Hyper-CVAD versus dose-adjusted EPOCH as initial treatment for adults with acute lymphoblastic leukemia

OBJECTIVES

We recently performed a single-arm phase II trial of DA-EPOCH in adults with acute lymphoblastic leukemia (ALL). We sought to compare these results to those with standard Hyper-CVAD.

METHODS

We created a retrospective matched cohort of patients who received Hyper-CVAD (n = 69) at our center and otherwise met eligibility criteria for the DA-EPOCH trial (n = 53).

RESULTS

Our outcomes support the use of Hyper-CVAD over DA-EPOCH in Ph- disease for both overall survival (OS; HR 0.18, p = .004) and event-free survival (EFS; HR 0.51, p = .06). In contrast, outcomes were similar in Ph+ disease (OS HR 0.97, p = .96; EFS HR 0.65, p = .21). Rates of morphologic remission and measurable residual-disease negativity were similar between the regimens. Hyper-CVAD was associated with significantly more febrile neutropenia (OR 1.9, p = .03) and a greater incidence of Grade 4 or 5 adverse events (20% vs. 6%). Average transfusions per cycle of both red blood cells (p < .001) and platelets (p < .001) were five-fold higher with Hyper-CVAD.

CONCLUSIONS

Our findings support continued use of Hyper-CVAD for Ph- ALL but suggest that DA-EPOCH may be a reasonable alternative for Ph+ ALL. These data also highlight a potential role for DA-EPOCH in resource-limited settings or when more intense therapy is not feasible.

Phase 1/2 study of sorafenib added to cladribine, high-dose cytarabine, G-CSF, and mitoxantrone in untreated AML

The multikinase inhibitor sorafenib improves event-free survival (EFS) when used with 7 + 3 in adults with newly-diagnosed acute myeloid leukemia (AML), irrespective of the FLT3-mutation status. Here, we evaluated adding sorafenib to cladribine, high-dose cytarabine, granulocyte colony-stimulating factor, and mitoxantrone (CLAG-M) in a phase 1/2 trial of 81 adults aged ≤60 years with newly diagnosed AML. Forty-six patients were treated in phase 1 with escalating doses of sorafenib and mitoxantrone. No maximum tolerated dose was reached, and a regimen including mitoxantrone 18 mg/m2 per day and sorafenib 400 mg twice daily was declared the recommended phase 2 dose (RP2D). Among 41 patients treated at RP2D, a measurable residual disease-negative complete remission (MRD- CR) rate of 83% was obtained. Four-week mortality was 2%. One-year overall survival (OS) and EFS were 80% and 76%, without differences in MRD- CR rates, OS, or EFS between patients with or without FLT3-mutated disease. Comparing outcomes using CLAG-M/sorafenib with those of a matched cohort of 76 patients treated with CLAG-M alone, multivariable-adjusted survival estimates were improved for 41 patients receiving CLAG-M/sorafenib at RP2D (OS: hazard ratio,0.24 [95% confidence interval, 0.07-0.82]; P = .023; EFS: hazard ratio, 0.16 [95% confidence interval, 0.05-0.53]; P = .003). Benefit was limited to patients with intermediate-risk disease (univariate analysis: P = .01 for OS; P = .02 for EFS). These data suggest that CLAG-M/sorafenib is safe and improves OS and EFS relative to CLAG-M alone, with benefits primarily in patients with intermediate-risk disease. The trial was registered at www.clinicaltrials.gov as #NCT02728050.

Phase II study of dose-adjusted EPOCH as initial therapy for adults with high-risk acute lymphoblastic leukemia

Treatments for adults with newly-diagnosed acute lymphoblastic leukemia (ALL) may be prohibitively toxic and/or resource-intense. To address this, we performed a phase II study of dose-adjusted etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin (DA-EPOCH). Imatinib or dasatinib was added for Ph + disease; rituximab was added when CD20+. Fifty-three patients were evaluable: 28 with Ph + disease, and 25 with Ph-. All patients had ≥1 high-risk clinical feature. Measurable residual disease-negativity by multiparameter flow cytometry within 4 cycles was achieved in 71% in patients with Ph + ALL and 64% in Ph - ALL. Median overall survival (OS) was 49 months, with a 2-year OS of 71%. Median relapse-free survival (RFS) in the 47 patients that attained morphologic remission was 24 months, with a 2-year RFS of 57%. Early mortality was 2%. In summary, DA-EPOCH yields deep and durable remissions in adults with ALL comparable to some resource-intense strategies but with a low rate of treatment-related death.

Poor post-induction outcomes in patients with acute myeloid leukemia previously treated with hypomethylating agents

Patients with acute myeloid leukemia (AML) who have failed hypomethylating agents (HMA) have a poor prognosis. We examined whether high intensity induction chemotherapy could abrogate negative outcomes in 270 patients with AML or other high-grade myeloid neoplasms. Prior HMA therapy was significantly associated with a lower overall survival (OS) as compared to a reference group of patients with secondary disease without prior HMA therapy (median 7.2 vs 13.1 months). In patients with prior HMA therapy, high intensity induction was associated with a non-significant trend toward longer OS (median 8.2 vs 4.8 months) and decreased rates of treatment failure (39% vs 64%). These results redemonstrate poor outcomes in patients with prior HMA and suggest possible benefit of high intensity induction that should be evaluated in future studies.

