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Extermann M, Artz A, Rebollo MA, Klepin HD, Krug U, Loh KP, Mims AS, Neuendorff N, Santini V, Stauder R, Vey N. Treating acute myelogenous leukemia in patients aged 70 and above: Recommendations from the International Society of Geriatric Oncology (SIOG). J Geriatr Oncol 2024; 15:101626. [PMID: 37741771 DOI: 10.1016/j.jgo.2023.101626] [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: 02/23/2023] [Revised: 08/28/2023] [Accepted: 09/06/2023] [Indexed: 09/25/2023]
Abstract
Acute myeloid leukemia (AML) treatment is challenging in older patients. There is a lack of evidence-based recommendations for older patients ≥70, a group largely underrepresented in clinical trials. With new treatment options being available in recent years, recommendations are needed for these patients. As such the International Society of Geriatric Oncology (SIOG) assembled a task force to review the evidence specific to treatment and outcomes in this population of patients ≥70 years. Six questions were selected by the expert panel in domains of (1) baseline assessment, (2) frontline therapy, (3) post-remission therapy, (4) treatment for relapse, (5) targeted therapies, and (6) patient reported outcome/function and enhancing treatment tolerance. Information from current literature was extracted, combining evidence from systematic reviews/meta-analyses, decision models, individual trials targeting these patients, and subgroup data. Accordingly, recommendations were generated using a GRADE approach upon reviewing current evidence by consensus of the whole panel. It is our firm recommendation and hope that direct evidence should be generated for patients aged ≥70 as a distinct group in high need of improvement of their survival outcomes. Such studies should integrate information from a geriatric assessment to optimize external validity and outcomes.
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Affiliation(s)
- Martine Extermann
- Senior Adult Oncology Program, Moffitt Cancer Center, Tampa, FL, USA.
| | - Andrew Artz
- Division of Leukemia, Department of Hematology & Hematopoietic Cell Transplantation, City of Hope, Duarte, CA, USA
| | - Maite Antonio Rebollo
- Institut Català d'Oncologia, Oncohematogeriatrics Unit, L'Hospitalet de Llobregat, Spain
| | - Heidi D Klepin
- Wake Forest University School of Medicine, Department of Internal Medicine, Section on Hematology and Oncology, Winston-Salem, NC, USA
| | - Utz Krug
- Klinikum Leverkusen, Department of Medicine 3, Leverkusen, Germany
| | - Kah Poh Loh
- University of Rochester Medical Center, Department of Medicine, Division of Hematology and Oncology, James P. Wilmot Cancer Institute, Rochester, NY, USA
| | - Alice S Mims
- The Ohio State University Wexner Medical Center, Department of Internal Medicine, Columbus, OH, USA
| | - Nina Neuendorff
- University Hospital Essen, Department of Hematology and Stem-Cell Transplantation, Essen, Germany
| | - Valeria Santini
- MDS Unit, AOUC, Hematology, University of Florence, Florence, Italy
| | - Reinhard Stauder
- Department of Internal Medicine V (Hematology Oncology), Innsbruck Medical University, Innsbruck, Austria
| | - Norbert Vey
- Aix-Marseille University, Institut Paoli-Calmettes, Hematology Department, Marseille, France
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Kong FC, Qi L, Zhou YL, Yu M, Huang WF, Li F. Chidamide, Decitabine, Cytarabine, Aclarubicin, and Granulocyte Colony-stimulating Factor Therapy for Patients with Relapsed/Refractory Acute Myeloid Leukemia: A Retrospective Study from a Single-Center. Curr Med Sci 2023; 43:1151-1161. [PMID: 38057538 DOI: 10.1007/s11596-023-2805-7] [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: 11/26/2022] [Accepted: 09/19/2023] [Indexed: 12/08/2023]
Abstract
OBJECTIVE Preclinical evidence and clinical trials have suggested synergistic effects of epigenetic modifiers in combination with cytotoxic agents for the treatment of leukemia. However, their efficacy in patients with relapsed/refractory acute myeloid leukemia (R/R AML) remains unclear. METHODS Clinical data of R/R AML patients who received a CDCAG regimen (chidamide, decitabine, cytarabine, aclarubicin, and granulocyte colony-stimulating factor) from July 1, 2018 to October 31, 2021 at our center were retrospectively assessed, and the safety and efficacy of the CDCAG regimen were evaluated. Patients were followed up until November 30, 2021, with a median follow-up of 21.6 months (95% CI: 10.0-33.2 months). RESULTS A total of 67 patients were enrolled. Two patients died within 3 weeks after the initiation, and therefore only 65 patients underwent the assement for clinical response and survival. It was found that 56.9% patients achieved complete remission with a median overall survival (OS) of 9.6 months. The median OS of responders was 25.9 months, while that of non-responders was 5.0 months (P<0.0001). Patients with gene mutations had a superior overall response rate (ORR) (80.4% vs. 45.5%, P=0.043) compared to those without gene mutations. The presence of DNA methyltransferase 3 A (DNMT3A), ten-eleven translocation-2 (TET2), and isocitrate dehydrogenase 1/2 (IDH1/2) mutations did not affect the response rate (88.2% vs. 68.9%, P=0.220) and reflected a better OS (not attained vs. 9.0 months, P=0.05). The most common non-hematologic adverse events were pulmonary infection (73.1%), followed by febrile neutropenia (23.9%) and sepsis (19.4%). CONCLUSIONS The CDCAG regimen was effective and well-tolerated in R/R AML patients, increasing the potential for allogeneic hematopoietic stem cell transplantation. Moreover, patients with DNMT3A, TET2, and IDH1/2 mutations might benefit from this regimen.
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Affiliation(s)
- Fan-Cong Kong
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, China
- Jiangxi Clinical Research Center for Hematologic Diseases, Nanchang, 330006, China
| | - Ling Qi
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, China
- Jiangxi Clinical Research Center for Hematologic Diseases, Nanchang, 330006, China
| | - Yu-Lan Zhou
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, China
- Jiangxi Clinical Research Center for Hematologic Diseases, Nanchang, 330006, China
| | - Min Yu
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, China
- Jiangxi Clinical Research Center for Hematologic Diseases, Nanchang, 330006, China
| | - Wen-Feng Huang
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, China
| | - Fei Li
- Center of Hematology, The First Affiliated Hospital of Nanchang University, Nanchang, 330006, China.
- Jiangxi Clinical Research Center for Hematologic Diseases, Nanchang, 330006, China.
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Ma YR, Zhao T, Ma L, Hu LJ, Duan WB, Jiang H, Huang XJ, Jiang Q. [Variables associated with hematological remission and survival in patients with acute myeloid leukemia after induction failure and relapse]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2022; 43:644-650. [PMID: 36709148 PMCID: PMC9593012 DOI: 10.3760/cma.j.issn.0253-2727.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Indexed: 11/28/2022]
Abstract
Objective: This study aimed to explore variables associated with remission rate and survival in patients with acute myeloid leukemia (AML) after induction failure and relapse. Methods: Data of 373 consecutive patients with AML were analyzed after induction failure and relapse. Binary logistics and the Cox model regression were used to identify variables associated with remission rate and outcomes. Results: In patients with AML after induction failure and relapse, the total CR+CRi rates were 50.6% and 40.3%, respectively; among those who achieved CR/CRi, the 3-year RFS rates were 34.4% and 30.4%, respectively, and the 3-year overall survival rates were 40.1% and 31.6%, respectively. In the multivariate analyses, using CLAG or FLAG regimen as a re-induction chemotherapy regimen, age <39 years and SWOG low-risk were significantly associated with higher remission rates in patients with induction failure. Male, secondary AML, SWOG high-risk, the interval from the first remission to relapse within 12 months, and bone marrow blasts ≥20% at the time of relapse were significantly associated with lower remission rates in relapsed patients. Transplantation was significantly associated with prolonged relapse-free survival and overall survival in patients achieving hematologic remission; the SWOG low-risk group was significantly associated with longer overall survival in those with induction failure; and achieving CR (not CRi) or having female gender was associated with longer RFS or overall survival in relapsed patients. Conclusion: Reinduction chemotherapy regimen, age, gender, SWOG risk, secondary AML, the interval from the first remission to relapse, and bone marrow blast percentage at the time of relapse were significantly associated with remission rates in the patients with AML after induction failure and relapse. Transplantation, SWOG low-risk, achieving CR, or female gender were associated with longer survivals in those achieving remission.
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Affiliation(s)
- Y R Ma
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing 100044, China
| | - T Zhao
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing 100044, China
| | - L Ma
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing 100044, China
| | - L J Hu
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing 100044, China
| | - W B Duan
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing 100044, China
| | - H Jiang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing 100044, China
| | - X J Huang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing 100044, China
| | - Q Jiang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing 100044, China
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Martínez-Cuadrón D, Serrano J, Mariz J, Gil C, Tormo M, Martínez-Sánchez P, Rodríguez-Arbolí E, García-Boyero R, Rodríguez-Medina C, Martínez-Chamorro C, Polo M, Bergua J, Aguiar E, Amigo ML, Herrera P, Alonso-Domínguez JM, Bernal T, Espadana A, Sayas MJ, Algarra L, Vidriales MB, Vasconcelos G, Vives S, Pérez-Encinas MM, López A, Noriega V, García-Fortes M, Chillón MC, Rodríguez-Gutiérrez JI, Calasanz MJ, Labrador J, López JA, Boluda B, Rodríguez-Veiga R, Martínez-López J, Barragán E, Sanz MA, Montesinos P. Characteristics and Outcomes of Adult Patients in the PETHEMA Registry with Relapsed or Refractory FLT3-ITD Mutation-Positive Acute Myeloid Leukemia. Cancers (Basel) 2022; 14:cancers14112817. [PMID: 35681796 PMCID: PMC9179309 DOI: 10.3390/cancers14112817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/26/2022] [Accepted: 05/31/2022] [Indexed: 02/01/2023] Open
Abstract
This retrospective study investigated outcomes of 404 patients with relapsed/refractory (R/R) FMS-like tyrosine kinase 3 (FLT3)-internal tandem duplication (ITD) acute myeloid leukemia (AML) enrolled in the PETHEMA registry, pre-approval of tyrosine kinase inhibitors. Most patients (63%) had received first-line intensive therapy with 3 + 7. Subsequently, patients received salvage with intensive therapy (n = 261), non-intensive therapy (n = 63) or supportive care only (n = 80). Active salvage therapy (i.e., intensive or non-intensive therapy) resulted in a complete remission (CR) or CR without hematological recovery (CRi) rate of 42%. More patients achieved a CR/CRi with intensive (48%) compared with non-intensive (19%) salvage therapy (p < 0.001). In the overall population, median overall survival (OS) was 5.5 months; 1- and 5-year OS rates were 25% and 7%. OS was significantly (p < 0.001) prolonged with intensive or non-intensive salvage therapy compared with supportive therapy, and in those achieving CR/CRi versus no responders. Of 280 evaluable patients, 61 (22%) had an allogeneic stem-cell transplant after they had achieved CR/CRi. In conclusion, in this large cohort study, salvage treatment approaches for patients with FLT3-ITD mutated R/R AML were heterogeneous. Median OS was poor with both non-intensive and intensive salvage therapy, with best long-term outcomes obtained in patients who achieved CR/CRi and subsequently underwent allogeneic stem-cell transplant.
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Affiliation(s)
- David Martínez-Cuadrón
- Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain; (B.B.); (R.R.-V.); (E.B.); (M.A.S.); (P.M.)
