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Bader P, Pötschger U, Dalle JH, Moser LM, Balduzzi A, Ansari M, Buechner J, Güngör T, Ifversen M, Krivan G, Pichler H, Renard M, Staciuk R, Sedlacek P, Stein J, Heusel JR, Truong T, Wachowiak J, Yesilipek A, Locatelli F, Peters C. Low rate of nonrelapse mortality in under-4-year-olds with ALL given chemotherapeutic conditioning for HSCT: a phase 3 FORUM study. Blood Adv 2024; 8:416-428. [PMID: 37738088 PMCID: PMC10827403 DOI: 10.1182/bloodadvances.2023010591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 09/05/2023] [Accepted: 09/08/2023] [Indexed: 09/23/2023] Open
Abstract
ABSTRACT Allogeneic hematopoietic stem cell transplantation (HSCT) is highly effective for treating pediatric high-risk or relapsed acute lymphoblastic leukemia (ALL). For young children, total body irradiation (TBI) is associated with severe late sequelae. In the FORUM study (NCT01949129), we assessed safety, event-free survival (EFS), and overall survival (OS) of 2 TBI-free conditioning regimens in children aged <4 years with ALL. Patients received fludarabine (Flu), thiotepa (Thio), and either busulfan (Bu) or treosulfan (Treo) before HSCT. From 2013 to 2021, 191 children received transplantation and were observed for ≥6 months (median follow-up: 3 years). The 3-year OS was 0.63 (95% confidence interval [95% CI], 0.52-0.72) and 0.76 (95% CI, 0.64-0.84) for Flu/Thio/Bu and Flu/Thio/Treo (P = .075), respectively. Three-year EFS was 0.52 (95% CI, 0.41-0.61) and 0.51 (95% CI, 0.39-0.62), respectively (P = .794). Cumulative incidence of nonrelapse mortality (NRM) and relapse at 3 years were 0.06 (95% CI, 0.02-0.12) vs 0.03 (95% CI: <0.01-0.09) (P = .406) and 0.42 (95% CI, 0.31-0.52) vs 0.45 (95% CI, 0.34-0.56) (P = .920), respectively. Grade >1 acute graft-versus-host disease (GVHD) occurred in 29% of patients receiving Flu/Thio/Bu and 17% of those receiving Flu/Thio/Treo (P = .049), whereas grade 3/4 occurred in 10% and 9%, respectively (P = .813). The 3-year incidence of chronic GVHD was 0.07 (95% CI, 0.03-0.13) vs 0.05 (95% CI, 0.02-0.11), respectively (P = .518). In conclusion, both chemotherapeutic conditioning regimens were well tolerated and NRM was low. However, relapse was the major cause of treatment failure. This trial was registered at www.clinicaltrials.gov as #NCT01949129.
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Affiliation(s)
- Peter Bader
- Goethe University, University Hospital, Department of Pediatrics, Division for Stem Cell Transplantation, Immunology and Intensive Care Medicine, Frankfurt, Germany
| | | | - Jean-Hugues Dalle
- Pediatric Hematology and Immunology Department, Robert Debré Hospital, Groupe Hospitalo-Universitaire Assistance Publique Hôpitaux de Paris (GHU AP-HP) Nord, Université Paris Cité, Paris, France
| | - Laura M. Moser
- Goethe University, University Hospital, Department of Pediatrics, Division for Stem Cell Transplantation, Immunology and Intensive Care Medicine, Frankfurt, Germany
| | - Adriana Balduzzi
- Università degli Studi di Milano-Fondazione, FONDAZIONE MONZA E BRIANZA PER IL BAMBINO E LA SUA MAMMA (MBBM), Department for Pediatric Hematology and Oncology, Monza, Italy
| | - Marc Ansari
- CANSEARCH Research Platform for Pediatric Oncology and Hematology, Faculty of Medicine, Department of Pediatrics, Gynecology and Obstetrics, University of Geneva, Switzerland
- Division of Pediatric Oncology and Hematology, Department of Women, Child and Adolescent, University Geneva Hospitals, Geneva, Switzerland
| | - Jochen Buechner
- Department of Pediatric Hematology and Oncology, Oslo University Hospital, Oslo, Norway
| | - Tayfun Güngör
- Department of Hematology/Oncology/Immunology, Gene Therapy, and Stem Cell Transplantation, University Children's Hospital Zürich, Eleonore Foundation & Children’s Research Center, Zürich, Switzerland
