arne Brecht
- Helios Dr. Horst Schmidt Kliniken Wiesbaden, Wiesbaden, Germany
| | - Gesine Bug
- Department of Medicine II, Hematology/Oncology, Goethe University, Frankfurt, Germany
| | - Donald Bunjes
- Department of Internal Medicine III, University Hospital of Ulm, Ulm, Germany
| | - Christoph Faul
- Department of Hematology and Oncology, Tuebingen University Hospital, Tübingen, Germany
| | - Jürgen Finke
- Department of Hematology, Oncology and Stem-Cell Transplantation, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | | | - Ernst Holler
- Department of Hematology and Oncology, University of Regensburg, Regensburg, Germany
| | - Guido Kobbe
- Department of Hematology, Oncology and Clinical Immunology, University Hospital Düsseldorf, Heinrich Heine University, Düsseldorf, Germany
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Wolf Rösler
- Department of Internal Medicine 5, Hematology/Oncology, University Hospital Erlangen, Erlangen, Germany
| | - Christof Scheid
- Department I of Internal Medicine, Center of Integrated Oncology Cologne, Cologne, Germany
| | - Stefan Schönland
- Department Medicine V, University of Heidelberg, Heidelberg, Germany
| | - Michael Stadler
- Hematology & Oncology, Medical Center University of Hannover, Hannover, Germany
| | - Johanna Tischer
- Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Eva Wagner-Drouet
- Department of Hematology, Medical Oncology and Pneumology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Knut Wendelin
- Department of Internal Medicine 5, Klinikum Nürnberg, Paracelsus Medizinische Privatuniversität, Nürnberg, Germany
| | - Monika Brüggemann
- Department of Internal Medicine II, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Lena Reiser
- Department of Medicine II, Hematology/Oncology, Goethe University, Frankfurt, Germany
| | - Dieter Hoelzer
- Department of Medicine II, Hematology/Oncology, Goethe University, Frankfurt, Germany
| | - Nicola Gökbuget
- Department of Medicine II, Hematology/Oncology, Goethe University, Frankfurt, Germany.
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15
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Larkin KT, Nicolet D, Kelly BJ, Mrózek K, LaHaye S, Miller KE, Wijeratne S, Wheeler G, Kohlschmidt J, Blachly JS, Mims AS, Walker CJ, Oakes CC, Orwick S, Boateng I, Buss J, Heyrosa A, Desai H, Carroll AJ, Blum W, Powell BL, Kolitz JE, Moore JO, Mayer RJ, Larson RA, Stone RM, Paskett ED, Byrd JC, Mardis ER, Eisfeld AK. High early death rates, treatment resistance, and short survival of Black adolescents and young adults with AML. Blood Adv 2022; 6:5570-5581. [PMID: 35788257 PMCID: PMC9577622 DOI: 10.1182/bloodadvances.2022007544] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 04/20/2022] [Indexed: 11/20/2022] Open
Abstract
Survival of patients with acute myeloid leukemia (AML) is inversely associated with age, but the impact of race on outcomes of adolescent and young adult (AYA; range, 18-39 years) patients is unknown. We compared survival of 89 non-Hispanic Black and 566 non-Hispanic White AYA patients with AML treated on frontline Cancer and Leukemia Group B/Alliance for Clinical Trials in Oncology protocols. Samples of 327 patients (50 Black and 277 White) were analyzed via targeted sequencing. Integrated genomic profiling was performed on select longitudinal samples. Black patients had worse outcomes, especially those aged 18 to 29 years, who had a higher early death rate (16% vs 3%; P=.002), lower complete remission rate (66% vs 83%; P=.01), and decreased overall survival (OS; 5-year rates: 22% vs 51%; P<.001) compared with White patients. Survival disparities persisted across cytogenetic groups: Black patients aged 18 to 29 years with non-core-binding factor (CBF)-AML had worse OS than White patients (5-year rates: 12% vs 44%; P<.001), including patients with cytogenetically normal AML (13% vs 50%; P<.003). Genetic features differed, including lower frequencies of normal karyotypes and NPM1 and biallelic CEBPA mutations, and higher frequencies of CBF rearrangements and ASXL1, BCOR, and KRAS mutations in Black patients. Integrated genomic analysis identified both known and novel somatic variants, and relative clonal stability at relapse. Reduced response rates to induction chemotherapy and leukemic clone persistence suggest a need for different treatment intensities and/or modalities in Black AYA patients with AML. Higher early death rates suggest a delay in diagnosis and treatment, calling for systematic changes to patient care.
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Affiliation(s)
- Karilyn T. Larkin
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
- Clara D. Bloomfield Center for Leukemia Outcomes Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Deedra Nicolet
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
- Clara D. Bloomfield Center for Leukemia Outcomes Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH
- Alliance Statistics and Data Center, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Benjamin J. Kelly
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH
| | - Krzysztof Mrózek
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
- Clara D. Bloomfield Center for Leukemia Outcomes Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Stephanie LaHaye
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH
| | - Katherine E. Miller
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
| | - Saranga Wijeratne
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH
| | - Gregory Wheeler
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH
| | - Jessica Kohlschmidt
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
- Clara D. Bloomfield Center for Leukemia Outcomes Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH
- Alliance Statistics and Data Center, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - James S. Blachly
- Clara D. Bloomfield Center for Leukemia Outcomes Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Alice S. Mims
- Clara D. Bloomfield Center for Leukemia Outcomes Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Christopher J. Walker
- Clara D. Bloomfield Center for Leukemia Outcomes Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Christopher C. Oakes
- Clara D. Bloomfield Center for Leukemia Outcomes Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Shelley Orwick
- Clara D. Bloomfield Center for Leukemia Outcomes Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Isaiah Boateng
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Jill Buss
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
- Clara D. Bloomfield Center for Leukemia Outcomes Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Adrienne Heyrosa
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
- Clara D. Bloomfield Center for Leukemia Outcomes Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Helee Desai
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
- Clara D. Bloomfield Center for Leukemia Outcomes Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Andrew J. Carroll
- Department of Genetics, University of Alabama at Birmingham, Birmingham, AL
| | - William Blum
- Emory University School of Medicine, Atlanta, GA
| | - Bayard L. Powell
- Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC
| | - Jonathan E. Kolitz
- Monter Cancer Center, Hofstra Northwell School of Medicine, Lake Success, NY
| | - Joseph O. Moore
- Duke Cancer Institute, Duke University Medical Center, Durham, NC
| | - Robert J. Mayer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | | | - Richard M. Stone
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Electra D. Paskett
- Division of Cancer Prevention and Control, Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, OH
- The Center for Cancer Health Equity, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - John C. Byrd
- Department of Internal Medicine, University of Cincinnati, Cincinnati, OH
| | - Elaine R. Mardis
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
| | - Ann-Kathrin Eisfeld
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
- Clara D. Bloomfield Center for Leukemia Outcomes Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, Columbus, OH
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16
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Bone Marrow Stromal Cell Regeneration Profile in Treated B-Cell Precursor Acute Lymphoblastic Leukemia Patients: Association with MRD Status and Patient Outcome. Cancers (Basel) 2022; 14:cancers14133088. [PMID: 35804860 PMCID: PMC9265080 DOI: 10.3390/cancers14133088] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/16/2022] [Accepted: 06/16/2022] [Indexed: 12/10/2022] Open
Abstract
For the last two decades, measurable residual disease (MRD) has become one of the most powerful independent prognostic factors in B-cell precursor acute lymphoblastic leukemia (BCP-ALL). However, the effect of therapy on the bone marrow (BM) microenvironment and its potential relationship with the MRD status and disease free survival (DFS) still remain to be investigated. Here we analyzed the distribution of mesenchymal stem cells (MSC) and endothelial cells (EC) in the BM of treated BCP-ALL patients, and its relationship with the BM MRD status and patient outcome. For this purpose, the BM MRD status and EC/MSC regeneration profile were analyzed by multiparameter flow cytometry (MFC) in 16 control BM (10 children; 6 adults) and 1204 BM samples from 347 children and 100 adult BCP-ALL patients studied at diagnosis (129 children; 100 adults) and follow-up (824 childhood samples; 151 adult samples). Patients were grouped into a discovery cohort (116 pediatric BCP-ALL patients; 338 samples) and two validation cohorts (74 pediatric BCP-ALL, 211 samples; and 74 adult BCP-ALL patients; 134 samples). Stromal cells (i.e., EC and MSC) were detected at relatively low frequencies in all control BM (16/16; 100%) and in most BCP-ALL follow-up samples (874/975; 90%), while they were undetected in BCP-ALL BM at diagnosis. In control BM samples, the overall percentage of EC plus MSC was higher in children than adults (p = 0.011), but with a similar EC/MSC ratio in both groups. According to the MRD status similar frequencies of both types of BM stromal cells were detected in BCP-ALL BM studied at different time points during the follow-up. Univariate analysis (including all relevant prognostic factors together with the percentage of stromal cells) performed in the discovery cohort was used to select covariates for a multivariate Cox regression model for predicting patient DFS. Of note, an increased percentage of EC (>32%) within the BCP-ALL BM stromal cell compartment at day +78 of therapy emerged as an independent unfavorable prognostic factor for DFS in childhood BCP-ALL in the discovery cohort—hazard ratio (95% confidence interval) of 2.50 (1−9.66); p = 0.05—together with the BM MRD status (p = 0.031). Further investigation of the predictive value of the combination of these two variables (%EC within stromal cells and MRD status at day +78) allowed classification of BCP-ALL into three risk groups with median DFS of: 3.9, 3.1 and 1.1 years, respectively (p = 0.001). These results were confirmed in two validation cohorts of childhood BCP-ALL (n = 74) (p = 0.001) and adult BCP-ALL (n = 40) (p = 0.004) treated at different centers. In summary, our findings suggest that an imbalanced EC/MSC ratio in BM at day +78 of therapy is associated with a shorter DFS of BCP-ALL patients, independently of their MRD status. Further prospective studies are needed to better understand the pathogenic mechanisms involved.