- Correspondence: ; Tel.: +34-96-1244925
| | - Josefina Serrano
- Hospital Universitario Reina Sofía and Instituto Maimónides de Investigación Biomédica Córdoba (IMIBIC), 14004 Córdoba, Spain;
| | - José Mariz
- IPO (Istituto Portugues Oncologia), 4200-072 Porto, Portugal;
| | - Cristina Gil
- Hospital General Universitario de Alicante, 03010 Alicante, Spain;
| | - Mar Tormo
- Hospital Clínico Universitario, INCLIVA Biomedical Research Institute, 46010 Valencia, Spain;
| | - Pilar Martínez-Sánchez
- Hospital Universitario 12 de Octubre, Complutense University, i+12, CNIO, 28041 Madrid, Spain; (P.M.-S.); (J.M.-L.)
| | | | | | | | | | - Marta Polo
- Hospital Clínico San Carlos, 28040 Madrid, Spain;
| | - Juan Bergua
- Hospital San Pedro Alcántara, 10003 Cáceres, Spain;
| | | | - María L. Amigo
- Hospital General Universitario Morales Meseguer, 30008 Murcia, Spain;
| | - Pilar Herrera
- Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain;
| | | | - Teresa Bernal
- Hospital Universitario Central de Asturias, 33011 Asturias, Spain;
| | - Ana Espadana
- Hospital de Coimbra, 3400-091 Coimbra, Portugal;
| | - María J. Sayas
- Hospital Universitario Doctor Peset, 46017 Valencia, Spain;
| | - Lorenzo Algarra
- Hospital General Universitario de Albacete, 02006 Albacete, Spain;
| | - María B. Vidriales
- Department of Hematology, University Hospital of Salamanca (HUS/IBSAL), CIBERONC and Cancer Research Institute of Salamanca-IBMCC (USAL-CSIC), 37007 Salamanca, Spain; (M.B.V.); (M.C.C.)
| | | | - Susana Vives
- ICO-Hospital Germans Trias i Pujol, Badalona, José Carreras Leukemia Research Institute, Universitat Autònoma de Barcelona, 08916 Barcelona, Spain;
| | | | | | - Víctor Noriega
- Complejo Hospitalario Universitario A Coruña, 15006 La Coruna, Spain;
| | | | - María C. Chillón
- Department of Hematology, University Hospital of Salamanca (HUS/IBSAL), CIBERONC and Cancer Research Institute of Salamanca-IBMCC (USAL-CSIC), 37007 Salamanca, Spain; (M.B.V.); (M.C.C.)
| | | | | | | | - Juan A. López
- Complejo Hospitalario Ciudad de Jaén, 23007 Jaén, Spain;
| | - Blanca Boluda
- Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain; (B.B.); (R.R.-V.); (E.B.); (M.A.S.); (P.M.)
| | - Rebeca Rodríguez-Veiga
- Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain; (B.B.); (R.R.-V.); (E.B.); (M.A.S.); (P.M.)
| | - Joaquín Martínez-López
- Hospital Universitario 12 de Octubre, Complutense University, i+12, CNIO, 28041 Madrid, Spain; (P.M.-S.); (J.M.-L.)
| | - Eva Barragán
- Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain; (B.B.); (R.R.-V.); (E.B.); (M.A.S.); (P.M.)
| | - Miguel A. Sanz
- Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain; (B.B.); (R.R.-V.); (E.B.); (M.A.S.); (P.M.)
| | - Pau Montesinos
- Hospital Universitari i Politècnic La Fe, 46026 Valencia, Spain; (B.B.); (R.R.-V.); (E.B.); (M.A.S.); (P.M.)
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Long-term outcomes in patients with relapsed/refractory acute myeloid leukemia and other high-risk myeloid malignancies after undergoing sequential conditioning regimen based on IDA-FLAG and high-dose melphalan. Bone Marrow Transplant 2022; 57:1304-1312. [DOI: 10.1038/s41409-022-01703-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 04/25/2022] [Accepted: 04/29/2022] [Indexed: 12/17/2022]
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Wang ZY, Gao WH, Zhao HJ, Yin CR, Wang ZW, Tian L, Wang L, Wang LN, Jiang JL, Devillier R, Wan M, Wang JM, Huang PP, Blaise D, Hu J. Chemotherapy or Allogeneic Stem Cell Transplantation as Salvage Therapy for Patients with Refractory Acute Myeloid Leukemia: A Multicenter Analysis. Acta Haematol 2022; 145:419-429. [PMID: 35231903 PMCID: PMC9393842 DOI: 10.1159/000511144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 08/26/2020] [Indexed: 12/03/2022]
Abstract
Introduction The overall outcome of patients with refractory AML (rAML) remains poor. Though allogeneic hematopoietic stem cell transplantation (allo-HSCT) is considered as the only curative therapy, it is routinely recommended only for patients after remission with salvage chemotherapy. Objective In this study, we evaluated the impact of salvage chemotherapy or allo-HSCT on the overall outcome in rAML. Methods We collected the clinical data of 220 patients from 4 medical centers and performed retrospective analysis of prognosis factors, including salvage chemotherapy, intensity of chemotherapy, and allo-HSCT. Results A total of 29 patients received allo-HSCT directly without salvage chemotherapy, 26 patients achieved complete remission (CR) or complete remission with incomplete hematological recovery (CRi) after transplantation and 4-year leukemia-free survival (LFS) and overall survival (OS) were 45.0 ± 10.7 and 51.0 ± 10.6%, respectively. Another 191 patients received salvage chemotherapy and 81 (42.2%) achieved CR or CRi. Thirty-four patients among them underwent subsequent allo-HSCT with 4-year LFS and OS of 46.0 ± 8.8 and 46.2 ± 9.0%. The 4-year LFS and OS in 26 patients who failed to obtain CR or CRi but received allo-HSCT with active disease were 32.9 ± 10.0 and 36.9 ± 10.8%, respectively. For patients who received salvage chemotherapy but not allo-HSCT, few of them became long-term survivors. In multivariate analysis, salvage chemotherapy and the intensity of chemotherapy failed to have significant impact on both OS and LFS. Allo-HSCT was the only prognostic factor for improved OS and LFS in multivariate analysis. Conclusions These results indicate the benefit of allo-HSCT in patients with rAML and direct allo-HSCT without salvage chemotherapy could be treatment option.
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Affiliation(s)
- Zhong-yu Wang
- Shanghai Institute of Hematology, Blood and Marrow Transplantation Center, Department of Hematology, Collaborative Innovation Center of Hematology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wen-hui Gao
- Shanghai Institute of Hematology, Blood and Marrow Transplantation Center, Department of Hematology, Collaborative Innovation Center of Hematology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Hui-jin Zhao
- Shanghai Institute of Hematology, Blood and Marrow Transplantation Center, Department of Hematology, Collaborative Innovation Center of Hematology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chun-rong Yin
- Department of Hematology, Tong Ren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zi-wei Wang
- Department of Hematology, Chang Hai Hospital, The Second Military Medical University, Shanghai, China
| | - Liang Tian
- Shanghai Clinical Research Center (SCRC), Feng Lin International Centre, Shanghai, China
| | - Ling Wang
- Shanghai Institute of Hematology, Blood and Marrow Transplantation Center, Department of Hematology, Collaborative Innovation Center of Hematology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Li-ning Wang
- Shanghai Institute of Hematology, Blood and Marrow Transplantation Center, Department of Hematology, Collaborative Innovation Center of Hematology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jie-ling Jiang
- Shanghai Institute of Hematology, Blood and Marrow Transplantation Center, Department of Hematology, Collaborative Innovation Center of Hematology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Raynier Devillier
- Department of Hematology, Program of Transplantation and Cell Therapy, Program of Leukemia, Centre de recherche en Cancérologie de Marseille (CRCM), Institut Paoli-Calmettes, Aix Marseille University, Marseille, France
| | - Ming Wan
- Shanghai Clinical Research Center (SCRC), Feng Lin International Centre, Shanghai, China
| | - Jian-Ming Wang
- Department of Hematology, Chang Hai Hospital, The Second Military Medical University, Shanghai, China
- *Jian-Ming Wang,
| | - Ping-ping Huang
- Department of Hematology, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Didier Blaise
- Department of Hematology, Program of Transplantation and Cell Therapy, Program of Leukemia, Centre de recherche en Cancérologie de Marseille (CRCM), Institut Paoli-Calmettes, Aix Marseille University, Marseille, France
| | - Jiong Hu
- Shanghai Institute of Hematology, Blood and Marrow Transplantation Center, Department of Hematology, Collaborative Innovation Center of Hematology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Gadaud N, Leroy H, Bérard E, Tavitian S, Leguay T, Dimicoli-Salazar S, Rieu JB, Luquet I, Largeaud L, Bidet A, Delabesse E, Klein E, Sarry A, de Grande AC, Bories P, Pigneux A, Récher C, Dumas PY, Bertoli S. Azacitidine, intensive chemotherapy or best supportive care in relapsed or refractory acute myeloid leukemia, a DATAML registry study. Leuk Lymphoma 2022; 63:1398-1406. [DOI: 10.1080/10428194.2021.2022140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Noémie Gadaud
- Service d’Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | - Harmony Leroy
- Centre Hospitalier Universitaire de Bordeaux, Service d’Hématologie Clinique et de Thérapie Cellulaire, Bordeaux, France
| | - Emilie Bérard
- Service d’Epidémiologie, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
- CERPOP, Université de Toulouse, Inserm, UPS, Toulouse, France
| | - Suzanne Tavitian
- Service d’Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | - Thibaut Leguay
- Centre Hospitalier Universitaire de Bordeaux, Service d’Hématologie Clinique et de Thérapie Cellulaire, Bordeaux, France
| | - Sophie Dimicoli-Salazar
- Centre Hospitalier Universitaire de Bordeaux, Service d’Hématologie Clinique et de Thérapie Cellulaire, Bordeaux, France
| | - Jean-Baptiste Rieu
- Laboratoire d’Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | - Isabelle Luquet
- Laboratoire d’Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | - Laetitia Largeaud
- Laboratoire d’Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
- Université Toulouse III Paul Sabatier, Toulouse, France
- Cancer Research Center of Toulouse, UMR1037 INSERM, ERL5294 CNRS, Toulouse, France
| | - Audrey Bidet
- Laboratoire d’Hématologie Biologique, CHU Bordeaux, Bordeaux, France
| | - Eric Delabesse
- Laboratoire d’Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
- Université Toulouse III Paul Sabatier, Toulouse, France
- Cancer Research Center of Toulouse, UMR1037 INSERM, ERL5294 CNRS, Toulouse, France
| | - Emilie Klein
- Laboratoire d’Hématologie Biologique, CHU Bordeaux, Bordeaux, France
| | - Audrey Sarry
- Service d’Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | - Anne-Charlotte de Grande
- Centre Hospitalier Universitaire de Bordeaux, Service d’Hématologie Clinique et de Thérapie Cellulaire, Bordeaux, France
| | - Pierre Bories
- Service d’Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | - Arnaud Pigneux
- Centre Hospitalier Universitaire de Bordeaux, Service d’Hématologie Clinique et de Thérapie Cellulaire, Bordeaux, France
- Université de Bordeaux, Bordeaux, France
- Institut National de la Santé et de la Recherche Médicale, Bordeaux, France
| | - Christian Récher
- Service d’Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
- Université Toulouse III Paul Sabatier, Toulouse, France
- Cancer Research Center of Toulouse, UMR1037 INSERM, ERL5294 CNRS, Toulouse, France
| | - Pierre-Yves Dumas
- Centre Hospitalier Universitaire de Bordeaux, Service d’Hématologie Clinique et de Thérapie Cellulaire, Bordeaux, France
- Université de Bordeaux, Bordeaux, France
- Institut National de la Santé et de la Recherche Médicale, Bordeaux, France
| | - Sarah Bertoli
- Service d’Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
- Université Toulouse III Paul Sabatier, Toulouse, France
- Cancer Research Center of Toulouse, UMR1037 INSERM, ERL5294 CNRS, Toulouse, France
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Weigert N, Rowe JM, Lazarus HM, Salman MY. Consolidation in AML: Abundant opinion and much unknown. Blood Rev 2021; 51:100873. [PMID: 34483002 DOI: 10.1016/j.blre.2021.100873] [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: 05/12/2021] [Revised: 06/24/2021] [Accepted: 08/01/2021] [Indexed: 11/25/2022]
Abstract
Consolidation therapy forms the backbone of post-remission therapy for AML and is uniformly accepted as an integral part of therapy designed to achieve long-term survival. The need for post-remission therapy was initially described over four decades ago and has since undergone many variations in terms of dosage, number of cycles and intensity of therapy. There is much empiricism in the current understanding of consolidation therapy and much that has not been rigorously studied. This review will consider the many aspects of consolidation therapy, focusing on the number of cycles, differences between young and older adults, first and subsequent remission as well as therapy prior to an allogeneic transplant. Emphasis will be given to differentiate strategies that are clearly evidence-based from those that have been incorporated into standard of care while bypassing the need for rigorous data-driven approaches. Finally, consideration will be given to the current ability to assess the minimal measureable residual disease and the impact that this may have on therapeutic paradigms, including superseding many of the time-honored prognostic features.
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Affiliation(s)
- Nir Weigert
- Department of Hematology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Jacob M Rowe
- Department of Hematology, Shaare Zedek Medical Center, Jerusalem, Israel; Department of Hematology and Bone Marrow Transplantation, Rambam Medical Center, Haifa, Israel; Technion, Israel Institute of Technology, Haifa, Israel.
