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Chen J, Wang K, Xiao Z, Xu Z. Efficacy and safety of combination therapies vs monotherapy of hypomethylating agents in accelerated or blast phase of Philadelphia negative myeloproliferative neoplasms: a systematic review and meta-analysis. Ann Med 2023; 55:348-360. [PMID: 36644935 PMCID: PMC9848335 DOI: 10.1080/07853890.2022.2164611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND There is a lack of evidence regarding whether combination therapy of hypomethylating agents (HMAs) has better outcomes than HMA monotherapy in patients with Philadelphia chromosome-negative accelerated or blast phase myeloproliferative neoplasms (MPN-AP/BP). MATERIALS AND METHODS Pubmed, Embase, Web of Science and Cochrane library databases were searched for studies from inception of each database until 31 December 2021. Data extraction and synthesis were conducted following the PRISMA reporting guideline. RESULTS It was found that HMAs plus venetoclax therapy yielded a higher CR/CRi rate than HMAs alone [36% vs 19%, p = .0204] and a higher CR rate than HMAs plus ruxolitinib [22% vs 8%, p = .0313]. HMAs plus ruxolitinib combination showed a higher ORR than HMA monotherapy [45% vs 30%, p = .0395], but there was no improvement in CR/CRi. The one-year and two-year OS rate for patients treated with HMAs plus venetoclx/ruxolitinib demonstrated a trend towards prolonged survival than HMAs alone [HMAs plus venetoclax: 24% vs 11%, p = .1295 and 12% vs 3%, p = .2357; HMAs plus ruxolitinib: 25% vs 11%, p = .0774 and 33% vs 3%, p = .051]. CONCLUSION It was confirmed that HMA in combination with venetoclax is an effective and well-tolerated option in MPN-AP/BP patients in pre- as well as post-haematopoietic stem cell transplantation settings. HMA plus ruxolitinib therapy was revealed to be effective in patients with MPN-AP.Key MessagesCombination therapy with HMAs and venetoclax/ruxolitinib was associated with improved outcomes than HMAs alone in MPN-AP/BP patients.Further large-scale randomized controlled trials are needed to confirm regarding to the optimal treatment for this patient population.
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Affiliation(s)
- Jia Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China.,MDS and MPN Centre, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Kefei Wang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China
| | - Zhijian Xiao
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China.,MDS and MPN Centre, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Zefeng Xu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.,Tianjin Institutes of Health Science, Tianjin, China.,MDS and MPN Centre, Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
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Gaál L, Ruff E, Wiedemann Á, Svorenj S, Szita VR, Tóth AD, Masszi A, Horváth L, Szombath G, Nagy Z, Várkonyi J, Benedek S, Farkas P, Bödör C, Masszi T, Varga G. [How did the survival of acute myeloid leukemia change over the last ten years in our unit?]. Orv Hetil 2023; 164:1787-1794. [PMID: 37952177 DOI: 10.1556/650.2023.32901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 09/03/2023] [Indexed: 11/14/2023]
Abstract
INTRODUCTION Acute myeloid leukemia (AML) is a hematological malignancy with high mortality rate. The treatment is especially challenging in patients older than 65 years, which is the large majority of those. For patients unfit for intensive chemotherapy regimens, only palliative cytoreduction and basic supportive care used to be the options in our unit. However, from 2018, the azacitidine-venetoclax combination has been a new therapeutic alternative. This treatment resulted in marked survival benefit in clinical trials, however, its impact on the daily clinical practice and the entire patient population is unclear. OBJECTIVE Our goal was to evaluate how the application of azacitidine-venetoclax changed the treatment and survival of AML patients in our practice. METHOD We retrospectively analyzed the available clinical data of all AML patients treated consecutively between January 1, 2011 and December 31, 2021 at the 3rd Department of Internal Medicine (from 2020 onward called Department of Internal Medicine and Hematology), examining their treatment depending on the time period of therapy (2011-2017 and 2018-2021). Patients with acute promyelocytic leukemia were excluded. RESULTS 423 patients were diagnosed during this period. The number of cases showed a marked increase: in the first 7 years of our study, 184 patients were diagnosed, while this rose to 239 during the subsequent 4 years. The median age of patients was 67.6 years, with more than 60% of patients aged over 65. An improving trend can be observed in the overall survival: between 2011 and 2017, the median overall survival was 4.8 ± 0.9 months, while between 2018 and 2021, it was 8.3 ± 1.4 months (p = 0.051). Moreover, in the case of patients over 65 there was a significant overall survival improvement: 3.1 ± 0.5 vs. 4.9 ± 0.6 months (p = 0,01). The main factor behind this improvement could be that a large proportion of over 65 patients previously only fit for supportive care could now be treated with azacitidine-venetoclax: the percentage of actively treated patients grew from 57.1% to 75.3% in the second period. CONCLUSION The survival of patients unfit for curative therapy and older than 65 showed a steady increase which can be attributed to the introduction of new therapeutic alternatives. Orv Hetil. 2023; 164(45): 1787-1794.
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Affiliation(s)
- Lilla Gaál
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Budapest Magyarország
| | - Eszter Ruff
- 1 Semmelweis Egyetem, Általános Orvostudományi Kar Budapest Magyarország
| | - Ádám Wiedemann
- 2 Semmelweis Egyetem, Általános Orvostudományi Kar, Belgyógyászati és Hematológiai Klinika Budapest, Szentkirályi u. 46., 1088 Magyarország
| | - Szabolcs Svorenj
- 2 Semmelweis Egyetem, Általános Orvostudományi Kar, Belgyógyászati és Hematológiai Klinika Budapest, Szentkirályi u. 46., 1088 Magyarország
| | - Virág Réka Szita
- 2 Semmelweis Egyetem, Általános Orvostudományi Kar, Belgyógyászati és Hematológiai Klinika Budapest, Szentkirályi u. 46., 1088 Magyarország
| | - András Dávid Tóth
- 2 Semmelweis Egyetem, Általános Orvostudományi Kar, Belgyógyászati és Hematológiai Klinika Budapest, Szentkirályi u. 46., 1088 Magyarország
| | - András Masszi
- 2 Semmelweis Egyetem, Általános Orvostudományi Kar, Belgyógyászati és Hematológiai Klinika Budapest, Szentkirályi u. 46., 1088 Magyarország
| | - Laura Horváth
- 2 Semmelweis Egyetem, Általános Orvostudományi Kar, Belgyógyászati és Hematológiai Klinika Budapest, Szentkirályi u. 46., 1088 Magyarország
| | - Gergely Szombath
- 2 Semmelweis Egyetem, Általános Orvostudományi Kar, Belgyógyászati és Hematológiai Klinika Budapest, Szentkirályi u. 46., 1088 Magyarország
| | - Zsolt Nagy
- 2 Semmelweis Egyetem, Általános Orvostudományi Kar, Belgyógyászati és Hematológiai Klinika Budapest, Szentkirályi u. 46., 1088 Magyarország
| | - Judit Várkonyi
- 2 Semmelweis Egyetem, Általános Orvostudományi Kar, Belgyógyászati és Hematológiai Klinika Budapest, Szentkirályi u. 46., 1088 Magyarország
| | - Szabolcs Benedek
- 2 Semmelweis Egyetem, Általános Orvostudományi Kar, Belgyógyászati és Hematológiai Klinika Budapest, Szentkirályi u. 46., 1088 Magyarország
| | - Péter Farkas
- 2 Semmelweis Egyetem, Általános Orvostudományi Kar, Belgyógyászati és Hematológiai Klinika Budapest, Szentkirályi u. 46., 1088 Magyarország
| | - Csaba Bödör
- 3 Semmelweis Egyetem, Általános Orvostudományi Kar, Patológiai és Kísérleti Rákkutató Intézet Budapest Magyarország
| | - Tamás Masszi
- 2 Semmelweis Egyetem, Általános Orvostudományi Kar, Belgyógyászati és Hematológiai Klinika Budapest, Szentkirályi u. 46., 1088 Magyarország
| | - Gergely Varga
- 2 Semmelweis Egyetem, Általános Orvostudományi Kar, Belgyógyászati és Hematológiai Klinika Budapest, Szentkirályi u. 46., 1088 Magyarország
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Belhabri A, Heiblig M, Morisset S, Vila L, Santana C, Nicolas‐Virelizier E, Hayette S, Tigaud I, Plesa A, Labussiere‐Wallet H, Sobh M, Michallet A, Marie B, Nicolini F, Guillermin Y, Gaëlle F, Lebras L, Rey P, Jauffret‐Bertholon L, Laude M, Sandrine L, Michallet M. Clinical outcome of therapy-related acute myeloid leukemia patients. Real-life experience in a University Hospital and a Cancer Center in France. Cancer Med 2023; 12:16929-16944. [PMID: 37548369 PMCID: PMC10501294 DOI: 10.1002/cam4.6322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 06/17/2023] [Accepted: 06/27/2023] [Indexed: 08/08/2023] Open
Abstract
BACKGROUND t-AML occurs after a primary malignancy treatment and retains a poor prognosis. AIMS To determine the impact of primary malignancies, therapeutic strategies, and prognostic factors on clinical outcomes of t-AML. RESULTS A total of 112 adult patients were included in this study. Fifty-Five patients received intensive chemotherapy (IC), 33 non-IC, and 24 best supportive care. At t-AML diagnosis, 42% and 44% of patients presented an unfavorable karyotype and unfavorable 2010 ELN risk profile, respectively. Among treated patients (n = 88), 43 (49%) achieved complete remission: four out of 33 (12%) and 39 out of 55 (71%) in non-IC and IC groups, respectively. With a median follow-up of 5.5 months, the median overall survival (OS) and disease-free survival (DFS) for the whole population were 9 months and 6.3 months, respectively, and for the 88 treated patients 13.5 months and 8.2 months, respectively. Univariate analysis on OS and DFS showed a significant impact of high white blood cells (WBC) and blast counts at diagnosis, unfavorable karyotype and ELN classification. Multivariate analysis showed a negative impact of WBC count at diagnosis and a positive impact of chemotherapy on OS and DFS in the whole population. It also showed a negative impact of previous auto-HCT and high WBC count on OS and DFS and of IC on OS in treated patients which disappeared when we considered only confounding variables (age, previous cancers, marrow blasts, and 2010 ELN classification). In a pair-matched analysis comparing IC treated t-AML with de novo AML, there was no difference of OS and DFS between the two populations. CONCLUSION We showed, in this study that t-AML patients with unfavorable features represented almost half of the population. Best outcomes obtained in patients receiving IC must be balanced by known confounding variables and should be improved by using new innovative agents and therapeutic strategies.
