1
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Guarnera L, Santinelli E, Galossi E, Cristiano A, Fabiani E, Falconi G, Voso MT. Microenvironment in acute myeloid leukemia: focus on senescence mechanisms, therapeutic interactions, and future directions. Exp Hematol 2024; 129:104118. [PMID: 37741607 DOI: 10.1016/j.exphem.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 09/10/2023] [Accepted: 09/12/2023] [Indexed: 09/25/2023]
Abstract
Acute myeloid leukemia (AML) is a disease with a dismal prognosis, mainly affecting the elderly. In recent years, new drugs have improved life expectancy and quality of life, and a better understanding of the genetic-molecular nature of the disease has shed light on previously unknown aspects of leukemogenesis. In parallel, increasing attention has been attracted to the complex interactions between cells and soluble factors in the bone marrow (BM) environment, collectively known as the microenvironment. In this review, we discuss the central role of the microenvironment in physiologic and pathologic hematopoiesis and the mechanisms of senescence, considered a fundamental protective mechanism against the proliferation of damaged and pretumoral cells. The microenvironment also represents a fertile ground for the development of myeloid malignancies, and the leukemic niche significantly interacts with drugs commonly used in AML treatment. Finally, we focus on the role of the microenvironment in the engraftment and complications of allogeneic hematopoietic stem cell transplantation, the only curative option in a conspicuous proportion of patients.
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Affiliation(s)
- Luca Guarnera
- Department of Biomedicine and Prevention, Tor Vergata University, Rome, Italy
| | - Enrico Santinelli
- Department of Biomedicine and Prevention, Tor Vergata University, Rome, Italy; Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Elisa Galossi
- Department of Biomedicine and Prevention, Tor Vergata University, Rome, Italy
| | - Antonio Cristiano
- Department of Biomedicine and Prevention, Tor Vergata University, Rome, Italy
| | - Emiliano Fabiani
- Department of Biomedicine and Prevention, Tor Vergata University, Rome, Italy; Saint Camillus International, University of Health Sciences, Rome, Italy
| | - Giulia Falconi
- Department of Biomedicine and Prevention, Tor Vergata University, Rome, Italy
| | - Maria Teresa Voso
- Department of Biomedicine and Prevention, Tor Vergata University, Rome, Italy; Neuro-Oncohematology Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Fondazione Santa Lucia, Rome, Italy.
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2
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Montoro J, Balaguer-Roselló A, Sanz J. Recent advances in allogeneic transplantation for acute myeloid leukemia. Curr Opin Oncol 2023; 35:564-573. [PMID: 37820092 DOI: 10.1097/cco.0000000000000992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
PURPOSE OF REVIEW This review highlights recent advancements in allogeneic hematopoietic stem cell transplantation (allo-HSCT) for patients with acute myeloid leukemia (AML). RECENT FINDINGS Important improvements have been observed throughout the allo-HSCT procedure and patient management. Universal donor availability and reduced risk of graft-versus-host disease (GVHD) have been achieved with the introduction of posttransplant cyclophosphamide for GVHD prophylaxis. It has contributed, together with advances in conditioning regimens, GVHD treatment and supportive care, to a reduced overall toxicity of the procedure. Relapse is now the most frequent cause of transplant failure. With increased knowledge of the biological characterization of AML, better prediction of transplant risks and more profound and standardized minimal residual disease (MRD) monitoring, pharmacological, and immunological strategies to prevent relapse are been developed. SUMMARY Allo-HSCT remains the standard of care for high-risk AML. Increased access to transplant, reduced toxicity and relapse are improving patient outcomes. Further research is needed to optimize MRD monitoring, refine conditioning regimens, and explore new GVHD management and relapse prevention therapies.
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Affiliation(s)
- Juan Montoro
- Hematology Department, Hospital Universitario y Politécnico La Fe
- Departamento de Medicina, Universidad Católica de Valencia
| | - Aitana Balaguer-Roselló
- Hematology Department, Hospital Universitario y Politécnico La Fe
- CIBERONC, Instituto Carlos III, Madrid
| | - Jaime Sanz
- Hematology Department, Hospital Universitario y Politécnico La Fe
- CIBERONC, Instituto Carlos III, Madrid
- Departamento de Medicina, Universidad de Valencia, Spain
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3
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Jiang S, Lu X, Wei R, Zhang A, Chen H, Shi W, Xia L. Salvage hematopoietic stem cell transplantation for patients with higher leukemia burden in relapsed or refractory acute myeloid leukemia: a ten-year study. Ann Hematol 2023; 102:3205-3216. [PMID: 37682324 DOI: 10.1007/s00277-023-05406-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 08/05/2023] [Indexed: 09/09/2023]
Abstract
Patients with relapsed and refractory acute myeloid leukemia (R-R AML), especially those in non-remission (NR) have a poor prognosis after allogeneic hematopoietic stem cell transplantation (allo-HSCT). In order to optimize the entire allo-HSCT process for R-R AML patients and identify potential factors affecting clinical outcomes after HSCT, we retrospectively analyzed 44 adult patients with R-R AML who underwent salvage allo-HSCT while in NR or with concomitant extramedullary leukemia at the Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology from 2013 to 2022. The 1-year and 2-year overall survival (OS) of the 44 patients were 55.3% (95% confidence interval [CI], 41.1%-74.3%) and 44.4% (95%CI, 30.2%-65.4%), respectively. The 1-year and 2-year cumulative incidence of relapse (CIR) were 39.4% (95%CI, 38.0%-40.7%) and 53.0% (95%CI, 51.0%-55.1%), respectively, and the 1-year and 2-year leukemia-free survival (LFS) were 37.8% (95%CI, 24.8%-57.7%) and 20.3% (95%CI, 9.1%-45.3%), respectively. The 100-day, 1-year and 2-year treatment-related mortality (TRM) was 13.8% (95%CI, 13.3%-14.4%), 22.8% (95%CI, 21.9%-23.7%) and 26.7% (95%CI, 25.5%-27.8%), respectively. Multivariate analysis revealed that patients who developed chronic graft-versus-host disease (cGVHD) after transplantation had lower relapse rate. Our analysis also indicated that patients with blast counts in bone marrow (BM) <20% and those with ≥20% had comparable clinical outcomes after allo-HSCT. In conclusion, our study demonstrated that R-R AML patients in NR or with concomitant extramedullary leukemia can benefit from allo-HSCT, regardless of leukemia burden at the time of transplantation. Patients who experience cGVHD after allo-HSCT may have lower relapse rate due to enhanced graft-versus-leukemia (GVL) effects, but cGVHD should be controlled at mild to moderate level to avoid life-threatening complications.
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Affiliation(s)
- Shan Jiang
- Department of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Xuan Lu
- Department of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Ruowen Wei
- Department of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Ao Zhang
- Department of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Haoran Chen
- Department of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Wei Shi
- Department of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
| | - Linghui Xia
- Department of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
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4
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Mori H, Koyama D, Sato Y, Kataoka Y, Taito S, Ishio T, Teshima T, Yokota I. Prognostic Value of Hematogones in Patients With Hematopoietic Disorders After Allogeneic Hematopoietic Stem Cell Transplantation: A Systematic Review and Meta-Analysis. Cureus 2023; 15:e47184. [PMID: 37854480 PMCID: PMC10580303 DOI: 10.7759/cureus.47184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2023] [Indexed: 10/20/2023] Open
Abstract
This systematic review and meta-analysis aimed to determine whether hematogones in patients with hematopoietic disorders after allogeneic hematopoietic stem cell transplantation (allo-HSCT) are associated with clinical outcomes. We searched the MEDLINE, Embase, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and World Health Organization International Clinical Trials Registry Platform databases from their inception to March 2023. The primary outcome in the summary of findings was three-year relapse-free survival (RFS), and secondary outcomes in the summary of findings included three-year relapse, non-relapse mortality (NRM), overall survival (OS), acute and chronic graft-versus-host disease (GVHD), and infection. The certainty of evidence was determined using the grading of recommendation assessment, development, and evaluation approaches. A systematic review and meta-analysis of outcome measures were conducted using a random-effects model. This study protocol was registered in the Open Science Framework. A total of six studies (including 888 patients) were included in the meta-analysis. Hematogones were related to favorable three-year RFS (risk ratio (RR) = 1.84; 95% confidence interval (CI) = 1.01 to 3.34) and favorable NRM (RR = 0.14; 95% CI = 0.04 to 0.51), OS (RR = 1.51; 95% CI = 1.13 to 2.02), and acute GVHD (RR = 0.44; 95% CI = 0.33 to 0.59). The certainty of the evidence was low for RFS, NRM, OS, and acute GVHD. Evidence regarding the association between hematogones, relapse, and infections is uncertain. Hematogones may be a prognostic factor for long-term prognosis and acute adverse events in patients with hematopoietic disorders after allo-HSCT. Further studies are required to address the long-term life-threatening events.