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9
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Báez-Gutiérrez N, Rodríguez-Ramallo H, Moreno MAP, Arboli ER, Abdel-Kader Martín L. Venetoclax combination therapy with hypomethylating agents in young adults with relapsed/refractory acute myeloid leukaemia. Ther Adv Hematol 2021; 12:20406207211040335. [PMID: 34471510 PMCID: PMC8404627 DOI: 10.1177/20406207211040335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 07/27/2021] [Indexed: 01/25/2023] Open
Abstract
In recent years, one of the most successful advances in treating acute myeloid leukaemia (AML) has been the combination of the B-cell lymphoma 2 (BCL-2) inhibitor venetoclax with hypomethylating agents (decitabine or azacytidine). This combination treatment has an accelerated approval by the Food and Drug Administration for newly diagnosed AML adults who are 75 years of age or older or who have comorbidities and are not eligible to receive intensive induction chemotherapy. AML is the most common form of acute leukaemia in adults, with a median age at diagnosis of 68 years. Consequently, most of the patients included in the studies are elderly. Traditionally, young patients achieve higher remission rates compared with the elderly AML population. Although venetoclax combination therapy could become a treatment option for treating young patients with relapsed/refractory AML, this regimen has not been systematically tested in this setting. In this study, we summarize the currently available evidence on the treatment of venetoclax in combination with hypomethylating agents for the treatment of young relapsed/refractory AML patients, in addition to our experience in clinical practice with two case reports. Venetoclax, combined with hypomethylating agents, seems to be an effective option for young relapsed/refractory AML patients. However, due to the poor quality of the evidence, additional well-designed studies with greater numbers of patients are needed to confirm the effectiveness and safety of venetoclax combination regimens for this population.
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Affiliation(s)
- Nerea Báez-Gutiérrez
- Hospital Pharmacy Department, Virgen del Rocio University Hospital, Seville, Spain
| | - Héctor Rodríguez-Ramallo
- Hospital Pharmacy Department, Virgen del Rocio University Hospital, Avda. Manuel Siurot s/n, 41013 Seville, Spain
| | | | - Eduardo-Rodriguez Arboli
- Department of Hematology, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla (IBIS/CSIC/CIBERONC), University of Seville, Seville, Spain
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10
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Heinicke T, Krahl R, Kahl C, Cross M, Scholl S, Wolf HH, Hähling D, Hegenbart U, Peter N, Schulze A, Florschütz A, Schmidt V, Reifenrath K, Zojer N, Junghanss C, Sayer HG, Maschmeyer G, Späth C, Hochhaus A, Fischer T, Al-Ali HK, Niederwieser D. Allogeneic hematopoietic stem cell transplantation improves long-term outcome for relapsed AML patients across all ages: results from two East German Study Group Hematology and Oncology (OSHO) trials. Ann Hematol 2021; 100:2387-2398. [PMID: 34232360 PMCID: PMC8357692 DOI: 10.1007/s00277-021-04565-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 06/04/2021] [Indexed: 12/14/2022]
Abstract
Relapse of acute leukemia is a frequent complication with uncertain outcome and poorly defined risk factors. From 1621 patients entered into two prospective clinical trials (AML02; n = 740 and AML04; n = 881), 74.2% reached complete remission (CR) 1 after induction(s) and 59 patients after additional induction ± hematopoietic cell transplantation (HCT). Of the non-refractory patients, 48.4% with a median age of 63 (range 17-85) years relapsed. Relapses occurred within 6 months after CR in 46.5%, between 7 and 18 months in 38.7%, and after 18 months in 14.8% of patients. Relapse treatment resulted in CR2 in 39% of patients depending upon age (54.5% of ≤ 60 and 28.6% of > 60 years), duration of CR1, and treatment of relapse. Overall survival (OS) was 10.9 (7.4-16.2) %, but OS after HCT ± intensive chemotherapy (ICT) was 39.3% (31.8-48.6) at 5 years and not different in younger and older patients. Donor lymphocyte infusion ± chemotherapy and ICT alone resulted only in OS of 15.4% and of 5%, respectively. Independent favorable factors for OS were long CR1 duration, and HCT, while non-monosomal disease was beneficial for OS in elderly patients. Leukemia-free survival [LFS; 24.9 (19.5-31.7) % at 10 years] was affected by similar risk factors. In a competing risk model, the relapse incidence at 5 years was 53.5 ± 3.5% and the non-relapse mortality rate 21.7 ± 2.9%. Lower relapse incidence was observed in patents with HCT, long CR1 duration, and female gender. Risk factors for non-relapse mortality were HCT in younger and type of AML in elderly patients. In conclusion, allogeneic HCT ± IC improved the results in relapsed AML in younger and elderly patients. Increasing CR2 rates and HCT frequency will be the challenge for the next years. Relapse of the disease remains the major problem.
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Affiliation(s)
- Thomas Heinicke
- Department of Hematology and Oncology, University of Magdeburg, Magdeburg, Germany
| | - Rainer Krahl
- University Hospital Leipzig, 04106, Leipzig, Germany
| | - Christoph Kahl
- Department of Hematology and Oncology, Hospital Magdeburg, Magdeburg, Germany
| | - Michael Cross
- University Hospital Leipzig, 04106, Leipzig, Germany
| | - Sebastian Scholl
- Klinik Für Innere Medizin II, Universitätsklinikum Jena, Jena, Germany
| | - Hans-Heinrich Wolf
- Department of Hematology and Oncology, University Hospital, Halle, Germany
| | - Detlev Hähling
- Department of Hematology and Oncology, Klinikum Schwerin, Schwerin, Germany
| | - Ute Hegenbart
- Departement of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| | - Norma Peter
- Medizinische Klinik, Carl-Thieme-Klinikum GmbH, Cottbus, Germany
| | - Antje Schulze
- Department of Hematology and Oncology, Helios Klinikum Erfurt, Erfurt, Germany
| | | | - Volker Schmidt
- Department of Hematology and Oncology, Helios Klinikum Erfurt, Erfurt, Germany
| | | | - Niklas Zojer
- Department of Medicine I, Wilhelminen Cancer Research Institute, Wilhelminenhospital, , Vienna, Austria
| | - Christian Junghanss
- Hematology, Oncology, Palliative Medicine, University of Rostock, Rostock, Germany
| | - Herbert G Sayer
- Department of Hematology and Oncology, Helios Klinikum Erfurt, Erfurt, Germany
| | - Georg Maschmeyer
- Department of Hematology, Oncology and Palliative Care, Ernst Von Bergmann Hospital, Potsdam, Germany
| | - Christian Späth
- Hematology and Oncology, University of Greifswald, Greifswald, Germany
| | - Andreas Hochhaus
- Klinik Für Innere Medizin II, Universitätsklinikum Jena, Jena, Germany
| | - Thomas Fischer
- Department of Hematology and Oncology, University of Magdeburg, Magdeburg, Germany
| | | | - Dietger Niederwieser
- University Hospital Leipzig, 04106, Leipzig, Germany.
- Lithuanian University of Health Sciences, Kaunas, Lithuania.
- Aichi Medical University, Nagakute, Japan.
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11
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Linch DC, Hills RK, Gilkes A, Burnett AK, Russell N, Gale RE. Additional impact of mutational genotype on prognostic determination in resistant and relapsed acute myeloid leukaemia. Leuk Res 2021; 108:106553. [PMID: 33706968 DOI: 10.1016/j.leukres.2021.106553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 02/13/2021] [Accepted: 02/23/2021] [Indexed: 11/28/2022]
Abstract
Outcome after failure of initial therapy in younger adult patients with acute myeloid leukaemia (AML) is highly variable. Cytogenetics, length of first remission (CR1) before relapse, and allogeneic transplantation are known prognostic factors, but the contribution of leukaemic genotype is less clear, particularly in resistant disease. Of 5,651 younger adult patients entered into UK MRC/NCRI AML trials between 1988 and 2014 with available FLT3ITD and NPM1 genotype, 326 (6%) had resistant disease and 2338 (41 %) relapsed after achieving CR1. Overall survival (OS) was significantly higher in relapsed compared to resistant disease (p = 0·03). Independent favourable prognostic factors for OS in resistant disease included lower blast cell percentage after two courses of induction therapy (p = 0.0006) and NPM1 mutant (NPM1MUT) (p = 0.04). In relapsed disease, longer CR1 was a favourable independent factor for attainment of CR2 (p < 0.0001) and OS from time of relapse (p < 0.0001), but CR2 rate and OS from relapse were significantly worse in those who had received an allograft in CR1 (respectively p < 0.05, p < 0·002). NPM1MUT was marginally beneficial for OS (p = 0.04). FLT3ITD and DNMT3AMUT were adverse factors for OS (respectively p < 0.0001, p = 0.02). Mutational analysis adds additional independent prognostic information to demographic features and previous therapy in patients with resistant and relapsed disease.
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MESH Headings
- Adolescent
- Adult
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Biomarkers, Tumor/genetics
- Cytogenetic Analysis
- Drug Resistance, Neoplasm/genetics
- Female
- Follow-Up Studies
- Genotype
- Humans
- Leukemia, Myeloid, Acute/drug therapy
- Leukemia, Myeloid, Acute/genetics
- Leukemia, Myeloid, Acute/pathology
- Male
- Middle Aged
- Mutation
- Neoplasm Recurrence, Local/drug therapy
- Neoplasm Recurrence, Local/genetics
- Neoplasm Recurrence, Local/pathology
- Nucleophosmin
- Prognosis
- Retrospective Studies
- Survival Rate
- Young Adult
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Affiliation(s)
- David C Linch
- Department of Haematology, UCL Cancer Institute, London, UK.
| | | | - Amanda Gilkes
- Department of Haematology, School of Medicine, Cardiff University, Cardiff, UK
| | - Alan K Burnett
- Department of Haematology, School of Medicine, Cardiff University, Cardiff, UK
| | - Nigel Russell
- Department of Haematology, Nottingham University Hospital NHS Trust, Nottingham, UK
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12
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Xu Q, He S, Yu L. Clinical Benefits and Safety of Gemtuzumab Ozogamicin in Treating Acute Myeloid Leukemia in Various Subgroups: An Updated Systematic Review, Meta-Analysis, and Network Meta-Analysis. Front Immunol 2021; 12:683595. [PMID: 34484181 PMCID: PMC8415423 DOI: 10.3389/fimmu.2021.683595] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 07/27/2021] [Indexed: 01/11/2023] Open
Abstract
Background Previous trials demonstrated evidence involving the total effects of gemtuzumab ozogamicin (GO), an anti-CD33 humanized antibody, on treating acute myeloid leukemia (AML). In this updated systematic review, meta-analysis, and network meta-analysis (NMA), we aimed to comprehensively explore the clinical benefits and safety of GO in various subtypes of AML. Methods PubMed, Embase, Cochrane, and Chinese databases were filtered to search randomized controlled trials (RCTs) and retrospective cohort studies that compared clinical efficiency and toxicity of GO with non-GO groups in AML. Random-effects models were used to calculate pooled effect sizes and 95% confidence intervals (CIs). Relative risk (RR) was used for estimating complete remission (CR), early death, and toxicity. Hazard risk (HR) was accomplished to evaluate survival. Results Fifteen RCTs and 15 retrospective cohort studies were identified (GO: 4,768; Control: 6,466). GO tended to improve CR (RR 0.95, p = 0.084), followed by significantly improved survival (overall survival: HR 0.86, p = 0.003; event-free survival: HR 0.86, p = 0.015; relapse-free survival: HR 0.83, p = 0.001; cumulative incidence of relapse: HR 0.82, p < 0.001). GO benefits of CR and survival were evident in favorable- and intermediate-risk karyotypes (p ≤ 0.023). GO advantages were also associated with nucleophosmin 1 mutations (p ≤ 0.04), wild-type FMS-like tyrosine kinase 3 internal tandem duplication gene (p ≤ 0.03), age of <70 years (p < 0.05), de novo AML (p ≤ 0.017), and CD33(+) (p ≤ 0.021). Both adding GO into induction therapy (p ≤ 0.011) and a lower (<6 mg/m2) dose of GO (p ≤ 0.03) enhanced survival. Prognosis of combined regimens with GO was heterogeneous in both meta-analysis and NMA, with several binding strategies showing improved prognosis. Additionally, GO was related to increased risk of early death at a higher dose (≥6 mg/m2) (RR 2.01, p = 0.005), hepatic-related adverse effects (RR 1.29, p = 0.02), and a tendency of higher risk for hepatic veno-occlusive disease or sinusoidal obstruction syndrome (RR 1.56, p = 0.072). Conclusions These data indicated therapeutic benefits and safety of GO in AML, especially in some subtypes, for which further head-to-head RCTs are warranted. Systematic Review Registration [PROSPERO: https://www.crd.york.ac.uk/prospero/], identifier [CRD42020158540].
