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Forsberg M, Konopleva M. AML treatment: conventional chemotherapy and emerging novel agents. Trends Pharmacol Sci 2024; 45:430-448. [PMID: 38643058 DOI: 10.1016/j.tips.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Revised: 03/25/2024] [Accepted: 03/25/2024] [Indexed: 04/22/2024]
Abstract
Acute myeloid leukemia (AML) is driven by complex mutations and cytogenetic abnormalities with profound tumoral heterogeneity, making it challenging to treat. Ten years ago, the 5-year survival rate of patients with AML was only 29% with conventional chemotherapy and stem cell transplantation. All attempts to improve conventional therapy over the previous 40 years had failed. Now, new genomic, immunological, and molecular insights have led to a renaissance in AML therapy. Improvements to standard chemotherapy and a wave of new targeted therapies have been developed. However, how best to incorporate these advances into frontline therapy and sequence them in relapse is not firmly established. In this review, we highlight current treatments of AML, targeted agents, and pioneering attempts to synthesize these developments into a rational standard of care (SoC).
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Affiliation(s)
- Mark Forsberg
- Montefiore Einstein Cancer Center, Department of Oncology, 1300 Morris Park Avenue, Bronx, NY 10461, USA
| | - Marina Konopleva
- Montefiore Einstein Cancer Center, Department of Oncology, 1300 Morris Park Avenue, Bronx, NY 10461, USA.
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2
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Zhong S, Kurish H, Walchack R, Li H, Edwards J, Singh A, Advani A. Efficacy and safety of mitoxantrone, etoposide, and cytarabine for treatment of relapsed or refractory acute myeloid leukemia. Leuk Res 2024; 139:107468. [PMID: 38460433 DOI: 10.1016/j.leukres.2024.107468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 02/20/2024] [Accepted: 02/26/2024] [Indexed: 03/11/2024]
Abstract
BACKGROUND/RATIONALE Most patients with acute myeloid leukemia (AML) develop relapsed or refractory (R/R) disease after receiving initial induction chemotherapy. Salvage chemotherapy followed by allogeneic hematopoietic stem cell transplantation (alloHSCT) is the only curative therapy for R/R AML. Mitoxantrone, etoposide, and cytarabine (MEC) is the current standard of care salvage regimen for R/R AML at Cleveland Clinic. The primary objective was to determine the overall remission rate (ORR: defined as patients achieving complete remission (CR) or complete remission with incomplete hematologic recovery (CRi)) in R/R AML patients who received MEC. METHODS Adult patients with R/R AML treated with MEC between July 1, 2014 and September 30, 2022 were included. ORR and its association with baseline characteristics were determined. Secondary outcomes included overall survival (OS), event-free survival (EFS), relapse-free survival (RFS), and safety. RESULTS Sixty patients were evaluated. The ORR was 51.7% (33.3% CR and 18.3% CRi). The median time from receipt of MEC to CR/CRi was 7.7 weeks. Patients with bone marrow blasts ≤20% and peripheral blood blasts ≤30% at MEC initiation were more than twice as likely to achieve CR/CRi compared to those with a higher blast burden. The median OS was 6.3 months. Twenty-four (40.0%) patients proceeded to alloHSCT. Twenty-one (35.0%) patients were transferred to the intensive care unit (ICU) during their admission. CONCLUSIONS MEC is an effective salvage regimen for patients with R/R AML, especially among those with low disease burden at initiation. Febrile neutropenia, infections, and severe oral mucositis were common with MEC administration.
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Affiliation(s)
- Sharon Zhong
- Department of Pharmacy, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA.
| | - Heena Kurish
- Department of Pharmacy, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA
| | - Robert Walchack
- Department of Pharmacy, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA
| | - Hong Li
- Taussig Cancer Institute, Cleveland Clinic, 10201 Carnegie Ave, Cleveland, OH 44106, USA
| | - Jessi Edwards
- Department of Pharmacy, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH 44195, USA
| | - Abhay Singh
- Taussig Cancer Institute, Cleveland Clinic, 10201 Carnegie Ave, Cleveland, OH 44106, USA
| | - Anjali Advani
- Taussig Cancer Institute, Cleveland Clinic, 10201 Carnegie Ave, Cleveland, OH 44106, USA
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3
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Ravandi F, Döhner H, Wei AH, Montesinos P, Pfeilstöcker M, Papayannidis C, Lai Y, Wang K, See WL, de Menezes DL, Petrlik E, Prebet T, Roboz GJ. Survival outcomes in patients with acute myeloid leukaemia who received subsequent therapy for relapse in QUAZAR AML-001. Br J Haematol 2024; 204:877-886. [PMID: 37952982 DOI: 10.1111/bjh.19202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 10/31/2023] [Indexed: 11/14/2023]
Abstract
In the phase 3 QUAZAR AML-001 trial (NCT01757535) of patients with acute myeloid leukaemia (AML) in remission following intensive chemotherapy (IC) and ineligible for haematopoietic stem cell transplant (HSCT), oral azacitidine (Oral-AZA) maintenance significantly prolonged overall survival (OS) versus placebo. The impact of subsequent treatment following maintenance has not been evaluated. In this post hoc analysis, OS was estimated for patients who received subsequent AML therapy, and by regimen received (IC or lower-intensity therapy). First subsequent therapy (FST) was administered after treatment discontinuation in 134/238 Oral-AZA and 173/234 placebo patients. OS from randomization in patients who received FST after Oral-AZA versus placebo was 17.8 versus 12.9 months (HR: 0.82 [95% CI: 0.64-1.04], median follow-up: 56.7 months); OS from FST was similar between arms. Among patients who received injectable hypomethylating agents as FST, median OS was 8.2 versus 4.9 months in the Oral-AZA versus placebo groups (HR: 0.66 [95% CI: 0.41-1.06]). Forty-eight patients (16/238 Oral-AZA, 32/234 placebo) received HSCT following treatment discontinuation, including six Oral-AZA patients still in first remission; Oral-AZA OS benefit persisted when censoring these patients. Oral-AZA maintenance can prolong AML remission duration without negatively impacting survival outcomes after salvage therapies.
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Affiliation(s)
- Farhad Ravandi
- Department of Leukemia, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Andrew H Wei
- Peter MacCallum Cancer Centre, Melbourne, Australia
- The Royal Melbourne Hospital, Melbourne, Australia
| | - Pau Montesinos
- Hematology Department, Hospital Universitari i Politècnic, La Fe, València, Spain
- CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Michael Pfeilstöcker
- Third Medical Department for Hematology and Oncology, Hanusch Hospital, Vienna, Austria
- Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria
| | - Cristina Papayannidis
- IRCCS, Azienda Ospedaliero Universitaria di Bologna, Istituto di Ematologia "L. e A. Seràgnoli", Bologna, Italy
| | - Yinzhi Lai
- Bristol Myers Squibb, Princeton, New Jersey, USA
| | - Kefeng Wang
- Bristol Myers Squibb, Princeton, New Jersey, USA
| | - Wendy L See
- Bristol Myers Squibb, San Francisco, California, USA
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4
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Jia X, Liao N, Yu S, Li H, Liu H, Zhang H, Xu J, Yao Y, He H, Yu G, Liu Q, Zhang Y, Shi P. Impact of measurable residual disease in combination with CD19 on postremission therapy choices for adult t(8;21) acute myeloid leukemia in first complete remission. Cancer Med 2024; 13:e7074. [PMID: 38457215 PMCID: PMC10922018 DOI: 10.1002/cam4.7074] [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: 10/08/2023] [Revised: 02/08/2024] [Accepted: 02/20/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND The post-remission therapy (PRT) choices for adult t(8;21) acute myeloid leukemia (AML) in first complete remission (CR1) need to be further explored. AIMS We aimed to investigate the impact of measurable residual disease (MRD) combined with CD19 on PRT choices for adult t(8;21) AML in CR1. METHODS A total of 150 t(8;21) AML patients were enrolled, including 67 underwent chemotherapy (CMT) and 83 allogeneic hematopoietic stem cell transplantation (allo-SCT) as PRT in CR1. Subgroup analyses were performed according to MRD level after three cycles of chemotherapy combined with CD19 expression. RESULTS Multivariate analysis indicated MRDhigh after three courses of treatment (HR, 0.14 [95% CI, 0.03-0.66]; p = 0.013) and CD19 negativity (HR, 0.14 [95% CI, 0.02-0.96]; p = 0.045) were risk factors for relapse, while allo-SCT was protective factor for relapse (HR, 0.34 [95% CI, 0.15-0.75]; p = 0.008). Grouped by MRD after three courses of chemotherapy, allo-SCT had lower CIR (p < 0.001) and better OS (p = 0.003) than CMT for MRDhigh patients, CMT showed a higher CIR (35.99% vs. 15.34%, p = 0.100) but comparable OS (p = 0.588) than allo-SCT for MRDlow patients. Grouped by CD19 expression, allo-SCT demonstrated lower CIR (p < 0.001) and better OS (p = 0.002) than CMT for CD19- patients. CMT had a higher CIR (41.37% vs. 10.48%, p = 0.007) but comparable OS (p = 0.147) than allo-SCT for CD19+ patients. Grouped by MRD combined with CD19, MRDhigh /CD19+ subsets were identified out of CD19+ patients benefiting from allo-SCT with lower CIR (p = 0.002) and superior OS (p = 0.020) than CMT. CMT preserved comparable CIR (p = 0.939) and OS (p = 0.658) with allo-SCT for MRDlow /CD19+ patients. MRDlow /CD19- subsets were also identified from MRDlow patients requiring allo-SCT with lower CIR (p < 0.001) and superior OS (p = 0.008) than CMT. Allo-SCT maintained lower CIR (p < 0.001) and superior OS (p = 0.008) than CMT for MRDhigh /CD19- patients. CONCLUSIONS MRD combined with CD19 might optimize PRT choices for adult t(8;21) AML patients in CR1.
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Affiliation(s)
- Xi Jia
- Department of Hematology, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
- Clinical Medical Research Center of Hematological Diseases of Guangdong ProvinceGuangzhouChina
| | - Naying Liao
- Department of Hematology, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
- Clinical Medical Research Center of Hematological Diseases of Guangdong ProvinceGuangzhouChina
| | - Sijian Yu
- Department of Hematology, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
- Clinical Medical Research Center of Hematological Diseases of Guangdong ProvinceGuangzhouChina
| | - Huan Li
- Department of Hematology, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
- Clinical Medical Research Center of Hematological Diseases of Guangdong ProvinceGuangzhouChina
| | - Hui Liu
- Department of Hematology, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
- Clinical Medical Research Center of Hematological Diseases of Guangdong ProvinceGuangzhouChina
| | - Haiyan Zhang
- Department of Hematology, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
- Clinical Medical Research Center of Hematological Diseases of Guangdong ProvinceGuangzhouChina
| | - Jun Xu
- Department of Hematology, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
- Clinical Medical Research Center of Hematological Diseases of Guangdong ProvinceGuangzhouChina
| | - Yunqian Yao
- Department of Hematology, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
- Clinical Medical Research Center of Hematological Diseases of Guangdong ProvinceGuangzhouChina
| | - Han He
- Department of Hematology, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
- Clinical Medical Research Center of Hematological Diseases of Guangdong ProvinceGuangzhouChina
| | - Guopan Yu
- Department of Hematology, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
- Clinical Medical Research Center of Hematological Diseases of Guangdong ProvinceGuangzhouChina
| | - Qifa Liu
- Department of Hematology, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
- Clinical Medical Research Center of Hematological Diseases of Guangdong ProvinceGuangzhouChina
| | - Yu Zhang
- Department of Hematology, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
- Clinical Medical Research Center of Hematological Diseases of Guangdong ProvinceGuangzhouChina
| | - Pengcheng Shi
- Department of Hematology, Nanfang HospitalSouthern Medical UniversityGuangzhouChina
- Clinical Medical Research Center of Hematological Diseases of Guangdong ProvinceGuangzhouChina
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5
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Darwish C, Farina K, Tremblay D. The core concepts of core binding factor acute myeloid leukemia: Current considerations for prognosis and treatment. Blood Rev 2023; 62:101117. [PMID: 37524647 DOI: 10.1016/j.blre.2023.101117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 07/04/2023] [Accepted: 07/21/2023] [Indexed: 08/02/2023]
Abstract
Core binding factor acute myeloid leukemia (CBF AML), defined by t(8;21) or inv(16), is a subset of favorable risk AML. Despite its association with a high complete remission rate after induction and relatively good prognosis overall compared with other subtypes of AML, relapse risk after induction chemotherapy remains high. Optimizing treatment planning to promote recurrence free survival and increase the likelihood of survival after relapse is imperative to improving outcomes. Recent areas of research have included evaluation of the role of gemtuzumab in induction and consolidation, the relative benefit of increased cycles of high dose cytarabine in consolidation, the utility of hypomethylating agents and kinase inhibitors, and the most appropriate timing of stem cell transplant. Surveillance with measurable residual disease testing is increasingly being utilized for monitoring disease in remission, and ongoing investigation seeks to determine how to use this tool for early identification of patients who would benefit from proceeding to transplant. In this review, we outline the current therapeutic approach from diagnosis to relapse while highlighting the active areas of investigation in each stage of treatment.
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Affiliation(s)
- Christina Darwish
- Tisch Cancer Institute, Division of Hematology/Oncology, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1079, New York, NY 10029, USA
| | - Kyle Farina
- Department of Pharmacy Practice, The Mount Sinai Hospital, New York, NY 10029, USA
| | - Douglas Tremblay
- Tisch Cancer Institute, Division of Hematology/Oncology, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1079, New York, NY 10029, USA.