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Affiliation(s)
- Hirotaka Mori
- Department of Biostatistics, Graduate School of Medicine, Hokkaido University, Sapporo, JPN
- Department of Hematology, Hokkaido University Faculty of Medicine, Sapporo, JPN
- Department of Systematic Reviewers, Scientific Research Works Peer Support Group, Osaka, JPN
| | - Daisuke Koyama
- Department of Hematology, Fukushima Medical University, Fukushima, JPN
| | - Yuki Sato
- Department of Hematology, Fukushima Medical University, Fukushima, JPN
| | - Yuki Kataoka
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine, School of Public Health, Kyoto, JPN
- Department of Community Medicine, Kyoto University Graduate School of Medicine, Section of Clinical Epidemiology, Kyoto, JPN
- Department of Internal Medicine, Kyoto Min-iren Asukai Hospital, Kyoto, JPN
- Department of Systematic Reviewers, Scientific Research Works Peer Support Group, Osaka, JPN
| | - Shunsuke Taito
- Department of Systematic Reviewers, Scientific Research Works Peer Support Group, Osaka, JPN
- Division of Rehabilitation, Hiroshima University Hospital, Hiroshima, JPN
| | - Takashi Ishio
- Department of Hematology, Hokkaido University Faculty of Medicine, Sapporo, JPN
| | - Takanori Teshima
- Department of Hematology, Hokkaido University Faculty of Medicine, Sapporo, JPN
| | - Isao Yokota
- Department of Biostatistics, Graduate School of Medicine, Hokkaido University, Sapporo, JPN
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5
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Gao Y, Wu H, Shi Z, Gao F, Shi J, Luo Y, Yu J, Lai X, Fu H, Liu L, Huang H, Zhao Y. Prognostic factors and clinical outcomes in patients with relapsed acute leukemia after allogeneic hematopoietic stem cell transplantation. Bone Marrow Transplant 2023; 58:863-873. [PMID: 37120616 DOI: 10.1038/s41409-023-01989-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 04/09/2023] [Accepted: 04/14/2023] [Indexed: 05/01/2023]
Abstract
Relapse is a significant barrier to allogeneic hematopoietic stem cell transplantation (allo-HSCT) success. To explore the prognosis of patients who underwent relapse after allo-HSCT, we retrospectively examined 740 consecutive acute leukemia patients in our single center transplanted between January 2013 and December 2018, of which 178 relapsed. The median survival was 204 days (95%CI, 160.7-247.3) from relapse, and the 3-year post-relapse overall survival (prOS) rate was 17.8% (95%CI, 12.5-25.3%). Overall complete remission (CR) or CR with incomplete hematologic recovery (CRi) was achieved in 32.1% for the acute myeloid leukemia and 45.3% for acute lymphoblastic leukemia patients after salvage therapy, respectively. Grade III-IV acute graft-versus-host disease (GVHD) after transplantation and >20% bone marrow blasts at relapse were associated with worse prOS, while patients with chronic GVHD after transplantation, relapse later than 1 year after transplantation, and solitary extramedullary disease had better prOS. Therefore, we developed a concise risk scoring system for prOS based on the number of risk factors affecting prOS. This scoring system was validated with another cohort of post-transplant relapsed acute leukemia patients who received allo-HSCT between 2019 and 2020. Identifying relapse risk factors and providing personalized care for patients with poor prognoses is crucial for improving survival.
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Affiliation(s)
- Yang Gao
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Liangzhu Laboratory, Zhejiang University Medical Center, 1369 West Wenyi Road, Hangzhou, 311121, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Hengwei Wu
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Liangzhu Laboratory, Zhejiang University Medical Center, 1369 West Wenyi Road, Hangzhou, 311121, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Zhuoyue Shi
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Liangzhu Laboratory, Zhejiang University Medical Center, 1369 West Wenyi Road, Hangzhou, 311121, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Fei Gao
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Liangzhu Laboratory, Zhejiang University Medical Center, 1369 West Wenyi Road, Hangzhou, 311121, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Jimin Shi
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Liangzhu Laboratory, Zhejiang University Medical Center, 1369 West Wenyi Road, Hangzhou, 311121, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Yi Luo
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Liangzhu Laboratory, Zhejiang University Medical Center, 1369 West Wenyi Road, Hangzhou, 311121, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Jian Yu
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Liangzhu Laboratory, Zhejiang University Medical Center, 1369 West Wenyi Road, Hangzhou, 311121, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Xiaoyu Lai
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Liangzhu Laboratory, Zhejiang University Medical Center, 1369 West Wenyi Road, Hangzhou, 311121, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Huarui Fu
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Liangzhu Laboratory, Zhejiang University Medical Center, 1369 West Wenyi Road, Hangzhou, 311121, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
| | - Lizhen Liu
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Liangzhu Laboratory, Zhejiang University Medical Center, 1369 West Wenyi Road, Hangzhou, 311121, China
- Institute of Hematology, Zhejiang University, Hangzhou, China
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China
| | - He Huang
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
- Liangzhu Laboratory, Zhejiang University Medical Center, 1369 West Wenyi Road, Hangzhou, 311121, China.
- Institute of Hematology, Zhejiang University, Hangzhou, China.
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China.
| | - Yanmin Zhao
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
- Liangzhu Laboratory, Zhejiang University Medical Center, 1369 West Wenyi Road, Hangzhou, 311121, China.
- Institute of Hematology, Zhejiang University, Hangzhou, China.
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China.
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6
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Pang Y, Holtzman NG. Immunopathogenic mechanisms and modulatory approaches to graft-versus-host disease prevention in acute myeloid leukaemia. Best Pract Res Clin Haematol 2023; 36:101475. [PMID: 37353287 PMCID: PMC10291443 DOI: 10.1016/j.beha.2023.101475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 05/03/2023] [Accepted: 05/03/2023] [Indexed: 06/25/2023]
Abstract
Allogeneic haematopoietic stem cell transplantation (HSCT) remains the only potential cure for intermediate to high-risk acute myeloid leukaemia (AML). The therapeutic effect of HSCT is largely dependent on the powerful donor-derived immune response against recipient leukaemia cells, known as graft-versus-leukaemia effect (GvL). However, the donor-derived immune system can also cause acute or chronic damage to normal recipient organs and tissues, in a process known as graft-versus-host disease (GvHD). GvHD is a leading cause of non-relapse mortality in HSCT recipients. There are many similarities and cross talk between the immune pathways of GvL and GvHD. Studies have demonstrated that both processes require the presence of mismatched alloantigens between the donor and recipient, and activation of immune responses centered around donor T-cells, which can be further modulated by various recipient or donor factors. Dissecting GvL from GvHD to achieve more effective GvHD prevention and enhanced GvL has been the holy grail of HSCT research. In this review, we focused on the key factors that contribute to the immune responses of GvL and GvHD, the effect on GvL with different GvHD prophylactic strategies, and the potential impact of various AML relapse prevention therapy or treatments on GvHD.
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Affiliation(s)
- Yifan Pang
- Department of Haematologic Oncology and Blood Disorders, Levine Cancer Institute, Charlotte, NC, USA.
| | - Noa G Holtzman
- Immune Deficiency Cellular Therapy Program, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
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7
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Rimando JC, Chendamarai E, Rettig MP, Jayasinghe R, Christopher MJ, Ritchey JK, Christ S, Kim MY, Bonvini E, DiPersio JF. Flotetuzumab and other T-cell immunotherapies upregulate MHC class II expression on acute myeloid leukemia cells. Blood 2023; 141:1718-1723. [PMID: 36563336 PMCID: PMC10273090 DOI: 10.1182/blood.2022017795] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 10/27/2022] [Accepted: 11/15/2022] [Indexed: 12/24/2022] Open
Abstract
Acute myeloid leukemia (AML) relapse is one of the most common and significant adverse events following allogeneic hematopoietic cell transplantation (HCT). Downregulation of major histocompatibility class II (MHC-II) surface expression on AML blasts may represent a mechanism of escape from the graft-versus-malignancy effect and facilitate relapse. We hypothesized that T-cell immunotherapies targeting AML antigens would upregulate MHC-II surface expression via localized release of interferon gamma (IFN-γ), a protein known to upregulate MHC-II expression via JAK-STAT signaling. We demonstrate that flotetuzumab (FLZ), a CD123 × CD3 bispecific DART molecule, and chimeric antigen receptor expressing T cells targeting CD123, CD33, or CD371 upregulate MHC-II surface expression in vitro on a THP-1 AML cell line with intermediate MHC-II expression and 4 primary AML samples from patients relapsing after HCT with low MHC-II expression. We additionally show that FLZ upregulates MHC-II expression in a patient-derived xenograft model and in patients with relapsed or refractory AML who were treated with FLZ in a clinical trial. Finally, we report that FLZ-induced MHC-II upregulation is mediated by IFN-γ. In conclusion, we provide evidence that T-cell immunotherapies targeting relapsed AML can kill AML via both MHC-independent mechanisms and by an MHC-dependent mechanism through local release of IFN-γ and subsequent upregulation of MHC-II expression.
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Affiliation(s)
- Joseph C. Rimando
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Ezhilarasi Chendamarai
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Michael P. Rettig
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Reyka Jayasinghe
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Matthew J. Christopher
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Julie K. Ritchey
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Stephanie Christ
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Miriam Y. Kim
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | | | - John F. DiPersio
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO
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8
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Kopińska A, Węglarz P, Koclęga A, Wieczorkiewicz-Kabut A, Woźniczka K, Armatys A, Spałek A, Grygoruk-Wiśniowska I, Grosicki S, Butrym A, Czyż J, Obara A, Gromek T, Helbig G. Allogeneic Hematopoietic Stem Cell Transplantation for Relapsed/Refractory Acute Myeloid Leukemia: A Single-Centre Experience. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:28-39. [PMID: 36323603 DOI: 10.1016/j.clml.2022.08.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 08/21/2022] [Accepted: 08/24/2022] [Indexed: 10/14/2022]
Abstract
INTRODUCTION Patients with relapsed/refractory acute myeloid leukemia (r/r AML) are characterized as having a poor prognosis. The only viable option of treatment for these patients is allogenic stem cell transplantation (allo-HSCT). Therefore, we have attempted to analyse factors related to both the disease itself and the transplantation procedure that could have an influence on the improvement of outcomes in this group of patients. PATIENTS AND METHODS Sixty-four patients with r/r AML underwent allo-HSCT at our center in 2012 to 2021. Fifty-two had active disease at the beginning of theallo-HSCT procedure, with amedian number of blasts in bone marrow (BM) of 18, and 12 had therapeutic aplasia after the last reinduction (blasts < 5% in BM). RESULTS The probability of overall survival (OS) at 2 years was 25%. The median follow-up for survivors was 21.5 months. Progression-free survival (PFS) estimates were above 46%. The main cause of death was disease progression (49%). A statistically significant effect on premature death was reported for the diagnosis of secondary AML (sAML) and cytomelovirus (CMV) reactivation post allo-HSCT. On the other hand, chronic graft versus host disease (cGVHD) decreased the risk of disease progression. sAML and CMV reactivation were found to have opposite effects.
