1
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Lim JJ, Othus M, Shaw CM, Russell K, Halpern AB, Appelbaum JS, Hendrie P, Walter RB, Estey EH, Percival MEM. Time independent factors that predict relapse in adults with acute myeloid leukemia. Blood Cancer J 2024; 14:5. [PMID: 38221523 PMCID: PMC10788333 DOI: 10.1038/s41408-023-00954-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 11/16/2023] [Accepted: 11/20/2023] [Indexed: 01/16/2024] Open
Affiliation(s)
- John J Lim
- University of Washington Medical Center, Seattle, WA, USA
| | - Megan Othus
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Carole M Shaw
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Kathryn Russell
- Division of Hematology and Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Anna B Halpern
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Division of Hematology and Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Jacob S Appelbaum
- Division of Hematology and Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Paul Hendrie
- Division of Hematology and Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Roland B Walter
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Division of Hematology and Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Elihu H Estey
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Division of Hematology and Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Mary-Elizabeth M Percival
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA.
- Division of Hematology and Oncology, Department of Medicine, University of Washington, Seattle, WA, USA.
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2
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Chang YM, Shen PS, Ho CY. Bayesian phase II adaptive randomization by jointly modeling efficacy and toxicity as time-to-event outcomes. J Biopharm Stat 2024:1-20. [PMID: 38163949 DOI: 10.1080/10543406.2023.2297782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 12/14/2023] [Indexed: 01/03/2024]
Abstract
The main goals of Phase II trials are to identify the therapeutic efficacy of new treatments and continue monitoring all the possible adverse effects. In Phase II trials, it is important to develop an adaptive randomization (AR) procedure that takes into account both the efficacy and toxicity. In most existing articles, toxicity is modeled as a binary endpoint through an unobservable random effect (frailty) to link the efficacy and toxicity. However, this approach does not capture toxicity profiles that evolve over time. In this article, we propose a new Bayesian adaptive randomization (BAR) procedure using the covariate-adjusted efficacy-toxicity ratio (ETR) index, where efficacy and toxicity are jointly modelled as time-to-event (TTE) outcomes. Furthermore, we also propose early stopping rules for toxicity and futility such that inferior treatments can be dropped at earlier time of trial. Simulation results show that compared to the BAR procedures based solely on the efficacy and that based on TTE efficacy and binary toxicity outcomes, the proposed BAR procedure can better identify the difference in treatment toxicity such that it can assign more patients to the superior treatment arm under some scenarios.
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Affiliation(s)
- Yu-Mei Chang
- Department of Statistics, Tunghai University, Taichung, Taiwan
| | - Pao-Sheng Shen
- Department of Statistics, Tunghai University, Taichung, Taiwan
| | - Chun-Ying Ho
- Department of Statistics, Tunghai University, Taichung, Taiwan
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3
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Hadisantoso DW, Ranuhardy D, Rajabto W, Rizka A, Setiawan L, Rinaldi I, Mansjoer A, Nelwan EJ, Shatri H. Association of leukocyte nadir with complete remission in Indonesian acute myeloid leukemia patients undergoing 7+3 remission induction chemotherapy. F1000Res 2022; 11:495. [PMID: 35721596 PMCID: PMC9194516 DOI: 10.12688/f1000research.110320.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/28/2022] [Indexed: 12/24/2022] Open
Abstract
Background: The 7+3 regimen is still the main choice of remission induction chemotherapy in acute myeloid leukemia (AML). Successfully achieving complete remission (CR) and the time required to achieve it determine patient’s survival. Hence, bone marrow examination on 14
th day of chemotherapy is recommended to predict CR. However, the examination is invasive and still inaccurate. Methods: A prognostic study with retrospective cohort design was conducted at two central hospitals in Indonesia based on medical record data of AML patients who underwent 7+3 induction chemotherapy from January 1st, 2015, to December 31st, 2019. The association of nadir leukocyte level and the time required to achieve it with CR occurrence was assessed. Results: One hundred and one subjects were recruited with median age 39 years and 55% men. A total of 55.4% subjects achieved CR. Nadir leukocyte level below 200/mcl was the most optimal cut-off point and independently associated with CR (OR 2.48; 95% CI 1.03–5.97) while time required to achieve it was not. Conclusions: The nadir leukocyte level is associated with an increase probability of CR but not for the time required to achieve it in AML patients undergoing 7+3 induction chemotherapy.
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Affiliation(s)
- Dwi Wahyunianto Hadisantoso
- Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Central Jakarta, Greater Jakarta, 10430, Indonesia
- Hematology-Medical Oncology, Dharmais Hospital National Cancer Center, West Jakarta, Greater Jakarta, 11420, Indonesia
| | - Dody Ranuhardy
- Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Central Jakarta, Greater Jakarta, 10430, Indonesia
- Hematology-Medical Oncology, Dharmais Hospital National Cancer Center, West Jakarta, Greater Jakarta, 11420, Indonesia
| | - Wulyo Rajabto
- Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Central Jakarta, Greater Jakarta, 10430, Indonesia
- Department of Internal Medicine, Faculty of Medicine, Dr. Cipto Mangunkusumo National Central Public Hospital, Central Jakarta, Greater Jakarta, 10430, Indonesia
| | - Aulia Rizka
- Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Central Jakarta, Greater Jakarta, 10430, Indonesia
- Department of Internal Medicine, Faculty of Medicine, Dr. Cipto Mangunkusumo National Central Public Hospital, Central Jakarta, Greater Jakarta, 10430, Indonesia
| | - Lyana Setiawan
- Clinical Pathology, Dharmais Hospital National Cancer Center, West Jakarta, Greater Jakarta, 11420, Indonesia
| | - Ikhwan Rinaldi
- Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Central Jakarta, Greater Jakarta, 10430, Indonesia
- Department of Internal Medicine, Faculty of Medicine, Dr. Cipto Mangunkusumo National Central Public Hospital, Central Jakarta, Greater Jakarta, 10430, Indonesia
| | - Arif Mansjoer
- Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Central Jakarta, Greater Jakarta, 10430, Indonesia
- Department of Internal Medicine, Faculty of Medicine, Dr. Cipto Mangunkusumo National Central Public Hospital, Central Jakarta, Greater Jakarta, 10430, Indonesia
| | - Erni Juwita Nelwan
- Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Central Jakarta, Greater Jakarta, 10430, Indonesia
- Department of Internal Medicine, Faculty of Medicine, Dr. Cipto Mangunkusumo National Central Public Hospital, Central Jakarta, Greater Jakarta, 10430, Indonesia
| | - Hamzah Shatri
- Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Central Jakarta, Greater Jakarta, 10430, Indonesia
- Department of Internal Medicine, Faculty of Medicine, Dr. Cipto Mangunkusumo National Central Public Hospital, Central Jakarta, Greater Jakarta, 10430, Indonesia
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4
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Percival ME, Wang HL, Zhang MJ, Saber W, de Lima M, Litzow M, Kebriaei P, Abdel-Azim H, Adekola K, Aljurf M, Bacher U, Badawy SM, Beitinjaneh A, Bejanyan N, Bhatt V, Byrne M, Cahn JY, Castillo P, Chao N, Chhabra S, Copelan E, Cutler C, DeFilipp Z, Dias A, Diaz MA, Estey E, Farhadfar N, Frangoul HA, Freytes CO, Gale RP, Ganguly S, Gowda L, Grunwald M, Hossain N, Kamble RT, Kanakry CG, Kansagra A, Kharfan-Dabaja MA, Krem M, Lazarus HM, Lee JW, Liesveld JL, Lin R, Liu H, McGuirk J, Munker R, Murthy HS, Nathan S, Nishihori T, Olsson RF, Palmisiano N, Passweg JR, Prestidge T, Ringdén O, Rizzieri DA, Rybka WB, Savoie ML, Schultz KR, Seo S, Sharma A, Solh M, Strair R, van der Poel M, Verdonck LF, Yared JA, Weisdorf D, Sandmaier BM. Impact of depth of clinical response on outcomes of acute myeloid leukemia patients in first complete remission who undergo allogeneic hematopoietic cell transplantation. Bone Marrow Transplant 2021; 56:2108-2117. [PMID: 33864019 PMCID: PMC8425595 DOI: 10.1038/s41409-021-01261-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 02/03/2021] [Accepted: 02/23/2021] [Indexed: 02/05/2023]
Abstract
Acute myeloid leukemia (AML) patients often undergo allogeneic hematopoietic cell transplantation (alloHCT) in first complete remission (CR). We examined the effect of depth of clinical response, including incomplete count recovery (CRi) and/or measurable residual disease (MRD), in patients from the Center for International Blood and Marrow Transplantation Research (CIBMTR) registry. We identified 2492 adult patients (1799 CR and 693 CRi) who underwent alloHCT between January 1, 2007 and December 31, 2015. The primary outcome was overall survival (OS). Multivariable analysis was performed to adjust for patient-, disease-, and transplant-related factors. Baseline characteristics were similar. Patients in CRi compared to those in CR had an increased likelihood of death (HR: 1.27; 95% confidence interval: 1.13-1.43). Compared to CR, CRi was significantly associated with increased non-relapse mortality (NRM), shorter disease-free survival (DFS), and a trend toward increased relapse. Detectable MRD was associated with shorter OS, shorter DFS, higher NRM, and increased relapse compared to absence of MRD. The deleterious effects of CRi and MRD were independent. In this large CIBMTR cohort, survival outcomes differ among AML patients based on depth of CR and presence of MRD at the time of alloHCT. Further studies should focus on optimizing post-alloHCT outcomes for patients with responses less than CR.
