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Scordo M, Flynn JR, Gonen M, Devlin SM, Parascondola A, Tomas AA, Shouval R, Brower J, Porter DL, Schuster SJ, Bachanova V, Maakaron J, Maziarz RT, Chen AI, Nastoupil LJ, McGuirk JP, Oluwole OO, Ip A, Leslie LA, Bishop MR, Riedell PA, Perales MA. Identifying an optimal fludarabine exposure for improved outcomes after axi-cel therapy for aggressive B-cell non-Hodgkin lymphoma. Blood Adv 2023; 7:5579-5585. [PMID: 37522731 PMCID: PMC10514205 DOI: 10.1182/bloodadvances.2023010302] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 07/18/2023] [Accepted: 07/21/2023] [Indexed: 08/01/2023] Open
Abstract
Fludarabine is one of the most common agents given for lymphodepletion before CD19 chimeric antigen receptor T cells, but its optimal therapeutic intensity is unknown. Using data from a multicenter consortium, we estimated fludarabine exposure (area under the curve [AUC]) using a population pharmacokinetic (PK) model in 199 adult patients with aggressive B-cell non-Hodgkin lymphomas who received commercial axicabtagene ciloleucel (Axi-cel). We evaluated the association of estimated fludarabine AUC with key outcomes, aiming to find an AUC that optimized efficacy and tolerability. We identified low (<18 mg × hour/L [mgh/L]), optimal (18-20 mgh/L), and high (>20 mgh/L) AUC groups for analyses; the 6-month cumulative incidences of relapse/progression of disease (relapse/POD) by AUC groups were 54% (45%-62%), 28% (15%-44%), and 30% (14%-47%), respectively; and the 1-year progression-free survival (PFS) rates were 39% (31%-48%), 66% (52%-84%), and 46% (30%-70%) and the overall survival (OS) rates were 58% (50%-67%), 77% (64%-92%), and 66% (50%-87%), respectively. In multivariable analyses compared with low AUC, an optimal AUC was associated with the highest PFS (hazard ratio [HR], 0.52; 0.3-0.91; P = .02) and lowest risk of relapse/POD (HR, 0.46; 0.25-0.84; P = .01) without an increased risk of any-grade cytokine release syndrome (HR, 1.1; 0.7-1.6; P = .8) or and immune effector cell-associated neurotoxicity syndrome (ICANS) (HR, 1.36; 0.83-2.3; P = .2). A high AUC was associated with the greatest risk of any-grade ICANS (HR, 1.9; 1.1-3.2; P = .02). Although the main cause of death in all groups was relapse/POD, nonrelapse-related deaths, including 3 deaths from ICANS, were more frequent in the high AUC group. These findings suggest that PK-directed fludarabine dosing to achieve an optimal AUC may result in improved outcomes for patients receiving axi-cel.
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Affiliation(s)
- Michael Scordo
- Adult Bone Marrow Transplant Service, Cellular Therapy Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Jessica R. Flynn
- Department of Biostatistics and Epidemiology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Mithat Gonen
- Department of Biostatistics and Epidemiology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Sean M. Devlin
- Department of Biostatistics and Epidemiology, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | - Roni Shouval
- Adult Bone Marrow Transplant Service, Cellular Therapy Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Jamie Brower
- Cell Therapy and Transplant and Lymphoma Programs, Division of Hematology-Oncology, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - David L. Porter
- Cell Therapy and Transplant and Lymphoma Programs, Division of Hematology-Oncology, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Stephen J. Schuster
- Cell Therapy and Transplant and Lymphoma Programs, Division of Hematology-Oncology, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Veronika Bachanova
- Division of Hematology, Oncology and Transplantation, Department of Medicine, Masonic Cancer Center, University of Minnesota, Minneapolis, MN
| | - Joseph Maakaron
- Division of Hematology, Oncology and Transplantation, Department of Medicine, Masonic Cancer Center, University of Minnesota, Minneapolis, MN
| | - Richard T. Maziarz
- Center for Hematologic Malignancies, Knight Cancer Institute, Oregon Health and Science University, Portland, OR
| | - Andy I. Chen
- Center for Hematologic Malignancies, Knight Cancer Institute, Oregon Health and Science University, Portland, OR
| | - Loretta J. Nastoupil
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Joseph P. McGuirk
- Division of Hematologic Malignancies & Cellular Therapeutics, University of Kansas Medical Center, Kansas City, KS
| | - Olalekan O. Oluwole
- Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - Andrew Ip
- Division of Lymphoma, John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, NJ
- Department of Oncology, Hackensack Meridian School of Medicine, Nutley, NJ
| | - Lori A. Leslie
- Division of Lymphoma, John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, NJ
- Department of Oncology, Hackensack Meridian School of Medicine, Nutley, NJ
| | - Michael R. Bishop
- The David and Etta Jonas Center for Cellular Therapy, University of Chicago, Chicago, IL
| | - Peter A. Riedell
- The David and Etta Jonas Center for Cellular Therapy, University of Chicago, Chicago, IL
| | - Miguel-Angel Perales
- Adult Bone Marrow Transplant Service, Cellular Therapy Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical College, New York, NY
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Corona M, Shouval R, Alarcón A, Flynn J, Devlin SM, Batlevi CW, Fein DJA, Giralt S, Lynn R, Nath K, Palomba ML, Parascondola A, Shah GL, Salles G, Scordo M, Walji DM, Perales MA, Dahi PB. Severe Persistent Cytopenias Following CAR T-Cell Therapy in Patients with Large B-Cell Lymphoma. Transplant Cell Ther 2023. [DOI: 10.1016/s2666-6367(23)00338-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Shah GL, Bal S, Rodriguez C, Chhabra S, Bayer RL, Costa LJ, Lambird J, Ferrer C, Parascondola A, Marcello L, Shulman L, Obadi O, Acosta J, Hassoun H, Hultcrantz M, Korde NS, Mailankody S, Tan CR, Shah UA, Lesokhin AM, Lahoud OB, Scordo M, Chung DJ, Landau HJ, Giralt SA. Interim Analysis of the 2nd Chance Protocol: A Multicenter Trial of Daratumumab, Carfilzomib, Lenalidomide, & Dexamethasone for Relapsed/Refractory Myeloma with Salvage Autologous Hematopoietic Cell Transplantation. Transplant Cell Ther 2022. [DOI: 10.1016/s2666-6367(22)00693-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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