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MESH Headings
- Antineoplastic Agents, Immunological/administration & dosage
- Antineoplastic Agents, Immunological/adverse effects
- Antineoplastic Agents, Immunological/therapeutic use
- Biomarkers, Tumor
- Gemtuzumab/administration & dosage
- Gemtuzumab/adverse effects
- Gemtuzumab/therapeutic use
- Humans
- Karyotype
- Leukemia, Myeloid, Acute/diagnosis
- Leukemia, Myeloid, Acute/drug therapy
- Leukemia, Myeloid, Acute/etiology
- Leukemia, Myeloid, Acute/mortality
- Molecular Targeted Therapy
- Mutation
- Prognosis
- Sialic Acid Binding Ig-like Lectin 3/antagonists & inhibitors
- Treatment Outcome
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Affiliation(s)
- Qingyu Xu
- Department of Hematology and Oncology, International Cancer Center, Shenzhen Key Laboratory, Shenzhen University General Hospital, Shenzhen University Clinical Medical Academy, Shenzhen University Health Science Center, Shenzhen, China
- Department of Hematology and Oncology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Shujiao He
- Department of Hematology and Oncology, International Cancer Center, Shenzhen Key Laboratory, Shenzhen University General Hospital, Shenzhen University Clinical Medical Academy, Shenzhen University Health Science Center, Shenzhen, China
| | - Li Yu
- Department of Hematology and Oncology, International Cancer Center, Shenzhen Key Laboratory, Shenzhen University General Hospital, Shenzhen University Clinical Medical Academy, Shenzhen University Health Science Center, Shenzhen, China
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13
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Ma J, Ge Z. Recent advances of targeted therapy in relapsed/refractory acute myeloid leukemia. Bosn J Basic Med Sci 2021; 21:409-421. [PMID: 33577442 PMCID: PMC8292864 DOI: 10.17305/bjbms.2020.5485] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 01/26/2021] [Indexed: 12/22/2022] Open
Abstract
Despite advances in the understanding of disease pathobiology, treatment for relapsed or refractory acute myeloid leukemia (R/R AML) remains challenging. The prognosis of R/R AML remains extremely poor despite chemotherapy and bone marrow transplants. Discoveries on recurrent and novel genetic mutations, such as FLT3-ITD and IDH1/IDH2, critical signaling pathways, and unique molecular markers expressed on the surface of leukemic cells have been under investigation for the management of R/R AML. Other than monoclonal antibodies, diabodies, and triabodies are new targeted therapies developed in recent years and will be the new direction of immunotherapy. Targeted agents combined intensive regimens can be viable options for salvage therapy and as bridges to allogeneic transplant. Future directions will focus on novel, efficient and targeted combinations, low-toxicity maintenance, and individualized precision strategies. Here, we review the major recent advances of targeted therapies in the treatment of R/R AML.
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Affiliation(s)
- Jiale Ma
- Department of Hematology, Zhongda Hospital, School of Medicine, Southeast University, Institute of Hematology Southeast University, Nanjing, China; Department of Hematology, Xuzhou Central Hospital, Xuzhou, China
| | - Zheng Ge
- Department of Hematology, Zhongda Hospital, School of Medicine, Southeast University, Institute of Hematology Southeast University, Nanjing, China
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14
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Venetoclax-based salvage therapy followed by Venetoclax and DLI maintenance vs. FLAG-Ida for relapsed or refractory acute myeloid leukemia after allogeneic stem cell transplantation. Bone Marrow Transplant 2021; 56:2804-2812. [PMID: 34274954 DOI: 10.1038/s41409-021-01416-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 07/03/2021] [Accepted: 07/08/2021] [Indexed: 11/08/2022]
Abstract
We retrospectively compared the outcomes of 20 patients receiving Venetoclax + low-dose Cytarabine + Actinomycin D (ACTIVE) with 29 patients receiving FLAG-Ida as salvage therapy for relapsed or refractory AML (R/R AML) after alloSCT. The groups were statistically balanced according to age, performance status, cytogenetics, and previous treatment. The overall response rate (CR + CRp + MLFS) of ACTIVE was 75% (15/20) in comparison to 66% (19/29) in the FLAG-Ida group (p = 0.542). The cumulative CR + CRp rate was significantly higher in the ACTIVE group compared to FLAG-Ida (70% (14/20) vs. 34% (10/29), respectively, p = 0.02). All three patients failing previous Venetoclax therapy and five out of seven patients with previous FLAG-Ida exposure achieved a CR/CRp after ACTIVE induction. ACTIVE patients survived longer compared to FLAG-Ida patients (13.1 vs. 5.1 months, respectively, p = 0.032). The treatment-related mortality was 0% in the ACTIVE group and 34% (10/29) in the FLAG-Ida patients (p = 0.003). The cumulative incidence of relapse did not differ between the two treatment groups. ACTIVE appears to have comparable antileukemic activity and lower toxicity compared to FLAG-Ida resulting in improved survival. Patients with Venetoclax or FLAG-Ida exposure responded to ACTIVE.
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15
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Boluda B, Martínez-Cuadrón D, Algarra L, Cano I, Sayas MJ, Acuña-Cruz E, Blanco A, Marco-Ayala J, DeLapuerta R, Díaz-González Á, Tormo M, Rodríguez-Veiga R, García R, Piñana JL, López-Pavía M, Barragán E, Amigo ML, Sargas C, López A, Solana-Altabella A, Gil C, Megías-Vericat JE, Sanz MA, Montesinos P. Evolving patterns of care and outcomes in relapsed/refractory FLT3 mutated acute myeloid leukemia adult patients. Leuk Lymphoma 2021; 62:2727-2736. [PMID: 34121593 DOI: 10.1080/10428194.2021.1938031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
We have analyzed treatment patterns and outcomes of relapsed/refractory(R/R) FLT3mut AML adult patients registered in our institutional data base between 1998 and 2018. Overall, 147 patients were evaluable: 34 from 1998 to 2009, 113 from 2010 to 2018. Salvage treatments were intensive chemotherapy (n = 25, 74%), and supportive care (n = 9, 26%) in the 1998-2009 period, and intensive chemotherapy (n = 63, 56%), hypomethylating agent (n = 7, 6%), low-dose cytarabine-based (n = 8, 7%), clinical trial (n = 16, 14%) and supportive care (n = 19, 17%) in the 2010-2018 period. Complete remission (CR) or with incomplete recovery (CRi) rate was 44%, 49% among patients treated intensively (vs 30% with non-intensive p = 0.005). Median overall survival since first R/R was 5.8 months, and 16.3 months in subjects receiving an allo-HSCT in CR/CRi after first salvage (vs 3.8 in the remaining patients p < 0.0001). Clinical outcomes of R/R FLT3mut AML remain unsatisfactory. Inclusion in clinical trials and expanding options could lead to improved outcomes.
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Affiliation(s)
- Blanca Boluda
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain.,Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - David Martínez-Cuadrón
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain.,Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - Lorenzo Algarra
- Hematology Department, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | - Isabel Cano
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain.,Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - María J Sayas
- Hematology Department, Hospital Doctor Peset, Valencia, Spain
| | - Evelyn Acuña-Cruz
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain.,Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - Albert Blanco
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Javier Marco-Ayala
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Rosalía DeLapuerta
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Álvaro Díaz-González
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Mar Tormo
- Hematology Department, Hospital Clínico Universitario, Valencia, Spain
| | - Rebeca Rodríguez-Veiga
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain.,Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - Raimundo García
- Hematology Department, Hospital General Castellón, Castellón, Spain
| | - José L Piñana
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain.,Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - María López-Pavía
- Hematology Department, Hospital General Universitario, Valencia, Spain
| | - Eva Barragán
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain.,Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - María L Amigo
- Hematology Department, Hospital Morales Meseguer, Murcia, Spain
| | - Claudia Sargas
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain.,Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - Aurelio López
- Hematology Department, Hospital Arnau de Vilanova, Valencia, Spain
| | - Antonio Solana-Altabella
- Instituto de Investigación Sanitaria La Fe, Valencia, Spain.,Pharmacy Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Cristina Gil
- Hematology Department, Hospital General Universitario de Alicante, Alicante, Spain
| | - Juan Eduardo Megías-Vericat
- Instituto de Investigación Sanitaria La Fe, Valencia, Spain.,Pharmacy Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Miguel A Sanz
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain.,Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - Pau Montesinos
- Hematology Department, Hospital Universitari i Politècnic La Fe, Valencia, Spain.,Instituto de Investigación Sanitaria La Fe, Valencia, Spain
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16
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Martínez Sánchez MP, Megías-Vericat JE, Rodríguez-Veiga R, Vives S, Bergua JM, Torrent A, Suárez-Varela S, Boluda B, Martínez-López J, Cano-Ferri I, Acuña-Cruz E, Torres-Miñana L, Martín-Herreros B, Serrano A, Sempere A, Barragán E, Sargas C, Sanz M, Martínez-Cuadrón D, Montesinos P. A phase I trial of selinexor plus FLAG-Ida for the treatment of refractory/relapsed adult acute myeloid leukemia patients. Ann Hematol 2021; 100:1497-1508. [PMID: 33914097 DOI: 10.1007/s00277-021-04542-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 04/19/2021] [Indexed: 11/25/2022]
Abstract
Prognosis for relapsed or refractory (R/R) acute myeloid leukemia (AML) despite salvage therapy is dismal. This phase I dose-escalation trial assessed the safety and preliminary clinical activity of selinexor, an oral exportin-1 (XPO1) inhibitor, in combination with FLAG-Ida in younger R/R AML patients. The aim was to find the recommended phase 2 dose (RP2D) and maximum tolerated dose (MTD). Fourteen patients were included, and selinexor dosage was 60 mg (3 patients), 80 mg (3 patients), and 100 mg (7 patients) weekly. No dose-limiting toxicities were reported. Grade ≥3 non-hematologic adverse events (AEs) occurred in 78.6% of patients. Two patients were non MTD evaluable due to early death, and overall, 3 out of 14 patients (21.4%) had fatal AEs. Five out of 12 (42%) response and MTD evaluable patients achieved a complete remission (CR; n=4) or CR with incomplete hematologic recovery (CRi, n=1), and 4 patients (33%) subsequently underwent allogeneic transplantation. The median overall survival (OS) and event-free survival (EFS) were 6.0 (range 0.9-19.3) and 1.1 months (range 0.7-19.3), respectively. Using selinexor 100 mg/weekly, CR/CRi rate of 66.7%, OS 13.6 months (range, 1.6-19.3), and EFS 10.6 months (range, 0.9-19.3). At last follow-up, 3 patients were alive. Selinexor 100 mg/weekly with FLAG-Ida combination in R/R AML showed acceptable tolerability and efficacy, establishing the RP2D of this regimen in future clinical trials. ClinicalTrials.gov Identifier: NCT03661515.
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Affiliation(s)
- María P Martínez Sánchez
- Servicio de Hematología y Hemoterapia, Hospital Universitario 12 de Octubre, UCM, CNIO, CIBERONC, Madrid, Spain
| | | | - Rebeca Rodríguez-Veiga
- Servicio de Hematología y Hemoterapia, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Susana Vives
- Servicio de Hematología y Hemoterapia, ICO-Hospital Germans Trias i Pujol, Josep Carreras Leukemia Research Institute, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Juan Miguel Bergua
- Servicio de Hematología y Hemoterapia, Hospital San Pedro de Alcántara, Cáceres, Spain
| | - Anna Torrent
- Servicio de Hematología y Hemoterapia, ICO-Hospital Germans Trias i Pujol, Josep Carreras Leukemia Research Institute, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Sara Suárez-Varela
- Servicio de Hematología y Hemoterapia, Hospital San Pedro de Alcántara, Cáceres, Spain
| | - Blanca Boluda
- Servicio de Hematología y Hemoterapia, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Joaquín Martínez-López
- Servicio de Hematología y Hemoterapia, Hospital Universitario 12 de Octubre, UCM, CNIO, CIBERONC, Madrid, Spain
| | - Isabel Cano-Ferri
- Servicio de Hematología y Hemoterapia, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Evelyn Acuña-Cruz
- Servicio de Hematología y Hemoterapia, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Laura Torres-Miñana
- Servicio de Hematología y Hemoterapia, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Beatriz Martín-Herreros
- Grupo de investigación en Hematología, Instituto de Investigación Sanitaria La Fe (IISLAFE), Valencia, Spain
| | - Alfons Serrano
- Servicio de Hematología y Hemoterapia, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Amparo Sempere
- Servicio de Hematología y Hemoterapia, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Eva Barragán
- Servicio de Hematología y Hemoterapia, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Claudia Sargas
- Servicio de Hematología y Hemoterapia, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Miguel Sanz
- Servicio de Hematología y Hemoterapia, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - David Martínez-Cuadrón
- Servicio de Hematología y Hemoterapia, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - Pau Montesinos
- Servicio de Hematología y Hemoterapia, Hospital Universitari i Politècnic La Fe, Valencia, Spain.