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Affiliation(s)
- Mary-Elizabeth Percival
- Division of Hematology, University of Washington and Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
| | - Hai-Lin Wang
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mei-Jie Zhang
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Wael Saber
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Marcos de Lima
- Department of Medicine, Seidman Cancer Center, University Hospitals Case Medical Center, Cleveland, OH, USA
| | - Mark Litzow
- Division of Hematology and Transplant Center, Mayo Clinic Rochester, Rochester, MN, USA
| | - Partow Kebriaei
- Department of Stem Cell Transplantation, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hisham Abdel-Azim
- Division of Hematology, Oncology and Blood & Marrow Transplantation, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA, USA
| | - Kehinde Adekola
- Division of Hematology and Oncology, Department of Medicine and Robert H. Lurie Comprehensive Cancer, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Mahmoud Aljurf
- Department of Oncology, King Faisal Specialist Hospital Center & Research, Riyadh, Saudi Arabia
| | - Ulrike Bacher
- Department of Hematology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Sherif M Badawy
- Division of Hematology, Oncology and Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Nelli Bejanyan
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL, USA
| | - Vijaya Bhatt
- The Fred and Pamela Buffett Cancer Center, University of Nebraska Medical Center, Omaha, NE, USA
| | - Michael Byrne
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jean-Yves Cahn
- Department of Hematology, CHU Grenoble Alpes, Grenoble, France
| | - Paul Castillo
- UF Health Shands Children's Hospital, Gainesville, FL, USA
| | - Nelson Chao
- Department of Medicine, Division of Cell Therapy and Hematology, Duke University Medical Center, Durham, NC, USA
| | - Saurabh Chhabra
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Medicine, Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Edward Copelan
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Corey Cutler
- Center for Hematologic Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Zachariah DeFilipp
- Blood and Marrow Transplant Program, Massachusetts General Hospital, Boston, MA, USA
| | - Ajoy Dias
- Beth Israel Deaconess Medical Center, Westwood, KS, USA
| | - Miguel Angel Diaz
- Department of Hematology/Oncology, Hospital Infantil Universitario Nino Jesus, Madrid, Spain
| | - Elihu Estey
- Division of Hematology, University of Washington and Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Nosha Farhadfar
- Division of Hematology and Oncology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Haydar A Frangoul
- The Children's Hospital at TriStar Centennial and Sarah Cannon Research Institute, Nashville, TN, USA
| | | | - Robert Peter Gale
- Haematology Research Centre, Department of Immunology and Inflammation, Imperial College London, London, UK
| | - Siddhartha Ganguly
- Division of Hematological Malignancy and Cellular Therapeutics, University of Kansas Health System, Kansas City, KS, USA
| | | | - Michael Grunwald
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, NC, USA
| | - Nasheed Hossain
- Department of Medicine, Division of Hematology and Oncology, Stem Cell Transplant Program-Loyola University Stritch School of Medicine, Maywood, IL, USA
| | - Rammurti T Kamble
- Center for Cell and Gene Therapy, Division of Hematology and Oncology, Baylor College of Medicine, Houston, TX, USA
| | - Christopher G Kanakry
- Experimental Transplantation and Immunology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Ankit Kansagra
- UT Southwestern Medical Center-BMT Program, Dallas, TX, USA
| | - Mohamed A Kharfan-Dabaja
- Division of Hematology-Oncology, Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL, USA
| | - Maxwell Krem
- University of Louisville Hospital/James Brown Cancer Center, Louisville, KY, USA
| | - Hillard M Lazarus
- University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Jong Wook Lee
- Division of Hematology, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Jane L Liesveld
- Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Richard Lin
- Memorial Sloan Kettering Cancer Center-Adults, New York, NY, USA
| | - Hongtao Liu
- University of Chicago Medicine, Chicago, IL, USA
| | | | - Reinhold Munker
- Markey Cancer Center, University of Kentucky, Lexington, KY, USA
| | - Hemant S Murthy
- Division of Hematology-Oncology, Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL, USA
| | | | - Taiga Nishihori
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, FL, USA
| | - Richard F Olsson
- Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
- Centre for Clinical Research Sormland, Uppsala University, Uppsala, Sweden
| | - Neil Palmisiano
- Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Tim Prestidge
- Blood and Cancer Centre, Starship Children's Hospital, Auckland, New Zealand
| | - Olov Ringdén
- Translational Cell Therapy Group, CLINTEC (Clinical Science, Intervention and Technology), Karolinska Institutet, Stockholm, Sweden
| | - David A Rizzieri
- Division of Hematologic Malignancies and Cellular Therapy, Duke University, Durham, NC, USA
| | | | | | - Kirk R Schultz
- Department of Pediatric Hematology, Oncology and Bone Marrow Transplant, British Columbia's Children's Hospital, The University of British Columbia, Vancouver, BC, Canada
| | - Sachiko Seo
- Department of Hematology and Oncology, Dokkyo Medical University, Tochigi, Japan
| | - Akshay Sharma
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Melhem Solh
- The Blood and Marrow Transplant Group of Georgia, Northside Hospital, Atlanta, GA, USA
| | - Roger Strair
- Rutgers Cancer Institute of New Jersey, Rutgers University, New Brunswick, NJ, USA
| | | | - Leo F Verdonck
- Department of Hematology/Oncology, Isala Clinic, Zwolle, The Netherlands
| | - Jean A Yared
- Blood & Marrow Transplantation Program, Department of Medicine, Division of Hematology and Oncology, Greenebaum Comprehensive Cancer Center, University of Maryland, Baltimore, MD, USA
| | - Daniel Weisdorf
- Department of Medicine, Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, MN, USA
- CIBMTR® (Center for International Blood and Marrow Transplant Research), National Marrow Donor Program/Be The Match, Minneapolis, MN, USA
| | - Brenda M Sandmaier
- Division of Medical Oncology, University of Washington and Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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Shallis RM, Pollyea DA, Zeidan AM. The complete story of less than complete responses: The evolution and application of acute myeloid leukemia clinical responses. Blood Rev 2021; 48:100806. [PMID: 33531169 DOI: 10.1016/j.blre.2021.100806] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/13/2020] [Accepted: 12/17/2020] [Indexed: 10/22/2022]
Abstract
Complete remission (CR) has long been the critical therapeutic response in acute myeloid leukemia (AML). However, "less than CR" responses have been and continue to be proposed to define clinically meaningful post-therapy outcomes. These responses include CR with incomplete recovery (CRi), CR with incomplete platelet recovery (CRp) and, most recently, CR with partial hematologic recovery (CRh), which has been introduced and subsequently used for regulatory approval. However, the clinical benefits associated with "less than CR" responses have primarily been evaluated in the context of intensive therapies. In an era with sophisticated measurable residual disease (MRD) assessments, including flow-based, cytogenetic and molecular techniques, and an increase in "targeted", non-intensive therapies, the clinical value of responses that are "less than CR" must be reevaluated. Improvements in the rate of CR has not always led to improvements in OS among older patients. As such, MRD techniques might help define a more stringent response criterion (MRD-negative CR) that might better correlate with OS and should be incorporated in future clinical trials. Here we discuss the evolution of CR and "less than CR" responses, data regarding their clinical benefits, and considerations relevant to response assessments with newer therapies.
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Affiliation(s)
- Rory M Shallis
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA; Yale Cancer Center, New Haven, CT, USA
| | - Daniel A Pollyea
- Division of Hematology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Amer M Zeidan
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA; Yale Cancer Center, New Haven, CT, USA.
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6
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The impact of response kinetics for multiple myeloma in the era of novel agents. Blood Adv 2020; 3:2895-2904. [PMID: 31594763 DOI: 10.1182/bloodadvances.2019000432] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 07/01/2019] [Indexed: 01/08/2023] Open
Abstract
Rapid remission by induction therapy has long been recognized as an important predictor for long-time survival in acute leukemia. However, the impact of response kinetics on multiple myeloma (MM) seems to be different and remains unexplored. The relationship between response kinetics and outcome were assessed in 626 patients with newly diagnosed MM who were included in a prospective, nonrandomized clinical trial (BDH 2008/02). Patients were assigned to either immunomodulatory drug- or proteasome inhibitor-based therapy. The response depth, time to best response (TBR) and duration of best response (DBR) were collected. Depth of response was associated with superior outcomes, consistent with findings from other studies. However, the early responders (defined as TBR ≤3 months) showed significantly worse survival compared with late responders. We found that patients with rapid complete remission experienced inferior survivals comparable to those attaining a gradual partial remission. Moreover, 4 distinct response kinetics patterns were identified. Patients with gradual and sustained remission ("U-valley" pattern) experienced superior outcomes, whereas poor outcomes were observed in rapid and transient responders ("roller coaster" pattern) (median overall survival, 126 vs 30 months). The effects of response patterns on survival were confirmed in patients at different stages of disease and cytogenetic risk, including transplant-eligible patients and those attaining different extents of response depth. Collectively, our data indicated that slow and gradual response is a favorable prognostic factor in MM. In addition to response depth, the kinetic pattern of response is a simple and powerful predictor for survival even in the era of novel agents.
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Impact of preleukemic mutations and their persistence on hematologic recovery after induction chemotherapy for AML. Blood Adv 2020; 3:2307-2311. [PMID: 31371380 DOI: 10.1182/bloodadvances.2019000306] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 06/12/2019] [Indexed: 01/20/2023] Open
Abstract
Key Points
DNMT3A R882, TET2, ASXL1, and SRSF2 mutations identified at the time of diagnosis are associated with delayed count recovery. Persistence of preleukemic mutations in remission at high variant allele frequency is associated with delayed count recovery.
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8
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Ciftciler R, Demiroglu H, Haznedaroglu IC, Sayınalp N, Aksu S, Ozcebe O, Goker H, Aydın MS, Buyukasık Y. Impact of Time Between Induction Chemotherapy and Complete Remission on Survival Outcomes in Patients With Acute Myeloid Leukemia. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2019; 19:729-734. [PMID: 31540855 DOI: 10.1016/j.clml.2019.08.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 07/09/2019] [Accepted: 08/16/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The majority of patients with acute myeloid leukemia (AML) receive intensive induction chemotherapy for obtaining a complete remission (CR). Despite consolidation chemotherapy and advances in allogeneic hematopoietic stem cell transplantation, most of these patients finally relapse and die from AML. The aim of this study is to determine the impact of duration of remission achievement on survival of patients with newly diagnosed AML who achieve CR after induction chemotherapy. MATERIALS AND METHODS We retrospectively analyzed patients with AML who received first induction chemotherapy between 2001 and 2018. RESULTS The 5-year overall survival for patients who had early remission after induction chemotherapy and patients who had delayed remission after induction chemotherapy were 83% (95% confidence interval [CI], 0.79-0.87) and 35% (95% CI, 0.31-0.39), respectively (P < .001). The 5-year disease-free survival for patients who had early remission after induction chemotherapy and patients who had delayed remission after induction chemotherapy were 81% (95% CI, 0.75-0.87) and 28% (95% CI, 0.21-0.35), respectively (P < .001). CONCLUSION In conclusion, time to entering CR is a predictor factor of overall survival and disease-free survival for patients with newly diagnosed AML who achieve CR after first induction chemotherapy. Patients achieving CR only after a lengthy time (eg, more than 29 days) should be considered to have high relapse rate and should undergo allogeneic hematopoietic stem cell transplantation.
