1
|
Burkart M, Dinner S. Advances in the treatment of Philadelphia chromosome negative acute lymphoblastic leukemia. Blood Rev 2024; 66:101208. [PMID: 38734488 DOI: 10.1016/j.blre.2024.101208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 04/23/2024] [Accepted: 04/24/2024] [Indexed: 05/13/2024]
Abstract
There have been major paradigm shifts in the treatment of Philadelphia chromosome negative (Ph-) acute lymphoblastic leukemia (ALL) in the last decade with the introduction of new immunotherapies and targeted agents, adoption of pediatric-type chemotherapy protocols in younger adults as well as chemotherapy light approaches in older adults and the incorporation of measurable residual disease (MRD) testing to inform clinical decision making. With this, treatment outcomes in adult Ph- ALL have improved across all age groups. However, a subset of patients will still develop relapsed disease, which can be challenging to treat and associated with poor outcomes. Here we review the treatment of Ph- ALL in both younger and older adults, including the latest advancements and future directions.
Collapse
Affiliation(s)
- Madelyn Burkart
- Wake Forest Baptist Health, Winston Salem, NC, United States of America
| | - Shira Dinner
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, United States of America.
| |
Collapse
|
2
|
Gökbuget N, Boissel N, Chiaretti S, Dombret H, Doubek M, Fielding A, Foà R, Giebel S, Hoelzer D, Hunault M, Marks DI, Martinelli G, Ottmann O, Rijneveld A, Rousselot P, Ribera J, Bassan R. Management of ALL in adults: 2024 ELN recommendations from a European expert panel. Blood 2024; 143:1903-1930. [PMID: 38306595 DOI: 10.1182/blood.2023023568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/19/2024] [Accepted: 01/21/2024] [Indexed: 02/04/2024] Open
Abstract
ABSTRACT Experts from the European Leukemia Net (ELN) working group for adult acute lymphoblastic leukemia have identified an unmet need for guidance regarding management of adult acute lymphoblastic leukemia (ALL) from diagnosis to aftercare. The group has previously summarized their recommendations regarding diagnostic approaches, prognostic factors, and assessment of ALL. The current recommendation summarizes clinical management. It covers treatment approaches, including the use of new immunotherapies, application of minimal residual disease for treatment decisions, management of specific subgroups, and challenging treatment situations as well as late effects and supportive care. The recommendation provides guidance for physicians caring for adult patients with ALL which has to be complemented by regional expertise preferably provided by national academic study groups.
Collapse
Affiliation(s)
- Nicola Gökbuget
- Department of Medicine II, Hematology/Oncology, Goethe University, University Hospital, Frankfurt, Germany
| | - Nicolas Boissel
- Hospital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Sabina Chiaretti
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Hervé Dombret
- Leukemia Department, University Hospital Saint-Louis, Assistance Publique-Hôpitaux de Paris, Saint-Louis Research Institute, Université Paris Cité, Paris, France
| | - Michael Doubek
- Department of Internal Medicine-Hematology and Oncology, University Hospital Brno, Brno, Czech Republic
| | | | - Robin Foà
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Sebastian Giebel
- Department of Bone Marrow Transplantation and Onco-Hematology, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | - Dieter Hoelzer
- Department of Medicine II, Hematology/Oncology, Goethe University, University Hospital, Frankfurt, Germany
| | - Mathilde Hunault
- Maladies du Sang University Hospital of Angers, FHU Goal, INSERM, National Centre for Scientific Research, Angers, France
| | - David I Marks
- University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| | - Giovanni Martinelli
- IRCCS Istituto Romagnolo per lo Studio dei Tumori Dino Amadori, Meldola, Italy
| | - Oliver Ottmann
- Division of Cancer and Genetics, Cardiff University School of Medicine, Cardiff, United Kingdom
| | | | - Philippe Rousselot
- Clinical Hematology Department, Centre Hospitalier de Versailles, Université Paris-Saclay, Versailles, France
| | - Josep Ribera
- Clinical Hematology Department, Institut Catala d'Oncologia Hospital Germans Trias I Pujol, Josep Carreras Research Institute, Badalona, Spain
| | - Renato Bassan
- Division of Hematology, Ospedale dell'Angelo, Mestre-Venice, Italy
| |
Collapse
|
3
|
Zarling LC, Stevenson PA, Soma LA, Martino CH, Percival MEM, Halpern AB, Ghiuzeli CM, Becker PS, Oehler VG, Cooper JP, Orozco JJ, Hendrie PC, Walter RB, Estey EH, Cassaday RD. Hyper-CVAD versus dose-adjusted EPOCH as initial treatment for adults with acute lymphoblastic leukemia. Eur J Haematol 2023; 111:863-871. [PMID: 37670560 DOI: 10.1111/ejh.14089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/10/2023] [Accepted: 08/16/2023] [Indexed: 09/07/2023]
Abstract
OBJECTIVES We recently performed a single-arm phase II trial of DA-EPOCH in adults with acute lymphoblastic leukemia (ALL). We sought to compare these results to those with standard Hyper-CVAD. METHODS We created a retrospective matched cohort of patients who received Hyper-CVAD (n = 69) at our center and otherwise met eligibility criteria for the DA-EPOCH trial (n = 53). RESULTS Our outcomes support the use of Hyper-CVAD over DA-EPOCH in Ph- disease for both overall survival (OS; HR 0.18, p = .004) and event-free survival (EFS; HR 0.51, p = .06). In contrast, outcomes were similar in Ph+ disease (OS HR 0.97, p = .96; EFS HR 0.65, p = .21). Rates of morphologic remission and measurable residual-disease negativity were similar between the regimens. Hyper-CVAD was associated with significantly more febrile neutropenia (OR 1.9, p = .03) and a greater incidence of Grade 4 or 5 adverse events (20% vs. 6%). Average transfusions per cycle of both red blood cells (p < .001) and platelets (p < .001) were five-fold higher with Hyper-CVAD. CONCLUSIONS Our findings support continued use of Hyper-CVAD for Ph- ALL but suggest that DA-EPOCH may be a reasonable alternative for Ph+ ALL. These data also highlight a potential role for DA-EPOCH in resource-limited settings or when more intense therapy is not feasible.
Collapse
Affiliation(s)
- Lucas C Zarling
- Department of Medicine, University of Washington, Seattle, Washington, DC, USA
| | - Philip A Stevenson
- Clinical Statistics Division, Fred Hutchinson Cancer Center, Seattle, Washington, DC, USA
| | - Lorinda A Soma
- Department of Pathology, City of Hope National Medical Center, Duarte, California, USA
| | - Christen H Martino
- Department of Medicine, University of Washington, Seattle, Washington, DC, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, DC, USA
| | - Mary-Elizabeth M Percival
- Department of Medicine, University of Washington, Seattle, Washington, DC, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, DC, USA
| | - Anna B Halpern
- Department of Medicine, University of Washington, Seattle, Washington, DC, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, DC, USA
| | - Cristina M Ghiuzeli
- Department of Medicine, University of Washington, Seattle, Washington, DC, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, DC, USA
| | - Pamela S Becker
- Department of Medicine, University of Washington, Seattle, Washington, DC, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, DC, USA
- Department of Hematology & Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California, USA
| | - Vivian G Oehler
- Department of Medicine, University of Washington, Seattle, Washington, DC, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, DC, USA
| | - Jason P Cooper
- Department of Medicine, University of Washington, Seattle, Washington, DC, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, DC, USA
| | - Johnnie J Orozco
- Department of Medicine, University of Washington, Seattle, Washington, DC, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, DC, USA
| | - Paul C Hendrie
- Department of Medicine, University of Washington, Seattle, Washington, DC, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, DC, USA
| | - Roland B Walter
- Department of Medicine, University of Washington, Seattle, Washington, DC, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, DC, USA
| | - Elihu H Estey
- Department of Medicine, University of Washington, Seattle, Washington, DC, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, DC, USA
| | - Ryan D Cassaday
- Department of Medicine, University of Washington, Seattle, Washington, DC, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, DC, USA
| |
Collapse
|
4
|
Wieduwilt MJ. Ph+ ALL in 2022: is there an optimal approach? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:206-212. [PMID: 36485090 PMCID: PMC9820632 DOI: 10.1182/hematology.2022000338] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Philadelphia chromosome-positive (Ph+) acute lymphoblastic leukemia (ALL) carried a very poor prognosis prior to the advent of tyrosine kinase inhibitors (TKIs) that block the activity of the BCR-ABL1 oncoprotein. With improvements in TKI efficacy and allogeneic hematopoietic cell transplantation (HCT), survival has improved over the past 3 decades, and the role of chemotherapy and allogeneic HCT is now changing. Better risk stratification, the application of the third-generation TKI ponatinib, and the use of immunotherapy with the CD19-CD3 bifunctional T-cell engaging antibody blinatumomab in place of chemotherapy has made therapy for Ph+ ALL more tolerable and arguably more efficacious, especially for older patients who comprise most patients with Ph+ ALL.
Collapse
Affiliation(s)
- Matthew J. Wieduwilt
- Correspondence Matthew J. Wieduwilt, 1 Medical Center Blvd #3rd, Winston- Salem, NC 27157, USA; e-mail:
| |
Collapse
|
5
|
Creasey T, Barretta E, Ryan SL, Butler E, Kirkwood AA, Leongamornlert D, Papaemmanuil E, Patrick P, Clifton-Hadley L, Patel B, Menne T, McMillan AK, Harrison CJ, Rowntree CJ, Morley N, Marks DI, Fielding AK, Moorman AV. Genetic and genomic analysis of acute lymphoblastic leukemia in older adults reveals a distinct profile of abnormalities: analysis of 210 patients from the UKALL14 and UKALL60+ clinical trials. Haematologica 2022; 107:2051-2063. [PMID: 34788984 PMCID: PMC9425332 DOI: 10.3324/haematol.2021.279177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 09/09/2021] [Indexed: 11/09/2022] Open
Abstract
Despite being predominantly a childhood disease, the incidence of acute lymphoblastic leukemia (ALL) has a second peak in adults aged 60 years and over. These older adults fare extremely poorly with existing treatment strategies and very few studies have undertaken a comprehensive genetic and genomic characterization to improve prognosis in this age group. We performed cytogenetic, single nucleotide polymorphism (SNP) array and next-generation sequencing (NGS) analyses on samples from 210 patients aged ≥60 years from the UKALL14 and UKALL60+ clinical trials. BCR-ABL1-positive disease was present in 26% (55/210) of patients, followed by low hypodiploidy/near triploidy in 13% (28/210). Cytogenetically cryptic rearrangements in CRLF2, ZNF384 and MEF2D were detected in 5%, 1% and <1% of patients, respectively. Copy number abnormalities were common and deletions in ALL driver genes were seen in 77% of cases. IKZF1 deletion was present in 51% (40/78) of samples tested and the IKZF1plus profile was identified in over a third (28/77) of cases of B-cell precursor ALL. The genetic good-risk abnormalities high hyperdiploidy (n=2), ETV6-RUNX1 (no cases) and ERG deletion (no cases) were exceptionally rare in this cohort. RAS pathway mutations were seen in 17% (4/23) of screened samples. KDM6A abnormalities, including biallelic deletions, were discovered in 5% (4/78) of SNP arrays and 9% (2/23) of NGS samples, and represent novel, potentially therapeutically actionable lesions using EZH2 inhibitors. Outcome remained poor with 5-year event-free and overall survival rates of 17% and 24%, respectively, across the cohort, indicating a need for novel therapeutic strategies.
