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Mannelli F, Piccini M, Bencini S, Gianfaldoni G, Peruzzi B, Caporale R, Scappini B, Fasano L, Quinti E, Ciolli G, Pasquini A, Crupi F, Pilerci S, Pancani F, Signori L, Tarantino D, Maccari C, Paradiso V, Annunziato F, Guglielmelli P, Vannucchi AM. Effect of age and treatment on predictive value of measurable residual disease: implications for clinical management of adult patients with acute myeloid leukemia. Haematologica 2024; 109:60-71. [PMID: 37345475 PMCID: PMC10772533 DOI: 10.3324/haematol.2023.283196] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 06/15/2023] [Indexed: 06/23/2023] Open
Abstract
Measurable residual disease (MRD) is a powerful predictor of outcome in acute myeloid leukemia. In the early phases of treatment, MRD refines initial disease risk stratification and is used for the allocation to allogeneic transplant. Despite its well-established role, a relatively high fraction of patients eventually relapses albeit achieving MRDneg status. The aim of this work was to assess specifically the influence of baseline features and treatment intensity on the predictive value of an MRDneg status, particularly focusing on MRD2, measured after two consecutive chemotherapy cycles. Among baseline features, younger MRD2neg patients (<55 years) had a significantly longer disease-free survival (median not reached) compared to their older counterparts (median 25.0 months, P=0.013, hazard ratio=2.08). Treatment intensity, specifically the delivery of a high dose of cytarabine in induction or first consolidation, apparently had a pejorative effect on the outcome of MRD2neg patients compared to standard dose (P=0.048, hazard ratio=1.80), a finding also confirmed by the analysis of data extracted from the literature. The combination of age and treatment intensity allowed us to identify categories of patients, among those who reached a MRD2neg status, characterized by significantly different disease-free survival rate. Our data showed that variables such as age and intensity of treatment administered can influence the predictive value of MRD in patients with acute myeloid leukemia. In addition to underscoring the need for further improvement of MRD analysis, these findings call for a reasoned application of MRD data, as currently available, to modulate consolidation therapy on adequately estimated relapse rates.
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Affiliation(s)
- Francesco Mannelli
- SOD Ematologia, Università di Firenze, AOU Careggi, Firenze, Italy; Centro Ricerca e Innovazione Malattie Mieloproliferative (CRIMM), AOU Careggi, Firenze.
| | - Matteo Piccini
- SOD Ematologia, Università di Firenze, AOU Careggi, Firenze
| | - Sara Bencini
- Centro Diagnostico di Citofluorimetria e Immunoterapia, AOU Careggi, Firenze
| | | | - Benedetta Peruzzi
- Centro Diagnostico di Citofluorimetria e Immunoterapia, AOU Careggi, Firenze
| | - Roberto Caporale
- Centro Diagnostico di Citofluorimetria e Immunoterapia, AOU Careggi, Firenze
| | | | - Laura Fasano
- SOD Ematologia, Università di Firenze, AOU Careggi, Firenze
| | - Elisa Quinti
- SOD Ematologia, Università di Firenze, AOU Careggi, Firenze
| | - Gaia Ciolli
- SOD Ematologia, Università di Firenze, AOU Careggi, Firenze
| | | | | | - Sofia Pilerci
- SOD Ematologia, Università di Firenze, AOU Careggi, Firenze
| | - Fabiana Pancani
- SOD Ematologia, Università di Firenze, AOU Careggi, Firenze, Italy; Centro Ricerca e Innovazione Malattie Mieloproliferative (CRIMM), AOU Careggi, Firenze
| | - Leonardo Signori
- SOD Ematologia, Università di Firenze, AOU Careggi, Firenze, Italy; Centro Ricerca e Innovazione Malattie Mieloproliferative (CRIMM), AOU Careggi, Firenze
| | - Danilo Tarantino
- SOD Ematologia, Università di Firenze, AOU Careggi, Firenze, Italy; Centro Ricerca e Innovazione Malattie Mieloproliferative (CRIMM), AOU Careggi, Firenze
| | - Chiara Maccari
- SOD Ematologia, Università di Firenze, AOU Careggi, Firenze, Italy; Centro Ricerca e Innovazione Malattie Mieloproliferative (CRIMM), AOU Careggi, Firenze
| | | | | | - Paola Guglielmelli
- SOD Ematologia, Università di Firenze, AOU Careggi, Firenze, Italy; Centro Ricerca e Innovazione Malattie Mieloproliferative (CRIMM), AOU Careggi, Firenze
| | - Alessandro M Vannucchi
- SOD Ematologia, Università di Firenze, AOU Careggi, Firenze, Italy; Centro Ricerca e Innovazione Malattie Mieloproliferative (CRIMM), AOU Careggi, Firenze
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2
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Park MN. The Therapeutic Potential of a Strategy to Prevent Acute Myeloid Leukemia Stem Cell Reprogramming in Older Patients. Int J Mol Sci 2023; 24:12037. [PMID: 37569414 PMCID: PMC10418941 DOI: 10.3390/ijms241512037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/22/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023] Open
Abstract
Acute myeloid leukemia (AML) is the most common and incurable leukemia subtype. Despite extensive research into the disease's intricate molecular mechanisms, effective treatments or expanded diagnostic or prognostic markers for AML have not yet been identified. The morphological, immunophenotypic, cytogenetic, biomolecular, and clinical characteristics of AML patients are extensive and complex. Leukemia stem cells (LSCs) consist of hematopoietic stem cells (HSCs) and cancer cells transformed by a complex, finely-tuned interaction that causes the complexity of AML. Microenvironmental regulation of LSCs dormancy and the diagnostic and therapeutic implications for identifying and targeting LSCs due to their significance in the pathogenesis of AML are discussed in this review. It is essential to perceive the relationship between the niche for LSCs and HSCs, which together cause the progression of AML. Notably, methylation is a well-known epigenetic change that is significant in AML, and our data also reveal that microRNAs are a unique factor for LSCs. Multiple-targeted approaches to reduce the risk of epigenetic factors, such as the administration of natural compounds for the elimination of local LSCs, may prevent potentially fatal relapses. Furthermore, the survival analysis of overlapping genes revealed that specific targets had significant effects on the survival and prognosis of patients. We predict that the multiple-targeted effects of herbal products on epigenetic modification are governed by different mechanisms in AML and could prevent potentially fatal relapses. Thus, these strategies can facilitate the incorporation of herbal medicine and natural compounds into the advanced drug discovery and development processes achievable with Network Pharmacology research.
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Affiliation(s)
- Moon Nyeo Park
- Department of Pathology, College of Korean Medicine, Kyung Hee University, Hoegidong Dongdaemungu, Seoul 05253, Republic of Korea
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3
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Tomasoni C, Pievani A, Rambaldi B, Biondi A, Serafini M. A Question of Frame: The Role of the Bone Marrow Stromal Niche in Myeloid Malignancies. Hemasphere 2023; 7:e896. [PMID: 37234820 PMCID: PMC10208717 DOI: 10.1097/hs9.0000000000000896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 04/18/2023] [Indexed: 05/28/2023] Open
Abstract
Until a few years ago, the onset of acute myeloid leukemia (AML) was entirely ascribed to genetic lesions in hematopoietic stem cells. These mutations generate leukemic stem cells, which are known to be the main ones responsible for chemoresistance and relapse. However, in the last years, increasing evidence demonstrated that dynamic interplay between leukemic cells and bone marrow (BM) niche is of paramount relevance in the pathogenesis of myeloid malignancies, including AML. Specifically, BM stromal niche components, such as mesenchymal stromal cells (MSCs) and their osteoblastic cell derivatives, play a key role not only in supporting normal hematopoiesis but also in the manifestation and progression of myeloid malignancies. Here, we reviewed recent clinical and experimental findings about how genetic and functional alterations in MSCs and osteolineage progeny can contribute to leukemogenesis and how leukemic cells in turn generate a corrupted niche able to support myeloid neoplasms. Moreover, we discussed how the newest single-cell technologies may help dissect the interactions between BM stromal cells and malignant hematopoiesis. The deep comprehension of the tangled relationship between stroma and AML blasts and their modulation during disease progression may have a valuable impact on the development of new microenvironment-directed therapeutic strategies, potentially useful for a wide cohort of patients.