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Affiliation(s)
- Rafiye Ciftciler
- Department of Hematology, Faculty of Medicine, Hacettepe University, Ankara, Turkey.
| | - Haluk Demiroglu
- Department of Hematology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | | | - Nilgun Sayınalp
- Department of Hematology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Salih Aksu
- Department of Hematology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Osman Ozcebe
- Department of Hematology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Hakan Goker
- Department of Hematology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Muruvvet Seda Aydın
- Department of Hematology, Ankara Numune Eduacation and Research Hospital, Ankara, Turkey
| | - Yahya Buyukasık
- Department of Hematology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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9
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Wang Y, Zhang G, Ye L, Dai Q, Peng L, Chen L, Chen Q, Jiang Y, Gao J. Clinical value of the quantitation of average daily platelet increase during the recovery period in childhood acute lymphoblastic leukaemia. Platelets 2018; 30:923-926. [PMID: 30497316 DOI: 10.1080/09537104.2018.1548011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The time to platelet recovery (TPR) is becoming a predicting factor during the treatment of childhood acute leukaemia. However, the initial pre-treatment platelet count (PPC) could interfere with TPR. Here, we integrated both TPR and PPC as the average daily platelet amount increase (Ap) to predict the prognosis in childhood B-ALL during the recovery period.148 patients were enrolled. The relationship between the Ap and MRD was evaluated, and Multivariate analysis was performed to evaluate whether Ap was independently associated with a better EFS. The PPC was inversely correlated with TPR (rs = -0.519, P = 0.021). Patients in Ap >3.9 × 109/L group had better EFS (x2 = 3.109, P = 0.028) than TPR ≤ 16d. Multivariate analysis indicated that Ap > 3.9 × 109/L was independently associated with a longer EFS (RR = 3.468; 95%CI: 1.037-11.597, P = 0.043). However, when introducing both MRD and Ap > 3.9 × 109/L as candidate variables, the Ap > 3.9 × 109/L lost its independent effect (P = 0.081). The strong association between MRD on treatment day 33 and Ap > 3.9 × 109/L (x2 = 148.00, P = 0.000) was responsible for this phenomenon. Ap could be a valuable prognostic indicator in childhood B-ALL.
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Affiliation(s)
- Yuefang Wang
- Department of Laboratory Medicine, West China Second University Hospital, Sichuan University , Chengdu , Sichuan , P. R. China
| | - Ge Zhang
- Department of Laboratory Medicine, West China Second University Hospital, Sichuan University , Chengdu , Sichuan , P. R. China
| | - Lei Ye
- Department of Laboratory Medicine, West China Second University Hospital, Sichuan University , Chengdu , Sichuan , P. R. China
| | - Qingkai Dai
- Department of Laboratory Medicine, West China Second University Hospital, Sichuan University , Chengdu , Sichuan , P. R. China
| | - Luyun Peng
- Department of Laboratory Medicine, West China Second University Hospital, Sichuan University , Chengdu , Sichuan , P. R. China
| | - Lan Chen
- Department of Laboratory Medicine, West China Second University Hospital, Sichuan University , Chengdu , Sichuan , P. R. China
| | - Qi Chen
- Department of Laboratory Medicine, West China Second University Hospital, Sichuan University , Chengdu , Sichuan , P. R. China
| | - Yongmei Jiang
- Department of Laboratory Medicine, West China Second University Hospital, Sichuan University , Chengdu , Sichuan , P. R. China
| | - Ju Gao
- Pediatric department of Hematology, Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University , Chengdu , Sichuan , P.R. China
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10
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Gbadamosi B, Ezekwudo D, Bastola S, Jaiyesimi I. Predictive and Prognostic Markers in Adults With Acute Myeloid Leukemia: A Single-Institution Experience. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2018; 18:e287-e294. [PMID: 29803615 DOI: 10.1016/j.clml.2018.05.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 04/26/2018] [Accepted: 05/02/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Acute myeloid leukemia (AML) is a heterogeneous malignancy with diverse genetic abnormalities, clinical presentations, and outcomes. Known predictive and prognostic factors in AML include age, performance status, comorbidities, cytogenetics, and molecular mutations. Identifying prognostic and predictive factors can inform the choice of induction therapy and outcomes prediction. PATIENTS AND METHODS A retrospective review was performed of 137 adult AML patients from 2010 to 2015. Predictors of complete remission (CR) and overall survival (OS) were determined for patients treated with 3+7 (3 days of anthracycline and 7 days of cytarabine) or hypomethylating agent. Variables associated with CR or OS were assessed using univariate Cox regression and a multivariate Cox model. RESULTS The average age was 65 years and 91 patients (66%), sample size is 137 patients had primary AML. Patients in the 3+7 induction group were younger, had a higher bone marrow blast percentage, and more de novo AML compared with those in the hypomethylating agent group (P < .001, P < .001, P = .005, respectively). Univariate logistic regression for CR showed a significant association between age (P < .001), choice of induction (P < .001), and monosomy (P = .015), although only induction with 3+7 (P < .001) and absence of monosomy (P = .042) remained significant in multivariate analysis. Univariate Cox regression indicated that age (P = .003), AML status (de novo or secondary; P = .0277), choice of induction (P = .030), and monosomy (P = .010) had a significant association with OS. Only younger age (P = .018) and absence of monosomy (P = .022) were predictive of OS in multivariate Cox analysis. CONCLUSION Positive predictors of CR in adult AML include absence of monosomy and induction treatment with 3+7; whereas positive predictors of OS are younger age and absence of monosomy.
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Affiliation(s)
- Bolanle Gbadamosi
- Department of Hematology and Oncology, Beaumont Hospital, Oakland University William Beaumont School of Medicine, Royal Oak, MI.
| | - Daniel Ezekwudo
- Department of Hematology and Oncology, Beaumont Hospital, Oakland University William Beaumont School of Medicine, Royal Oak, MI
| | - Sanjog Bastola
- Department of Internal Medicine, Beaumont Hospital, Oakland University William Beaumont School of Medicine, Royal Oak, MI
| | - Ishmael Jaiyesimi
- Department of Hematology and Oncology, Beaumont Hospital, Oakland University William Beaumont School of Medicine, Royal Oak, MI
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11
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Wang M, Bu J, Zhou M, Sido J, Lin Y, Liu G, Lin Q, Xu X, Leavenworth JW, Shen E. CD8 +T cells expressing both PD-1 and TIGIT but not CD226 are dysfunctional in acute myeloid leukemia (AML) patients. Clin Immunol 2018; 190:64-73. [PMID: 28893624 DOI: 10.1016/j.clim.2017.08.021] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Revised: 08/16/2017] [Accepted: 08/24/2017] [Indexed: 01/07/2023]
Abstract
Acute myeloid leukemia (AML) is one of the most common types of leukemia among adults with an overall poor prognosis and very limited treatment management. Immune checkpoint blockade of PD-1 alone or combined with other immune checkpoint blockade has gained impressive results in murine AML models by improving anti-leukemia CD8+T cell function, which has greatly promoted the strategy to utilize combined immune checkpoint inhibitors to treat AML patients. However, the expression profiles of these immune checkpoint receptors, such as co-inhibitory receptors PD-1 and TIGIT and co-stimulatory receptor CD226, in T cells from AML patients have not been clearly defined. Here we have defined subsets of CD8+ and CD4+ T cells in the peripheral blood (PB) from newly diagnosed AML patients and healthy controls (HCs). We have observed increased frequencies of PD-1- and TIGIT- expressing CD8+ T cells but decreased occurrence of CD226-expressing CD8+T cells in AML patients. Further analysis of these CD8+ T cells revealed a unique CD8+ T cell subset that expressed PD-1 and TIGIT but displayed lower levels of CD226 was associated with failure to achieve remission after induction chemotherapy and FLT3-ITD mutations which predict poor clinical prognosis in AML patients. Importantly, these PD-1+TIGIT+CD226-CD8+T cells are dysfunctional with lower expression of intracellular IFN-γ and TNF-α than their counterparts in HCs. Therefore, our studies revealed that an increased frequency of a unique CD8+ T cell subset, PD-1+TIGIT+CD226-CD8+T cells, is associated with CD8+T cell dysfunction and poor clinical prognosis of AML patients, which may reveal critical diagnostic or prognostic biomarkers and direct more efficient therapeutic strategies.
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Affiliation(s)
- Mengjie Wang
- Department of Pathogenic Biology and Immunology, Guangzhou Hoffmann Institute of Immunology, School of Basic Sciences, Guangzhou Medical University, Guangzhou 510182, China
| | - Jin Bu
- Editorial Department of Journals of Nanjing Medical University, Nanjing Medical University, Nanjing, Jiangsu 211166, China
| | - Maohua Zhou
- Department of Laboratory Medicine, Guangdong General Hospital, Academy of Medical Sciences, Guangzhou 510080, China
| | - Jessica Sido
- Department of Cancer Immunology and Virology, Dana Farber Cancer Institute, Boston, MA 02115, USA; Department of Microbiology & Immunobiology, Division of Immunology, Harvard Medical School, Boston, MA 02115, USA
| | - Yu Lin
- Shenzhen Withsum Technology Limited, Shenzhen 518031, China
| | - Guanfang Liu
- Department of Pathogenic Biology and Immunology, Guangzhou Hoffmann Institute of Immunology, School of Basic Sciences, Guangzhou Medical University, Guangzhou 510182, China
| | - Qiwen Lin
- Guangzhou Blood Center, Guangzhou 510095, China
| | - Xiuzhang Xu
- Guangzhou Blood Center, Guangzhou 510095, China
| | - Jianmei W Leavenworth
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL 35233, USA; Department of Microbiology, University of Alabama at Birmingham, Birmingham, AL 35233, USA.
| | - Erxia Shen
- Department of Pathogenic Biology and Immunology, Guangzhou Hoffmann Institute of Immunology, School of Basic Sciences, Guangzhou Medical University, Guangzhou 510182, China; Department of Cancer Immunology and Virology, Dana Farber Cancer Institute, Boston, MA 02115, USA.
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12
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Boddu P, Kantarjian H, Garcia-Manero G, Ravandi F, Jabbour E, Borthakur G, Daver N, Pemmaraju N, Pierce S, Cortes J, Kadia TM. Time to response and survival in hypomethylating agent-treated acute myeloid leukemia. Leuk Lymphoma 2017; 59:1012-1015. [DOI: 10.1080/10428194.2017.1365857] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Prajwal Boddu
- 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
| | - Guillermo Garcia-Manero
- Department of Leukemia, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Elias Jabbour
- Department of Leukemia, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Gautam Borthakur
- Department of Leukemia, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Naval Daver
- Department of Leukemia, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Naveen Pemmaraju
- Department of Leukemia, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Sherry Pierce
- Department of Leukemia, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Jorge Cortes
- Department of Leukemia, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Tapan M. Kadia
- Department of Leukemia, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
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13
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Li Volti G, Tibullo D, Vanella L, Giallongo C, Di Raimondo F, Forte S, Di Rosa M, Signorelli SS, Barbagallo I. The Heme Oxygenase System in Hematological Malignancies. Antioxid Redox Signal 2017; 27:363-377. [PMID: 28257621 DOI: 10.1089/ars.2016.6735] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
SIGNIFICANCE Several lines of evidence suggest that hematological malignancies exhibit an altered redox balance homeostasis that can lead to the activation of various survival pathways that, in turn, lead to the progression of disease and chemoresistance. Among these pathways, the heme oxygenase-1 (HO-1) pathway is likely to play a major role. HO catalyzes the enzymatic degradation of heme with the simultaneous release of carbon monoxide (CO), ferrous iron (Fe2+), and biliverdin. This review focuses on the role of HO-1 in various hematological malignancies and the possibility of exploiting such targets to improve the outcome of well-established chemotherapeutic regimens. Recent Advances and Critical Issues: Interestingly, the inhibition of the expression of HO-1 (e.g., with siRNA) or HO activity (with competitive inhibitors) contributes to the increased efficacy of chemotherapy and improves the outcome in animal models. Furthermore, some hematological malignancies (e.g., chronic myeloid leukemia and multiple myeloma) have served to explore the non-canonical functions of HO-1, such as the association between nuclear compartmentalization and genetic instability and/or chemoresistance. FUTURE DIRECTIONS The HO system may serve as an important tool in the field of hematological malignancies because it can be exploited to counteract chemoresistance and to monitor the outcome of bone marrow transplants and may be an additional target for combined therapies. Antioxid. Redox Signal. 27, 363-377.
