1
|
Norsworthy KJ, DeZern AE, Tsai HL, Hand WA, Varadhan R, Gore SD, Gojo I, Pratz K, Carraway HE, Showel M, McDevitt MA, Gladstone D, Ghiaur G, Prince G, Seung AH, Benani D, Levis MJ, Karp JE, Smith BD. Timed sequential therapy for acute myelogenous leukemia: Results of a retrospective study of 301 patients and review of the literature. Leuk Res 2017; 61:25-32. [PMID: 28869816 DOI: 10.1016/j.leukres.2017.08.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 08/09/2017] [Accepted: 08/20/2017] [Indexed: 11/16/2022]
Abstract
Timed sequential therapy (TST) aims to improve outcomes in acute myelogenous leukemia (AML) by harnessing drug-induced cell cycle kinetics of AML, where a second drug is timed to coincide with peak leukemia proliferation induced by the first drugs. We analyzed outcomes in 301 newly diagnosed AML patients treated from 2004-2013 with cytarabine, anthracycline, and etoposide TST induction. Median age was 52 (range 20-74) and complete remission rate 68%. With median follow-up 5.8 years, 5-year DFS and overall survival (OS) were 37% (95% CI 31-45%) and 32% (95% CI 27-38%), respectively. In multivariate analysis, older age, unfavorable cytogenetics, and WBC≥50×109/L resulted in worse OS. Among patients not undergoing blood and marrow transplant, a propensity score analysis, which reduces imbalance in baseline characteristics, showed consolidation with TST compared with 1 or more cycles high-dose cytarabine trended toward lower DFS and post-remission survival with hazard ratio (HR) 1.9 (95% CI 0.9-4.0), and 1.6 (95% CI 0.7-3.6), respectively. Our results demonstrate the efficacy and feasibility of TST induction for newly diagnosed patients with AML, with results comparable to that seen in clinical trials with other TST therapies and 7+3.
Collapse
Affiliation(s)
- Kelly J Norsworthy
- Johns Hopkins University, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, United States
| | - Amy E DeZern
- Johns Hopkins University, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, United States
| | - Hua-Ling Tsai
- Johns Hopkins University, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, United States
| | - Wesley A Hand
- Johns Hopkins University, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, United States
| | - Ravi Varadhan
- Johns Hopkins University, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, United States
| | - Steven D Gore
- Johns Hopkins University, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, United States; Yale Cancer Center, New Haven, CT, United States
| | - Ivana Gojo
- Johns Hopkins University, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, United States
| | - Keith Pratz
- Johns Hopkins University, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, United States
| | - Hetty E Carraway
- Johns Hopkins University, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, United States; Cleveland Clinic, Taussig Cancer Institute, Cleveland, OH, United States
| | - Margaret Showel
- Johns Hopkins University, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, United States
| | - Michael A McDevitt
- Johns Hopkins University, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, United States; Global Medicines Development, AstraZeneca, Gaithersburg, MD, United States
| | - Douglas Gladstone
- Johns Hopkins University, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, United States
| | - Gabriel Ghiaur
- Johns Hopkins University, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, United States
| | - Gabrielle Prince
- Johns Hopkins University, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, United States
| | - Amy H Seung
- Johns Hopkins University, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, United States; AssistRx, Orlando, FL, United States
| | - Dina Benani
- Johns Hopkins University, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, United States
| | - Mark J Levis
- Johns Hopkins University, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, United States
| | - Judith E Karp
- Johns Hopkins University, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, United States
| | - B Douglas Smith
- Johns Hopkins University, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, United States.
| |
Collapse
|
3
|
Shen YM, Hung GY, Yen HJ, Hsieh MY, Hsieh TK. Early development of acute myeloid leukemia following treatment of osteosarcoma: a case report and review of the literature. Pediatr Neonatol 2009; 50:239-44. [PMID: 19856869 DOI: 10.1016/s1875-9572(09)60070-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
We report a case of treatment-related acute myeloid leukemia (t-AML) in a 16-year-old male following treatment for osteosarcoma (OS). He had been treated with a protocol comprising neoadjuvant chemotherapy, definitive surgery with wide excision and adjuvant chemotherapy for OS. Four months after completion of the treatment, a routine hemogram showed hyperleukocytosis with 90% blasts. Bone marrow aspirate and a chromosomal analysis disclosed acute myeloid leukemia (AML), M5b with 46, XY, t(11;19)(q23;p13.3). The t-AML was characterized by early development (just 4 months after completion of chemotherapy for OS) and generalized leukemia cutis. The patient received an alkylating agent (ifosfamide) and DNA topoisomerase II-targeted drugs (etoposide and doxorubicin). In terms of latency, cytogenetics, and presentation, DNA topoisomerase II-targeted drug-related leukemia seemed likely for this patient. Clinically, his leukemia cutis had developed during a nadir in white blood cell count after the first induction of chemotherapy for AML. The rapid progression and its refractoriness to chemotherapy were poor prognostic signs.