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Affiliation(s)
- Chiara Tomasoni
- Tettamanti Center, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Alice Pievani
- Tettamanti Center, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Benedetta Rambaldi
- Hematology and Bone Marrow Transplant Unit, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Andrea Biondi
- Pediatrics, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Marta Serafini
- Tettamanti Center, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
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4
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Zhang B, Liu Q, Li J, Hu Y, Zhao X, Huang P, Li S, Wang Y. Venetoclax plus cyclophosphamide and cytarabine as induction regimen for adult acute myeloid leukemia. Front Oncol 2023; 13:1193874. [PMID: 37274294 PMCID: PMC10235496 DOI: 10.3389/fonc.2023.1193874] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 04/24/2023] [Indexed: 06/06/2023] Open
Abstract
Background The efficacy of induction chemotherapy (IC) for acute myeloid leukemia (AML) has improved significantly with the application of targeting drugs. Our previous study showed that a 4-day IC regimen of cyclophosphamide (CTX) and Ara-C [CA (4 + 3)] achieved similar complete remission (CR) rate (80%) compared with the traditional 7-day regimen, and the survival rate appeared to be better. Methods In this pilot study, we further shortened the CA regimen to 3 days, added low-dose venetoclax (VEN, 200 mg/day) (VCA), and reported the efficacy and safety here. Results Twenty-five newly diagnosed adult AML patients were enrolled in this study and evaluated for the remission rate after one cycle of the VCA regimen. The CR/Cri was 92%, and all these patients had undetectable minimal residual disease (MRD-). The estimated overall survival at 12 months was 79.3%. The median time for both platelet recovery and absolute neutrophil count recovery was 16 days, faster than that of traditional IC. Compared with the previous CA (4 + 3) regimen, a higher CR rate (92% vs. 80%, P < 0.01) and a deeper degree of remission (CRMRD- rate, 92% vs. 45%, P < 0.01) were found in the VCA group. Conclusions This study showed that the 3-day CTX and Ara-C regimen is highly effective in newly diagnosed AML patients, and the addition of VEN to the CA regimen achieves higher and deeper one-course remission.
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Affiliation(s)
- Baohang Zhang
- National Clinical Research Center for Blood Diseases, State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Qingguo Liu
- National Clinical Research Center for Blood Diseases, State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Junfan Li
- National Clinical Research Center for Blood Diseases, State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Yimin Hu
- National Clinical Research Center for Blood Diseases, State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Xin Zhao
- National Clinical Research Center for Blood Diseases, State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Pingping Huang
- National Clinical Research Center for Blood Diseases, State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Shangzhu Li
- National Clinical Research Center for Blood Diseases, State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Ying Wang
- National Clinical Research Center for Blood Diseases, State Key Laboratory of Experimental Hematology, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
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5
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Longitudinal single-cell profiling of chemotherapy response in acute myeloid leukemia. Nat Commun 2023; 14:1285. [PMID: 36890137 PMCID: PMC9995364 DOI: 10.1038/s41467-023-36969-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 02/22/2023] [Indexed: 03/10/2023] Open
Abstract
Acute myeloid leukemia may be characterized by a fraction of leukemia stem cells (LSCs) that sustain disease propagation eventually leading to relapse. Yet, the contribution of LSCs to early therapy resistance and AML regeneration remains controversial. We prospectively identify LSCs in AML patients and xenografts by single-cell RNA sequencing coupled with functional validation by a microRNA-126 reporter enriching for LSCs. Through nucleophosmin 1 (NPM1) mutation calling or chromosomal monosomy detection in single-cell transcriptomes, we discriminate LSCs from regenerating hematopoiesis, and assess their longitudinal response to chemotherapy. Chemotherapy induced a generalized inflammatory and senescence-associated response. Moreover, we observe heterogeneity within progenitor AML cells, some of which proliferate and differentiate with expression of oxidative-phosphorylation (OxPhos) signatures, while others are OxPhos (low) miR-126 (high) and display enforced stemness and quiescence features. miR-126 (high) LSCs are enriched at diagnosis in chemotherapy-refractory AML and at relapse, and their transcriptional signature robustly stratifies patients for survival in large AML cohorts.
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6
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Single-cell analysis reveals the chemotherapy-induced cellular reprogramming and novel therapeutic targets in relapsed/refractory acute myeloid leukemia. Leukemia 2023; 37:308-325. [PMID: 36543880 PMCID: PMC9898038 DOI: 10.1038/s41375-022-01789-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 12/01/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022]
Abstract
Chemoresistance and relapse are the leading cause of AML-related deaths. Utilizing single-cell RNA sequencing (scRNA-seq), we dissected the cellular states of bone marrow samples from primary refractory or short-term relapsed AML patients and defined the transcriptional intratumoral heterogeneity. We found that compared to proliferating stem/progenitor-like cells (PSPs), a subpopulation of quiescent stem-like cells (QSCs) were involved in the chemoresistance and poor outcomes of AML. By performing longitudinal scRNA-seq analyses, we demonstrated that PSPs were reprogrammed to obtain a QSC-like expression pattern during chemotherapy in refractory AML patients, characterized by the upregulation of CD52 and LGALS1 expression. Flow cytometric analysis further confirmed that the preexisting CD99+CD49d+CD52+Galectin-1+ (QSCs) cells at diagnosis were associated with chemoresistance, and these cells were further enriched in the residual AML cells of refractory patients. Interaction of CD52-SIGLEC10 between QSCs and monocytes may contribute to immune evading and poor outcomes. Furthermore, we identified that LGALS1 was a promising target for chemoresistant AML, and LGALS1 inhibitor could help eliminate QSCs and enhance the chemotherapy in patient-derived primary AML cells, cell lines, and AML xenograft models. Our results will facilitate a better understanding of the AML chemoresistance mechanism and the development of novel therapeutic strategies for relapsed/refractory AML patients.
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7
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Eng L, Brual J, Nagee A, Mok S, Fazelzad R, Chaiton M, Saunders D, Mittmann N, Truscott R, Liu G, Bradbury P, Evans W, Papadakos J, Giuliani M. Reporting of tobacco use and tobacco-related analyses in cancer cooperative group clinical trials: a systematic scoping review. ESMO Open 2022; 7:100605. [PMID: 36356412 PMCID: PMC9646674 DOI: 10.1016/j.esmoop.2022.100605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 09/21/2022] [Accepted: 09/23/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Continued smoking after a diagnosis of cancer negatively impacts cancer outcomes, but the impact of tobacco on newer treatments options is not well established. Collecting and evaluating tobacco use in clinical trials may advance understanding of the consequences of tobacco use on treatment modalities, but little is known about the frequency of reporting and analysis of tobacco use in cancer cooperative clinical trial groups. PATIENTS AND METHODS A comprehensive literature search was conducted to identify cancer cooperative group clinical trials published from January 2017-October 2019. Eligible studies evaluated either systemic and/or radiation therapies, included ≥100 adult patients, and reported on at least one of: overall survival, disease/progression-free survival, response rates, toxicities/adverse events, or quality-of-life. RESULTS A total of 91 studies representing 90 trials met inclusion criteria with trial start dates ranging from 1995 to 2015 with 14% involving lung and 5% head and neck cancer patients. A total of 19 studies reported baseline tobacco use; 2 reported collecting follow-up tobacco use. Seven studies reported analysis of the impact of baseline tobacco use on clinical outcomes. There was significant heterogeneity in the reporting of baseline tobacco use: 7 reported never/ever status, 10 reported never/ex-smoker/current smoker status, and 4 reported measuring smoking intensity. None reported verifying smoking status or second-hand smoke exposure. Trials of lung and head and neck cancers were more likely to report baseline tobacco use than other disease sites (83% versus 6%, P < 0.001). CONCLUSIONS Few cancer cooperative group clinical trials report and analyze trial participants' tobacco use. Significant heterogeneity exists in reporting tobacco use. Routine standardized collection and reporting of tobacco use at baseline and follow-up in clinical trials should be implemented to enable investigators to evaluate the impact of tobacco use on new cancer therapies.