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Affiliation(s)
- Giovanni Li Volti
- 1 Department of Biomedical and Biotechnological Sciences, University of Catania , Catania, Italy .,2 EuroMediterranean Institute of Science and Technology , Palermo, Italy
| | - Daniele Tibullo
- 3 Division of Haematology, AOU "Policlinico - Vittorio Emanuele", University of Catania , Catania, Italy
| | - Luca Vanella
- 4 Department of Drug Sciences, University of Catania , Catania, Italy
| | - Cesarina Giallongo
- 3 Division of Haematology, AOU "Policlinico - Vittorio Emanuele", University of Catania , Catania, Italy
| | - Francesco Di Raimondo
- 3 Division of Haematology, AOU "Policlinico - Vittorio Emanuele", University of Catania , Catania, Italy
| | - Stefano Forte
- 1 Department of Biomedical and Biotechnological Sciences, University of Catania , Catania, Italy .,5 Istituto Oncologico del Mediterraneo Ricerca srl Viagrande , Catania, Italy
| | - Michelino Di Rosa
- 1 Department of Biomedical and Biotechnological Sciences, University of Catania , Catania, Italy
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14
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Percival ME, Lai C, Estey E, Hourigan CS. Bone marrow evaluation for diagnosis and monitoring of acute myeloid leukemia. Blood Rev 2017; 31:185-192. [PMID: 28190619 DOI: 10.1016/j.blre.2017.01.003] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 01/31/2017] [Indexed: 12/20/2022]
Abstract
The diagnosis of acute myeloid leukemia (AML) can be made based on peripheral blood or bone marrow blasts. In this review, we will discuss the role of bone marrow evaluation and peripheral blood monitoring in the diagnosis, management, and follow up of AML patients. For patients with circulating blasts, it is reasonable to perform the necessary studies needed for diagnosis and risk stratification, including multiparametric flow cytometry, cytogenetics, and molecular analysis, on a peripheral blood specimen. The day 14 marrow is used to document hypocellularity in response to induction chemotherapy, but it is unclear if that assessment is necessary as it often does not affect immediate management. Currently, response assessments performed at count recovery for evaluation of remission and measurable residual disease rely on bone marrow sampling. For monitoring of relapse, peripheral blood evaluation may be adequate, but the sensitivity of bone marrow testing is in some cases superior. While bone marrow evaluation can certainly be avoided in particular situations, this cumbersome and uncomfortable procedure currently remains the de facto standard for response assessment.
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Affiliation(s)
- Mary-Elizabeth Percival
- Department of Medicine, University of Washington, Seattle, WA, USA; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
| | - Catherine Lai
- Myeloid Malignancies Section, Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Elihu Estey
- Department of Medicine, University of Washington, Seattle, WA, USA; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Christopher S Hourigan
- Myeloid Malignancies Section, Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
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15
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Estey E. Acute myeloid leukemia: 2016 Update on risk-stratification and management. Am J Hematol 2016; 91:824-46. [PMID: 27417880 DOI: 10.1002/ajh.24439] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 05/26/2016] [Indexed: 11/09/2022]
Abstract
Evidence suggest that even patients aged 70 or above benefit from specific AML therapy. The fundamental decision in AML then becomes whether to recommend standard or investigational treatment. This decision must rest on the likely outcome of standard treatment. Hence we review factors that predict treatment related mortality and resistance to therapy, the latter the principal cause of failure even in patients aged 70 or above. We emphasize the limitations of prediction of resistance based only on pre- treatment factors and stress the need to incorporate post-treatment factors, for example indicators of minimal residual disease. We review various newer therapeutic options and considerations that underlie the decision to recommend allogeneic hematopoietic cell transplant. Am. J. Hematol. 91:825-846, 2016. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Elihu Estey
- Division of Hematology, University of Washington School of Medicine, Seattle, WA, Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
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16
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Should acute myeloid leukemia patients with actionable targets be offered investigational treatment after failing one cycle of standard induction therapy? Curr Opin Hematol 2016; 23:102-7. [PMID: 26766538 DOI: 10.1097/moh.0000000000000213] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Therapeutic failure in acute myeloid leukemia remains common. It may be advantageous to identify patients with suboptimal treatment responses early as they may benefit from timely care strategy changes. Here, responses portending failure of standard induction therapy are reviewed and therapeutic options examined, including use of investigational, targeted agents for suitable patients. RECENT FINDINGS Patients entering complete remission without minimal residual disease early, that is, with one cycle of standard induction chemotherapy, have a lower relapse risk and live longer than other similarly-treated patients, supporting the proposition of early complete remission without minimal residual disease as a criterion for induction therapy success. Investigational small molecule drugs are appealing for patients who fail standard therapies, but complete remission rates as a single agent are typically modest. SUMMARY The relative value of different treatment strategies if a first standard induction therapy cycle fails to produce complete remission is unknown. However, retreatment with the same therapy often leads to complete remission and provides a benchmark against which other approaches should be compared. Addition of investigational small molecule drugs to standard reinduction therapy in patients with actionable targets could offer an attractive therapeutic strategy in this situation that might improve outcomes and facilitate clinical drug testing.
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17
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Shadman M, Mawad R, Dean C, Chen TL, Shannon-Dorcy K, Sandhu V, Hendrie PC, Scott BL, Walter RB, Becker PS, Pagel JM, Estey EH. Idarubicin, cytarabine, and pravastatin as induction therapy for untreated acute myeloid leukemia and high-risk myelodysplastic syndrome. Am J Hematol 2015; 90:483-6. [PMID: 25689471 DOI: 10.1002/ajh.23981] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 02/12/2015] [Indexed: 11/08/2022]
Abstract
Previous studies suggest that idarubicin/cytarabine(ara-C)/pravastatin (IAP) is an active salvage regimen for patients with AML. We therefore investigated this regimen in patients with newly-diagnosed AML or MDS (≥10% blasts). Patients were eligible if the anticipated treatment-related mortality (TRM) was <10%. Patients received pravastatin (1,280 mg/day po; days 1-8), cytarabine (1.5 g/m(2) /day; days 4-7), and idarubicin (12 mg/m(2) /day, days 4-6). Up to 3 cycles of consolidation with a shortened course was permitted. The primary endpoints were "good CR" rate (CR on day 35 without minimal residual disease) and TRM in the first 28 days. The study was to stop if after each cohort of 5 patients (a) the Bayesian posterior probability was < 5% that the true "good CR rate" was ≥ 70% or (b) the posterior probability was >25% that the TRM rate was ≥5%. Twenty-four patients were included. Conventional CR was achieved in 15 (63%) patients but only 12 (50%) achieved "good CR". 4 of 12 (33%) patients with "good CR" relapsed at median of 16 weeks (10.5-19). Five (21%) patients had refractory disease. Survival probability at 1 year was 72% (48.7-64). Two (8.3%) patients died within 28 days from multiorgan failure. The most common grade 3-4 adverse effects were febrile neutropenia (75%) and diarrhea (25%). Based on the stopping rules accrual ceased after entry of these 24 patients. IAP did not meet the predefined efficacy criteria for success. Therefore, we would not recommend this regimen for phase three testing in this patient subset.
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Affiliation(s)
- Mazyar Shadman
- Clinical Research Division, Fred Hutchinson Cancer Research Center; Seattle Washington
- Medical Oncology Division; Department of Medicine; University of Washington; Seattle Washington
| | - Raya Mawad
- Swedish Cancer Institute, Swedish Medical Center; Seattle Washington
| | - Carol Dean
- Clinical Research Division, Fred Hutchinson Cancer Research Center; Seattle Washington
| | - Tara L. Chen
- Department of Pharmacy; University of Washington; Seattle Washington
| | | | - Vicky Sandhu
- Clinical Research Division, Fred Hutchinson Cancer Research Center; Seattle Washington
| | - Paul C. Hendrie
- Hematology Division; Department of Medicine, University of Washington; Seattle Washington
| | - Bart L. Scott
- Clinical Research Division, Fred Hutchinson Cancer Research Center; Seattle Washington
- Medical Oncology Division; Department of Medicine; University of Washington; Seattle Washington
| | - Rol B. Walter
- Clinical Research Division, Fred Hutchinson Cancer Research Center; Seattle Washington
- Hematology Division; Department of Medicine, University of Washington; Seattle Washington
| | - Pamela S. Becker
- Clinical Research Division, Fred Hutchinson Cancer Research Center; Seattle Washington
- Hematology Division; Department of Medicine, University of Washington; Seattle Washington
| | - John M. Pagel
- Swedish Cancer Institute, Swedish Medical Center; Seattle Washington
| | - Elihu H. Estey
- Clinical Research Division, Fred Hutchinson Cancer Research Center; Seattle Washington
- Hematology Division; Department of Medicine, University of Washington; Seattle Washington
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18
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Low platelet count reduces subsequent complete remission rate despite marrow with <5% blasts after AML induction therapy. Leukemia 2015; 29:1779-80. [DOI: 10.1038/leu.2015.23] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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19
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Estey EH. Acute myeloid leukemia: 2014 update on risk-stratification and management. Am J Hematol 2014; 89:1063-81. [PMID: 25318680 DOI: 10.1002/ajh.23834] [Citation(s) in RCA: 101] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Indexed: 12/11/2022]
Abstract
OVERVIEW Evidence suggests that even patients aged 70 or above benefit from specific AML therapy. The fundamental decision in AML then becomes whether to recommend standard or investigational treatment. This decision must rest on the likely outcome of standard treatment. Hence we review factors that predict treatment related mortality and resistance to therapy, the latter the principal cause of failure even in patients aged 70 or above. We emphasize the limitations of prediction of resistance based only on pre-treatment factors and stress the need to incorporate post-treatment factors, for example indicators of minimal residual disease. We review various newer therapeutic options and considerations that underlie the decision to recommend allogeneic hematopoietic cell transplant.