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Affiliation(s)
- Anna Kopińska
- Department of Hematology and Bone Marrow Transplantation, Silesian Medical University, Katowice Poland.
| | - Patryk Węglarz
- Department of Hematology and Bone Marrow Transplantation, Silesian Medical University, Katowice Poland
| | - Anna Koclęga
- Department of Hematology and Bone Marrow Transplantation, Silesian Medical University, Katowice Poland
| | | | - Krzysztof Woźniczka
- Department of Hematology and Bone Marrow Transplantation, Silesian Medical University, Katowice Poland
| | - Anna Armatys
- Department of Hematology and Bone Marrow Transplantation, Silesian Medical University, Katowice Poland
| | - Adrianna Spałek
- Department of Hematology and Bone Marrow Transplantation, Silesian Medical University, Katowice Poland
| | - Iwona Grygoruk-Wiśniowska
- Department of Hematology and Bone Marrow Transplantation, Silesian Medical University, Katowice Poland
| | - Sebastian Grosicki
- Department of Hematology and Cancer Prevention, Silesian Medical University, Katowice, Poland
| | - Aleksandra Butrym
- Department of Cancer Prevention and Therapy, Wroclaw Medical University, Wroclaw, Poland
| | - Jarosław Czyż
- Department of Hematology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Bydgoszcz, Poland
| | - Agata Obara
- Departament of Hematology, Świętokrzyskie Cancer Centre, Kielce, Poland
| | - Tomasz Gromek
- Department of Haematooncology and Bone Marrow Transplantation, Medical University of Lublin, Poland
| | - Grzegorz Helbig
- Department of Hematology and Bone Marrow Transplantation, Silesian Medical University, Katowice Poland
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9
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Fei X, Zhang S, Gu J, Wang J. FLT3
inhibitors as maintenance therapy post allogeneic hematopoietic stem cell transplantation in acute myeloid leukemia patients with
FLT3
mutations: A meta‐analysis. Cancer Med 2022; 12:6877-6888. [PMID: 36411731 PMCID: PMC10067110 DOI: 10.1002/cam4.5480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 08/31/2022] [Accepted: 11/13/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Acute myeloid leukemia (AML) patients with a Fms-like tyrosine kinase 3 (FLT3) mutation have a high incidence of relapse despite allogeneic hematopoietic stem cell transplantation (allo-HSCT) and a subsequent poor prognosis. FLT3 inhibitors (FLT3i) have been suggested to reduce the post-transplant relapse risk in recent studies. As more evidence is accumulated, we perform the present meta-analysis to assess the efficacy and safety of FLT3i as post-transplant maintenance therapy in AML patients. METHODS Literature search was performed in public databases from inception to December 31, 2021. Overall survival (OS), relapse-free survival (RFS), cumulative incidence of relapse (CIR), non-relapse mortality (NRM), graft-versus-host disease (GVHD) and adverse events were compared between FLT3i and control groups. Pooled hazard ratio (HR) or relative risk (RR) with corresponding 95% confidence interval (CI) were calculated. RESULTS We identified 12 eligible studies with 2282 FLT3-mutated AML patients who had received HSCT. There was no between-study heterogeneity and a fix-effect model was used. Post-transplant FLT3i maintenance significantly prolonged OS (HR = 0.41, 95%CI: 0.32-0.52, p < 0.001) and RFS (HR = 0.39, 95%CI 0.31-0.50, p < 0.001), and reduced CIR (HR = 0.31, 95%CI 0.20-0.46, p < 0.001) as compared with control. There were no significant risk differences in NRM (RR = 0.69, 95%CI 0.41-1.17, p = 0.169), acute GVHD (RR = 1.17, 95%CI 0.93-1.47, p = 0.175), chronic GVHD (RR = 1.31, 95%CI 0.91-1.39, p = 0.276) and grade ≥3 adverse events between both groups, except for skin toxicity (RR = 5.86, 95%CI 1.34-25.57, p = 0.019). CONCLUSION Post-transplant FLT3i maintenance can improve survival and reduce relapse in FLT3-mutated AML patients and is tolerable.
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Affiliation(s)
- Xinhong Fei
- Department of Hematology Aerospace Center Hospital Beijing China
| | - Shuqin Zhang
- Department of Hematology Aerospace Center Hospital Beijing China
| | - Jiangying Gu
- Department of Hematology Aerospace Center Hospital Beijing China
| | - Jingbo Wang
- Department of Hematology Aerospace Center Hospital Beijing China
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10
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Kharfan-Dabaja MA, Reljic T, Yassine F, Nishihori T, Kumar A, Tawk MM, Keller K, Ayala E, Savani B, Mohty M, Aljurf M, Saber W. Efficacy of a Second Allogeneic Hematopoietic Cell Transplant in Relapsed Acute Myeloid Leukemia: Results of a Systematic Review and Meta-Analysis. Transplant Cell Ther 2022; 28:767.e1-767.e11. [DOI: 10.1016/j.jtct.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 07/22/2022] [Accepted: 08/01/2022] [Indexed: 11/25/2022]
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11
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Tang Y, Zhou Z, Yan H, You Y. Case Report: Preemptive Treatment With Low-Dose PD-1 Blockade and Azacitidine for Molecular Relapsed Acute Myeloid Leukemia With RUNX1-RUNX1T1 After Allogeneic Hematopoietic Stem Cell Transplantation. Front Immunol 2022; 13:810284. [PMID: 35185899 PMCID: PMC8847388 DOI: 10.3389/fimmu.2022.810284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 01/17/2022] [Indexed: 11/25/2022] Open
Abstract
Acute myeloid leukemia (AML) patients who develop hematological relapse (HR) after allogeneic hematopoietic stem cell transplantation (allo-HSCT) generally have dismal clinical outcomes. Measurable residual disease (MRD)-directed preemptive interventions are effective approaches to prevent disease progression and improve prognosis for molecular relapsed patients with warning signs of impending HR. In this situation, boosting the graft-vs-leukemia (GVL) effect with immune checkpoint inhibitors (ICIs) might be a promising prevention strategy, despite the potential for causing severe graft-vs-host disease (GVHD). In the present study, we reported for the first time an AML patient with RUNX1-RUNX1T1 who underwent preemptive treatment with the combined application of tislelizumab (an anti-PD-1 antibody) and azacitidine to avoid HR following allo-HSCT. On day +81, molecular relapse with MRD depicted by RUNX1-RUN1T1-positivity as well as mixed donor chimerism occurred in the patient. On day +95, with no signs of GVHD and an excellent eastern cooperative oncology group performance status (ECOG PS), the patient thus was administered with 100 mg of tislelizumab on day 1 and 100 mg of azacitidine on days 1-7. After the combination therapy, complete remission was successfully achieved with significant improvement in hematologic response, and the MRD marker RUNX1-RUNX1T1 turned negative, along with a complete donor chimerism in bone marrow. Meanwhile, the patient experienced moderate GVHD and immune-related adverse events (irAEs), successively involving the lung, liver, lower digestive tract and urinary system, which were well controlled by immunosuppressive therapies. As far as we know, this case is the first one to report the use of tislelizumab in combination with azacitidine to prevent post-transplant relapse in AML. In summary, the application of ICIs in MRD positive patients might be an attractive strategy for immune modulation in the future to reduce the incidence of HR in the post-transplant setting, but safer clinical application schedules need to be explored.
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Affiliation(s)
- Yutong Tang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhenyang Zhou
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Han Yan
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yong You
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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12
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Abou Dalle I, Atoui A, Bazarbachi A. The Elephant in The Room: AML Relapse Post Allogeneic Hematopoietic Cell Transplantation. Front Oncol 2022; 11:793274. [PMID: 35047405 PMCID: PMC8761806 DOI: 10.3389/fonc.2021.793274] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 12/09/2021] [Indexed: 12/19/2022] Open
Abstract
Relapsed acute myeloid leukemia (AML) following allogeneic hematopoietic cell transplantation (allo-HCT) is an unfavorable event associated with a poor prognosis, particularly for patients with early relapses. It usually arises from resistant leukemic blasts that escaped both preparative chemotherapy regimen and the graft-versus-leukemia (GVL) effect. Independent from the choice of salvage treatment, only minority of patients can achieve durable remissions. In recent years, better understanding of the disease relapse biology post allo-HCT allowed the application of newer strategies that could induce higher rates of remission, and potential longer survival. Those strategies aim at optimizing drugs that have a direct anti-leukemia activity by targeting different oncogenic mutations, metabolism pathways or surface antigens, and concurrently enhancing the immune microenvironment to promote GVL effect. This review discusses the current treatment landscape of AML relapse post allo-HCT.