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17
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Shi Z, Zhu Y, Zhang J, Chen B. Monoclonal antibodies: new chance in the management of B-cell acute lymphoblastic leukemia. Hematology 2022; 27:642-652. [PMID: 35622074 DOI: 10.1080/16078454.2022.2074704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES This review aims to see the progress of several clinically-used monoclonal antibodies in treating ALL patients and how they improved patients' outcomes. METHODS We searched Web of Science, Elsevier and PubMed for relevant published studies, and summarized eligible evidence on the management of newly-diagnosed and relapsed or refractory ALL with monoclonal antibodies. Ongoing trials were identified from ClinicalTrials.gov. RESULTS Rituximab, an anti-CD20 monoclonal antibody, prolonged patients' complete remission duration and overall survival when combined with hyper-CVAD regimen. Another anti-CD20 monoclonal antibody, Ofatumumab, was reported to have similar benefits. Blinatumomab allows endogenous CD3-positive cytotoxic T cells to target and eliminate CD19-positive blasts. FDA has approved its efficacy in patients with R/R B-ALL and eliminating minimal residual disease (MRD). It serves as a bridge to eradicate MRD before transplantation, and may also be a new choice for patients unable to undergo transplantation. An anti-CD22 monoclonal antibody named Inotuzumab Ozogamicin showed great improvement in patients' outcome, but its toxicity to liver is also worthy of our attention. CONCLUSION Monoclonal antibodies are proven to be a promising immunotherapeutic strategy to improve ALL patients' outcome in the long term. There's still a need for individualized treatment with effective and well-tolerated medicines.Trial registration: ClinicalTrials.gov identifier: NCT01363128.Trial registration: ClinicalTrials.gov identifier: NCT01466179.Trial registration: ClinicalTrials.gov identifier: NCT02013167.Trial registration: ClinicalTrials.gov identifier: NCT02000427.Trial registration: ClinicalTrials.gov identifier: NCT01564784.Trial registration: ClinicalTrials.gov identifier: NCT03677596.Trial registration: ClinicalTrials.gov identifier: NCT01363297.Trial registration: ClinicalTrials.gov identifier: NCT02981628.Trial registration: ClinicalTrials.gov identifier: NCT03094611.Trial registration: ClinicalTrials.gov identifier: NCT01371630.Trial registration: ClinicalTrials.gov identifier: NCT04224571.Trial registration: ClinicalTrials.gov identifier: NCT02458014.Trial registration: ClinicalTrials.gov identifier: NCT04546399.Trial registration: ClinicalTrials.gov identifier: NCT02879695.Trial registration: ClinicalTrials.gov identifier: NCT03913559.Trial registration: ClinicalTrials.gov identifier: NCT03441061.Trial registration: ClinicalTrials.gov identifier: NCT03739814.Trial registration: ClinicalTrials.gov identifier: NCT02877303.Trial registration: ClinicalTrials.gov identifier: NCT03698552.Trial registration: ClinicalTrials.gov identifier: NCT04601584.Trial registration: ClinicalTrials.gov identifier: NCT04684147.Trial registration: ClinicalTrials.gov identifier: NCT04681105.
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Affiliation(s)
- Zheng Shi
- Department of Hematology and Oncology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, People's Republic of China
| | - Yiqian Zhu
- Department of Hematology and Oncology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, People's Republic of China
| | - Jing Zhang
- Department of Hematology and Oncology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, People's Republic of China
| | - Baoan Chen
- Department of Hematology and Oncology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, People's Republic of China
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18
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Pierce E, Mautner B, Mort J, Blewett A, Morris A, Keng M, El Chaer F. MRD in ALL: Optimization and Innovations. Curr Hematol Malig Rep 2022; 17:69-81. [PMID: 35616771 DOI: 10.1007/s11899-022-00664-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Measurable residual disease (MRD) is an important monitoring parameter that can help predict survival outcomes in acute lymphoblastic leukemia (ALL). Identifying patients with MRD has the potential to decrease the risk of relapse with the initiation of early salvage therapy and to help guide decision making regarding allogeneic hematopoietic cell transplantation. In this review, we discuss MRD in ALL, focusing on advantages and limitations between MRD testing techniques and how to monitor MRD in specific patient populations. RECENT FINDINGS MRD has traditionally been measured through bone marrow samples, but more data for evaluation of MRD via peripheral blood is emerging. Current and developmental testing strategies for MRD include multiparametric flow cytometry (MFC), next-generation sequencing (NGS), quantitative polymerase chain reaction (qPCR), and ClonoSeq. Novel therapies are incorporating MRD as an outcome measure to demonstrate efficacy, including blinatumomab, inotuzumab ozogamicin, and chimeric antigen receptor T (CAR-T) cell therapy. Understanding how to incorporate MRD testing into the management of ALL could improve patient outcomes and predict efficacy of new therapy options.
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Affiliation(s)
- Eric Pierce
- Department of Medicine, Division of Hematology and Oncology, University of Virginia Comprehensive Cancer Center, 1300 Jefferson Park Ave, PO Box 800716, Charlottesville, VA, 22908, USA
| | - Benjamin Mautner
- Department of Medicine, Division of Hematology and Oncology, University of Virginia Comprehensive Cancer Center, 1300 Jefferson Park Ave, PO Box 800716, Charlottesville, VA, 22908, USA
| | - Joseph Mort
- Department of Medicine, Division of Hematology and Oncology, University of Virginia Comprehensive Cancer Center, 1300 Jefferson Park Ave, PO Box 800716, Charlottesville, VA, 22908, USA
| | - Anastassia Blewett
- Department of Pharmacy Services, University of Virginia Comprehensive Cancer Center, 1300 Jefferson Park Ave, PO Box 800716, Charlottesville, VA, 22908, USA
| | - Amy Morris
- Department of Pharmacy Services, University of Virginia Comprehensive Cancer Center, 1300 Jefferson Park Ave, PO Box 800716, Charlottesville, VA, 22908, USA
| | - Michael Keng
- Department of Medicine, Division of Hematology and Oncology, University of Virginia Comprehensive Cancer Center, 1300 Jefferson Park Ave, PO Box 800716, Charlottesville, VA, 22908, USA
| | - Firas El Chaer
- Department of Medicine, Division of Hematology and Oncology, University of Virginia Comprehensive Cancer Center, 1300 Jefferson Park Ave, PO Box 800716, Charlottesville, VA, 22908, USA.
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19
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Komitopoulou A, Baltadakis I, Peristeri I, Goussetis E. Immunotherapy and Allogeneic Bone Marrow Transplantation in B Acute Lymphoblastic Leukemia: How to Sequence? Clin Hematol Int 2022; 4:11-20. [PMID: 35950202 PMCID: PMC9358786 DOI: 10.1007/s44228-022-00006-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 03/10/2022] [Indexed: 01/04/2023] Open
Abstract
Long-term disease control is achieved in 80–90% of patients with acute lymphoblastic leukemia of B origin (B-ALL). About half of adult and 10% of pediatric patients develop refractory or relapsed disease, whereas survival after relapse accounts about 10% in adults and 30–50% in children. Allogeneic bone marrow transplantation offers remarkable benefit in cases with unfavorable outcome. Nevertheless, novel immunotherapeutic options have been approved for patients with adverse prognosis. Immunotherapeutic agents, nowadays, are preferred over standard chemotherapy for patients with relapsed or refractory B-ALL The mode of action, efficacy and safety data of immunotherapeutic agents released, indications and sequence of those therapies over the course of treatment, are herein reviewed.
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Affiliation(s)
- Anna Komitopoulou
- Stem Cell Transplant Unit, “Agia Sofia Children’s Hospital”, Mikras Asias 46 and Levadias 8, 11527 Athens, Greece
| | - I. Baltadakis
- Department of Haematology and Bone Marrow Transplantation Unit, Evangelismos Hospital, Athens, Greece
| | - I. Peristeri
- Stem Cell Transplant Unit, “Agia Sofia Children’s Hospital”, Mikras Asias 46 and Levadias 8, 11527 Athens, Greece
| | - E. Goussetis
- Stem Cell Transplant Unit, “Agia Sofia Children’s Hospital”, Mikras Asias 46 and Levadias 8, 11527 Athens, Greece
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20
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Kamel AM, Elsharkawy NM, Kandeel EZ, Hanafi M, Samra M, Osman RA. Leukemia Stem Cell Frequency at Diagnosis Correlates With Measurable/Minimal Residual Disease and Impacts Survival in Adult Acute Myeloid Leukemia. Front Oncol 2022; 12:867684. [PMID: 35530356 PMCID: PMC9069678 DOI: 10.3389/fonc.2022.867684] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/03/2022] [Indexed: 11/17/2022] Open
Abstract
Acute myeloid leukemia (AML) is a heterogenous disease in which the initiation and maintenance of the malignant clone is blamed on a rare population of leukemia stem cells (LSCs). The persistence of such a malignant population is referred to as measurable/minimal residual disease (MRD). Evaluation of MRD is the gold standard for follow-up of therapy and constitutes an independent prognostic parameter. As LSCs are the main contributor to the persistence of MRD, then MRD should correlate with the bulk of LSCs at the individual case level. MRD is measured at defined time points during therapy. However, LSCs can be evaluated at diagnosis, which ensures the advantage of early prediction of high-risk patients and allows for early therapeutic decisions. Using two simple four-color monoclonal antibody combinations (CD38/CD123/CD34/CD45 and CD90/CD133/CD45/CD33) and the prism function of the Coulter Navios flow cytometer, the frequency of LSC subsets was evaluated in 84 newly diagnosed adult AML patients. For each panel, 16 possible combinations were detected. Our results showed that there was extreme variability in the percentage of the LSC fraction between different cases, as well as at the individual case level. For each LSC subset, the median value was used to divide cases into low and high expressors. LSC subsets that showed an impact on overall survival (OS) and disease-free survival (DFS) included CD123+, CD 123+/CD34-, CD34-/CD38+/CD123+, CD34+/CD38-/CD123+, CD133+, and CD133+/CD33-. On multivariate analysis, only CD123 (p ≤ 0.001, SE = 0.266, HR = 2.8, 95% CI = 1.74.7) and CD133+/CD33- (p = 0.017, SE = 0.263, HR = 1.9, 95% CI = 1.1–3.1) retained their significance for OS. Likewise, only CD34+/CD38-/CD123+ (p ≤ 0.001, HR 2.3, SE: 0.499, 95% CI: 2.4–17.4) and CD133 (p = 0.015, HR 2.3, SE 0.34, 95% CI: 1.2–4.4) retained their statistical significance for DFS. The LSC frequency at diagnosis showed a moderate to strong correlation with MRD status at day 14 and day 28. In conclusion, the level of LSCs at diagnosis correlated with MRD status at day 14 and day 28 in AML patients and had a deleterious impact on OS and DFS. It may be used as an early marker for high-risk patients allowing for early therapeutic decisions.