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17
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Chandra Sekaran U, Grove CS. Prognostic factors and their importance in relapsed and refractory AML: Comments on "Additional impact of mutational genotype on prognostic determination in resistant and relapsed acute myeloid leukaemia" by Linch et al. Leuk Res 2021; 105:106572. [PMID: 33836481 DOI: 10.1016/j.leukres.2021.106572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 03/17/2021] [Indexed: 11/20/2022]
Affiliation(s)
- Usha Chandra Sekaran
- Department of Haematology, Sir Charles Gairdner Hospital, Perth, Australia; Department of Haematology, PathWest Laboratory Medicine, Perth, Australia
| | - Carolyn S Grove
- Department of Haematology, Sir Charles Gairdner Hospital, Perth, Australia; Department of Haematology, PathWest Laboratory Medicine, Perth, Australia; School of Biomedical Sciences, University of Western Australia, Perth, Australia.
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18
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Récher C. Clinical Implications of Inflammation in Acute Myeloid Leukemia. Front Oncol 2021; 11:623952. [PMID: 33692956 PMCID: PMC7937902 DOI: 10.3389/fonc.2021.623952] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 01/04/2021] [Indexed: 02/06/2023] Open
Abstract
Recent advances in the description of the tumor microenvironment of acute myeloid leukemia, including the comprehensive analysis of the leukemic stem cell niche and clonal evolution, indicate that inflammation may play a major role in many aspects of acute myeloid leukemia (AML) such as disease progression, chemoresistance, and myelosuppression. Studies on the mechanisms of resistance to chemotherapy or tyrosine kinase inhibitors along with high-throughput drug screening have underpinned the potential role of glucocorticoids in this disease classically described as steroid-resistant in contrast to acute lymphoblastic leukemia. Moreover, some mutated oncogenes such as RUNX1, NPM1, or SRSF2 transcriptionally modulate cell state in a manner that primes leukemic cells for glucocorticoid sensitivity. In clinical practice, inflammatory markers such as serum ferritin or IL-6 have a strong prognostic impact and may directly affect disease progression, whereas interesting preliminary data suggested that dexamethasone may improve the outcome for AML patients with a high white blood cell count, which paves the way to develop prospective clinical trials that evaluate the role of glucocorticoids in AML.
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Affiliation(s)
- Christian Récher
- Service d'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Université Toulouse III Paul Sabatier, Centre de Recherches en Cancérologie de Toulouse, Toulouse, France
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19
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Ma TT, Lin XJ, Cheng WY, Xue Q, Wang SY, Liu FJ, Yan H, Zhu YM, Shen Y. Development and validation of a prognostic model for adult patients with acute myeloid leukaemia. EBioMedicine 2020; 62:103126. [PMID: 33232873 PMCID: PMC7689519 DOI: 10.1016/j.ebiom.2020.103126] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/28/2020] [Accepted: 10/28/2020] [Indexed: 12/22/2022] Open
Abstract
Background The high heterogeneity of acute myeloid leukaemia (AML) reflected in the patient- and disease-related factors accounts for the unsatisfactory prognosis despite the introduction of novel therapeutic approaches and drugs in recent years. Methods In the development set (n = 412), parameters including age, hematopoietic cell transplantation-comorbidity index, white blood cell count, hemoglobin, biallelic CEBPA mutations, DNMT3A mutations, FLT3-ITD/NPM1 status, and ELN cytogenetic risk status were identified as independent prognostic factors for overall survival (OS) in the multivariable Cox regression analysis. A nomogram combining these predictors for individual risk estimation was established thereby. Findings The prognostic model demonstrated promising performance in the development cohort. The calibration plot, C-index (0.74), along with the 1-, 2- and 3-year area under the receiver operating characteristic curve (AUC, 0.76, 0.79, and 0.74, respectively) in the validation set (n = 238) substantiated the robustness of the model. In addition to stratifying young (age ≤ 60 years) and elderly patients (age > 60 years) into three and two risk groups with significant distinct outcomes, the prognostic model succeeded in distinguishing eligible candidates for hematopoietic stem cell transplantation. Interpretation The prognostic model is capable of survival prediction, risk stratification and helping with therapeutic decision-making with the use of easily acquired variables in daily clinical routine. Funding This work was supported in part by grants from the National Natural Science Foundation of China (81770141), the National Key R&D Program of China (2016YFE0202800), and Shanghai Municipal Education Commission-Gaofeng Clinical Medicine Grant Support (20161406).
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Affiliation(s)
- Ting-Ting Ma
- Shanghai Institute of Haematology, Department of Haematology, State Key Laboratory of Medical Genomics, National Research Centre for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No.197 Ruijin Er Road, Shanghai, China
| | - Xiao-Jing Lin
- Shanghai Institute of Haematology, Department of Haematology, State Key Laboratory of Medical Genomics, National Research Centre for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No.197 Ruijin Er Road, Shanghai, China
| | - Wen-Yan Cheng
- Shanghai Institute of Haematology, Department of Haematology, State Key Laboratory of Medical Genomics, National Research Centre for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No.197 Ruijin Er Road, Shanghai, China
| | - Qing Xue
- Shanghai Institute of Haematology, Department of Haematology, State Key Laboratory of Medical Genomics, National Research Centre for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No.197 Ruijin Er Road, Shanghai, China
| | - Shi-Yang Wang
- Shanghai Institute of Haematology, Department of Haematology, State Key Laboratory of Medical Genomics, National Research Centre for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No.197 Ruijin Er Road, Shanghai, China
| | - Fu-Jia Liu
- Shanghai Institute of Haematology, Department of Haematology, State Key Laboratory of Medical Genomics, National Research Centre for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No.197 Ruijin Er Road, Shanghai, China
| | - Han Yan
- Shanghai Institute of Haematology, Department of Haematology, State Key Laboratory of Medical Genomics, National Research Centre for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No.197 Ruijin Er Road, Shanghai, China
| | - Yong-Mei Zhu
- Shanghai Institute of Haematology, Department of Haematology, State Key Laboratory of Medical Genomics, National Research Centre for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No.197 Ruijin Er Road, Shanghai, China
| | - Yang Shen
- Shanghai Institute of Haematology, Department of Haematology, State Key Laboratory of Medical Genomics, National Research Centre for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No.197 Ruijin Er Road, Shanghai, China.
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20
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Cancilla D, Rettig MP, DiPersio JF. Targeting CXCR4 in AML and ALL. Front Oncol 2020; 10:1672. [PMID: 33014834 PMCID: PMC7499473 DOI: 10.3389/fonc.2020.01672] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 07/29/2020] [Indexed: 12/13/2022] Open
Abstract
The interaction of acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL) blasts with the bone marrow microenvironment regulates self-renewal, growth signaling, as well as chemotherapy resistance. The chemokine receptor, CXC receptor 4 (CXCR4), with its ligand chemokine ligand 12 (CXCL12), plays a key role in the survival and migration of normal and malignant stem cells to the bone marrow. High expression of CXCR4 on AML and ALL blasts has been shown to be a predictor of poor prognosis for these diseases. Several small molecule inhibitors, short peptides, antibodies, and antibody drug conjugates have been developed for the purposes of more effective targeting and killing of malignant cells expressing CXCR4. In this review we will discuss recent results and strategies in targeting CXCR4 with these agents in patients with AML or ALL.
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Affiliation(s)
| | | | - John F. DiPersio
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, United States
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21
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Practical Considerations for Treatment of Relapsed/Refractory FLT3-ITD Acute Myeloid Leukaemia with Quizartinib: Illustrative Case Reports. Clin Drug Investig 2020; 40:227-235. [PMID: 31912423 PMCID: PMC7035240 DOI: 10.1007/s40261-019-00881-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Quizartinib is a tyrosine kinase inhibitor selectively targeting the FMS-like tyrosine kinase 3 (FLT3) receptor that has been developed for the treatment of acute myeloid leukaemia (AML). The Phase 3 QuANTUM-R study investigated the efficacy of quizartinib monotherapy in patients with relapsed/refractory FLT3-ITD mutation-positive AML. The clinical course of four QuANTUM-R participants exemplifies issues specific to quizartinib treatment and is described here. Patient 1 was FLT3-ITD mutation-negative at AML diagnosis, but became FLT3-ITD mutation-positive during treatment that included several lines of chemotherapy and was therefore a suitable candidate for quizartinib. Because of the clonal shifts of AML during treatment, retesting genetic alterations at each relapse or resistance may help to identify candidates for targeted treatment options. Patient 2 developed QTc prolongation during quizartinib treatment, but the QTc interval normalised after dose reduction, allowing the patient to continue treatment and eventually resume the recommended dose. Patient 3 responded to quizartinib and was scheduled for haematopoietic stem cell transplant (HSCT), but developed febrile neutropenia and invasive aspergillosis during conditioning and subsequently died (to avoid drug-drug interactions, no azole antifungal was administered concomitantly). Care is required when selecting concomitant medications, and if there is potential for interactions (e.g. if prophylactic azole antifungals are required) the quizartinib dose should be reduced to minimise the risk of QTc prolongation. Patient 4 was able to undergo HSCT after responding to quizartinib and experienced a durable response after HSCT while on quizartinib maintenance therapy. Together, these cases illustrate the main issues to be addressed when managing patients under quizartinib, allowing for adequate scheduling and tolerability, bridging to HSCT, and durable remission on maintenance therapy in some patients.
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22
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Canaani J, Nagar M, Heering G, Gefen C, Yerushalmi R, Shem-Tov N, Volchek Y, Merkel D, Avigdor A, Shimoni A, Amariglio N, Rechavi G, Nagler A. Reassessing the role of high dose cytarabine and mitoxantrone in relapsed/refractory acute myeloid leukemia. Oncotarget 2020; 11:2233-2245. [PMID: 32577167 PMCID: PMC7289527 DOI: 10.18632/oncotarget.27618] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 05/14/2020] [Indexed: 01/04/2023] Open
Abstract
A substantial segment of patients with acute myeloid leukemia (AML) will relapse following an initial response to induction therapy or will prove to be primary refractory. High-dose cytarabine and mitoxantrone (HiDAC/MITO) is an established salvage therapy for these patients. We studied all adult patients with relapsed/refractory (R/R) AML who were treated with HiDAC/MITO in our center between the years 2008-2017. To determine whether responding patients harbored a unique molecular signature, we performed targeted next-generation sequencing (NGS) on a subset of patients. The study cohort consisted of 172 patients with a median age of 54 years (range 18–77). The composite complete remission rate was 58%; 11 patients (6%) died during salvage therapy. Median survival was 11.4 months with a 1-year survival rate of 48%. In multivariate analysis favorable risk cytogenetics [Odds ratio (OR)=0.34, confidence interval (CI) 95%, 0.17–0.68; P = 0.002], and de-novo AML (OR = 0.4, CI 95%, 0.16–0.98; P = 0.047) were independently associated with a favorable response. Patients who attained a complete remission had a median survival of 43.7 months compared with 5.2 months for refractory patients (p < 0.0001). Neither the FLT3-ITD and NPM1 mutational status nor the indication for salvage therapy significantly impacted on the response to HiDAC/MITO salvage. NGS analysis identified 20 different mutations across the myeloid gene spectrum with a distinct TP53 signature detected in non-responding patients. HiDAC/MITO is an effective salvage regimen in R/R AML, however patients with adverse cytogenetics or secondary disease may not benefit as much from this approach.