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Affiliation(s)
- Iman Abou Dalle
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ali Atoui
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ali Bazarbachi
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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13
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Webster JA, Luznik L, Gojo I. Treatment of AML Relapse After Allo-HCT. Front Oncol 2022; 11:812207. [PMID: 34976845 PMCID: PMC8716583 DOI: 10.3389/fonc.2021.812207] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 11/25/2021] [Indexed: 01/02/2023] Open
Abstract
With advances in allogeneic hematopoietic stem cell transplant (allo-HCT), disease relapse has replaced transplant-related mortality as the primary cause of treatment failure for patients with acute myeloid leukemia (AML). The efficacy of allo-HCT in AML is a consequence of a graft-versus-leukemia (GVL) effect that is mediated by T lymphocytes, and unique mechanisms of immune evasion underlying post-allo-HCT AML relapses have recently been characterized. Relapsed AML following allo-HCT presents a particularly vexing clinical challenge because transplant-related toxicities, such as graft-versus-host (GVHD) and infections, increase the risk of treatment-related morbidity and mortality. In general, the prognosis of relapsed AML following allo-HCT is poor with most patients failing to achieve a subsequent remission and 2-year survival consistently <15%. The two factors that have been found to predict a better prognosis are a longer duration of post-transplant remission prior to relapse and a lower disease burden at the time of relapse. When considered in combination with a patient's age; co-morbidities; and performance status, these factors can help to inform the appropriate therapy for the treatment of post-transplant relapse. This review discusses the options for the treatment of post-transplant AML relapse with a focus on the options to achieve a subsequent remission and consolidation with cellular immunotherapy, such as a second transplant or donor lymphocyte infusion (DLI). While intensive reinduction therapy and less intensive approaches with hypomethylating agents have long represented the two primary options for the initial treatment of post-transplant relapse, molecularly targeted therapies and immunotherapy are emerging as potential alternative options to achieve remission. Herein, we highlight response and survival outcomes achieved specifically in the post-transplant setting using each of these approaches and discuss how some therapies may overcome the immunologic mechanisms that have been implicated in post-transplant relapse. As long-term survival in post-transplant relapse necessarily involves consolidation with cellular immunotherapy, we present data on the efficacy and toxicity of both DLI and second allo-HCT including when such therapies are integrated with reinduction. Finally, we provide our general approach to the treatment of post-transplant relapse, integrating both novel therapies and our improved understanding of the mechanisms underlying post-transplant relapse.
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Affiliation(s)
- Jonathan A Webster
- Hematologic Malignancies and Bone Marrow Transplantation Program, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Leo Luznik
- Hematologic Malignancies and Bone Marrow Transplantation Program, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Ivana Gojo
- Hematologic Malignancies and Bone Marrow Transplantation Program, Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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14
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Bewersdorf JP, Derkach A, Gowda L, Menghrajani K, DeWolf S, Ruiz JD, Ponce DM, Shaffer BC, Tamari R, Young JW, Jakubowski AA, Gyurkocza B, Chan A, Xiao W, Glass J, King AC, Cai SF, Daniyan A, Famulare C, Cuello BM, Podoltsev NA, Roshal M, Giralt S, Perales MA, Seropian S, Cho C, Zeidan AM, Prebet T, Stein EM, Tallman MS, Goldberg AD, Stahl M. Venetoclax-based combinations in AML and high-risk MDS prior to and following allogeneic hematopoietic cell transplant. Leuk Lymphoma 2021; 62:3394-3401. [PMID: 34477024 DOI: 10.1080/10428194.2021.1966788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The role of allogeneic hematopoietic cell transplant (allo-HCT) as consolidation after initial venetoclax therapy and the efficacy of venetoclax salvage therapy for relapse after allo-HCT in patients with acute myeloid leukemia (AML) are unclear. We conducted a retrospective study of patients with AML or myelodysplastic syndrome (MDS) who received venetoclax either before or after allo-HCT at Memorial Sloan Kettering Cancer Center and Yale University from 11 August 2016 to 16 November 2020. Among 39 heavily pretreated patients who received venetoclax before allo-HCT, median OS from allo-HCT was not reached after a median follow up of 12.5 months resulting in a 12-month OS estimate of 79.0%. In 37 patients who had received venetoclax-based combinations as salvage therapy after allo-HCT, the overall response rate was 32% with a median OS of 4.7 months (12-month OS estimate: 43.4%). Four patients underwent a second allo-HCT following venetoclax-based salvage therapy suggesting it as a potential salvage treatment option.
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Affiliation(s)
- Jan Philipp Bewersdorf
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, Yale University, New Haven, CT, USA
| | - Andriy Derkach
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Lohith Gowda
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, Yale University, New Haven, CT, USA
| | - Kamal Menghrajani
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY.,Weill Cornell Medical College, New York, NY, USA
| | - Susan DeWolf
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Josel D Ruiz
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Doris M Ponce
- Weill Cornell Medical College, New York, NY, USA.,Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Brian C Shaffer
- Weill Cornell Medical College, New York, NY, USA.,Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Roni Tamari
- Weill Cornell Medical College, New York, NY, USA.,Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - James W Young
- Weill Cornell Medical College, New York, NY, USA.,Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,The Rockefeller University, New York, NY, USA
| | - Ann A Jakubowski
- Weill Cornell Medical College, New York, NY, USA.,Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Boglarka Gyurkocza
- Weill Cornell Medical College, New York, NY, USA.,Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alexander Chan
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Wenbin Xiao
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jacob Glass
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY.,Weill Cornell Medical College, New York, NY, USA
| | - Amber C King
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sheng F Cai
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY.,Weill Cornell Medical College, New York, NY, USA
| | - Anthony Daniyan
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY.,Weill Cornell Medical College, New York, NY, USA
| | - Christopher Famulare
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Bernadette M Cuello
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nikolai A Podoltsev
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, Yale University, New Haven, CT, USA
| | - Mikhail Roshal
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sergio Giralt
- Weill Cornell Medical College, New York, NY, USA.,Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Miguel-Angel Perales
- Weill Cornell Medical College, New York, NY, USA.,Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Stuart Seropian
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, Yale University, New Haven, CT, USA
| | - Christina Cho
- Weill Cornell Medical College, New York, NY, USA.,Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Amer M Zeidan
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, Yale University, New Haven, CT, USA
| | - Thomas Prebet
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, Yale University, New Haven, CT, USA
| | - Eytan M Stein
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY.,Weill Cornell Medical College, New York, NY, USA
| | - Martin S Tallman
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY.,Weill Cornell Medical College, New York, NY, USA
| | - Aaron D Goldberg
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY.,Weill Cornell Medical College, New York, NY, USA
| | - Maximilian Stahl
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY.,Weill Cornell Medical College, New York, NY, USA
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15
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Outcomes of pediatric patients who relapse after first HCT for acute leukemia or MDS. Bone Marrow Transplant 2021; 56:1866-1875. [PMID: 33742153 DOI: 10.1038/s41409-021-01267-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 02/12/2021] [Accepted: 03/03/2021] [Indexed: 11/08/2022]
Abstract
Disease relapse remains a major cause of treatment failure in patients receiving allogeneic hematopoietic cell transplantation (alloHCT) for high-risk acute leukemias or myelodysplastic syndromes (MDS). Comprehensive data on outcomes after post-transplant relapse are lacking, especially in pediatric patients. Our objective was to assess the impact of various transplant-, patient-, and disease-related variables on survival and outcomes in patients who relapse after alloHCT. We describe our institutional experience with 221 pediatric patients who experienced disease relapse after their first alloHCT for acute leukemias or MDS between 1990 and 2018. In a multivariable model, being in first complete remission at first alloHCT, longer duration of remission after alloHCT, experiencing GVHD and receiving a transplant in a more recent time period were significantly associated with a higher likelihood of receiving a second alloHCT after post-transplant relapse. Of these variables, only longer interval from alloHCT to relapse, receiving a second alloHCT or DLI, and receiving a transplant in a more recent time period were associated with improved overall survival. Our data support pursuing second alloHCT for patients who have experienced relapse after their first transplant, as that remains the only salvage modality with a reasonable chance of inducing long-term remission.
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16
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Keruakous AR, Holter-Chakrabarty J, Schmidt SA, Khawandanah MO, Selby G, Yuen C. Azacitidine maintenance therapy post-allogeneic stem cell transplantation in poor-risk acute myeloid leukemia. Hematol Oncol Stem Cell Ther 2021; 16:52-60. [PMID: 36634281 DOI: 10.1016/j.hemonc.2021.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 01/24/2021] [Accepted: 03/06/2021] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE/BACKGROUND Allogeneic hematopoietic stem cell transplant (HSCT) is the potential curative modality for poor-risk acute myeloid leukemia (AML), relapse remains the main reason for transplant failure. Early-phase studies showed azacitidine is safe for post-transplant maintenance therapy in AML. METHODS We performed a single institutional prospective cohort study to evaluate the benefit of azacitidine maintenance therapy following allogeneic HSCT in poor-risk AML. The main objective of this study is to generate a hypothesis aiming to optimize post-transplantation outcomes in poor-risk AML. Forty-nine adults with poor-risk AML who underwent allogeneic HSCT were evaluated in a nonrandomized prospective cohort fashion. Thirty-one participants received post-transplant azacitidine (32 mg/m2) on Days 1-5 for a 28-day treatment cycle beginning approximately 40 days after transplantation. The study was controlled using 18 matched individuals who were on a noninterventional surveillance protocol. RESULTS The relapse rate was significantly higher in the control cohort (66.67%) versus (25.81%) in the azacitidine maintenance cohort (p < .005). Time to relapse was significantly prolonged by azacitidine maintenance, not reached versus 4.1 months in the control arm (p < .0001). In addition, median overall survival was lower in the control cohort at 7.6 versus 27.4 months in the interventional cohort (p < .0001). At a median follow-up of 24 months, incidence of graft-versus-host disease (GVHD) did not differ between study groups (p = .325). In both cohorts, minimal residual disease was correlated with higher hazard of relapse (95% confidence interval, 2.31-13.74; p < .001). CONCLUSION We conclude that low dose azacitidine maintenance following allogeneic HSCT in poor-risk AML, decreased relapse rate, and increased both the time to relapse and overall survival without increased risk of GVHD.
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Affiliation(s)
- Amany R Keruakous
- University of Oklahoma Health Sciences Center, Stephenson Cancer Center, Oklahoma City, OK 73104, USA.
| | | | - Sarah A Schmidt
- University of Oklahoma Health Sciences Center, Stephenson Cancer Center, Oklahoma City, OK 73104, USA
| | - Mohamad O Khawandanah
- University of Oklahoma Health Sciences Center, Stephenson Cancer Center, Oklahoma City, OK 73104, USA
| | - George Selby
- University of Oklahoma Health Sciences Center, Stephenson Cancer Center, Oklahoma City, OK 73104, USA
| | - Carrie Yuen
- University of Oklahoma Health Sciences Center, Stephenson Cancer Center, Oklahoma City, OK 73104, USA.