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Affiliation(s)
- Azza M Kamel
- Department of Clinical Pathology, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Nahla M Elsharkawy
- Department of Clinical Pathology, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Eman Z Kandeel
- Department of Clinical Pathology, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Marwa Hanafi
- Department of Clinical Pathology, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Mohammed Samra
- Department of Medical Oncology, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Randa A Osman
- Department of Clinical Pathology, National Cancer Institute, Cairo University, Cairo, Egypt
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21
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High-sensitivity next-generation sequencing MRD assessment in ALL identifies patients at very low risk of relapse. Blood Adv 2022; 6:4006-4014. [PMID: 35533262 PMCID: PMC9278301 DOI: 10.1182/bloodadvances.2022007378] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/21/2022] [Indexed: 11/20/2022] Open
Abstract
Measurable residual disease (MRD) is highly prognostic for relapse and overall survival (OS) in acute lymphoblastic leukemia (ALL), although many patients with apparent "MRD negativity" by standard assays still relapse. We evaluated the clinical impact of a highly sensitive next-generation sequencing (NGS) MRD assay in 74 adults with ALL undergoing frontline therapy. Among remission samples that were MRD negative by multiparameter flow cytometry (MFC), 46% were MRD positive by the NGS assay. After one cycle of induction chemotherapy, MRD negativity by MFC at a sensitivity of 1x10-4 and NGS at a sensitivity of 1x10-6 was achieved in 66% and 23% of patients, respectively. The 5-year cumulative incidence of relapse (CIR) among patients who achieved MRD negativity by MFC at CR was 29%; in contrast, no patients who achieved early MRD negativity by NGS relapsed, and their 5-year OS was 90%. NGS MRD negativity at CR was associated with significantly decreased risk of relapse compared with MRD positivity (5-year CIR: 0% versus 45%, respectively, P=0.04). Among patients who were MRD negative by MFC, detection of low levels of MRD by NGS identified patients who still had a significant risk of relapse (5-year CIR: 39%). Early assessment of MRD using a highly sensitive NGS assay adds clinically relevant prognostic information to standard MFC-based approaches and can identify patients with ALL undergoing frontline therapy who have a very low risk of relapse and excellent long-term survival.
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22
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Hein K, Short N, Jabbour E, Yilmaz M. Clinical Value of Measurable Residual Disease in Acute Lymphoblastic Leukemia. Blood Lymphat Cancer 2022; 12:7-16. [PMID: 35340663 PMCID: PMC8943430 DOI: 10.2147/blctt.s270134] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 02/24/2022] [Indexed: 01/04/2023]
Abstract
Measurable (minimal) residual disease (MRD) status in acute lymphoblastic leukemia (ALL) has largely superseded the importance of traditional risk factors for ALL, such as baseline white blood cell count, cytogenetics, and immunophenotype, and has emerged as the most powerful independent prognostic predictor. The development of sensitive MRD techniques, such as multicolor flow cytometry (MFC), quantitative polymerase chain reaction (PCR), and next-generation sequencing (NGS), may further improve risk stratification and expand its impact in therapy. Additionally, the availability of highly effective agents for MRD eradication, such as blinatumomab, inotuzumab ozogamicin, and chimeric antigen receptor (CAR) T-cell therapies, enabled the development of frontline regimens capable of eradicating MRD early in the treatment course. While long-term follow-up of this approach is lacking, it has the potential to significantly reduce the need for intensive post-remission treatments, including allogeneic bone marrow transplantation, in a significant proportion of patients with ALL.
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Affiliation(s)
- Kyaw Hein
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nicholas Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Musa Yilmaz
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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23
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Aleem A, Haque AR, Roloff GW, Griffiths EA. Application of Next-Generation Sequencing-Based Mutational Profiling in Acute Lymphoblastic Leukemia. Curr Hematol Malig Rep 2021; 16:394-404. [PMID: 34613552 DOI: 10.1007/s11899-021-00641-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE OF REVIEW Recent efforts to characterize hematologic cancers with genetic and molecular detail have largely relied on mutational profiling via next-generation sequencing (NGS). The application of NGS-guided disease prognostication and clinical decision making requires a basic understanding of sequencing advantages, pitfalls, and areas where clinical care might be enhanced by the knowledge generated. This article identifies avenues within the landscape of adult acute lymphoblastic leukemia (ALL) where mutational data hold the opportunity to enhance understanding of disease biology and patient care. RECENT FINDINGS NGS-based assessment of measurable residual disease (MRD) after ALL treatment allows for a sensitive and specific molecular survey that is at least comparable, if not superior, to existing techniques. Mutational assessment by NGS has unraveled complex signaling networks that drive pathogenesis of T-cell ALL. Sequencing of patients with familial clustering of ALL has also identified novel germline mutations whose inheritance predisposes to disease development in successive generations. While NGS-based assessment of hematopoietic malignancies often provides actionable information to clinicians, patients with acute lymphoblastic leukemia are left underserved due to a lack of disease classification and prognostication schema that integrate molecular data. Ongoing research is positioned to enrich the molecular toolbox available to clinicians caring for adult ALL patients and deliver new insights to guide therapeutic selection, monitor clinical response, and detect relapse.
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Affiliation(s)
- Ahmed Aleem
- Department of Medicine, Loyola University Medical Center, 2160 S. 1st Ave, Maywood, IL, 60153, USA
| | - Ali R Haque
- Department of Medicine, Loyola University Medical Center, 2160 S. 1st Ave, Maywood, IL, 60153, USA
| | - Gregory W Roloff
- Department of Medicine, Loyola University Medical Center, 2160 S. 1st Ave, Maywood, IL, 60153, USA.
| | - Elizabeth A Griffiths
- Leukemia Service, Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
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24
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Short NJ, Kantarjian H, Jabbour E. SOHO State of the Art Updates & Next Questions: Intensive and Non-Intensive Approaches for Adults With Philadelphia Chromosome-Positive Acute Lymphoblastic Leukemia. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 22:61-66. [PMID: 34561201 DOI: 10.1016/j.clml.2021.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 08/09/2021] [Accepted: 08/16/2021] [Indexed: 10/20/2022]
Abstract
Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) was historically considered to be a very poor-risk subtype of ALL. However, with the introduction of highly potent BCR-ABL tyrosine kinase inhibitors (TKIs), Ph+ ALL can now be considered relatively favorable-risk acute leukemia. Considering the high rates of measurable residual disease negativity and excellent long-term survival that has been achieved with regimens incorporating later-generation TKIs and particularly with ponatinib, lower-intensity and even chemotherapy-free regimens are now being evaluated for patients of all ages with Ph+ ALL. The very encouraging early results observed with blinatumomab-based, chemotherapy-free regimens challenge previous notions that all patients with Ph+ ALL should undergo allogeneic stem cell transplantation in first remission, as these regimens are capable of achieving deep and durable remissions without need for transplant in the vast majority of patients, particularly when combined with ponatinib. In this review, we discuss the evolving approach to the treatment of adults with newly diagnosed Ph+ ALL and the major principles that should guide therapy in this disease. We also review the rationale and data supporting the use of novel, chemotherapy-free regimens in Ph+ ALL, and how these approaches may soon become new standards of care.
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Affiliation(s)
- Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
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25
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Short NJ, Kantarjian H, Jabbour E. Optimizing the treatment of acute lymphoblastic leukemia in younger and older adults: new drugs and evolving paradigms. Leukemia 2021; 35:3044-3058. [PMID: 34172894 DOI: 10.1038/s41375-021-01277-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 04/12/2021] [Accepted: 04/29/2021] [Indexed: 12/18/2022]
Abstract
In the past decade, the available treatments for patients with acute lymphoblastic leukemia (ALL) have rapidly expanded, in parallel with an increased understanding of the genomic features that impact the disease biology and clinical outcomes. With the development of the anti-CD22 antibody-drug conjugate inotuzumab ozogamicin, the CD3-CD19 bispecific T-cell engager antibody blinatumomab, CD19 chimeric antigen receptor T-cell therapy, and the potent BCR-ABL1 tyrosine kinase inhibitor ponatinib, the outlook of ALL in both younger and older adults has substantially improved. The availability of highly effective drugs raised important questions concerning the optimal combination and sequence of these agents, their incorporation into frontline regimens, and the role of hematopoietic stem cell transplantation. In this review, we discuss the rapidly evolving paradigms in the treatment of ALL, highlighting both established and effective regimens, as well as promising new therapies that are being evaluated in ongoing clinical trials. We specifically focus on novel combination regimens in both the frontline and salvage settings that are leading to new standards of care in the treatment of ALL.
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Affiliation(s)
- Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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26
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Chemotherapy or allogeneic transplantation in high-risk Philadelphia chromosome-negative adult lymphoblastic leukemia. Blood 2021; 137:1879-1894. [PMID: 33150388 DOI: 10.1182/blood.2020007311] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 10/01/2020] [Indexed: 01/02/2023] Open
Abstract
The need for allogeneic hematopoietic stem cell transplantation (allo-HSCT) in adults with Philadelphia chromosome-negative (Ph-) acute lymphoblastic leukemia (ALL) with high-risk (HR) features and adequate measurable residual disease (MRD) clearance remains unclear. The aim of the ALL-HR-11 trial was to evaluate the outcomes of HR Ph- adult ALL patients following chemotherapy or allo-HSCT administered based on end-induction and consolidation MRD levels. Patients aged 15 to 60 years with HR-ALL in complete response (CR) and MRD levels (centrally assessed by 8-color flow cytometry) <0.1% after induction and <0.01% after early consolidation were assigned to receive delayed consolidation and maintenance therapy up to 2 years in CR. The remaining patients were allocated to allo-HSCT. CR was attained in 315/348 patients (91%), with MRD <0.1% after induction in 220/289 patients (76%). By intention-to-treat, 218 patients were assigned to chemotherapy and 106 to allo-HSCT. The 5-year (±95% confidence interval) cumulative incidence of relapse (CIR), overall survival (OS), and event-free survival probabilities for the whole series were 43% ± 7%, 49% ± 7%, and 40% ± 6%, respectively, with CIR and OS rates of 45% ± 8% and 59% ± 9% for patients assigned to chemotherapy and of 40% ± 12% and 38% ± 11% for those assigned to allo-HSCT, respectively. Our results show that avoiding allo-HSCT does not hamper the outcomes of HR Ph- adult ALL patients up to 60 years with adequate MRD response after induction and consolidation. Better postremission alternative therapies are especially needed for patients with poor MRD clearance. This trial was registered at www.clinicaltrials.gov as # NCT01540812.