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Affiliation(s)
- Elihu H. Estey
- Division of Hematology; University of Washington and Member, Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
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20
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Hemmati PG, Terwey TH, Na IK, le Coutre P, Jehn CF, Vuong LG, Dörken B, Arnold R. Impact of early remission by induction therapy on allogeneic stem cell transplantation for acute myeloid leukemia with an intermediate-risk karyotype in first complete remission. Eur J Haematol 2014; 94:431-8. [PMID: 25220715 DOI: 10.1111/ejh.12449] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2014] [Indexed: 01/08/2023]
Abstract
For patients with acute myeloid leukemia (AML) early achievement of remission during induction treatment is an important predictor for long-term outcome irrespective of the type of consolidation therapy employed. Here, we retrospectively examined the prognostic impact of early remission (ER) vs. delayed remission (DR) in a cohort of 132 AML patients with an intermediate-risk karyotype undergoing allogeneic stem cell transplantation (alloSCT) in first complete remission (CR1). In contrast to patients showing DR, patients achieving ER had a significantly higher 3-yr overall survival (OS) and disease-free survival (DFS) of 76% vs. 54% (P = 0.03) and 76% vs. 53% (P = 0.03). Likewise, 3 yr after alloSCT the cumulative incidence of relapse (CI-R) was significantly lower in the ER subgroup as compared to patients achieving DR, that is, 10% vs. 35% (P = 0.004), whereas non-relapse mortality (NRM) did not differ significantly. Multivariate analysis identified DR as an independent prognosticator for an inferior DFS (HR 3.37, P = 0.002) and a higher CI-R (HR 3.55, P = 0.002). Taken together, these data may indicate that the rapid achievement of remission predicts a favorable outcome in patients with intermediate-risk AML undergoing alloSCT in CR1. In turn, the adverse effect of DR may not be fully overcome by alloSCT.
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Affiliation(s)
- Philipp G Hemmati
- Department of Hematology, Oncology and Tumorimmunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
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21
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Wang HI, Aas E, Howell D, Roman E, Patmore R, Jack A, Smith A. Long-term medical costs and life expectancy of acute myeloid leukemia: a probabilistic decision model. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2014; 17:205-14. [PMID: 24636378 DOI: 10.1016/j.jval.2013.12.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Revised: 10/12/2013] [Accepted: 12/15/2013] [Indexed: 05/22/2023]
Abstract
BACKGROUND Acute myeloid leukemia (AML) can be diagnosed at any age and treatment, which can be given with supportive and/or curative intent, is considered expensive compared with that for other cancers. Despite this, no long-term predictive models have been developed for AML, mainly because of the complexities associated with this disease. OBJECTIVE The objective of the current study was to develop a model (based on a UK cohort) to predict cost and life expectancy at a population level. METHODS The model developed in this study combined a decision tree with several Markov models to reflect the complexity of the prognostic factors and treatments of AML. The model was simulated with a cycle length of 1 month for a time period of 5 years and further simulated until age 100 years or death. Results were compared for two age groups and five different initial treatment intents and responses. Transition probabilities, life expectancies, and costs were derived from a UK population-based specialist registry-the Haematological Malignancy Research Network (www.hmrn.org). RESULTS Overall, expected 5-year medical costs and life expectancy ranged from £8,170 to £81,636 and 3.03 to 34.74 months, respectively. The economic and health outcomes varied with initial treatment intent, age at diagnosis, trial participation, and study time horizon. The model was validated by using face, internal, and external validation methods. The results show that the model captured more than 90% of the empirical costs, and it demonstrated good fit with the empirical overall survival. CONCLUSIONS Costs and life expectancy of AML varied with patient characteristics and initial treatment intent. The robust AML model developed in this study could be used to evaluate new diagnostic tools/treatments, as well as enable policy makers to make informed decisions.
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Affiliation(s)
- Han-I Wang
- Epidemiology & Cancer Statistics Group, University of York, York, UK.
| | - Eline Aas
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - Debra Howell
- Epidemiology & Cancer Statistics Group, University of York, York, UK
| | - Eve Roman
- Epidemiology & Cancer Statistics Group, University of York, York, UK
| | - Russell Patmore
- Queens Centre for Oncology and Haematology, Castle Hill Hospital, Hull, UK
| | - Andrew Jack
- Haematological Malignancy Diagnostic Service, St James's University Hospital, Leeds, UK
| | - Alexandra Smith
- Epidemiology & Cancer Statistics Group, University of York, York, UK
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22
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Xu J, Yin G. Two-stage adaptive randomization for delayed response in clinical trials. J R Stat Soc Ser C Appl Stat 2013. [DOI: 10.1111/rssc.12048] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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23
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Abstract
Acute myeloid leukemia (AML) is proving to be a heterogeneous disease process that is driven by various genetic mutations and aberrant protein expression. As our population ages, the incidence of AML is likely to increase, with approximately a third of adult cases categorized with normal cytogenetics. Advances in technology are now allowing us to explore the genetic expression and protein transcription patterns of AML, providing more information that must find its place in the prognosis and the therapeutic algorithm of this disease. As we learn more, we hope to further categorize patients with normal karyotype AML into discrete risk categories that will help in treatment decision making and further elucidate the necessity for hematopoietic cell transplantation. However, at this time, many of the identified mutations and expression patterns are still experimental, requiring further analysis to determine their exact role in AML.
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Affiliation(s)
- Raya Mawad
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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24
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Morris TA, DeCastro CM, Diehl LF, Gockerman JP, Lagoo AS, Li Z, Moore JO, Rizzieri DA, Rao AV. Re-induction therapy decisions based on day 14 bone marrow biopsy in acute myeloid leukemia. Leuk Res 2012; 37:28-31. [PMID: 23046833 DOI: 10.1016/j.leukres.2012.09.016] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Revised: 09/17/2012] [Accepted: 09/18/2012] [Indexed: 11/29/2022]
Abstract
PURPOSE The decision to re-induce patients with acute myeloid leukemia (AML) based on results of the day 14 bone marrow (BM) biopsy is variable and lacks evidence based data. The aim of our review was to evaluate the accuracy of a day 14 BM biopsy in determining the need for re-induction chemotherapy. METHODS Seventy-four patients with newly diagnosed de novo AML treated with induction chemotherapy were retrospectively reviewed for the purpose of evaluating treatment decisions and outcomes based on their day 14 BM biopsy. Response to therapy in this analysis was based on morphology alone. RESULTS Of the 74 patients undergoing standard induction, 45 patients (61%) had no evidence of leukemia on their day 14 BM biopsy. Eighteen patients (24%) had definitive residual disease (RD), and 11 patient's (15%) were classified as indeterminate response (IR). Fifteen patients with RD and one with IR underwent re-induction chemotherapy. However, thirteen patients (3 RD and 10 IR) were observed until count recovery without any re-induction therapy. Eleven of these 13 patients who were observed eventually attained a morphologic complete remission (CR), including two patients with RD. CONCLUSIONS A day 14 BM biopsy may have suboptimal sensitivity for the detection of residual leukemia. Some patients with an IR on day 14 may not require re-induction chemotherapy, but instead, may benefit from careful observation until count recovery to avoid the mortality and morbidity associated with re-induction chemotherapy.
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Affiliation(s)
- Tod A Morris
- Division of Medical Oncology, Duke University Health System, Durham, NC, USA
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Wahed AS, Thall PF. Evaluating Joint Effects of Induction-Salvage Treatment Regimes on Overall Survival in Acute Leukemia. J R Stat Soc Ser C Appl Stat 2012; 62:67-83. [PMID: 24014891 DOI: 10.1111/j.1467-9876.2012.01048.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Typical oncology practice often includes not only an initial, frontline treatment, but also subsequent treatments given if the initial treatment fails. The physician chooses a treatment at each stage based on the patient's baseline covariates and history of previous treatments and outcomes. Such sequentially adaptive medical decision-making processes are known as dynamic treatment regimes, treatment policies, or multi-stage adaptive treatment strategies. Conventional analyses in terms of frontline treatments that ignore subsequent treatments may be misleading, because they actually are an evaluation of more than front-line treatment effects on outcome. We are motivated by data from a randomized trial of four combination chemotherapies given as frontline treatments to patients with acute leukemia. Most patients in the trial also received a second-line treatment, chosen adaptively and subjectively rather than by randomization, either because the initial treatment was ineffective or the patient's cancer later recurred. We evaluate effects on overall survival time of the 16 two-stage strategies that actually were used. Our methods include a likelihood-based regression approach in which the transition times of all possible multi-stage outcome paths are modeled, and estimating equations with inverse probability of treatment weighting to correct for bias. While the two approaches give different numerical estimates of mean survival time, they lead to the same substantive conclusions when comparing the two-stage regimes.
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Affiliation(s)
- Abdus S Wahed
- Dept. of Biostatistics, Univ. of Pittsburgh, 130 DeSoto St, 318C, Pittsburgh, PA 15261, USA
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Estey E. What is the optimal induction strategy for older patients? Best Pract Res Clin Haematol 2011; 24:515-22. [DOI: 10.1016/j.beha.2011.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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A prediction model for complete remission upon reinduction for patients with acute myeloid leukemia after failure of anthracycline and cytarabine standard chemotherapy. Ann Hematol 2011; 90:1283-91. [DOI: 10.1007/s00277-011-1228-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Accepted: 03/24/2011] [Indexed: 10/18/2022]
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Atfy M, Eissa M, Salah HE, El Shabrawy DA. Role of urokinase plasminogen activator receptor (CD87) as a prognostic marker in acute myeloid leukemia. Med Oncol 2011; 29:2063-9. [DOI: 10.1007/s12032-011-9993-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2011] [Accepted: 05/18/2011] [Indexed: 11/28/2022]
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Phase 1 study of epigenetic priming with decitabine prior to standard induction chemotherapy for patients with AML. Blood 2011; 118:1472-80. [PMID: 21613261 DOI: 10.1182/blood-2010-11-320093] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
We conducted an open-label phase 1 study exploring the feasibility, safety, and biologic activity of epigenetic priming with decitabine before standard induction chemotherapy in patients with less-than-favorable risk of acute myelogenous leukemia (AML). We directly compared the clinical and DNA-hypomethylating activity of decitabine delivered at 20 mg/m² by either a 1-hour infusion (Arm A) or a continuous infusion (Arm B) for 3, 5, or 7 days before a single, standard induction with infusional cytarabine (100 mg/m² for 7 days) and daunorubicin (60 mg/m² × 3 doses). Toxicity was similar to that of standard induction chemotherapy alone. Although we did not identify a maximum tolerated dose, there was more gastro-intestinal toxicity with 7 days of decitabine priming. Decitabine induced DNA hypomethylation at all dose levels and there was a trend toward greater hypomethylation in CD34(+) bone marrow cells when decitabine was delivered by a short pulse (Arm A). Twenty-seven subjects (90%) responded to therapy: 17 with complete remission (57%) and 10 with partial remission (33%). Of the patients with partial remission to protocol treatment, 8 achieved remission to their next therapy, bringing the overall complete remission rate to 83%. We conclude that epigenetic priming of intensive chemotherapy can be safely delivered in an attempt to improve response rates. This trial was registered at www.clinicaltrials.gov as NCT00538876.