| | - Marianne Ifversen
- Copenhagen University Hospital Rigshospitalet, Department for Pediatric Hematology and Oncology, Copenhagen, Denmark
| | - Gergely Krivan
- Pediatric Hematology and Stem Cell Transplantation Department, Central Hospital of Southern Pest, National Institute of Hematology and Infectious Diseases, Budapest, Hungary
| | - Herbert Pichler
- St. Anna Children's Hospital, University Vienna, Vienna, Austria
| | - Marleen Renard
- Department of Paediatric Oncology, University Hospital Leuven, Leuven, Belgium
| | - Raquel Staciuk
- Hospital de Pediatría “Prof. Dr. Juan P. Garrahan,” Buenos Aires, Buenos Aires, Argentina
| | - Petr Sedlacek
- Department of Pediatric Hematology and Oncology, Motol University Hospital, Prague, Czech Republic
| | - Jerry Stein
- Schneider Children's Medical Center of Israel and Sackler Faculty of Medicine, Tel Aviv University, Petah Tikva, Israel
| | - Jan Robert Heusel
- Goethe University, University Hospital, Department of Pediatrics, Division for Stem Cell Transplantation, Immunology and Intensive Care Medicine, Frankfurt, Germany
| | - Tony Truong
- Division of Pediatric Oncology and Cellular Therapy, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Jacek Wachowiak
- Department of Pediatric Oncology, Hematology and Transplantology, Poznań University of Medical Sciences, Poznań, Poland
| | | | - Franco Locatelli
- Department of Pediatric Hematology and Oncology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ospedale Pediatrico Bambino Gesù, Catholic University of the Sacred Heart, Rome, Italy
| | - Christina Peters
- St. Anna Children's Cancer Research Institute, Vienna, Austria
- St. Anna Children's Hospital, University Vienna, Vienna, Austria
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Górecki M, Kozioł I, Kopystecka A, Budzyńska J, Zawitkowska J, Lejman M. Updates in KMT2A Gene Rearrangement in Pediatric Acute Lymphoblastic Leukemia. Biomedicines 2023; 11:biomedicines11030821. [PMID: 36979800 PMCID: PMC10045821 DOI: 10.3390/biomedicines11030821] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 03/01/2023] [Accepted: 03/04/2023] [Indexed: 03/10/2023] Open
Abstract
The KMT2A (formerly MLL) encodes the histone lysine-specific N-methyltransferase 2A and is mapped on chromosome 11q23. KMT2A is a frequent target for recurrent translocations in acute myeloid leukemia (AML), acute lymphoblastic leukemia (ALL), or mixed lineage (biphenotypic) leukemia (MLL). Over 90 KMT2A fusion partners have been identified until now, including the most recurring ones—AFF1, MLLT1, and MLLT3—which encode proteins regulating epigenetic mechanisms. The presence of distinct KMT2A rearrangements is an independent dismal prognostic factor, while very few KMT2A rearrangements display either a good or intermediate outcome. KMT2A-rearranged (KMT2A-r) ALL affects more than 70% of new ALL diagnoses in infants (<1 year of age), 5–6% of pediatric cases, and 15% of adult cases. KMT2A-rearranged (KMT2A-r) ALL is characterized by hyperleukocytosis, a relatively high incidence of central nervous system (CNS) involvement, an aggressive course with early relapse, and early relapses resulting in poor prognosis. The exact pathways of fusions and the effects on the final phenotypic activity of the disease are still subjects of much research. Future trials could consider the inclusion of targeted immunotherapeutic agents and prioritize the identification of prognostic factors, allowing for the less intensive treatment of some infants with KMT2A ALL. The aim of this review is to summarize our knowledge and present current insight into the mechanisms of KMT2A-r ALL, portray their characteristics, discuss the clinical outcome along with risk stratification, and present novel therapeutic strategies.