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27
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Jonas BA, Fisch SC, Rosenberg AS, Hoeg RT, Tuscano JM, Abedi M. Phase I study of escalating doses of carfilzomib with HyperCVAD in patients with newly diagnosed acute lymphoblastic leukemia. Am J Hematol 2021; 96:E114-E117. [PMID: 33476436 DOI: 10.1002/ajh.26105] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 01/11/2021] [Indexed: 12/18/2022]
Affiliation(s)
- Brian A. Jonas
- University of California, Davis School of Medicine Sacramento California USA
- University of California Davis Comprehensive Cancer Center Sacramento California USA
- Veterans Administration Northern California Health Care System Mather California USA
| | - Samantha C. Fisch
- University of California, Davis School of Medicine Sacramento California USA
| | - Aaron S. Rosenberg
- University of California, Davis School of Medicine Sacramento California USA
- University of California Davis Comprehensive Cancer Center Sacramento California USA
| | - Rasmus T. Hoeg
- University of California, Davis School of Medicine Sacramento California USA
- University of California Davis Comprehensive Cancer Center Sacramento California USA
| | - Joseph M. Tuscano
- University of California, Davis School of Medicine Sacramento California USA
- University of California Davis Comprehensive Cancer Center Sacramento California USA
- Veterans Administration Northern California Health Care System Mather California USA
| | - Mehrdad Abedi
- University of California, Davis School of Medicine Sacramento California USA
- University of California Davis Comprehensive Cancer Center Sacramento California USA
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28
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Wang H, Zhou Y, Huang X, Zhang Y, Qian J, Li J, Li C, Li X, Lou Y, Zhu Q, Huang Y, Meng H, Yu W, Tong H, Jin J, Zhu HH. Minimal residual disease level determined by flow cytometry provides reliable risk stratification in adults with T-cell acute lymphoblastic leukaemia. Br J Haematol 2021; 193:1096-1104. [PMID: 33764511 DOI: 10.1111/bjh.17424] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 02/28/2021] [Indexed: 01/21/2023]
Abstract
Minimal residual disease (MRD) is an important independent prognostic factor for relapse and survival in acute lymphoblastic leukaemia (ALL). Compared with adult B-cell ALL, reports of adult T-cell ALL (T-ALL) MRD have been scarce and mostly based on molecular methods. We evaluated the prognostic value of multiparameter flow cytometry (FCM)-based MRD at the end of induction (EOI-MRD). The present retrospective study included 94 adult patients with T-ALL. MRD was detected by six- to eight-colour FCM. Patients who were EOI-MRD positive had a higher cumulative incidence of relapse (CIR) (87·6% vs. 38·8%, P = 0·0020), and a lower relapse-free survival (RFS) (5·4% vs. 61·0%, P = 0·0005) and overall survival (OS) (32·7% vs. 69·7%, P < 0·0001) than those who were EOI-MRD negative. Moreover, for patients who received allogeneic haematopoietic stem cell transplantation (allo-HSCT) at their first remission, EOI-MRD positivity was predictive of post-transplant relapse (2-year CIR: 68·2% vs. 4·0%, P = 0·0003). Multivariate analysis showed that EOI-MRD was an independent prognostic factor for CIR [hazard ratio (HR) 2·139, P = 0·046], RFS (HR 2·125, P = 0·048) and OS (HR 2·987, P = 0·017). In conclusion, EOI-MRD based on FCM was an independent prognostic factor for relapse and survival in adult T-ALL. For patients who underwent HSCT, EOI-MRD could be used to identify patients with a high risk of relapse after allo-HSCT.
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Affiliation(s)
- Huanping Wang
- Department of Hematology, School of Medicine, the First Affiliated Hospital, Zhejiang University, Hangzhou, China.,Zhejiang Province Key Laboratory of Hematology Oncology Diagnosis and Treatment, Hangzhou, China
| | - Yile Zhou
- Department of Hematology, School of Medicine, the First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Xin Huang
- Department of Hematology, School of Medicine, the First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Yi Zhang
- Department of Hematology, School of Medicine, the First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Jiejing Qian
- Department of Hematology, School of Medicine, the First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Jianhu Li
- Department of Hematology, School of Medicine, the First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Chenying Li
- Department of Hematology, School of Medicine, the First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Xueying Li
- Department of Hematology, School of Medicine, the First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Yinjun Lou
- Department of Hematology, School of Medicine, the First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Qiaoyun Zhu
- Central Laboratory, School of Medicine, the First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Yujie Huang
- Key Laboratory of Drug Clinical Research and Evaluation Technology of Zhejiang Province, School of Medicine, the First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Haitao Meng
- Department of Hematology, School of Medicine, the First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Wenjuan Yu
- Department of Hematology, School of Medicine, the First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Hongyan Tong
- Department of Hematology, School of Medicine, the First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Jie Jin
- Department of Hematology, School of Medicine, the First Affiliated Hospital, Zhejiang University, Hangzhou, China.,Zhejiang Province Key Laboratory of Hematology Oncology Diagnosis and Treatment, Hangzhou, China
| | - Hong-Hu Zhu
- Department of Hematology, School of Medicine, the First Affiliated Hospital, Zhejiang University, Hangzhou, China.,Zhejiang Province Key Laboratory of Hematology Oncology Diagnosis and Treatment, Hangzhou, China.,Zhejiang University Cancer Center, Hangzhou, China.,Zhejiang Laboratory for Systems and Precision Medicine, Zhejiang University Medical Center, Hangzhou, China
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29
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Koller P, Saliba RM, Ledesma C, Rondon G, Popat U, Alousi A, Mehta R, Oran B, Olson A, Hosing C, Qazilbash M, Khouri I, Ciurea S, Shpall E, Jorgensen J, Wang S, Jain N, Jabbour E, Kantarjian H, Champlin R, Konopleva M, Kebriaei P. Outcomes in patients with CRLF2 overexpressed acute lymphoblastic leukemia after allogeneic hematopoietic cell transplantation. Bone Marrow Transplant 2021; 56:1746-1749. [PMID: 33767403 DOI: 10.1038/s41409-021-01262-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 02/02/2021] [Accepted: 02/23/2021] [Indexed: 11/09/2022]
Affiliation(s)
- Paul Koller
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Rima M Saliba
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Celina Ledesma
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gabriela Rondon
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Uday Popat
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amin Alousi
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rohtesh Mehta
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Betul Oran
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amanda Olson
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Chitra Hosing
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Muzaffar Qazilbash
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Issa Khouri
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Stefan Ciurea
- Division of Hematology/Oncology, Department of Medicine, University of California Irvine School of Medicine, Irvine, CA, USA
| | - Elizabeth Shpall
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey Jorgensen
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sa Wang
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Richard Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Marina Konopleva
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Partow Kebriaei
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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30
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Jabbour E, Sasaki K, Short NJ, Ravandi F, Huang X, Khoury JD, Kanagal-Shamanna R, Jorgensen J, Khouri IF, Kebriaei P, Jain N, Alvarado Y, Kadia TM, Paul S, Garcia-Manero G, Dabaja BS, Burger JA, DiNardo CD, Daver NA, Montalban-Bravo G, Yilmaz M, Ohanian M, Ferrajoli A, Jacob J, Rostykus M, Garris R, O'Brien S, Kantarjian HM. Long-term follow-up of salvage therapy using a combination of inotuzumab ozogamicin and mini-hyper-CVD with or without blinatumomab in relapsed/refractory Philadelphia chromosome-negative acute lymphoblastic leukemia. Cancer 2021; 127:2025-2038. [PMID: 33740268 DOI: 10.1002/cncr.33469] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 12/28/2020] [Accepted: 01/04/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND The outcome of patients with relapsed/refractory (R/R) acute lymphoblastic leukemia (ALL) is poor. The combination of inotuzumab with low-intensity mini-hyper-CVD (mini-hyper-CVD; cyclophosphamide and dexamethasone at 50% dose reduction, no anthracycline, methotrexate at 75% dose reduction, cytarabine at 0.5 g/m2 × 4 doses) chemotherapy has shown encouraging results. The sequential addition of blinatumomab might improve outcome in patients with R/R ALL. METHODS We used lower intensity chemotherapy, mini-hyper-CVD (cyclophosphamide and dexamethasone at 50% dose reduction, no anthracycline, methotrexate at 75% dose reduction, cytarabine at 0.5 g/m2 x 4 doses) compared to conventional hyper-CVAD. RESULTS Ninety-six patients with a median age of 37 years (range, 18-87 years) were treated. Overall, 77 patients (80%) responded, 55 (57%) of whom achieved complete response. The overall measurable residual disease negativity rate among responders was 83%. Forty-four (46%) patients underwent later allogeneic stem cell transplantation. Veno-occlusive disease of any grade occurred in 10 (10%) patients. The rates were 13% with the original schedule and 3% with the use of lower-dose inotuzumab and sequential blinatumomab. With a median follow-up of 36 months, the median overall survival (OS) was 13.4 months, with 3-year OS rates of 33%. The 3-year OS rate for patients with CD22 expression ≥70% and without adverse cytogenetics (KMT2A rearrangements, low hypodiploidy/near triploidy) was 55%. CONCLUSION The combination of inotuzumab and low-intensity mini-hyper-CVD chemotherapy with or without blinatumomab shows sustained efficacy in patients with R/R ALL.
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Affiliation(s)
- Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Koji Sasaki
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Xuelin Huang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Joseph D Khoury
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Rashmi Kanagal-Shamanna
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jeffrey Jorgensen
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Issa F Khouri
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Partow Kebriaei
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Yesid Alvarado
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Tapan M Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Shilpa Paul
- Department of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Bouthaina S Dabaja
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jan A Burger
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Courtney D DiNardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Naval A Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Musa Yilmaz
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Maro Ohanian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Alessandra Ferrajoli
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jovitta Jacob
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Meagan Rostykus
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Rebecca Garris
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Susan O'Brien
- Chao Family Comprehensive Cancer Center, University of California Irvine, Orange, California
| | - Hagop M Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
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31
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Wang Y, Xue YJ, Jia YP, Zuo YX, Lu AD, Zhang LP. Re-Emergence of Minimal Residual Disease Detected by Flow Cytometry Predicts an Adverse Outcome in Pediatric Acute Lymphoblastic Leukemia. Front Oncol 2021; 10:596677. [PMID: 33614482 PMCID: PMC7892594 DOI: 10.3389/fonc.2020.596677] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 12/21/2020] [Indexed: 11/20/2022] Open
Abstract
Purpose While the role of minimal residual disease (MRD) assessment and the significance of achieving an MRD-negative status during treatment have been evaluated in previous studies, there is limited evidence on the significance of MRD re-emergence without morphological relapse in acute lymphoblastic leukemia (ALL). We sought to determine the clinical significance of MRD re-emergence in pediatric ALL patients. Methods Between 2005 and 2017, this study recruited 1126 consecutive patients newly diagnosed with ALL. Flow cytometry was performed to monitor MRD occurrence during treatment. Results Of 1030 patients with MRD-negative results, 150 (14.6%) showed MRD re-emergence while still on morphological complete remission (CR). Patients with white blood cell counts of ≥50 × 109/L (p = 0.033) and MRD levels of ≥0.1% on day 33 (p = 0.012) tended to experience MRD re-emergence. The median re-emergent MRD level was 0.12% (range, 0.01–10.00%), and the median time to MRD re-emergence was 11 months (range, <1–52 months). Eighty-five (56.6%) patients subsequently developed relapse after a median of 4.1 months from detection of MRD re-emergence. The median re-emergent MRD level was significantly higher in the relapsed cohort than in the cohort with persistent CR (1.05% vs. 0.48%, p = 0.005). Of the 150 patients, 113 continued to receive chemotherapy and 37 underwent transplantation. The transplantation group demonstrated a significantly higher 2-year overall survival (88.7 ± 5.3% vs. 46.3 ± 4.8%, p < 0.001) and cumulative incidence of relapse (23.3 ± 7.4% vs. 64.0 ± 4.6%, p < 0.001) than the chemotherapy group. Conclusions MRD re-emergence during treatment was associated with an adverse outcome in pediatric ALL patients. Transplantation could result in a significant survival advantage for these patients.