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Affiliation(s)
- L. Eng
- Division of Medical Oncology and Hematology, Department of Medicine, Princess Margaret Cancer Centre/University Health Network and University of Toronto, Toronto, Canada,Prof L. Eng, Princess Margaret Cancer Centre, 610 University Avenue, Toronto, Ontario M5G 2M9, Canada. Tel: +1-416-946-2953; Fax: +1-416-946-6546 @Lawson_Eng@MeredithGiulia1@PMcancercentre
| | - J. Brual
- Cancer Education Program, Princess Margaret Cancer Centre, Toronto, Canada
| | - A. Nagee
- Cancer Education Program, Princess Margaret Cancer Centre, Toronto, Canada
| | - S. Mok
- Cancer Education Program, Princess Margaret Cancer Centre, Toronto, Canada
| | - R. Fazelzad
- Library and Information Services, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - M. Chaiton
- Centre for Addiction and Mental Health, University of Toronto, Toronto, Canada
| | - D.P. Saunders
- Northeast Cancer Centre of Health Sciences North, Northern Ontario School of Medicine, Sudbury, Canada
| | - N. Mittmann
- Canadian Agency for Drugs and Technologies in Health, Toronto, Canada
| | - R. Truscott
- Division of Prevention Policy and Stakeholder Engagement, Ontario Health (Cancer Care Ontario), Toronto, Canada
| | - G. Liu
- Division of Medical Oncology and Hematology, Department of Medicine, Princess Margaret Cancer Centre/University Health Network and University of Toronto, Toronto, Canada
| | - P.A. Bradbury
- Division of Medical Oncology and Hematology, Department of Medicine, Princess Margaret Cancer Centre/University Health Network and University of Toronto, Toronto, Canada
| | - W.K. Evans
- Department of Oncology, McMaster University, Hamilton, Canada
| | - J. Papadakos
- Cancer Education Program, Princess Margaret Cancer Centre, Toronto, Canada,Patient Education, Ontario Health (Cancer Care Ontario), Toronto, Canada
| | - M.E. Giuliani
- Cancer Education Program, Princess Margaret Cancer Centre, Toronto, Canada,Department of Radiation Oncology, Princess Margaret Cancer Centre, Toronto, Canada,Correspondence to: Prof M. Giuliani, Princess Margaret Cancer Centre, 610 University Avenue, Toronto, Ontario M5G 2M9, Canada. Tel: +1-416-946-2983; Fax: +1-416-946-6546
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8
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Prognostic Relevance of NPM1 and FLT3 Mutations in Acute Myeloid Leukaemia, Longterm Follow-Up-A Single Center Experience. Cancers (Basel) 2022; 14:cancers14194716. [PMID: 36230640 PMCID: PMC9562865 DOI: 10.3390/cancers14194716] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/18/2022] [Accepted: 09/23/2022] [Indexed: 11/29/2022] Open
Abstract
The prognosis of acute myeloid leukemia depends on genetic aberrations, particularly NPM1 and FLT3-ITD mutations. The targeted drugs’ availability has renewed interest in FLT3 mutations, but the impact of these genetic alterations using these treatments is yet to be confirmed. Our objective was to evaluate the results obtained with the intensified NILG-AML 01/00 protocol (ClinicalTrials.gov Identifier: NCT 00400673) in 171 unselected patients (median age, 54.5 years, range 15−74) carrying the FLT3 (ITD or TKD) and/or NPM1 mutations. The CR rate and 5-y survival were 88.3% and 58% +/− 4, respectively, significantly higher in the NPM1-mutated (CR 93.9%, p: 0.0001; survival 71% +/− 6, p: 0.0017, respectively). In isolated ITD patients, the CR was lower (66.7%, p: 0.0009), and the 3 years-relapse-free survival worse (24%, p: <0.0002). The presence of ITD, irrespective of the allelic ratio, or TKD mutation, did not significantly affect the survival or relapse-free survival among the NPM1-co-mutated patients. Our data indicate that a high dose of ARAC plus idarubicin consolidation exerts a strong anti-leukemic effect in NPM1-mutated patients both with the FLT3 wild-type and mutated AML, while in the NPM1 wild-type and FLT3-mutated, the therapeutic effect remains unsatisfactory. New strategies incorporating target therapy with second-generation inhibitors will improve these results and their addition to this aggressive chemotherapeutic program merits testing.
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9
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Kolonen A, Sinisalo M, Huhtala H, Rimpiläinen J, Rintala H, Sankelo M, Koivunen E, Silvennoinen R, Räty R, Ruutu T, Volin L, Porkka K, Jantunen E, Nousiainen T, Kuittinen T, Penttilä K, Pyörälä M, Säily M, Koistinen P, Kauppila M, Itälä-Remes M, Ollikainen H, Rauhala A, Kairisto V, Pelliniemi TT, Elonen E. Efficacy of conventional-dose cytarabine, idarubicin and thioguanine versus intermediate-dose cytarabine and idarubicin in the induction treatment of acute myeloid leukemia: Long-term results of the prospective randomized nationwide AML-2003 study by the Finnish Leukemia Group. Eur J Haematol Suppl 2022; 109:257-270. [PMID: 35634931 DOI: 10.1111/ejh.13805] [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: 02/27/2022] [Revised: 05/18/2022] [Accepted: 05/23/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVES AML-2003 study sought to compare the long-term efficacy and safety of IAT and IdAraC-Ida in induction chemotherapy of acute myeloid leukemia (AML) and introduce the results of an integrated genetic and clinical risk classification guided treatment strategy. METHODS Patients were randomized to receive either IAT or IdAraC-Ida as the first induction treatment. Intensified postremission strategies were employed based on measurable residual disease (MRD) and risk classification. Structured questionnaire forms were used to gather data prospectively. RESULTS A total of 356 AML patients with a median age of 53 years participated in the study. Long-term overall survival (OS) and relapse-free survival (RFS) were both 49% at 10 years. The median follow-up was 114 months. No significant difference in remission rate, OS or RFS was observed between the two induction treatments. Risk classification according to the protocol, MRD after the first and the last consolidation treatment affected the OS and RFS significantly (p < .001). CONCLUSIONS Intensified cytarabine dose in the first induction treatment was not better than IAT in patients with AML. Intensification of postremission treatment in patients with clinical risk factors or MRD seems reasonable, but randomized controlled studies are warranted in the future.