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Affiliation(s)
- Amine Belhabri
- Department of HematologyLeon Berard Cancer CenterLyonFrance
| | - Mael Heiblig
- Department of HematologyUniversity Hospital Lyon SudPierre BeniteFrance
| | | | - Liliana Vila
- Department of HematologyLeon Berard Cancer CenterLyonFrance
| | | | | | - Sandrine Hayette
- Department of biology – GHSUniversity Hospital Lyon SudPierre BeniteFrance
| | - Isabelle Tigaud
- Department of biology – GHSUniversity Hospital Lyon SudPierre BeniteFrance
| | - Adriana Plesa
- Department of biology – GHSUniversity Hospital Lyon SudPierre BeniteFrance
| | | | - Mohamad Sobh
- Research Advisor, Faculty of MedicineUniversity of OttawaOttawaCanada
| | | | - Balsat Marie
- Department of HematologyUniversity Hospital Lyon SudPierre BeniteFrance
| | | | | | - Fossard Gaëlle
- Department of HematologyUniversity Hospital Lyon SudPierre BeniteFrance
| | - Laure Lebras
- Department of HematologyLeon Berard Cancer CenterLyonFrance
| | - Philippe Rey
- Department of HematologyLeon Berard Cancer CenterLyonFrance
| | | | | | - Loron Sandrine
- Department of HematologyUniversity Hospital Lyon SudPierre BeniteFrance
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Association between Prior Cytotoxic Therapy, Antecedent Hematologic Disorder, and Outcome after Allogeneic Hematopoietic Cell Transplantation in Adult Acute Myeloid Leukemia. Cancers (Basel) 2023; 15:cancers15020352. [PMID: 36672303 PMCID: PMC9856876 DOI: 10.3390/cancers15020352] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/20/2022] [Accepted: 01/03/2023] [Indexed: 01/06/2023] Open
Abstract
(1) Background: Secondary acute myeloid leukemia (AML), i.e., AML arising from prior therapy (therapy-related) and/or an antecedent hematologic disorder (AHD) is generally associated with worse outcomes compared to de novo AML. However, recognizing the prognostic importance of genetic characteristics rather than clinical history, secondary AML is now considered a diagnostic qualifier rather than a separate disease entity. (2) Methods: To assess the association between clinical history and AML outcomes in the context of allogeneic hematopoietic cell transplantation (HCT), we retrospectively analyzed 759 patients with de novo AML, 115 with AHD AML, and 105 with therapy-related AML who received first allografts while in first or second remission. (3) Results: At the time of HCT, these three cohorts differed significantly regarding many patient and disease-specific characteristics, including age (p < 0.001), gender (p < 0.001), disease risk (p = 0.005), HCT-CI score (p < 0.001), blood count recovery (p = 0.003), first vs. second remission (p < 0.001), remission duration (p < 0.001), measurable residual disease (MRD; p < 0.001), and conditioning intensity (p < 0.001). Relative to patients with de novo AML, relapse rates were similar for patients with AHD (hazard ratio [HR] = 1.07, p = 0.7) and therapy-related AML (HR = 0.86, p = 0.4) after multivariable adjustment, as were relapse-free survival (HR = 1.20, p = 0.2, and HR = 0.89, p = 0.5) and overall survival (HR = 1.19, p = 0.2, and HR = 0.93, p = 0.6). Non-relapse mortality was higher for AHD AML (HR = 1.59, p = 0.047). (4) Conclusions: These data suggest that the clinical history by itself contains limited prognostic value for adults with AML undergoing allografting, supporting the most recent approach to use this information as a diagnostic qualifier rather than a disease entity.
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Castaneda-Avila MA, Suárez Ramos T, Torres-Cintrón CR, Cotto-Santana LA, Tortolero-Luna G, Ortiz-Ortiz KJ. Induction Therapy and Survival for Acute Myeloid Leukemia in Hispanic Adults from Puerto Rico. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:e922-e930. [PMID: 35853812 DOI: 10.1016/j.clml.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 06/15/2022] [Accepted: 06/17/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Acute myeloid leukemia (AML) is the most common type of leukemia in adults. There are no previous studies evaluating AML treatment patterns in Puerto Rico. We describe the first-line therapy patterns and survival of patients diagnosed with AML in Puerto Rico using the Puerto Rico Central Cancer Registry Health Insurance Linkage Database (2011-2015). METHODS We describe patient characteristics according to intensive, non-intensive, and non-treatment status. We used Cox proportional hazard models to evaluate the factors associated with the risk of death stratified by intensive and non-intensive therapy. For this study, 385 patients with AML were included. RESULTS The mean age was 67 years old and 50.1% were female. Nearly half of AML patients (46.8%) received intensive treatment, 23.6% received non-intensive treatment, and 26.2% did not receive treatment. The overall 3-year survival rate was 17.9%. Among those who received intensive therapy, the risk of death among females was lower than males (hazard ratio [HR]: 0.64, 95% confidence interval [CI]: 0.44-0.93). Patients 60 years or older who received intensive treatment had a higher risk of death than younger patients (HR: 1.67, 95% CI: 1.09-2.55). Patients with poor/adverse risk receiving intensive (HR: 3.43, 95% CI: 1.76-6.69) or non-intensive (HR: 4.32, 95% CI: 1.66-11.28) treatment had a higher risk of death than patients with a favorable risk category. CONCLUSION Our findings are the first step to monitor the quality of care of patients with AML in Puerto Rico, particularly related to the administration of appropriate induction therapies, which is one of the most important predictors of AML survival.
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Affiliation(s)
- Maira A Castaneda-Avila
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA
| | - Tonatiuh Suárez Ramos
- Puerto Rico Central Cancer Registry, University of Puerto Rico, Comprehensive Cancer Center, San Juan, Puerto Rico
| | - Carlos R Torres-Cintrón
- Puerto Rico Central Cancer Registry, University of Puerto Rico, Comprehensive Cancer Center, San Juan, Puerto Rico
| | | | - Guillermo Tortolero-Luna
- Puerto Rico Central Cancer Registry, University of Puerto Rico, Comprehensive Cancer Center, San Juan, Puerto Rico; Division of Cancer Control and Population Sciences, University of Puerto Rico Comprehensive Cancer Center, San Juan, Puerto Rico
| | - Karen J Ortiz-Ortiz
- Puerto Rico Central Cancer Registry, University of Puerto Rico, Comprehensive Cancer Center, San Juan, Puerto Rico; Division of Cancer Control and Population Sciences, University of Puerto Rico Comprehensive Cancer Center, San Juan, Puerto Rico; Department of Health Services Administration, Graduate School of Public Health, Medical Sciences Campus, University of Puerto Rico, San Juan, Puerto Rico.
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Castillo Tokumori F, Al Ali N, Chan O, Sallman D, Yun S, Sweet K, Padron E, Lancet J, Komrokji R, Kuykendall AT. Comparison of Different Treatment Strategies for Blast-Phase Myeloproliferative Neoplasms. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:e521-e525. [PMID: 35241387 PMCID: PMC10766145 DOI: 10.1016/j.clml.2022.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 01/26/2022] [Accepted: 01/28/2022] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Up to 20% of patients with myeloproliferative neoplasms (MPN) will progress to blast phase (MPN-BP). Outcomes are dismal, with intensive chemotherapy providing little benefit. Low-intensity therapy is preferred due to better tolerability, but the prognosis remains poor. Allogeneic stem cell transplant (AHSCT) is still the only potential for long term survival. PATIENTS AND METHODS To better evaluate the initial treatment approach in MPN-BP, we performed a single-institution retrospective analysis of 75 patients with MPN-BP treated at Moffitt Cancer Center between 2001 and 2021. Patients were stratified by initial treatment: best supportive care (BSC), hypomethylating agent (HMA)-based therapy or intensive chemotherapy (IC). RESULTS Median overall survival (mOS) for the entire cohort was 4.8 months (BSC 0.8 months, HMA 4.7 months, and IC 11.4 months). Among IC patients, improved survival was evident in those that received AHSCT (mOS 40.8 months vs. 4.9 months, p < .01). Most patients that underwent AHSCT were initially treated with IC (p < .01). All patients that underwent AHSCT had achieved complete response (CR) or CR with incomplete hematological recovery (CRi). On multivariate analysis, factors associated with improved survival were receipt of therapy (HMA or IC) (P = .017), CR/CRi (P = .037) and receipt of AHSCT (p < .001). CONCLUSION We show that active treatment with IC improves survival, but it is mostly tied to receipt of AHSCT. IC is a reasonable approach in appropriate patients as it can provide an effective bridge to AHSCT. Other treatment strategies such as molecularly targeted therapy and novel agents are desperately needed.