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6
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Ma YR, Zhao T, Ma L, Hu LJ, Duan WB, Jiang H, Huang XJ, Jiang Q. [Variables associated with hematological remission and survival in patients with acute myeloid leukemia after induction failure and relapse]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2022; 43:644-650. [PMID: 36709148 PMCID: PMC9593012 DOI: 10.3760/cma.j.issn.0253-2727.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Indexed: 11/28/2022]
Abstract
Objective: This study aimed to explore variables associated with remission rate and survival in patients with acute myeloid leukemia (AML) after induction failure and relapse. Methods: Data of 373 consecutive patients with AML were analyzed after induction failure and relapse. Binary logistics and the Cox model regression were used to identify variables associated with remission rate and outcomes. Results: In patients with AML after induction failure and relapse, the total CR+CRi rates were 50.6% and 40.3%, respectively; among those who achieved CR/CRi, the 3-year RFS rates were 34.4% and 30.4%, respectively, and the 3-year overall survival rates were 40.1% and 31.6%, respectively. In the multivariate analyses, using CLAG or FLAG regimen as a re-induction chemotherapy regimen, age <39 years and SWOG low-risk were significantly associated with higher remission rates in patients with induction failure. Male, secondary AML, SWOG high-risk, the interval from the first remission to relapse within 12 months, and bone marrow blasts ≥20% at the time of relapse were significantly associated with lower remission rates in relapsed patients. Transplantation was significantly associated with prolonged relapse-free survival and overall survival in patients achieving hematologic remission; the SWOG low-risk group was significantly associated with longer overall survival in those with induction failure; and achieving CR (not CRi) or having female gender was associated with longer RFS or overall survival in relapsed patients. Conclusion: Reinduction chemotherapy regimen, age, gender, SWOG risk, secondary AML, the interval from the first remission to relapse, and bone marrow blast percentage at the time of relapse were significantly associated with remission rates in the patients with AML after induction failure and relapse. Transplantation, SWOG low-risk, achieving CR, or female gender were associated with longer survivals in those achieving remission.
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Affiliation(s)
- Y R Ma
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing 100044, China
| | - T Zhao
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing 100044, China
| | - L Ma
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing 100044, China
| | - L J Hu
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing 100044, China
| | - W B Duan
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing 100044, China
| | - H Jiang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing 100044, China
| | - X J Huang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing 100044, China
| | - Q Jiang
- Peking University People's Hospital, Peking University Institute of Hematology, National Clinical Research Center for Hematologic Disease, Beijing 100044, China
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7
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Impact of the MRD status in AML patients undergoing allogeneic stem cell transplantation in first vs second remission. Blood Adv 2022; 6:4570-4580. [PMID: 35605254 DOI: 10.1182/bloodadvances.2022007168] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 05/01/2022] [Indexed: 11/20/2022] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) offers the best chance for relapse-free survival to most acute myeloid leukemia (AML) patients. It might be performed in complete remission or delayed until after first relapse due to relevant treatment-related morbidity and mortality. The measurable residual disease (MRD) status at HSCT adds refined prognostic information to the assigned European LeukemiaNet (ELN) 2017 genetic risk at diagnosis. We analyzed 580 AML patients receiving allogeneic HSCT in either first (79%) or second (21%) remission. Although - due to common treatment strategies - some adverse risk characteristics, such as monosomal or complex karyotypes were less frequent in patients transplanted in second remission, they had worse outcomes compared to patients transplanted in first remission. The MRD status at HSCT was an independent prognostic factor irrespective of the number of remission at HSCT. Noteworthy, MRDpos patients transplanted in first remission and MRDneg patients transplanted in second remission had similar outcomes. In the clinically highly relevant group of ELN2017 intermediate risk individuals, the MRD status provided the highest prognostic value with very dismal outcomes of patients transplanted in MRDpos second remission. The adverse outcomes of MRDpos patients and individuals transplanted in second remission should be considered when planning consolidation treatment, to avert an allogeneic HSCT in MRDpos second remission when possible.
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8
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Augmented FLAMSA-Bu versus FluBu2 reduced-intensity conditioning in patients with active relapsed/refractory acute myeloid leukemia: an EBMT analysis. Bone Marrow Transplant 2022; 57:934-941. [PMID: 35393528 DOI: 10.1038/s41409-022-01611-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 12/16/2021] [Accepted: 02/04/2022] [Indexed: 11/09/2022]
Abstract
Comparative data of fludarabine, cytarabine and amsacrine (FLAMSA) chemotherapy followed by busulfan (Bu)-based reduced-intensity conditioning (RIC) (FLAMSA-Bu) versus RIC regimens are lacking in patients with active relapsed/refractory (R/R) acute myeloid leukemia (AML) at the time of allogeneic hematopoietic stem cell transplantation (alloSCT). Here, we retrospectively analyzed outcomes after FLAMSA-Bu versus fludarabine/busulfan (FluBu2) conditioning in this patient population. A total of 476 patients fulfilled the inclusion criteria, of whom 257 received FluBu2 and 219 FLAMSA-Bu. Median follow-up was 41 months. Two-year non-relapse mortality (21%), graft-versus-host disease-free, relapse-free survival (24%) and chronic graft-versus-host disease (GVHD) (29%) were not statistically different between cohorts. FLAMSA-Bu was associated with lower 2-year relapse incidence (RI) (38 vs 49% after FluBu2, p = 0.004), and increased leukemia-free survival (LFS) (42 vs 29%, p = 0.001), overall survival (47 vs 39%, p = 0.008) and grades II-IV acute GVHD (36 vs 20%, p = 0.001). In the multivariate analysis, FLAMSA-Bu remained associated with lower RI (HR 0.69, p = 0.042), increased LFS (HR 0.74, p = 0.048) and a higher risk of acute GVHD (HR 2.06, p = 0.005). Notwithstanding the limitations inherent in this analysis, our data indicate that FLAMSA-Bu constitutes a tolerable conditioning strategy, resulting in a long-term benefit in a subset of patients reaching alloSCT with active disease.
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Abstract
PURPOSE OF REVIEW The treatment of patients with relapsed or refractory (R/R) acute myeloid leukaemia (AML) has been an unequal challenge for many decades. Although significant progress has been made in the discovery of the mechanisms underlying the molecular pathogenesis of the disease, more than 50% of AML patients still die, mostly from relapsed disease. Currently, the only potential curative option for patients with R/R AML remains allogeneic bone marrow transplantation in second complete remission, which is far being easy to achieve, mainly for patients with primary induction failure or older than 65 years. The purpose of this review is to discuss recent advances in the management of patients with R/R AML, with particular emphasis to new therapeutic options that are replacing conventional salvage chemotherapy. RECENT FINDINGS The development of new agents selectively targeting molecular abnormalities offer more effective and less toxic alternative to chemotherapy, potentially useful as a bridge to allogeneic stem cell transplantation in second complete remission. SUMMARY The recent approval of new drugs for R/R is transforming the paradigm of care we have relied on for the past 50 years. Ongoing clinical trials will tell us how bright is the future for R/R AML patients.
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Yin J, Wan CL, Zhang L, Zhang H, Bai L, Zhou HX, Xu MZ, Chen LY, Qian CS, Qiu HY, Chen SN, Tang XW, Wu DP, Zhang YM, Sun AN, Xue SL. A Phase II Trial of the Double Epigenetic Priming Regimen Including Chidamide and Decitabine for Relapsed/Refractory Acute Myeloid Leukemia. Front Oncol 2021; 11:726926. [PMID: 34540696 PMCID: PMC8446637 DOI: 10.3389/fonc.2021.726926] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 08/20/2021] [Indexed: 12/19/2022] Open
Abstract
Objective To explore the role of chidamide, decitabine plus priming regimen in the salvage treatment of relapsed/refractory acute myeloid leukemia. Methods A clinical trial was conducted in relapsed/refractory acute myeloid leukemia patients using chidamide, decitabine, cytarabine, idarubicin, and granulocyte-colony stimulating factor, termed CDIAG, a double epigenetic priming regimen. Results Thirty-five patients were recruited. Three patients received 2 treatment cycles. In 32 evaluable patients and 35 treatment courses, the completed remission rate (CRR) was 42.9%. The median OS time was 11.7 months. The median OS times of responders were 18.4 months, while those of nonresponders were 7.4 months (P = 0.015). The presence of RUNX1 mutations was associated with a high CRR but a short 2-year OS (P = 0.023) and PFS (P = 0.018) due to relapse after treatment. The presence of IDH mutations had no effect on the remission rate (80.0% vs. 73.3%), but showed a better OS (2-year OS rate: 100.0% vs. 28.9%). Grade 3/4 nonhematological adverse events included pneumonia, hematosepsis, febrile neutropenia, skin and soft tissue infection and others. Conclusion The double epigenetic priming regimen (CDIAG regimen) showed considerably good antileukemia activity in these patients. Adverse events were acceptable according to previous experience. The study was registered as a clinical trial. Clinical Trial Registration https://clinicaltrials.gov/, identifier:NCT03985007
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Affiliation(s)
- Jia Yin
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Chao-Ling Wan
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Ling Zhang
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Hao Zhang
- Department of Hematology, The Affiliated Hospital of Jining Medical College, Jining, China
| | - Lian Bai
- Department of Hematology, Canglang Hospital of Suzhou, Suzhou, China
| | - Hai-Xia Zhou
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Ming-Zhu Xu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Li-Yun Chen
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Chong-Sheng Qian
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Hui-Ying Qiu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Su-Ning Chen
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Xiao-Wen Tang
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - De-Pei Wu
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Yan-Ming Zhang
- Department of Hematology, The Affiliated Huai'an Hospital of Xuzhou Medical University and The Second People's Hospital of Huai'an, Huai'an, China
| | - Ai-Ning Sun
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Sheng-Li Xue
- National Clinical Research Center for Hematologic Diseases, Jiangsu Institute of Hematology, The First Affiliated Hospital of Soochow University, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
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11
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Linch DC, Hills RK, Gilkes A, Burnett AK, Russell N, Gale RE. Additional impact of mutational genotype on prognostic determination in resistant and relapsed acute myeloid leukaemia. Leuk Res 2021; 108:106553. [PMID: 33706968 DOI: 10.1016/j.leukres.2021.106553] [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: 11/25/2020] [Revised: 02/13/2021] [Accepted: 02/23/2021] [Indexed: 11/28/2022]
Abstract
Outcome after failure of initial therapy in younger adult patients with acute myeloid leukaemia (AML) is highly variable. Cytogenetics, length of first remission (CR1) before relapse, and allogeneic transplantation are known prognostic factors, but the contribution of leukaemic genotype is less clear, particularly in resistant disease. Of 5,651 younger adult patients entered into UK MRC/NCRI AML trials between 1988 and 2014 with available FLT3ITD and NPM1 genotype, 326 (6%) had resistant disease and 2338 (41 %) relapsed after achieving CR1. Overall survival (OS) was significantly higher in relapsed compared to resistant disease (p = 0·03). Independent favourable prognostic factors for OS in resistant disease included lower blast cell percentage after two courses of induction therapy (p = 0.0006) and NPM1 mutant (NPM1MUT) (p = 0.04). In relapsed disease, longer CR1 was a favourable independent factor for attainment of CR2 (p < 0.0001) and OS from time of relapse (p < 0.0001), but CR2 rate and OS from relapse were significantly worse in those who had received an allograft in CR1 (respectively p < 0.05, p < 0·002). NPM1MUT was marginally beneficial for OS (p = 0.04). FLT3ITD and DNMT3AMUT were adverse factors for OS (respectively p < 0.0001, p = 0.02). Mutational analysis adds additional independent prognostic information to demographic features and previous therapy in patients with resistant and relapsed disease.
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MESH Headings
- Adolescent
- Adult
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Biomarkers, Tumor/genetics
- Cytogenetic Analysis
- Drug Resistance, Neoplasm/genetics
- Female
- Follow-Up Studies
- Genotype
- Humans
- Leukemia, Myeloid, Acute/drug therapy
- Leukemia, Myeloid, Acute/genetics
- Leukemia, Myeloid, Acute/pathology
- Male
- Middle Aged
- Mutation
- Neoplasm Recurrence, Local/drug therapy
- Neoplasm Recurrence, Local/genetics
- Neoplasm Recurrence, Local/pathology
- Nucleophosmin
- Prognosis
- Retrospective Studies
- Survival Rate
- Young Adult
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Affiliation(s)
- David C Linch
- Department of Haematology, UCL Cancer Institute, London, UK.
| | | | - Amanda Gilkes
- Department of Haematology, School of Medicine, Cardiff University, Cardiff, UK
| | - Alan K Burnett
- Department of Haematology, School of Medicine, Cardiff University, Cardiff, UK
| | - Nigel Russell
- Department of Haematology, Nottingham University Hospital NHS Trust, Nottingham, UK
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12
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Alahmari B, Alzahrani M, Al Shehry N, Tawfiq O, Alwasaidi T, Alhejazi A, Bakkar M, Al Behainy A, Radwi M, Alaskar A. Management Approach to Acute Myeloid Leukemia Leveraging the Available Resources in View of the Latest Evidence: Consensus of the Saudi Society of Blood and Marrow Transplantation. JCO Glob Oncol 2021; 7:1220-1232. [PMID: 34343012 PMCID: PMC8457782 DOI: 10.1200/go.20.00660] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Acute myeloid leukemia (AML) is the most prevalent acute leukemia in adults and is responsible for the majority of cancer-related mortality. In Saudi Arabia, leukemia is ranked the fifth most prevalent type of malignancy in adults. Our aim is to review existing epidemiologic data in Saudi Arabia and develop consensus guidelines for management of AML.