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Chen BB, Hsu CY, Yu CW, Hou HA, Liu CY, Wei SY, Chou WC, Tien HF, Shih TTF. Dynamic Contrast-enhanced MR Imaging Measurement of Vertebral Bone Marrow Perfusion May Be Indicator of Outcome of Acute Myeloid Leukemia Patients in Remission. Radiology 2011; 258:821-831. [DOI: 10.1148/radiol.10100995] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Rowe JM, Kim HT, Cassileth PA, Lazarus HM, Litzow MR, Wiernik PH, Tallman MS. Adult patients with acute myeloid leukemia who achieve complete remission after 1 or 2 cycles of induction have a similar prognosis: a report on 1980 patients registered to 6 studies conducted by the Eastern Cooperative Oncology Group. Cancer 2010; 116:5012-21. [PMID: 20629023 DOI: 10.1002/cncr.25263] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Patients with newly diagnosed acute myeloid leukemia (AML) often have residual leukemia in the bone marrow 10 to 14 days after the start of induction therapy. Some cooperative groups administer a second cycle of similar induction therapy on Day 14 if there is residual leukemia. It is a common perception that the presence of residual leukemia at that point predicts a worse prognosis irrespective of the therapy received. The objective of this study was to determine whether patients who required a second cycle of induction (given on or about Day 14) to achieve complete remission (CR) had a worse prognosis than patients who achieved CR after only 1 cycle, because a worse prognosis may alter postremission therapy. METHODS Patients who were enrolled on 6 consecutive studies for AML that were conducted by the Eastern Cooperative Oncology Group (ECOG) between 1983 to 1993 received induction therapy. If residual leukemia was present in the bone marrow on the Day 14 after the start of induction, then patients were to receive a second cycle of identical induction therapy. All patients who achieved CR after 1 or 2 cycles received the identical postremission therapy. RESULTS In each of the 6 ECOG studies, the long-term outcome was similar for patients who required 1 or 2 cycles of induction therapy to achieve CR, and their outcome was independent of other prognostic variables, such as age or karyotype. CONCLUSIONS The presence of residual leukemia in bone marrow 10 to 14 days after induction therapy did not predict a worse prognosis if patients received second, similar cycle of induction therapy and achieved CR.
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Affiliation(s)
- Jacob M Rowe
- Department of Hematology and Bone Marrow Transplantation, Rambam Medical Center and Technion, Israel Institute of Technology, Haifa, Israel.
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Abstract
Biomarkers and surrogate end points have great potential for use in clinical oncology, but their statistical validation presents major challenges, and few biomarkers have been robustly confirmed. Provisional supportive data for prognostic biomarkers, which predict the likely outcome independently of treatment, is possible through small retrospective studies, but it has proved more difficult to achieve robust multi-site validation. Predictive biomarkers, which predict the likely response of patients to specific treatments, require more extensive data for validation, specifically large randomized clinical trials and meta-analysis. Surrogate end points are even more challenging to validate, and require data demonstrating both that the surrogate is prognostic for the true end point independently of treatment, and that the effect of treatment on the surrogate reliably predicts its effect on the true end point. In this Review, we discuss the nature of prognostic and predictive biomarkers and surrogate end points, and examine the statistical techniques and designs required for their validation. In cases where the statistical requirements for validation cannot be rigorously achieved, the biological plausibility of an end point or surrogate might support its adoption. No consensus yet exists on processes or standards for pragmatic evaluation and adoption of biomarkers and surrogate end points in the absence of robust statistical validation.
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Walter RB, Kantarjian HM, Huang X, Pierce SA, Sun Z, Gundacker HM, Ravandi F, Faderl SH, Tallman MS, Appelbaum FR, Estey EH. Effect of complete remission and responses less than complete remission on survival in acute myeloid leukemia: a combined Eastern Cooperative Oncology Group, Southwest Oncology Group, and M. D. Anderson Cancer Center Study. J Clin Oncol 2010; 28:1766-71. [PMID: 20159819 PMCID: PMC2849766 DOI: 10.1200/jco.2009.25.1066] [Citation(s) in RCA: 166] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE It is known that complete remission (CR) prolongs survival in acute myeloid leukemia (AML). In 2003, less stringent response categories were introduced, most notably CR with incomplete platelet recovery (CRp). Although the significance of CRp for survival remains unclear, reports of AML trials frequently combine CR with CRp rather than considering CR as a separate entity. PATIENTS AND METHODS This practice led us to retrospectively examine the effect of CR on outcome in newly diagnosed AML, by using data from 6,283 patients treated on Eastern Cooperative Oncology Group (ECOG) and Southwest Oncology Group (SWOG) protocols or at M. D. Anderson Cancer Center. This effect was then contrasted with the effect of CRp in the M. D. Anderson Cancer Center cohort. RESULTS At least 94% of patients receiving cytarabine-based therapy and surviving for more than 3 or 5 years achieved a CR with either initial or salvage therapy; limited data suggest the same for patients receiving initial therapies that did not contain cytarabine. Patients with CR were more likely to live beyond 3 or 5 years than patients with CRp. The likelihood of achieving a CR rather than CRp was greater for patients with AML who had better prognosis. After adjustment for covariates, the relapse-free survival of patients achieving CR was longer than that of patients achieving CRp, whereas patients with CRp survived longer than those with resistant disease. CONCLUSION Our data indicate that CR is of unique clinical significance and should be reported as separate response in trials of newly diagnosed AML. Nonetheless, our findings validate CRp as a clinically meaningful response.
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Affiliation(s)
- Roland B. Walter
- From the Clinical Research Division and Southwest Oncology Group Statistical Center, Fred Hutchinson Cancer Research Center; Department of Medicine, Division of Hematology, and Division of Medical Oncology, University of Washington, Seattle, WA; Leukemia Department and Department of Biostatistics, The University of Texas M. D. Anderson Cancer Center, Houston, TX; Dana Farber Cancer Institute, Boston, MA; and Northwestern University Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL.,Corresponding author: Roland B. Walter, MD, PhD; Clinical Research Division, Fred Hutchinson Cancer Research Center; 1100 Fairview Ave N, D2-190; Seattle, WA 98109-1024; e-mail:
| | - Hagop M. Kantarjian
- From the Clinical Research Division and Southwest Oncology Group Statistical Center, Fred Hutchinson Cancer Research Center; Department of Medicine, Division of Hematology, and Division of Medical Oncology, University of Washington, Seattle, WA; Leukemia Department and Department of Biostatistics, The University of Texas M. D. Anderson Cancer Center, Houston, TX; Dana Farber Cancer Institute, Boston, MA; and Northwestern University Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Xuelin Huang
- From the Clinical Research Division and Southwest Oncology Group Statistical Center, Fred Hutchinson Cancer Research Center; Department of Medicine, Division of Hematology, and Division of Medical Oncology, University of Washington, Seattle, WA; Leukemia Department and Department of Biostatistics, The University of Texas M. D. Anderson Cancer Center, Houston, TX; Dana Farber Cancer Institute, Boston, MA; and Northwestern University Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Sherry A. Pierce
- From the Clinical Research Division and Southwest Oncology Group Statistical Center, Fred Hutchinson Cancer Research Center; Department of Medicine, Division of Hematology, and Division of Medical Oncology, University of Washington, Seattle, WA; Leukemia Department and Department of Biostatistics, The University of Texas M. D. Anderson Cancer Center, Houston, TX; Dana Farber Cancer Institute, Boston, MA; and Northwestern University Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Zhuoxin Sun
- From the Clinical Research Division and Southwest Oncology Group Statistical Center, Fred Hutchinson Cancer Research Center; Department of Medicine, Division of Hematology, and Division of Medical Oncology, University of Washington, Seattle, WA; Leukemia Department and Department of Biostatistics, The University of Texas M. D. Anderson Cancer Center, Houston, TX; Dana Farber Cancer Institute, Boston, MA; and Northwestern University Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Holly M. Gundacker
- From the Clinical Research Division and Southwest Oncology Group Statistical Center, Fred Hutchinson Cancer Research Center; Department of Medicine, Division of Hematology, and Division of Medical Oncology, University of Washington, Seattle, WA; Leukemia Department and Department of Biostatistics, The University of Texas M. D. Anderson Cancer Center, Houston, TX; Dana Farber Cancer Institute, Boston, MA; and Northwestern University Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Farhad Ravandi
- From the Clinical Research Division and Southwest Oncology Group Statistical Center, Fred Hutchinson Cancer Research Center; Department of Medicine, Division of Hematology, and Division of Medical Oncology, University of Washington, Seattle, WA; Leukemia Department and Department of Biostatistics, The University of Texas M. D. Anderson Cancer Center, Houston, TX; Dana Farber Cancer Institute, Boston, MA; and Northwestern University Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Stefan H. Faderl
- From the Clinical Research Division and Southwest Oncology Group Statistical Center, Fred Hutchinson Cancer Research Center; Department of Medicine, Division of Hematology, and Division of Medical Oncology, University of Washington, Seattle, WA; Leukemia Department and Department of Biostatistics, The University of Texas M. D. Anderson Cancer Center, Houston, TX; Dana Farber Cancer Institute, Boston, MA; and Northwestern University Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Martin S. Tallman
- From the Clinical Research Division and Southwest Oncology Group Statistical Center, Fred Hutchinson Cancer Research Center; Department of Medicine, Division of Hematology, and Division of Medical Oncology, University of Washington, Seattle, WA; Leukemia Department and Department of Biostatistics, The University of Texas M. D. Anderson Cancer Center, Houston, TX; Dana Farber Cancer Institute, Boston, MA; and Northwestern University Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Frederick R. Appelbaum
- From the Clinical Research Division and Southwest Oncology Group Statistical Center, Fred Hutchinson Cancer Research Center; Department of Medicine, Division of Hematology, and Division of Medical Oncology, University of Washington, Seattle, WA; Leukemia Department and Department of Biostatistics, The University of Texas M. D. Anderson Cancer Center, Houston, TX; Dana Farber Cancer Institute, Boston, MA; and Northwestern University Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Elihu H. Estey
- From the Clinical Research Division and Southwest Oncology Group Statistical Center, Fred Hutchinson Cancer Research Center; Department of Medicine, Division of Hematology, and Division of Medical Oncology, University of Washington, Seattle, WA; Leukemia Department and Department of Biostatistics, The University of Texas M. D. Anderson Cancer Center, Houston, TX; Dana Farber Cancer Institute, Boston, MA; and Northwestern University Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
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Wahed AS. Inference for two-stage adaptive treatment strategies using mixture distributions. J R Stat Soc Ser C Appl Stat 2010. [DOI: 10.1111/j.1467-9876.2009.00679.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Yuan Y, Yin G. Bayesian dose finding by jointly modelling toxicity and efficacy as time-to-event outcomes. J R Stat Soc Ser C Appl Stat 2009. [DOI: 10.1111/j.1467-9876.2009.00674.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Yanada M, Borthakur G, Garcia-Manero G, Ravandi F, Faderl S, Pierce S, Kantarjian H, Estey E. Blood counts at time of complete remission provide additional independent prognostic information in acute myeloid leukemia. Leuk Res 2008; 32:1505-9. [PMID: 18405972 DOI: 10.1016/j.leukres.2008.03.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2008] [Revised: 02/29/2008] [Accepted: 03/01/2008] [Indexed: 11/26/2022]
Abstract
Prognostic relevance of blood counts at complete remission (CR) in acute myeloid leukemia (AML) is not clear. To address this issue, we analyzed 891 AML patients in first CR. From the data of randomly selected 446 patients (training set), we first established optimal cutoffs for neutrophil and platelet counts and hemoglobin level at CR in terms of relapse-free survival (RFS). Patients whose counts were higher than each optimal cutoff were shown to have significantly better RFS (p<0.01 for neutrophil and platelets, and p=0.02 for hemoglobin). Then we tested whether these cutoffs were, after accounting for better known prognostic covariates, also predictive of RFS in the remaining 445 patients (validation set). Our data revealed that higher neutrophil count was independently predictive of longer RFS in the validation set (hazard ratio 1.38, p=0.02), as was higher platelet count (hazard ratio 1.35, p=0.04). These findings suggest that blood counts at CR, information readily available, are useful in prognostication in AML.