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Affiliation(s)
- Aarne Kolonen
- Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - Marjatta Sinisalo
- Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - Heini Huhtala
- Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Johanna Rimpiläinen
- Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - Hannele Rintala
- Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - Marja Sankelo
- Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - Elli Koivunen
- Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - Raija Silvennoinen
- Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - Riikka Räty
- Department of Hematology, Helsinki University Hospital Comprehensive Cancer Center and University of Helsinki, Helsinki, Finland
| | - Tapani Ruutu
- Department of Hematology, Helsinki University Hospital Comprehensive Cancer Center and University of Helsinki, Helsinki, Finland
| | - Liisa Volin
- Department of Hematology, Helsinki University Hospital Comprehensive Cancer Center and University of Helsinki, Helsinki, Finland
| | - Kimmo Porkka
- Department of Hematology, Helsinki University Hospital Comprehensive Cancer Center and University of Helsinki, Helsinki, Finland
| | - Esa Jantunen
- Department of Medicine, Kuopio University Hospital, Kuopio, Finland
| | - Tapio Nousiainen
- Department of Medicine, Kuopio University Hospital, Kuopio, Finland
| | - Taru Kuittinen
- Department of Medicine, Kuopio University Hospital, Kuopio, Finland
| | - Karri Penttilä
- Department of Medicine, Kuopio University Hospital, Kuopio, Finland
| | - Marja Pyörälä
- Department of Medicine, Kuopio University Hospital, Kuopio, Finland
| | - Marjaana Säily
- Department of Medicine, Oulu University Hospital, Oulu, Finland
| | - Pirjo Koistinen
- Department of Medicine, Oulu University Hospital, Oulu, Finland
| | - Marjut Kauppila
- Stem Cell Transplantation Unit, Turku University Hospital, Turku, Finland
| | - Maija Itälä-Remes
- Stem Cell Transplantation Unit, Turku University Hospital, Turku, Finland
| | - Hanna Ollikainen
- Department of Medicine, Satakunta Central Hospital, Pori, Finland
| | - Auvo Rauhala
- The Faculty of Education and Welfare Studies, Department of Health Sciences, Åbo Akademi University, Vaasa, Finland.,Client and Patient Safety Center, Vaasa Central Hospital, Vaasa, Finland
| | - Veli Kairisto
- Laboratory of Molecular Haematology and Pathology, Turku University Central Hospital, Turku, Finland
| | - Tarja-Terttu Pelliniemi
- Department of Clinical Chemistry, University of Turku, Finland and Fimlab Laboratories Ltd, Tampere, Finland
| | - Erkki Elonen
- Department of Hematology, Helsinki University Hospital Comprehensive Cancer Center and University of Helsinki, Helsinki, Finland
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10
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Versluis J, Pandey M, Flamand Y, Haydu JE, Belizaire R, Faber M, Vedula RS, Charles A, Copson KM, Shimony S, Rozental A, Bendapudi PK, Wolach O, Griffiths EA, Thompson JE, Stone RM, DeAngelo DJ, Neuberg D, Luskin MR, Wang ES, Lindsley RC. Prediction of life-threatening and disabling bleeding in patients with AML receiving intensive induction chemotherapy. Blood Adv 2022; 6:2835-2846. [PMID: 35081257 PMCID: PMC9092400 DOI: 10.1182/bloodadvances.2021006166] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 01/11/2022] [Indexed: 11/20/2022] Open
Abstract
Bleeding in patients with acute myeloid leukemia (AML) receiving intensive induction chemotherapy is multifactorial and contributes to early death. We sought to define the incidence and risk factors of grade 4 bleeding to support strategies for risk mitigation. Bleeding events were retrospectively assessed between day-14 and day +60 of induction treatment according to the World Health Organization (WHO) bleeding assessment scale, which includes grade 4 bleeding as fatal, life-threatening, retinal with visual impairment, or involving the central nervous system. Predictors were considered pretreatment or prior to grade 4 bleeding. Using multivariable competing-risk regression analysis with grade 4 bleeding as the primary outcome, we identified risk factors in the development cohort (n = 341), which were tested in an independent cohort (n = 143). Grade 4 bleeding occurred in 5.9% and 9.8% of patients in the development and validation cohort, respectively. Risk factors that were independently associated with grade 4 bleeding included baseline platelet count ≤40 × 109/L compared with >40 × 109/L, and baseline international normalized ratio of prothrombin time (PT-INR) >1.5 or 1.3 > 1.5 compared with ≤1.3. These variables were allocated points, which allowed for stratification of patients with low- and high-risk for grade 4 bleeding. Cumulative incidence of grade 4 bleeding at day+60 was significantly higher among patients with high- vs low-risk (development: 31 ± 7% vs 2 ± 1%; P < .001; validation: 25 ± 9% vs 7 ± 2%; P = .008). In both cohorts, high bleeding risk was associated with disseminated intravascular coagulation (DIC) and proliferative disease. We developed and validated a simple risk model for grade 4 bleeding, which enables the development of rational risk mitigation strategies to improve early mortality of intensive induction treatment.
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Affiliation(s)
- Jurjen Versluis
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Manu Pandey
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Yael Flamand
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
| | - J. Erika Haydu
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Roger Belizaire
- Division of Transfusion Medicine, Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Mark Faber
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Rahul S. Vedula
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Anne Charles
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Kevin M. Copson
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Shai Shimony
- Institute of Hematology, Davidoff Cancer Centre, Beilinson Hospital, Rabin Medical Center, Petah-Tikva, Israel
- Sackler Medical School, Tel Aviv University, Tel Aviv, Israel; and
| | - Alon Rozental
- Institute of Hematology, Davidoff Cancer Centre, Beilinson Hospital, Rabin Medical Center, Petah-Tikva, Israel
- Sackler Medical School, Tel Aviv University, Tel Aviv, Israel; and
| | - Pavan K. Bendapudi
- Division of Hematology and Blood Transfusion Service, Massachusetts General Hospital, Boston, MA
| | - Ofir Wolach
- Institute of Hematology, Davidoff Cancer Centre, Beilinson Hospital, Rabin Medical Center, Petah-Tikva, Israel
- Sackler Medical School, Tel Aviv University, Tel Aviv, Israel; and
| | | | - James E. Thompson
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Richard M. Stone
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Daniel J. DeAngelo
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Donna Neuberg
- Department of Data Science, Dana-Farber Cancer Institute, Boston, MA
| | - Marlise R. Luskin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Eunice S. Wang
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - R. Coleman Lindsley
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
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11
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Martella F, Cerrano M, Di Cuonzo D, Secreto C, Olivi M, Apolito V, D'Ardia S, Frairia C, Giai V, Lanzarone G, Urbino I, Freilone R, Giaccone L, Busca A, Dellacasa CM, Audisio E, Ferrero D, Beggiato E. Frequency and risk factors for thrombosis in acute myeloid leukemia and high-risk myelodysplastic syndromes treated with intensive chemotherapy: a two centers observational study. Ann Hematol 2022; 101:855-867. [PMID: 35128571 DOI: 10.1007/s00277-022-04770-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 01/21/2022] [Indexed: 12/17/2022]
Abstract
The frequency of thrombosis in AML has been evaluated only in a few studies and no validated predictive model is currently available. Recently, DIC score was shown to identify patients at higher thrombotic risk. We aimed to evaluate the frequency of thromboembolism in AML patients treated with intensive chemotherapy and to assess the ability of genetic and clinical factors to predict the thrombotic risk. We performed a retrospective observational study including 222 newly diagnosed adult AML (210) and high-risk MDS (12), treated with intensive chemotherapy between January 2013 and February 2020. With a median follow-up of 44 months, we observed 50 thrombotic events (90% were venous, VTE). The prevalence of thrombosis was 22.1% and the 6-months cumulative incidence of thrombosis was 10%. The median time to thrombosis was 84 days and 52% of the events occurred within 100 days from AML diagnosis. Khorana and DIC score failed to stratify patients according to their thrombotic risk. Only history of a thrombotic event (p = 0.043), particularly VTE (p = 0.0053), platelet count above 100 × 109/L at diagnosis (p = 0.036) and active smoking (p = 0.025) significantly and independently increased the risk of thrombosis, the latter particularly of arterial events. AML genetic profile did not affect thrombosis occurrence. Results were confirmed considering only thromboses occurring within day 100 from diagnosis. DIC score at diagnosis, but not thrombosis, was independently associated with reduced survival (p = 0.004). Previous VTE, platelet count above 100 × 109/L and active smoking were the only factors associate with increased thrombotic risk in AML patients treated intensively, but further studies are needed to validate these results.