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Affiliation(s)
- Yu Wang
- Department of Pediatrics, Peking University People's Hospital, Peking University, Beijing, China
| | - Yu-Juan Xue
- Department of Pediatrics, Peking University People's Hospital, Peking University, Beijing, China
| | - Yue-Ping Jia
- Department of Pediatrics, Peking University People's Hospital, Peking University, Beijing, China
| | - Ying-Xi Zuo
- Department of Pediatrics, Peking University People's Hospital, Peking University, Beijing, China
| | - Ai-Dong Lu
- Department of Pediatrics, Peking University People's Hospital, Peking University, Beijing, China
| | - Le-Ping Zhang
- Department of Pediatrics, Peking University People's Hospital, Peking University, Beijing, China
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Liu Z, Li Y, Shi C. Monitoring minimal/measurable residual disease in B-cell acute lymphoblastic leukemia by flow cytometry during targeted therapy. Int J Hematol 2021; 113:337-343. [PMID: 33502735 DOI: 10.1007/s12185-021-03085-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 01/12/2021] [Accepted: 01/13/2021] [Indexed: 11/24/2022]
Abstract
B-cell acute lymphoblastic leukemia (B-ALL) is a hematologic malignancy of B-type lymphoid precursor cells. Minimal/measurable residual disease (MRD) is an important prognostic factor for B-ALL relapse. Traditional flow cytometry detection mainly relies on CD19-based gating strategies. However, relapse of CD19-negative B-ALL frequently occurs in patients who receive cellular and targeted therapy. This review will summarize the technical aspects of standard MRD assessment in B-ALL by flow cytometry, and then discuss the challenges of MRD strategies to deal with the scenario of CD19 negative or dim B-ALL relapse.
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Affiliation(s)
- Zhiyu Liu
- Department of Laboratory Diagnostics, First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Yang Li
- Central Laboratory of Hematology and Oncology, First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Ce Shi
- Central Laboratory of Hematology and Oncology, First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China.
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Yilmaz M, Kantarjian HM, Toruner G, Yin CC, Kanagal-Shamanna R, Cortes JE, Issa G, Short NJ, Khoury JD, Garcia-Manero G, Ravandi F, Kadia T, Konopleva M, Wierda WG, Jain N, Estrov Z, Sasaki K, Pierce S, O'Brien SM, Jabbour EJ. Translocation t(1;19)(q23;p13) in adult acute lymphoblastic leukemia - a distinct subtype with favorable prognosis. Leuk Lymphoma 2021; 62:224-228. [PMID: 32955970 DOI: 10.1080/10428194.2020.1824071] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 09/08/2020] [Indexed: 10/25/2022]
Abstract
The recurring translocation t(1;19) (q23;p13) with TCF3-PBX1 rearrangements are uncommon in adult acute lymphoblastic leukemia (ALL), and their prognostic impact remains to be described in the era of modern chemotherapies. We investigated 427 adult patients with newly diagnosed pre-B ALL, 16 (4%) had t(1;19)(q23;p13) at diagnosis. All 16 patients achieved complete remission after induction with intensive chemotherapy, and with a median of 7-year follow-up, 2 relapsed. The 5-year cumulative incidence of relapse and overall survival rates were 14% and 82%, respectively. Our analysis showed that adult patients with t(1;19)(q23;p13) positive ALL had favorable prognosis with intensive chemotherapy regimens.
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Affiliation(s)
- Musa Yilmaz
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hagop M Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gokce Toruner
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - C Cameron Yin
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rashmi Kanagal-Shamanna
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jorge E Cortes
- Georgia Cancer Center, Augusta University, Augusta, GA, USA
| | - Ghayyas Issa
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph D Khoury
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tapan Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Marina Konopleva
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William G Wierda
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zeev Estrov
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Koji Sasaki
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sherry Pierce
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Susan M O'Brien
- Chao Family Comprehensive Cancer Center, University of California Irvine, Orange, CA, USA
| | - Elias J Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Abdel Rahman ZH, Heckman MG, Miller K, Alkhateeb H, Patnaik MS, Sproat LZ, Jiang L, Roy V, Murthy HS, Ayala E, Hogan WJ, Greipp PT, Kharfan-Dabaja MA, Litzow MR, Foran JM. Impact of Novel Targeted Therapies and Cytogenetic Risk Groups on Outcome After Allogeneic Transplantation for Adult ALL. Transplant Cell Ther 2020; 27:165.e1-165.e11. [PMID: 33830026 DOI: 10.1016/j.jtct.2020.10.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 10/19/2020] [Accepted: 10/25/2020] [Indexed: 11/26/2022]
Abstract
Novel high-risk groups have recently been identified in adult acute lymphoblastic leukemia (ALL), including Philadelphia-like, therapy-related, and measurable residual disease after induction therapy. Furthermore, modern targeted therapies have recently been incorporated into ALL management; rituximab for CD20-positive and blinatumomab for measurable residual disease after induction therapy or relapsed or refractory disease. Allogeneic hematopoietic cell transplantation (allo-HCT) is recommended as consolidation therapy for high-risk ALL; however, its relative benefit for these high-risk groups and after novel therapies is unclear. We performed an analysis of posttransplantation outcomes in a cohort of 261 consecutive patients who underwent allo-HCT for ALL at the 3-site Mayo Clinic Cancer Center (January 1, 2008-December 31, 2018). With a median (range) follow-up of 22.4 months (0.5-135.0), the 100-day and 5-year cumulative incidences of nonrelapse mortality rates were 6.5% and 26.7%, respectively. The 5-year cumulative incidences of relapse and death were 22.6% and 46.2%, respectively. The 1-year estimate of the composite endpoint of graft-versus-host disease/relapse-free survival was 39.3%. We observed no associations of novel high-risk groups or modern targeted therapies with overall survival, nonrelapse mortality, or relapse in multivariable analysis. An increased risk of relapse was observed with T-ALL (hazard ratio, 2.16; 95% confidence interval, 1.14-4.09; P = .02) and hypodiploidy/near-triploidy (hazard ratio, 2.84; 95% confidence interval, 1.06-7.62; P = .04). Our analysis suggests that novel high-risk groups derive a similar benefit from allo-HCT as traditional high-risk adult ALL and that novel targeted therapies do not seem to independently predict for posttransplantation outcomes. It also calls for further exploration of maintenance strategies after Allo-HCT to prevent relapse in high-risk subgroups.
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Affiliation(s)
- Zaid H Abdel Rahman
- Division of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, Florida
| | - Michael G Heckman
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, Florida
| | - Kevin Miller
- Department of Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | | | | | - Lisa Z Sproat
- Division of Hematology and Medical Oncology, Mayo Clinic, Phoenix, Arizona
| | - Liuyan Jiang
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, Florida
| | - Vivek Roy
- Division of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, Florida
| | - Hemant S Murthy
- Division of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, Florida
| | - Ernesto Ayala
- Division of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, Florida
| | | | | | | | - Mark R Litzow
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | - James M Foran
- Division of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, Florida.
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Combariza JF, Arango M, Díaz L, Agudelo C, Hernandez S, Madera AM, León G, Avila V, Bautista L, Valdés J, Orduz R, Mejía F, Moreno L, Ramirez C. Measurable Residual Disease Assessment and Allogeneic Transplantation as Consolidation Therapy in Adult Acute Lymphoblastic Leukemia in Colombia. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 21:e365-e372. [PMID: 33277225 DOI: 10.1016/j.clml.2020.11.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 11/05/2020] [Accepted: 11/09/2020] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Detectable minimal residual disease (MRD) after therapy for acute lymphoblastic leukemia (ALL) is the strongest predictor of hematologic relapse. The objective of the study was to assess disease-free survival (DFS) and overall survival (OS) of patients with ALL according with MRD status at the end of induction therapy in a Colombian population. PATIENTS AND METHODS We assessed a retrospective cohort to compare DFS and OS in adults with de novo ALL according to MRD status at the end of induction chemotherapy, and the type of postinduction consolidation strategy used. RESULTS A total of 165 adults with ALL were included in the MRD part of the study, 73 patients in the MRD-negative group and 92 in the MRD-positive group. Median DFS for the MRD-positive group was 11 months (95% confidence interval, 11.7-22.2) and was not reached for the MRD-negative group (P < .001). At 3 years, DFS was 18% and 55%, respectively (P < .001). The median OS for MRD-positive patients was 16 months (95% confidence interval, 8.8-23.15) and was not reached in the MRD-negative group. At 3 years, OS was 26% and 51% for the former and latter group, respectively. Among subjects who did not receive a transplant, median DFS was 21 months for MRD-negative patients and 9 months for MRD-positive patients (P < .001). The median DFS was not reached in either group, whereas 3-year DFS was 64% for MRD-negative and 70% for MRD-positive patients who underwent transplantation in first remission (P = .861). CONCLUSION MRD status at the end of induction is an independent prognostic factor for DFS and OS in adult ALL. Allogeneic transplantation in first remission could overcome the adverse prognostic impact of MRD.