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Affiliation(s)
- Jonathan Canaani
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Meital Nagar
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Gabriel Heering
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Chen Gefen
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Ronit Yerushalmi
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Noga Shem-Tov
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Yulia Volchek
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Drorit Merkel
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Abraham Avigdor
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Avichai Shimoni
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Ninette Amariglio
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Gidi Rechavi
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Arnon Nagler
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
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23
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da Silva WF, da Rosa LI, Seguro FS, Silveira DRA, Bendit I, Buccheri V, Velloso EDRP, Rocha V, Rego EM. Salvage treatment for refractory or relapsed acute myeloid leukemia: a 10-year single-center experience. Clinics (Sao Paulo) 2020; 75:e1566. [PMID: 32294670 PMCID: PMC7134553 DOI: 10.6061/clinics/2020/e1566] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 01/27/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES The outcomes of refractory and relapsed acute myeloid leukemia (AML) patients in developing countries are underreported, even though the similar classic regimens are widely used. METHODS We conducted a retrospective comparison of "MEC" (mitoxantrone, etoposide, and cytarabine) and "FLAG-IDA" (fludarabine, cytarabine, idarubicin, and filgrastim) in adults with first relapse or refractory AML. RESULTS In total, 60 patients were included, of which 28 patients received MEC and 32 received FLAG-IDA. A complete response (CR) rate of 48.3% was observed. Of the included patients, 16 (27%) died before undergoing bone marrow assessment. No statiscally significant difference in CR rate was found between the two protocols (p=0.447). The median survival in the total cohort was 4 months, with a 3-year overall survival (OS) rate of 9.7%. In a multivariable model including age, fms-like tyrosine kinase 3 (FLT3) status, and stem-cell transplantation (SCT), only the last two indicators remained significant: FLT3-ITD mutation (hazard ratio [HR]=4.6, p<0.001) and SCT (HR=0.43, p=0.01). CONCLUSION In our analysis, there were no significant differences between the chosen regimens. High rates of early toxicity were found, emphasizing the role of supportive care and judicious selection of patients who are eligible for intensive salvage therapy in this setting. The FLT3-ITD mutation and SCT remained significant factors for survival in our study, in line with the results of previous studies.
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Affiliation(s)
- Wellington Fernandes da Silva
- Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Corresponding author. E-mail:
| | - Lidiane Inês da Rosa
- Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Fernanda Salles Seguro
- Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | | | - Israel Bendit
- Hematologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Valeria Buccheri
- Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | | | - Vanderson Rocha
- Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Eduardo M Rego
- Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
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24
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Del Principe MI, De Bellis E, Gurnari C, Buzzati E, Savi A, Consalvo MAI, Venditti A. Applications and efficiency of flow cytometry for leukemia diagnostics. Expert Rev Mol Diagn 2019; 19:1089-1097. [PMID: 31709836 DOI: 10.1080/14737159.2019.1691918] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Introduction: Multiparametric flow cytometry immunophenotype (MFCI) plays a crucial role in the diagnosis of acute leukemia (AL). Through the comprehensive assessment of surface and intracellular antigens expressed by blasts, MFCI permits to distinguish myeloid or B/T lymphoid AL, or AL of ambiguous lineages. By means of MFCI, the blasts can be characterized in bone marrow, peripheral blood, and body fluids, such as cerebrospinal fluid.Area covered: This review discusses how MFCI is currently applied in the diagnostic evaluation of AL; it also focuses on 'peculiar' issues such as the role of MFCI for the diagnosis of central nervous system leukemic involvement.Expert commentary: Despite the improved knowledge about the biology of AL, MFCI remains a fundamental tool to make a prompt and accurate diagnosis. MFCI also provides prognostic information for some antigens are associated with specific cytogenetic/genetic abnormalities and, recently, it became a powerful tool to evaluate the quality and depth of response (the so called 'measurable residual disease'). Its role as an efficient detector of residual disease paved the way to the investigation of tissues other than bone marrow and peripheral blood, demonstrating that even small amounts of AL appear to have a prognostic impact and may require personalized intervention.
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Affiliation(s)
- Maria Ilaria Del Principe
- Cattedra di Ematologia, Dipartimento di Biomedicina e Prevenzione, Università Tor Vergata, Roma, Italia.,Ematologia, Dipartimento di Onco-Ematologia, Fondazione Policlinico Tor Vergata, Roma, Italia
| | - Eleonora De Bellis
- Cattedra di Ematologia, Dipartimento di Biomedicina e Prevenzione, Università Tor Vergata, Roma, Italia.,Ematologia, Dipartimento di Onco-Ematologia, Fondazione Policlinico Tor Vergata, Roma, Italia
| | - Carmelo Gurnari
- Cattedra di Ematologia, Dipartimento di Biomedicina e Prevenzione, Università Tor Vergata, Roma, Italia.,Ematologia, Dipartimento di Onco-Ematologia, Fondazione Policlinico Tor Vergata, Roma, Italia
| | - Elisa Buzzati
- Cattedra di Ematologia, Dipartimento di Biomedicina e Prevenzione, Università Tor Vergata, Roma, Italia.,Ematologia, Dipartimento di Onco-Ematologia, Fondazione Policlinico Tor Vergata, Roma, Italia
| | - Arianna Savi
- Cattedra di Ematologia, Dipartimento di Biomedicina e Prevenzione, Università Tor Vergata, Roma, Italia.,Ematologia, Dipartimento di Onco-Ematologia, Fondazione Policlinico Tor Vergata, Roma, Italia
| | | | - Adriano Venditti
- Cattedra di Ematologia, Dipartimento di Biomedicina e Prevenzione, Università Tor Vergata, Roma, Italia.,Ematologia, Dipartimento di Onco-Ematologia, Fondazione Policlinico Tor Vergata, Roma, Italia
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25
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Montesinos P, Bergua J, Infante J, Esteve J, Guimaraes JE, Sierra J, Sanz MÁ. Update on management and progress of novel therapeutics for R/R AML: an Iberian expert panel consensus. Ann Hematol 2019; 98:2467-2483. [PMID: 31667544 DOI: 10.1007/s00277-019-03820-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 10/08/2019] [Indexed: 12/19/2022]
Abstract
A significant proportion of adult patients with acute myeloid leukemia (AML) fail to achieve complete remission or will relapse later on after achieving it. Prognosis for relapsed or refractory (R/R) AML patients remains discouraging, with the main curative option still relying on hematopoietic stem cell transplant (HSCT) for those who are eligible. Beyond morphological bone marrow and peripheral blood assessment, evaluation of patient performance status and comorbidities, as well as genetic/molecular characterization, is crucial to make an accurate diagnosis and prognosis, which will be useful to select the most appropriate treatment. Emerging strategies are mainly focusing on the development of immune- and molecular-based approaches. Novel targeted therapies are generally well tolerated, potentially allowing them to be administered alone or in combination with classical chemotherapy agents. Enrolment in clinical trials should be considered first option for R/R AML patients, either as a bridge to HSCT or to benefit from novel therapies that eventually may prolong survival and improve quality of life. An Iberian expert panel has reviewed the recent advances in the management of R/R AML with the aim to develop updated evidence and expert opinion-based recommendations.
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Affiliation(s)
- Pau Montesinos
- Hematology Department, Hospital Universitari I Politècnic La Fe, Av. Fernando Abril Martorell, 106, 46026, Valencia, Spain. .,CIBERONC, Instituto de Salud Carlos III, Madrid, Spain.
| | - Juan Bergua
- Division of Hematology/Oncology, Hospital San Pedro Alcántara, Cáceres, Spain
| | - Joana Infante
- Serviço de Hematologia e Transplantação de Medula Óssea, Hospital de Santa Maria, Centro Hospitalar de Lisboa Norte, Lisbon, Portugal
| | - Jordi Esteve
- Department of Hematology, IDIBAPS, Hospital Clinic, Barcelona, Spain
| | - José Eduardo Guimaraes
- Serviço de Hematologia Clínica, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Jordi Sierra
- Hematology Department, Hospital de la Santa Creu i Sant Pau, IIB Sant Pau and Jose Carreras Leukemia Research Institutes, Autonomous University of Barcelona, Barcelona, Spain
| | - Miguel Ángel Sanz
- Hematology Department, Hospital Universitari I Politècnic La Fe, Av. Fernando Abril Martorell, 106, 46026, Valencia, Spain
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26
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Westhus J, Noppeney R, Schmitz C, Flasshove M, Dührsen U, Hanoun M. Etoposide Combined with FLAG Salvage Therapy Is Effective in Multiple Relapsed/Refractory Acute Myeloid leukemia. Acta Haematol 2019; 143:438-445. [PMID: 31655809 DOI: 10.1159/000503056] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 08/30/2019] [Indexed: 11/19/2022]
Abstract
Managing acute myeloid leukemia (AML) is often hampered by repeated failure to achieve complete remission as well as recurrent relapse that causes an emergent need for alternative salvage therapies. The efficacy of most salvage therapies is based on anthracycline combinations. In highly pretreated patients who are not eligible for anthracycline-based protocols therapeutic alternatives are limited. For this particular group we evaluated the efficacy and safety of fludarabine, cytarabine, granulocyte colony-stimulating factor (FLAG) in combination with etoposide (FLAG-Eto) in 36 patients. The complete remission rate (CR) was 25.7% with a median overall survival of 6 months (95% CI 4.5-7.7). The median disease-free survival for CR/CRi/MLFS (CR/CR with incomplete he-matological recovery/morphologic leukemia-free state) patients was 8 months (95% CI 0.6-15.5). The mortality rate on day 30 was 8% and increased on day 60 to 17%. Our results show meaningful anti-leukemic activity of the FLAG-Eto regimen with a moderate toxicity profile in heavily pretreated relapsed/refractory AML patients enabling consolidating allogeneic stem cell transplantation.
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Affiliation(s)
- Jonas Westhus
- Department of Hematology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Richard Noppeney
- Department of Hematology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Christine Schmitz
- Department of Hematology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | | | - Ulrich Dührsen
- Department of Hematology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Maher Hanoun
- Department of Hematology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany,
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Del Principe MI, Paterno G, Palmieri R, Maurillo L, Buccisano F, Venditti A. An evaluation of enasidenib for the treatment of acute myeloid leukemia. Expert Opin Pharmacother 2019; 20:1935-1942. [DOI: 10.1080/14656566.2019.1654456] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Maria Ilaria Del Principe
- Cattedra di Ematologia, Dipartimento di Biomedicina e Prevenzione, Università Tor Vergata, Roma, Italia
- Ematologia, Dipartimento di Onco-Ematologia, Fondazione Policlinico Tor Vergata, Roma, Italia
| | - Giovangiacinto Paterno
- Cattedra di Ematologia, Dipartimento di Biomedicina e Prevenzione, Università Tor Vergata, Roma, Italia
- Ematologia, Dipartimento di Onco-Ematologia, Fondazione Policlinico Tor Vergata, Roma, Italia
| | - Raffaele Palmieri
- Cattedra di Ematologia, Dipartimento di Biomedicina e Prevenzione, Università Tor Vergata, Roma, Italia
- Ematologia, Dipartimento di Onco-Ematologia, Fondazione Policlinico Tor Vergata, Roma, Italia
| | - Luca Maurillo
- Ematologia, Dipartimento di Onco-Ematologia, Fondazione Policlinico Tor Vergata, Roma, Italia
| | - Francesco Buccisano
- Cattedra di Ematologia, Dipartimento di Biomedicina e Prevenzione, Università Tor Vergata, Roma, Italia
- Ematologia, Dipartimento di Onco-Ematologia, Fondazione Policlinico Tor Vergata, Roma, Italia
| | - Adriano Venditti
- Cattedra di Ematologia, Dipartimento di Biomedicina e Prevenzione, Università Tor Vergata, Roma, Italia
- Ematologia, Dipartimento di Onco-Ematologia, Fondazione Policlinico Tor Vergata, Roma, Italia
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Ye P, Pei R, Jin J, Sun J, Li K, Cao J, Zhou D, Lu Y. Modified cladribine, cytarabine, and G-CSF as a salvage regimen in patients with relapsed/refractory acute myeloid leukemia: a bridge to myeloablative allogeneic hematopoietic stem cell transplantation. Ann Hematol 2019; 98:2073-2080. [PMID: 31201514 DOI: 10.1007/s00277-019-03723-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 05/28/2019] [Indexed: 12/27/2022]
Abstract
Patients with primary refractory or early relapsed acute myeloid leukemia (AML) have a dismal prognosis, and the treatment options for these patients are limited. The present study retrospectively examined the efficacy and toxicities of the combination of cladribine 5 mg/m2 per day and intermediate-dose cytarabine 1 g/m2 per day for 5 days and granulocyte colony-stimulating factor (G-CSF) as a salvage treatment in 36 patients with relapsed/refractory AML. Among these, 32 patients had de novo AML, and the remaining 4 patients had secondary AML. The median age for the study cohort was 45.8 years. According to the European LeukemiaNet prognostic index, 5 patients had favorable risk, 18 had intermediate risk, and 11 had poor risk. The complete remission was achieved in 58% of the patients with tolerable toxicities. Fifteen patients underwent stem cell transplantation later. Patients who underwent allogeneic hematopoietic stem cell transplantation had a significantly improved 1-year overall survival compared with those who did not (73% vs. 29%, P < 0.001). The results suggested that, as a salvage regimen, modified cladribine, cytarabine, and G-CSF were effective and well tolerated for patients with relapsed/refractory AML, especially for patients who underwent subsequent stem cell transplantation.