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Affiliation(s)
- Federica Martella
- Department of Molecular Biotechnology and Health Sciences, Division of Hematology, University of Torino, Turin, Italy
| | - Marco Cerrano
- Department of Oncology, Division of Hematology, AOU Città della Salute e della Scienza di Torino, Presidio Molinette, 10126, Turin, Italy.
| | - Daniela Di Cuonzo
- Unit of Clinical Epidemiology, CPO, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Carolina Secreto
- Department of Molecular Biotechnology and Health Sciences, Division of Hematology, University of Torino, Turin, Italy
| | - Matteo Olivi
- Department of Molecular Biotechnology and Health Sciences, Division of Hematology, University of Torino, Turin, Italy
| | - Vincenzo Apolito
- Department of Molecular Biotechnology and Health Sciences, Division of Hematology, University of Torino, Turin, Italy
| | - Stefano D'Ardia
- Department of Oncology, Division of Hematology, AOU Città della Salute e della Scienza di Torino, Presidio Molinette, 10126, Turin, Italy
| | - Chiara Frairia
- Department of Oncology, Division of Hematology, AOU Città della Salute e della Scienza di Torino, Presidio Molinette, 10126, Turin, Italy
| | - Valentina Giai
- Department of Oncology, Division of Hematology, AOU Città della Salute e della Scienza di Torino, Presidio Molinette, 10126, Turin, Italy
| | - Giuseppe Lanzarone
- Department of Molecular Biotechnology and Health Sciences, Division of Hematology, University of Torino, Turin, Italy
| | - Irene Urbino
- Department of Molecular Biotechnology and Health Sciences, Division of Hematology, University of Torino, Turin, Italy
| | - Roberto Freilone
- Department of Oncology, Division of Hematology, AOU Città della Salute e della Scienza di Torino, Presidio Molinette, 10126, Turin, Italy
| | - Luisa Giaccone
- Department of Oncology, SSD Trapianto Allogenico, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Alessandro Busca
- Department of Oncology, SSD Trapianto Allogenico, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Chiara Maria Dellacasa
- Department of Oncology, SSD Trapianto Allogenico, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Ernesta Audisio
- Department of Oncology, Division of Hematology, AOU Città della Salute e della Scienza di Torino, Presidio Molinette, 10126, Turin, Italy
| | - Dario Ferrero
- Department of Molecular Biotechnology and Health Sciences, Division of Hematology, University of Torino, Turin, Italy
| | - Eloise Beggiato
- Department of Molecular Biotechnology and Health Sciences, Division of Hematology, University of Torino, Turin, Italy
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12
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Caprioli C, Lussana F, Salmoiraghi S, Cavagna R, Buklijas K, Elidi L, Zanghi' P, Michelato A, Delaini F, Oldani E, Intermesoli T, Grassi A, Gianfaldoni G, Mannelli F, Ferrero D, Audisio E, Terruzzi E, De Paoli L, Cattaneo C, Borlenghi E, Cavattoni I, Tajana M, Scattolin AM, Mattei D, Corradini P, Campiotti L, Ciceri F, Bernardi M, Todisco E, Cortelezzi A, Falini B, Pavoni C, Bassan R, Spinelli O, Rambaldi A. Clinical significance of chromatin-spliceosome acute myeloid leukemia: a report from the Northern Italy Leukemia Group (NILG) randomized trial 02/06. Haematologica 2021; 106:2578-2587. [PMID: 32855275 PMCID: PMC8485674 DOI: 10.3324/haematol.2020.252825] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Indexed: 12/05/2022] Open
Abstract
Secondary acute myeloid leukemia (sAML) after myelodysplastic or myeloproliferative disorders is a high-risk category currently identified by the clinical history or specific morphological and cytogenetic abnormalities. However, in the absence of these features, uncertainties to identify the secondary nature of some cases, otherwise defined as de novo AML, remain. In order to test whether a chromatinspliceosome (CS) mutational signature might better define the de novo AML group, we analyzed a prospective cohort of 413 newly diagnosed AML patients who were enrolled in a randomized clinical trial (NILG AML 02/06) and who provided samples for accurate cytogenetic and molecular characterization. Among clinically defined de novo AML, 17.6% carried CS mutations (CS-AML) and showed clinical characteristics closer to sAML (older age, lower white blood cell counts and higher rate of multilineage dysplasia). Outcomes in this group were adverse, more similar to those of sAML as compared to de novo AML (overall survival, 30% in CS-AML and 17% in sAML vs. 61% in de novo AML, P<0.0001; disease-free survival, 26% in CS-AML and 22% in sAML vs. 54% of de novo AML, P<0.001) and independently confirmed by multivariable analysis. Allogeneic transplant in first complete remission improved survival in both sAML and CS-AML patients. In conclusion, these findings highlight the clinical significance of identifying CS-AML for improved prognostic prediction and potential therapeutic implications. (NILG AML 02/06; clinicaltrials gov. Identifier: NCT00495287).
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Affiliation(s)
| | | | - Silvia Salmoiraghi
- ASST Ospedale Papa Giovanni XXIII and FROM Research Foundation, Bergamo, Italy
| | | | | | - Lara Elidi
- ASST Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | | | | | | | - Elena Oldani
- ASST Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | | | - Anna Grassi
- ASST Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | | | | | - Dario Ferrero
- AOU Città della Salute e della Scienza, Torino, Italy
| | | | | | - Lorella De Paoli
- Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Renato Bassan
- Ospedale dell'Angelo e SS. Giovanni e Paolo, Venezia Mestre, Italy
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13
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Mannelli F, Gianfaldoni G, Guglielmelli P, Buccisano F, Caporale R, Chiarini M, Rossi G, Venditti A, Fazi P, Crea E, Piciocchi A, Voso MT, Vignetti M, Amadori S, Vannucchi AM. AMELIORATE: early intensification in FLT3-mutated acute myeloid leukemia based on peripheral blast clearance - MYNERVA-GIMEMA AML1919 trial. Future Oncol 2021; 17:3787-3796. [PMID: 34254530 DOI: 10.2217/fon-2021-0388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AMELIORATE is a Phase III, randomized trial aiming to personalize treatment intensity in FLT3-mutated acute myeloid leukemia. The current study provides an early appraisal of chemosensitivity based on peripheral blasts clearance, as assessed by multiparameter flow cytometry, from baseline to day 4 of induction. This biomarker was previously demonstrated to predict complete remission achievement and measurable residual disease status. For patients experiencing low peripheral blast cells (i.e., ≤2.0 logs), two major adjustments of treatment as compared with current standard of care are envisioned in the experimental arm: the immediate switch to intensified induction with high-doses cytarabine (1500 mg/m2 b.i.d. on days 5-7 of induction); and the early allocation of the patient to high-risk disease category, to be further refined later based on postinduction measurable residual disease status.