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Affiliation(s)
- Franco Castillo Tokumori
- University of South Florida, Morsani College of Medicine, Department of Internal Medicine. Tampa, FL; H. Lee Moffitt Cancer Center & Research Institute, Department of Malignant Hematology. Tampa, FL.
| | - Najla Al Ali
- H. Lee Moffitt Cancer Center & Research Institute, Department of Malignant Hematology. Tampa, FL
| | - Onyee Chan
- H. Lee Moffitt Cancer Center & Research Institute, Department of Malignant Hematology. Tampa, FL
| | - David Sallman
- H. Lee Moffitt Cancer Center & Research Institute, Department of Malignant Hematology. Tampa, FL
| | - Seongseok Yun
- H. Lee Moffitt Cancer Center & Research Institute, Department of Malignant Hematology. Tampa, FL
| | - Kendra Sweet
- H. Lee Moffitt Cancer Center & Research Institute, Department of Malignant Hematology. Tampa, FL
| | - Eric Padron
- H. Lee Moffitt Cancer Center & Research Institute, Department of Malignant Hematology. Tampa, FL
| | - Jeffrey Lancet
- H. Lee Moffitt Cancer Center & Research Institute, Department of Malignant Hematology. Tampa, FL
| | - Rami Komrokji
- H. Lee Moffitt Cancer Center & Research Institute, Department of Malignant Hematology. Tampa, FL
| | - Andrew T Kuykendall
- H. Lee Moffitt Cancer Center & Research Institute, Department of Malignant Hematology. Tampa, FL
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Short NJ, Kantarjian H. Choosing between intensive and less intensive front-line treatment approaches for older patients with newly diagnosed acute myeloid leukaemia. Lancet Haematol 2022; 9:e535-e545. [PMID: 35772432 DOI: 10.1016/s2352-3026(22)00167-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 05/12/2022] [Accepted: 05/17/2022] [Indexed: 06/15/2023]
Abstract
The outcomes of older patients with acute myeloid leukaemia are inferior to their younger counterparts, because, in part, of a more aggressive disease biology and poorer tolerance of cytotoxic chemotherapy. Although intensive chemotherapy was historically considered the only effective treatment for these patients, many older patients are not suitable for intensive chemotherapy owing to comorbidities or general frailty. Determination of patient fitness for intensive chemotherapy is imperfect, and even older patients who appear to be suitable (also known as fit) for intensive chemotherapy can have high rates of morbidity and early and late mortality with this approach. Fortunately, the outcomes of older or unfit patients with acute myeloid leukaemia have substantially improved with the use of a hypomethylating agent plus venetoclax in the front-line setting. Although the formal approval of this combination is limited to patients aged 75 years or older, or those with a clinically significant comorbidity, the high response rates and survival improvement in these patients have led many practitioners to consider this low-intensity regimen in older patients without significant comorbidities and even in younger patients with high-risk disease features for whom the expected outcomes with intensive chemotherapy are poor. Modifications to the hypomethylating agent plus venetoclax backbone might further improve the outlook for these patients, particularly in some acute myeloid leukaemia subsets with a targetable mutation. In this Viewpoint, we review the retrospective and prospective data supporting both intensive chemotherapy and low-intensity venetoclax-based approaches in older patients with acute myeloid leukaemia. We also discuss our own approach to the management of older or unfit patients with acute myeloid leukaemia, including how cytomolecular features have a role in establishing the optimal front-line therapy.
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Affiliation(s)
- Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Chauvet P, Nibourel O, Berthon C, Goursaud L, Carpentier B, Lionne-Huyghe P, Wemeau M, Quesnel B. Resurgence of myeloproliferative neoplasm in patients in remission from blast transformation after treatment with hypomethylating agents. Leuk Res 2022; 118:106871. [DOI: 10.1016/j.leukres.2022.106871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 05/16/2022] [Accepted: 05/19/2022] [Indexed: 11/28/2022]
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Gadaud N, Leroy H, Bérard E, Tavitian S, Leguay T, Dimicoli-Salazar S, Rieu JB, Luquet I, Largeaud L, Bidet A, Delabesse E, Klein E, Sarry A, de Grande AC, Bories P, Pigneux A, Récher C, Dumas PY, Bertoli S. Azacitidine, intensive chemotherapy or best supportive care in relapsed or refractory acute myeloid leukemia, a DATAML registry study. Leuk Lymphoma 2022; 63:1398-1406. [DOI: 10.1080/10428194.2021.2022140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Noémie Gadaud
- Service d’Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | - Harmony Leroy
- Centre Hospitalier Universitaire de Bordeaux, Service d’Hématologie Clinique et de Thérapie Cellulaire, Bordeaux, France
| | - Emilie Bérard
- Service d’Epidémiologie, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
- CERPOP, Université de Toulouse, Inserm, UPS, Toulouse, France
| | - Suzanne Tavitian
- Service d’Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | - Thibaut Leguay
- Centre Hospitalier Universitaire de Bordeaux, Service d’Hématologie Clinique et de Thérapie Cellulaire, Bordeaux, France
| | - Sophie Dimicoli-Salazar
- Centre Hospitalier Universitaire de Bordeaux, Service d’Hématologie Clinique et de Thérapie Cellulaire, Bordeaux, France
| | - Jean-Baptiste Rieu
- Laboratoire d’Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | - Isabelle Luquet
- Laboratoire d’Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | - Laetitia Largeaud
- Laboratoire d’Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
- Université Toulouse III Paul Sabatier, Toulouse, France
- Cancer Research Center of Toulouse, UMR1037 INSERM, ERL5294 CNRS, Toulouse, France
| | - Audrey Bidet
- Laboratoire d’Hématologie Biologique, CHU Bordeaux, Bordeaux, France
| | - Eric Delabesse
- Laboratoire d’Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
- Université Toulouse III Paul Sabatier, Toulouse, France
- Cancer Research Center of Toulouse, UMR1037 INSERM, ERL5294 CNRS, Toulouse, France
| | - Emilie Klein
- Laboratoire d’Hématologie Biologique, CHU Bordeaux, Bordeaux, France
| | - Audrey Sarry
- Service d’Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | - Anne-Charlotte de Grande
- Centre Hospitalier Universitaire de Bordeaux, Service d’Hématologie Clinique et de Thérapie Cellulaire, Bordeaux, France
| | - Pierre Bories
- Service d’Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
| | - Arnaud Pigneux
- Centre Hospitalier Universitaire de Bordeaux, Service d’Hématologie Clinique et de Thérapie Cellulaire, Bordeaux, France
- Université de Bordeaux, Bordeaux, France
- Institut National de la Santé et de la Recherche Médicale, Bordeaux, France
| | - Christian Récher
- Service d’Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
- Université Toulouse III Paul Sabatier, Toulouse, France
- Cancer Research Center of Toulouse, UMR1037 INSERM, ERL5294 CNRS, Toulouse, France
| | - Pierre-Yves Dumas
- Centre Hospitalier Universitaire de Bordeaux, Service d’Hématologie Clinique et de Thérapie Cellulaire, Bordeaux, France
- Université de Bordeaux, Bordeaux, France
- Institut National de la Santé et de la Recherche Médicale, Bordeaux, France
| | - Sarah Bertoli
- Service d’Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France
- Université Toulouse III Paul Sabatier, Toulouse, France
- Cancer Research Center of Toulouse, UMR1037 INSERM, ERL5294 CNRS, Toulouse, France
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10
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Treatment patterns and outcomes of 2310 patients with secondary acute myeloid leukemia: a PETHEMA registry study. Blood Adv 2021; 6:1278-1295. [PMID: 34794172 PMCID: PMC8864639 DOI: 10.1182/bloodadvances.2021005335] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 10/12/2021] [Indexed: 11/20/2022] Open
Abstract
The large PETHEMA registry shows that secondary AML represents 27% of AML cases and confirms its independent adverse prognostic value. Subcategories of secondary AML were analyzed, including MSD/MPN and therapy-related cases, with different features and outcomes.