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17
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Antar AI, Otrock ZK, Abou Dalle I, El-Cheikh J, Bazarbachi A. Pharmacologic Therapies to Prevent Relapse of Acute Myeloid Leukemia After Allogeneic Hematopoietic Stem Cell Transplantation. Front Oncol 2020; 10:596134. [PMID: 33224890 PMCID: PMC7667262 DOI: 10.3389/fonc.2020.596134] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 10/09/2020] [Indexed: 12/29/2022] Open
Abstract
Relapse is the main cause of mortality in patients with acute myeloid leukemia (AML) after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Adverse cytogenetic or molecular risk factors, as well as refractory disease or persistent measurable residual disease (MRD) at the time of transplantation are associated with an increased risk of recurrence. Salvage therapy for AML relapse after allo-HSCT is often limited to chemotherapy, donor lymphocyte infusions and/or second transplants and is rarely successful. Effective post-transplant preventive intervention in high risk AML may be crucial. The most frequent and promising approach is the use of post-transplant maintenance with hypomethylating agents or with FLT3 tyrosine kinase inhibitors when the target is present. Moreover, IDH1/IDH2 inhibitors and BCL-2 inhibitors in combination with other strategies are promising approaches in the maintenance setting. Here we summarize the current knowledge about the preemptive and prophylactic use of pharmacologic agents after allo-HSCT to prevent relapse of AML.
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Affiliation(s)
- Ahmad I. Antar
- Almoosa Specialist Hospital, Department of Internal Medicine, Division of Hematology-Oncology, Al-Ahsa, Saudi Arabia
- Department of Hematology and Oncology, Hammoud Hospital University Medical Center, Saida, Lebanon
| | - Zaher K. Otrock
- Department of Pathology and Laboratory Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Iman Abou Dalle
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Jean El-Cheikh
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ali Bazarbachi
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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18
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Shi W, Jin W, Xia L, Hu Y. Novel agents targeting leukemia cells and immune microenvironment for prevention and treatment of relapse of acute myeloid leukemia after allogeneic hematopoietic stem cell transplantation. Acta Pharm Sin B 2020; 10:2125-2139. [PMID: 32837873 PMCID: PMC7326461 DOI: 10.1016/j.apsb.2020.06.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/27/2020] [Accepted: 06/05/2020] [Indexed: 12/20/2022] Open
Abstract
Relapse remains the worst life-threatening complications after allogeneic hematopoietic stem cell transplantation (allo-HSCT) in patients with acute myeloid leukemia (AML), whose prognosis has been historically dismal. Given the rapid development of genomics and immunotherapies, the interference strategies for AML recurrence have been changing these years. More and more novel targeting agents that have received the U.S. Food and Drug Administration (FDA) approval for de novo AML treatment have been administrated in the salvage or maintenance therapy of post-HSCT relapse. Targeted strategies that regulate the immune microenvironment of and optimize the graft versus leukemia (GVL) effect of immune cells are gradually improved. Such agents not only have been proven to achieve clinical benefits from a single drug, but if combined with classic therapies, can significantly improve the poor prognosis of AML patients who relapse after allo-HSCT. This review will focus on currently available and promising upcoming agents and also discuss the challenges and limitations of targeted therapies in the allogeneic hematopoietic stem cell transplantation community.
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Affiliation(s)
- Wei Shi
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Fred Hutchinson Cancer Research Center, Seattle, WA 98109-1024, USA
| | - Weiwei Jin
- Department of Cardiovascular, Optical Valley School District, Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan 430061, China
- Hubei Province Academy of Traditional Chinese Medicine, Wuhan 430074, China
| | - Linghui Xia
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Yu Hu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
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19
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Bazarbachi A, Schmid C, Labopin M, Beelen D, Wolfgang Blau I, Potter V, Niittyvuopio R, Socié G, Blaise D, Sanz J, Ciceri F, Abou Dalle I, Spyridonidis A, Bug G, Esteve J, Savani BN, Nagler A, Mohty M. Evaluation of Trends and Prognosis Over Time in Patients with AML Relapsing After Allogeneic Hematopoietic Cell Transplant Reveals Improved Survival for Young Patients in Recent Years. Clin Cancer Res 2020; 26:6475-6482. [PMID: 32988970 DOI: 10.1158/1078-0432.ccr-20-3134] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 09/10/2020] [Accepted: 09/22/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE Relapsed acute myeloid leukemia (AML) post allogeneic hematopoietic cell transplantation (allo-HCT) has a dismal prognosis. EXPERIMENTAL DESIGN To assess prognosis of patients with recurrent AML post allo-HCT over time, we analyzed European Society for Blood and Marrow Transplantation registry data of 8,162 adult patients with AML who relapsed between 2000 and 2018 after allo-HCT performed in first complete remission from matched sibling, unrelated, or haploidentical donors. RESULTS The 2-year overall survival (OS) rate from relapse was 17%. For 3,630 patients, <50 years of age, the 2-year OS continuously increased from 16% between 2000 and 2004 to 18% for 2005-2009, to 21% for 2010-2014, and to 26% for 2015-2018 (P = 0.001). Improvement over time was noted both after relapse within and beyond 6 months from allo-HCT. On multivariate analysis among patients <50 years of age, OS was positively affected by a later year of relapse (baseline: 2000-2004; HR, 0.82; P < 0.02 for 2010-2014 and HR, 0.72; P = 0.0002 for 2015-2018), good performance status, favorable cytogenetics, and longer time from transplant to relapse, but negatively affected by increasing age. In contrast, among 4,532 patients, >50 years of age, the year of relapse had no influence on OS (16% for 2000-2004 and 14% for 2015-2018; P = 0.56). Regarding treatment, encouraging results were observed after second allo-HCT, which was performed within 2 years after relapse in 17% of the entire cohort, resulting in a 2-year OS of 30.7%. CONCLUSIONS Outcome after posttransplant relapse among younger patients has improved significantly in recent years, likely reflecting, among other factors, the efficacy of posttransplant salvage including second allo-HCT.
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Affiliation(s)
- Ali Bazarbachi
- Bone marrow Transplant Program, Department of Internal Medicine, American University of Beirut, Beirut, Lebanon.
| | - Christoph Schmid
- Department of Haematology and Oncology, Augsburg University Hospital and Medical Faculty, Augsburg, Germany.
| | - Myriam Labopin
- Department of Haematology and EBMT Paris Study Office/CEREST-TC, Saint Antoine Hospital, Paris, France
| | - Dietrich Beelen
- Department of Bone Marrow Transplantation, University Hospital, Essen, Germany
| | - Igor Wolfgang Blau
- Medizinische Klinik m. S. Hämatologie, Onkologie und Tumorimmunologie, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Victoria Potter
- Department of Haematological Medicine, GKT School of Medicine, London, United Kingdom
| | - Riitta Niittyvuopio
- HUCH Comprehensive Cancer Center, Stem Cell Transplantation Unit, Helsinki, Finland
| | - Gerard Socié
- Programme de Transplantation & Thérapie Cellulaire, Centre de Recherche en Cancérologie de Marseille, Institut Paoli Calmettes, Marseille, France
| | - Didier Blaise
- Programme de Transplantation & Thérapie Cellulaire, Centre de Recherche en Cancérologie de Marseille, Institut Paoli Calmettes, Marseille, France
| | - Jaime Sanz
- Department of Hematology (Torre F, Planta 7), University Hospital La Fe, Valencia, Spain
| | - Fabio Ciceri
- Ospedale San Raffaele s.r.l., Haematology and BMT, Milano, Italy
| | - Iman Abou Dalle
- Bone marrow Transplant Program, Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | | | - Gesine Bug
- Goethe-Universitaet, Medizinische Klinik II, Hämatologie, Medizinische Onkologie, Frankfurt Main, Germany
| | - Jordi Esteve
- Department of Hematology, Hospital Clinic, Institute of Hematology & Oncology, Barcelona, Spain
| | - Bipin N Savani
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Arnon Nagler
- Department of Bone Marrow Transplantation, Chaim Sheba Medical Center, Tel HaShomer, Ramat Gan, Israel
| | - Mohamad Mohty
- Department of Clinical Hematology and Cellular Therapy, Saint-Antoine Hospital, INSERM UMR 938 and Sorbonne University, Paris, France
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20
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Genthon A, Brissot E, Malard F, van de Wyngaert Z, Bonnin A, Banet A, Marjanovic Z, Ikhlef S, Lapusan S, Sestili S, Corre E, Paviglianiti A, Adaeva R, 'Hammedi-Bouzina FM, Labopin M, Dulery R, Mohty M, Legrand O. Gemtuzumab Ozogamicin Combined With Intensive Chemotherapy in Patients With Acute Myeloid Leukemia Relapsing After Allogenic Stem Cell Transplantation. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 20:791-796. [PMID: 32741743 DOI: 10.1016/j.clml.2020.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/01/2020] [Accepted: 07/02/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND More than one-third of patients with acute myeloid leukemia (AML) will relapse after allogenic hematopoietic cell transplant (allo-HCT). The main challenge is to overcome disease resistance to achieve a new complete remission while avoiding excessive toxicity. Gemtuzumab ozogamicin (GO), a conjugate of calicheamicin linked to the humanized monoclonal anti-CD33 antibody, has been used for refractory or relapsed AML with promising response rates, but liver toxicity of GO has long been considered a limiting factor. PATIENTS AND METHODS We included 18 consecutive patients with AML relapsing after a first allo-HCT and treated with fractioned GO (fGO) and intensive chemotherapy. The median age was 40 years (range, 18-65). RESULTS The overall response rate was 72% (13/18), including 7 complete remissions. No death was attributed to treatment toxicity. The main liver toxicity was transient and consisted of transaminase level elevation and hyperbilirubinemia. No cases of veno-occlusive disease were observed after the GO treatment. From the time of salvage treatment initiation, 1- and 2-year OS rates were 54% (95% confidence interval, 28%-74%) and 42% (95% confidence interval, 19%-63%), respectively. CONCLUSIONS Our study suggests the feasibility, efficacy, and safety of an fGO-based salvage regimen combined with intensive chemotherapy in patients with CD33+ AML in the case of early relapse after an allo-HCT.