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Affiliation(s)
| | - Marcos Arango
- Department of Hematology, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - Laura Díaz
- Department of Hematology, Hospital Pablo Tobón Uribe, Medellín, Colombia
| | - Claudia Agudelo
- Department of Hematology, Clínica Universitaria Colombia, Bogotá, Colombia
| | - Sonia Hernandez
- Department of Hematology, Clínica Universitaria Colombia, Bogotá, Colombia
| | - Ana María Madera
- Department of Hematology, Clínica Universitaria Colombia, Bogotá, Colombia
| | - Guillermo León
- Department of Hematology, Clínica Universitaria Colombia, Bogotá, Colombia
| | - Vladimir Avila
- Department of Hematology, Clínica Universitaria Colombia, Bogotá, Colombia
| | - Leonardo Bautista
- Department of Hematology, Clínica Universitaria Colombia, Bogotá, Colombia
| | - Jaime Valdés
- Department of Hematology, Clínica Universitaria Colombia, Bogotá, Colombia
| | - Rocio Orduz
- Department of Pathology, Clínica Universitaria Colombia, Bogotá, Colombia
| | - Fabian Mejía
- Department of Pathology, Clínica Universitaria Colombia, Bogotá, Colombia
| | - Liliana Moreno
- Department of Pathology, Clínica Universitaria Colombia, Bogotá, Colombia
| | - Carlos Ramirez
- Department of Hematology, Clínica Reina Sofía, Bogotá, Colombia
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Huang A, Chen Q, Fei Y, Wang Z, Ni X, Gao L, Chen L, Chen J, Zhang W, Yang J, Wang J, Hu X. Dynamic prediction of relapse in patients with acute leukemias after allogeneic transplantation: Joint model for minimal residual disease. Int J Lab Hematol 2020; 43:84-92. [PMID: 32881394 DOI: 10.1111/ijlh.13328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 07/21/2020] [Accepted: 08/04/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Relapse remains the leading cause of treatment failure after allogeneic hematopoietic stem cell transplantation (alloHSCT) in leukemia. Numerous investigations have demonstrated that minimal residual disease (MRD) before or after alloHSCT is prognostic of relapse risk. These MRD data were collected at specific checkpoints and could not dynamically predict the relapse risk after alloHSCT, which needs serial monitoring. METHODS In the present study, we retrospectively analyzed MRD measured with multi-parameter flow cytometry in 207 acute myeloid leukemia (AML) patients (acute promyelocytic leukemia excluded), and 124 acute B lymphoblastic leukemia (ALL) patients. A three-step method based on joint model was used to build a relapse risk prediction model. RESULTS The 3-year overall survival and relapse-free survival rates of the entire cohort were 67.1% ± 2.8% and 61.6% ± 2.8%, respectively. The model included disease status before alloHSCT, acute and chronic graft-versus-host disease, and serial MRD data. The time-dependent receiver operating characteristics was used to evaluate the ability of the model. It fitted well with actual incidence of relapse. The serial MRD data collected after alloHSCT had better discrimination capabilities for recurrence prediction with the area under the curve from 0.67 to 0.91 (AML: 0.66-0.89; ALL: 0.70-0.96). CONCLUSION The joint model was able to dynamically predict relapse-free probability after alloHSCT, which would be a useful tool to provide important information to guide decision-making in the clinic and facilitate the individualized therapy.
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Affiliation(s)
- Aijie Huang
- Department of Hematology, Institute of Hematology, Changhai Hospital, Shanghai, China
| | - Qi Chen
- Department of Health Statistics, Second Military Medical University, Shanghai, China
| | - Yang Fei
- Department of Hematology, Institute of Hematology, Changhai Hospital, Shanghai, China
| | - Ziwei Wang
- Department of Hematology, Institute of Hematology, Changhai Hospital, Shanghai, China
| | - Xiong Ni
- Department of Hematology, Institute of Hematology, Changhai Hospital, Shanghai, China
| | - Lei Gao
- Department of Hematology, Institute of Hematology, Changhai Hospital, Shanghai, China
| | - Li Chen
- Department of Hematology, Institute of Hematology, Changhai Hospital, Shanghai, China
| | - Jie Chen
- Department of Hematology, Institute of Hematology, Changhai Hospital, Shanghai, China
| | - Weiping Zhang
- Department of Hematology, Institute of Hematology, Changhai Hospital, Shanghai, China
| | - Jianmin Yang
- Department of Hematology, Institute of Hematology, Changhai Hospital, Shanghai, China
| | - Jianmin Wang
- Department of Hematology, Institute of Hematology, Changhai Hospital, Shanghai, China
| | - Xiaoxia Hu
- Department of Hematology, Institute of Hematology, Changhai Hospital, Shanghai, China
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Rank CU, Schmiegelow K. Optimal approach to the treatment of young adults with acute lymphoblastic leukemia in 2020. Semin Hematol 2020; 57:102-114. [PMID: 33256899 DOI: 10.1053/j.seminhematol.2020.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 08/12/2020] [Accepted: 08/14/2020] [Indexed: 01/19/2023]
Abstract
Akin to the introduction of tyrosine kinase inhibitors to Philadelphia chromosome-positive acute lymphoblastic leukemia (ALL), pediatric-based asparaginase-heavy approaches have revolutionized the treatment of young adults with the Philadelphia chromosome-negative subset the past decades. Once again, we are approaching a new era. An era of precision medicine with immunotherapy and other molecularly targeted treatments that offers unique opportunities to customize treatment intensity with or without hematopoietic stem cell transplantation, reduce the burden of toxicities, and combat persistent residual disease. Recently approved agents for refractory/relapsed B-cell precursor ALL include the chimeric antigen receptor-modified T-cells, the anti-CD22 monoclonal antibody-drug conjugate, inotuzumab ozogamicin, and the bispecific anti-CD19 T-cell engager, blinatumomab. These agents are expected to move widely into the frontline setting along with the proteasome inhibitors, bortezomib and carfilzomib, as well as tyrosine kinase inhibitors for Philadelphia-like rearrangements that are especially frequent among young adults. To this add the BH3 mimetics, venetoclax and navitoclax, which are being widely explored in refractory/relapsed as well as frontline settings for B- and T-cell ALL. The promising anti-CD38 monoclonal antibody, daratumumab, is entering the scene of refractory/relapsed T-ALL, whereas the old purine analogue, nelarabine, is being evaluated in a new upfront setting. This review focuses on 2 main questions: How do we optimize frontline as well as salvage ALL treatment of young adults in the 2020s? Not least, how do we address the current burden of serious toxicities unique to young adults?
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Affiliation(s)
- Cecilie Utke Rank
- Pediatric Oncology Research Laboratory, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Department of Hematology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Kjeld Schmiegelow
- Pediatric Oncology Research Laboratory, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Department of Pediatrics and Adolescent Medicine, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Institute of Clinical Medicine, Faculty of Medicine, University of Copenhagen, Copenhagen, Denmark.
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Role of Allogeneic HCT as Postremission Therapy for Transplant-Eligible Adult Lymphoblastic Leukemia/Lymphoma After Frontline Hyper-CVAD. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 20:690-696. [PMID: 32636149 DOI: 10.1016/j.clml.2020.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 05/13/2020] [Accepted: 05/14/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Hyperfractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone alternating with cytarabine and methotrexate (hyper-CVAD) is a commonly used regimen in adults with acute lymphoblastic leukemia (ALL)/lymphoblastic lymphoma (LBL). Adult patients fit for pediatric-inspired protocols have an excellent outcome with chemotherapy alone. However, it is unclear whether patients receiving hyper-CVAD should undergo allogeneic hematopoietic cell transplantation (HCT) as postremission therapy. Our aim was to examine the role of HCT at first complete remission (CR1) in adult ALL/LBL after hyper-CVAD. PATIENTS AND METHODS Adult patients with newly diagnosed ALL/LBL receiving frontline hyper-CVAD from 2008 to 2018 were identified and records retrospectively extracted. RESULTS A total of 85 patients were identified and included for further analysis. The median (range) age was 23 (14-68) years, and 56 (66%) were male. A total of 24 (28%) had adverse cytogenetics, and 48 (56%) had at least one risk factor. All patients received hyper-CVAD as induction; induction failure was seen in 10 (12%). A total of 38 patients continued the hyper-CVAD course, while the remaining 47 received HCT in CR1. Three-year event-free survival (EFS) and overall survival for the entire cohort were 51.4% and 61.6%, respectively. Median follow-up of alive patients was 39.9 (3.8-123.8) months. At multivariable analysis for EFS, induction failure was associated with worse outcome (hazard ratio [HR], 4.8; 95% confidence interval [CI] 1.7-13.7; P = .003), whereas HCT in CR1 improved outcome (HR, 0.42; 95% CI 0.18-0.97; P = .044). Furthermore, HCT in CR1 was the only prognostic factor for overall survival (HR, 0.3; 95% CI 0.11-0.85; P = .023). CONCLUSION HCT at CR1 resulted in a favorable EFS and overall survival in ALL/LBL patients after hyper-CVAD frontline therapy. Given that hyper-CVAD is a widely used protocol for adult patients, further examination of this observation is warranted.
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Bartram J, Patel B, Fielding AK. Monitoring MRD in ALL: Methodologies, technical aspects and optimal time points for measurement. Semin Hematol 2020; 57:142-148. [PMID: 33256904 DOI: 10.1053/j.seminhematol.2020.06.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 06/02/2020] [Indexed: 01/21/2023]
Abstract
The accurate determination of minimal or measurable residual disease (MRD) during the early months of therapy in acute lymphoblastic leukemia is well established as the most important independent prognostic biomarker, predicting response to combination chemotherapy. Stratification based on MRD maximizes treatment effectiveness while minimizing adverse effects. Allele-specific real-time quantitative PCR of clone-defining immunoglobin/T-cell receptor gene rearrangements in the patients' leukemic clones and/or multiparametric flow cytometric tracking of leukemia-associated immunophenotypes are considered standard of care. Following recent advances in high throughput sequencing (HTS; next generation sequencing), much attention has been devoted to the development of HTS-based MRD assays, which can increase sensitivity; theoretically only limited by the number of cells input into the assay. Knowledge of the methods and limitations of each technology, along with awareness of the sensitivity and specificity of MRD at particular treatment time points is important in interpretation of the MRD value. MRD negativity at pre-established protocol-appropriate time points guides continuance with consolidation/maintenance chemotherapy, whereas positivity leads to a change to a biological therapy such as blinatumomab and intensification of therapy to allogeneic stem cell transplant. Positivity after maintenance may herald impending relapse enabling treatment intervention. MRD has been integral to the introduction of novel agents and cellular therapies into clinical trials and standard of care, but the long-term predictive value of MRD on outcome of novel therapies is not yet established. Integration of somatic genetics with MRD may further improve accurate identification of patients with the lowest and highest risk of relapse.
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Affiliation(s)
- Jack Bartram
- Department of Haematology, Great Ormond Street Hospital for Children, London, UK; Cancer Section, DBC Programme, University College London, London, UK.