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Affiliation(s)
- Masamitsu Yanada
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States.
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Elliott MA, Litzow MR, Letendre LL, Wolf RC, Hanson CA, Tefferi A, Tallman MS. Early peripheral blood blast clearance during induction chemotherapy for acute myeloid leukemia predicts superior relapse-free survival. Blood 2007; 110:4172-4. [PMID: 17909077 DOI: 10.1182/blood-2007-07-104091] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
In childhood acute lymphoblastic leukemia (ALL), a rapid decline of circulating leukemic blasts in response to induction chemotherapy or prednisone is one of the most important prognostic factors, not only for achieving remission but also for relapse-free survival (RFS). However, in acute myeloid leukemia (AML) parameters of chemosensitivity have been restricted mainly to the rapidity of achievement of complete remission (CR) or the assessment of residual leukemic bone marrow blasts during aplasia. We hypothesized that the time to circulating peripheral blood blast clearance, as a potential surrogate for in vivo chemosensitivity, would have prognostic relevance in AML also. In a retrospective analysis of a cohort of 86 adult patients with AML receiving uniform induction and consolidation chemotherapy, we demonstrate that the time to clearance of circulating blasts during induction chemotherapy is an independent prognostic marker of RFS, superseding other known or established risk factors, including karyotype and number of inductions to achieve CR.
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Affiliation(s)
- Michelle A Elliott
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA.
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Konoplev S, Rassidakis GZ, Estey E, Kantarjian H, Liakou CI, Huang X, Xiao L, Andreeff M, Konopleva M, Medeiros LJ. Overexpression of CXCR4 predicts adverse overall and event-free survival in patients with unmutated FLT3 acute myeloid leukemia with normal karyotype. Cancer 2007; 109:1152-6. [PMID: 17315232 DOI: 10.1002/cncr.22510] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND CXC chemokine receptor 4 (CXCR4) expression in acute myeloid leukemia (AML) is reported to correlate with FLT3 gene mutation and poorer prognosis. The prognostic significance of CXCR4 expression in patients with AML that have a normal karyotype and no evidence of FLT3 gene mutations was examined. METHODS The prognostic significance of CXCR4 expression in 122 AML patients with normal karyotype and no evidence of FLT3 gene mutation treated at our institution between 1997 and 2003 was analyzed. All patients received intensive chemotherapy according to institutional protocols; 84% received cytarabine-containing regimens. Bone marrow biopsy or clot specimens obtained before treatment were immunostained for CXCR4. RESULTS There were 70 men and 52 women with a median age of 62 years (range, 22-82 years). Median follow-up was 18 months (range, <1-97 months). Seventy-six patients achieved complete remission (CR); 39 had recurrence. Sixty-six patients died, including 9 with no evidence of disease. CXCR4 was positive in 70 and negative in 52 patients, with CR rates of 58% and 71%, respectively (P = .09). Multivariate analysis demonstrated that CXCR4 expression, presence of multilineage dysplasia, and high creatinine level predicted poorer overall (OS) and event-free (EFS) survival. CONCLUSIONS.: The results suggest that CXCR4 expression is associated with poor prognosis in AML patients with an unmutated FLT3 gene.
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Affiliation(s)
- Sergej Konoplev
- Department of Hematopathology, University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
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Abstract
Acute myeloid leukaemia (AML) is a heterogeneous clonal disorder of haemopoietic progenitor cells and the most common malignant myeloid disorder in adults. The median age at presentation for patients with AML is 70 years. In the past few years, research in molecular biology has been instrumental in deciphering the pathogenesis of the disease. Genetic defects are thought to be the most important factors in determining the response to chemotherapy and outcome. Whereas significant progress has been made in the treatment of younger adults, the prospects for elderly patients have remained dismal, with median survival times of only a few months. This difference is related to comorbidities associated with ageing and to disease biology. Current efforts in clinical research focus on the assessment of targeted therapies. Such new approaches will probably lead to an increase in the cure rate.
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Affiliation(s)
- Elihu Estey
- Leukemia Department, University of Texas M D Anderson Cancer Center, Houston, TX 77030, USA.
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Abstract
CXCR4 chemokine receptors retain hematopoietic progenitors and leukemia cells within the marrow microenvironment. We prospectively evaluated the prognostic implication of CXCR4 in 90 consecutive patients with acute myelogenous leukemia (AML) by flow cytometry. Patients were divided into groups with low (n=32), intermediate (n=26), or high (n=32) CXCR4 expression, as defined by CXCR4 mean fluorescence intensity ratio thresholds of less than 5, 5 to 10, or more than 10, respectively. We found that low CXCR4 expression on AML cells correlated with a better prognosis, resulting in a longer relapse-free and overall survival of 24.3+/-2.9 months for low CXCR4-expressing patients, compared with 17.4+/-3.4 months for intermediate and 12.8+/-2 months (mean+/-SEM) for patients with high expression. In univariate analyses, CXCR4 expression, cytogenetics, white blood cell count, and serum lactate dehydrogenase (LDH) predicted for shorter survival. Multivariate analysis revealed CXCR4 expression and unfavorable cytogenetics as independent prognostic factors. We conclude that CXCR4 expression in AML is an independent prognostic predictor for disease relapse and survival that can rapidly and easily be determined at disease presentation. These findings warrant further investigation into the role of CXCR4 in AML and suggest that CXCR4 should be incorporated into the risk assessment of AML patients.
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MESH Headings
- Adolescent
- Adult
- Aged
- Aged, 80 and over
- Biomarkers, Tumor/analysis
- Biomarkers, Tumor/biosynthesis
- Biomarkers, Tumor/metabolism
- Disease-Free Survival
- Female
- Flow Cytometry/methods
- Humans
- Leukemia, Myeloid, Acute/diagnosis
- Leukemia, Myeloid, Acute/metabolism
- Male
- Middle Aged
- Prognosis
- Receptors, CXCR4/analysis
- Receptors, CXCR4/biosynthesis
- Receptors, CXCR4/metabolism
- Recurrence
- Sensitivity and Specificity
- Survival Rate
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Affiliation(s)
- Anke C Spoo
- Department of Medicine, Freiburg University Hospital, Germany
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42
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Lazarus HM, Pérez WS, Klein JP, Kollman C, Bate-Boyle B, Bredeson CN, Gale RP, Geller RB, Keating A, Litzow MR, Marks DI, Miller CB, Douglas Rizzo J, Spitzer TR, Weisdorf DJ, Zhang MJ, Horowitz MM. Autotransplantation versus HLA-matched unrelated donor transplantation for acute myeloid leukaemia: a retrospective analysis from the Center for International Blood and Marrow Transplant Research. Br J Haematol 2006; 132:755-69. [PMID: 16487177 DOI: 10.1111/j.1365-2141.2005.05947.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Most acute myeloid leukaemia (AML) patients lack human leucocyte antigen-identical sibling donors for transplantation. Autotransplants and unrelated donor (URD) transplants are therapeutic options. To compare autologous versus URD transplantation for AML in first (CR1) or second complete remission (CR2), we studied the outcomes of 668 autotransplants were compared with 476 URD transplants reported to the Center for International Blood and Marrow Transplant Research. Proportional hazards regression adjusted for differences in prognostic variables. In multivariate analyses transplant-related mortality (TRM) was significantly higher and relapse lower with URD transplantation. Adjusted 3-year survival probabilities were: in CR1 57 (53-61)% with autotransplants and 44 (37-51)% URD (P = 0.002), in CR2 46 (39-53)% and 33 (28-38)% respectively (P = 0.006). Adjusted 3-year leukaemia-free survival (LFS) probabilities were: CR1 53 (48-57)% with autotransplants and 43 (36-50)% with URD (P = 0.021), CR2 39 (32-46)% and 33 (27-38)% respectively (P = 0.169). Both autologous and URD transplantation produced prolonged LFS. High TRM offsets the superior antileukaemia effect of URD transplantation. This retrospective, observational database study showed that autotransplantation, in general, offered higher 3-year survival for AML patients in CR1 and CR2. Cytogenetics, however, were known in only two-thirds of patients and treatment bias cannot be eliminated.
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Affiliation(s)
- Hillard M Lazarus
- University Hospitals of Cleveland, Ireland Cancer Center, Cleveland, OH, USA
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Creutzig U, Zimmermann M, Ritter J, Reinhardt D, Hermann J, Henze G, Jürgens H, Kabisch H, Reiter A, Riehm H, Gadner H, Schellong G. Treatment strategies and long-term results in paediatric patients treated in four consecutive AML-BFM trials. Leukemia 2006; 19:2030-42. [PMID: 16304570 DOI: 10.1038/sj.leu.2403920] [Citation(s) in RCA: 154] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
A total of 1111 children with acute myeloblastic leukaemia (AML) were treated in four consecutive Berlin-Frankfurt-Münster (BFM) studies from 1978 to 1998. The first cooperative trial AML-BFM 78 established intensive chemotherapy with seven drugs, CNS irradiation and 2-year maintenance, achieving a long-term survival (overall survival (OS)) of 40%. Induction intensification in AML-BFM 83 resulted in significant improvement of disease-free survival (DFS). The risk of haemorrhage, especially in children with hyperleukocytosis, proved the high relevance of supportive care. In AML-BFM 87, the benefit of CNS irradiation in preventing CNS/systemic relapses was demonstrated. In AML-BFM 93, the introduction of idarubicin during first induction followed by intensification with HAM increased the 5-year EFS, DFS and OS to 50+/-2, 61+/-3 and 57+/-2%, respectively. Stem cell transplantation (SCT), as applied in high-risk patients with a matched related donor, did not significantly improve the outcome compared to chemotherapy alone. In spite of treatment intensification, the therapy-related death rate decreased from trial to trial, mainly during induction. The future aim is to reduce long-term sequelae, especially cardiotoxicity, by administration of less cardiotoxic drugs, and toxicity of SCT by risk-adapted indications. The AML-BFM studies performed in three European countries with >70 cooperating centres have significantly improved the outcome in AML children; nevertheless, increasing experience with these intensive treatment regimens is of fundamental importance to reduce fatal complications.