Secondary acute myeloid leukemia (sAML) comprises a heterogeneous group of patients and is associated with poor overall survival (OS). We analyze the characteristics, treatment patterns, and outcomes of adult patients with sAML in the Programa Español de Tratamientos en Hematología (PETHEMA) registry. Overall, 6211 (72.9%) were de novo and 2310 (27.1%) had sAML, divided into myelodysplastic syndrome AML (MDS-AML, 44%), MDS/myeloproliferative AML (MDS/MPN-AML, 10%), MPN-AML (11%), therapy-related AML (t-AML, 25%), and antecedent neoplasia without prior chemotherapy/radiotherapy (neo-AML, 9%). Compared with de novo, patients with sAML were older (median age, 69 years), had more Eastern Cooperative Oncology Group ≥2 (35%) or high-risk cytogenetics (40%), less FMS-like tyrosine kinase 3 internal tandem duplication (11%), and nucleophosmin 1 (NPM1) mutations (21%) and received less intensive chemotherapy regimens (38%) (all P < .001). Median OS was higher for de novo than sAML (10.9 vs 5.6 months; P < .001) and shorter in sAML after hematologic disorder (MDS, MDS/MPN, or MPN) compared with t-AML and neo-AML (5.3 vs 6.1 vs 5.7 months, respectively; P = .04). After intensive chemotherapy, median OS was better among patients with de novo and neo-AML (17.2 and 14.6 months, respectively). No OS differences were observed after hypomethylating agents according to type of AML. sAML was an independent adverse prognostic factor for OS. We confirmed high prevalence and adverse features of sAML and established its independent adverse prognostic value. This trial was registered at www.clinicaltrials.gov as #NCT02607059.
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11
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Long-term survival after intensive chemotherapy or hypomethylating agents in AML patients aged 70 years and older: a large patient data set study from European registries. Leukemia 2021; 36:913-922. [PMID: 34775483 PMCID: PMC8979811 DOI: 10.1038/s41375-021-01425-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 09/02/2021] [Accepted: 09/13/2021] [Indexed: 11/25/2022]
Abstract
The outcome of acute myeloid leukemia patients aged 70 years or older is poor. Defining the best treatment option remains controversial especially when choosing between intensive chemotherapy and hypomethylating agents. We set up a multicentric European database collecting data of 3 700 newly diagnosed acute myeloid leukemia patients ≥70 years. The primary objective was to compare overall survival in patients selected for intensive chemotherapy (n = 1199) or hypomethylating agents (n = 1073). With a median follow-up of 49.5 months, the median overall survival was 10.9 (95% CI: 9.7–11.6) and 9.2 months (95% CI: 8.3–10.2) with chemotherapy and hypomethylating agents, respectively. Complete remission or complete remission with incomplete hematologic recovery was 56.1% and 19.7% with chemotherapy and hypomethylating agents, respectively (P < 0.0001). Treatment effect on overall survival was time-dependent. The Royston and Parmar model showed that patients treated with hypomethylating agents had a significantly lower risk of death before 1.5 months of follow-up; no significant difference between 1.5 and 4.0 months, whereas patients treated with intensive chemotherapy had a significantly better overall survival from four months after start of therapy. This study shows that intensive chemotherapy remains a valuable option associated with a better long-term survival in older AML patients.
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12
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Goel H, Rahul E, Gupta I, Chopra A, Ranjan A, Gupta AK, Meena JP, Viswanathan GK, Bakhshi S, Misra A, Hussain S, Kumar R, Singh A, Rath GK, Sharma A, Mittan S, Tanwar P. Molecular and genomic landscapes in secondary & therapy related acute myeloid leukemia. AMERICAN JOURNAL OF BLOOD RESEARCH 2021; 11:472-497. [PMID: 34824881 PMCID: PMC8610791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 09/04/2021] [Indexed: 06/13/2023]
Abstract
Acute myeloid leukemia (AML) is a complex, aggressive myeloid neoplasm characterized by frequent somatic mutations that influence different functional categories' genes, resulting in maturational arrest and clonal expansion. AML can arise de novo (dn-AML) or can be secondary AML (s-AML) refers to a leukemic process which may arise from an antecedent hematologic disorder (AHD-AML), mostly from a myelodysplastic syndrome (MDS) or myeloproliferative neoplasm (MPN) or can be the result of an antecedent cytotoxic chemotherapy or radiation therapy (therapy-related AML, t-AML). Clinical and biological features in secondary and therapy-related AML are distinct from de novo AML. Secondary and therapy-related AML occurs mainly in the elderly population and responds worse to therapy with higher relapse rates due to resistance to cytotoxic chemotherapy. Over the last decade, advances in molecular genetics have disclosed the sub-clonal architecture of secondary and therapy-related AML. Recent investigations have revealed that cytogenetic abnormalities and underlying genetic aberrations (mutations) are likely to be significant factors dictating prognosis and critical impacts on treatment outcome. Secondary and therapy-related AML have a poorer outcome with adverse cytogenetic abnormalities and higher recurrences of unfavorable mutations compared to de novo AML. In this review, we present an overview of the clinical features of secondary and therapy-related AML and address the function of genetic mutations implicated in the pathogenesis of secondary leukemia. Detailed knowledge of the pathogenetic mechanisms gives an overview of new prognostic markers, including targetable mutations that will presumably lead to the designing and developing novel molecular targeted therapies for secondary and therapy-related AML. Despite significant advances in knowing the genetic aspect of secondary and therapy-related AML, its influence on the disease's pathophysiology, standard treatment prospects have not significantly evolved during the past three decades. Thus, we conclude this review by summarizing the modern and developing treatment strategies in secondary and therapy-related acute myeloid leukemia.
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Affiliation(s)
- Harsh Goel
- Laboratory Oncology Unit, Dr.B.R.A. Institute Rotary Cancer Hospital All India Institute of Medical SciencesNew Delhi 110029, India
| | - Ekta Rahul
- Laboratory Oncology Unit, Dr.B.R.A. Institute Rotary Cancer Hospital All India Institute of Medical SciencesNew Delhi 110029, India
| | - Ishan Gupta
- All India Institute of Medical SciencesNew Delhi 110029, India
| | - Anita Chopra
- Laboratory Oncology Unit, Dr.B.R.A. Institute Rotary Cancer Hospital All India Institute of Medical SciencesNew Delhi 110029, India
| | - Amar Ranjan
- Laboratory Oncology Unit, Dr.B.R.A. Institute Rotary Cancer Hospital All India Institute of Medical SciencesNew Delhi 110029, India
| | - Aditya Kumar Gupta
- Division of Pediatric Oncology, Department of Pediatrics, All India Institute of Medical Sciences New DelhiNew Delhi 110029, India
| | - Jagdish Prasad Meena
- Division of Pediatric Oncology, Department of Pediatrics, All India Institute of Medical Sciences New DelhiNew Delhi 110029, India
| | - Ganesh Kumar Viswanathan
- Department of Hematology, All India Institute of Medical Sciences New DelhiNew Delhi 110029, India
| | - Sameer Bakhshi
- Department of Medical Oncology, Dr.B.R.A. Institute Rotary Cancer Hospital All India Institute of Medical Sciences New DelhiNew Delhi 110029, India
| | - Aroonima Misra
- National Institute of Pathology, ICMRNew Delhi 110029, India
| | - Showket Hussain
- Division Of Molecular Oncology, National Institute of Cancer Prevention & Research I-7, Sector-39Noida 201301, India
| | - Ritesh Kumar
- Department of Radiation Oncology, Rudgers Cancer Institute of New JerseyNJ 07103, United States
| | - Archana Singh
- Department of Pathology, College of Medical Sciences, Rajasthan University of Health SciencesJaipur 302033, India
| | - GK Rath
- Department of Radiotherapy, Dr.B.R.A. Institute Rotary Cancer Hospital All India Institute of Medical Sciences New DelhiNew Delhi 110029, India
| | - Ashok Sharma
- Department of Biochemistry, All India Institute of Medical Sciences New DelhiNew Delhi 110029, India
| | - Sandeep Mittan
- Department of Cardiology, Ichan School of Medicine, Mount Sinai Hospital1468 Madison Avenue, New York 10028, United States
| | - Pranay Tanwar
- Laboratory Oncology Unit, Dr.B.R.A. Institute Rotary Cancer Hospital All India Institute of Medical SciencesNew Delhi 110029, India
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13
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Short NJ, Kantarjian H. When Less Is More: Reevaluating the Role of Intensive Chemotherapy for Older Adults With Acute Myeloid Leukemia in the Modern Era. J Clin Oncol 2021; 39:3104-3108. [PMID: 34406793 PMCID: PMC8478366 DOI: 10.1200/jco.21.00960] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 06/29/2021] [Accepted: 07/30/2021] [Indexed: 11/20/2022] Open
Affiliation(s)
- Nicholas J. Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
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14
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Shahin OA, Chifotides HT, Bose P, Masarova L, Verstovsek S. Accelerated Phase of Myeloproliferative Neoplasms. Acta Haematol 2021; 144:484-499. [PMID: 33882481 DOI: 10.1159/000512929] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 11/09/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Myeloproliferative neoplasms (MPNs) can transform into blast phase MPN (leukemic transformation; MPN-BP), typically via accelerated phase MPN (MPN-AP), in ∼20-25% of the cases. MPN-AP and MPN-BP are characterized by 10-19% and ≥20% blasts, respectively. MPN-AP/BP portend a dismal prognosis with no established conventional treatment. Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is the sole modality associated with long-term survival. SUMMARY MPN-AP/BP has a markedly different mutational profile from de novo acute myeloid leukemia (AML). In MPN-AP/BP, TP53 and IDH1/2 are more frequent, whereas FLT3 and DNMT3A are rare. Higher incidence of leukemic transformation has been associated with the most aggressive MPN subtype, myelofibrosis (MF); other risk factors for leukemic transformation include rising blast counts above 3-5%, advanced age, severe anemia, thrombocytopenia, leukocytosis, increasing bone marrow fibrosis, type 1 CALR-unmutated status, lack of driver mutations (negative for JAK2, CALR, or MPL genes), adverse cytogenetics, and acquisition of ≥2 high-molecular risk mutations (ASXL1, EZH2, IDH1/2, SRSF2, and U2AF1Q157). The aforementioned factors have been incorporated in several novel prognostic scoring systems for MF. Currently, elderly/unfit patients with MPN-AP/BP are treated with hypomethylating agents with/without ruxolitinib; these regimens appear to confer comparable benefit to intensive chemotherapy but with lower toxicity. Retrospective studies in patients who acquired actionable mutations during MPN-AP/BP showed positive outcomes with targeted AML treatments, such as IDH1/2 inhibitors, and require further evaluation in clinical trials. Key Messages: Therapy for MPN-AP patients represents an unmet medical need. MF patients, in particular, should be appropriately stratified regarding their prognosis and the risk for transformation. Higher-risk patients should be monitored regularly and treated prior to progression to MPN-BP. MPN-AP patients may be treated with hypomethylating agents alone or in combination with ruxolitinib; also, patients can be provided with the option to enroll in rationally designed clinical trials exploring combination regimens, including novel targeted drugs, with an ultimate goal to transition to transplant.