Collapse
Affiliation(s)
- Yu-Mei Shen
- Department of Pediatrics, Hsin Chu General Hospital, Hsinchu, Taiwan
| | | | | | | | | |
Collapse
|
4
|
Cornillon J, Fawaz A, Depil S, Dufosse F, Duhamel A, Bauters F, Fenaux P, Jouet JP, Yakoub-Agha I. Outcome of patients less than 55 years of age with high-risk acute leukemia who did not have an human leukocyte antigen-identical related donor: a long-term study of 97 consecutive patients. Leuk Lymphoma 2009; 46:841-9. [PMID: 16019528 DOI: 10.1080/10428190500080090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Between January 1993 and December 2000, an unrelated donor search (UDS) was initiated for 97 consecutive patients [46 acute lymphoblastic leukemia (ALL) and 51 acute myeloid leukemia (AML)]. Leukemia was considered to be of poor prognosis in cases of refractory disease (n=70), unfavourable karyotype (n=22) or miscellaneous (n=5). All patients had previously received various chemotherapies and 9 had undergone an autologous stem cell transplantation (SCT). The median age at UDS initiation was 25 (range 2.7-55) years. The median time to identify a suitable living donor or cord blood (CB) was 60 days. Eventually, 33 patients received unrelated allo-SCT (including 9 CB), 12 auto-SCT, 39 chemotherapy and 13 palliative treatment. At a median of 54 months, 18 patients were alive, including 15 in remission. The 4-year overall survival rates were 32%, 37%, 15% and 0% for allo-SCT, auto-SCT, chemotherapy or palliative treatment, respectively. Patients who received either allo- or auto-SCT had better survival than those who did not (P<0.0001). For ALL, only allo-SCT significantly improved survival (P<0.007). Finally, patients who received allo-SCT died less often of relapse than patients who did not (P<0.0001). Unrelated allo-SCT gives a substantial long-term survival and cure in patients with high-risk acute leukemia. For patients who achieve remission and for whom UDS fails, auto-SCT may prove to be a good approach. For patients who fail to enter into remission, intensive salvage chemotherapy has a very limited effect.
Collapse
|
5
|
Thomas X. The role of timed sequential chemotherapy in adult acute myelogenous leukemia. Curr Hematol Malig Rep 2008; 3:89-95. [PMID: 20425452 DOI: 10.1007/s11899-008-0014-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Consecutive trials of timed sequential chemotherapy (TSC) have been conducted in adults with acute myelogenous leukemia. The rationale for TSC was based on the observation that leukemic cells can be recruited synchronously into the cell cycle after initial intensive therapy, at which time they may become more susceptible to killing by chemotherapeutic agents. Achieving complete remission is essential for prolonged disease-free survival and may affect long-term outcome. TSC has led to higher rates of complete remission and has improved long-term outcomes. This article reviews the results of important trials in which TSC was used as an induction regimen in de novo, relapsed, or refractory acute myelogenous leukemia or as postremission therapy.
Collapse
Affiliation(s)
- Xavier Thomas
- Service d'Hématologie, Hôpital Edouard Herriot, Lyon Cedex 03, France.
| |
Collapse
|
7
|
He XY, Pohlman B, Lichtin A, Rybicki L, Kalaycio M. Timed-sequential chemotherapy with concomitant granulocyte colony-stimulating factor for newly diagnosed de novo acute myelogenous leukemia. Leukemia 2003; 17:1078-84. [PMID: 12764371 DOI: 10.1038/sj.leu.2402955] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
EMA, consisting of etoposide, mitoxantrone, and cytarabine, is a timed-sequential chemotherapy (TSC) regimen and an efficacious option for induction treatment of acute myelogenous leukemia (AML). Hematopoietic growth factors (HGFs) have been shown to recruit leukemic blasts into cell cycle. We postulated the addition of granulocyte colony-stimulating factor (G-CSF) to EMA (EMA-G) might enhance treatment efficacy. EMA-G consisted of mitoxantrone on days 1-3, cytarabine on days 1-3 and 8-10, etoposide on days 8-10, and G-CSF from day 4 until absolute neutrophil count (ANC) >500/microl. In total, 28 patients were enrolled. All patients had newly diagnosed de novo AML. The median age was 42 years. Of the 27 patients with cytogenetic analysis, six had favorable karyotype, 18 intermediate karyotype, and three unfavorable karyotype. The median follow-up was 37.5 months. The median time for both ANC recovery and last platelet transfusion was 26 days. The toxicities associated with this regimen were no more than those expected with the standard chemotherapy. In all, 24 (86%) patients achieved complete remission (CR), three (11%) patients had no response, and one patient died within 24 h of induction therapy before response could be evaluated. Of the 24 patients who achieved CR, 22 received high-dose cytosine arabinoside and two received allogeneic bone marrow transplant as initial postremission therapy. For the whole cohort, the estimated 3-year survival rate was 67%. The median relapse-free survival was 30.5 months. We conclude that EMA-G regimen is a safe regimen and administration of G-CSF during and after induction treatment is not associated with prolongation of marrow aplasia or acceleration of leukemia relapse. It is efficacious for induction therapy for newly diagnosed de novo AML. A high CR rate can be achieved with only one course of this chemotherapy.
Collapse
Affiliation(s)
- X-Y He
- Department of Hematology and Medical Oncology, 9500 Euclid Avenue, R35, The Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | | | | | | | | |
Collapse
|