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Affiliation(s)
- U Creutzig
- Department of Haematology, Oncology, University Children's Hospital, Münster, Germany. ursula.creutzig.de
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44
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Bacher U, Kern W, Schoch C, Schnittger S, Hiddemann W, Haferlach T. Evaluation of complete disease remission in acute myeloid leukemia. Cancer 2006; 106:839-47. [PMID: 16419072 DOI: 10.1002/cncr.21665] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Different diagnostic methods add information to define complete remission (CR) in patients with acute myeloid leukemia (AML). The detection of minimal residual disease (MRD) for predicting prognosis and for therapeutic planning still are under discussion. METHODS The authors studied 216 patients with AML at the time of initial diagnosis and during follow-up and correlated cytomorphology, interphase fluorescence in situ hybridization (FISH), and flow cytometry results to evaluate response status. They further tested the prognostic impact of those results, especially in patients who achieved a morphologic CR. RESULTS Interphase FISH was found to be correlated significantly with the clinical course at the time of complete cytomorphologic remission and was more reliable than morphology for defining CR. Furthermore, interphase FISH was correlated with immunophenotyping results at all times during follow-up. CONCLUSIONS The current results indicated that interphase FISH may be used as a valid MRD parameter in patients with AML. Multiparameter immunophenotyping for MRD also was correlated strongly with the clinical course, and the authors suggest integrating such immunophenotyping into the routine diagnostic panel at the time of diagnosis and during the clinical course in patients with AML.
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Affiliation(s)
- Ulrike Bacher
- Laboratory for Leukemia Diagnostics, Department for Internal Medicine III, Klinikum Grosshadern, Ludwig-Maximilians University, Munich, Germany.
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Kern W, Schoch C, Haferlach T, Schnittger S. Monitoring of minimal residual disease in acute myeloid leukemia. Crit Rev Oncol Hematol 2005; 56:283-309. [PMID: 16213150 DOI: 10.1016/j.critrevonc.2004.06.004] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2004] [Revised: 06/24/2004] [Accepted: 06/24/2004] [Indexed: 11/17/2022] Open
Abstract
Monitoring minimal residual disease (MRD) becomes increasingly important in the risk-adapted management of patients with acute myeloid leukemia (AML). The two most sensitive and quantitative methods for MRD detection are multiparameter flow cytometry (MFC) and real-time polymerase chain reaction (QRT-PCR). Fusion gene-specific PCR in AML is based on the RNA level, and thus in contrast to MFC expression levels rather than cell counts are assessed. For both methods independent prognostic values have been shown. The strong power of MFC has been shown mainly in the assessment of early clearance of the malignant clone. MRD levels in AML with fusion genes have the strongest prognostic power after the end of consolidation therapy. In addition, with QRT-PCR highly predictive initial expression levels can be assessed. With both methods early detection of relapse is possible. So far, validated PCR-based MRD was done with fusion genes that are detectable in only 20-25% of all AML MFC is superior since it is applicable for most AML. However, QRT-PCR is still more sensitive in most cases. Thus, it is desirable to establish new molecular markers for PCR-based studies. Large clinical trials will determine the role and place of immunologic and PCR-based monitoring in the prognostic stratification of patients with AML.
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Affiliation(s)
- Wolfgang Kern
- Laboratory for Leukemia Diagnostics, Ludwig-Maximilians-University, University Hospital Grosshadern, Department of Internal Medicine III, 81366 Muenchen, Germany.
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Abstract
In therapy of rapidly fatal diseases, early treatment efficacy often is characterized by an event, "response," which is observed relatively quickly. Since the risk of death decreases at the time of response, it is desirable not only to achieve a response, but to do so as rapidly as possible. We propose a Bayesian method for comparing treatments in this setting based on a competing risks model for response and death without response. Treatment effect is characterized by a two-dimensional parameter consisting of the probability of response within a specified time and the mean time to response. Several target parameter pairs are elicited from the physician so that, for a reference covariate vector, all elicited pairs embody the same improvement in treatment efficacy compared to a fixed standard. A curve is fit to the elicited pairs and used to determine a two-dimensional parameter set in which a new treatment is considered superior to the standard. Posterior probabilities of this set are used to construct rules for the treatment comparison and safety monitoring. The method is illustrated by a randomized trial comparing two cord blood transplantation methods.
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Affiliation(s)
- Peter F Thall
- Department of Biostatistics and Applied Mathematics, The University of Texas, M.D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas 77030, USA.
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47
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Abstract
PURPOSE OF REVIEW Cytogenetics offers the most important prognostic information at both presentation and relapse. However, this classification appears to be insufficient, especially for patients presenting with standard-risk cytogenetics, whose relapse risk is variable. Other prognostic factors, stratifying this heterogeneous group of patients into more clearly defined risk groups, are warranted. RECENT FINDINGS Several molecular markers have been described that predict for long-term outcome in this heterogeneous group of patients; however, there is as yet no consensus as to the prognostic significance of each. Time to morphologic and molecular remission may also be important; however, further studies are warranted to establish their prognostic role in acute myeloid leukemia. SUMMARY Much has been learnt over the past decade and a better understanding of disease biology, determined by gene expression profiling and proteomic analyses, may help to target therapy and improve the outcome.
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MESH Headings
- Biomarkers, Tumor/analysis
- Biomarkers, Tumor/classification
- Cytogenetic Analysis/methods
- Gene Expression Profiling
- Humans
- Leukemia, Myeloid, Acute/diagnosis
- Leukemia, Myeloid, Acute/genetics
- Leukemia, Myeloid, Acute/pathology
- Middle Aged
- Mutation
- Neoplasm, Residual/diagnosis
- Neoplasm, Residual/genetics
- Prognosis
- Proteomics
- Risk Factors
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Affiliation(s)
- Irit Avivi
- Department of Hematology and Bone Marrow Transplantation, Rambam Medical Center, Bruce Rappaport Faculty of Medicine, Technion, Haifa,
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48
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Abstract
Although the cure of acute leukaemia has improved significantly, many patients will still relapse and die. The unraveling of the molecular pathogenesis of acute leukaemia has lead to the identification of new prognostic factors and improved the detection of minimal residual disease. The treatment of relapsed acute leukaemia with chemotherapy remains unsatisfactory. Allogeneic or autologous blood and marrow transplant (BMT) can cure a subset of patients with relapsed acute leukaemia. The identification of the graft-vs-leukaemia (GVL) effect has lead to the development of donor lymphocyte infusions to re-induce remission in patients with relapsed leukaemia after allogeneic BMT and also stimulated the development of the less toxic nonmyeloablative allogeneic transplant approach. The identification of molecular targets of therapy and the development of monoclonal antibody-directed therapy has generated optimism. It is possible that combinations of chemotherapy, molecularly directed therapy, and immunotherapy may be combined to cure an increasing proportion of patients with acute leukaemia.
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Affiliation(s)
- Mark R Litzow
- Division of Hematology, Mayo Clinic and Mayo Medical School, 200 First Streeet, SW, Rochester, MN 55905, USA.
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49
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Holowiecki J, Grosicki S, Robak T, Kyrcz-Krzemien S, Giebel S, Hellmann A, Skotnicki A, Jedrzejczak WW, Konopka L, Kuliczkowski K, Zdziarska B, Dmoszynska A, Marianska B, Pluta A, Zawilska K, Komarnicki M, Kloczko J, Sulek K, Haus O, Stella-Holowiecka B, Baran W, Jakubas B, Paluszewska M, Wierzbowska A, Kielbinski M, Jagoda K. Addition of cladribine to daunorubicin and cytarabine increases complete remission rate after a single course of induction treatment in acute myeloid leukemia. Multicenter, phase III study. Leukemia 2004; 18:989-97. [PMID: 14999298 DOI: 10.1038/sj.leu.2403336] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
To assess the efficacy of an original DAC-7 regimen: daunorubicine (DNR) 60 mg/m2/day, days 1-3; cytarabine (AraC) 200 mg/m2/day, days 1-7; cladribine (2-CdA) 5 mg/m2/day, days 1-5, 400 untreated adult acute myeloid leukemia patients (including 63 with preceding myelodysplastic syndrome), aged 45 (16-60) years were randomized to either DAC-7 (n=200) or DA-7 (without 2-CdA, n=200). The overall CR rate equaled 72% for DAC-7 and 69% for DA-7 arm (P=NS). After a single course of DAC-7 induction, the CR rate equaled 64% and was significantly higher compared to 47% in the DA-7 arm (P=0.0009). Median hospitalization time during the induction was 7 days shorter for DAC-7 compared to the DA-7 group (33 vs 40 days, P=0.002). Toxicity was comparable in both groups. The probability of 3-year leukemia-free survival (LFS) for DAC-7 and DA-7 group equaled 43 and 34%, respectively (P=NS). There was a trend toward higher LFS rate for patients aged >40 years receiving DAC-7 compared with DA-7 regimen (44 vs 28%, P=0.05). This study proves that addition of 2-CdA increases antileukemic potency of DNR+AraC regimen, thus resulting in a higher CR rate after one induction cycle when compared to DA-7, without additional toxicity. It shortens hospitalization time and may improve long-term survival in patients aged >40 years.
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Affiliation(s)
- J Holowiecki
- University Department of Haematology and BMT, Silesian Medical University, Katowice, Poland.
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Coustan-Smith E, Ribeiro RC, Rubnitz JE, Razzouk BI, Pui CH, Pounds S, Andreansky M, Behm FG, Raimondi SC, Shurtleff SA, Downing JR, Campana D. Clinical significance of residual disease during treatment in childhood acute myeloid leukaemia. Br J Haematol 2003; 123:243-52. [PMID: 14531905 DOI: 10.1046/j.1365-2141.2003.04610.x] [Citation(s) in RCA: 110] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
In children with acute myeloid leukaemia (AML), morphological and karyotypic studies cannot precisely assess response to treatment, and less than one-third of patients have genetic markers for molecular studies of residual disease. We determined the usefulness of a four-colour flow cytometric strategy developed in our laboratory to study residual disease. We first compared the immunophenotypes of AML cells obtained from 54 children at diagnosis with those of cells from 59 normal or regenerating bone marrow samples. Forty-six of the 54 AML cases (85.2%) had immunophenotypes that allowed detection of 0.1-0.01% residual leukaemic cells. Of 230 bone marrow samples obtained from those 46 patients during and off treatment, 61 (26.5%) had >/= 0.1% AML cells by flow cytometry. We found that core binding factor-associated AML had a significantly better early treatment response. Mean (+/- standard error) 2-year survival estimate was 33.1 +/- 19.1% for patients with >/= 0.1% AML cells by flow cytometry after induction therapy, but 72.1 +/- 11.5% for those with < 0.1% AML cells (P = 0.022); overt recurrence of AML within the subsequent 6 months was significantly more likely in the former group. The assay described here holds promise for guiding the choice of post-remission treatment options in children with AML.
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Affiliation(s)
- Elaine Coustan-Smith
- Department of Hematology-Oncology, St Jude Children's Research Hospital, Memphis, TN, USA
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