Collapse
Affiliation(s)
- Thomas Creasey
- Leukaemia Research Cytogenetics Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne.
| | - Emilio Barretta
- Leukaemia Research Cytogenetics Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne
| | - Sarra L Ryan
- Leukaemia Research Cytogenetics Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne
| | - Ellie Butler
- Leukaemia Research Cytogenetics Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne
| | - Amy A Kirkwood
- Cancer Research UK and UCL Cancer Trials Centre, UCL Cancer Institute University College London
| | | | | | - Pip Patrick
- Cancer Research UK and UCL Cancer Trials Centre, UCL Cancer Institute University College London
| | - Laura Clifton-Hadley
- Cancer Research UK and UCL Cancer Trials Centre, UCL Cancer Institute University College London
| | - Bela Patel
- Department of Haematology, Queen Mary University of London, London
| | - Tobias Menne
- Department of Haematology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne
| | - Andrew K McMillan
- Department of Haematology, Nottingham University Hospital NHS Trust, Nottingham
| | - Christine J Harrison
- Leukaemia Research Cytogenetics Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne
| | - Clare J Rowntree
- Department of Haematology, Cardiff And Vale University Health Board, Cardiff
| | - Nick Morley
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield
| | - David I Marks
- Department of Haematology, University Hospitals Bristol NHS Foundation Trust, Bristol
| | | | - Anthony V Moorman
- Leukaemia Research Cytogenetics Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne.
| |
Collapse
|
6
|
Changing Landscape in the Treatment of Adult Acute Lymphoblastic Leukemia (ALL). Cancers (Basel) 2022; 14:cancers14174290. [PMID: 36077822 PMCID: PMC9454969 DOI: 10.3390/cancers14174290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/28/2022] [Accepted: 08/29/2022] [Indexed: 11/22/2022] Open
Abstract
Simple Summary The improved understanding of acute lymphoblastic leukemia has brought with it several new therapy strategies as well as novel treatment agents. The aim of our review was to create a well-arranged overview of the currently available treatment strategies for ALL. Abstract Acute lymphoblastic leukemia (ALL) is a rare hematological malignancy characterized by proliferation and accumulation of premature lymphoid blasts. Depending on risk factors, the survival of acute lymphoblastic leukemia has significantly improved over the last decades. During the last years, measurable residual disease (MRD) assessment has evolved into one of the most sensitive markers for prognosis and risk of relapse. For this reason, measurable residual disease detection and monitoring count as standard evaluation in patients with acute lymphoblastic leukemia. Allogeneic stem cell transplantation is still the recommended treatment option for patients with high and highest risk profiles as well as for relapsed or refractory settings. The increased understanding of the pathomechanism and heterogeneity of acute lymphoblastic leukemia has led to the development of several novel therapeutic opportunities such as tyrosine-kinase inhibitors, antibody-based therapies and CAR-T cells with the aim of improving clinical outcomes. Furthermore, the major advances in disease understanding of ALL have led to the identification of different subgroups and better disease stratification. Even though novel therapy targets are constantly developed, acute lymphoblastic leukemia remains a challenging and life-threatening disease. To improve the historically unsatisfying result in therapy of adult acute lymphoblastic leukemia many clinical trials have recently been initiated to determine the optimum combination regimens of novel and old agents for adult acute lymphoblastic leukemia.
Collapse
|
7
|
Luskin MR. SOHO State of the Art Updates and Next Questions: Mini-Hyper-CVD Combinations for Older Adults: Results of Recent Trials and a Glimpse into the Future. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:436-441. [PMID: 34996739 DOI: 10.1016/j.clml.2021.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 11/20/2021] [Accepted: 12/06/2021] [Indexed: 06/14/2023]
Abstract
Acute lymphoblastic leukemia (ALL) is an aggressive blood cancer that affects both children and adults. Although the majority of children diagnosed with ALL are now cured and outcomes are improving for younger adults, older adults diagnosed with ALL usually succumb to their disease. Traditional chemotherapy regimens are poorly tolerated and ineffective in most older adults. Recently, novel chemotherapy agents such as inotuzumab ozogamicin and venetoclax have been successfully combined with dose reduced chemotherapy (mini-hyper-CVD) with promising results. Further study is needed to define the optimal combination and sequencing of novel agents and chemotherapy for different patient populations. This review discusses the challenge of treating older adults with traditional chemotherapy, experience to date with novel agents in combination with mini-hyper-CVD, as well as future directions and unanswered questions.
Collapse
|
8
|
Luskin MR. Acute lymphoblastic leukemia in older adults: curtain call for conventional chemotherapy? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:7-14. [PMID: 34889389 PMCID: PMC8791151 DOI: 10.1182/hematology.2021000226] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Unlike younger adults with acute lymphoblastic leukemia (ALL), older adults are rarely cured due to a combination of intrinsic disease resistance and treatment-related toxicities. Novel therapeutics such as inotuzumab ozogamicin, blinatumomab, venetoclax, and ABL kinase inhibitors have high activity in ALL and are well tolerated by older adults. Frontline treatment regimens for older adults using novel therapeutics with reduction or omission of conventional chemotherapy are being developed with early results demonstrating high remission rates and lower toxicity, but long-term efficacy and toxicity data are lacking. Collaboration between academic and pharmaceutical stakeholders is needed to develop clinical trials to define the optimal treatment regimens for older adults with ALL.
Collapse
Affiliation(s)
- Marlise R. Luskin
- Correspondence Marlise R. Luskin, Dana-Farber Cancer Institute, Department of Medical Oncology, Division of Leukemia, 450 Brookline Ave, Dana 2056, Boston, MA 02215; e-mail:
| |
Collapse
|
9
|
Douer D, Gökbuget N, Stock W, Boissel N. Optimizing use of L-asparaginase–based treatment of adults with acute lymphoblastic leukemia. Blood Rev 2021; 53:100908. [DOI: 10.1016/j.blre.2021.100908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 11/04/2021] [Accepted: 11/08/2021] [Indexed: 01/19/2023]
|
10
|
Carraway HE, Sawalha Y, Gojo I, Lee MJ, Lee S, Tomita Y, Yuno A, Greer J, Smith BD, Pratz KW, Levis MJ, Gore SD, Ghosh N, Dezern A, Blackford AL, Baer MR, Gore L, Piekarz R, Trepel JB, Karp JE. Phase 1 study of the histone deacetylase inhibitor entinostat plus clofarabine for poor-risk Philadelphia chromosome-negative (newly diagnosed older adults or adults with relapsed refractory disease) acute lymphoblastic leukemia or biphenotypic leukemia. Leuk Res 2021; 110:106707. [PMID: 34563945 DOI: 10.1016/j.leukres.2021.106707] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 08/22/2021] [Accepted: 09/08/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Despite advances in immunotherapies, the prognosis for adults with Philadelphia chromosome-negative, newly diagnosed (ND) or relapsed/refractory (R/R) acute lymphoblastic leukemia/acute biphenotypic leukemia (ALL/ABL) remains poor. The benzamide derivative entinostat inhibits histone deacetylase and induces histone hyperacetylation. The purine nucleoside analogue clofarabine is FDA-approved for R/R ALL in children 1-21 years of age. Low doses of clofarabine have been reported to induce DNA hypomethylation. We conducted a phase 1 study of low dose clofarabine with escalating doses of entinostat in adults with ND or R/R ALL/ABL. EXPERIMENTAL DESIGN Adults ≥60 years with ND ALL/ABL or ≥21 years with R/R ALL/ABL received repeated cycles every 3 weeks of entinostat (4 mg, 6 mg or 8 mg orally days 1 and 8) and clofarabine (10 mg/m2/day IV for 5 days, days 3-7) (Arm A). Adults aged 40-59 years with ND ALL/ABL or age ≥21 years in first relapse received entinostat and clofarabine prior to traditional chemotherapy on day 11 (Arm B). Changes in DNA damage, global protein lysine acetylation, myeloid-derived suppressor cells and monocytes were measured in PBMCs before and during therapy. RESULTS Twenty-eight patients were treated at three entinostat dose levels with the maximum administered dose being entinostat 8 mg. The regimen was well tolerated with infectious and metabolic derangements more common in the older population versus the younger cohort. There was no severe hyperglycemia and no peripheral neuropathy in this small study. There were 2 deaths (1 sepsis, 1 intracranial bleed). Overall response rate was 32 %; it was 50 % for ND ALL/ABL. Entinostat increased global protein acetylation and inhibited immunosuppressive monocyte subpopulations, while clofarabine induced DNA damage in all cell subsets examined. CONCLUSION Entinostat plus clofarabine appears to be tolerable and active in older adults with ND ALL/ABL, but less active in R/R patients. Further evaluation of this regimen in ND ALL/ABL appears warranted.
Collapse
Affiliation(s)
- Hetty E Carraway
- Hematology Oncology Program, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, United States.