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Sasaki K, Kantarjian H, Wierda W, Ravandi-Kashani F, Jorgensen J, Wang SA, Khoury J, Daver N, Burger J, Di Nardo CD, Jain N, Short NJ, Estrov Md Z, Konopleva Md PhD M, Ohanian DO M, Garcia-Manero G, Kadia T, Alvarado-Valero Y, Yilmaz M, Pierce S, Garris R, Ingram A, Cortes J, OʼBrien S, Jabbour E. Phase 2 study of hyper-CMAD with liposomal vincristine for patients with newly diagnosed acute lymphoblastic leukemia. Am J Hematol 2020; 95:734-739. [PMID: 32170867 DOI: 10.1002/ajh.25784] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 03/04/2020] [Accepted: 03/10/2020] [Indexed: 11/10/2022]
Abstract
Liposomal vincristine is designed to reduce neurotoxicity and increase dose intensity delivery, and has been approved as salvage therapy in relapsed/refractory acute lymphoblastic leukemia (ALL). Our aim was to evaluate the response rate, toxicities, and outcome of adults with newly diagnosed ALL who received liposomal vincristine, rather than regular vincristine in combination with intensive chemotherapy (Hyper-CMAD). In a single-center, phase 2 study, patients ≥18 years with newly-diagnosed B-cell ALL were eligible to receive hyper-CMAD alternating with high-dose methotrexate and cytarabine. Rituximab was administered in CD20 positive ALL. Tyrosine kinase inhibitors (imatinib or dasatinib) were added in Philadelphia chromosome-positive (Ph-positive) ALL. Thirty-one patients were enrolled, median follow-up of 59 months (0.3-70). Thirteen patients (42%) had CD20 positive ALL, and 21 (68%) had Ph-positive ALL. Thirty (97%) achieved complete remission (CR). All 26 patients with abnormal karyotype achieved complete cytogenetic response (CCyR), and 27/30 (90%) achieved negative minimal residual disease status by multicolor flow cytometry. Of 20 evaluable Ph-positive ALL patients, major molecular response (MMR) was achieved in 19 patients (95%); complete molecular response (CMR) in 14 (70%). Grade 3/4 peripheral neuropathy was observed in five (16%) with all grade peripheral neuropathy in 21 (68%). With a median follow-up of 59 months, 21 (68%) patients are alive. The 5-year CR duration and survival rates were 73% and 61%, respectively. Ten (32%) patients died: one, sepsis on C1D10; four, unknown; one, post-transplant complications; four, relapse. Hyper-CMAD with liposomal vincristine is safe and demonstrated high response and survival rates in newly diagnosed ALL.
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Affiliation(s)
- Koji Sasaki
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | - Hagop Kantarjian
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | - William Wierda
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | - Farhad Ravandi-Kashani
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | - Jeffrey Jorgensen
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | - Sa A Wang
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | - Joseph Khoury
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | - Naval Daver
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | - Jan Burger
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | - Courtney D Di Nardo
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | - Nitin Jain
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | - Nicholas J Short
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | - Zeev Estrov Md
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Maro Ohanian DO
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Tapan Kadia
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | - Yesid Alvarado-Valero
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | - Musa Yilmaz
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | - Sherry Pierce
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | - Rebecca Garris
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | - April Ingram
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Susan OʼBrien
- Chao Family Comprehensive Cancer Center, University of California Irvine, Orange, California, USA
| | - Elias Jabbour
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
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Samra B, Jabbour E, Ravandi F, Kantarjian H, Short NJ. Evolving therapy of adult acute lymphoblastic leukemia: state-of-the-art treatment and future directions. J Hematol Oncol 2020; 13:70. [PMID: 32503572 PMCID: PMC7275444 DOI: 10.1186/s13045-020-00905-2] [Citation(s) in RCA: 91] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 05/22/2020] [Indexed: 12/20/2022] Open
Abstract
Recent years have witnessed major advances that have improved outcome of adults with acute lymphoblastic leukemia (ALL). The emergence of the concept of measurable residual disease has fine-tuned our prognostic models and guided our treatment decisions. The treatment paradigms of ALL have been revolutionized with the advent of tyrosine kinase inhibitors targeting BCR-ABL1, monoclonal antibodies targeting CD20 (rituximab), antibody-drug conjugates targeting CD22 (inotuzumab ozogamicin), bispecific antibodies (blinatumomab), and CD19 chimeric antigen receptor T cell therapy (tisagenlecleucel). These highly effective new agents are allowing for novel approaches that reduce reliance on intensive cytotoxic chemotherapy and hematopoietic stem cell transplantation in first remission. This comprehensive review will focus on the recent advances and future directions in novel therapeutic strategies in adult ALL.
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Affiliation(s)
- Bachar Samra
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA.
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Abou Dalle I, Jabbour E, Short NJ. Evaluation and management of measurable residual disease in acute lymphoblastic leukemia. Ther Adv Hematol 2020; 11:2040620720910023. [PMID: 32215194 PMCID: PMC7065280 DOI: 10.1177/2040620720910023] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 01/27/2020] [Indexed: 12/16/2022] Open
Abstract
With standard chemotherapy regimens for adults with acute lymphoblastic leukemia, approximately 90% of patients achieve complete remission. However, up to half of patients have persistent minimal/measurable residual disease (MRD) not recognized by routine microscopy, which constitutes the leading determinant of relapse. Many studies in pediatric and adult populations have demonstrated that achievement of MRD negativity after induction chemotherapy or during consolidation is associated with significantly better long-term outcomes, and MRD status constitutes an independently prognostic marker, often superseding other conventional risk factors. Persistence of MRD after intensive chemotherapy is indicative of treatment refractoriness and warrants alternative therapeutic approaches including allogeneic stem cell transplantation, blinatumomab, or investigational therapies such as inotuzumab ozogamicin or chimeric antigen receptor T cells. Furthermore, the incorporation of novel monoclonal antibodies or potent BCR-ABL1 tyrosine kinase inhibitors, such as ponatinib into frontline treatment may have the advantage of achieving higher rates of MRD negativity while minimizing chemotherapy-related toxicities. Many studies are therefore ongoing to determine whether this strategy can improve cure rates without the need for allogeneic stem cell transplantation.
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Affiliation(s)
- Iman Abou Dalle
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Division of Hematology and Oncology, American University of Beirut, Beirut, Lebanon
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nicholas J. Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Box 428, Houston, TX 77030, USA
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Yilmaz M, Kantarjian H, Wang X, Khoury JD, Ravandi F, Jorgensen J, Short NJ, Loghavi S, Cortes J, Garcia-Manero G, Kadia T, Sasaki K, Konopleva M, Takahashi K, Wierda W, Jain N, Verstovsek S, Estrov Z, Bose P, Pierce S, Garris R, O'Brien S, Jabbour E. The early achievement of measurable residual disease negativity in the treatment of adults with Philadelphia-negative B-cell acute lymphoblastic leukemia is a strong predictor for survival. Am J Hematol 2020; 95:144-150. [PMID: 31682008 DOI: 10.1002/ajh.25671] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 10/28/2019] [Accepted: 10/30/2019] [Indexed: 02/03/2023]
Abstract
The minimal or measurable residual disease (MRD) status following induction/consolidation chemotherapy is an important prognostic endpoint in adult patients with newly diagnosed acute lymphoblastic leukemia (ALL). However, the optimal time-point (TP) of MRD assessment and its impact on outcome remains unclear. We analyzed 215 patients with newly diagnosed Philadelphia negative B-cell ALL who received intensive chemotherapy, and had available MRD assessment by multicolor flow cytometry at two separate TPs. The median time to first TP (1TP) and second TP (2TP) were 24 and 110 days, respectively. At 1TP, 148 patients (68%) were MRD negative and 67 (32%) were positive. Of the 148 patients with negative MRD at 1TP, 147 (99%) maintained it through 2TP. Patients who were MRD negative at both TPs, early MRD responders, had the 3-year event-free survival (EFS), and overall survival (OS) rates of 65% and 76%, respectively. Patients with improved MRD status from positive to negative, late MRD responders, had lower 3-year EFS and OS rates, 42% and 58%, respectively (P = .001). Multivariate analysis showed that KMT2A (MLL) rearrangement and MRD positivity at 1TP were the only factors correlated with worse OS. In conclusion, the earlier achievement of MRD negative remission is a stronger prognostic factor for survival.
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Affiliation(s)
- Musa Yilmaz
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Xuemei Wang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Joseph D Khoury
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jeffrey Jorgensen
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sanam Loghavi
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jorge Cortes
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Tapan Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Koji Sasaki
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Marina Konopleva
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Koichi Takahashi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - William Wierda
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Srdan Verstovsek
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Zeev Estrov
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Prithviraj Bose
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sherry Pierce
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Rebecca Garris
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Susan O'Brien
- Chao Family Comprehensive Cancer Center, University of California Irvine, Orange, California
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Gökbuget N, Dombret H, Giebel S, Brüggemann M, Doubek M, Foa R, Hoelzer D, Kim C, Martinelli G, Parovichnikova E, Maria Ribera J, Schoonen M, Tuglus C, Zugmaier G, Bassan R. Blinatumomab vs historic standard-of-care treatment for minimal residual disease in adults with B-cell precursor acute lymphoblastic leukaemia. Eur J Haematol 2020; 104:299-309. [PMID: 31876009 PMCID: PMC7079006 DOI: 10.1111/ejh.13375] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 12/19/2019] [Accepted: 12/20/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Survival outcomes from a single-arm phase 2 blinatumomab study in patients with minimal residual disease (MRD)-positive B-cell precursor (BCP)-acute lymphoblastic leukaemia (ALL) were compared with those receiving standard of care (SOC) in a historic data set. METHODS The primary analysis comprised adult Philadelphia chromosome (Ph)-negative patients in first complete haematologic remission (MRD ≥ 10-3 ). Relapse-free survival (RFS) and overall survival (OS) were compared between blinatumomab- and SOC-treatment groups. Baseline differences between groups were adjusted by propensity scores. RESULTS The primary analysis included 73 and 182 patients from the blinatumomab and historic data sets, respectively. When weighted by age to the blinatumomab-treatment group, median RFS was 7.8 months and median OS was 25.9 months in the SOC-treated group. In the blinatumomab study, median RFS was 35.2 months; median OS was not evaluable. Propensity score weighting achieved balance with seven baseline prognostic factors. With adjustment for haematopoietic stem cell transplantation (HSCT) status, a 50% reduction in risk of relapse or death was observed with blinatumomab vs SOC. Median RFS, unadjusted for HSCT status, was 35.2 months with blinatumomab and 8.3 months with SOC. CONCLUSIONS These analyses suggest that blinatumomab improves RFS, and possibly OS, in adults with MRD-positive Ph-negative BCP-ALL vs SOC.