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Affiliation(s)
- Alexis Genthon
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France.
| | - Eolia Brissot
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - Florent Malard
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - Zoe van de Wyngaert
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - Agnès Bonnin
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - Anne Banet
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - Zora Marjanovic
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - Souhila Ikhlef
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - Simona Lapusan
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - Simona Sestili
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - Elise Corre
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - Annalisa Paviglianiti
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - Rosa Adaeva
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - Fella M 'Hammedi-Bouzina
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - Myriam Labopin
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - Rémy Dulery
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - Mohamad Mohty
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
| | - Ollivier Legrand
- Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, Sorbonne Université, INSERM UMRs 938, Paris, France
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Bewersdorf JP, Stahl M, Zeidan AM. One plus one does not always equal two, especially with regard to hypomethylating agents: the question of synergy of azacitidine and lenalidomide for treatment of relapsed acute myeloid leukemia and myelodysplastic syndromes post allogeneic hematopoietic stem cell transplant. Expert Rev Hematol 2019; 12:575-578. [PMID: 31225770 DOI: 10.1080/17474086.2019.1635005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Key paper evaluation: Craddock C, et al. Combination Lenalidomide and Azacitidine: A Novel Salvage Therapy in Patients Who Relapse After Allogeneic Stem-Cell Transplantation for Acute Myeloid Leukemia. J Clin Oncol. 2019; 37: 580-8. Allogeneic hematopoietic stem cell transplant (allo-HSCT) is the only potentially curative treatment for acute myeloid leukemia (AML) and myelodysplastic syndrome (MDS). However, most patients relapse after allo-HSCT and treatment options are limited. Craddock et al. reported recently in the Journal of Clinical Oncology results from a small phase Ib study combining azacitidine (AZA) and lenalidomide (LEN) for treatment of 29 patients (24 AML and 5 MDS patients) who relapsed after allo-HSCT. Overall response rate was 24%. Patients who received ≥3 cycles of treatment had a higher response rate and responders had a better survival compared to non-responders (27 months vs. 10 months; p = 0.004). Combination treatment was well tolerated with three cases of graft-versus-host disease. While this study suggests a potential synergistic effect of LEN + AZA combination therapy, many questions remain. Efficacy and safety should be confirmed in larger, ideally randomized, studies. Further research on mechanism of action of this combination, comparison with other treatment combinations (e.g. AZA + venetoclax) and use during other disease stages are needed.
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Affiliation(s)
- Jan Philipp Bewersdorf
- a Department of Internal Medicine, Section of Hematology, Yale School of Medicine , New Haven , CT , USA
| | - Maximilian Stahl
- b Leukemia Service, Memorial Sloan Kettering Cancer Center , New York , NY , USA
| | - Amer M Zeidan
- a Department of Internal Medicine, Section of Hematology, Yale School of Medicine , New Haven , CT , USA.,c Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University , New Haven , CT , USA
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22
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What is the role of a second allogeneic hematopoietic cell transplant in relapsed acute myeloid leukemia? Bone Marrow Transplant 2019; 55:325-331. [PMID: 31160807 DOI: 10.1038/s41409-019-0584-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 04/29/2019] [Accepted: 05/15/2019] [Indexed: 11/08/2022]
Abstract
Relapsed acute myeloid leukemia (AML) after an allogeneic hematopoietic cell transplant (allo-HCT) entails a poor prognosis. Treating these cases is challenging due to lack of effective therapies and, in some cases, poor performance status and/or presence of graft-versus-host disease (GVHD), among others. No randomized controlled trial (RCT) has ever been conducted comparing a second allo-HCT against other treatments. Existing data are mainly from observational studies or registries. Success of a second allo-HCT is dependent on appropriately selecting patients who might achieve best outcomes with reasonable non-relapse mortality (NRM) risk. Several factors are associated with worse outcomes, namely a shorter time from first allo-HCT to relapse or to the second allo-HCT, and AML not being in complete hematologic remission (CR). Patients relapsing earlier than 6 months or having active/persistent disease should be enrolled in clinical trials. Limitations of the published literature include retrospective small size studies, a heterogeneous population, and absence of information on somatic mutations, among others. Future studies assessing the role of a second allo-HCT should evaluate the impact of IDH1, IDH2, or others on outcomes; and the feasibility and efficacy of targeted therapies in the pre-, peri-, or post-second allo-HCT setting.
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23
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Mobilization of Leukemic Cells Using Plerixafor as Part of a Myeloablative Preparative Regimen for Patients with Acute Myelogenous Leukemia Undergoing Allografting: Assessment of Safety and Tolerability. Biol Blood Marrow Transplant 2019; 25:1158-1163. [DOI: 10.1016/j.bbmt.2019.01.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 01/07/2019] [Indexed: 01/24/2023]
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24
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Claiborne J, Bandyopathyay D, Roberts C, Hawks K, Aziz M, Simmons G, Wiedl C, Chung H, Clark W, McCarty J, Toor A. Managing post allograft relapse of myeloid neoplasms: azacitidine and donor lymphocyte infusions as salvage therapy. Leuk Lymphoma 2019; 60:2733-2743. [DOI: 10.1080/10428194.2019.1605066] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- John Claiborne
- Bone Marrow Transplant Program, Massey Cancer Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Dipankar Bandyopathyay
- Bone Marrow Transplant Program, Massey Cancer Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Catherine Roberts
- Bone Marrow Transplant Program, Massey Cancer Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Kelly Hawks
- Bone Marrow Transplant Program, Massey Cancer Center, Virginia Commonwealth University, Richmond, VA, USA
| | - May Aziz
- Bone Marrow Transplant Program, Massey Cancer Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Gary Simmons
- Bone Marrow Transplant Program, Massey Cancer Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Christina Wiedl
- Bone Marrow Transplant Program, Massey Cancer Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Harold Chung
- Bone Marrow Transplant Program, Massey Cancer Center, Virginia Commonwealth University, Richmond, VA, USA
| | - William Clark
- Bone Marrow Transplant Program, Massey Cancer Center, Virginia Commonwealth University, Richmond, VA, USA
| | - John McCarty
- Bone Marrow Transplant Program, Massey Cancer Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Amir Toor
- Bone Marrow Transplant Program, Massey Cancer Center, Virginia Commonwealth University, Richmond, VA, USA
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Haploidentical Donor Transplantation Using a Novel Clofarabine-containing Conditioning Regimen for Very High-risk Hematologic Malignant Neoplasms. J Pediatr Hematol Oncol 2018; 40:e479-e485. [PMID: 29750747 PMCID: PMC6197927 DOI: 10.1097/mph.0000000000001222] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Recurrent/refractory hematologic malignancies have a poor prognosis, and there is a need for novel treatment regimens that can be tolerated by this heavily pretreated patient group. Clofarabine has antileukemic activity with an acceptable toxicity profile. In a phase I clinical trial (NCT00824135), we substituted clofarabine for fludarabine in a well-established reduced-intensity conditioning regimen for a T cell-depleted, mismatched-related (haploidentical) donor transplant backbone and explored the maximum tolerated dose of clofarabine in this combination in 15 patients undergoing hematopoietic cell transplantation for recurrent/refractory or secondary leukemia. Clofarabine was well tolerated at a dose of 50 mg/m/d for 5 days in this regimen, with minimal treatment-related mortality in a heavily pretreated group of high-risk patients. All patients exhibited quick hematopoietic recovery, with median times to neutrophil and platelet engraftment being 11 and 16 days, respectively. Transient elevation of transaminases was the most common toxicity-observed in 13 patients (86.7%), with 6 (40%) grade III or above. Three patients (20%) developed hepatic veno-occlusive disease. Eleven patients (73.3%) died, with the most common cause of death being disease relapse (in 9 patients [60%]), followed by treatment-related mortality (in 2 patients [13.3%]). Four (26.6%) of the patients are long-term survivors.
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26
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Delsing Malmberg E, Johansson Alm S, Nicklasson M, Lazarevic V, Ståhlman S, Samuelsson T, Lenhoff S, Asp J, Ehinger M, Palmqvist L, Brune M, Fogelstrand L. Minimal residual disease assessed with deep sequencing of NPM1 mutations predicts relapse after allogeneic stem cell transplant in AML. Leuk Lymphoma 2018; 60:409-417. [DOI: 10.1080/10428194.2018.1485910] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Erik Delsing Malmberg
- Department of Clinical Chemistry and Transfusion Medicine, Institute of Biomedicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Sofie Johansson Alm
- Department of Clinical Chemistry and Transfusion Medicine, Institute of Biomedicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Malin Nicklasson
- Department of Medicine, Section of Hematology and Coagulation, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Vladimir Lazarevic
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Sara Ståhlman
- Department of Clinical Chemistry, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Tore Samuelsson
- Department of Medical Biochemistry and Cell Biology, Institute of Biomedicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Stig Lenhoff
- Department of Hematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Julia Asp
- Department of Clinical Chemistry and Transfusion Medicine, Institute of Biomedicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Chemistry, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mats Ehinger
- Division of Oncology and Pathology, Lund University, Lund, Sweden
| | - Lars Palmqvist
- Department of Clinical Chemistry and Transfusion Medicine, Institute of Biomedicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Chemistry, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mats Brune
- Department of Medicine, Section of Hematology and Coagulation, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Linda Fogelstrand
- Department of Clinical Chemistry and Transfusion Medicine, Institute of Biomedicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Chemistry, Sahlgrenska University Hospital, Gothenburg, Sweden
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27
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Schneidawind C, Hagmaier V, Faul C, Kanz L, Bethge W, Schneidawind D. Second allogeneic hematopoietic cell transplantation enables long-term disease-free survival in relapsed acute leukemia. Ann Hematol 2018; 97:2491-2500. [PMID: 30066039 DOI: 10.1007/s00277-018-3454-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 07/19/2018] [Indexed: 01/19/2023]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) is the treatment of choice for high-risk myeloid and lymphoid leukemias. Relapse after allogeneic HCT is associated with a dismal prognosis and further therapeutic options are limited. One potential curative approach is a second allogeneic HCT. However, there is no consensus about optimal transplant modalities, suitable patients, and entities. We performed a retrospective analysis of our institutional database to evaluate risk factors that influence survival after a second allogeneic HCT for the treatment of relapsed acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL). We identified 40 patients (AML, n = 29; ALL, n = 11) that received a second allogeneic HCT at our institution. At time of second HCT, 48% of patients were in complete remission (CR). Current overall survival (OS) was 14/40 patients with a median follow-up of 64 months (range 4-140) of patients alive resulting in a Kaplan-Meier estimated 2-year event-free survival (EFS) and OS of 32%, respectively. Cumulative incidence of non-relapse mortality (NRM) and relapse at 2 years was 31 and 37%, respectively. We identified several independent risk factors influencing OS: > 6 months from first to second transplant (p = 0.02), complete remission prior to transplant (p = 0.003), and the subsequent occurrence of chronic graft-versus-host disease (p = 0.003) were associated with a significantly improved OS. In conclusion, our data suggest that a second allogeneic HCT is a curative treatment option for relapsed acute leukemias in selected patients.