| | - Yazeed Sawalha
- Arthur G. James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Ivana Gojo
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Hospital, Baltimore, MD, United States
| | - Min-Jung Lee
- Developmental Therapeutics Branch, Center for Cancer Research, National Cancer Institute, NIH, Bethesda, MD, United States
| | - Sunmin Lee
- Developmental Therapeutics Branch, Center for Cancer Research, National Cancer Institute, NIH, Bethesda, MD, United States
| | - Yusuke Tomita
- Developmental Therapeutics Branch, Center for Cancer Research, National Cancer Institute, NIH, Bethesda, MD, United States
| | - Akira Yuno
- Developmental Therapeutics Branch, Center for Cancer Research, National Cancer Institute, NIH, Bethesda, MD, United States
| | - Jackie Greer
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Hospital, Baltimore, MD, United States
| | - B Douglas Smith
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Hospital, Baltimore, MD, United States
| | - Keith W Pratz
- The University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark J Levis
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Hospital, Baltimore, MD, United States
| | - Steven D Gore
- Cancer Therapy Evaluation Program (CTEP), National Cancer Institute, NIH, Bethesda, MD, United States
| | - Nilanjan Ghosh
- Atrium Health, Carolinas HealthCare System, Charlotte, NC, United States
| | - Amy Dezern
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Hospital, Baltimore, MD, United States
| | - Amanda L Blackford
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Hospital, Baltimore, MD, United States
| | - Maria R Baer
- University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, MD, United States
| | - Lia Gore
- University of Colorado Cancer Center, Aurora, CO, United States
| | - Richard Piekarz
- Cancer Therapy Evaluation Program (CTEP), National Cancer Institute, NIH, Bethesda, MD, United States
| | - Jane B Trepel
- Developmental Therapeutics Branch, Center for Cancer Research, National Cancer Institute, NIH, Bethesda, MD, United States
| | - Judith E Karp
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Hospital, Baltimore, MD, United States
| |
Collapse
|
11
|
Ganesan P, Kayal S. How I Treat Adult Acute Lymphoblastic Leukemia in India. Indian J Med Paediatr Oncol 2021. [DOI: 10.1055/s-0041-1731979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- Prasanth Ganesan
- Department of Medical Oncology, Regional Cancer Center, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, India
| | - Smita Kayal
- Department of Medical Oncology, Regional Cancer Center, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Puducherry, India
| |
Collapse
|
12
|
Short NJ, Kantarjian H, Jabbour E. Optimizing the treatment of acute lymphoblastic leukemia in younger and older adults: new drugs and evolving paradigms. Leukemia 2021; 35:3044-3058. [PMID: 34172894 DOI: 10.1038/s41375-021-01277-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 04/12/2021] [Accepted: 04/29/2021] [Indexed: 12/18/2022]
Abstract
In the past decade, the available treatments for patients with acute lymphoblastic leukemia (ALL) have rapidly expanded, in parallel with an increased understanding of the genomic features that impact the disease biology and clinical outcomes. With the development of the anti-CD22 antibody-drug conjugate inotuzumab ozogamicin, the CD3-CD19 bispecific T-cell engager antibody blinatumomab, CD19 chimeric antigen receptor T-cell therapy, and the potent BCR-ABL1 tyrosine kinase inhibitor ponatinib, the outlook of ALL in both younger and older adults has substantially improved. The availability of highly effective drugs raised important questions concerning the optimal combination and sequence of these agents, their incorporation into frontline regimens, and the role of hematopoietic stem cell transplantation. In this review, we discuss the rapidly evolving paradigms in the treatment of ALL, highlighting both established and effective regimens, as well as promising new therapies that are being evaluated in ongoing clinical trials. We specifically focus on novel combination regimens in both the frontline and salvage settings that are leading to new standards of care in the treatment of ALL.
Collapse
Affiliation(s)
- Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| |
Collapse
|
13
|
Concepts in immuno-oncology: tackling B cell malignancies with CD19-directed bispecific T cell engager therapies. Ann Hematol 2020; 99:2215-2229. [PMID: 32856140 PMCID: PMC7481145 DOI: 10.1007/s00277-020-04221-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 08/11/2020] [Indexed: 12/11/2022]
Abstract
The B cell surface antigen CD19 is a target for treating B cell malignancies, such as B cell precursor acute lymphoblastic leukemia and B cell non-Hodgkin lymphoma. The BiTE® immuno-oncology platform includes blinatumomab, which is approved for relapsed/refractory B cell precursor acute lymphoblastic leukemia and B cell precursor acute lymphoblastic leukemia with minimal residual disease. Blinatumomab is also being evaluated in combination with other agents (tyrosine kinase inhibitors, checkpoint inhibitors, and chemotherapy) in various treatment settings, including frontline protocols. An extended half-life BiTE molecule is also under investigation. Patients receiving blinatumomab may experience cytokine release syndrome and neurotoxicity; however, these events may be less frequent and severe than in patients receiving other CD19-targeted immunotherapies, such as chimeric antigen receptor T cell therapy. We review BiTE technology for treating malignancies that express CD19, analyzing the benefits and limitations of this bispecific T cell engager platform from clinical experience with blinatumomab.
Collapse
|
14
|
Niyongere S, Sanchez-Petitto G, Masur J, Baer MR, Duong VH, Emadi A. Frontline Blinatumomab in Older Adults with Philadelphia Chromosome-Negative B-Cell Acute Lymphoblastic Leukemia. Pharmaceuticals (Basel) 2020; 13:E124. [PMID: 32560218 PMCID: PMC7345996 DOI: 10.3390/ph13060124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 05/26/2020] [Accepted: 06/11/2020] [Indexed: 11/17/2022] Open
Abstract
Outcomes of acute lymphoblastic leukemia (ALL) in older adults treated with chemotherapy are poor. The CD19/CD3 bispecific T-cell engager (BiTE) antibody blinatumomab is approved for refractory, relapsed or minimal/measurable residual disease (MRD)-positive B-cell ALL, but there is little experience in the upfront setting, including in older patients. We retrospectively analyzed outcomes of blinatumomab monotherapy in five newly diagnosed Philadelphia chromosome-negative B-cell ALL patients over 70 years. Three had cytokine release syndrome, treated with dexamethasone and/or tocilizumab, and four patients had neurotoxicity, treated with dexamethasone, without blinatumomab interruption. All five achieved complete remission (CR) after cycle one, three with undetectable MRD. All five were alive at 8 to 15 months. Three remained in MRD-negative CR. Two relapsed after cycle 3, one with extramedullary disease. In our small cohort of patients over 70 years, blinatumomab was safe initial therapy and produced a high response rate.
Collapse
Affiliation(s)
- Sandrine Niyongere
- Departments of Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (S.N.); (G.S.-P.); (J.M.); (M.R.B.); (V.H.D.)
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, Baltimore, MD 21201, USA
| | - Gabriela Sanchez-Petitto
- Departments of Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (S.N.); (G.S.-P.); (J.M.); (M.R.B.); (V.H.D.)
| | - Jack Masur
- Departments of Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (S.N.); (G.S.-P.); (J.M.); (M.R.B.); (V.H.D.)
| | - Maria R. Baer
- Departments of Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (S.N.); (G.S.-P.); (J.M.); (M.R.B.); (V.H.D.)
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, Baltimore, MD 21201, USA
| | - Vu H. Duong
- Departments of Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (S.N.); (G.S.-P.); (J.M.); (M.R.B.); (V.H.D.)
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, Baltimore, MD 21201, USA
| | - Ashkan Emadi
- Departments of Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA; (S.N.); (G.S.-P.); (J.M.); (M.R.B.); (V.H.D.)
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, Baltimore, MD 21201, USA
- Departments of Pharmacology, University of Maryland School of Medicine, Baltimore, MD 21201, USA
| |
Collapse
|
15
|
Samra B, Jabbour E, Ravandi F, Kantarjian H, Short NJ. Evolving therapy of adult acute lymphoblastic leukemia: state-of-the-art treatment and future directions. J Hematol Oncol 2020; 13:70. [PMID: 32503572 PMCID: PMC7275444 DOI: 10.1186/s13045-020-00905-2] [Citation(s) in RCA: 91] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 05/22/2020] [Indexed: 12/20/2022] Open
Abstract
Recent years have witnessed major advances that have improved outcome of adults with acute lymphoblastic leukemia (ALL). The emergence of the concept of measurable residual disease has fine-tuned our prognostic models and guided our treatment decisions. The treatment paradigms of ALL have been revolutionized with the advent of tyrosine kinase inhibitors targeting BCR-ABL1, monoclonal antibodies targeting CD20 (rituximab), antibody-drug conjugates targeting CD22 (inotuzumab ozogamicin), bispecific antibodies (blinatumomab), and CD19 chimeric antigen receptor T cell therapy (tisagenlecleucel). These highly effective new agents are allowing for novel approaches that reduce reliance on intensive cytotoxic chemotherapy and hematopoietic stem cell transplantation in first remission. This comprehensive review will focus on the recent advances and future directions in novel therapeutic strategies in adult ALL.
Collapse
Affiliation(s)
- Bachar Samra
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA.
| |
Collapse
|
16
|
Yates SJ, Lyerly S, Manuel M, Tooze JA, Klepin HD, Powell BL, Dralle S, Uprety A, Pardee TS. The prognostic value of standardized phase angle in adults with acute leukemia: A prospective study. Cancer Med 2020; 9:2403-2413. [PMID: 32049445 PMCID: PMC7131844 DOI: 10.1002/cam4.2835] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 12/16/2019] [Accepted: 12/27/2019] [Indexed: 12/13/2022] Open
Abstract
Standardized phase angle (SPhA) is a tool used to estimate body composition and cell membrane integrity. Standardized phase angle has been shown to predict survival in solid malignancies and hematopoietic stem cell transplant patients. We investigated the predictive value of SPhA on 60-day mortality, overall survival (OS), and length of hospital stay (LHS) for adults with acute myelogenous and lymphoblastic leukemia (AML and ALL). Consecutive patients ≥18 years with newly diagnosed acute leukemia receiving intensive chemotherapy were enrolled. Phase angle measurements were taken on day 1 of therapy for all patients and on the day of nadir marrow for AML patients. Measurements were standardized by BMI, gender, and age to calculate the SPhA. The difference between SPhA at nadir bone marrow compared to day 1 of induction was used to calculate change in SPhA. A cutoff of 25th percentile was used to dichotomize baseline SPhA. Among 100 patients, 88% were AML, 56% were female, and mean age was 59 years. Though not statistically significant, OS by Kaplan-Meier analysis was shorter for those below the 25th percentile SPhA compared to those above (median OS: 11.0 months vs 19.5 months; P = .09). Lower baseline SPhA was associated with increased incidence of 60-day mortality in univariable (odds ratio [OR] = 5.25; 1.35, 20.44; P = .02) but not multivariable analysis (OR = 3.12; 0.67, 14.48; P = .15) adjusted for age, creatinine, and cytogenetics. Increased change in SPhA was associated with worse OS (hazard ratio = 1.15; 1.00,1.33; P = .05) in multivariable analysis. Standardized phase angle is a rapid, noninvasive, and objective measure that may be used to inform risk stratification.