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Affiliation(s)
| | - Hervé Dombret
- Hôpital Saint-Louis, University Paris Diderot, Paris, France
| | - Sebastian Giebel
- Maria Sklodowska-Curie Institute-Oncology Center, Gliwice, Poland
| | | | - Michael Doubek
- University Hospital and CEITEC Masaryk University, Brno, Czech Republic
| | - Robin Foa
- 'Sapienza' University of Rome, Rome, Italy
| | | | - Christopher Kim
- Center for Observational Research, Amgen Inc, Thousand Oaks, CA, USA
| | | | | | - Josep Maria Ribera
- ICO-Hospital Germans Trias i Pujol, Jose Carreras Research Institute, Barcelona, Spain
| | | | | | | | - Renato Bassan
- UOC Ematologia, Ospedale dell'Angelo, Mestre-Venezia, Italy
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45
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Pandey A, Ahlawat S, Singh A, Singh S, Murari K, Aryan R. Outcomes and impact of minimal residual disease (MRD) in pediatric, adolescent and young adults (AYA) with acute lymphoblastic leukemia treated with modified MCP 841 protocol. CANCER RESEARCH, STATISTICS, AND TREATMENT 2020. [DOI: 10.4103/crst.crst_85_20] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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46
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Jabbour E, Gökbuget N, Advani A, Stelljes M, Stock W, Liedtke M, Martinelli G, O’Brien S, Wang T, Laird AD, Vandendries E, Neuhof A, Nguyen K, Dakappagari N, DeAngelo DJ, Kantarjian H. Impact of minimal residual disease status in patients with relapsed/refractory acute lymphoblastic leukemia treated with inotuzumab ozogamicin in the phase III INO-VATE trial. Leuk Res 2020; 88:106283. [DOI: 10.1016/j.leukres.2019.106283] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 11/23/2019] [Indexed: 01/05/2023]
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Zhao J, Song Y, Liu D. Recent advances on blinatumomab for acute lymphoblastic leukemia. Exp Hematol Oncol 2019; 8:28. [PMID: 31709129 PMCID: PMC6833142 DOI: 10.1186/s40164-019-0152-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 10/31/2019] [Indexed: 01/14/2023] Open
Abstract
Although complete remission rate of B cell acute lymphoblastic leukemia (B-ALL) has improved significantly over the past few decades, patients with relapsed/refractory ALL still have dismal outcome. Tyrosine kinase inhibitors, antibody–drug conjugates and chimeric antigen receptor T cell therapy are changing the therapy landscape for B- ALL. Blinatumomab, a bi-specific T cell engager, has been approved for patients with relapsed/refractory and minimal residual disease positive B-ALL. This review summarized data from recent clinical trials of blinatumomab for B-ALL treatment.
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Affiliation(s)
- Juanjuan Zhao
- 1Department of Hematology, The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Yongping Song
- 1Department of Hematology, The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Delong Liu
- 1Department of Hematology, The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China.,2Department of Medicine, New York Medical College and Westchester Medical Center, Valhalla, NY 10595 USA
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48
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Gidman W, Shah S, Zhang L, McKendrick J, Cong Z, Cohan D, Ottmann O. Clinicians' Perspectives on Cure in Adult Patients with Acute Lymphoblastic Leukemia with Minimal Residual Disease: A Delphi Study. Adv Ther 2019; 36:3017-3029. [PMID: 31586302 PMCID: PMC6822800 DOI: 10.1007/s12325-019-01099-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Indexed: 02/07/2023]
Abstract
Hematologic complete remission (CR) is achievable for most adults with B cell precursor acute lymphoblastic leukemia (BCP-ALL). However, minimal residual disease (MRD) in patients with hematologic CR is associated with increased risk of relapse, shorter survival, and poorer transplantation outcomes. This study explored the concept of cure in adults with Philadelphia chromosome-negative (Ph−) BCP-ALL by MRD status at first hematologic CR (CR1) to inform evaluation of the clinical and economic benefits of new agents, where the concept of cure is important but long-term data are not available. The study used modified Delphi methodology involving clinicians experienced in the treatment of adult ALL. Participants completed a questionnaire, which was followed by country-specific panel discussions to discuss results and identify consensus on concepts and definitions. Clinicians from France (n = 4), Germany (n = 4), and the UK (n = 5) took part. Participants described cure in terms of the probability of future relapse. Relapse-free survival (RFS) was the preferred outcome measure to describe cure for the three patient groups considered (patients with MRD at CR1; patients who become negative for MRD after further treatment; patients who continue to have MRD). Consensus was reached on definitions of cure: that cure would begin to be considered at 3 years’ RFS and/or would be highly likely at 5 years’ RFS. Participants agreed that patients with MRD should usually undergo hematopoietic stem cell transplantation to have the best chance of survival; consensus was reached that alternatives are required when transplantation is not an option. Panels agreed that patients who achieve cure have a higher mortality rate and lower health-related quality of life than the general population. This study provides quantitative and qualitative information on the concept of cure in Ph− BCP-ALL in CR by MRD status applicable to interpreting the value of new therapies. Funding: Amgen. Plain Language Summary: Plain language summary available for this article.
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Bassan R, Brüggemann M, Radcliffe HS, Hartfield E, Kreuzbauer G, Wetten S. A systematic literature review and meta-analysis of minimal residual disease as a prognostic indicator in adult B-cell acute lymphoblastic leukemia. Haematologica 2019; 104:2028-2039. [PMID: 30890593 PMCID: PMC6886415 DOI: 10.3324/haematol.2018.201053] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 03/14/2019] [Indexed: 11/09/2022] Open
Abstract
Minimal (or 'measurable') residual disease in acute lymphoblastic leukemia appears to be a prognostic indicator, with potential value in informing individualized treatment decisions. Complete understanding of the strength of the association between minimal residual disease and long-term outcomes is, however, lacking. A systematic literature review and meta-analysis were performed to elucidate the clinical significance of minimal residual disease with respect to relapse-free survival and overall survival in precursor B-cell acute lymphoblastic leukemia. A total of 23 articles and abstracts, most published between 2012 and 2016, were identified for inclusion in the primary meta-analysis. Typically, patients were in their first complete remission at the time of minimal residual disease assessment; in two studies, all patients were in their second, or later, complete remission. The primary analysis revealed improved relapse-free survival across all studies for patients who achieved minimal residual disease negativity (random effects hazard ratio, 2.34; 95% confidence interval, 1.91-2.86). Improved overall survival for patients who achieved minimal residual disease negativity was also observed (hazard ratio, 2.19; 95% confidence interval, 1.63-2.94). There was no observed difference in the impact of minimal residual disease status in subgroups based on disease stage, minimal residual disease sensitivity threshold level, Philadelphia chromosome status, histological phenotype, risk group, minimal residual disease testing location, minimal residual disease timing after induction, or minimal residual disease detection method. Despite heterogeneity in study design and patient populations between the contributing studies, these data provide a compelling argument for minimal residual disease as a clinical tool for assessing prognosis and guiding treatment decisions in precursor B-cell acute lymphoblastic leukemia.
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Affiliation(s)
- Renato Bassan
- Complex Operative Unit of Haematology, dell'Angelo Hospital and Santissimi Giovanni and Paolo Hospital, Mestre and Venice, Italy
| | - Monika Brüggemann
- Department of Medicine II, Schleswig-Holstein University Hospital, Kiel, Germany
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50
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Jabbour E, Ravandi F, Kebriaei P, Huang X, Short NJ, Thomas D, Sasaki K, Rytting M, Jain N, Konopleva M, Garcia-Manero G, Champlin R, Marin D, Kadia T, Cortes J, Estrov Z, Takahashi K, Patel Y, Khouri MR, Jacob J, Garris R, O'Brien S, Kantarjian H. Salvage Chemoimmunotherapy With Inotuzumab Ozogamicin Combined With Mini-Hyper-CVD for Patients With Relapsed or Refractory Philadelphia Chromosome-Negative Acute Lymphoblastic Leukemia: A Phase 2 Clinical Trial. JAMA Oncol 2019; 4:230-234. [PMID: 28859185 DOI: 10.1001/jamaoncol.2017.2380] [Citation(s) in RCA: 116] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Importance The outcome of patients with relapsed or refractory (R/R) acute lymphoblastic leukemia (ALL) is poor. Inotuzumab ozogamicin, a CD22 monoclonal antibody bound to calicheamicin, has single-agent activity in R/R ALL. Objective To evaluate the efficacy and safety of inotuzumab ozogamicin plus low-intensity chemotherapy in patients with R/R ALL. Design, Setting, and Participants A single-arm, phase 2 study of adults with R/R B-cell ALL conducted at The University of Texas MD Anderson Cancer Center, Houston. Interventions The chemotherapy used was lower intensity than hyper-CVAD (cyclophosphamide, vincristine, doxorubicin [trade name, Adriamycin; Pfizer], and dexamethasone) and is referred to as mini-hyper-CVD (mini-HCVD: cyclophosphamide and dexamethasone at 50% dose reduction, no anthracycline, methotrexate at 75% dose reduction, and cytarabine at 0.5 g/m2 × 4 doses). Inotuzumab was given on day 3 of the first 4 courses at 1.8 to 1.3 mg/m2 for cycle 1 followed by 1.3 to 1.0 mg/m2 for subsequent cycles. Main Outcomes and Measures The primary end points were the overall response rate and overall survival (OS). Secondary end points included safety, relapse-free survival (RFS), the rate of allogeneic stem cell transplantation (ASCT), and the minimal residual disease (MRD) negativity rate. Results Fifty-nine patients (30 women and 29 men) with a median age of 35 years (range, 18-87 years) were treated. Overall, 46 patients (78%) responded, 35 of them (59%) achieving complete response. The overall MRD negativity rate among responders was 82%. Twenty-six patients (44%) received ASCT. Grade 3 to 4 toxic effects included prolonged thrombocytopenia (81%; n = 48), infections (73%; n = 43), and hyperbilirubinemia (14%; n = 8). Veno-occlusive disease (VOD) occurred in 9 patients (15%). With a median follow-up of 24 months, the median RFS and OS were 8 and 11 months, respectively. The 1-year RFS and OS rates were 40% and 46%, respectively. The 1-year OS rates for patients treated in salvage 1, salvage 2, and salvage 3 or beyond were 57%, 26%, and 39%, respectively (P = .03). Conclusions and Relevance The combination of inotuzumab with low-intensity mini-HCVD chemotherapy shows encouraging results in R/R ALL. The risk of VOD should be considered carefully in patients with previous liver damage and among transplant candidates. Trial Registration clinicaltrials.gov Identifier: NCT01371630.
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Affiliation(s)
- Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston
| | - Partow Kebriaei
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston
| | - Xuelin Huang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston
| | - Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston
| | - Deborah Thomas
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston
| | - Koji Sasaki
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston
| | - Michael Rytting
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston
| | - Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston
| | - Marina Konopleva
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston
| | | | - Richard Champlin
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston
| | - David Marin
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston
| | - Tapan Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston
| | - Jorge Cortes
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston
| | - Zeev Estrov
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston
| | - Koichi Takahashi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston
| | - Yogin Patel
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston
| | - Maria R Khouri
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston
| | - Jovitta Jacob
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston
| | - Rebecca Garris
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston
| | - Susan O'Brien
- Chao Family Comprehensive Cancer Center, University of California-Irvine, Orange
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston
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