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Affiliation(s)
- Peipei Ye
- Department of Hematology, Yinzhou Hospital Affiliated to Medical School of Ningbo University, No. 251, East Baizhang Road, Yinzhou District, Ningbo, 315040, Zhejiang, China
| | - Renzhi Pei
- Department of Hematology, Yinzhou Hospital Affiliated to Medical School of Ningbo University, No. 251, East Baizhang Road, Yinzhou District, Ningbo, 315040, Zhejiang, China
| | - Jie Jin
- Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Jie Sun
- Department of Hematology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Kongfei Li
- Department of Hematology, Yinzhou Hospital Affiliated to Medical School of Ningbo University, No. 251, East Baizhang Road, Yinzhou District, Ningbo, 315040, Zhejiang, China
| | - Junjie Cao
- Department of Hematology, Yinzhou Hospital Affiliated to Medical School of Ningbo University, No. 251, East Baizhang Road, Yinzhou District, Ningbo, 315040, Zhejiang, China
| | - Dandan Zhou
- Department of Hematology, Yinzhou Hospital Affiliated to Medical School of Ningbo University, No. 251, East Baizhang Road, Yinzhou District, Ningbo, 315040, Zhejiang, China
| | - Ying Lu
- Department of Hematology, Yinzhou Hospital Affiliated to Medical School of Ningbo University, No. 251, East Baizhang Road, Yinzhou District, Ningbo, 315040, Zhejiang, China.
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29
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Boluda B, Rodríguez-Veiga R, Martínez-Cuadrón D, Lorenzo I, Sanz J, Regadera A, Sempere A, Senent L, Cervera JV, Solves P, Reitan J, Gea S, Sanz MA, Montesinos P. Time and Cost of Hospitalisation for Salvage Therapy in Adults with Philadelphia Chromosome-Negative B Cell Precursor Relapsed or Refractory Acute Lymphoblastic Leukaemia in Spain. PHARMACOECONOMICS - OPEN 2019; 3:229-235. [PMID: 30324566 PMCID: PMC6533337 DOI: 10.1007/s41669-018-0098-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Philadelphia chromosome-negative (Ph-) relapsed or refractory (R/R) B-cell precursor acute lymphoblastic leukaemia (ALL) is rare, and information on its impact on healthcare systems is scarce. OBJECTIVE To quantify the time and reimbursement associated with hospitalisations of patients with R/R ALL in a Spanish hospital. METHODS Retrospective review of medical charts identified patients aged ≥ 18 years with Ph- R/R ALL hospitalised between 1998 and 2014. Data were collected from the date of first diagnosis of R/R ALL (index) until death or loss to follow-up. The primary endpoint was the proportion of time hospitalised during chemotherapy. Reimbursement associated with hospitalisations (including associated chemotherapy) was also assessed. RESULTS Thirty-two patients were eligible for inclusion. Their median age was 41 years, and 50% had a first remission duration of ≤ 1 year; 34% had undergone allogeneic haematological stem-cell transplantation (alloHSCT). Overall, 31 patients had received intensive salvage chemotherapy, during which there were 42 hospitalisations (mean 1.4/patient; mean duration 26 days). Patients spent a mean of 71% of the chemotherapy period in hospital. Total mean reimbursement was €26,417 per patient, almost all (€25,723) attributable to inpatient stays (€18,986/hospitalisation). From the index date to death or loss to follow-up (excluding alloHSCT-related hospitalisations), there were 80 hospitalisations (mean duration 24 days); mean reimbursement was €16,692 per hospitalisation and €41,730 per patient. AlloHSCT (n = 8) involved 18 hospitalisations (mean reimbursement €39,782/hospitalisation; €89,510/patient). CONCLUSION Data from this sample of patients suggest that hospitalisations in R/R ALL are lengthy and associated with high costs in Spain.
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Affiliation(s)
- Blanca Boluda
- Haematology Department, Hospital Universitari i Politècnic La Fe, Avinguda de Fern ando Abril Martorell, 106, 46026, Valencia, Spain
| | - Rebeca Rodríguez-Veiga
- Haematology Department, Hospital Universitari i Politècnic La Fe, Avinguda de Fern ando Abril Martorell, 106, 46026, Valencia, Spain
| | - David Martínez-Cuadrón
- Haematology Department, Hospital Universitari i Politècnic La Fe, Avinguda de Fern ando Abril Martorell, 106, 46026, Valencia, Spain
- CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Ignacio Lorenzo
- Haematology Department, Hospital Universitari i Politècnic La Fe, Avinguda de Fern ando Abril Martorell, 106, 46026, Valencia, Spain
| | - Jaime Sanz
- Haematology Department, Hospital Universitari i Politècnic La Fe, Avinguda de Fern ando Abril Martorell, 106, 46026, Valencia, Spain
- CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Ana Regadera
- Haematology Department, Hospital Universitari i Politècnic La Fe, Avinguda de Fern ando Abril Martorell, 106, 46026, Valencia, Spain
| | - Amparo Sempere
- Haematology Department, Hospital Universitari i Politècnic La Fe, Avinguda de Fern ando Abril Martorell, 106, 46026, Valencia, Spain
- CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Leonor Senent
- Haematology Department, Hospital Universitari i Politècnic La Fe, Avinguda de Fern ando Abril Martorell, 106, 46026, Valencia, Spain
| | - Jose Vicente Cervera
- Haematology Department, Hospital Universitari i Politècnic La Fe, Avinguda de Fern ando Abril Martorell, 106, 46026, Valencia, Spain
- CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Pilar Solves
- Haematology Department, Hospital Universitari i Politècnic La Fe, Avinguda de Fern ando Abril Martorell, 106, 46026, Valencia, Spain
- CIBERONC, Instituto Carlos III, Madrid, Spain
| | | | | | - Miguel Angel Sanz
- Haematology Department, Hospital Universitari i Politècnic La Fe, Avinguda de Fern ando Abril Martorell, 106, 46026, Valencia, Spain
- CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Pau Montesinos
- Haematology Department, Hospital Universitari i Politècnic La Fe, Avinguda de Fern ando Abril Martorell, 106, 46026, Valencia, Spain.
- CIBERONC, Instituto Carlos III, Madrid, Spain.
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30
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Galkin M, Jonas BA. Enasidenib in the treatment of relapsed/refractory acute myeloid leukemia: an evidence-based review of its place in therapy. CORE EVIDENCE 2019; 14:3-17. [PMID: 31118877 PMCID: PMC6503332 DOI: 10.2147/ce.s172912] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Accepted: 03/31/2019] [Indexed: 12/19/2022]
Abstract
Introduction: Acute myeloid leukemia (AML) remains a disease with high mortality, especially for older patients and those with relapsed/refractory (R/R) disease. With recent advances in molecular testing, targeting particular leukemogenic mutations such as those occurring in isocitrate dehydrogenase (IDH) became possible. Enasidenib is a new small-molecule inhibitor of mutant isocitrate dehydrogenase-2 (IDH2). Aim: The objective of this article is to review the evidence for the use of enasidenib in R/R AML, as well as to outline future directions of enasidenib therapy. Evidence Review: Enasidenib was approved in August 2017, after a successful Phase I/II trial showing an overall response rate (ORR) of 40.3% in R/R disease, with 19.3% of patients achieving complete remission (CR). Enrollees in the trial were mostly older adults. The most prominent toxicities were hyperbilirubinemia and IDH-differentiation syndrome (IDH-DS), though the drug was generally well tolerated and the maximum tolerated dose was not reached. A Phase III trial is currently ongoing. Conclusion: Enasidenib provides a new therapeutic option for patients with R/R AML. Further studies are ongoing to ascertain its role in combination with other agents and newly diagnosed disease.
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Affiliation(s)
- Maria Galkin
- Department of Internal Medicine, University of California Davis School of Medicine, Sacramento, CA, USA
| | - Brian A Jonas
- Department of Internal Medicine, Division of Hematology and Oncology, University of California Davis School of Medicine, Sacramento, CA, USA
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31
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Michaelis LC. Cytotoxic therapy in acute myeloid leukemia: not quite dead yet. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2018; 2018:51-62. [PMID: 30504291 PMCID: PMC6246033 DOI: 10.1182/asheducation-2018.1.51] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Given the recent approvals of new agents for acute myeloid leukemia (AML), a clinical trial pipeline stocked with novel therapies, and the rapid integration of imaginative approaches in diseases like acute lymphocytic leukemia and chronic lymphocytic leukemia, it is reasonable to ask whether treatment of AML might finally depart from the classical cytotoxic induction therapy that has been employed since the 1970s. However, for better or worse, in 2018, cytotoxic induction regimens remain the standard of care for most patients. Indeed, the future likely lies in combinations of therapies that act with a spectrum of mechanisms. Using a case-based format, this review will outline current treatment expectations for patients according to karyotypic risk and familiarize readers with the basis for common induction choices. Relapsed/refractory disease may be especially amenable to interventions with novel agents or clinical trials; however, there are still some patients who most benefit from intensive chemotherapy. This review will outline risk systems that help the practitioner identify those with the best chances for response and survival. Finally, clinical tools, including geriatric assessments and comorbidity calculators, may help clinicians recognize patients for whom disease risk and comorbidity tip the balance against classical chemotherapy, a frequent challenge for those who treat this devastating disease.
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Affiliation(s)
- Laura C Michaelis
- Department of Medicine, Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, WI
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32
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Westhus J, Noppeney R, Dührsen U, Hanoun M. FLAG salvage therapy combined with idarubicin in relapsed/refractory acute myeloid leukemia. Leuk Lymphoma 2018; 60:1014-1022. [PMID: 30277107 DOI: 10.1080/10428194.2018.1508670] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Acute myeloid leukemia (AML) is characterized by a high failure rate to achieve complete remission as well as high relapse rates that cause an emergent need for efficient and tolerable salvage therapies. The combination of FLAG with idarubicin (FLAG-Ida) is a widely used protocol. However, its efficacy has been analyzed in only a limited number of studies with majorly small patient cohorts. Here, we analyzed 132 patients with largely primary refractory or first-time relapsed AML treated according to the FLAG-Ida protocol. The overall complete remission rate (CR + CRi) was 56% with a median overall survival of 15 months (95% CI, 5.7-25.1). The median disease-free survival for CR/CRi-patients was not reached. The mortality rate on day 30 was 9% and increased on day 60 to 16%. Our results show in relapsed/refractory AML patients a high efficacy and compatibility for the FLAG-Ida regimen.