Collapse
Affiliation(s)
| | - Susan Lyerly
- Comprehensive Cancer Center of Wake Forest University, Winston-Salem, NC, USA
| | - Megan Manuel
- Comprehensive Cancer Center of Wake Forest University, Winston-Salem, NC, USA
| | - Janet A Tooze
- Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Heidi D Klepin
- Comprehensive Cancer Center of Wake Forest University, Winston-Salem, NC, USA
| | - Bayard L Powell
- Comprehensive Cancer Center of Wake Forest University, Winston-Salem, NC, USA
| | - Sarah Dralle
- Comprehensive Cancer Center of Wake Forest University, Winston-Salem, NC, USA
| | - Alok Uprety
- Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Timothy S Pardee
- Comprehensive Cancer Center of Wake Forest University, Winston-Salem, NC, USA
| |
Collapse
|
17
|
Jabbour E, Sasaki K, Ravandi F, Short NJ, Garcia-Manero G, Daver N, Kadia T, Konopleva M, Jain N, Cortes J, Issa GC, Jacob J, Kwari M, Thompson P, Garris R, Pemmaraju N, Yilmaz M, O’Brien S, Kantarjian H. Inotuzumab ozogamicin in combination with low-intensity chemotherapy (mini-HCVD) with or without blinatumomab versus standard intensive chemotherapy (HCVAD) as frontline therapy for older patients with Philadelphia chromosome-negative acute lymphoblastic leukemia: A propensity score analysis. Cancer 2019; 125:2579-2586. [PMID: 30985931 PMCID: PMC6625850 DOI: 10.1002/cncr.32139] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 02/08/2019] [Accepted: 03/08/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND The outcome of older patients with newly diagnosed, Philadelphia chromosome (Ph)-negative acute lymphoblastic leukemia (ALL) is poor. The combination of targeted therapy with low-intensity chemotherapy is safe and effective. The objective of the current analysis was to compare the outcome of patients who received a combination of inotuzumab ozogamicin plus low-intensity chemotherapy (mini-hyperfractionated cyclophosphamide, vincristine, and dexamethasone [mini-HCVD]) with or without blinatumomab versus the outcome of those who received the standard, intensive, hyperfractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone (HCVAD) regimen. METHODS The authors analyzed 135 older patients with newly diagnosed, Ph-negative ALL who were treated prospectively with standard HCVAD (n = 77) or with the combination of inotuzumab ozogamicin plus mini-HCVD with or without blinatumomab (n = 58). A propensity score analysis was conducted using 1:1 matching using the nearest neighbor matching method. RESULTS Propensity score matching identified 38 patients in each cohort. The antibody plus low-intensity chemotherapy combination induced higher response rates (98% vs 88%), with lower rates of early death (0% vs 8%) and lower rates of death in complete remission (5% vs 17%). With propensity score matching, the 3-year event-free survival rates for patients who received HCVAD and those who received the combination of inotuzumab ozogamicin plus mini-HCVD with or without blinatumomab were 34% and 64%, respectively (P = .003), and the 3-year overall survival rates were 34% and 63%, respectively (P = .004). By multivariate analysis, age (P = .019; hazard ratio, 1.045) and the combination of inotuzumab plus mini-HCVD with or without blinatumomab (P = .020; hazard ratio, 0.550) were identified as independent prognostic factors for survival. CONCLUSIONS The combination of inotuzumab ozogamicin plus mini-HCVD with or without blinatumomab is safe and effective in older patients with newly diagnosed, Ph-negative ALL and confers a better outcome compared with standard HCVAD chemotherapy.
Collapse
Affiliation(s)
- Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Koji Sasaki
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nicholas J. Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Naval Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Tapan Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Marina Konopleva
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jorge Cortes
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ghayas C. Issa
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jovitta Jacob
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Monica Kwari
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Philip Thompson
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Rebecca Garris
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Musa Yilmaz
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Susan O’Brien
- Chao Family Comprehensive Cancer Center, University of California Irvine, Orange, CA
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| |
Collapse
|
18
|
Lennmyr E, Karlsson K, Ahlberg L, Garelius H, Hulegårdh E, Izarra AS, Joelsson J, Kozlowski P, Moicean A, Tomaszewska-Toporska B, Lübking A, Hallböök H. Survival in adult acute lymphoblastic leukaemia (ALL): A report from the Swedish ALL Registry. Eur J Haematol 2019; 103:88-98. [PMID: 31074910 PMCID: PMC6851994 DOI: 10.1111/ejh.13247] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 05/01/2019] [Accepted: 05/03/2019] [Indexed: 01/05/2023]
Abstract
OBJECTIVES As new, effective therapies emerge for acute lymphoblastic leukaemia (ALL), the results of clinical trials need to relate to standard of care. METHODS We used the population-based Swedish ALL Registry to evaluate characteristics, treatment and long-term outcome in 933 patients with diagnosis between 1997 and 2015. RESULTS The median age was 53 years. The frequency of Philadelphia (Ph)-positive leukaemia was 34% of examined B-ALL with a peak incidence at 50-59 years. Five-year overall survival (OS) improved between 1997-2006 and 2007-2015; in patients 18-45 years from 50% (95% CI 43-57) to 65% (95% CI 58-72), 46-65 years from 25% (95% CI 18-32) to 46% (95% CI 37-55) and >65 years from 7% (95% CI 2.6-11) to 11% (95% CI 5.9-16) (P < 0.05). Men with Ph-neg B-ALL 46-65 years had inferior OS compared with women (P < 0.01). Standardised mortality ratio was 5.7 (95% CI 5.0-6.3) for patients who survived 5 years from diagnosis. In multivariable analysis, Ph-positive disease was not associated with impaired prognosis but with lower risk of death in 2007-2015. CONCLUSIONS In a population-based cohort, OS has improved in adult ALL, especially for Ph-positive disease but for middle-aged men with Ph-negative B-ALL outcome was poor. Cure without late toxicity or relapse is still desired.
Collapse
Affiliation(s)
- Emma Lennmyr
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Karin Karlsson
- Department of Haematology, Oncology and Radiophysics, Skåne University Hospital, Lund, Sweden
| | - Lucia Ahlberg
- Department of Haematology, University Hospital of Linköping, Linköping, Sweden
| | - Hege Garelius
- Department of Medicine, Section of Haematology and Coagulation, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Erik Hulegårdh
- Department of Medicine, Section of Haematology and Coagulation, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Antonio S Izarra
- Department of Haematology, Cancer Centre, University Hospital of Umeå, Umeå, Sweden
| | - Joel Joelsson
- Division of Haematology, Department of Medicine, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Piotr Kozlowski
- Department of Medicine, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Andreea Moicean
- Department of Medicine, Central Hospital Skövde, Skövde, Sweden
| | | | - Anna Lübking
- Department of Haematology, Oncology and Radiophysics, Skåne University Hospital, Lund, Sweden
| | - Helene Hallböök
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | | |
Collapse
|
19
|
King AC, Pappacena JJ, Tallman MS, Park JH, Geyer MB. Blinatumomab administered concurrently with oral tyrosine kinase inhibitor therapy is a well-tolerated consolidation strategy and eradicates measurable residual disease in adults with Philadelphia chromosome positive acute lymphoblastic leukemia. Leuk Res 2019; 79:27-33. [PMID: 30831480 DOI: 10.1016/j.leukres.2019.02.009] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Revised: 02/21/2019] [Accepted: 02/22/2019] [Indexed: 11/28/2022]
Abstract
Incorporation of ABL-targeted oral tyrosine kinase inhibitors (TKIs) into frontline therapeutic regimens has improved outcomes for adults with Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph + ALL). However, patients with persistent minimal residual disease (MRD) exhibit increased risk of relapse. Combining consolidative chemotherapy with TKIs may increase rates of infectious complications, organ toxicity, hospitalization, and non-relapse mortality. Blinatumomab has demonstrated single-agent activity in patients with relapsed B-ALL or persistent MRD, including Ph + B-ALL. We have used blinatumomab concomitantly with commercially available TKIs as consolidative therapy to spare toxicities of conventional chemotherapy. We evaluated 11 adults with previously treated Ph + B-ALL who received blinatumomab concurrent with TKI (ponatinib, n = 5; dasatinib, n = 4; nilotinib, n = 1; imatinib, n = 1) to eradicate MRD or sustain MRD-negativity. Eight of 9 patients with MRD achieved BCR-ABL1 negativity (complete molecular response, CMR) after a median of one cycle; 2/2 patients without measurable disease durably maintained CMR. Cytokine release syndrome (all grade 1-2) was observed in 3/11 patients; one patient experienced transient grade 1 neurologic toxicity. Transient grade 2 transaminitis was observed in 6/11 patients, including 4/5 recipients of blinatumomab + ponatinib. This small series suggests blinatumomab + TKI is a safe and effective consolidation strategy for patients with Ph + ALL to achieve or maintain CMR.
Collapse
Affiliation(s)
- Amber C King
- Department of Pharmacy, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
| | - Jeremy J Pappacena
- Department of Pharmacy, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
| | - Martin S Tallman
- Leukemia Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
| | - Jae H Park
- Leukemia Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA; Cellular Therapeutics Center, Department of Medicine, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
| | - Mark B Geyer
- Leukemia Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA; Cellular Therapeutics Center, Department of Medicine, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
| |
Collapse
|
20
|
Kantarjian H, O’Brien S. Poor Penetration of Existing Effective Chemoimmunotherapy for the Treatment of Older Patients With Newly Diagnosed Acute Lymphocytic Leukemia (ALL) or Refractory/Relapsed ALL. J Oncol Pract 2019; 15:77-79. [DOI: 10.1200/jop.18.00799] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
21
|
Kim C, Molony JT, Chia VM, Kota VK, Katz AJ, Li S. Patient characteristics, treatment patterns, and mortality in elderly patients newly diagnosed with ALL. Leuk Lymphoma 2018; 60:1462-1468. [PMID: 30541363 DOI: 10.1080/10428194.2018.1538505] [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: 10/27/2022]
Abstract
To describe patient characteristics and treatment patterns among elderly patients (≥66 years) newly diagnosed with acute lymphoblastic leukemia (ALL), we analyzed 100% Medicare ALL data from 2007 to 2015. Only 764 out of 1428 (53.5%) elderly patients received treatment within 90 d of diagnosis with ≥30-d follow-up; 32.4% received chemotherapy without tyrosine kinase inhibitors (TKIs), 8.8% received both chemotherapy and TKIs, 9.8% received steroids only and 2.6% received TKIs only. Among 717 patients receiving chemotherapy any time during follow-up, 65.8% received only one course of treatment. Patients treated with chemotherapy or TKIs compared to untreated patients were younger (<75 years: 51.5 vs. 21.7%) and had a lower comorbidity burden (Charlson Comorbidity index ≤ 2: 90.9 vs. 71.4%). Overall, 67.5% of patients died within 3 years of diagnosis. Our findings demonstrate that many elderly ALL patients are not treated in the real-world setting and highlight the need for tolerable therapies for these patients.
Collapse
Affiliation(s)
- Christopher Kim
- a Center for Observational Research, Amgen Inc. , Thousand Oaks , CA , USA
| | - Julia T Molony
- b Chronic Disease Research Group , Hennepin Healthcare Research Institute , Minneapolis , MN , USA
| | - Victoria M Chia
- a Center for Observational Research, Amgen Inc. , Thousand Oaks , CA , USA
| | - Vamsi K Kota
- c Department of Hematology and Medical Oncology , Georgia Cancer Center at Augusta University , Augusta , GA , USA
| | - Aaron J Katz
- a Center for Observational Research, Amgen Inc. , Thousand Oaks , CA , USA
| | - Shuling Li
- b Chronic Disease Research Group , Hennepin Healthcare Research Institute , Minneapolis , MN , USA
| |
Collapse
|
22
|
Medinger M, Passweg J. What the internist should know about stem cell transplant in the elderly patient. Eur J Intern Med 2018; 58:43-47. [PMID: 29960832 DOI: 10.1016/j.ejim.2018.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 06/21/2018] [Indexed: 11/23/2022]
Abstract
Most hematological malignancies are increasing in frequency with age. Allogeneic hematopoietic cell transplantation (allo-HCT) is a potentially curative therapeutic option for patients with malignant and non-malignant hematological diseases. The treatment of elderly patients with advanced hematological malignancies has expanded to include reduced intensity conditioning allo-HCT. Physicians increasingly refer older patients for allo-HCT due to more experience and improved supportive care in allo-HCT. This review article discusses the available data regarding the feasibility, tolerability, toxicity, and effectiveness of allo-HCT in different hematological diseases in the elderly. Over the past decade, utilization and survival after allo-HCT have increased in patients ≥70 years. Selected adults ≥70 years with hematological diseases should be evaluated for transplantation.