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Affiliation(s)
- Omar A Shahin
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Helen T Chifotides
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Prithviraj Bose
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Lucia Masarova
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Srdan Verstovsek
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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15
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Chang Y, Guyatt GH, Teich T, Dawdy JL, Shahid S, Altman JK, Stone RM, Sekeres MA, Mukherjee S, LeBlanc TW, Abel GA, Hourigan CS, Litzow MR, Michaelis LC, Alibhai SMH, Desai P, Buckstein R, MacEachern J, Brignardello-Petersen R. Intensive versus less-intensive antileukemic therapy in older adults with acute myeloid leukemia: A systematic review. PLoS One 2021; 16:e0249087. [PMID: 33784346 PMCID: PMC8009379 DOI: 10.1371/journal.pone.0249087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 03/08/2021] [Indexed: 12/18/2022] Open
Abstract
To compare the effectiveness and safety of intensive antileukemic therapy to less-intensive therapy in older adults with acute myeloid leukemia (AML) and intermediate or adverse cytogenetics, we searched the literature in Medline, Embase, and CENTRAL to identify relevant studies through July 2020. We reported the pooled hazard ratios (HRs), risk ratios (RRs), mean difference (MD) and their 95% confidence intervals (CIs) using random-effects meta-analyses and the certainty of evidence using the GRADE approach. Two randomized trials enrolling 529 patients and 23 observational studies enrolling 7296 patients proved eligible. The most common intensive interventions included cytarabine-based intensive chemotherapy, combination of cytarabine and anthracycline, or daunorubicin/idarubicin, and cytarabine plus idarubicin. The most common less-intensive therapies included low-dose cytarabine alone, or combined with clofarabine, azacitidine, and hypomethylating agent-based chemotherapy. Low certainty evidence suggests that patients who receive intensive versus less-intensive therapy may experience longer survival (HR 0.87; 95% CI, 0.76-0.99), a higher probability of receiving allogeneic hematopoietic stem cell transplantation (RR 6.14; 95% CI, 4.03-9.35), fewer episodes of pneumonia (RR, 0.25; 95% CI, 0.06-0.98), but a greater number of severe, treatment-emergent adverse events (RR, 1.34; 95% CI, 1.03-1.75), and a longer duration of intensive care unit hospitalization (MD, 6.84 days longer; 95% CI, 3.44 days longer to 10.24 days longer, very low certainty evidence). Low certainty evidence due to confounding in observational studies suggest superior overall survival without substantial treatment-emergent adverse effect of intensive antileukemic therapy over less-intensive therapy in older adults with AML who are candidates for intensive antileukemic therapy.
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Affiliation(s)
- Yaping Chang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Gordon H. Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Trevor Teich
- Drexel University College of Medicine, Philadelphia, Pennsylvania, United States of America
| | - Jamie L. Dawdy
- School of Nursing, McMaster University, Hamilton, Ontario, Canada
| | - Shaneela Shahid
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Jessica K. Altman
- Division of Hematology/Oncology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America
| | - Richard M. Stone
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, United States of America
| | - Mikkael A. Sekeres
- Leukemia Program, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Sudipto Mukherjee
- Leukemia Program, Cleveland Clinic, Cleveland, Ohio, United States of America
| | - Thomas W. LeBlanc
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Gregory A. Abel
- Division of Hematologic Malignances and Population Sciences, Dana-Farber Cancer Institute, Boston, Massachusetts, United States of America
| | - Christopher S. Hourigan
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Mark R. Litzow
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Laura C. Michaelis
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - Shabbir M. H. Alibhai
- Department of Medicine, University Health Network & University of Toronto, Toronto, Ontario, Canada
| | - Pinkal Desai
- Weill Cornell Medicine, New York City, New York, United States of America
| | - Rena Buckstein
- Odette Cancer Centre, Division of Medical Oncology and Hematology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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16
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Bories P, Prade N, Lagarde S, Cabarrou B, Largeaud L, Plenecassagnes J, Luquet I, De Mas V, Filleron T, Cassou M, Sarry A, Fornecker LM, Simand C, Bertoli S, Recher C, Delabesse E. Impact of TP53 mutations in acute myeloid leukemia patients treated with azacitidine. PLoS One 2020; 15:e0238795. [PMID: 33001991 PMCID: PMC7529302 DOI: 10.1371/journal.pone.0238795] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 08/24/2020] [Indexed: 12/31/2022] Open
Abstract
Hypomethylating agents are a classical frontline low-intensity therapy for older patients with acute myeloid leukemia. Recently, TP53 gene mutations have been described as a potential predictive biomarker of better outcome in patients treated with a ten-day decitabine regimen., However, functional characteristics of TP53 mutant are heterogeneous, as reflected in multiple functional TP53 classifications and their impact in patients treated with azacitidine is less clear. We analyzed the therapeutic course and outcome of 279 patients treated with azacitidine between 2007 and 2016, prospectively enrolled in our regional healthcare network. By screening 224 of them, we detected TP53 mutations in 55 patients (24.6%), including 53 patients (96.4%) harboring high-risk cytogenetics. The identification of any TP53 mutation was associated with worse overall survival but not with response to azacitidine in the whole cohort and in the subgroup of patients with adverse karyotype. Stratification of patients according to three recent validated functional classifications did not allow the identification of TP53 mutated patients who could benefit from azacitidine. Systematic TP53 mutant classification will deserve further exploration in the setting of patients treated with conventional therapy and in the emerging field of therapies targeting TP53 pathway.
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MESH Headings
- Aged
- Aged, 80 and over
- Antimetabolites, Antineoplastic/therapeutic use
- Azacitidine/therapeutic use
- Biomarkers, Tumor/genetics
- Female
- France/epidemiology
- Genes, p53
- Humans
- Kaplan-Meier Estimate
- Leukemia, Myeloid, Acute/drug therapy
- Leukemia, Myeloid, Acute/genetics
- Leukemia, Myeloid, Acute/mortality
- Male
- Middle Aged
- Mutation
- Prognosis
- Prospective Studies
- Registries
- Tumor Suppressor Protein p53/genetics
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Affiliation(s)
- Pierre Bories
- Laboratoire d'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
- Service d'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
- Réseau Onco-occitanie, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
- * E-mail:
| | - Naïs Prade
- Laboratoire d'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
| | - Stéphanie Lagarde
- Laboratoire d'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
| | - Bastien Cabarrou
- Unité de biostatistique, Institut Claudius Régaud, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
| | - Laetitia Largeaud
- Laboratoire d'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
| | - Julien Plenecassagnes
- Unité de bioinformatique, Institut Claudius Régaud, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
| | - Isabelle Luquet
- Laboratoire d'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
| | - Véronique De Mas
- Laboratoire d'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
| | - Thomas Filleron
- Unité de biostatistique, Institut Claudius Régaud, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
| | - Manon Cassou
- Unité de bioinformatique, Institut Claudius Régaud, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
| | - Audrey Sarry
- Service d'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
| | - Luc-Matthieu Fornecker
- Service d'Onco-Hématologie, Centre Hospitalier Universitaire de Strasbourg, Strasbourg, France
| | - Célestine Simand
- Service d'Onco-Hématologie, Centre Hospitalier Universitaire de Strasbourg, Strasbourg, France
| | - Sarah Bertoli
- Service d'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
| | - Christian Recher
- Service d'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
| | - Eric Delabesse
- Laboratoire d'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
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17
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Sekeres MA, Guyatt G, Abel G, Alibhai S, Altman JK, Buckstein R, Choe H, Desai P, Erba H, Hourigan CS, LeBlanc TW, Litzow M, MacEachern J, Michaelis LC, Mukherjee S, O'Dwyer K, Rosko A, Stone R, Agarwal A, Colunga-Lozano LE, Chang Y, Hao Q, Brignardello-Petersen R. American Society of Hematology 2020 guidelines for treating newly diagnosed acute myeloid leukemia in older adults. Blood Adv 2020; 4:3528-3549. [PMID: 32761235 PMCID: PMC7422124 DOI: 10.1182/bloodadvances.2020001920] [Citation(s) in RCA: 116] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 05/08/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Older adults with acute myeloid leukemia (AML) represent a vulnerable population in whom disease-based and clinical risk factors, patient goals, prognosis, and practitioner- and patient-perceived treatment risks and benefits influence treatment recommendations. OBJECTIVE These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in their decisions about management of AML in older adults. METHODS ASH formed a multidisciplinary guideline panel that included specialists in myeloid leukemia, geriatric oncology, patient-reported outcomes and decision-making, frailty, epidemiology, and methodology, as well as patients. The McMaster Grading of Recommendations Assessment, Development and Evaluation (GRADE) Centre supported the guideline-development process, including performing systematic evidence reviews (up to 24 May 2019). The panel prioritized clinical questions and outcomes according to their importance to patients, as judged by the panel. The panel used the GRADE approach, including GRADE's Evidence-to-Decision frameworks, to assess evidence and make recommendations, which were subject to public comment. RESULTS The panel agreed on 6 critical questions in managing older adults with AML, mirroring real-time practitioner-patient conversations: the decision to pursue antileukemic treatment vs best supportive management, the intensity of therapy, the role and duration of postremission therapy, combination vs monotherapy for induction and beyond, duration of less-intensive therapy, and the role of transfusion support for patients no longer receiving antileukemic therapy. CONCLUSIONS Treatment is recommended over best supportive management. More-intensive therapy is recommended over less-intensive therapy when deemed tolerable. However, these recommendations are guided by the principle that throughout a patient's disease course, optimal care involves ongoing discussions between clinicians and patients, continuously addressing goals of care and the relative risk-benefit balance of treatment.