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Affiliation(s)
- Jonas Westhus
- a Department of Hematology , University Hospital, University of Duisburg-Essen , Essen , Germany
| | - Richard Noppeney
- a Department of Hematology , University Hospital, University of Duisburg-Essen , Essen , Germany
| | - Ulrich Dührsen
- a Department of Hematology , University Hospital, University of Duisburg-Essen , Essen , Germany
| | - Maher Hanoun
- a Department of Hematology , University Hospital, University of Duisburg-Essen , Essen , Germany
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33
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Megías-Vericat JE, Martínez-Cuadrón D, Sanz MÁ, Montesinos P. Salvage regimens using conventional chemotherapy agents for relapsed/refractory adult AML patients: a systematic literature review. Ann Hematol 2018; 97:1115-1153. [DOI: 10.1007/s00277-018-3304-y] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 03/12/2018] [Indexed: 12/26/2022]
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34
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Martínez-Cuadrón D, Boluda B, Martínez P, Bergua J, Rodríguez-Veiga R, Esteve J, Vives S, Serrano J, Vidriales B, Salamero O, Cordón L, Sempere A, Jiménez-Ubieto A, Prieto-Delgado J, Díaz-Beyá M, Garrido A, Benavente C, Pérez-Simón JA, Moscardó F, Sanz MA, Montesinos P. A phase I-II study of plerixafor in combination with fludarabine, idarubicin, cytarabine, and G-CSF (PLERIFLAG regimen) for the treatment of patients with the first early-relapsed or refractory acute myeloid leukemia. Ann Hematol 2018; 97:763-772. [PMID: 29392425 DOI: 10.1007/s00277-018-3229-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 12/28/2017] [Indexed: 12/01/2022]
Abstract
Clinical outcomes of patients with acute myeloid leukemia (AML) showing the first primary refractory or early-relapsed disease remain very poor. The Programa Español de Tratamientos en Hematología (PETHEMA) group designed a phase I-II trial using FLAG-Ida (fludarabine, idarubicin, cytarabine, and G-CSF) plus high-dose intravenous plerixafor, a molecule inducing mobilization of blasts through the SDF-1α-CXCR4 axis blockade and potentially leading to chemosensitization of the leukemic cells. We aimed to establish a recommended phase 2 dose (RP2D) of plerixafor plus FLAG-Ida, as well as the efficacy and safety of this combination for early-relapsed (first complete remission (CR/CRi) < 12 months) or primary refractory AML. Between 2012 and 2015, 57 patients were enrolled, and 41 received the RP2D (median age 52 years [range, 18-64]). Among these patients, 20 (49%) achieved CR/CRi, and 3 (7%) died during induction. CR/CRi rate was 50% (13/26) among primary refractory and 47% (7/15) among early relapse. Overall, 25 patients (61%) were allografted. Median overall and disease-free survivals were 9.9 and 13 months, respectively. In summary, the combination of plerixafor plus FLAG-Ida resulted in a relatively high CR/CRi rate in adult patients with primary refractory or early relapsed AML, with an acceptable toxicity profile and induction mortality rate, bridging the majority of patients to allogeneic stem cell transplantation. ClinicalTrials.gov Identifier: NCT01435343.
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Affiliation(s)
- David Martínez-Cuadrón
- Hematology Department, Hospital Universitari i Politècnic, La Fe, Avinguda Fernando Abril Martorell, 106, 46026, València, Spain.,CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Blanca Boluda
- Hematology Department, Hospital Universitari i Politècnic, La Fe, Avinguda Fernando Abril Martorell, 106, 46026, València, Spain
| | | | - Juan Bergua
- Hospital San Pedro de Alcántara, Cáceres, Spain
| | - Rebeca Rodríguez-Veiga
- Hematology Department, Hospital Universitari i Politècnic, La Fe, Avinguda Fernando Abril Martorell, 106, 46026, València, Spain
| | | | - Susana Vives
- Hospital ICO-Universitari Germans Trias i Pujol, José Carreras Leukemia Research Institute, Badalona, Spain
| | | | | | - Olga Salamero
- Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Lourdes Cordón
- Hematology Department, Hospital Universitari i Politècnic, La Fe, Avinguda Fernando Abril Martorell, 106, 46026, València, Spain.,CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Amparo Sempere
- Hematology Department, Hospital Universitari i Politècnic, La Fe, Avinguda Fernando Abril Martorell, 106, 46026, València, Spain.,CIBERONC, Instituto Carlos III, Madrid, Spain
| | | | | | | | - Ana Garrido
- Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | | | - Federico Moscardó
- Hematology Department, Hospital Universitari i Politècnic, La Fe, Avinguda Fernando Abril Martorell, 106, 46026, València, Spain
| | - Miguel A Sanz
- Hematology Department, Hospital Universitari i Politècnic, La Fe, Avinguda Fernando Abril Martorell, 106, 46026, València, Spain.,CIBERONC, Instituto Carlos III, Madrid, Spain.,Department of Medicine, University of Valencia, Valencia, Spain
| | - Pau Montesinos
- Hematology Department, Hospital Universitari i Politècnic, La Fe, Avinguda Fernando Abril Martorell, 106, 46026, València, Spain. .,CIBERONC, Instituto Carlos III, Madrid, Spain.
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35
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DeAngelo DJ, Brunner AM, Werner L, Avigan D, Fathi AT, Sperling AS, Washington A, Stroopinsky D, Rosenblatt J, McMasters M, Luptakova K, Wadleigh M, Steensma DP, Hobbs GS, Attar EC, Amrein PC, Ebert BL, Stone RM, Ballen KK. A phase I study of lenalidomide plus chemotherapy with mitoxantrone, etoposide, and cytarabine for the reinduction of patients with acute myeloid leukemia. Am J Hematol 2018; 93:254-261. [PMID: 29119643 DOI: 10.1002/ajh.24968] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 10/27/2017] [Accepted: 11/06/2017] [Indexed: 12/17/2022]
Abstract
Patients with relapsed AML have a poor prognosis and limited responses to standard chemotherapy. Lenalidomide is an immunomodulatory drug that may modulate anti-tumor immunity. We performed a study to evaluate the safety and tolerability of lenalidomide with mitoxantrone, etoposide and cytarabine (MEC) in relapsed/refractory AML. Adult patients with relapsed/refractory AML were eligible for this phase I dose-escalation study. We enrolled 35 patients using a "3 + 3" design, with a 10 patient expansion cohort at the maximum tolerated dose (MTD). Lenalidomide was initially given days 1-14 and MEC days 4-8; due to delayed count recovery, the protocol was amended to administer lenalidomide days 1-10. The dose of lenalidomide was then escalated starting at 5 mg/d (5-10-25-50). The primary objective was tolerability and MTD determination, with secondary outcomes including overall survival (OS). The MTD of lenalidomide combined with MEC was 50 mg/d days 1-10. Among the 35 enrolled patients, 12 achieved complete remission (CR) (34%, 90%CI 21-50%); 30-day mortality was 6% and 60-day mortality 13%. The median OS for all patients was 11.5 months. Among 17 patients treated at the MTD, 7 attained CR (41%); the median OS was not reached while 12-month OS was 61%. Following therapy with MEC and lenalidomide, patient CD4+ and CD8+ T-cells demonstrated increased inflammatory responses to autologous tumor lysate. The combination of MEC and lenalidomide is tolerable with an RP2D of lenalidomide 50 mg/d days 1-10, yielding encouraging response rates. Further studies are planned to explore the potential immunomodulatory effect of lenalidomide and MEC.
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Affiliation(s)
| | | | | | - David Avigan
- Beth-Israel Deaconess Medical Center; Boston Massachusetts
| | - Amir T. Fathi
- Massachusetts General Hospital; Boston Massachusetts
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36
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Rashidi A, Weisdorf DJ, Bejanyan N. Treatment of relapsed/refractory acute myeloid leukaemia in adults. Br J Haematol 2018; 181:27-37. [PMID: 29318584 DOI: 10.1111/bjh.15077] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The prognosis of relapsed acute myeloid leukaemia (AML) is poor and treatment is challenging. While the most potent treatment modality for patients who achieve a complete remission after relapse is still allogeneic haematopoietic cell transplantation (allo-HCT), both transplant-related mortality and relapse rates are high and many patients are not candidates for this approach. After a few decades of relative stasis in this field, a large number of novel approaches have become available to tackle this highly fatal disease. This is mostly due to our improved understanding of disease pathogenesis (including targetable mutations) and the anti-leukaemia potential of the immune system. Several small-molecule inhibitors and immunotherapeutic options are being explored in clinical trials and many more are in pre-clinical phase. Future studies will focus on novel and mechanistically driven combinations, sequential treatments, and low-toxicity maintenance strategies. While cure of relapsed/refractory AML without allo-HCT is currently unlikely, treatments are becoming less toxic and remissions are lasting longer.
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Affiliation(s)
- Armin Rashidi
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Daniel J Weisdorf
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Nelli Bejanyan
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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37
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Rongmu L, Xiaomei Z, Zhenlan D, Ya W, Wei C, Yingjian S, Wenjing G, Guosheng X, Yang W, Wanming D. Tumorablative conditioning regimen for haploidentical stem cell transplantation in 102 children with hematologic malignancies: a single-center experience. Oncotarget 2017; 8:113749-113757. [PMID: 29371943 PMCID: PMC5768360 DOI: 10.18632/oncotarget.22893] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 11/13/2017] [Indexed: 11/25/2022] Open
Abstract
Haploidentical hematopoietic stem cell transplantation (Haplo-HSCT) is widely carried out in China, and transplantation related complications decreased gradually with the transplant technology improving, and the overall survival(OS) increased year by year. However, relapse after transplantation is still one of the main causes of death in patients with hematological malignancy. In order to reduce the recurrence after HSCT, we set a tumorablative conditioning regimen (TAC ) regimen; the aim is as much as possible to eliminate the malignant clone to reduce the recurrence without increasing the conditioning toxicity. We retrospectively analyzed 102 cases of haplo-HSCT in our hospital from 2012 to 2017. Ninety-eight out of the 99 (99.0%) patients achieved primary engraftment. The 2-year OS and disease free survival (DFS) are 81.4% (83/102) and 77.45% (79/102). The cumulative incidence of leukemia relapse is 16.2% (16/99), Twenty-nine patients developed II-IV acute graft-versus-host disease (aGVHD) (29%) within 100 days and only nine patients have grade III-IV aGVHD (9%) in measurable 99 patients. The conditioning regimen was relatively well tolerated with limited regimen-related toxicity. The preliminary results show that TAC is safe and effective in haplo-HSCT of children with hematologic malignancies. This study will provide a clinical basis for the individualized conditioning regimen.
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Affiliation(s)
- Luo Rongmu
- Affiliated BaYi Children's Hospital, PLA Army General Hospital, Beijing, China.,National Engineering Laboratory for Birth Defects Prevention and Control of Key Technology, Beijing, China.,Beijing Key Laboratory of Pediatric Organ Failure, Beijing, China
| | - Zhang Xiaomei
- Affiliated BaYi Children's Hospital, PLA Army General Hospital, Beijing, China.,National Engineering Laboratory for Birth Defects Prevention and Control of Key Technology, Beijing, China.,Beijing Key Laboratory of Pediatric Organ Failure, Beijing, China
| | - Du Zhenlan
- Affiliated BaYi Children's Hospital, PLA Army General Hospital, Beijing, China.,National Engineering Laboratory for Birth Defects Prevention and Control of Key Technology, Beijing, China.,Beijing Key Laboratory of Pediatric Organ Failure, Beijing, China
| | - Wang Ya
- Affiliated BaYi Children's Hospital, PLA Army General Hospital, Beijing, China.,National Engineering Laboratory for Birth Defects Prevention and Control of Key Technology, Beijing, China.,Beijing Key Laboratory of Pediatric Organ Failure, Beijing, China
| | - Chen Wei
- Affiliated BaYi Children's Hospital, PLA Army General Hospital, Beijing, China.,National Engineering Laboratory for Birth Defects Prevention and Control of Key Technology, Beijing, China.,Beijing Key Laboratory of Pediatric Organ Failure, Beijing, China
| | - Si Yingjian
- Affiliated BaYi Children's Hospital, PLA Army General Hospital, Beijing, China.,National Engineering Laboratory for Birth Defects Prevention and Control of Key Technology, Beijing, China.,Beijing Key Laboratory of Pediatric Organ Failure, Beijing, China
| | - Gu Wenjing
- Affiliated BaYi Children's Hospital, PLA Army General Hospital, Beijing, China.,National Engineering Laboratory for Birth Defects Prevention and Control of Key Technology, Beijing, China.,Beijing Key Laboratory of Pediatric Organ Failure, Beijing, China
| | - Xing Guosheng
- Affiliated BaYi Children's Hospital, PLA Army General Hospital, Beijing, China.,National Engineering Laboratory for Birth Defects Prevention and Control of Key Technology, Beijing, China.,Beijing Key Laboratory of Pediatric Organ Failure, Beijing, China
| | - Wang Yang
- Affiliated BaYi Children's Hospital, PLA Army General Hospital, Beijing, China.,National Engineering Laboratory for Birth Defects Prevention and Control of Key Technology, Beijing, China.,Beijing Key Laboratory of Pediatric Organ Failure, Beijing, China
| | - Da Wanming
- Affiliated BaYi Children's Hospital, PLA Army General Hospital, Beijing, China.,Department of Hematology, Chinese PLA General Hospital, Beijing, China
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[How I treat acute myeloid leukemia with t (8;21)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2017; 38:6-9. [PMID: 28219217 PMCID: PMC7348410 DOI: 10.3760/cma.j.issn.0253-2727.2017.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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