Collapse
Affiliation(s)
- Michael Medinger
- Division of Hematology, Department of Medicine, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland; Division of Internal Medicine, Department of Medicine, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Jakob Passweg
- Division of Hematology, Department of Medicine, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland.
| |
Collapse
|
23
|
Kantarjian H, Jabbour E. Incorporating Immunotherapy Into the Treatment Strategies of B-Cell Adult Acute Lymphoblastic Leukemia: The Role of Blinatumomab and Inotuzumab Ozogamicin. Am Soc Clin Oncol Educ Book 2018; 38:574-578. [PMID: 30231308 DOI: 10.1200/edbk_199505] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Monoclonal antibodies and bispecific antibody constructs hold considerable promise in improving the outcomes of patients with acute lymphoblastic leukemia (ALL). Antibody-drug conjugates such as inotuzumab ozogamicin and the bispecific T-cell engager blinatumomab represent novel antibody constructs that have shown substantial clinical activity in ALL. Although most studies have focused on the use of these agents in the salvage setting, incorporation of these antibodies into the frontline regimens is imperative to improve long-term survival for patients with ALL and to increase the cure rates of adult ALL to the levels achieved in the pediatric population.
Collapse
Affiliation(s)
- Hagop Kantarjian
- From the Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Elias Jabbour
- From the Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| |
Collapse
|
24
|
Piil K, Jarden M, Pii KH. Research agenda for life-threatening cancer. Eur J Cancer Care (Engl) 2018; 28:e12935. [PMID: 30345723 DOI: 10.1111/ecc.12935] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 08/28/2018] [Accepted: 09/02/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The aim of this study was to identify future research agendas that reflect the concerns and unexplored areas of interest for patients with life-threatening cancer, their relatives and the clinical specialists during the cancer trajectory. METHODS Six focus group discussions were conducted addressing two different cancer trajectories: primary malignant brain tumour and acute leukaemia. For each of the two cancer trajectories, separate FGIs were carried out with patients, relatives and clinical specialists to identify important concerns, challenges and uncertainties. The FGIs were video/audio-recorded, transcribed and thematically analysed within and across FGI groups to construct research topics. Finally, the literature was reviewed for existing evidence concerning the identified research topic(s) to strengthen the suggested research agendas. RESULTS New research agendas related to high-grade glioma brain tumour and acute leukaemia with corresponding research questions were formulated within the topics of supportive care/palliation, education/information, rehabilitation, complementary and alternative therapy and organization of health care. CONCLUSION User involvement in identifying research agendas has the potential to improve quality of care for patients and caregivers across the cancer trajectory, while minimizing the gap in research between the healthcare user and healthcare provider.
Collapse
Affiliation(s)
- Karin Piil
- Department of Oncology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,University Hospitals Center for Health Research (UCSF) and Center for Integrated Rehabilitation of Cancer Patients (CIRE), Copenhagen, Denmark.,Department of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Mary Jarden
- University Hospitals Center for Health Research (UCSF) and Center for Integrated Rehabilitation of Cancer Patients (CIRE), Copenhagen, Denmark.,Department of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Hematology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Kathrine Hoffmann Pii
- Copenhagen University College, Institute of Nursing and Nutrition, Copenhagen, Denmark
| |
Collapse
|
25
|
Miller KC, Al-Kali A, Shah MV, Hogan WJ, Elliott MA, Begna KH, Gangat N, Patnaik MM, Viswanatha DS, He R, Greipp PT, Sproat LZ, Foran JM, Litzow MR, Alkhateeb HB. Elderly acute lymphoblastic leukemia: a Mayo Clinic study of 124 patients. Leuk Lymphoma 2018; 60:990-999. [PMID: 30277111 DOI: 10.1080/10428194.2018.1509318] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Poor outcomes in elderly acute lymphoblastic leukemia (ALL) are well recognized, but the contributors are ill-defined. We characterized 124 patients ≥60 years old at our institution. The majority (n = 102, 82%) were treated with intensive chemotherapy. Of these, 8/102 (8%) died within the first 100 days; 92/102 (90%) achieved complete remission (CR/CRi). Only 31/124 (25%) patients underwent allogeneic hematopoietic stem cell transplantation. The median overall survival (OS) for the entire cohort was 19.8 months. In a multivariate analysis, ECOG performance status ≥2, high white blood cell count, and high lactate dehydrogenase (at time of diagnosis) negatively influenced OS (p<.01). In a subgroup analysis of the intensive treatment group, BCR-ABL1+ patients had markedly better OS (hazard ratio 0.3, 95% CI 0.1-0.7; p<.01). In summary, despite few early deaths and a high CR/CRi rate, elderly ALL continues to have a poor prognosis, underscoring the need for more effective therapies.
Collapse
Affiliation(s)
- Kevin C Miller
- a Mayo Clinic School of Medicine , Mayo Clinic , Rochester , MN , USA
| | - Aref Al-Kali
- b Division of Hematology , Mayo Clinic , Rochester , MN , USA
| | - Mithun V Shah
- b Division of Hematology , Mayo Clinic , Rochester , MN , USA
| | - William J Hogan
- b Division of Hematology , Mayo Clinic , Rochester , MN , USA
| | | | - Kebede H Begna
- b Division of Hematology , Mayo Clinic , Rochester , MN , USA
| | - Naseema Gangat
- b Division of Hematology , Mayo Clinic , Rochester , MN , USA
| | | | | | - Rong He
- c Division of Hematopathology , Mayo Clinic , Rochester , MN , USA
| | - Patricia T Greipp
- d Department of Laboratory Medicine and Pathology , Mayo Clinic , Rochester , MN , USA
| | - Lisa Z Sproat
- e Division of Hematology and Medical Oncology , Mayo Clinic , Phoenix , AZ , USA
| | - James M Foran
- f Division of Hematology/Oncology , Mayo Clinic , Jacksonville , FL , USA
| | - Mark R Litzow
- b Division of Hematology , Mayo Clinic , Rochester , MN , USA
| | | |
Collapse
|
26
|
Bassan R, Bourquin JP, DeAngelo DJ, Chiaretti S. New Approaches to the Management of Adult Acute Lymphoblastic Leukemia. J Clin Oncol 2018; 36:JCO2017773648. [PMID: 30240326 DOI: 10.1200/jco.2017.77.3648] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Traditional treatment regimens for adult acute lymphoblastic leukemia, including allogeneic hematopoietic cell transplantation, result in an overall survival of approximately 40%, a figure hardly comparable with the extraordinary 80% to 90% cure rate currently reported in children. When translated to the adult setting, modern pediatric-type regimens improve the survival to approximately 60% in young adults. The addition of tyrosine kinase inhibitors for patients with Philadelphia chromosome-positive disease and the measurement of minimal residual disease to guide risk stratification and postremission approaches has led to additional improvements in outcomes. Relapsed disease and treatment toxicity-sparing no patient but representing a major concern especially in the elderly-are the most critical current issues awaiting further therapeutic advancement. Recently, there has been considerable progress in understanding the disease biology, specifically the Philadelphia-like signature, as well as other high-risk subgroups. In addition, there are several new agents that will undoubtedly contribute to additional improvement in the current outcomes. The most promising agents are monoclonal antibodies, immunomodulators, and chimeric antigen receptor T cells, and, to a lesser extent, several new drugs targeting key molecular pathways involved in leukemic cell growth and proliferation. This review examines the evidence supporting the increasing role of the new therapeutic tools and treatment options in different disease subgroups, including frontline and relapsed or refractory disease. It is now possible to define the best individual approach on the basis of the emerging concepts of precision medicine.
Collapse
Affiliation(s)
- Renato Bassan
- Renato Bassan, Ospedale dell'Angelo, Mestre-Venezia; Sabina Chiaretti, "Sapienza" University, Rome, Italy; Jean-Pierre Bourquin, University Children's Hospital, Zurich, Switzerland; and Daniel J. DeAngelo, Dana-Farber Cancer Institute, Boston, MA
| | - Jean-Pierre Bourquin
- Renato Bassan, Ospedale dell'Angelo, Mestre-Venezia; Sabina Chiaretti, "Sapienza" University, Rome, Italy; Jean-Pierre Bourquin, University Children's Hospital, Zurich, Switzerland; and Daniel J. DeAngelo, Dana-Farber Cancer Institute, Boston, MA
| | - Daniel J DeAngelo
- Renato Bassan, Ospedale dell'Angelo, Mestre-Venezia; Sabina Chiaretti, "Sapienza" University, Rome, Italy; Jean-Pierre Bourquin, University Children's Hospital, Zurich, Switzerland; and Daniel J. DeAngelo, Dana-Farber Cancer Institute, Boston, MA
| | - Sabina Chiaretti
- Renato Bassan, Ospedale dell'Angelo, Mestre-Venezia; Sabina Chiaretti, "Sapienza" University, Rome, Italy; Jean-Pierre Bourquin, University Children's Hospital, Zurich, Switzerland; and Daniel J. DeAngelo, Dana-Farber Cancer Institute, Boston, MA
| |
Collapse
|
27
|
Kotb A, El Fakih R, Hanbali A, Hawsawi Y, Alfraih F, Hashmi S, Aljurf M. Philadelphia-like acute lymphoblastic leukemia: diagnostic dilemma and management perspectives. Exp Hematol 2018; 67:1-9. [PMID: 30075295 DOI: 10.1016/j.exphem.2018.07.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 07/22/2018] [Accepted: 07/24/2018] [Indexed: 01/02/2023]
Abstract
Acute lymphoblastic leukemia (ALL) is an aggressive hematologic malignancy characterized by suboptimal outcomes in the adult age group. Recently, a new subtype called Philadelphia (Ph)-like ALL has been described. This subgroup is characterized by high cytokine receptor and tyrosine kinase signaling expression, resulting in kinase activation through stimulation of two main pathways, the ABL and JAK/STAT pathways. The diagnostic method or approach for Ph-like ALL is still not standardized and efforts are ongoing to identify an easy and applicable diagnostic method. Accurate and standard testing approaches are much needed and this will facilitate better understanding of this subgroup, including better estimation of the prevalence and incidence in different age groups and the clinical outcomes of such new entity. Here, we review the currently available diagnostic tools, activated pathways, and different therapeutic approaches used to target this subgroup.