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Affiliation(s)
- Mikkael A Sekeres
- Leukemia Program, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Gregory Abel
- Leukemia Division, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Shabbir Alibhai
- Institute of Medical Sciences, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Jessica K Altman
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Rena Buckstein
- Odette Cancer Centre, Division of Medical Oncology and Hematology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Hannah Choe
- Division of Hematology, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Pinkal Desai
- Division of Hematology and Medical Oncology, Weill Cornell Medicine, New York, NY
| | - Harry Erba
- Department of Medicine, School of Medicine, Duke University, Durham, NC
| | | | - Thomas W LeBlanc
- Department of Medicine, School of Medicine, Duke University, Durham, NC
| | - Mark Litzow
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | - Laura C Michaelis
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Sudipto Mukherjee
- Leukemia Program, Taussig Cancer Center, Cleveland Clinic, Cleveland, OH
| | - Kristen O'Dwyer
- Division of Hematology/Oncology, Department of Medicine, University of Rochester, Rochester, NY
| | - Ashley Rosko
- Division of Hematology, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Richard Stone
- Leukemia Division, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Arnav Agarwal
- Department of Internal Medicine, University of Toronto, Toronto, ON, Canada
| | - L E Colunga-Lozano
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Health Science Center, Department of Clinical Medicine, Universidad de Guadalajara, Guadalajara, Mexico; and
| | - Yaping Chang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - QiuKui Hao
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- The Center of Gerontology and Geriatrics/National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
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18
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Oliai C, Schiller G. How to address second and therapy-related acute myelogenous leukaemia. Br J Haematol 2020; 188:116-128. [PMID: 31863469 DOI: 10.1111/bjh.16354] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Secondary acute myelogenous leukaemia (AML), as compared to de novo AML, occurs in the more elderly population, is independently more resistant to cytotoxic chemotherapy, has a higher relapse rate, and a worse prognosis. Secondary AML (sAML) is a heterogeneous disease, both biologically and clinically, even within the World Health Organization subgroups of sAML. Outcomes are the poorest in subgroups with sAML arising from an antecedent haematologic disorder which has been previously treated (ts-AML), and sAML in patients <55 years of age. This review describes the suboptimal outcomes of contemporary therapy, to support the notion of an unmet need for innovative treatment strategies in sAML. Despite the recent approval of CPX-351, long-term outcomes for this high-risk disease remain dismal. Resistance mechanisms to intensive chemotherapy contribute to relapse. Targeted immune therapy may avoid multidrug resistance mechanisms, but are unlikely to provide long-term remission due to a complex and rapidly evolving clonal disease profile. Advances for sAML will likely be accomplished by CAR T cell therapy or bispecific antibodies providing a bridge to allogeneic stem cell transplantation. Therefore, focus should be placed on novel strategies that can augment the untargeted effector function of allogeneic grafts.
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Affiliation(s)
- Caspian Oliai
- David Geffen School of Medicine at University of California, Los Angeles, CA, USA.,Division of Hematology & Oncology, Hematological Malignancies and Stem Cell Transplantation Program, Los Angeles, CA, USA
| | - Gary Schiller
- David Geffen School of Medicine at University of California, Los Angeles, CA, USA.,Division of Hematology & Oncology, Hematological Malignancies and Stem Cell Transplantation Program, Los Angeles, CA, USA
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19
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Melody M, Kuykendall A, Sallman D, Al Ali N, Zhang L, Talati C, Padron E, Sweet K, Extermann M, List A, Lancet J, Komrokji R. Defining Acute Myeloid Leukemia Ontogeny in Older Patients. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 20:312-315. [DOI: 10.1016/j.clml.2019.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 11/01/2019] [Accepted: 11/04/2019] [Indexed: 10/25/2022]
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20
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Winer ES. Secondary Acute Myeloid Leukemia: A Primary Challenge of Diagnosis and Treatment. Hematol Oncol Clin North Am 2020; 34:449-463. [PMID: 32089222 DOI: 10.1016/j.hoc.2019.11.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Secondary acute myeloid leukemia (sAML) is a complex diagnosis that includes AML caused by either an antecedent hematologic disease (AML-AHD) or from previous treatment with chemotherapy or radiation. This disease carries a poor prognosis and is historically chemorefractory; additionally, often patients are ineligible for standard chemotherapy because of advanced age and other comorbidities. The advances of molecular diagnostics and reclassification of World Health Organization criteria have aided in the categorization of this disease. This article describes the etiology and pathophysiology of sAML, and delves into past successful treatments as well as promising new treatments.
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Affiliation(s)
- Eric S Winer
- Adult Leukemia Program, Department of Medical Oncology, Dana Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215, USA.
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21
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Bertoli S, Tavitian S, Bories P, Luquet I, Delabesse E, Comont T, Sarry A, Huguet F, Bérard E, Récher C. Outcome of patients aged 60-75 years with newly diagnosed secondary acute myeloid leukemia: A single-institution experience. Cancer Med 2019; 8:3846-3854. [PMID: 31173485 PMCID: PMC6639188 DOI: 10.1002/cam4.2020] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 01/09/2019] [Accepted: 01/16/2019] [Indexed: 12/19/2022] Open
Abstract
A recent phase 3 trial showed that outcome of older patients with secondary acute myeloid leukemia (AML) may be improved by a liposomal encapsulation of cytarabine and daunorubicin (CPX‐351). This phase 3 study represents a unique example of prospective data in this rare subgroup providing basis for comparison with real life data. Here, we retrospectively assessed characteristics and outcome of patients aged 60‐75 years with secondary or therapy‐related AML in real life. Out of 218 patients that fulfilled CPX‐351 study criteria, 181 patients (83.0%) received antileukemic treatment either intensive chemotherapy (n = 121) or hypomethylating agents (HMA, n = 60). As compared with patients treated by chemotherapy, HMA‐treated patients were older, had lower WBC, more often AML with antecedent myelodysplastic syndrome and adverse cytogenetic risk. In chemotherapy‐treated patients, the complete response rate was 69%, median overall survival (OS) was 11 months whereas 3‐year and 5‐year OS was 21% and 17%, respectively. In HMA‐treated patients, the complete response rate was 15%, median OS was 11 months whereas 3‐year and 5‐year OS was 15% and 2%, respectively. In conclusion, although outcome of older patients with high‐risk AML is very poor, a significant proportion of patients treated by standard intensive chemotherapy but not HMA are long‐term survivors.