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Affiliation(s)
- Francesco Mannelli
- SOD Ematologia, AOU Careggi, Firenze 50134, Italy.,Centro Ricerca e Innovazione Malattie Mieloproliferative (CRIMM), AOU Careggi, Firenze 50134, Italy
| | | | - Paola Guglielmelli
- SOD Ematologia, AOU Careggi, Firenze 50134, Italy.,Centro Ricerca e Innovazione Malattie Mieloproliferative (CRIMM), AOU Careggi, Firenze 50134, Italy
| | - Francesco Buccisano
- Ematologia, Dipartimento di Biomedicina e Prevenzione, Università di Tor Vergata, Roma 00133, Italy.,Fondazione Policlinico Tor Vergata, Roma 00133, Italy
| | - Roberto Caporale
- Centro Diagnostico di Citofluorimetria e Immunoterapia, AOU Careggi, Firenze 50134, Italy
| | - Marco Chiarini
- Laboratorio di Citofluorimetria; Dipartimento di Diagnostica di Laboratorio, Spedali Civili, Brescia 25121, Italy
| | - Giuseppe Rossi
- Divisione di Ematologia, Spedali Civili, Brescia 25121, Italy
| | - Adriano Venditti
- Ematologia, Dipartimento di Biomedicina e Prevenzione, Università di Tor Vergata, Roma 00133, Italy.,Fondazione Policlinico Tor Vergata, Roma 00133, Italy
| | | | | | | | - Maria Teresa Voso
- Ematologia, Dipartimento di Biomedicina e Prevenzione, Università di Tor Vergata, Roma 00133, Italy.,Fondazione Policlinico Tor Vergata, Roma 00133, Italy
| | | | | | - Alessandro Maria Vannucchi
- SOD Ematologia, AOU Careggi, Firenze 50134, Italy.,Centro Ricerca e Innovazione Malattie Mieloproliferative (CRIMM), AOU Careggi, Firenze 50134, Italy
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14
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Kantarjian HM, Short NJ, Fathi AT, Marcucci G, Ravandi F, Tallman M, Wang ES, Wei AH. Acute Myeloid Leukemia: Historical Perspective and Progress in Research and Therapy Over 5 Decades. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2021; 21:580-597. [PMID: 34176779 DOI: 10.1016/j.clml.2021.05.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/20/2021] [Accepted: 05/22/2021] [Indexed: 12/17/2022]
Abstract
With the Food and Drug Administration approval of 9 agents for different acute myeloid leukemia (AML) indications, the prognosis and management of AML is evolving rapidly. Herein, we review the important milestones in the history of AML research and therapy, discuss insights regarding prognostic assessment and prediction of treatment outcome, detail practical supportive care measures, and summarize the current treatment landscape and areas of evolving research.
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Affiliation(s)
| | - Nicholas J Short
- Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
| | - Amir T Fathi
- Leukemia Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Guido Marcucci
- Gehr Family Center for Leukemia Research City of Hope, Duarte, CA, USA
| | - Farhad Ravandi
- Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
| | - Martin Tallman
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY, USA
| | - Eunice S Wang
- Leukemia Service, Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Andrew H Wei
- Department of Clinical Hematology, The Alfred Hospital and Monash University, Melbourne, Australia
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15
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Kantarjian HM, Kadia TM, DiNardo CD, Welch MA, Ravandi F. Acute myeloid leukemia: Treatment and research outlook for 2021 and the MD Anderson approach. Cancer 2021; 127:1186-1207. [PMID: 33734442 DOI: 10.1002/cncr.33477] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 12/31/2020] [Accepted: 01/11/2021] [Indexed: 12/17/2022]
Abstract
The unraveling of the pathophysiology of acute myeloid leukemia (AML) has resulted in rapid translation of the information into clinical practice. After more than 40 years of slow progress in AML research, the US Food and Drug Administration has approved nine agents for different AML treatment indications since 2017. In this review, we detail the progress that has been made in the research and treatment of AML, citing key publications related to AML research and therapy in the English literature since 2000. The notable subsets of AML include acute promyelocytic leukemia (APL), core-binding factor AML (CBF-AML), AML in younger patients fit for intensive chemotherapy, and AML in older/unfit patients (usually at the age cutoff of 60-70 years). We also consider within each subset whether the AML is primary or secondary (therapy-related, evolving from untreated or treated myelodysplastic syndrome or myeloproliferative neoplasm). In APL, therapy with all-trans retinoic acid and arsenic trioxide results in estimated 10-year survival rates of ≥80%. Treatment of CBF-AML with fludarabine, high-dose cytarabine, and gemtuzumab ozogamicin (GO) results in estimated 10-year survival rates of ≥75%. In younger/fit patients, the "3+7" regimen (3 days of daunorubicin + 7 days of cytarabine) produces less favorable results (estimated 5-year survival rates of 35%; worse in real-world experience); regimens that incorporate high-dose cytarabine, adenosine nucleoside analogs, and GO are producing better results. Adding venetoclax, FLT3, and IDH inhibitors into these regimens has resulted in encouraging preliminary data. In older/unfit patients, low-intensity therapy with hypomethylating agents (HMAs) and venetoclax is now the new standard of care. Better low-intensity regimens incorporating cladribine, low-dose cytarabine, and other targeted therapies (FLT3 and IDH inhibitors) are emerging. Maintenance therapy now has a definite role in the treatment of AML, and oral HMAs with potential treatment benefits are also available. In conclusion, AML therapy is evolving rapidly and treatment results are improving in all AML subsets as novel agents and strategies are incorporated into traditional AML chemotherapy. LAY SUMMARY: Ongoing research in acute myeloid leukemia (AML) is progressing rapidly. Since 2017, the US Food and Drug Administration has approved 10 drugs for different AML indications. This review updates the research and treatment pathways for AML.
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Affiliation(s)
| | - Tapan M Kadia
- Department of Leukemia, MD Anderson Cancer Center, Houston, Texas
| | | | - Mary Alma Welch
- Department of Leukemia, MD Anderson Cancer Center, Houston, Texas
| | - Farhad Ravandi
- Department of Leukemia, MD Anderson Cancer Center, Houston, Texas
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16
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Kantarjian H, Kadia T, DiNardo C, Daver N, Borthakur G, Jabbour E, Garcia-Manero G, Konopleva M, Ravandi F. Acute myeloid leukemia: current progress and future directions. Blood Cancer J 2021; 11:41. [PMID: 33619261 PMCID: PMC7900255 DOI: 10.1038/s41408-021-00425-3] [Citation(s) in RCA: 307] [Impact Index Per Article: 102.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/14/2020] [Accepted: 01/18/2021] [Indexed: 12/12/2022] Open
Abstract
Progress in the understanding of the biology and therapy of acute myeloid leukemia (AML) is occurring rapidly. Since 2017, nine agents have been approved for various indications in AML. These included several targeted therapies like venetoclax, FLT3 inhibitors, IDH inhibitors, and others. The management of AML is complicated, highlighting the need for expertise in order to deliver optimal therapy and achieve optimal outcomes. The multiple subentities in AML require very different therapies. In this review, we summarize the important pathophysiologies driving AML, review current therapies in standard practice, and address present and future research directions.
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Affiliation(s)
- Hagop Kantarjian
- Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA.