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Affiliation(s)
- Bader Alahmari
- Department of Oncology, Ministry of the National Guard-Health Affairs, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Mohsen Alzahrani
- Department of Oncology, Ministry of the National Guard-Health Affairs, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | | | - Osamah Tawfiq
- King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Turki Alwasaidi
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,Medicine Department, Taibah University, Al Madinah Al Munawarrah, Saudi Arabia.,Prince Mohammed Bin Abdulaziz Hospital, Al Madinah, Ministry of National Guard-Health Affairs, Al Madinah, Saudi Arabia
| | - Ayman Alhejazi
- Department of Oncology, Ministry of the National Guard-Health Affairs, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | | | - Amal Al Behainy
- King Fahad Hospital, Madinah, Al Madinah Al Munawarrah, Saudi Arabia
| | - Mansour Radwi
- Faculty of Medicine, University of Jeddah, Jeddah, Saudi Arabia
| | - Ahmed Alaskar
- Department of Oncology, Ministry of the National Guard-Health Affairs, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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13
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Measurable residual disease status and outcome of transplant in acute myeloid leukemia in second complete remission: a study by the acute leukemia working party of the EBMT. Blood Cancer J 2021; 11:88. [PMID: 33980810 PMCID: PMC8116335 DOI: 10.1038/s41408-021-00479-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 11/07/2020] [Accepted: 12/01/2020] [Indexed: 12/11/2022] Open
Abstract
Measurable residual disease (MRD) prior to hematopoietic cell transplant (HCT) for acute myeloid leukemia (AML) in first complete morphological remission (CR1) is an independent predictor of outcome, but few studies address CR2. This analysis by the Acute Leukemia Working Party of the European Society for Blood and Marrow Transplantation registry assessed HCT outcomes by declared MRD status in a cohort of 1042 adult patients with AML CR2 at HCT. Patients were transplanted 2006–2016 from human leukocyte antigen (HLA) matched siblings (n = 719) or HLA 10/10 matched unrelated donors (n = 293). Conditioning was myeloablative (n = 610) or reduced-intensity (n = 432) and 566 patients (54%) had in-vivo T cell depletion. At HCT, 749 patients (72%) were MRD negative (MRD NEG) and 293 (28%) were MRD positive (MRD POS). Time from diagnosis to HCT was longer in MRD NEG than MRD POS patients (18 vs. 16 months (P < 0.001). Two-year relapse rates were 24% (95% CI, 21–28) and 40% (95% CI, 34–46) in MRD NEG and MRD POS groups (P < 0.001), respectively. Leukemia-free survival (LFS) was 57% (53–61) and 46% (40–52%), respectively (P = 0.001), but there was no difference in terms of overall survival. Prognostic factors for relapse and LFS were MRD NEG status, good risk cytogenetics, and longer time from diagnosis to HCT. In-vivo T cell depletion predicted relapse.
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14
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Tao S, Song L, Deng Y, Chen Y, Gan Y, Li Y, Ding Y, Zhang Z, Ding B, He Z, Wang C, Yu L. Successful treatment of two relapsed patients with t(11;19)(q23;p13) acute myeloid leukemia by CLAE chemotherapy sequential with allogeneic hematopoietic stem cell transplantation: Case reports. Oncol Lett 2021; 21:178. [PMID: 33574917 PMCID: PMC7816337 DOI: 10.3892/ol.2021.12439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 11/20/2020] [Indexed: 12/26/2022] Open
Abstract
The prognosis of patients with relapsed/refractory acute myeloid leukemia (R/R AML) is poor, with a 3-year overall survival rate of 10%. Patients with translocation (t)(11;19)(q23;p13) have a higher risk of relapse and there is no optimal regimen for these patients. The present study treated two young patients with t(11;19)(q23;p13) AML, who relapsed after one or two cycles of consolidation, with a salvage treatment consisting of sequential cladribine, cytarabine and etoposide (CLAE) and allogeneic hematopoietic stem cell transplantation (allo-HSCT). Both neutrophil and platelet engraftments were achieved within 15 days, and no severe transplant-related complications and graft-versus-host diseases were observed. Following allo-HSCT, both patients achieved complete hematologic and cytogenetic remission. Decitabine was used for the prophylaxis of relapse. The two patients remained alive and disease-free for 100 days following allo-HSCT. The results presented here suggest that CLAE regimen sequential with allo-HSCT may be effective in treating patients with R/R AML, with t(11;19)(q23;p13). However, further studies and a larger sample size are required to validate the effectiveness of this treatment regimen.
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Affiliation(s)
- Shandong Tao
- Department of Hematology, The Affiliated Huai'an No. 1 People's Hospital of Nanjing Medical University, Huai'an, Jiangsu 223300, P.R. China.,Key Laboratory of Hematology, Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - Lixiao Song
- Department of Hematology, The Affiliated Huai'an No. 1 People's Hospital of Nanjing Medical University, Huai'an, Jiangsu 223300, P.R. China.,Key Laboratory of Hematology, Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - Yuan Deng
- Department of Hematology, The Affiliated Huai'an No. 1 People's Hospital of Nanjing Medical University, Huai'an, Jiangsu 223300, P.R. China.,Key Laboratory of Hematology, Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - Yue Chen
- Department of Hematology, The Affiliated Huai'an No. 1 People's Hospital of Nanjing Medical University, Huai'an, Jiangsu 223300, P.R. China.,Key Laboratory of Hematology, Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - Yimin Gan
- Department of Hematology, The Affiliated Huai'an No. 1 People's Hospital of Nanjing Medical University, Huai'an, Jiangsu 223300, P.R. China.,Key Laboratory of Hematology, Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - Yunjie Li
- Department of Hematology, The Affiliated Huai'an No. 1 People's Hospital of Nanjing Medical University, Huai'an, Jiangsu 223300, P.R. China.,Key Laboratory of Hematology, Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - Yihan Ding
- Department of Hematology, The Affiliated Huai'an No. 1 People's Hospital of Nanjing Medical University, Huai'an, Jiangsu 223300, P.R. China.,Key Laboratory of Hematology, Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - Zhe Zhang
- Department of Hematology, The Affiliated Huai'an No. 1 People's Hospital of Nanjing Medical University, Huai'an, Jiangsu 223300, P.R. China.,Key Laboratory of Hematology, Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - Banghe Ding
- Department of Hematology, The Affiliated Huai'an No. 1 People's Hospital of Nanjing Medical University, Huai'an, Jiangsu 223300, P.R. China.,Key Laboratory of Hematology, Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - Zhengmei He
- Department of Hematology, The Affiliated Huai'an No. 1 People's Hospital of Nanjing Medical University, Huai'an, Jiangsu 223300, P.R. China.,Key Laboratory of Hematology, Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - Chunling Wang
- Department of Hematology, The Affiliated Huai'an No. 1 People's Hospital of Nanjing Medical University, Huai'an, Jiangsu 223300, P.R. China.,Key Laboratory of Hematology, Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
| | - Liang Yu
- Department of Hematology, The Affiliated Huai'an No. 1 People's Hospital of Nanjing Medical University, Huai'an, Jiangsu 223300, P.R. China.,Key Laboratory of Hematology, Nanjing Medical University, Nanjing, Jiangsu 210029, P.R. China
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15
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FLAMSA-Based Reduced-Intensity Conditioning versus Myeloablative Conditioning in Younger Patients with Relapsed/Refractory Acute Myeloid Leukemia with Active Disease at the Time of Allogeneic Stem Cell Transplantation: An Analysis from the Acute Leukemia Working Party of the European Society for Blood and Marrow Transplantation. Biol Blood Marrow Transplant 2020; 26:2165-2173. [DOI: 10.1016/j.bbmt.2020.07.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/07/2020] [Accepted: 07/15/2020] [Indexed: 12/20/2022]
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16
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Brandwein JM, Saini L, Geddes MN, Yusuf D, Liu F, Schwann K, Billawala A, Westcott C, Kurniawan JA, Cheung WY. Outcomes of patients with relapsed or refractory acute myeloid leukemia: a population-based real-world study. AMERICAN JOURNAL OF BLOOD RESEARCH 2020; 10:124-133. [PMID: 32923092 PMCID: PMC7486485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 07/05/2020] [Indexed: 06/11/2023]
Abstract
With standard therapies for patients with acute myeloid leukemia (AML), many patients either do not achieve complete response (CR) or relapse after CR. There are a scarcity of real-world data on outcomes of unselected patients with relapsed/refractory acute myeloid leukemia (RR-AML). We retrospectively evaluated treatment patterns and survival outcomes of unselected patients aged ≥18 years diagnosed with RR-AML identified from the Alberta Cancer Registry, Alberta, Canada, between January 2013 and December 2016. We included 199 patients who met predefined criteria for RR-AML. Following RR-AML diagnosis, 23% of patients received intensive therapy (IT), 33% non-intensive therapy (NIT), and 44% best supportive care (BSC). The unadjusted median overall survival (OS) of the study cohort was 5.3 months from the time of RR-AML diagnosis, with a 5-year OS rate of 12.6% (95% confidence interval 7.5-21.1). According to treatment intensity after RR-AML, the median OS outcomes were 13.6, 9.4, and 2.0 months for IT, NIT, and BSC groups, respectively (P<0.001). Patients who received treatment (IT or NIT) had better survival than those who received only BSC. This study emphasizes the need for newer therapy options for patients with RR-AML.
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Affiliation(s)
| | | | | | - Dimas Yusuf
- Oncocare Health IncorporatedVancouver, BC, Canada
| | - Fei Liu
- Bristol Myers Squibb, PrincetonNJ, USA
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17
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Canaani J, Nagar M, Heering G, Gefen C, Yerushalmi R, Shem-Tov N, Volchek Y, Merkel D, Avigdor A, Shimoni A, Amariglio N, Rechavi G, Nagler A. Reassessing the role of high dose cytarabine and mitoxantrone in relapsed/refractory acute myeloid leukemia. Oncotarget 2020; 11:2233-2245. [PMID: 32577167 PMCID: PMC7289527 DOI: 10.18632/oncotarget.27618] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 05/14/2020] [Indexed: 01/04/2023] Open
Abstract
A substantial segment of patients with acute myeloid leukemia (AML) will relapse following an initial response to induction therapy or will prove to be primary refractory. High-dose cytarabine and mitoxantrone (HiDAC/MITO) is an established salvage therapy for these patients. We studied all adult patients with relapsed/refractory (R/R) AML who were treated with HiDAC/MITO in our center between the years 2008-2017. To determine whether responding patients harbored a unique molecular signature, we performed targeted next-generation sequencing (NGS) on a subset of patients. The study cohort consisted of 172 patients with a median age of 54 years (range 18–77). The composite complete remission rate was 58%; 11 patients (6%) died during salvage therapy. Median survival was 11.4 months with a 1-year survival rate of 48%. In multivariate analysis favorable risk cytogenetics [Odds ratio (OR)=0.34, confidence interval (CI) 95%, 0.17–0.68; P = 0.002], and de-novo AML (OR = 0.4, CI 95%, 0.16–0.98; P = 0.047) were independently associated with a favorable response. Patients who attained a complete remission had a median survival of 43.7 months compared with 5.2 months for refractory patients (p < 0.0001). Neither the FLT3-ITD and NPM1 mutational status nor the indication for salvage therapy significantly impacted on the response to HiDAC/MITO salvage. NGS analysis identified 20 different mutations across the myeloid gene spectrum with a distinct TP53 signature detected in non-responding patients. HiDAC/MITO is an effective salvage regimen in R/R AML, however patients with adverse cytogenetics or secondary disease may not benefit as much from this approach.
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Affiliation(s)
- Jonathan Canaani
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Meital Nagar
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Gabriel Heering
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Chen Gefen
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Ronit Yerushalmi
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Noga Shem-Tov
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Yulia Volchek
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Drorit Merkel
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Abraham Avigdor
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Avichai Shimoni
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Ninette Amariglio
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Gidi Rechavi
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Arnon Nagler
- Hematology Division, Chaim Sheba Medical Center, Tel Aviv University, Tel Aviv, Israel
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18
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The prognostic impact of FLT3-ITD, NPM1 and CEBPa in cytogenetically intermediate-risk AML after first relapse. Int J Hematol 2020; 112:200-209. [PMID: 32495317 DOI: 10.1007/s12185-020-02894-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 03/30/2020] [Accepted: 05/22/2020] [Indexed: 12/19/2022]
Abstract
We evaluated the impact of FLT3-ITD, NPM1 mutations, and double mutant CEBPa (dmCEBPa) on overall survival (OS) after relapse in patients with cytogenetically intermediate-risk acute myeloid leukemia (AML) who were treated with chemotherapy alone in the first remission (CR1). Patients aged 16-65 years diagnosed with cytogenetically intermediate-risk AML, and who achieved CR1 were included. We retrospectively analyzed FLT3-ITD, NPM1 mutations and CEBPa using samples obtained at diagnosis, which therefore did not affect the therapeutic decisions. Among 235 patients who had achieved CR1, 152 relapsed, and 52% of them achieved second CR. The rate of achieving second CR was significantly higher (85%) in those with dmCEBPa. Patients with FLT3-ITD had significantly worse OS after relapse than those without (19% vs 41%, p = 0.002), while OS was comparable between patients with and without NPM1 mutations (37% vs 34%, p = 0.309). Patients with dmCEBPa had improved OS than those without (61% vs 32%, p = 0.006). By multivariate analysis, FLT3-ITD was independently associated with worse OS after relapse [hazard ratio (HR) 1.99, 95% CI 1.27-3.12, p = 0.003], and dmCEBPa with improved OS (HR 0.40, 95% CI 0.17-0.93, p = 0.033). Our data show that screening for these mutations at diagnosis is useful for facilitating effective therapeutic decision-making even after relapse.