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Affiliation(s)
- Sarah Bertoli
- Service d'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France.,Université Toulouse III Paul Sabatier, Toulouse, France.,Cancer Research Center of Toulouse, UMR1037-INSERM, ERL5294 CNRS, Toulouse, France
| | - Suzanne Tavitian
- Service d'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
| | - Pierre Bories
- Réseau Onco-occitanie, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
| | - Isabelle Luquet
- Laboratoire d'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
| | - Eric Delabesse
- Université Toulouse III Paul Sabatier, Toulouse, France.,Cancer Research Center of Toulouse, UMR1037-INSERM, ERL5294 CNRS, Toulouse, France.,Laboratoire d'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
| | - Thibault Comont
- Service de Médecine Interne, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
| | - Audrey Sarry
- Service d'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
| | - Françoise Huguet
- Service d'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France
| | - Emilie Bérard
- Service d'Epidémiologie, Centre Hospitalier Universitaire de Toulouse, Toulouse, France.,UMR 1027, INSERM-Université de Toulouse III, Toulouse, France
| | - Christian Récher
- Service d'Hématologie, Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Toulouse, France.,Université Toulouse III Paul Sabatier, Toulouse, France.,Cancer Research Center of Toulouse, UMR1037-INSERM, ERL5294 CNRS, Toulouse, France
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22
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Canaani J, Beohou E, Labopin M, Ghavamzadeh A, Beelen D, Hamladji RM, Niederwieser D, Volin L, Markiewicz M, Arnold R, Mufti G, Ehninger G, Socié G, Kröger N, Mohty M, Nagler A. Trends in patient outcome over the past two decades following allogeneic stem cell transplantation for acute myeloid leukaemia: an ALWP/EBMT analysis. J Intern Med 2019; 285:407-418. [PMID: 30372796 DOI: 10.1111/joim.12854] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Outcomes for patients with acute myeloid leukaemia (AML) undergoing allogeneic stem cell transplantation (allo-SCT) have significantly improved in recent years. OBJECTIVES To assess the incremental improvement of transplanted AML patients in the last two decades. METHODS Patients included in this analysis were adult AML patients who underwent allo-SCT from an HLA-matched sibling donor (MSD) or HLA-matched unrelated donor (MUD) in first remission. Patient outcomes were assessed between three cohorts according to the year of transplant (1993-2002, 2003-2007 and 2008-2012). RESULTS The analysis comprised a total of 20 187 patients of whom 4763 were transplanted between 1993 and 2002, 5835 in 2003 and 2007, and 9589 in 2008 and 2012. In multivariate analysis, leukaemia-free survival (LFS) rates were significantly improved in more recently transplanted patients compared to patients transplanted in 1993-2002 [Hazard ratio (HR) = 0.84, confidence interval (CI) 95%, 0.77-0.92; P = 0.003], a benefit which also extended to improved overall survival (OS; HR = 0.8, CI 95%, 0.73-0.89; P < 0.0001), and decreased nonrelapse mortality (NRM) rates (HR = 0.65, CI 95%, 0.56-0.75; P < 0.0001). Subset analysis revealed that in MSD, the rates of LFS, NRM and OS significantly improved in patients in the more recent cohort with similar results also seen in MUD. Finally, the incidence of acute graft-versus-host disease (GVHD) was significantly reduced leading to improved GVHD-free/relapse-free survival (GRFS) rates in more recently transplanted patients. CONCLUSION Outcome of allo-SCT for AML patients has markedly improved in the last two decades owing to decreased nonrelapse mortality and improved rates of leukaemia-free survival resulting in significantly longer survival.
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Affiliation(s)
- J Canaani
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel-Hashomer, Israel
| | - E Beohou
- Acute Leukemia Working Party -EBMT and Department of Hematology and Cell Therapy, Hȏpital Saint-Antoine, Paris, France
| | - M Labopin
- Acute Leukemia Working Party -EBMT and Department of Hematology and Cell Therapy, Hȏpital Saint-Antoine, Paris, France
| | - A Ghavamzadeh
- Hematology-Oncology and BMT Research, Shariati Hospital, Teheran, Iran
| | - D Beelen
- Department of Bone Marrow Transplantation, University Hospital, Essen, Germany
| | - R-M Hamladji
- Service Hématologie Greffe de Moëlle, Centre Pierre et Marie Curie, Alger, Algeria
| | - D Niederwieser
- Division of Haematology & Oncology, University Hospital Leipzig, Leipzig, Germany
| | - L Volin
- Stem Cell Transplantation Unit, Comprehensive Cancer Centre, Helsinki University Hospital, Helsinki, Finland
| | - M Markiewicz
- Department of Haematology and BMT, Medical University of Silesia, Katowice, Poland
| | - R Arnold
- Medizinische Klinik m. S. Hämatologie/Onkologie, Charité Universitaetsmedizin Berlin, Berlin, Germany
| | - G Mufti
- Department of Haematological Medicine, GKT School of Medicine, London, UK
| | - G Ehninger
- Universitaetsklinikum Dresden Medizinische Klinik und Poliklinik I, Dresden, Germany
| | - G Socié
- Department of Hematology - BMT, Hȏpital St. Louis, Paris, France
| | - N Kröger
- Bone Marrow Transplantation Centre, University Hospital Eppendorf, Hamburg, Germany
| | - M Mohty
- Acute Leukemia Working Party -EBMT and Department of Hematology and Cell Therapy, Hȏpital Saint-Antoine, Paris, France
| | - A Nagler
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel-Hashomer, Israel.,Acute Leukemia Working Party -EBMT and Department of Hematology and Cell Therapy, Hȏpital Saint-Antoine, Paris, France
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23
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Huemer F, Melchardt T, Jansko B, Wahida A, Jilg S, Jost PJ, Klieser E, Steiger K, Magnes T, Pleyer L, Greil-Ressler S, Rass C, Greil R, Egle A. Durable remissions with venetoclax monotherapy in secondary AML refractory to hypomethylating agents and high expression of BCL-2 and/or BIM. Eur J Haematol 2019; 102:437-441. [PMID: 30725494 PMCID: PMC6849823 DOI: 10.1111/ejh.13218] [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: 01/28/2019] [Revised: 01/29/2019] [Accepted: 01/30/2019] [Indexed: 02/03/2023]
Abstract
Acute myeloid leukemia (AML) is a disease of the elderly population and survival remains poor after failure of hypomethylating agents (HMA). The BCL‐2 inhibitor venetoclax demonstrated activity as monotherapy and in combination with chemotherapy or HMA in AML. In this case series, patients with secondary AML (sAML) not eligible for intensive chemotherapy and refractory to HMA were treated with venetoclax within a named patient program at our tertiary cancer center in Salzburg, Austria. Between April 2017 and September 2018, seven patients with sAML received venetoclax therapy. Two out of seven patients achieved a complete remission upon venetoclax initiation with a PFS of 505 days and 352 days and another patient achieved complete peripheral blood blast clearing within nine days after start of venetoclax. Among the venetoclax responders, primary refractory disease to prior HMA therapy was documented, 2 patients harbored IDH1/IDH2 mutations and one patient had an antecedent myeloproliferative neoplasm. High BCL‐2 and/or BIM expression in myeloblasts was found in venetoclax responders and response was significantly associated with overall survival (responders: 364 days versus non‐responders: 24 days, P = 0.018). Venetoclax monotherapy is safe and is able to induce durable responses in elderly patients with secondary AML after treatment failure with HMA.
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Affiliation(s)
- Florian Huemer
- Department of Internal Medicine III with Haematology, Medical Oncology, Haemostaseology, Infectiology and Rheumatology, Oncologic Center, Salzburg Cancer Research Institute - Laboratory for Immunological and Molecular Cancer Research (SCRI-LIMCR), Cancer Cluster Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Thomas Melchardt
- Department of Internal Medicine III with Haematology, Medical Oncology, Haemostaseology, Infectiology and Rheumatology, Oncologic Center, Salzburg Cancer Research Institute - Laboratory for Immunological and Molecular Cancer Research (SCRI-LIMCR), Cancer Cluster Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Bettina Jansko
- Department of Internal Medicine III with Haematology, Medical Oncology, Haemostaseology, Infectiology and Rheumatology, Oncologic Center, Salzburg Cancer Research Institute - Laboratory for Immunological and Molecular Cancer Research (SCRI-LIMCR), Cancer Cluster Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Adam Wahida
- Medizinische Klinik für Hämatologie und Internistische Onkologie, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Stefanie Jilg
- Medizinische Klinik für Hämatologie und Internistische Onkologie, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Philipp J Jost
- Medizinische Klinik für Hämatologie und Internistische Onkologie, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Eckhard Klieser
- Institute of Pathology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Katja Steiger
- Comparative Experimental Pathology and Digital Pathology, Institute of Pathology and Pathological Anatomy, Technical University of Munich, Munich, Germany
| | - Teresa Magnes
- Department of Internal Medicine III with Haematology, Medical Oncology, Haemostaseology, Infectiology and Rheumatology, Oncologic Center, Salzburg Cancer Research Institute - Laboratory for Immunological and Molecular Cancer Research (SCRI-LIMCR), Cancer Cluster Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Lisa Pleyer
- Department of Internal Medicine III with Haematology, Medical Oncology, Haemostaseology, Infectiology and Rheumatology, Oncologic Center, Salzburg Cancer Research Institute - Laboratory for Immunological and Molecular Cancer Research (SCRI-LIMCR), Cancer Cluster Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Sigrun Greil-Ressler
- Department of Internal Medicine III with Haematology, Medical Oncology, Haemostaseology, Infectiology and Rheumatology, Oncologic Center, Salzburg Cancer Research Institute - Laboratory for Immunological and Molecular Cancer Research (SCRI-LIMCR), Cancer Cluster Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Christof Rass
- Department of Internal Medicine III with Haematology, Medical Oncology, Haemostaseology, Infectiology and Rheumatology, Oncologic Center, Salzburg Cancer Research Institute - Laboratory for Immunological and Molecular Cancer Research (SCRI-LIMCR), Cancer Cluster Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Richard Greil
- Department of Internal Medicine III with Haematology, Medical Oncology, Haemostaseology, Infectiology and Rheumatology, Oncologic Center, Salzburg Cancer Research Institute - Laboratory for Immunological and Molecular Cancer Research (SCRI-LIMCR), Cancer Cluster Salzburg, Paracelsus Medical University, Salzburg, Austria
| | - Alexander Egle
- Department of Internal Medicine III with Haematology, Medical Oncology, Haemostaseology, Infectiology and Rheumatology, Oncologic Center, Salzburg Cancer Research Institute - Laboratory for Immunological and Molecular Cancer Research (SCRI-LIMCR), Cancer Cluster Salzburg, Paracelsus Medical University, Salzburg, Austria
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24
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The leukemia strikes back: a review of pathogenesis and treatment of secondary AML. Ann Hematol 2019; 98:541-559. [PMID: 30666431 DOI: 10.1007/s00277-019-03606-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 01/04/2019] [Indexed: 12/17/2022]
Abstract
Secondary AML is associated with a disproportionately poor prognosis, consistently shown to exhibit inferior response rates, event-free survival, and overall survival in comparison with de novo AML. Secondary AML may arise from the evolution of an antecedent hematologic disorder, or it may arise as a complication of prior cytotoxic chemotherapy or radiation therapy in the case of therapy-related AML. Because of the high frequency of poor-risk cytogenetics and high-risk molecular features, such as alterations in TP53, leukemic clones are often inherently chemoresistant. Standard of care induction had long remained conventional 7 + 3 until its reformulation as CPX-351, recently FDA approved specifically for secondary AML. However, recent data also suggests relatively favorable outcomes with regimens based on high-dose cytarabine or hypomethylating agents. With several investigational agents being studied, the therapeutic landscape becomes even more complex, and the treatment approach involves patient-specific, disease-specific, and therapy-specific considerations.