| | - Tapan Kadia
- Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
| | - Courtney DiNardo
- Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
| | - Naval Daver
- Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
| | - Gautam Borthakur
- Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
| | - Elias Jabbour
- Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
| | | | - Marina Konopleva
- Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
| | - Farhad Ravandi
- Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
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17
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Mannelli F, Gianfaldoni G, Bencini S, Piccini M, Cutini I, Bonetti MI, Scappini B, Pancani F, Ponziani V, Chiarini M, Borlenghi E, Bassan R, Rossi G, Bosi A. Early peripheral blast cell clearance predicts minimal residual disease status and refines disease prognosis in acute myeloid leukemia. Am J Hematol 2020; 95:1304-1313. [PMID: 32697337 DOI: 10.1002/ajh.25942] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 07/16/2020] [Accepted: 07/20/2020] [Indexed: 12/17/2022]
Abstract
Minimal residual disease (MRD) assessment in acute myeloid leukemia (AML) is increasingly used in risk stratification. However, several issues around this use are unresolved, including, among others, the most suitable time-point(s) for its application. Overall, late assessments appear more effective at distinguishing outcome but, in some studies, the early evaluations were already highly informative, anticipating the value of later ones. Our work integrated MRD with peripheral blast clearance (PBC), a treatment-related biomarker previously demonstrated to be a powerful predictor of response. From 2007 to 2014, we have studied 120 patients treated according to the NILG 02-06 trial and who achieved CR after induction. Patients in PBC-defined categories (separated by a 1.5-log threshold) showed significantly different probabilities of attaining MRD negativity, after either induction (MRD1) or consolidation (MRD2). Peripheral blast clearance combined with MRD1 largely anticipated MRD2-related information: when both biomarkers predicted chemosensitive disease (PBChigh /MRD1neg ), the rate of MRD2-negativity was 90%, and DFS and OS estimates were 68% and 76% at 3 years, respectively. When both markers were unfavorable (PBClow /MRD1pos ), rates of MRD2 negativity, DFS, and OS were 20%, 34%, and 24%, respectively, at 3 years. In fact, MRD2 added prognostic value only in cases with discordant PBC/MRD1 data. Our data support a reasoned timing for MRD-based therapeutic decisions, modulated on individual chemosensitivity, an approach we have implemented in a forthcoming prospective multi-center trial by Gruppo Italiano Malattie EMatologiche dell'Adulto (GIMEMA).
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Affiliation(s)
- Francesco Mannelli
- SOD Ematologia Università di Firenze, AOU Careggi Florence Italy
- Centro Ricerca e Innovazione Malattie Mieloproliferative (CRIMM) AOU Careggi Florence Italy
| | | | - Sara Bencini
- SOD Ematologia Università di Firenze, AOU Careggi Florence Italy
- Centro Diagnostico di Citofluorimetria e Immunoterapia AOU Careggi Florence Italy
| | - Matteo Piccini
- SOD Ematologia Università di Firenze, AOU Careggi Florence Italy
| | - Ilaria Cutini
- SOD Ematologia Università di Firenze, AOU Careggi Florence Italy
- SOD Terapie Cellulari e Medicina Trasfusionale AOU Careggi Florence Italy
| | - Maria Ida Bonetti
- SOD Ematologia Università di Firenze, AOU Careggi Florence Italy
- Centro Diagnostico di Citofluorimetria e Immunoterapia AOU Careggi Florence Italy
| | - Barbara Scappini
- SOD Ematologia Università di Firenze, AOU Careggi Florence Italy
| | - Fabiana Pancani
- SOD Ematologia Università di Firenze, AOU Careggi Florence Italy
| | - Vanessa Ponziani
- SOD Ematologia Università di Firenze, AOU Careggi Florence Italy
| | - Marco Chiarini
- Centro di Ricerca Emato‐Oncologica AIL (CREA) Spedali Civili Brescia Italy
- Laboratorio di Citofluorimetria; Dipartimento di Diagnostica di Laboratorio Spedali Civili Brescia Italy
| | | | - Renato Bassan
- Unità Operativa di Ematologia Ospedale dell'Angelo Mestre ‐ Venezia Italy
| | | | - Alberto Bosi
- SOD Ematologia Università di Firenze, AOU Careggi Florence Italy
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18
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Borlenghi E, Cattaneo C, Cerqui E, Archetti S, Bertoli D, Bellotti D, Gramegna D, Soverini G, Oberti M, Schieppati F, Pagani C, Passi A, Sciumé M, Farina M, Carbone C, Crippa C, Dalceggio D, Tucci A, Rossi G. Postremission therapy with repeated courses of high-dose cytarabine, idarubicin, and limited autologous stem cell support achieves a very good long-term outcome in European leukemia net favorable and intermediate-risk acute myeloid leukemia. Hematol Oncol 2020; 38:754-762. [PMID: 32950042 DOI: 10.1002/hon.2806] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 09/16/2020] [Accepted: 09/18/2020] [Indexed: 12/17/2022]
Abstract
Consolidation treatment in acute myeloid leukemia (AML) patients achieving complete remission (CR) is warranted. High-dose cytarabine (HDAC) is considered first choice in favorable risk and an option in intermediate-risk AML. However, its optimal dose and schedule, as well as the benefit of additional chemotherapy agents remain controversial. Herein, we report on the long-term outcome of consecutive unselected AML patients treated with repeated courses of HDAC, with the addition of idarubicin, followed by autologous peripheral blood stem cell (PBSC) support, in order to limit toxicity, according to Northern Italy Leukemia Group (NILG) AML-01/00 study (EUDRACT number 00400673). Among 338 patients consecutively diagnosed from 2001 to 2017 at our center, 148 with high-risk AML (adverse cytogenetic, isolated FLT3-internal tandem duplication mutation, refractory to first induction) were addressed to allogeneic stem cell transplant. All other cases, 186 patients (55%), median age 53 (range 19-75), were considered standard-risk and received the NILG AML-01/00 program. After achieving CR, patients were mobilized with cytarabine 8 g/sqm to collect autologous CD34+-PBSC and received three consolidation cycles with HDAC (20 g/sqm) plus idarubicin (20 mg/sqm) per cycle, followed by reinfusion of limited doses of CD34+ PBSC (1-2x106/kg). The program was completed by 160 (86%) patients. Toxicity was acceptable. Neutrophils recovered a median of 10 days. Treatment-related mortality was 3/160 (1.8%). After a median follow-up of 66.4 months, overall survival (OS) and relapse-free survival (RFS) at 5-years were 61.4% and 52.4%, respectively. Twenty-eight selected patients aged >65 had similar outcomes. According to European leukemia net-2010 classification, the OS and RFS at 5-years were 76.4% and 65% in favorable risk, without differences between molecular subgroups, 52.3% and 47.2% in Intermediate-I, 45.2% and 36.5% in Intermediate-II risk patients, respectively. In conclusion, consolidation including repeated courses of high dose cytarabine and idarubicin, with limited PBSC support, proved feasible and very effective in nonhigh risk patients. The incorporation of novel agents in its backbone may be tested to further improve patient's prognosis.
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Affiliation(s)
| | | | - Elisa Cerqui
- Hematology Department, ASST Spedali Civili, Brescia, Italy
| | - Silvana Archetti
- Diagnostic Department, Clinical Chemistry Laboratory, ASST Spedali Civili, Brescia, Italy
| | - Diego Bertoli
- Diagnostic Department, Clinical Chemistry Laboratory, ASST Spedali Civili, Brescia, Italy
| | - Daniela Bellotti
- Laboratorio di Citogenetica e Genetica Medica, ASST Spedali Civili, Brescia, Italy
| | | | | | | | - Francesca Schieppati
- Immunohematology and Trasfusion Medicine, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Chiara Pagani
- Hematology Department, ASST Spedali Civili, Brescia, Italy
| | - Angela Passi
- Hematology Department, ASST Spedali Civili, Brescia, Italy
| | | | - Mirko Farina
- Hematology Department, ASST Spedali Civili, Brescia, Italy
| | | | - Claudia Crippa
- Hematology Department, ASST Spedali Civili, Brescia, Italy
| | | | | | - Giuseppe Rossi
- Hematology Department, ASST Spedali Civili, Brescia, Italy
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19
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High Throughput Molecular Characterization of Normal Karyotype Acute Myeloid Leukemia in the Context of the Prospective Trial 02/06 of the Northern Italy Leukemia Group (NILG). Cancers (Basel) 2020; 12:cancers12082242. [PMID: 32796597 PMCID: PMC7464263 DOI: 10.3390/cancers12082242] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/20/2020] [Accepted: 07/27/2020] [Indexed: 12/11/2022] Open
Abstract
By way of a Next-Generation Sequencing NGS high throughput approach, we defined the mutational profile in a cohort of 221 normal karyotype acute myeloid leukemia (NK-AML) enrolled into a prospective randomized clinical trial, designed to evaluate an intensified chemotherapy program for remission induction. NPM1, DNMT3A, and FLT3-ITD were the most frequently mutated genes while DNMT3A, FLT3, IDH1, PTPN11, and RAD21 mutations were more common in the NPM1 mutated patients (p < 0.05). IDH1 R132H mutation was strictly associated with NPM1 mutation and mutually exclusive with RUNX1 and ASXL1. In the whole cohort of NK-AML, no matter the induction chemotherapy used, by multivariate analysis, the achievement of complete remission was negatively affected by the SRSF2 mutation. Alterations of FLT3 (FLT3-ITD) and U2AF1 were associated with a worse overall and disease-free survival (p < 0.05). FLT3-ITD positive patients who proceeded to alloHSCT had a survival probability similar to FLT3-ITD negative patients and the transplant outcome was no different when comparing high and low-AR-FLT3-ITD subgroups in terms of both OS and DFS. In conclusion, a comprehensive molecular profile for NK-AML allows for the identification of genetic lesions associated to different clinical outcomes and the selection of the most appropriate and effective treatment strategies, including stem cell transplantation and targeted therapies.