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19
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Rufibach K, Heinzmann D, Monnet A. Integrating phase 2 into phase 3 based on an intermediate endpoint while accounting for a cure proportion—With an application to the design of a clinical trial in acute myeloid leukemia. Pharm Stat 2019; 19:44-58. [DOI: 10.1002/pst.1969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 06/13/2019] [Accepted: 07/11/2019] [Indexed: 01/05/2023]
Affiliation(s)
- Kaspar Rufibach
- Methods, Collaboration, and Outreach Group (MCO), Department of BiostatisticsHoffmann‐La Roche Ltd Basel Switzerland
| | - Dominik Heinzmann
- Oncology Biostatistics, Department of BiostatisticsHoffmann‐La Roche Ltd Basel Switzerland
| | - Annabelle Monnet
- Oncology Biostatistics, Department of BiostatisticsHoffmann‐La Roche Ltd Basel Switzerland
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20
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Allogeneic haemopoietic transplantation for acute myeloid leukaemia in second complete remission: a registry report by the Acute Leukaemia Working Party of the EBMT. Leukemia 2019; 34:87-99. [PMID: 31363160 DOI: 10.1038/s41375-019-0527-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Revised: 05/15/2019] [Accepted: 06/06/2019] [Indexed: 11/08/2022]
Abstract
Allogeneic haemopoietic cell transplant (allo-HCT) may be curative in acute myeloid leukaemia (AML) in second complete remission (CR2) but the impact of reduced intensity (RIC) versus myeloablative conditioning (MAC) is uncertain. The Acute Leukaemia Working Party of the European Society for Blood and Bone Marrow Transplantation Registry studied an AML CR2 cohort characterised by age ≥ 18 years, first allo-HCT 2007-2016, available cytogenetic profile at diagnosis, donors who were matched family, volunteer unrelated with HLA antigen match 10/10 or 9/10 or haplo-identical. The 1879 eligible patients included 1010 (54%) MAC allo-HCT recipients. In patients <50 years (y), two year outcomes for MAC vs RIC allo-HCT were equivalent with leukaemia-free survival (LFS) 54% for each, overall survival (OS), 61% vs 62%, non-relapse mortality (NRM) 18% vs 15% and graft versus host disease relapse-free survival (GRFS) 38% vs 42%. In patients ≥50 y, 2 y outcomes for MAC vs RIC allo-HCT were equivalent for LFS 52% vs 49%, OS 58% vs 55% and GRFS 42.4% vs 36%. However, NRM was significantly inferior after MAC allo-HCT, 27% vs 19% (P = 0.01) despite worse cGVHD after RIC-allo (32% vs 39%). These data support the need for ongoing prospective study of conditioning intensity and GVHD mitigation in AML.
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21
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Efficacy and Feasibility of Allogeneic Hematopoietic Stem-Cell Transplantation in the Treatment of Refractory Acute Myeloid Leukemia. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2019; 19:177-182. [PMID: 30616990 DOI: 10.1016/j.clml.2018.11.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 11/06/2018] [Accepted: 11/15/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND Refractory acute myeloid leukemia (AML) includes AML includes failure of disease to respond to standard induction chemotherapy, relapse within 6 months after first CR, and 2 or more relapses. The outcome of these patients is usually very poor; only a small proportion can be rescued by allogenic hematopoietic stem-cell transplantation (allo-HSCT). The aim of this study was to evaluate the efficacy and feasibility of allo-HSCT in patients with refractory AML. PATIENTS AND METHODS We retrospectively analyzed the clinical outcome of 91 patients who were diagnosed with treatment-refractory AML at Hacettepe University Hospital between January 2002 and June 2018. Patients' disease status included refractory AML, defined as failure to respond to standard induction chemotherapy and relapse within 6 months after first complete remission. RESULTS The median follow-up was 12 months (range, 0.5-184 months) for the entire group. Kaplan-Meier estimates of the 3-year overall survival for patients who underwent allo-HSCT and patients who received only salvage chemotherapy were 67% and 12%, respectively. Additionally, the Kaplan-Meier estimates of 5-year overall survival for patients who underwent allo-HSCT and patients who received only salvage chemotherapy were 44% and 4%, respectively (P < .001). Complete remission was obtained in 25 patients (83.3%) who underwent allo-HSCT; however, the disease of only 3 patients (3.8%) exhibited complete response after salvage chemotherapy. CONCLUSION Allo-HSCT is still the best-known treatment option with curative potential in patients with treatment-refractory AML. Therefore, all efforts should be made in an attempt to find a suitable matched donor in order to perform allo-HSCT.
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22
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23
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Abstract
For several decades, few substantial therapeutic advances have been made for patients with acute myeloid leukaemia. However, since 2017 unprecedented growth has been seen in the number of drugs available for the treatment of acute myeloid leukaemia, with several new drugs receiving regulatory approval. In addition to advancing our therapeutic armamentarium, an increased understanding of the biology and genomic architecture of acute myeloid leukaemia has led to refined risk assessment of this disease, with consensus risk stratification guidelines now incorporating a growing number of recurrent molecular aberrations that aid in the selection of risk-adapted management strategies. Despite this promising recent progress, the outcomes of patients with acute myeloid leukaemia remain unsatisfactory, with more than half of patients ultimately dying from their disease. Enrolment of patients into clinical trials that evaluate novel drugs and rational combination therapies is imperative to continuing this progress and further improving the outcomes of patients with acute myeloid leukaemia.
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MESH Headings
- Aminoglycosides/therapeutic use
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antineoplastic Agents/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Consolidation Chemotherapy
- Cytarabine/administration & dosage
- Gemtuzumab
- Genomics
- Hematopoietic Stem Cell Transplantation
- Humans
- Leukemia, Myeloid, Acute/diagnosis
- Leukemia, Myeloid, Acute/drug therapy
- Leukemia, Myeloid, Acute/genetics
- Leukemia, Myeloid, Acute/therapy
- Patient Selection
- Recurrence
- Remission Induction
- Risk Assessment
- Risk Factors
- Staurosporine/analogs & derivatives
- Staurosporine/therapeutic use
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Affiliation(s)
- Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michael E Rytting
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Pediatrics-Patient Care, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jorge E Cortes
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Kantarjian HM, DiNardo CD, Nogueras-Gonzalez GM, Kadia TM, Jabbour E, Bueso-Ramos CE, O'Brien SM, Konopleva M, Jain NB, Daver NG, Shpall EJ, Champlin RE, Simkins A, Garcia-Manero G, Keating MJ, Huang X, Cortes JE, Pierce SA, Ravandi F, Freireich EJ. Results of second salvage therapy in 673 adults with acute myelogenous leukemia treated at a single institution since 2000. Cancer 2018; 124:2534-2540. [PMID: 29645075 DOI: 10.1002/cncr.31370] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 02/21/2018] [Accepted: 02/22/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND The prognosis is poor for patients who have relapsed-refractory acute myelogenous leukemia (AML). Most published reports analyzed results from therapies in first-salvage AML or in studies that were conducted before 2000. Several novel agents and strategies are being tested for potential approval as treatment for patients with relapsed-refractory AML in second salvage. Therefore, it is important to establish the historic results of anti-AML therapies in this setting in the modern era. The objective of the current study was to analyze the results from second salvage therapies in patients with AML since 2000 with regard to response and survival. METHODS In total, 673 patients who received second salvage therapies for AML since 2000 were analyzed. Their median age was 60 years (range, 18-89 years). Salvage therapy consisted of cytarabine-based regimens in 267 patients, noncytarabine combinations in 37, hypomethylating agent-based regimens in 136, and phase 1 and 2 single agents in 233. RESULTS Eighty-six of the 673 patients (13%) achieved a complete response (CR) or a CR with low platelet count (CRp). The median duration of CR-CRp was 7.2 months. The median survival was 4.4 months (95% confidence interval, 4.0-4.8 months), and the 1-year survival rate was 16% (95% confidence interval, 14%-19%). Multivariate analysis identified the following as independent adverse factors for achievement of CR-CRp: platelets < 50 × 109 /L (P < .001), complex karyotype with ≥3 chromosomal abnormalities (P = .02), regimens that did not include cytarabine or hypomethylating agents (P = .014), and no prior CR lasting ≥12 months with frontline or salvage 1 therapies (P < .001). The independent adverse factors associated with worse survival were age ≥60 years (P = .01), platelets < 50 × 109 /L (P = .02), peripheral blasts ≥ 20% (P = .03), albumin ≤ 3 g/dL (P = .04), and complex karyotype (P = .003). The authors also applied and validated, in the current population, the 2 multivariate-derived prognostic models for CR and survival developed in their previous study of 594 patients who received treatment for second salvage AML from the previous 2 decades. CONCLUSIONS This large-scale analysis establishes the modern historic results of second salvage therapy in AML and validates the prognostic models associated with outcome. These data could be used to analyze the differential benefits of current or future investigational strategies under evaluation in this setting and for the purpose of potential approval of new agents in the United States and the world. Cancer 2018;124:2534-40. © 2018 American Cancer Society.
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Affiliation(s)
- Hagop M Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Courtney D DiNardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Tapan M Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Carlos E Bueso-Ramos
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Susan M O'Brien
- Chao Family Comprehensive Cancer Center, University of California at Irvine, Irvine, California
| | - Marina Konopleva
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Nitin B Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Naval G Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Elizabeth J Shpall
- Department of Cellular Therapy and Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Richard E Champlin
- Department of Cellular Therapy and Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Aron Simkins
- Department of Internal Medicine, University of Texas Health Science Center, Houston, Texas
| | | | - Michael J Keating
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Xuelin Huang
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jorge E Cortes
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sherry A Pierce
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Emil J Freireich
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Phase 2b study of 2 dosing regimens of quizartinib monotherapy in FLT3-ITD-mutated, relapsed or refractory AML. Blood 2018; 132:598-607. [PMID: 29875101 DOI: 10.1182/blood-2018-01-821629] [Citation(s) in RCA: 112] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 05/26/2018] [Indexed: 12/27/2022] Open
Abstract
This randomized, open-label, phase 2b study (NCT01565668) evaluated the efficacy and safety of 2 dosing regimens of quizartinib monotherapy in patients with relapsed/refractory (R/R) FLT3-internal tandem duplication (ITD)-mutated acute myeloid leukemia (AML) who previously underwent transplant or 1 second-line salvage therapy. Patients (N = 76) were randomly assigned to 30- or 60-mg/day doses (escalations to 60 or 90 mg/day, respectively, permitted for lack/loss of response) of single-agent oral quizartinib dihydrochloride. Allelic frequency of at least 10% was defined as FLT3-ITD-mutated disease. Coprimary endpoints were composite complete remission (CRc) rates and incidence of QT interval corrected by Fridericia's formula (QTcF) of more than 480 ms (grade 2 or greater). Secondary endpoints included overall survival (OS), duration of CRc, bridge to transplant, and safety. CRc rates were 47% in both groups, similar to earlier reports with higher quizartinib doses. Incidence of QTcF above 480 ms was 11% and 17%, and QTcF above 500 ms was 5% and 3% in the 30- and 60-mg groups, respectively, which is less than earlier reports with higher doses of quizartinib. Median OS (20.9 and 27.3 weeks), duration of CRc (4.2 and 9.1 weeks), and bridge to transplant rates (32% and 42%) were higher in the 60-mg groups than in the 30-mg group. Dose escalation occurred in 61% and 14% of patients in the 30- and 60-mg groups, respectively. This high clinical activity of quizartinib at the evaluated doses is consistent with previous reports with an improved safety profile. Need to dose-escalate more than half of patients who received quizartinib 30 mg also supports further investigation of treatment with quizartinib 60 mg/day.
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Cortes J, Perl AE, Döhner H, Kantarjian H, Martinelli G, Kovacsovics T, Rousselot P, Steffen B, Dombret H, Estey E, Strickland S, Altman JK, Baldus CD, Burnett A, Krämer A, Russell N, Shah NP, Smith CC, Wang ES, Ifrah N, Gammon G, Trone D, Lazzaretto D, Levis M. Quizartinib, an FLT3 inhibitor, as monotherapy in patients with relapsed or refractory acute myeloid leukaemia: an open-label, multicentre, single-arm, phase 2 trial. Lancet Oncol 2018; 19:889-903. [PMID: 29859851 DOI: 10.1016/s1470-2045(18)30240-7] [Citation(s) in RCA: 187] [Impact Index Per Article: 31.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 03/09/2018] [Accepted: 03/12/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Old age and FMS-like tyrosine kinase 3 internal tandem duplication (FLT3-ITD) mutations in patients with acute myeloid leukaemia are associated with early relapse and poor survival. Quizartinib is an oral, highly potent, and selective next-generation FLT3 inhibitor with clinical antileukaemic activity in relapsed or refractory acute myeloid leukaemia. We aimed to assess the efficacy and safety of single-agent quizartinib in patients with relapsed or refractory acute myeloid leukaemia. METHODS We did an open-label, multicentre, single-arm, phase 2 trial at 76 hospitals and cancer centres in the USA, Europe, and Canada. We enrolled patients with morphologically documented primary acute myeloid leukaemia or acute myeloid leukaemia secondary to myelodysplastic syndromes and an Eastern Cooperative Oncology Group (ECOG) performance status of 0-2 into two predefined, independent cohorts: patients who were aged 60 years or older with relapsed or refractory acute myeloid leukaemia within 1 year after first-line therapy (cohort 1), and those who were 18 years or older with relapsed or refractory disease following salvage chemotherapy or haemopoietic stem cell transplantation (cohort 2). Patients with an FLT3-ITD allelic frequency of more than 10% were considered as FLT3-ITD positive, whereas all other patients were considered as FLT3-ITD negative. Patients received quizartinib once daily as an oral solution; the initial 17 patients received 200 mg per day but the QTcF interval was prolonged for more than 60 ms above baseline in some of these patients. Subsequently, doses were amended for all patients to 135 mg per day for men and 90 mg per day for women. The co-primary endpoints were the proportion of patients who achieved a composite complete remission (defined as complete remission + complete remission with incomplete platelet recovery + complete remission with incomplete haematological recovery) and the proportion of patients who achieved a complete remission. Efficacy and safety analyses included all patients who received at least one dose of quizartinib (ie, the intention-to-treat population). Patients with a locally assessed post-treatment bone marrow aspirate or biopsy were included in efficacy analyses by response; all other patients were considered to have an unknown response. This study is registered with ClinicalTrials.gov, number NCT00989261, and with the European Clinical Trials Database, EudraCT 2009-013093-41, and is completed. FINDINGS Between Nov 19, 2009, and Oct 31, 2011, a total of 333 patients were enrolled (157 in cohort 1 and 176 in cohort 2). In cohort 1, 63 (56%) of 112 FLT3-ITD-positive patients and 16 (36%) of 44 FLT3-ITD-negative patients achieved composite complete remission, with three (3%) FLT3-ITD-positive patients and two (5%) FLT3-ITD-negative patients achieving complete remission. In cohort 2, 62 (46%) of 136 FLT3-ITD-positive patients achieved composite complete remission with five (4%) achieving complete remission, whereas 12 (30%) of 40 FLT3-ITD-negative patients achieved composite complete remission with one (3%) achieving complete remission. Across both cohorts (ie, the intention-to-treat population of 333 patients), grade 3 or worse treatment-related treatment-emergent adverse events in 5% or more of patients were febrile neutropenia (76 [23%] of 333), anaemia (75 [23%]), thrombocytopenia (39 [12%]), QT interval corrected using Fridericia's formula (QTcF) prolongation (33 [10%]), neutropenia (31 [9%]), leucopenia (22 [7%]), decreased platelet count (20 [6%]), and pneumonia (17 [5%]). Serious adverse events occurring in 5% or more of patients were febrile neutropenia (126 [38%] of 333; 76 treatment related), acute myeloid leukaemia progression (73 [22%]), pneumonia (40 [12%]; 14 treatment related), QTcF prolongation (33 [10%]; 32 treatment related), sepsis (25 [8%]; eight treatment related), and pyrexia (18 [5%]; nine treatment related). Notable serious adverse events occurring in less than 5% of patients were torsades de pointes (one [<1%]) and hepatic failure (two [1%]). In total, 125 (38%) of 333 patients died within the study treatment period, including the 30-day follow-up. 18 (5%) patients died because of an adverse event considered by the investigator to be treatment related (ten [6%] of 157 patients in cohort 1 and eight [5%] of 176 in cohort 2. INTERPRETATION Single-agent quizartinib was shown to be highly active and generally well tolerated in patients with relapsed or refractory acute myeloid leukaemia, particularly those with FLT3-ITD mutations. These findings confirm that targeting the FLT3-ITD driver mutation with a highly potent and selective FLT3 inhibitor is a promising clinical strategy to help improve clinical outcomes in patients with very few options. Phase 3 studies (NCT02039726; NCT02668653) will examine quizartinib at lower starting doses. FUNDING Ambit Biosciences/Daiichi Sankyo.