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25
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Vachhani P, Al Yacoub R, Miller A, Zhang F, Cronin TL, Ontiveros EP, Thompson JE, Griffiths EA, Wang ES. Intensive chemotherapy vs. hypomethylating agents in older adults with newly diagnosed high-risk acute myeloid leukemia: A single center experience. Leuk Res 2018; 75:29-35. [PMID: 30445237 DOI: 10.1016/j.leukres.2018.10.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 10/01/2018] [Accepted: 10/24/2018] [Indexed: 10/28/2022]
Abstract
Acute myeloid leukemia (AML) in older patients is often associated with biologic and clinical characteristics that predict poor outcomes to cytarabine and anthracycline based induction chemotherapy (IC). The impact of hypomethylating agents (HMA) in the treatment of these high-risk patients is unknown. Here we retrospectively examined the remission rates and survival outcomes of 201 newly diagnosed patients ≥60 years old with therapy-related (t-AML), secondary (s-AML), or AML with myelodysplasia-related changes (AML-MRC). Ninety-eight patients received IC, and 103 received HMA. Patients in the IC cohort were younger than those who received HMA (68 vs. 74 years; p < 0.01) with lower comorbidity burden. Composite complete remission rates (CR) were 39% in IC and 27% in the HMA cohorts (p = 0.10). Overall survival (OS) was not significantly different between the two cohorts (7.59 mos vs. 5.49 mos; HR 0.75 95% CI 0.55-1.02) despite the fact that more patients in the IC cohort (33% versus 5%, p < 0.01) underwent allogeneic stem cell transplant. Patients with t-AML (HR 0.56; 95% CI 0.33-0.97) and complex karyotype without monosomal karyotype (CK + MK-; HR 0.37; 95% CI 0.19-0.75) had better OS following IC. Patients with CK + MK+ (HR 2.00; 95% CI 1.08-3.70) had improved OS following HMA. Our results support the use of HMA as an alternative upfront regimen in older individuals with newly diagnosed high-risk AML based on similar clinical outcomes to IC.
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Affiliation(s)
- Pankit Vachhani
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, NY, USA.
| | - Raed Al Yacoub
- Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Austin Miller
- Department of Biostatistics & Bioinformatics, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Fan Zhang
- Department of Biostatistics & Bioinformatics, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Tara L Cronin
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, NY, USA
| | - Evelena P Ontiveros
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, NY, USA
| | - James E Thompson
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, NY, USA
| | - Elizabeth A Griffiths
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, NY, USA
| | - Eunice S Wang
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Elm and Carlton Streets, Buffalo, NY, USA
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26
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Mollard LM, Chauveau A, Boyer-Perrard F, Douet-Guilbert N, Houot R, Quintin-Roué I, Couturier MA, Dagorne A, Malou M, Le Calloch R, Luycx O, Thepot S, Hunault M, Guillerm G, Berthou C, Ugo V, Lippert É, Ianotto JC. Outcome of Ph negative myeloproliferative neoplasms transforming to accelerated or leukemic phase. Leuk Lymphoma 2018; 59:2812-2820. [PMID: 29616837 DOI: 10.1080/10428194.2018.1441408] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Myeloproliferative neoplasms (MPN) are chronic disorders that can sometimes evolve into accelerated or leukemic phases. We retrospectively identified 122 patients with such blastic phases. The overall median survival was four months: 10.2 months for patients treated with intensive treatments compared to three months for best supportive care (p = .005). Azacytidine, intensive chemotherapies, or allogeneic stem cell transplantation gave the highest median survivals with 9, 10.2, and 19.4 months, respectively. Accelerated phases (AP) had a longer median survival compared to acute leukemia (4.8 months vs. 3.1 months; p = .02). In this retrospective and observational study, we observe that the longest survivals are seen in patients eligible for intensive treatments. Azacytidine shows interesting results in patients non-fit for intensive chemotherapy. Supportive care should probably be restricted to elderly patients and those with unfavorable karyotype. An early diagnosis of AP could also result in a better survival rate.
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Affiliation(s)
- Lise-Marie Mollard
- a Service d'Hématologie Clinique, Institut de Cancéro-Hématologie, CHRU de Brest , Brest , France
| | | | | | | | - Roch Houot
- e Laboratoire d'Anatomo-Pathologie, CHRU Brest , Brest , France
| | | | | | - Anaig Dagorne
- h Service d'Hématologie Clinique, CH de Morlaix , Brest , France
| | - Mohamed Malou
- i Service de Médecine Interne, CH de Quimper , Brest , France
| | | | - Odile Luycx
- k Laboratoire d'Hématologie, CHU d'Angers , Brest , France
| | - Sylvain Thepot
- c Service des Maladies du Sang, CHU d'Angers , Brest , France
| | | | - Gaelle Guillerm
- a Service d'Hématologie Clinique, Institut de Cancéro-Hématologie, CHRU de Brest , Brest , France
| | - Christian Berthou
- a Service d'Hématologie Clinique, Institut de Cancéro-Hématologie, CHRU de Brest , Brest , France
| | - Valérie Ugo
- i Service de Médecine Interne, CH de Quimper , Brest , France
| | - Éric Lippert
- b Laboratoire d'Hématologie, CHRU de Brest , Brest , France
| | - Jean-Christophe Ianotto
- a Service d'Hématologie Clinique, Institut de Cancéro-Hématologie, CHRU de Brest , Brest , France
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27
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Dombret H, Itzykson R. How and when to decide between epigenetic therapy and chemotherapy in patients with AML. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:45-53. [PMID: 29222236 PMCID: PMC6142607 DOI: 10.1182/asheducation-2017.1.45] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Remission induction with chemotherapy has long been the frontline treatment of acute myeloid leukemia (AML). However, intensive therapy is limited in frail patients by its associated toxicity and higher rates of failure or relapse in patients with chemoresistant disease, such as secondary AML or poor-risk cytogenetics. Frailty and chemoresistance are more frequent in older adults with AML. In recent years, epigenetic therapies with the hypomethylating agents decitabine and azacitidine have been thoroughly explored in AML. The results of two pivotal studies carried out with these agents in older adults with newly diagnosed AML have challenged the role of intensive chemotherapy as the frontline treatment option in this high-risk population. Here, we review the results of treatment with intensive chemotherapy and hypomethylating agents in older patients with AML; discuss the patient- and disease-specific criteria to integrate into treatment decision making; and also, highlight the methodological limitations of cross-study comparison in this population.
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Affiliation(s)
- Hervé Dombret
- Hôpital Saint-Louis, Institut Universitaire d'Hématologie, Université Paris Diderot, Paris, France
| | - Raphael Itzykson
- Hôpital Saint-Louis, Institut Universitaire d'Hématologie, Université Paris Diderot, Paris, France
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Treatment of Low-Blast Count AML using Hypomethylating Agents. Mediterr J Hematol Infect Dis 2017; 9:e2017045. [PMID: 28698788 PMCID: PMC5499495 DOI: 10.4084/mjhid.2017.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Accepted: 06/10/2017] [Indexed: 11/08/2022] Open
Abstract
In 2002, the WHO classification reduced the proportion of blasts in the bone marrow (BM) necessary for the diagnosis of acute myeloid leukemia (AML) from 30% to 20%, eliminating the RAEB-t subtype of myelodysplastic syndromes (MDS). However, this AML subtype, defined as low-blast count AML (LBC-AML, with 20-30% BM-blasts) is characterized by peculiar features, as increased frequency in elderly individuals and after cytotoxic treatment for a different primary disease (therapy-related), poor-risk cytogenetics, lower white blood cell counts, and less frequent mutations of NPM1 and FLT3 genes. The clinical course of this entity is often similar to MDS with 10-19% BM-blasts. The hypomethylating agents azacitidine and decitabine have been shown to induce responses and prolong survival both in MDS and LBC-AML. The role of these agents has also been demonstrated in AML with >30% BM-blasts, particularly in patients with poor-risk cytogenetics and in AML with myelodysplasia-related changes. Most recent studies are evaluating strategies to improve outcome, including combinations of hypomethylating agents with immune-response checkpoint inhibitors, which have a role in cancer immune surveillance. Efforts are also ongoing to identify mutations which may predict response and survival in these patients.
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