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Affiliation(s)
- Corina Schneidawind
- Blood and Marrow Transplantation, Department of Medicine II, University Hospital Tuebingen, Eberhard Karls University, Tuebingen, Germany
| | - Volker Hagmaier
- Blood and Marrow Transplantation, Department of Medicine II, University Hospital Tuebingen, Eberhard Karls University, Tuebingen, Germany
| | - Christoph Faul
- Blood and Marrow Transplantation, Department of Medicine II, University Hospital Tuebingen, Eberhard Karls University, Tuebingen, Germany
| | - Lothar Kanz
- Blood and Marrow Transplantation, Department of Medicine II, University Hospital Tuebingen, Eberhard Karls University, Tuebingen, Germany
| | - Wolfgang Bethge
- Blood and Marrow Transplantation, Department of Medicine II, University Hospital Tuebingen, Eberhard Karls University, Tuebingen, Germany
| | - Dominik Schneidawind
- Blood and Marrow Transplantation, Department of Medicine II, University Hospital Tuebingen, Eberhard Karls University, Tuebingen, Germany.
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28
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Ortí G, Sanz J, García-Cadenas I, Sánchez-Ortega I, Alonso L, Jiménez MJ, Sisinni L, Azqueta C, Salamero O, Badell I, Ferra C, de Heredia CD, Parody R, Sanz MA, Sierra J, Piñana JL, Querol S, Valcárcel D. Analysis of relapse after transplantation in acute leukemia: A comparative on second allogeneic hematopoietic cell transplantation and donor lymphocyte infusions. Exp Hematol 2018. [DOI: 10.1016/j.exphem.2018.03.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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29
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Lim ABM, Curley C, Fong CY, Bilmon I, Beligaswatte A, Purtill D, Getta B, Johnston AM, Armytage T, Collins M, Mason K, Fielding K, Greenwood M, Gibson J, Hertzberg M, Wright M, Lewis I, Moore J, Curtis D, Szer J, Kennedy G, Ritchie D. Acute myeloid leukaemia relapsing after allogeneic haemopoietic stem cell transplantation: prognostic factors and impact of initial therapy of relapse. Intern Med J 2018. [DOI: 10.1111/imj.13522] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Andrew B. M. Lim
- Department of Clinical Haematology and BMT Service; The Royal Melbourne Hospital; Melbourne Victoria Australia
- The University of Melbourne; Melbourne Victoria Australia
| | - Cameron Curley
- Department of Haematology and BMT; Royal Brisbane and Women's Hospital; Brisbane Queensland Australia
| | - Chun Y. Fong
- Department of Clinical Haematology; The Alfred; Melbourne Victoria Australia
| | - Ian Bilmon
- Haematology Department; St Vincent's Hospital; Sydney New South Wales Australia
- Department of Haematology; Westmead Hospital; Sydney New South Wales Australia
| | - Ashanka Beligaswatte
- Clinical Haematology Bone Marrow Transplant Unit; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - Duncan Purtill
- Department of Haematology; Royal Perth Hospital; Perth Western Australia Australia
| | - Bartlomiej Getta
- Department of Haematology; Westmead Hospital; Sydney New South Wales Australia
| | - Anne M. Johnston
- Institute of Haematology; Royal Prince Alfred Hospital; Sydney New South Wales Australia
| | - Tasman Armytage
- Haematology Department; Royal North Shore Hospital; Sydney New South Wales Australia
| | - Marnie Collins
- Centre for Biostatistics and Clinical Trials; Melbourne Victoria Australia
| | - Kate Mason
- Department of Clinical Haematology and BMT Service; The Royal Melbourne Hospital; Melbourne Victoria Australia
| | - Katherine Fielding
- Department of Clinical Haematology and BMT Service; The Royal Melbourne Hospital; Melbourne Victoria Australia
| | - Matthew Greenwood
- Haematology Department; Royal North Shore Hospital; Sydney New South Wales Australia
| | - John Gibson
- Institute of Haematology; Royal Prince Alfred Hospital; Sydney New South Wales Australia
- The University of Sydney; Sydney New South Wales Australia
| | - Mark Hertzberg
- Department of Haematology; Westmead Hospital; Sydney New South Wales Australia
| | - Matthew Wright
- Department of Haematology; Royal Perth Hospital; Perth Western Australia Australia
| | - Ian Lewis
- Clinical Haematology Bone Marrow Transplant Unit; Royal Adelaide Hospital; Adelaide South Australia Australia
| | - John Moore
- Haematology Department; St Vincent's Hospital; Sydney New South Wales Australia
| | - David Curtis
- Department of Clinical Haematology; The Alfred; Melbourne Victoria Australia
| | - Jeff Szer
- Department of Clinical Haematology and BMT Service; The Royal Melbourne Hospital; Melbourne Victoria Australia
- The University of Melbourne; Melbourne Victoria Australia
| | - Glen Kennedy
- Department of Haematology and BMT; Royal Brisbane and Women's Hospital; Brisbane Queensland Australia
| | - David Ritchie
- Department of Clinical Haematology and BMT Service; The Royal Melbourne Hospital; Melbourne Victoria Australia
- The University of Melbourne; Melbourne Victoria Australia
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30
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Aljasem HA, Messner HA, Lipton JH, Kim DDH, Viswabandya A, Thyagu S, Deotare U, Michelis FV. Outcome following second allogeneic hematopoietic cell transplantation: A single-center experience. Eur J Haematol 2018; 100:308-314. [PMID: 29240253 DOI: 10.1111/ejh.13015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2017] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Second allogeneic hematopoietic cell transplantation (HCT) may be indicated following relapse or graft failure following first HCT. Our retrospective single-center study sought to investigate parameters that influence post-second allogeneic HCT survival. METHOD We investigated 92 patients who underwent second allogeneic HCT between 1980 and 2016 for relapse or graft failure following first HCT. Median age at second HCT was 41 years (range 16-68), performed for relapse in 59 patients (64%) and for graft failure in 33 patients (36%). RESULTS On univariate analysis, 3-year OS of the entire cohort was 35% (95% CI=25-45). Eastern Cooperative Oncology Group (ECOG) score (3-year OS 48% for ECOG 0-1, 18% for ECOG 2-3, P=.0006), second HCT indication (3-year OS 43% for relapse, 20% for graft failure, P=.02), time from first HCT to relapse/graft failure (3-year OS for <12months 21%, for ≥12months 46%, P=.009), and conditioning intensity (3-year OS for MA 42% vs other regimens 23%, P=.08) significantly influenced OS. Multivariable analysis confirmed ECOG score (HR=2.15 for ECOG 2-3, 95% CI=1.32-3.51, P=.002) and second HCT indication (HR=1.67 for graft failure, 95% CI=1.02-2.75, P=.04) to independently influence survival. CONCLUSION Second HCT may offer long-term survival particularly to patients with good performance status who relapse post-first HCT.
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Affiliation(s)
- Hassan A Aljasem
- Allogeneic Blood and Marrow Transplant Program, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
| | - Hans A Messner
- Allogeneic Blood and Marrow Transplant Program, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
| | - Jeffrey H Lipton
- Allogeneic Blood and Marrow Transplant Program, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
| | - Dennis Dong Hwan Kim
- Allogeneic Blood and Marrow Transplant Program, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
| | - Auro Viswabandya
- Allogeneic Blood and Marrow Transplant Program, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
| | - Santhosh Thyagu
- Allogeneic Blood and Marrow Transplant Program, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
| | - Uday Deotare
- Allogeneic Blood and Marrow Transplant Program, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
| | - Fotios V Michelis
- Allogeneic Blood and Marrow Transplant Program, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, Canada
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[Preventative and therapeutic relapse strategies after allogeneic hematopoietic stem cell transplantation: Guidelines from the Francophone society of bone marrow transplantation and cellular therapy (SFGM-TC)]. Bull Cancer 2017; 104:S84-S98. [PMID: 29179894 DOI: 10.1016/j.bulcan.2017.05.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 05/01/2017] [Indexed: 12/20/2022]
Abstract
Disease relapse remains the first cause of mortality of hematological malignancies after allogeneic hematopoietic stem cell transplantation (allo-HCT). The risk of recurrence is elevated in patients with high-risk cytogenetic or molecular abnormalities, as well as when allo-HCT is performed in patients with refractory disease or with persistent molecular or radiological (PET-CT scan) residual disease. Within the frame of the 7th annual workshops of the francophone society for bone marrow transplantation and cellular therapy, the working group reviewed the literature in order to elaborate unified guidelines for the prevention and treatment of relapse after allo-HCT. For high risk AML and MDS, a post transplant maintenance strategy is possible, using hypomethylating agents or TKI anti-FLT3 when the target is present. For Philadelphia positive ALL, there was a consensus for the use of post-transplant TKI maintenance. For lymphomas, there are no strong data on the use of post-transplant maintenance, and hence a preemptive strategy is recommended based on modulation of immunosuppression, close follow-up of donor chimerism, and donor lymphocytes infusion. For multiple myeloma, even though the indication of allo-HCT is controversial, our recommendation is post transplant maintenance using bortezomib, due to its a good toxicity profile without increasing the risk of GVHD.