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MESH Headings
- Administration, Oral
- Adult
- Aged
- Benzothiazoles/therapeutic use
- Canada
- Disease-Free Survival
- Dose-Response Relationship, Drug
- Drug Administration Schedule
- Europe
- Female
- Humans
- Internationality
- Leukemia, Myeloid, Acute/diagnosis
- Leukemia, Myeloid, Acute/drug therapy
- Leukemia, Myeloid, Acute/mortality
- Male
- Maximum Tolerated Dose
- Middle Aged
- Neoplasm Recurrence, Local/diagnosis
- Neoplasm Recurrence, Local/drug therapy
- Neoplasm Recurrence, Local/mortality
- Phenylurea Compounds/therapeutic use
- Prognosis
- Survival Rate
- Treatment Outcome
- United States
- Young Adult
- fms-Like Tyrosine Kinase 3/administration & dosage
- fms-Like Tyrosine Kinase 3/antagonists & inhibitors
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Affiliation(s)
- Jorge Cortes
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Alexander E Perl
- Division of Hematology and Oncology, Abramson Cancer Center of the University of Pennsylvania, Philadelphia, PA, USA
| | - Hartmut Döhner
- Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Giovanni Martinelli
- Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Meldola, Italy
| | - Tibor Kovacsovics
- Center for Hematologic Malignancies, Oregon Health & Science University, Portland, OR, USA
| | - Philippe Rousselot
- Service d'Hématologie et Oncologie, Hôpital de Versailles, Université Versailles Saint-Quentin-en-Yvelines Paris-Saclay U1173, Le Chesnay, France
| | - Björn Steffen
- Department of Medicine II, Hematology/Oncology, Goethe University, Frankfurt, Germany
| | - Hervé Dombret
- University Hospital Saint-Louis, Assistance Publique-Hôpitaux de Paris (AP-HP), University Paris Diderot, Paris, France
| | - Elihu Estey
- Seattle Cancer Care Alliance, University of Washington School of Medicine, Seattle, WA, USA
| | | | - Jessica K Altman
- Department of Medicine, Division of Hematology and Oncology, Robert H Lurie Comprehensive Cancer Center of Northwestern University, Chicago, IL, USA
| | - Claudia D Baldus
- Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Hematology and Oncology, Berlin, Germany
| | - Alan Burnett
- Department of Haematology, Cardiff University, Cardiff, Wales, UK
| | - Alwin Krämer
- Klinische Kooperationseinheit Molekulare Hämatologie/Onkologie, Medizinische Klinik V, Universität Heidelberg and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Nigel Russell
- Department of Haematology, Nottingham University Hospital, Nottingham, UK
| | - Neil P Shah
- Department of Medicine, Division of Hematology and Oncology, University of California at San Francisco, San Francisco, CA, USA
| | - Catherine C Smith
- Department of Medicine, Division of Hematology and Oncology, University of California at San Francisco, San Francisco, CA, USA
| | - Eunice S Wang
- Department of Immunology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Norbert Ifrah
- Service des Maladies du Sang, Centre Hospitalier Universitaire d'Angers, Angers, France
| | | | | | | | - Mark Levis
- The Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA
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Konuma T, Yanada M, Yamasaki S, Kuwatsuka Y, Fukuda T, Kobayashi T, Ozawa Y, Uchida N, Ota S, Hoshino T, Takahashi S, Kanda Y, Ueda Y, Takanashi M, Kanda J, Ichinohe T, Atsuta Y, Yano S. Allogeneic haematopoietic cell transplantation for adult acute myeloid leukaemia in second remission: a retrospective study of the Adult Acute Myeloid Leukaemia Working Group of the Japan Society for Haematopoietic Cell Transplantation (JSHCT). Br J Haematol 2018; 182:245-250. [PMID: 29808919 DOI: 10.1111/bjh.15399] [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] [Received: 01/26/2018] [Accepted: 04/09/2018] [Indexed: 11/26/2022]
Abstract
To evaluate the outcomes and prognostic factors following allogeneic haematopoietic cell transplantation (HCT) for adult acute myeloid leukaemia (AML) in second complete remission (CR2), we retrospectively analysed the Japanese registration data of 1080 adult AML patients in CR2 who had received allogeneic HCT. The probability of overall survival and the cumulative incidence of relapse at 3 years was 66% and 19%, respectively. In multivariate analysis, older age, poor cytogenetics and shorter duration of first complete remission were significantly associated with a higher overall mortality. Our data demonstrated the significant efficacy of allogeneic HCT for adult AML in CR2.
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Affiliation(s)
- Takaaki Konuma
- Department of Haematology/Oncology, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Masamitsu Yanada
- Department of Haematology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Satoshi Yamasaki
- Department of Haematology and Clinical Research Institute, National Hospital Organization Kyushu Medical Centre, Fukuoka, Japan
| | - Yachiyo Kuwatsuka
- Centre for Advanced Medicine and Clinical Research, Nagoya University Hospital, Nagoya, Japan
| | - Takahiro Fukuda
- Department of Haematopoietic Stem Cell Transplantation, National Cancer Centre Hospital, Tokyo, Japan
| | - Takeshi Kobayashi
- Haematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Centre, Komagome Hospital, Tokyo, Japan
| | - Yukiyasu Ozawa
- Department of Haematology, Japanese Red Cross Nagoya First Hospital, Nagoya, Japan
| | - Naoyuki Uchida
- Department of Haematology, Federation of National Public Service Personnel Mutual Aid Associations Toranomon Hospital, Tokyo, Japan
| | - Shuichi Ota
- Department of Haematology, Sapporo Hokuyu Hospital, Sapporo, Japan
| | - Takumi Hoshino
- Leukaemia Research Centre, Saiseikai Maebashi Hospital, Maebashi, Japan
| | - Satoshi Takahashi
- Division of Molecular Therapy, The Advanced Clinical Research Centre, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Yoshinobu Kanda
- Division of Haematology, Saitama Medical Centr, Jichi Medical University, Saitama, Japan
| | - Yasunori Ueda
- Department of Haematology and Oncology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Minoko Takanashi
- Blood Service Headquarters, Japanese Red Cross Society, Tokyo, Japan
| | - Junya Kanda
- Department of Haematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tatsuo Ichinohe
- Department of Haematology and Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Yoshiko Atsuta
- Japanese Data Centre for Haematopoietic Cell Transplantation, Nagoya, Japan.,Department of Healthcare Administration, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shingo Yano
- Division of Clinical Oncology and Haematology, Department of Internal Medicine, Jikei University School of Medicine, Tokyo, Japan
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Decroocq J, Itzykson R, Vigouroux S, Michallet M, Yakoub-Agha I, Huynh A, Beckerich F, Suarez F, Chevallier P, Nguyen-Quoc S, Ledoux MP, Clement L, Hicheri Y, Guillerm G, Cornillon J, Contentin N, Carre M, Maillard N, Mercier M, Mohty M, Beguin Y, Bourhis JH, Charbonnier A, Dauriac C, Bay JO, Blaise D, Deconinck E, Jubert C, Raus N, Peffault de Latour R, Dhedin N. Similar outcome of allogeneic stem cell transplantation after myeloablative and sequential conditioning regimen in patients with refractory or relapsed acute myeloid leukemia: A study from the Société Francophone de Greffe de Moelle et de Thérapie Cellulaire. Am J Hematol 2018; 93:416-423. [PMID: 29226497 DOI: 10.1002/ajh.25004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Revised: 12/05/2017] [Accepted: 12/07/2017] [Indexed: 01/22/2023]
Abstract
Patients with acute myeloid leukemia (AML) in relapse or refractory to induction therapy have a dismal prognosis. Allogeneic hematopoietic stem cell transplantation is the only curative option. In these patients, we aimed to compare the results of a myeloablative transplant versus a sequential approach consisting in a cytoreductive chemotherapy followed by a reduced intensity conditioning regimen and prophylactic donor lymphocytes infusions. We retrospectively analyzed 99 patients aged 18-50 years, transplanted for a refractory (52%) or a relapsed AML not in remission (48%). Fifty-eight patients received a sequential approach and 41 patients a myeloablative conditioning regimen. Only 6 patients received prophylactic donor lymphocytes infusions. With a median follow-up of 48 months, 2-year overall survival was 39%, 95% confidence interval (CI) (24-53) in the myeloablative group versus 33%, 95% CI (21-45) in the sequential groups (P = .39), and 2-year cumulative incidence of relapse (CIR) was 57% versus 50% respectively (P = .99). Nonrelapse mortality was not higher in the myeloablative group (17% versus 15%, P = .44). In multivariate analysis, overall survival, CIR and nonrelapse mortality remained similar between the two groups. However, in multivariate analysis, sequential conditioning led to fewer acute grade II-IV graft versus host disease (GVHD) (HR for sequential approach = 0.37; 95% CI: 0.21-0.65; P < .001) without a significant impact on chronic GVHD (all grades and extensive). In young patients with refractory or relapsed AML, myeloablative transplant and sequential approach offer similar outcomes except for a lower incidence of acute GvHD after a sequential transplant.
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Affiliation(s)
| | | | | | | | - Ibrahim Yakoub-Agha
- Hematology department; CHU de Lille, LIRIC INSERM U995, Université Lille 2, Lille; France
| | - Anne Huynh
- Hematology department; IUCT Oncopole; Toulouse France
| | | | - Felipe Suarez
- Hematology department; Hôpital Necker Enfants malades; Paris France
| | | | | | | | | | - Yosr Hicheri
- Hematology department; CHU Lapeyronie; Montpellier France
| | | | | | | | - Martin Carre
- Hematology department; CHU Grenoble; Grenoble France
| | | | | | - Mohamad Mohty
- Hematology department; Hôpital Saint Antoine; Paris France
| | - Yves Beguin
- Hematology department; CHU Liège; Liège Belgium
| | | | | | | | | | - Didier Blaise
- Hematology department; Institut Paoli Calmettes; Marseille France
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DeAngelo DJ, Brunner AM, Werner L, Avigan D, Fathi AT, Sperling AS, Washington A, Stroopinsky D, Rosenblatt J, McMasters M, Luptakova K, Wadleigh M, Steensma DP, Hobbs GS, Attar EC, Amrein PC, Ebert BL, Stone RM, Ballen KK. A phase I study of lenalidomide plus chemotherapy with mitoxantrone, etoposide, and cytarabine for the reinduction of patients with acute myeloid leukemia. Am J Hematol 2018; 93:254-261. [PMID: 29119643 DOI: 10.1002/ajh.24968] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 10/27/2017] [Accepted: 11/06/2017] [Indexed: 12/17/2022]
Abstract
Patients with relapsed AML have a poor prognosis and limited responses to standard chemotherapy. Lenalidomide is an immunomodulatory drug that may modulate anti-tumor immunity. We performed a study to evaluate the safety and tolerability of lenalidomide with mitoxantrone, etoposide and cytarabine (MEC) in relapsed/refractory AML. Adult patients with relapsed/refractory AML were eligible for this phase I dose-escalation study. We enrolled 35 patients using a "3 + 3" design, with a 10 patient expansion cohort at the maximum tolerated dose (MTD). Lenalidomide was initially given days 1-14 and MEC days 4-8; due to delayed count recovery, the protocol was amended to administer lenalidomide days 1-10. The dose of lenalidomide was then escalated starting at 5 mg/d (5-10-25-50). The primary objective was tolerability and MTD determination, with secondary outcomes including overall survival (OS). The MTD of lenalidomide combined with MEC was 50 mg/d days 1-10. Among the 35 enrolled patients, 12 achieved complete remission (CR) (34%, 90%CI 21-50%); 30-day mortality was 6% and 60-day mortality 13%. The median OS for all patients was 11.5 months. Among 17 patients treated at the MTD, 7 attained CR (41%); the median OS was not reached while 12-month OS was 61%. Following therapy with MEC and lenalidomide, patient CD4+ and CD8+ T-cells demonstrated increased inflammatory responses to autologous tumor lysate. The combination of MEC and lenalidomide is tolerable with an RP2D of lenalidomide 50 mg/d days 1-10, yielding encouraging response rates. Further studies are planned to explore the potential immunomodulatory effect of lenalidomide and MEC.