Collapse
Affiliation(s)
- Ahmed Kotb
- King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Riad El Fakih
- King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia.
| | - Amr Hanbali
- King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Yousef Hawsawi
- King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Feras Alfraih
- King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Shahrukh Hashmi
- King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | - Mahmoud Aljurf
- King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| |
Collapse
|
28
|
Can we incorporate geriatric assessment in the management of acute lymphoblastic leukemia in older adults? J Geriatr Oncol 2018; 9:296-301. [DOI: 10.1016/j.jgo.2018.03.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Revised: 02/07/2018] [Accepted: 03/23/2018] [Indexed: 02/03/2023]
|
29
|
Advani AS. Perspectives and Future Directions for Acute Lymphoblastic Leukemia. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2018; 16 Suppl:S6-9. [PMID: 27521327 DOI: 10.1016/j.clml.2016.02.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 02/09/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Anjali S Advani
- Department of Hematology/Oncology, Cleveland Clinic, Cleveland, OH.
| |
Collapse
|
30
|
Prolonged Survival of Acute Lymphoblastic Leukemia with Intrathecal Treatments for Isolated Central Nervous System Relapse. Case Rep Hematol 2018; 2018:8765285. [PMID: 29651352 PMCID: PMC5830976 DOI: 10.1155/2018/8765285] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 12/29/2017] [Accepted: 01/03/2018] [Indexed: 12/20/2022] Open
Abstract
Acute lymphoblastic leukemia is commonly cured when diagnosed in the pediatric population. It portends a poorer prognosis if present in adult patients. Although adults frequently achieve complete remission, relapse rates are substantial, particularly among the elderly and high-risk populations. In the absence of prophylactic intrathecal chemotherapy, more than half of patients may develop CNS involvement or relapse, which is associated with significant risk for systemic illness. This report describes a patient with acute lymphoblastic leukemia with repeated isolated CNS relapses. This case should remind clinicians that isolated CNS disease in the absence of systemic recurrence could successfully respond to intrathecal therapy and offer patients a favorable quality of life.
Collapse
|
31
|
Chiaretti S, Jabbour E, Hoelzer D. "Society of Hematologic Oncology (SOHO) State of the Art Updates and Next Questions"-Treatment of ALL. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2018; 18:301-310. [PMID: 29653823 DOI: 10.1016/j.clml.2018.03.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 03/28/2018] [Indexed: 10/17/2022]
Abstract
The outcome of adult acute lymphoblastic leukemia (ALL) has substantially improved by adopting pediatric-inspired regimens, and approximately half of the patients are nowadays cured. The evaluation of minimal residual disease currently represents the most important prognostic indicator, which drives treatment algorithms, which include allogeneic stem cell transplantation (allo-SCT) allocation. Indeed, for high-risk patients, allo-SCT should be pursued as soon as possible, whereas in standard-risk patients this procedure should be avoided also in light of related toxicity and because there are no significant benefits. Furthermore, better characterization of the molecular genetic events can drive therapeutic decisions: a historical example in this respect is represented by the use of tyrosine kinase inhibitors (TKIs) in Philadelphia chromosome-positive ALL; in the upcoming future, TKIs might be used also in other subgroups, such as breakpoint cluster region/Abelson 1-like cases and others with deregulated tyrosine kinases. Finally, the greatest progress is currently achieved with new immunotherapies targeting frequently expressed surface antigens in ALL. It is also a new chance for elderly ALL patients, so far spared from intensive chemotherapy and allo-SCT. These targeted therapies will substantially change this treatment algorithm and the great challenge is to find optimal sequence of the extended therapy options in an individual patient.
Collapse
Affiliation(s)
- Sabina Chiaretti
- Hematology, Department of Cellular Biotechnologies and Hematology, "Sapienza" University, Rome, Italy
| | - Elias Jabbour
- Department of Leukemia, University of Texas M.D. Anderson Cancer Center, Houston, TX
| | - Dieter Hoelzer
- Onkologikum, Frankfurt am Museumsufer, Frankfurt, Germany.
| |
Collapse
|
32
|
Short NJ, Kantarjian H, Jabbour E, Ravandi F. Novel Therapies for Older Adults With Acute Lymphoblastic Leukemia. Curr Hematol Malig Rep 2018; 13:91-99. [PMID: 29423571 DOI: 10.1007/s11899-018-0440-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE OF REVIEW Older adults with acute lymphoblastic leukemia (ALL) have worse survival compared to their younger counterparts. Here, we review the reasons for the poorer outcomes of older patients with ALL and also summarize the current and future therapeutic approaches to ALL in the elderly population. RECENT FINDINGS The poor outcomes of older adults with ALL are driven largely by lack of tolerance to standard-dose chemotherapy, which leads to unacceptably high rates of myelosuppression-related deaths. Recent studies have shown promising results with the use of low-intensity or chemotherapy-free regimens in older patients with ALL, which are able to retain efficacy without excess toxicity. Novel antibody constructs such as inotuzumab ozogamicin and blinatumomab as well as potent later-generation tyrosine kinase inhibitors such as ponatinib hold significant promise in the management of ALL in the older adult. Innovative combination strategies may further improve the outcomes of these patients.
Collapse
Affiliation(s)
- Nicholas J Short
- Department of Leukemia, Unit 428, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Hagop Kantarjian
- Department of Leukemia, Unit 428, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Elias Jabbour
- Department of Leukemia, Unit 428, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA
| | - Farhad Ravandi
- Department of Leukemia, Unit 428, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX, 77030, USA.
| |
Collapse
|
33
|
Kantarjian H, Ravandi F, Short NJ, Huang X, Jain N, Sasaki K, Daver N, Pemmaraju N, Khoury JD, Jorgensen J, Alvarado Y, Konopleva M, Garcia-Manero G, Kadia T, Yilmaz M, Bortakhur G, Burger J, Kornblau S, Wierda W, DiNardo C, Ferrajoli A, Jacob J, Garris R, O'Brien S, Jabbour E. Inotuzumab ozogamicin in combination with low-intensity chemotherapy for older patients with Philadelphia chromosome-negative acute lymphoblastic leukaemia: a single-arm, phase 2 study. Lancet Oncol 2018; 19:240-248. [PMID: 29352703 DOI: 10.1016/s1470-2045(18)30011-1] [Citation(s) in RCA: 164] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 10/19/2017] [Accepted: 10/23/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND Inotuzumab ozogamicin, an anti-CD22 monoclonal antibody bound to a toxin, calicheamicin, has shown single-agent activity in relapsed or refractory acute lymphoblastic leukaemia. We aimed to assess the activity and safety of inotuzumab ozogamicin in combination with low-intensity chemotherapy in older patients with acute lymphoblastic leukaemia. METHODS We did a single-arm, phase 2 study at the MD Anderson Cancer Center (Houston, TX, USA). Eligible patients were aged 60 years or older and had newly diagnosed, Philadelphia chromosome-negative, acute lymphoblastic leukaemia, and an Eastern Cooperative Oncology Group performance status of 3 or lower. The induction chemotherapy regimen used was mini-hyper-CVD (a lower intensity version of the conventional hyper-CVAD). Odd-numbered cycles (1,3, 5, and 7) comprised intravenous cyclophosphamide (150 mg/m2 every 12 h on days 1-3) and oral or intravenous dexamethasone (20 mg per day on days 1-4 and days 11-14); no anthracycline was administered. Intravenous vincristine (2 mg flat dose) was given on days 1 and 8. Even-numbered cycles comprised intravenous methotrexate (250 mg/m2 on day 1) and intravenous cytarabine (0·5 g/m2 given every 12 h on days 2 and 3). Intravenous inotuzumab ozogamicin was given on day 3 of the first four cycles at the dose of 1·3-1·8 mg/m2 at cycle 1, followed by 1·0 -1·3 mg/m2 in subsequent cycles. Maintenance therapy with dose-reduced POMP (purinethol [6-mercaptopurine], oncovin [vincristine sulfate], methotrexate, and prednisone) was given for 3 years. The primary endpoint of this study was progression-free survival at 2 years. Analyses were by intention to treat. The study is ongoing, recruiting patients for an approved expansion phase with a modified treatment plan by protocol amendment. The trial is registered with ClinicalTrials.gov, number NCT01371630. FINDINGS Between Nov 12, 2011, and April 22, 2017, 52 patients with a median age of 68 years (IQR 64-72) were enrolled. With a median follow-up of 29 months (IQR 13-48), 2-year progression-free survival was 59% (95% CI 43-72). The most frequent grade 3-4 adverse events were prolonged thrombocytopenia (42 [81%] patients), infections during induction (27 [52%]) and consolidation chemotherapy (36 [69%]), hyperglycaemia (28 [54%]), hypokalaemia (16 [31%]), increased aminotransferases (ten [19%]), hyperbilirubinaemia (nine [17%]), and haemorrhage (seven [15%]). Veno-occlusive disease occurred in four (8%) patients. Six (12%) patients died from adverse events that were deemed treatment related (five [10%] from sepsis and one [2%] from veno-occlusive disease). INTERPRETATION Inotuzumab ozogamicin plus mini-hyper-CVD chemotherapy is a safe and active first-line therapy option in older patients with newly diagnosed acute lymphoblastic leukaemia and could represent a new therapy for this population. Randomised, phase 3 trials to evaluate the efficacy of this combination compared with the current standard of care in this setting, combination chemotherapy without inotuzumab ozogamicin, are warranted. FUNDING MD Anderson Cancer Center.
Collapse
Affiliation(s)
- Hagop Kantarjian
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Farhad Ravandi
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nicholas J Short
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Xuelin Huang
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nitin Jain
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Koji Sasaki
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naval Daver
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Naveen Pemmaraju
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph D Khoury
- Department of Hematopathology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey Jorgensen
- Department of Hematopathology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yesid Alvarado
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Marina Konopleva
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Tapan Kadia
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Musa Yilmaz
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gautam Bortakhur
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jan Burger
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Steven Kornblau
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - William Wierda
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Courtney DiNardo
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alessandra Ferrajoli
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jovitta Jacob
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rebecca Garris
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Susan O'Brien
- the Chao Family Comprehensive Cancer Center, University of California Irvine, Orange County, CA, USA
| | - Elias Jabbour
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| |
Collapse
|
34
|
Jabbour EJ, DeAngelo DJ, Stelljes M, Stock W, Liedtke M, Gökbuget N, O'Brien S, Wang T, Paccagnella ML, Sleight B, Vandendries E, Advani AS, Kantarjian HM. Efficacy and safety analysis by age cohort of inotuzumab ozogamicin in patients with relapsed or refractory acute lymphoblastic leukemia enrolled in INO-VATE. Cancer 2018; 124:1722-1732. [PMID: 29381191 DOI: 10.1002/cncr.31249] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 12/15/2017] [Accepted: 12/28/2017] [Indexed: 11/08/2022]
Abstract
BACKGROUND Inotuzumab ozogamicin (InO) has demonstrated efficacy and tolerability in patients aged 18 to 78 years with relapsed/refractory acute lymphoblastic leukemia (ALL) in the INO-VATE trial. This subset analysis compared the efficacy and safety of InO in younger and older patients. METHODS Intent-to-treat analyses of morphologic responses and overall survival (OS) included 326 randomized patients, and safety assessments included 307 patients receiving 1 or more doses of the study treatment. Of the 326 patients, 164 received InO at a starting dose of 1.8 mg/m2 /cycle (0.8 mg/m2 on day 1 and 0.5 mg/m2 on days 8 and 15 of a 21- to 28-day cycle [≤6 cycles]); 60 patients were aged ≥55 years, and 104 were aged <55 years. RESULTS For older and younger patients, the median duration of InO therapy and the types and frequencies of adverse events of any grade were generally similar. Although the remission rates, median duration of remission (DOR), and progression-free survival were similar with InO for those aged <55 years and those aged ≥55 years, OS was longer for younger patients (median, 8.6 vs 5.6 months; hazard ratio, 0.610). Among patients proceeding to hematopoietic stem cell transplantation after InO treatment (28% of older patients and 58% of younger patients), the incidence of veno-occlusive disease was greater in older patients (41% vs 17%). The study database was not locked at the time of this analysis. CONCLUSIONS InO was tolerable in older patients with relapsed/refractory ALL. Although OS was longer for younger patients versus older patients, InO demonstrated high response rates with similar DOR in the 2 age groups. Cancer 2018;124:1722-32. © 2018 American Cancer Society.