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20
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Gianfaldoni G, Mannelli F, Intermesoli T, Bencini S, Giupponi D, Farina G, Cutini I, Bonetti MI, Masciulli A, Audisio E, Ferrero D, Pavoni C, Scattolin AM, Bosi A, Rambaldi A, Bassan R. Early peripheral clearance of leukemia-associated immunophenotypes in AML: centralized analysis of a randomized trial. Blood Adv 2020; 4:301-311. [PMID: 31978214 PMCID: PMC6988394 DOI: 10.1182/bloodadvances.2019000406] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 12/20/2019] [Indexed: 12/15/2022] Open
Abstract
Although genetics is a relevant risk factor in acute myeloid leukemia (AML), it can be minimally informative and/or not readily available for the early identification of patients at risk for treatment failure. In a randomized trial comparing standard vs high-dose induction (ClinicalTrials.gov #NCT00495287), we studied early peripheral blast cell clearance (PBC) as a rapid predictive assay of chemotherapy response to determine whether it correlates with the achievement of complete remission (CR), as well as postremission outcome, according to induction intensity. Individual leukemia-associated immunophenotypes (LAIPs) identified pretherapy by flow cytometry were validated and quantified centrally after 3 days of treatment, expressing PBC on a logarithmic scale as the ratio of absolute LAIP+ cells on day 1 and day 4. Of 178 patients, 151 (84.8%) were evaluable. Patients in CR exhibited significantly higher median PBC (2.3 log) compared with chemoresistant patients (1.0 log; P < .0001). PBC < 1.0 predicted the worst outcome (CR, 28%). With 1.5 log established as the most accurate cutoff predicting CR, 87.5% of patients with PBC >1.5 (PBChigh, n = 96) and 43.6% of patients with PBC ≤1.5 (PBClow, n = 55) achieved CR after single-course induction (P < .0001). CR and PBChigh rates were increased in patients randomized to the high-dose induction arm (P = .04) and correlated strongly with genetic/cytogenetic risk. In multivariate analysis, PBC retained significant predictive power for CR, relapse risk, and survival. Thus, PBC analysis can provide a very early prediction of outcome, correlates with treatment intensity and disease subset, and may support studies of customized AML therapy.
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Affiliation(s)
- Giacomo Gianfaldoni
- Struttura Organizzativa Dipartimentale (SOD) Ematologia, Università di Firenze, and
| | - Francesco Mannelli
- Struttura Organizzativa Dipartimentale (SOD) Ematologia, Università di Firenze, and
- Centro Ricerca e Innovazione Malattie Mieloproliferative, Azienda Ospedaliero-Universitaria (AOU) Careggi, Florence, Italy
| | - Tamara Intermesoli
- Unità Strutturale Complessa di Ematologia, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - Sara Bencini
- Struttura Organizzativa Dipartimentale (SOD) Ematologia, Università di Firenze, and
- Centro Diagnostico di Citofluorimetria e Immunoterapia, AOU Careggi, Florence, Italy
| | - Damiano Giupponi
- Unità Strutturale Complessa di Ematologia, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - Giorgio Farina
- Unità Operativa Laboratorio Analisi-Citofluorimetria, Ospedale dell'Angelo, Mestre-Venezia, Italy
| | - Ilaria Cutini
- Struttura Organizzativa Dipartimentale (SOD) Ematologia, Università di Firenze, and
- SOD Terapie Cellulari e Medicina Trasfusionale, AOU Careggi, Florence, Italy
| | - Maria Ida Bonetti
- Struttura Organizzativa Dipartimentale (SOD) Ematologia, Università di Firenze, and
| | - Arianna Masciulli
- Unità Strutturale Complessa di Ematologia, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - Ernesta Audisio
- Struttura Complessa di Ematologia, Ospedale Molinette, Turin, Italy
| | - Dario Ferrero
- Divisione di Ematologia, Università di Torino, Azienda Ospedaliera S. Giovanni Battista, Turin, Italy; and
| | - Chiara Pavoni
- Unità Strutturale Complessa di Ematologia, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | | | - Alberto Bosi
- Struttura Organizzativa Dipartimentale (SOD) Ematologia, Università di Firenze, and
| | - Alessandro Rambaldi
- Unità Strutturale Complessa di Ematologia, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - Renato Bassan
- Unità Operativa di Ematologia, Ospedale dell'Angelo, Mestre-Venezia, Italy
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21
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Molecular Detection of Minimal Residual Disease before Allogeneic Stem Cell Transplantation Predicts a High Incidence of Early Relapse in Adult Patients with NPM1 Positive Acute Myeloid Leukemia. Cancers (Basel) 2019; 11:cancers11101455. [PMID: 31569375 PMCID: PMC6826431 DOI: 10.3390/cancers11101455] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 09/20/2019] [Accepted: 09/23/2019] [Indexed: 01/07/2023] Open
Abstract
We analyzed the impact of alloHSCT in a single center cohort of 89 newly diagnosed NPM1mut AML patients, consecutively treated according to the Northern Italy Leukemia Group protocol 02/06 [NCT00495287]. After two consolidation cycles, the detection of measurable residual disease (MRD) by RQ-PCR was strongly associated with an inferior three-year overall survival (OS, 45% versus 84%, p = 0.001) and disease-free survival (DFS, 44% versus 76%, p = 0.006). In MRD-negative patients, post-remissional consolidation with alloHSCT did not provide a significant additional benefit over a conventional chemotherapy in terms of overall survival [OS, 89% (95% CI 71–100%) versus 81% (95% CI 64–100%), p = 0.59] and disease-free survival [DFS, 80% (95% CI 59–100%) versus 75% (95% CI 56–99%), p = 0.87]. On the contrary, in patients with persistent MRD positivity, the three-year OS and DFS were improved in patients receiving an alloHSCT compared to those allocated to conventional chemotherapy (OS, 52% versus 31%, p = 0.45 and DFS, 50% versus 17%, p = 0.31, respectively). However, in this group of patients, the benefit of alloHSCT was still hampered by a high incidence of leukemia relapse during the first year after transplantation (43%, 95% CI 25–60%). Consolidative alloHSCT improves outcomes compared to standard chemotherapy in patients with persistent NPM1mut MRD positivity, but in these high-risk patients, the significant incidence of leukemia relapse must be tackled by post-transplant preemptive treatments.
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22
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Pollyea DA. Acute myeloid leukemia drug development in the post-venetoclax era. Am J Hematol 2019; 94:959-962. [PMID: 31179583 DOI: 10.1002/ajh.25556] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 06/06/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Daniel A. Pollyea
- Division of HematologyUniversity of Colorado Department of Medicine Aurora Colorado
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