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Affiliation(s)
| | | | | | - David Avigan
- Beth-Israel Deaconess Medical Center; Boston Massachusetts
| | - Amir T. Fathi
- Massachusetts General Hospital; Boston Massachusetts
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30
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Khan M, Cortes J, Qiao W, Alzubaidi MA, Pierce SA, Ravandi F, Kantarjian HM, Borthakur G. Outcomes of Patients With Relapsed Core Binding Factor-Positive Acute Myeloid Leukemia. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2018; 18:e19-e25. [PMID: 29107583 PMCID: PMC5861376 DOI: 10.1016/j.clml.2017.09.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 09/19/2017] [Indexed: 01/24/2023]
Abstract
PURPOSE To determine the factors associated with outcomes in patients with core binding factor acute myeloid leukemia (CBF-AML) in first relapse. MATERIAL AND METHODS We conducted a retrospective analysis of 92 patients with CBF-AML in first relapse who presented to our institution from 1990-2014. Clinical and demographic parameters were included in univariate and multivariate Cox proportional hazards regression model to predict overall survival. RESULTS Among the 92 relapsed patients, 60 (65%) patients had inv (16) and 32 (35%) had t (8;21). The median survival for patients with inv(16) cytogenetic group was 15.6 months (range 10.32 to 20.88 months) while for the t(8;21) group was 9 months (range 3.68 to 14.32) (P = .004). Univariate Cox model analysis showed that increased age, high white blood cell count, t (8;21) cytogenetic group, and high bone marrow blast percentage were associated with poor overall outcome, while stem cell transplant intervention was associated with better survival. Additional cytogenetic aberrations at relapse were not associated with survival outcomes (P = .4). Multivariate Cox model analysis showed that t(8;21) cytogenetic group has more hazard of death after adjusting, age, marrow blast percentage, blood cell count, and stem cell transplant(hazard ratio 1.802; P = .02). CONCLUSION Among patients with relapsed CBF-AML, median survival was less than a year and half and the outcome was worse in patients with t (8;21). Despite the relatively better outcomes, dedicated clinical trials are needed to improve the outcome in all patients with relapsed CBF-AML.
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Affiliation(s)
- Maliha Khan
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jorge Cortes
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Wei Qiao
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mohanad A Alzubaidi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sherry A Pierce
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Hagop M Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Gautam Borthakur
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX.
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Singh AA, Mandoli A, Prange KHM, Laakso M, Martens JHA. AML associated oncofusion proteins PML-RARA, AML1-ETO and CBFB-MYH11 target RUNX/ETS-factor binding sites to modulate H3ac levels and drive leukemogenesis. Oncotarget 2017; 8:12855-12865. [PMID: 28030795 PMCID: PMC5355061 DOI: 10.18632/oncotarget.14150] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 11/21/2016] [Indexed: 12/11/2022] Open
Abstract
Chromosomal translocations are one of the hallmarks of acute myeloid leukemia (AML), often leading to gene fusions and expression of an oncofusion protein. Over recent years it has become clear that most of the AML associated oncofusion proteins molecularly adopt distinct mechanisms for inducing leukemogenesis. Still these unique molecular properties of the chimeric proteins converge and give rise to a common pathogenic molecular mechanism. In the present study we compared genome-wide DNA binding and transcriptome data associated with AML1-ETO, CBFB-MYH11 and PML-RARA oncofusion protein expression to identify unique and common features. Our analyses revealed targeting of oncofusion binding sites to RUNX1 and ETS-factor occupied genomic regions. In addition, it revealed a highly comparable global histone acetylation pattern, similar expression of common target genes and related enrichment of several biological pathways critical for maintenance of AML, suggesting oncofusion proteins deregulate common gene programs despite their distinct binding signatures and mechanisms of action.
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Affiliation(s)
- Abhishek A Singh
- Radboud University, Department of Molecular Biology, Faculty of Science, Nijmegen Centre for Molecular Life Sciences, 6500 HB Nijmegen, The Netherlands
| | - Amit Mandoli
- Radboud University, Department of Molecular Biology, Faculty of Science, Nijmegen Centre for Molecular Life Sciences, 6500 HB Nijmegen, The Netherlands
| | - Koen H M Prange
- Radboud University, Department of Molecular Biology, Faculty of Science, Nijmegen Centre for Molecular Life Sciences, 6500 HB Nijmegen, The Netherlands
| | - Marko Laakso
- Genome Scale Biology Research Program, Research Programs Unit, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Joost H A Martens
- Radboud University, Department of Molecular Biology, Faculty of Science, Nijmegen Centre for Molecular Life Sciences, 6500 HB Nijmegen, The Netherlands
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Shimizu H, Yokohama A, Ishizaki T, Hatsumi N, Takada S, Saitoh T, Sakura T, Nojima Y, Handa H. Clonal evolution detected with conventional cytogenetic analysis is a potent prognostic factor in adult patients with relapsed AML. Hematol Oncol 2017; 36:252-257. [DOI: 10.1002/hon.2393] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 01/25/2017] [Accepted: 02/10/2017] [Indexed: 11/07/2022]
Affiliation(s)
- Hiroaki Shimizu
- Department of Medicine and Clinical Science; Gunma University Graduate School of Medicine; Maebashi Gunma Japan
| | - Akihiko Yokohama
- Division of Blood Transfusion Service, Faculty of Medicine; Gunma University Hospital; Maebashi Gunma Japan
| | - Takuma Ishizaki
- Department of Medicine and Clinical Science; Gunma University Graduate School of Medicine; Maebashi Gunma Japan
| | - Nahoko Hatsumi
- Leukemia Research Center; Saiseikai Maebashi Hospital; Maebashi Gunma Japan
| | - Satoru Takada
- Leukemia Research Center; Saiseikai Maebashi Hospital; Maebashi Gunma Japan
| | - Takayuki Saitoh
- Gunma University School of Health Sciences, Faculty of Medicine; Gunma University; Maebashi Gunma Japan
| | - Toru Sakura
- Leukemia Research Center; Saiseikai Maebashi Hospital; Maebashi Gunma Japan
| | - Yoshihisa Nojima
- Department of Medicine and Clinical Science; Gunma University Graduate School of Medicine; Maebashi Gunma Japan
| | - Hiroshi Handa
- Department of Medicine and Clinical Science; Gunma University Graduate School of Medicine; Maebashi Gunma Japan
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Irish W, Ryan M, Gache L, Gunnarsson C, Bell T, Shapiro M. Acute myeloid leukemia: a retrospective claims analysis of resource utilization and expenditures for newly diagnosed patients from first-line induction to remission and relapse. Curr Med Res Opin 2017; 33:519-527. [PMID: 27966377 DOI: 10.1080/03007995.2016.1267615] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The objective of this study was to estimate resource utilization and expenditures for patients with acute myeloid leukemia (AML) in a real-world claims database. RESEARCH DESIGN AND METHODS AML patients were identified in MarketScan claims databases between 1 January 2009 and 31 January 2015. Patients had a minimum of two AML diagnosis codes, hospitalization within 14 days after initial diagnosis, and ≥6 months of enrollment before initial diagnosis. Patients were monitored from first-line induction to a record of remission. A subset had a record of a second treatment period, defined as time from relapse to remission. Patient demographics, AML risk factors, and comorbidities were recorded. Descriptive analysis of utilization and expenditures (in 2014 $US) were reported for each cohort. RESULTS The inclusion criteria were met in 1597 patients (mean age, 58.4 years; 51.0% male). Ninety percent of patients had ≥1 risk factor for AML. Mean (SD) healthcare expenditures for patients from first-line induction to remission (n = 681) were $208,857 ($152,090). Of the 157 who had a record of relapse, 70 had a record of a second remission. Expenditures for these patients (n = 70) from relapse to remission were $142,569 ($208,307); 60% were admitted to a hospital for a mean of 18.5 hospital days, and 20% had ≥1 emergency room visit. CONCLUSIONS Although this claims-based analysis is limited by a lack of generalizability to noninsured populations and potential underreporting of certain events and diagnoses, we found that treating AML patients poses a significant healthcare burden, during both first-line induction and relapse. With people living longer, the number of cases of AML is expected to increase in the future.
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Affiliation(s)
- William Irish
- a CTI Clinical Trial and Consulting Services Inc. , Cincinnati , OH , USA
| | - Michael Ryan
- a CTI Clinical Trial and Consulting Services Inc. , Cincinnati , OH , USA
| | - Larry Gache
- a CTI Clinical Trial and Consulting Services Inc. , Cincinnati , OH , USA
| | - Candace Gunnarsson
- a CTI Clinical Trial and Consulting Services Inc. , Cincinnati , OH , USA
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Michelis FV, Gupta V, Zhang MJ, Wang HL, Aljurf M, Bacher U, Beitinjaneh A, Chen YB, DeFilipp Z, Gale RP, Kebriaei P, Kharfan-Dabaja M, Lazarus HM, Nishihori T, Olsson RF, Oran B, Rashidi A, Rizzieri DA, Tallman MS, de Lima M, Khoury HJ, Sandmaier BM, Weisdorf D, Saber W. Cytogenetic risk determines outcomes after allogeneic transplantation in older patients with acute myeloid leukemia in their second complete remission: A Center for International Blood and Marrow Transplant Research cohort analysis. Cancer 2017; 123:2035-2042. [PMID: 28117898 DOI: 10.1002/cncr.30567] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 12/06/2016] [Accepted: 12/19/2016] [Indexed: 01/25/2023]
Abstract
BACKGROUND Allogeneic hematopoietic cell transplantation (HCT) offers curative potential to a number of older patients with acute myeloid leukemia (AML) in their first complete remission. However, there are limited data in the literature concerning post-HCT outcomes for older patients in their second complete remission (CR2). METHODS The purpose of the current study was to retrospectively investigate within the Center for International Blood and Marrow Transplant Research database parameters influencing posttransplant outcomes for patients 60 years of age or older undergoing HCT for AML in CR2. RESULTS In total, 196 patients from 78 centers were identified; the median age was 64 years (range, 60-78 years). Seventy-one percent had a Karnofsky performance status ≥ 90 at the time of HCT. Reduced-intensity conditioning regimens were used in 159 patients (81%). A univariate analysis demonstrated a 3-year overall survival (OS) rate of 42% (95% confidence interval [CI], 35%-49%), a leukemia-free survival rate of 37% (95% CI, 30%-44%), a cumulative incidence of nonrelapse mortality of 25% (95% CI, 19%-32%), and a cumulative incidence of relapse (CIR) of 38% (95% CI, 31%-45%). A multivariate analysis demonstrated that cytogenetic risk was the only independent risk factor for OS (P = .023) with a hazard ratio (HR) of 1.14 (95% CI, 0.59-2.19) for intermediate-risk cytogenetics and an HR of 2.32 (95% CI, 1.05-5.14) for unfavorable-risk cytogenetics. For CIR, cytogenetic risk was also the only independent prognostic factor (P = .01) with an HR of 1.10 (95% CI, 0.47-2.56) for intermediate-risk cytogenetics and an HR of 2.98 (95% CI, 1.11-8.00) for unfavorable-risk cytogenetics. CONCLUSIONS Allogeneic HCT is a curative treatment option for older patients with AML in CR2, particularly for those with favorable or intermediate cytogenetic risk. Cancer 2017;123:2035-2042. © 2017 American Cancer Society.
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Affiliation(s)
- Fotios V Michelis
- Allogeneic Blood and Marrow Transplant Program, Princes Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Vikas Gupta
- Allogeneic Blood and Marrow Transplant Program, Princes Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Mei-Jie Zhang
- 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
| | - Mahmoud Aljurf
- Department of Oncology, King Faisal Specialist Hospital Center & Research, Riyadh, Saudi Arabia
| | - Ulrike Bacher
- Department of Hematology/Oncology, University Medicine Gottingen, Gottingen, Germany
- Interdisciplinary Clinic for Stem Cell Transplantation, University Cancer Center Hamburg, Hamburg, Germany
| | | | - Yi-Bin Chen
- Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Robert Peter Gale
- Hematology Research Centre, Division of Experimental Medicine, Department of Medicine, Imperial College London, London, United Kingdom
| | - Partow Kebriaei
- Department of Stem Cell Transplantation, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mohamed Kharfan-Dabaja
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Hillard M Lazarus
- Department of Medicine, Seidman Cancer Center, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Taiga Nishihori
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Richard F Olsson
- Division of Therapeutic Immunology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
- Centre for Clinical Research Sormland, Uppsala University, Uppsala, Sweden
| | - Betul Oran
- Department of Stem Cell Transplantation, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Armin Rashidi
- Division of Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - David A Rizzieri
- Division of Hematologic Malignancies and Cellular Therapy, Duke University, Durham, North Carolina
| | - Martin S Tallman
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marcos de Lima
- Department of Medicine, Seidman Cancer Center, University Hospitals Case Medical Center, Cleveland, Ohio
| | | | - Brenda M Sandmaier
- Division of Medical Oncology, University of Washington, Seattle, Washington
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Daniel Weisdorf
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Wael Saber
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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Shah NN. Antibody Based Therapies in Acute Leukemia. Curr Drug Targets 2017; 18:257-270. [PMID: 27593687 PMCID: PMC8335750 DOI: 10.2174/1389450117666160905091459] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 03/24/2015] [Accepted: 11/09/2015] [Indexed: 01/05/2023]
Abstract
Despite great progress in the curative treatment of acute leukemia, outcomes for those with relapsed and/or chemotherapy-refractory disease remain poor. Current intensive cytotoxic therapies can be associated with significant morbidity and novel therapies are needed to improve outcomes. Immunotherapy based approaches provide an alternative mechanism of action in the treatment of acute leukemia. Due to cell surface antigen expression, leukemia in particular is amenable to targeted therapies, such as antibody-based therapy. Based on the potential for non-overlapping toxicity, the possibility of synergistic action with standard chemotherapy, and by providing a novel method to overcome chemotherapy resistance, antibody-based therapies have shown potential for benefit. Modifications to standard monoclonal antibodies, including drug conjugation and linkage to T-cells, may further enhance efficacy of antibody-based therapies. Identifying the ideal timing for incorporation of antibody-based therapies, within standard regimens, may lead to improvement in overall outcomes. This article will provide an overview of antibody-based therapies in clinical development for the treatment of acute leukemia in children and adults, with a particular focus on the current strategies and future developments.