Collapse
Affiliation(s)
- Elias J Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Daniel J DeAngelo
- Department of Medical Oncology/Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Matthias Stelljes
- Department of Internal Medicine, University of Münster, Münster, Germany
| | - Wendy Stock
- Department of Hematology/Oncology, University of Chicago, Chicago, Illinois
| | - Michaela Liedtke
- Divisions of Hematology and Oncology, Stanford Cancer Institute, Stanford, California
| | - Nicola Gökbuget
- Department of Medicine, Goethe University, Frankfurt, Germany
| | - Susan O'Brien
- Division of Hematology/Oncology, University of California Irvine, Orange, California
| | - Tao Wang
- Pfizer, Inc, Groton, Connecticut
| | | | | | | | - Anjali S Advani
- Department of Medical Oncology/Hematologic Malignancies, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Hagop M Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| |
Collapse
|
35
|
|
36
|
Leonard J, Stock W. Progress in adult ALL: incorporation of new agents to frontline treatment. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:28-36. [PMID: 29222234 PMCID: PMC6142560 DOI: 10.1182/asheducation-2017.1.28] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Treatment of acute lymphoblastic leukemia (ALL) in adults remains a challenge, as the delivery of intensive chemotherapeutic regimens in this population is less feasible than it is in the pediatric population. This has led to higher rates of treatment-related toxicity as well as lower overall survival in the adult population. Over the past several years, a host of novel therapies (eg, immunotherapy and targeted therapies) with better tolerability than traditional chemotherapy are now being introduced into the relapsed/refractory population with very encouraging results. Additionally, insights into how to choose effective therapies for patients while minimizing drug toxicity through pharmacogenomics and the use of minimal residual disease (MRD) monitoring to escalate/de-escalate therapy have enhanced our ability to reduce treatment-related toxicity. This has led to the design of a number of clinical trials which incorporate both novel therapeutics as well as MRD-directed treatment pathways into the frontline setting. The use of increasingly personalized treatment strategies for specific disease subsets combined with standardized and rapid molecular diagnostic testing in the initial diagnosis and frontline treatment of ALL will hopefully lead to further improvements in survival for our adult patients.
Collapse
Affiliation(s)
- Jessica Leonard
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health and Science University, Portland, OR; and
| | | |
Collapse
|
37
|
Abstract
INTRODUCTION Treatment of elderly patients with acute leukemia is challenging. Older age is associated with increased risk of treatment-related toxicity. Currently, no consensus exists regarding optimal therapy in this patient population. Areas covered: The following review is a comprehensive summary of various therapeutic options reported over the past few years in elderly patients with acute leukemia. Expert commentary: While evidences can guide identification of frail older patients, sensitive assessment strategies are required to identify fit and vulnerable patients regardless of chronologic age. Individualized treatments may take into account not only an increase in survival, but also the maintenance or improvement in terms of quality of life, the management of symptoms, and a maximization of time outside of hospital care. In this setting, comprehensive geriatric assessments have been shown to improve routine assessment. Molecular abnormalities provide the genomic footprint for the development of targeted therapies. The addition of new monoclonal antibodies to conventional treatments also demonstrated promising primary results. Ongoing clinical trials testing the activity of these new agents may reshape treatment strategies in the elderly patient population.
Collapse
Affiliation(s)
- Xavier Thomas
- a Hospices Civils de Lyon, Hematology Department , Lyon-Sud Hospital , Pierre Bénite , France
| |
Collapse
|
38
|
Fedorov VD, Upadhyay VA, Fathi AT. The Approach to Acute Lymphoblastic Leukemia in Older Patients: Conventional Treatments and Emerging Therapies. Curr Hematol Malig Rep 2017; 11:165-74. [PMID: 26939921 DOI: 10.1007/s11899-016-0316-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Acute lymphoblastic leukemia (ALL) among older adult patients presents significant clinical challenges. As opposed to pediatric populations, in whom long-term outcomes are markedly superior, those for adults remain grim. Nevertheless, younger adults with ALL have experienced a steady improvement in long-term survival in the last few decades. This is significantly different for older ALL patients, for whom long-term outcomes remain poor. Conventional chemotherapies are associated with sub-optimal outcomes and increased toxicity in this population. However, several emerging therapies, including antibody-drug conjugates, bi-specific engagers, and chimeric antigen receptor (CAR) T cells, have demonstrated much promise and are either incorporated into the existing therapeutic paradigms or being actively investigated to improve outcomes.
Collapse
Affiliation(s)
- Victor D Fedorov
- Stanbury Service PSP Group, Department of Medicine, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Vivek A Upadhyay
- Department of Medicine, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Amir T Fathi
- Harvard Medical School, Massachusetts General Hospital, Division of Hematology and Medical Oncology, Zero Emerson Place, Suite 118, Boston, MA, 02114, USA.
| |
Collapse
|
39
|
Inbar T, Rowe JM, Horowitz NA. Which patients should I transplant with acute lymphoblastic leukemia? Best Pract Res Clin Haematol 2017; 30:249-260. [DOI: 10.1016/j.beha.2017.07.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Revised: 07/05/2017] [Accepted: 07/10/2017] [Indexed: 12/18/2022]
|
40
|
Wieduwilt MJ. How should we treat older adults with Ph+ adult ALL and what novel approaches are being investigated? Best Pract Res Clin Haematol 2017; 30:201-211. [DOI: 10.1016/j.beha.2017.07.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 06/13/2017] [Accepted: 07/03/2017] [Indexed: 01/21/2023]
|
41
|
Marini BL, Perissinotti AJ, Bixby DL, Brown J, Burke PW. Catalyzing improvements in ALL therapy with asparaginase. Blood Rev 2017; 31:328-338. [DOI: 10.1016/j.blre.2017.06.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 05/11/2017] [Accepted: 06/19/2017] [Indexed: 11/25/2022]
|
42
|
Wilke AC, Gökbuget N. Clinical applications and safety evaluation of the new CD19 specific T-cell engager antibody construct blinatumomab. Expert Opin Drug Saf 2017; 16:1191-1202. [PMID: 28825327 DOI: 10.1080/14740338.2017.1338270] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Blinatumomab is a T-cell engager antibody construct with dual specificity for CD19 and CD3, inducing serial lysis of CD19 positive B cells by redirecting cytotoxic T cells. It has been approved for the indication of Ph chromosome negative relapsed or refractory B-acute lymphoblastic leukemia (ALL), but has also been tested in ALL with minimal residual disease, relapsed Ph/BCR-ABL positive ALL, relapsed ALL in pediatric patients and relapsed or refractory non-Hodgkin's lymphoma (NHL). Adverse events have been mainly related to infection and hematological toxicities, as well as cytokine release syndrome and neurotoxicity. Areas covered: The review will discuss mechanisms of action, published literature on efficacy in ALL and NHL, specific aspects of administration, frequent adverse events and practical management. Expert opinion: Blinatumomab represents an effective new treatment for highly resistant relapsed/refractory B-precursor ALL. Practical handling bears challenges due to application as four week continous infusion and specific adverse effects which can be well handled by experienced centers. Most promising outcomes are reported for patients with resistant disease but lower tumor load such as MRD positive ALL patients. Future studies will focus on the use of blinatumomab during first-line therapy and the role of stem cell transplantation after blinatumomab treatment.
Collapse
Affiliation(s)
- Anne C Wilke
- a University Hospital , Department of Medicine II , Frankfurt , Germany
| | - Nicola Gökbuget
- a University Hospital , Department of Medicine II , Frankfurt , Germany
| |
Collapse
|
43
|
Affiliation(s)
- Ibrahim Aldoss
- Gehr Family Center for Leukemia Research, City of Hope, Duarte, CA, USA
| | - Anthony S. Stein
- Gehr Family Center for Leukemia Research, City of Hope, Duarte, CA, USA
| |
Collapse
|
44
|
Kozlowski P, Lennmyr E, Ahlberg L, Bernell P, Hulegårdh E, Karbach H, Karlsson K, Tomaszewska-Toporska B, Åström M, Hallböök H. Age but not Philadelphia positivity impairs outcome in older/elderly patients with acute lymphoblastic leukemia in Sweden. Eur J Haematol 2017; 99:141-149. [PMID: 28419558 DOI: 10.1111/ejh.12896] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2017] [Indexed: 01/29/2023]
Abstract
OBJECTIVES Older/elderly patients with acute lymphoblastic leukemia (ALL) are poorly represented in clinical trials. METHODS Using Swedish national leukemia registries, we investigated disease/patient characteristics, treatment choices, outcome, and the impact of an age-adapted protocol (introduced in 2009) in this population-based study of patients aged 55-85 years, diagnosed with ALL 2005-2012. RESULTS Of 174 patients, 82% had B-phenotype, 11% Burkitt leukemia (excluded), and 7% T-phenotype. Philadelphia chromosome positivity (Ph+) occurred in 35%. Of the 155 B- and T-ALL patients, 80% were treated with intensive protocols, and 20% with a palliative approach. Higher age and WHO performance status ≥2 influenced the choice of palliation. Intensive, palliative, and both approaches resulted in complete remission rate 83/16/70% and 3-year overall survival (OS) 32/3/26%. The age-adapted protocol did not improve outcome. With intensive treatment, platelet count ≤35×109 /L and age ≥75 years were adverse prognostic factors for OS, Ph+ was not. Male sex was an adverse prognostic factor in the 55-64 year age-group. CONCLUSIONS We report a high frequency of Ph+ in older/elderly patients, with no evidence of poorer outcome compared to Ph-negative disease. Overall prognosis for elderly patients with ALL remains dismal, despite the use of age-adapted treatment.