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Isolated Extramedullary Relapse of Acute Leukemia after Allogeneic Stem Cell Transplantation: Different Kinetics and Better Prognosis than Systemic Relapse. Biol Blood Marrow Transplant 2017; 23:1087-1094. [DOI: 10.1016/j.bbmt.2017.03.023] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 03/20/2017] [Indexed: 11/19/2022]
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Yafour N, Beckerich F, Bulabois C, Chevallier P, Daguindau E, Dumesnil C, Guillaume T, Huynh A, Masouridi Levrat S, Menard A, Pautas C, Poiré X, Ravinet A, Michallet M, Bazarbachi A. How to prevent relapse after allogeneic hematopoietic stem cell transplantation in patients with acute leukemia and myelodysplastic syndrome. Curr Res Transl Med 2017; 65:65-69. [DOI: 10.1016/j.retram.2017.06.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 06/02/2017] [Accepted: 06/06/2017] [Indexed: 12/24/2022]
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Abstract
Management of relapsed leukemia following allogeneic transplantation is challenging. Intensive chemotherapy, donor lymphocyte infusions (DLI), or second transplantation have some value, but most reported series describe only a limited number of patients surviving beyond 2 or 3 years following relapse. Additionally, understandable selection-bias of reports describing the outcomes of intensive management approaches for relapsed leukemia confound generalizability to a broader population. However numerous reports suggest that second allogeneic transplantation for relapsed leukemia following an initial transplant may produce extended disease control and survival for patients with favorable performance status, remission at the time of second transplant, and most importantly a long interval between initial transplant and relapse. Reduced intensity conditioning for second allografts may be preferable and little data exists to suggest that a new donor will improve disease control by inducing a stronger graft-versus-leukemia effect. Improved measures to prevent the first relapse, however, may protect more patients and produce a greater fraction enjoying extended leukemia-free survival.
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Affiliation(s)
- Daniel Weisdorf
- University of Minnesota Medical School, Division of Hematology, Oncology and Transplantation, Mayo Mail Code 480, 420 Delaware St SE, Minneapolis, MN 55455, USA.
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35
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Motabi IH, Ghobadi A, Liu J, Schroeder M, Abboud CN, Cashen AF, Stockler-Goldstein KE, Uy GL, Vij R, Westervelt P, DiPersio JF. Chemotherapy versus Hypomethylating Agents for the Treatment of Relapsed Acute Myeloid Leukemia and Myelodysplastic Syndrome after Allogeneic Stem Cell Transplant. Biol Blood Marrow Transplant 2016; 22:1324-1329. [DOI: 10.1016/j.bbmt.2016.03.023] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 03/18/2016] [Indexed: 11/16/2022]
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Low incidence of GvHD with T-cell depleted allografts facilitates further treatments for post-transplantation relapse in AML and MDS. Bone Marrow Transplant 2016; 51:991-3. [PMID: 26926229 DOI: 10.1038/bmt.2016.23] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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37
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Bejanyan N, Weisdorf DJ, Logan BR, Wang HL, Devine SM, de Lima M, Bunjes DW, Zhang MJ. Survival of patients with acute myeloid leukemia relapsing after allogeneic hematopoietic cell transplantation: a center for international blood and marrow transplant research study. Biol Blood Marrow Transplant 2015; 21:454-9. [PMID: 25460355 PMCID: PMC4329076 DOI: 10.1016/j.bbmt.2014.11.007] [Citation(s) in RCA: 230] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 11/09/2014] [Indexed: 12/21/2022]
Abstract
Acute myeloid leukemia (AML) relapse after allogeneic hematopoietic cell transplantation (alloHCT) remains a major therapeutic challenge. We studied outcomes of 1788 AML patients relapsing after alloHCT (1990 to 2010) during first or second complete remission (CR) to identify factors associated with longer postrelapse survival. Median time to post-HCT relapse was 7 months (range, 1 to 177). At relapse, 1231 patients (69%) received intensive therapy, including chemotherapy alone (n = 660), donor lymphocyte infusion (DLI) ± chemotherapy (n = 202), or second alloHCT ± chemotherapy ± DLI (n = 369), with subsequent CR rates of 29%. Median follow-up after relapse was 39 months (range, <1 to 193). Survival for all patients was 23% at 1 year after relapse; however, 3-year overall survival correlated with time from HCT to relapse (4% for relapse during the 1- to 6-month period, 12% during the 6-month to 2-year period, 26% during the 2- to 3-year period, and 38% for ≥3 years). In multivariable analysis, lower mortality was significantly associated with longer time from alloHCT to relapse (relative risk, .55 for 6 months to 2 years; relative risk, .39 for 2 to 3 years; and relative risk, .28 for ≥3 years; P < .0001) and a first HCT using reduced-intensity conditioning (relative risk, .77; 95% confidence interval [CI], .66 to .88; P = .0002). In contrast, inferior survival was associated with age >40 years (relative risk, 1.42; 95% CI, 1.24 to 1.64; P < .0001), active graft-versus-host disease at relapse (relative risk, 1.25; 95% CI, 1.13 to 1.39; P < .0001), adverse cytogenetics (relative risk, 1.37; 95% CI, 1.09 to 1.71; P = .0062), mismatched unrelated donor (relative risk, 1.61; 95% CI, 1.22 to 2.13; P = .0008), and use of cord blood for first HCT (relative risk, 1.23; 95% CI, 1.06 to 1.42; P = .0078). AML relapse after alloHCT predicted poor survival; however, patients who relapsed ≥6 months after their initial alloHCT had better survival and may benefit from intensive therapy, such as second alloHCT ± DLI.
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Affiliation(s)
- Nelli Bejanyan
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota.
| | - Daniel J Weisdorf
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Brent R Logan
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Hai-Lin Wang
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Steven M Devine
- Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center - James, Columbus, Ohio
| | - Marcos de Lima
- Department of Medicine, Seidman Cancer Center, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Donald W Bunjes
- Department of Internal Medicine III, Universitätsklinikum Ulm, Ulm, Germany
| | - Mei-Jie Zhang
- Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, Wisconsin
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Treatment strategies in patients with AML or high-risk myelodysplastic syndrome relapsed after Allo-SCT. Bone Marrow Transplant 2015; 50:485-92. [PMID: 25599163 DOI: 10.1038/bmt.2014.300] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2014] [Revised: 11/02/2014] [Accepted: 11/22/2014] [Indexed: 11/09/2022]
Abstract
Non-relapse mortality after Allo-SCT has significantly decreased over the last years. Nevertheless, relapse remains a major cause for post SCT mortality in patients with AML and high-risk myelodysplastic syndrome (MDS). In this retrospective single-center analysis, we have analyzed the treatment outcomes of 108 patients with AML or MDS, who relapsed after Allo-SCT. Seventy of these patients (65%) were treated with salvage therapies containing chemotherapy alone, allogeneic cell-based treatment or the combination of both. Thirty-eight patients (35%) received palliative treatment. Median OS after diagnosis of relapse was 130 days. Compared with patients who received chemotherapy alone, response to salvage therapy was significantly improved in patients treated with a combination of chemo- and allogeneic cell-based therapy (CR rate 57% vs 13%, P=0.002). Among risk factors concerning pretreatment characteristics, disease status before first Allo-SCT, and details of transplantation, only the time interval from Allo-SCT to relapse was an independent predictor of response to salvage therapy and OS. These data confirmed that time to relapse after transplantation is an important prognostic factor. Up to now, only patients eligible for treatment regimens containing allogeneic cell-based interventions achieved relevant response rates.
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Clinical outcomes of AML patients relapsing after matched-related donor and umbilical cord blood transplantation. Bone Marrow Transplant 2014; 49:1029-35. [PMID: 24887379 DOI: 10.1038/bmt.2014.116] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Revised: 03/31/2014] [Accepted: 04/16/2014] [Indexed: 11/08/2022]
Abstract
AML relapse remains the leading cause of transplant failure among Allo-SCT recipients. A single institution study was conducted on 348 patients with AML who received an Allo-SCT from an umbilical cord blood (UCB, 222) or HLA-matched-related (RD, 126) donor between 2000-2011. Relapse after Allo-SCT occurred in 72 UCB and 32 RD transplant recipients. Three patients achieved CR after withdrawal of immune suppression with no further therapy. Fifty-two patients received intensive post-relapse therapy, defined as systemic chemotherapy (22 UCB, 7 RD), second Allo-SCT (nine UCB, two RD), or DLI±systemic chemotherapy (0 UCB, 12 RD); of these, 25% achieved CR (21% UCB vs 35% RD, P=0.16). Survival at 1 year after relapse was 22% for all patients (19% UCB vs 28% RD, P=0.36). In multivariable analysis, post-relapse mortality was lower in patients receiving intensive therapy for relapse (hazard ratio (HR)=0.4; 95% confidence interval (CI) 0.2-0.6, P<0.01) and higher in patients with peripheral blood blasts above the median (HR=3.8; 95% CI 2.2-6.6, P<0.01), active infection (HR=1.9; 95% CI 1.0-3.5, P=0.05) and non-infectious medical complications (HR=2.0; 95% CI 1.2-3.5, P=0.01). In conclusion, patients with AML relapsing after Allo-SCT who were in good-enough clinical condition to receive intensive therapy had superior short-term survival.
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