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Affiliation(s)
- Nirali N. Shah
- Pediatric Oncology Branch, Center for Cancer Research (CCR), National Cancer Institute (NCI), NIH, Bethesda, MD, USA
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36
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Andersson BS, Thall PF, Valdez BC, Milton DR, Al-Atrash G, Chen J, Gulbis A, Chu D, Martinez C, Parmar S, Popat U, Nieto Y, Kebriaei P, Alousi A, de Lima M, Rondon G, Meng QH, Myers A, Kawedia J, Worth LL, Fernandez-Vina M, Madden T, Shpall EJ, Jones RB, Champlin RE. Fludarabine with pharmacokinetically guided IV busulfan is superior to fixed-dose delivery in pretransplant conditioning of AML/MDS patients. Bone Marrow Transplant 2016; 52:580-587. [PMID: 27991894 PMCID: PMC5382042 DOI: 10.1038/bmt.2016.322] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 09/28/2016] [Accepted: 09/30/2016] [Indexed: 11/25/2022]
Abstract
We hypothesized that IV Busulfan (Bu) dosing could be safely intensified through pharmacokinetic (PK-) dose guidance to minimize the inter-patient variability in systemic exposure (SE) associated with body-sized dosing, and this should improve outcome of AML/MDS patients undergoing allogeneic stem cell transplantation (allo-HSCT). To test this hypothesis, we treated 218 patients (median age 50.7 years, male/female 50/50%) with fludarabine (Flu) 40 mg/m2 once daily ×4, each dose followed by IV Bu, randomized to 130 mg/m2 (N=107) or PK-guided to average daily SE, AUC of 6,000 µM-min (N=111), stratified for remission-status, and allo-grafting from HLA-matched donors. Toxicity and graft vs. host disease (GvHD) rates in the groups were similar; the risk of relapse or treatment-related mortality remained higher in the fixed-dose group throughout the 80-month observation period. Further, PK-guidance yielded safer disease-control, leading to improved overall and progression-free survival, most prominently in MDS-patients and in AML-patients not in remission at allo-HSCT. We conclude that AML/MDS patients receiving pretransplant conditioning treatment with our 4-day regimen may benefit significantly from PK-guided Bu-dosing. This could be considered an alternative to fixed dose delivery since it provides the benefit of precise dose delivery to a predetermined SE without increasing risk(s) of serious toxicity and/or GvHD.
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Affiliation(s)
- B S Andersson
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - P F Thall
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - B C Valdez
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - D R Milton
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - G Al-Atrash
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - J Chen
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - A Gulbis
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - D Chu
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - C Martinez
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - S Parmar
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - U Popat
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Y Nieto
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - P Kebriaei
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - A Alousi
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - M de Lima
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - G Rondon
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Q H Meng
- Division of Laboratory Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - A Myers
- Division of Pharmacy Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - J Kawedia
- Division of Pharmacy Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - L L Worth
- Division of Pediatrics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - T Madden
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - E J Shpall
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - R B Jones
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - R E Champlin
- Department of Stem Cell Transplantation & Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Tachibana T, Matsumoto K, Tanaka M, Hagihara M, Motohashi K, Yamamoto W, Ogusa E, Koyama S, Numata A, Tomita N, Taguchi J, Fujisawa S, Kanamori H, Nakajima H. Outcome and prognostic factors among patients who underwent a second transplantation for disease relapse post the first allogeneic cell transplantation. Leuk Lymphoma 2016; 58:1403-1411. [DOI: 10.1080/10428194.2016.1243678] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Takayoshi Tachibana
- Department of Hematology and Clinical Immunology, Yokohama City University, Graduate School of Medicine, Yokohama, Japan
- Department of Hematology, Kanagawa Cancer Center, Yokohama, Japan
| | | | - Masatsugu Tanaka
- Department of Hematology, Kanagawa Cancer Center, Yokohama, Japan
| | - Maki Hagihara
- Yokohama City University Medical Center, Yokohama, Japan
| | | | | | - Eriko Ogusa
- Department of Hematology, Kanagawa Cancer Center, Yokohama, Japan
| | - Satoshi Koyama
- Department of Hematology and Clinical Immunology, Yokohama City University, Graduate School of Medicine, Yokohama, Japan
| | - Ayumi Numata
- Yokohama City University Medical Center, Yokohama, Japan
| | - Naoto Tomita
- Department of Hematology and Clinical Immunology, Yokohama City University, Graduate School of Medicine, Yokohama, Japan
| | - Jun Taguchi
- Department of Hematology, Shizuoka Red Cross Hospital, Shizuoka, Japan
| | - Shin Fujisawa
- Yokohama City University Medical Center, Yokohama, Japan
| | - Heiwa Kanamori
- Department of Hematology, Kanagawa Cancer Center, Yokohama, Japan
| | - Hideaki Nakajima
- Department of Hematology and Clinical Immunology, Yokohama City University, Graduate School of Medicine, Yokohama, Japan
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Chen Y, Yang T, Zheng X, Yang X, Zheng Z, Zheng J, Liu T, Hu J. The outcome and prognostic factors of 248 elderly patients with acute myeloid leukemia treated with standard-dose or low-intensity induction therapy. Medicine (Baltimore) 2016; 95:e4182. [PMID: 27472687 PMCID: PMC5265824 DOI: 10.1097/md.0000000000004182] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The prognosis of elderly patients with acute myeloid leukemia (AML) is poor, and the recommendation of standard-dose or low-intensity induction regimen for these patients remains controversial. We retrospectively analyzed treatment outcome and prognostic factors of elderly AML patients who had received either standard-dose or low-intensity induction regimens.Two hundred forty-eight elderly AML patients with good Eastern Cooperative Oncology Group performance status (ECOG PS ≤ 2) received one of three regimens for induction in this study: standard-dose cytarabine plus idarubicin (IA; n = 144) or daunorubicin (DA; n = 42); low-intensity cytarabine, aclarubicin, and granulocyte colony-stimulating factor (G-CSF) (CAG; n = 62).After first induction treatment cycle, the overall complete remission (CR) rate was 42.7%. Patients in IA group had a higher CR rate than in DA or CAG group (49.3%, 35.7%, and 32.3%, respectively; P = 0.046). The 1-year, 3-year, and 5-year overall survival (OS) rates were 42.2%, 18.9%, and 13.5% for these 248 patients, with median survival of 9.2 months. Long-term survival of IA group was better than DA or CAG group. The 1-year, 3-year, and 5-year OS rates of IA group were 45.9%, 23.5%, and 19.4%, respectively, as compared to 39.8%, 8.3%, and estimated 2.4% in DA group, and 34.9%, 15.9%, and 6.3% in CAG group, respectively. Early induction mortality and 2-year relapse rates showed no difference among 3 groups. Univariate analysis and multivariate analysis identified lactic dehydrogenase (LDH) more than two times of upper normal limit at diagnosis and nonremission after first induction cycle as adverse prognostic factors for OS. A simple and valid scoring model was constructed for risk stratification and prediction of long-term survival of elderly AML patients.Standard-dose IA regimen could improve the prognosis of elderly AML patients with good performance status compared with standard-dose DA or low-intensity CAG regimen. All prognostic factors and risk assessment should be considered to ensure that each patient receives the suitable individualized treatment.
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Affiliation(s)
| | | | | | | | | | | | | | - Jianda Hu
- Fujian Provincial Key Laboratory of Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou, Fujian, P. R. China
- Correspondence: Jianda Hu, Fujian Provincial Key Laboratory of Hematology, Fujian Institute of Hematology, Fujian Medical University Union Hospital, Fuzhou 350001, Fujian, P. R. China (e-mail: )
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Relapsed Acute Myeloid Leukemia: Need for Innovative Treatment Strategies to Improve Outcome. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2016; 15 Suppl:S104-8. [PMID: 26297261 DOI: 10.1016/j.clml.2015.03.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 03/18/2015] [Indexed: 12/27/2022]
Abstract
Relapse continues to be a major hurdle in achieving cure in patients with acute myeloid leukemia (AML). The outcome after relapse is not uniform in all patients with AML and is dependent on several prognostic variables, including age, cytogenetics at initial diagnosis, duration of first complete remission, whether an allogeneic stem cell transplant was performed during first complete remission, and the presence of a number of molecular aberrations. Despite extensive research over the past several decades, there is no standard of care for treating patients with relapsed AML. This is possibly due to the accrual of patients with widely different disease profiles in most trials for relapsed AML. With increasing insights into the disease biology based on identification of pathogenic and aberrant molecular and cellular pathways, novel therapeutic strategies are emerging. Hopefully in the near future, we can improve the outcome of patients with relapsed AML with treatment strategies based on identification of specific targets and methods to overcome these aberrant processes.
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40
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Kell J. Considerations and challenges for patients with refractory and relapsed acute myeloid leukaemia. Leuk Res 2016; 47:149-60. [PMID: 27371910 DOI: 10.1016/j.leukres.2016.05.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 05/30/2016] [Indexed: 12/29/2022]
Abstract
Despite advances in understanding the complexities of acute myeloid leukaemia (AML), the treatment of refractory or relapsed AML (rrAML) remains a daunting clinical challenge. Numerous clinical trials have failed to identify new treatments or combinations of existing therapies that substantially improve outcomes and survival. This may be due, at least in part, to heterogeneity among study patients with respect to multiple inter-related factors that have been shown to affect treatment outcomes for patients with rrAML; such factors include age, cytogenetics, immunophenotypic changes, and (in the case of relapsed AML) duration of first complete remission, or if the patient has had a previous blood and marrow transplant (BMT). A clear understanding of disease characteristics and patient-related factors that influence treatment response, as well as expected outcomes with existing and emerging therapies, can aid clinicians in helping their patients navigate through this complex disease state.
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Affiliation(s)
- Jonathan Kell
- University Hospital of Wales, Department of Haematology, Heath Park, Cardiff, GB, United Kingdom.
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41
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Decision Analysis of Postremission Therapy in Cytogenetically Intermediate-Risk Acute Myeloid Leukemia: The Impact of FLT3 Internal Tandem Duplication, Nucleophosmin, and CCAAT/Enhancer Binding Protein Alpha. Biol Blood Marrow Transplant 2016; 22:1125-1132. [DOI: 10.1016/j.bbmt.2016.03.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2015] [Accepted: 03/08/2016] [Indexed: 01/28/2023]
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Bergua JM, Montesinos P, Martinez-Cuadrón D, Fernández-Abellán P, Serrano J, Sayas MJ, Prieto-Fernandez J, García R, García-Huerta AJ, Barrios M, Benavente C, Pérez-Encinas M, Simiele A, Rodríguez-Macias G, Herrera-Puente P, Rodríguez-Veiga R, Martínez-Sánchez MP, Amador-Barciela ML, Riaza-Grau R, Sanz MA. A prognostic model for survival after salvage treatment with FLAG-Ida +/− gemtuzumab-ozogamicine in adult patients with refractory/relapsed acute myeloid leukaemia. Br J Haematol 2016; 174:700-10. [DOI: 10.1111/bjh.14107] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Accepted: 02/29/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Juan M. Bergua
- Department of Haematology; Hospital San Pedro de Alcántara; Cáceres Spain
| | - Pau Montesinos
- Department of Haematology; University Hospital La Fe; Valencia Spain
| | | | | | | | - María J. Sayas
- Department of Haematology; Hospital Doctor Peset; Valencia Spain
| | | | - Raimundo García
- Department of Haematology; General Hospital Castellón; Castellón Spain
| | | | - Manuel Barrios
- Department of Haematology; Hospital Carlos Haya; Málaga Spain
| | | | | | | | | | | | | | | | | | | | - Miguel A. Sanz
- Department of Haematology; University Hospital La Fe; Valencia Spain
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Duration of first remission and hematopoietic cell transplantation-specific comorbidity index but not age predict survival of patients with AML transplanted in CR2: a retrospective multicenter study. Bone Marrow Transplant 2016; 51:1019-21. [PMID: 26974273 DOI: 10.1038/bmt.2016.60] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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44
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Are we curing more older adults with acute myeloid leukemia with allogeneic transplantation in CR1? Curr Opin Hematol 2016; 23:95-101. [PMID: 26825695 DOI: 10.1097/moh.0000000000000220] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Despite the fact that acute myeloid leukemia (AML) is most common in older adults aged at least 60 years, curative therapy remains elusive in this population. Here we examine the data for predicting which patients are candidates for 'curative therapy', available therapeutic options, and the utilization of reduced intensity allogeneic stem cell transplantation in first remission. RECENT FINDINGS Incorporation of geriatric assessment tools to assess patient frailty, in addition to evaluation of comorbid conditions, improves patient selection for intense therapy. The majority of patients eligible for and treated with induction chemotherapy achieve complete remission, and overall survival in the older AML population is superior after allogeneic stem cell transplant. However, population-based studies continue to demonstrate the undertreatment or lack of treatment of older AML patients. SUMMARY New patient assessment tools, ability to offer more successful outcomes after induction chemotherapy, and improved survival after allogeneic transplantation has not yet translated to increased 'curative' treatment on a population level of older AML patients. It is critical that the tools and therapies available be put into practice while older patient enrollment in well designed therapeutic clinical trials which include the option of allogeneic transplantation is increased.