Collapse
Affiliation(s)
- Piotr Kozlowski
- Department of Medicine, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Emma Lennmyr
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Lucia Ahlberg
- Department of Hematology, University Hospital of Linköping, Linköping, Sweden
| | - Per Bernell
- Division of Hematology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Erik Hulegårdh
- Department of Hematology and Coagulation, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Holger Karbach
- Department of Hematology, Cancer Center, University Hospital of Umeå, Umeå, Sweden
| | - Karin Karlsson
- Department of Hematology and Oncology, Skåne University Hospital, Lund, Sweden
| | | | - Maria Åström
- Department of Medicine, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Heléne Hallböök
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | | |
Collapse
|
45
|
|
46
|
Gökbuget N. Treatment of older patients with acute lymphoblastic leukemia. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:573-579. [PMID: 27913531 PMCID: PMC6142461 DOI: 10.1182/asheducation-2016.1.573] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
The treatment of older patients with acute lymphoblastic leukemia (ALL) is an unmet medical need. With increasing age, ALL patients have a significantly lower clinical remission rate, higher early mortality, higher relapse rate, and poorer survival compared with younger patients. This is only partly explained by a higher incidence of poor prognostic factors in the older age group. Most importantly, intensive chemotherapy with or without stem cell transplantation (SCT) is less well tolerated in older patients. Some progress has been made with delivering age-adapted, moderately intensive chemotherapy protocols for Ph/BCR-ABL-negative ALL and combinations of tyrosine kinase inhibitors with chemotherapy in Ph/BCR-ABL-positive ALL. For the future, optimizing supportive care, introducing targeted therapies, novel immunotherapies, moderately intensified consolidation strategies, and reduced intensity SCT are promising approaches. Prospective clinical trials for older patients are urgently needed to test these approaches.
Collapse
Affiliation(s)
- Nicola Gökbuget
- Department of Medicine II, Goethe University Hospital, Frankfurt am Main, Germany
| |
Collapse
|
47
|
El-Cheikh J, El Dika I, Massoud R, Charafeddine M, Mahfouz R, Kharfan-Dabaja MA, Bazarbachi A. Hyper-CVAD Compared With BFM-like Chemotherapy for the Treatment of Adult Acute Lymphoblastic Leukemia. A Retrospective Single-Center Analysis. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2016; 17:179-185. [PMID: 27988194 DOI: 10.1016/j.clml.2016.11.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 09/16/2016] [Accepted: 11/07/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Several induction regimens have been developed for treatment of adult patients with acute lymphoblastic leukemia (ALL). However, only a few prospective randomized trials have directly compared these regimens. PATIENTS AND METHODS In this report, we retrospectively evaluated the outcome of 62 adult ALL patients treated with either hyper-CVAD (hyper fractionated cyclophosphamide, vincristine, doxorubicin, and dexamethasone; n = 38) or a BFM (Berlin-Frankfurt-Munster)-like regimen (n = 24) between November 2000 and January 2016 at the American university of Beirut Medical Center in Lebanon. The feasibility of allogeneic stem cell transplantation (allo-SCT) for those patients was also evaluated. RESULTS The median follow-up time was 29 (range, 1-129) months. Fifteen (39%) and 10 (42%) patients underwent allo-SCT in the hyper-CVAD and BFM-like group, respectively. At the time of the last follow-up, 28 patients (74%) were in complete remission in the hyper-CVAD group versus 18 patients (75%) in the BFM-like group. Of those, 20 patients (53%) versus 11 patients (46%) were minimal residual disease-negative at the last follow-up, respectively. The 3-year overall survival rate (71.9% vs. 76.9%; P = .808) and 3-year disease-free survival (54.7% vs. 76.4%; P = .435) were similar in hyper-CVAD group compared with the BFM-like group, respectively. Both chemotherapies were relatively well tolerated. CONCLUSION Overall, despite the older age and a greater number of patients with high-risk category (including Philadelphia chromosome-positive) in the hyper-CVAD group, this did not translate into a difference in survival outcome between the 2 groups. The hyper-CVAD regimen appears to be feasible for adult patients with ALL in terms of tolerability and efficacy.
Collapse
Affiliation(s)
- Jean El-Cheikh
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
| | - Imane El Dika
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Radwan Massoud
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Maya Charafeddine
- Division of Hematology and Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Rami Mahfouz
- Department of Pathology and Laboratory Medicine, American University of Beirut, Beirut, Lebanon
| | | | - Ali Bazarbachi
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| |
Collapse
|
48
|
Paul S, Kantarjian H, Jabbour EJ. Adult Acute Lymphoblastic Leukemia. Mayo Clin Proc 2016; 91:1645-1666. [PMID: 27814839 DOI: 10.1016/j.mayocp.2016.09.010] [Citation(s) in RCA: 124] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 09/26/2016] [Accepted: 09/26/2016] [Indexed: 02/08/2023]
Abstract
Conventional cytotoxic chemotherapy used to treat acute lymphoblastic leukemia (ALL) results in high cure rates in pediatric patients but is suboptimal in the treatment of adult patients. The 5-year overall survival is approximately 90% in children and 30% to 40% in adults and elderly patients. Adults with ALL tend to have higher risk factors at diagnosis, more comorbidities, and increasing age that often requires dose reductions. Major advancements have been made in redefining the pathologic classification of ALL, identifying new cytogenetic-molecular abnormalities, and developing novel targeted agents in order to improve survival. The addition of new monoclonal antibodies and tyrosine kinase inhibitors to conventional chemotherapy in the frontline setting has resulted in increased rates of complete remission and overall survival. These new developments are changing the treatment of adult ALL from a "one therapy fits all" approach to individualized treatment based on patient's cytogenetic and molecular profile.
Collapse
Affiliation(s)
- Shilpa Paul
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Hagop Kantarjian
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Elias J Jabbour
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, TX.
| |
Collapse
|
49
|
Allahyari A, Hashemi SM, Nazemian F, Karimi M, Kazemi MR, Sadeghi M. The Relationship Between Risk Factors and Survival in Adult Acute Lymphoblastic Leukemia. IRANIAN JOURNAL OF CANCER PREVENTION 2016; 9:e5045. [PMID: 27761210 PMCID: PMC5056011 DOI: 10.17795/ijcp-5045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 02/06/2016] [Accepted: 08/06/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Acute lymphoblastic leukemia (ALL) is aggressive cancer, especially in adults as only 20-40% is cured with current treatment regimens. OBJECTIVES The aim of this study is to evaluate prognostic factors and their effects on survival in ALL patients in the Northeast of Iran. METHODS In a descriptive and retrospective study from 2009 to 2015, 48 ALL patients referred to hematology-oncology clinic. Age, sex, fever, blood group, type of ALL and consumption of amphotericin B, forms of cytogenetic, survival in the patients, WBC, hemoglobin, and platelet were checked in the first referral for every patient. The mean follow-up was 27.3 months in which 28 patients (59.3%) died. overall survival (OS) was plotted by GraphPad Prism 5 and the Log-rank test was used for analysis of survival with risk factors. RESULTS The mean age for all the ALL patients at diagnosis was 32.3 years (range, 15-71 years), and 81.3% were male. Of all patients, 62.5% had fever and 25% consumed amphotericin B. 1-, 2-, 3-, 4-, 5-year OS rates were 62.2%, 52.7%, 40.6%, 39.1%, 22.2%, respectively. 75%, 29.2% and 39.6% of patients had WBC < 20 × 103/μl, Hb < 7 g/dL and platelet < 30 × 103/μL, respectively. There was a significant difference in survival based on age (P = 0.000). CONCLUSIONS Based on the results, age > 35 years is the most prognostic factor in ALL patients. Also, patients who received amphotericin B had lower life expectancy because these patients were suffering from fungal infection or due to lack of response to antibacterial drugs, they have been treated with amphotericin B.
Collapse
Affiliation(s)
- Abolghasem Allahyari
- Department of Hematology and Medical Oncology, Mashhad University of Medical Sciences, Mashhad, IR Iran
| | - Seyed-Mehdi Hashemi
- Department of Hematology and Medical Oncology, Zahedan University of Medical Sciences, Zahedan, IR Iran
| | - Fahimeh Nazemian
- Cancer Research Center, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
| | - Mohammad Karimi
- Department of Hematology and Medical Oncology, Mashhad University of Medical Sciences, Mashhad, IR Iran
| | - Mohammad-Reza Kazemi
- Department of Hematology and Medical Oncology, Mashhad University of Medical Sciences, Mashhad, IR Iran
| | - Masoud Sadeghi
- Cancer Research Center, Kermanshah University of Medical Sciences, Kermanshah, IR Iran
| |
Collapse
|
50
|
Wolach O, Stevenson KE, Wadleigh M, DeAngelo DJ, Steensma DP, Ballen KK, Soiffer RJ, Antin JH, Neuberg DS, Ho VT, Stone RM. Allogeneic transplantation is not superior to chemotherapy in most patients over 40 years of age with Philadelphia-negative acute lymphoblastic leukemia in first remission. Am J Hematol 2016; 91:793-9. [PMID: 27153389 DOI: 10.1002/ajh.24410] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 04/29/2016] [Accepted: 05/03/2016] [Indexed: 01/09/2023]
Abstract
Survival of patients ≥40 years of age with Philadelphia-negative acute lymphoblastic leukemia (ALL) remains poor with current therapeutic approaches. It is unknown whether allogeneic hematopoietic stem-cell transplantation (HSCT) in first remission confers a survival benefit compared to a chemotherapy-only approach. We retrospectively compared the outcome of patients >40 years treated with HSCT or chemotherapy alone in first remission (n = 40 in each cohort). Three-year overall survival (OS) and disease-free survival (DFS) were not significantly different between the chemotherapy-only and HSCT groups (OS, 46% [31-68] vs. 40% [27-59], P = 0.35; DFS, 31% [18-52] vs. 40% [27-59], P = 0.98). The 3-year cumulative incidence of relapse (CIR) and non-relapse mortality (NRM) were 61% [41-76] and 9% [2-21] for the chemotherapy-only group and 28% [15-43] and 32% [17-47] for the transplant group (CIR, P = 0.011; NRM, P = 0.014). Allogeneic transplantation for patients ≥40 years with Ph-negative ALL in first remission is associated with a lower CIR, but this benefit is offset by considerable NRM as compared with chemotherapy-only approach. HSCT may be beneficial in patients with high-risk disease features. Am. J. Hematol. 91:793-799, 2016. © 2016 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- Ofir Wolach
- Department of Medical Oncology; Dana-Farber Cancer Institute; Boston Massachusetts
| | - Kristen E. Stevenson
- Department of Biostatistics and Computational Biology; Dana-Farber Cancer Institute; Boston Massachusetts
| | - Martha Wadleigh
- Department of Medical Oncology; Dana-Farber Cancer Institute; Boston Massachusetts
| | - Daniel J. DeAngelo
- Department of Medical Oncology; Dana-Farber Cancer Institute; Boston Massachusetts
| | - David P. Steensma
- Department of Medical Oncology; Dana-Farber Cancer Institute; Boston Massachusetts
| | - Karen K. Ballen
- Department of Hematology/Oncology; Massachusetts General Hospital; Boston Massachusetts
| | - Robert J. Soiffer
- Department of Medical Oncology; Dana-Farber Cancer Institute; Boston Massachusetts
| | - Joseph H. Antin
- Department of Medical Oncology; Dana-Farber Cancer Institute; Boston Massachusetts
| | - Donna S. Neuberg
- Department of Biostatistics and Computational Biology; Dana-Farber Cancer Institute; Boston Massachusetts
| | - Vincent T. Ho
- Department of Medical Oncology; Dana-Farber Cancer Institute; Boston Massachusetts
| | - Richard M. Stone
- Department of Medical Oncology; Dana-Farber Cancer Institute; Boston Massachusetts
| |
Collapse
|