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Affiliation(s)
- Mateusz Górecki
- Student Scientific Society of Independent Laboratory of Genetic Diagnostics, Medical University of Lublin, 20-093 Lublin, Poland
| | - Ilona Kozioł
- Student Scientific Society of the Department of Pediatric Hematology, Oncology and Transplantology, Medical University of Lublin, 20-093 Lublin, Poland
| | - Agnieszka Kopystecka
- Student Scientific Society of the Department of Pediatric Hematology, Oncology and Transplantology, Medical University of Lublin, 20-093 Lublin, Poland
| | - Julia Budzyńska
- Student Scientific Society of the Department of Pediatric Hematology, Oncology and Transplantology, Medical University of Lublin, 20-093 Lublin, Poland
| | - Joanna Zawitkowska
- Department of Paediatric Haematology, Oncology and Transplantology, Medical University of Lublin, 20-093 Lublin, Poland
| | - Monika Lejman
- Independent Laboratory of Genetic Diagnostics, Medical University of Lublin, 20-093 Lublin, Poland
- Correspondence:
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Tomizawa D. Evolution and optimization of therapies for acute lymphoblastic leukemia in infants. Int J Hematol 2023; 117:162-172. [PMID: 36441356 DOI: 10.1007/s12185-022-03502-w] [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: 10/18/2022] [Revised: 11/21/2022] [Accepted: 11/22/2022] [Indexed: 11/29/2022]
Abstract
Acute lymphoblastic leukemia (ALL) in infants accounts for less than 5% of pediatric ALL and is biologically and clinically unique. Approximately 70% to 80% of cases present as an aggressive leukemia with KMT2A gene rearrangement (KMT2A-r), which is one of the most difficult-to-cure forms of pediatric leukemia. Owing to continuing global efforts through multicenter clinical trials since the mid-1990s, a standard of care for infant KMT2A-r ALL, including minimal residual disease-based risk stratifications, "hybrid chemotherapy" incorporating myeloid leukemia-like drugs (e.g., cytarabine) into the ALL chemotherapy backbone, and selective use of allogeneic hematopoietic stem cell transplantation, has now been established. However, there are still many concerns regarding treatment of infants with KMT2A-r ALL, including insufficient efficacy of the current standard therapies, limited pharmacokinetic/pharmacodynamic data on drugs in infants, and management of both acute and late toxicities. Refinements in risk stratification based on leukemia biology, as well as the introduction of emerging novel immunotherapies and molecular-targeted drugs to contemporary therapy, through international collaboration would provide key solutions for further improvement in outcomes.
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Affiliation(s)
- Daisuke Tomizawa
- Division of Leukemia and Lymphoma, Children's Cancer Center, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-Ku, Tokyo, 157-8535, Japan.
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Dinikina YV, Mikhailov AV, Rusina MA, Smirnova AY, Vorob’ov NA, Kataev NA, Kubasov AV. First experience of total body irradiation in conditioning regimes for allogenic hematopoietic stem cells transplantation in children with acute lymphoblastic leukemia in Saint Petersburg. ONCOHEMATOLOGY 2022. [DOI: 10.17650/1818-8346-2022-17-4-126-137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Background. Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is an effective treatment method of refractory and recurrent forms of acute leukemia in children, while the question of choosing a conditioning regimen in order to achieve the best treatment results remains debatable. Conditioning based on total body irradiation (TbI) was confirmed to be most effective in some trials, but there are still issues of overcoming early and late toxicity, as well as difficulties in planning and routing patients.Aim. To share the experience of interdisciplinary patient management during the conditioning period with TbI inclusion in Saint petersburg, to evaluate the feasibility, toxicity and effectiveness of the method.Materials and methods. patients undergoing allo-HSCT for high risk acute lymphoblastic leukemia conditioned either with TbI (n = 12) or chemotherapy (n = 10) were included. Medical data were retrospectively analyzed with an assessment of the following transplant outcomes: HSCT-associated toxicity, the frequency and severity of infectious complications, graft versus host disease, as well as overall and event-free survival rates. we have evaluated radiotherapy plans in order to assess the compliance of radiation exposure with acceptable values for critical organs.Results. All patients with acute lymphoblastic leukemia in both groups received appropriate myeloablative conditioning. According to the study results, despite the lack of significance, we obtained differences in HSCT-associated mortality (8.3 and 30 %; p = 0.151), 2-years overall and event-free survival (66 ± 13.6 and 36 ± 16.1 %; p = 0.122) in group with TbI and HdCT respectively. It should be noted that there was a trend towards a decrease of toxic reactions frequency in case of TbI-containing regimens; however we didn’t reveal any significant differences in the number of infectious complications during post-transplant period. The median follow-up was 24.2 months and there were no signs of delayed toxicity.Conclusion. TbI-based conditioning was well tolerated with a low incidence of early and delayed toxicity, better overall and event-free survival. based on feasibility of TbI in Saint petersburg hospitals it is possible to recommend the method in routine practice, taking into account clinical indications.
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Affiliation(s)
- Yu. V. Dinikina
- V.A. Almazov National Medical Research Centre, Ministry of Health of Russia
| | - A. V. Mikhailov
- Diagnostic and Treatment Center, International Institute of Biological Systems named after Sergey Berezin; I.I. Mechnikov North-West State Medical University, Ministry of Health of Russia
| | - M. A. Rusina
- V.A. Almazov National Medical Research Centre, Ministry of Health of Russia
| | - A. Yu. Smirnova
- V.A. Almazov National Medical Research Centre, Ministry of Health of Russia
| | - N. A. Vorob’ov
- Diagnostic and Treatment Center, International Institute of Biological Systems named after Sergey Berezin; Saint Petersburg State University
| | - N. A. Kataev
- Diagnostic and Treatment Center, International Institute of Biological Systems named after Sergey Berezin
| | - A. V. Kubasov
- Diagnostic and Treatment Center, International Institute of Biological Systems named after Sergey Berezin
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