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Yanada M, Kanda J, Ohtake S, Fukuda T, Sakamaki H, Miyamura K, Miyawaki S, Uchida N, Maeda T, Nagamura-Inoue T, Asou N, Morishima Y, Atsuta Y, Miyazaki Y, Kimura F, Kobayashi Y, Takami A, Naoe T, Kanda Y. Unrelated bone marrow transplantation or immediate umbilical cord blood transplantation for patients with acute myeloid leukemia in first complete remission. Eur J Haematol 2016; 97:278-87. [PMID: 26680003 DOI: 10.1111/ejh.12723] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND While unrelated bone marrow transplantation (UBMT) has been widely used as alternative donor transplantation, the use of umbilical cord blood transplantation (UCBT) is increasing recently. METHODS We conducted a decision analysis to address which transplantation procedure should be prioritized for younger patients with acute myeloid leukemia (AML) harboring high- or intermediate-risk cytogenetics in first complete remission (CR1), when they lack a matched related donor but have immediate access to a suitable umbilical cord blood unit. Main sources for our analysis comprised the data from three phase III trials for a chemotherapy cohort (n = 907) and the registry data for a transplantation cohort (n = 752). RESULTS The baseline analysis showed that when the 8/8 match was considered for UBMT, the expected 5-year survival rate was higher for UBMT than for UCBT (58.1% vs. 51.8%). This ranking did not change even when the 7/8 match was considered for UBMT. Sensitivity analysis showed consistent superiority of UBMT over UCBT when the time elapsed between CR1 and UBMT was varied within a plausible range of 3-9 months. CONCLUSIONS These results suggest that 8/8 or 7/8 UBMT is a better transplantation option than UCBT even after allowing time required for donor coordination.
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Affiliation(s)
| | - Junya Kanda
- Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Shigeki Ohtake
- Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | | | - Hisashi Sakamaki
- Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | | | - Shuichi Miyawaki
- Tokyo Metropolitan Ohtsuka Hospital, Tokyo, Japan.,Saiseikai Maebashi Hospital, Maebashi, Japan
| | | | - Tomoya Maeda
- Saitama International Medical Center, Saitama Medical University, Hidaka, Japan
| | | | - Norio Asou
- Saitama International Medical Center, Saitama Medical University, Hidaka, Japan.,Kumamoto University School of Medicine, Kumamoto, Japan
| | | | - Yoshiko Atsuta
- Japanese Data Center for Hematopoietic Cell Transplantation, Nagoya, Japan.,Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yasushi Miyazaki
- Atomic Bomb Disease Institute, Nagasaki University, Nagasaki, Japan
| | | | | | | | - Tomoki Naoe
- Nagoya University Graduate School of Medicine, Nagoya, Japan.,National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Yoshinobu Kanda
- Saitama Medical Center, Jichi Medical University, Saitama, Japan
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46
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Im A, Amjad A, Agha M, Raptis A, Hou JZ, Farah R, Lim S, Sehgal A, Dorritie KA, Redner RL, McLaughlin B, Shuai Y, Duggal S, Boyiadzis M. Mitoxantrone and Etoposide for the Treatment of Acute Myeloid Leukemia Patients in First Relapse. Oncol Res 2016; 24:73-80. [PMID: 27296947 PMCID: PMC7838693 DOI: 10.3727/096504016x14586627440156] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Relapsed acute myeloid leukemia (AML) represents a major therapeutic challenge. Achieving complete remission (CR) with salvage chemotherapy is the first goal of therapy for relapsed AML. However, there is no standard salvage chemotherapy. The current study evaluated outcomes and prognostic factors for achievement of CR in 91 AML patients in first relapse who were treated with the mitoxantrone-etoposide combination regimen. The overall response rate (CR and CRi) was 25%. Factors that were associated with a lower rate of CR included older age, shorter duration of first CR, low hemoglobin, and low platelet count. The median overall survival for all patients was 7.4 months. The survival of patients who achieved CR and underwent allogeneic hematopoietic cell transplantation (allo-HCT) was higher than those who achieved CR and did not undergo allo-HCT (35.3 months vs. 16.8 months, p = 0.057). The median duration of relapse-free survival was 12.7 months in the patients achieving CR. Older age at the time of AML relapse was associated with worse overall survival. The all-cause 4-week mortality rate was 4%, and the all-cause 8-week mortality rate was 13%. The findings of this study underscore the need for newer therapies, especially those that will improve the ability for patients with relapsed AML to achieve CR and to allow them to receive additional therapies.
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Affiliation(s)
- Annie Im
- Division of Hematology-Oncology, University of Pittsburgh Cancer Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Ali Amjad
- Division of Hematology-Oncology, University of Pittsburgh Cancer Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Mounzer Agha
- Division of Hematology-Oncology, University of Pittsburgh Cancer Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Anastasios Raptis
- Division of Hematology-Oncology, University of Pittsburgh Cancer Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jing-Zhou Hou
- Division of Hematology-Oncology, University of Pittsburgh Cancer Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Rafic Farah
- Division of Hematology-Oncology, University of Pittsburgh Cancer Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Seah Lim
- Division of Hematology-Oncology, University of Pittsburgh Cancer Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alison Sehgal
- Division of Hematology-Oncology, University of Pittsburgh Cancer Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Kathleen A. Dorritie
- Division of Hematology-Oncology, University of Pittsburgh Cancer Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Robert L. Redner
- Division of Hematology-Oncology, University of Pittsburgh Cancer Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Brian McLaughlin
- Division of Hematology-Oncology, University of Pittsburgh Cancer Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Yongli Shuai
- Division of Hematology-Oncology, University of Pittsburgh Cancer Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Shrina Duggal
- Division of Hematology-Oncology, University of Pittsburgh Cancer Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Michael Boyiadzis
- Division of Hematology-Oncology, University of Pittsburgh Cancer Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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47
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Qu Q, Liu L, Zhang Y, Li X, Wu D. Increasing aclarubicin dosage of the conventional CAG (low-dose cytarabine and aclarubicin in combination with granulocyte colony-stimulating factor) regimen is more efficacious as a salvage therapy than CAG for relapsed/refractory acute myeloid leukemia. Leuk Res 2015; 39:1353-9. [DOI: 10.1016/j.leukres.2015.09.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Revised: 08/10/2015] [Accepted: 09/13/2015] [Indexed: 10/23/2022]
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Ikegame K, Yoshida T, Yoshihara S, Daimon T, Shimizu H, Maeda Y, Ueda Y, Kaida K, Ishii S, Taniguchi K, Okada M, Tamaki H, Okumura H, Kaya H, Kurokawa T, Kodera Y, Taniguchi S, Kanda Y, Ogawa H. Unmanipulated Haploidentical Reduced-Intensity Stem Cell Transplantation Using Fludarabine, Busulfan, Low-Dose Antithymocyte Globulin, and Steroids for Patients in Non-Complete Remission or at High Risk of Relapse: A Prospective Multicenter Phase I/II Study in Japan. Biol Blood Marrow Transplant 2015; 21:1495-505. [PMID: 25921715 DOI: 10.1016/j.bbmt.2015.04.012] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Accepted: 04/08/2015] [Indexed: 11/12/2022]
Abstract
This prospective, multicenter phase I/II study of unmanipulated HLA-haploidentical reduced-intensity stem cell transplantation using a low dose of anti-T lymphocyte globulin (ATG) and steroid was conducted in 5 institutions in Japan. Thirty-four patients with hematologic malignancies who were in an advanced stage or at a high risk of relapse at the time of transplantation were enrolled. Among them, 7 patients underwent transplantation as a second transplantation because of relapse after the previous allogeneic stem cell transplantation. The conditioning regimen consisted of fludarabine, busulfan, and ATG (Fresenius, 8 mg/kg), and graft-versus-host disease (GVHD) prophylaxis consisted of tacrolimus and methylprednisolone (1 mg/kg). All patients except 1 (97.1%) achieved donor-type engraftment. Rapid hematopoietic engraftment was achieved, with neutrophils > .5 × 10(9)/L on day 11 and platelets > 20 × 10(9)/L on day 17.5. Treatment was started for ≥grade I GVHD, and the cumulative incidences of acute grade I and grade II to IV GVHD were 27.5% and 30.7%, respectively. The incidence of chronic GVHD (extensive type) was 20%. Fourteen patients (41.2%) had a relapse. The cumulative incidence of transplantation-related mortality at 1 year after transplantation was 26.5%. The survival rate at day 100 was 88.2%. The survival rates at 1 year for patients with complete remission (CR)/chronic phase (n = 8) and non-CR (n = 26) status before transplantation were 62.5% and 42.3%, respectively. In the multivariate analysis, non-CR status before transplantation was the only factor significant prognostic factor of increased relapse (P = .0424), which tended to be associated with a lower survival rate (P = .0524). This transplantation protocol is safe and feasible, if a suitable donor is not available in a timely manner. As the main cause of death was relapse and not GVHD, more intensified conditioning or attenuation of GVHD prophylaxis and/or donor lymphocyte infusion may be desirable for patients with non-CR status.
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Affiliation(s)
- Kazuhiro Ikegame
- Division of Hematology, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Takashi Yoshida
- Department of Internal Medicine, Toyama Prefectural Central Hospital, Toyama, Japan
| | - Satoshi Yoshihara
- Division of Hematology, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Takashi Daimon
- Department of Biostatistics, Hyogo College of Medicine, Hyogo, Japan
| | - Hiroaki Shimizu
- Leukemia Research Center, Saiseikai Maebashi Hospital, Maebashi, Japan
| | - Yoshinobu Maeda
- Department of Hematology and Oncology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Yasunori Ueda
- Department of Hematology/Oncology, Transfusion and Hemapheresis Center, Kurashiki Central Hospital, Kurashiki, Japan
| | - Katsuji Kaida
- Division of Hematology, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Shinichi Ishii
- Division of Hematology, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Kyoko Taniguchi
- Division of Hematology, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Masaya Okada
- Division of Hematology, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Hiroya Tamaki
- Division of Hematology, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
| | - Hirokazu Okumura
- Department of Internal Medicine, Toyama Prefectural Central Hospital, Toyama, Japan
| | - Hiroyasu Kaya
- Department of Internal Medicine, Toyama Prefectural Central Hospital, Toyama, Japan
| | - Toshiro Kurokawa
- Department of Internal Medicine, Toyama Prefectural Central Hospital, Toyama, Japan
| | - Yoshihisa Kodera
- Department of Promotion for Blood and Marrow Transplantation, Aichi Medical University School of Medicine, Aichi, Japan
| | | | - Yoshinobu Kanda
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Hiroyasu Ogawa
- Division of Hematology, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan.
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Ramos NR, Mo CC, Karp JE, Hourigan CS. Current Approaches in the Treatment of Relapsed and Refractory Acute Myeloid Leukemia. J Clin Med 2015; 4:665-95. [PMID: 25932335 PMCID: PMC4412468 DOI: 10.3390/jcm4040665] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 03/20/2015] [Indexed: 01/07/2023] Open
Abstract
The limited sensitivity of the historical treatment response criteria for acute myeloid leukemia (AML) has resulted in a different paradigm for treatment compared with most other cancers presenting with widely disseminated disease. Initial cytotoxic induction chemotherapy is often able to reduce tumor burden to a level sufficient to meet the current criteria for "complete" remission. Nevertheless, most AML patients ultimately die from their disease, most commonly as clinically evident relapsed AML. Despite a variety of available salvage therapy options, prognosis in patients with relapsed or refractory AML is generally poor. In this review, we outline the commonly utilized salvage cytotoxic therapy interventions and then highlight novel investigational efforts currently in clinical trials using both pathway-targeted agents and immunotherapy based approaches. We conclude that there is no current standard of care for adult relapsed or refractory AML other than offering referral to an appropriate clinical trial.
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Affiliation(s)
- Nestor R. Ramos
- Myeloid Malignancies Section, Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD 20892-1583, USA; E-Mail:
- Department of Hematology-Oncology, John P. Murtha Cancer Center, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA; E-Mail:
| | - Clifton C. Mo
- Department of Hematology-Oncology, John P. Murtha Cancer Center, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA; E-Mail:
| | - Judith E. Karp
- Division of Hematologic Malignancies, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA; E-Mail:
| | - Christopher S. Hourigan
- Myeloid Malignancies Section, Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD 20892-1583, USA; E-Mail:
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50
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Hemmati PG, Terwey TH, Na IK, Jehn CF, le Coutre P, Vuong LG, Dörken B, Arnold R. Allogeneic stem cell transplantation for refractory acute myeloid leukemia: a single center analysis of long-term outcome. Eur J Haematol 2015; 95:498-506. [PMID: 25598394 DOI: 10.1111/ejh.12522] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2014] [Indexed: 11/30/2022]
Abstract
For patients with refractory acute myeloid leukemia (AML), allogeneic stem cell transplantation (alloSCT) represents the only curative approach. We here analyzed the long-term outcome of 131 consecutive patients with active AML, which was either primary refractory or unresponsive to salvage chemotherapy, transplanted at our center between 1997 and 2013. After a median follow-up of 48 months for the surviving patients, disease-free survival (DFS) at 5 yr post alloSCT was 26% (94% CI: 17-35). Relapses, most of which occurred within the first 2 yr from transplant, were the predominant cause of treatment failure affecting 48% (95%CI: 40-58) of patients, whereas non-relapse mortality was 26% (95%CI: 20-36) at 5 yr and thereafter. A marrow blast count ≥20% before alloSCT was an independent prognosticator associated with an inferior DFS (HR: 1.58, P = 0.027), whereas the development of chronic graft-versus-host disease (cGvHD) predicted an improved DFS (HR 0.21, P < 0.001) and a decreased relapse incidence (HR: 0.18, P = 0.026), respectively. These results indicate that alloSCT represents a curative treatment option in a substantial proportion of patients with refractory AML. A pretransplant blast count <20% before alloSCT and the development of cGvHD are the most important predictors of long-term disease control.
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Affiliation(s)
- Philipp G Hemmati
- Department of Hematology, Oncology and Tumor Immunology, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Theis H Terwey
- Department of Hematology, Oncology and Tumor Immunology, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Il-Kang Na
- Department of Hematology, Oncology and Tumor Immunology, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Christian F Jehn
- Department of Hematology, Oncology and Tumor Immunology, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Philipp le Coutre
- Department of Hematology, Oncology and Tumor Immunology, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Lam G Vuong
- Department of Hematology, Oncology and Tumor Immunology, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Bernd Dörken
- Department of Hematology, Oncology and Tumor Immunology, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Renate Arnold
- Department of Hematology, Oncology and Tumor Immunology, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
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