Phase 1/2 Trial of CLAG-M with Dose-Escalated Mitoxantrone in Combination with Fractionated-Dose Gemtuzumab Ozogamicin for Newly Diagnosed Acute Myeloid Leukemia and Other High-Grade Myeloid Neoplasms

Simple Summary

Several studies have demonstrated that gemtuzumab ozogamicin (GO) improves outcomes with intensive chemotherapy in some adults with acute myeloid leukemia (AML), but it has remained unclear which dosing schedule of GO is best. Here, we conducted a phase 1/2 study in 66 adults with newly diagnosed AML or other high-grade myeloid neoplasm, and found that a fractionated dosing schedule of GO (GO3) can be safely combined with cladribine, high-dose cytarabine, G-CSF, and dose-escalated mitoxantrone (CLAG-M). Fifty-two out of sixty (87%) patients treated with CLAG-M/GO3 achieved a complete remission (CR)/CR with incomplete hematologic recovery (CRi), 45/52 (87%) without flow cytometric measurable residual disease. Six- and twelve-month event-free survival were 73% and 58%; among favorable-risk patients, these estimates were 100% and 95%. Compared to 186 medically matched adults treated with CLAG-M alone, CLAG-M/GO3 was associated with better survival in patients with favorable-risk disease. These data indicate that CLAG-M/GO3 is safe and more efficacious than CLAG-M alone in favorable-risk AML/high-grade myeloid neoplasm.

Abstract

Gemtuzumab ozogamicin (GO) improves outcomes when added to intensive AML chemotherapy. A meta-analysis suggested the greatest benefit when combining fractionated doses of GO (GO3) with 7 + 3. To test whether GO3 can be safely used with high intensity chemotherapy, we conducted a phase 1/2 study of cladribine, high-dose cytarabine, G-CSF, and dose-escalated mitoxantrone (CLAG-M) in adults with newly diagnosed AML or other high-grade myeloid neoplasm (NCT03531918). Sixty-six patients with a median age of 65 (range: 19–80) years were enrolled. Cohorts of six and twelve patients were treated in phase 1 with one dose of GO or three doses of GO (GO3) at 3 mg/m² per dose. Since a maximum-tolerated dose was not reached, the recommended phase 2 dose (RP2D) was declared to be GO3. At RP2D, 52/60 (87%) patients achieved a complete remission (CR)/CR with incomplete hematologic recovery (CRi), 45/52 (87%) without flow cytometric measurable residual disease (MRD). Eight-week mortality was 0%. Six- and twelve-month event-free survival (EFS) were 73% and 58%; among favorable-risk patients, these estimates were 100% and 95%. Compared to 186 medically matched adults treated with CLAG-M alone, CLAG-M/GO3 was associated with better survival in patients with favorable-risk disease (EFS: p = 0.007; OS: p = 0.030). These data indicate that CLAG-M/GO3 is safe and leads to superior outcomes than CLAG-M alone in favorable-risk AML/high-grade myeloid neoplasm.

Comparative analysis of infectious complications with outpatient vs. inpatient care for adults with high-risk myeloid neoplasm receiving intensive induction chemotherapy

We recently reported an early hospital discharge (EHD) care strategy following intensive acute myeloid leukemia (AML)-like chemotherapy is safe. To evaluate its impact on infectious outcomes, we compared all adults treated from 8/1/2014 to 7/31/2018 discharging within 72 h of completing chemotherapy (EHD) with hospitalized patients (controls) across 354 induction and 259 post-remission cycles. While overall outcomes were similar, gram-positive bacteremias were more common in EHD patients than control (p<.001), although they received fewer days of IV antimicrobials (p< .001). Notably, cumulative infection risks in EHD patients were similar after induction and post-remission therapy. In multivariable analysis, only EHD status was independently associated with risk for gram-positive bacteremia (p= .01), whereas the only independent risk factor for fungal infection was fluconazole (vs. posaconazole) use (p< .001). The observation of increased rates of gram-positive bacteremias with EHD identifies improvements in catheter management as one area to further increase the safety of this care approach.

Survival of patients with newly diagnosed high-grade myeloid neoplasms who do not meet standard trial eligibility

Few patients with cancer, including those with acute myeloid leukemia and high-grade myeloid neoplasms, participate in clinical trials. Broadening standard eligibility criteria may increase clinical trial participation. In this retrospective single-center analysis, we identified 442 consecutive newly diagnosed patients from 2014 to 2016. Patients were considered “eligible” if they had a performance status 0-2, normal renal and hepatic function, no recent solid tumor, left ventricular ejection fraction (EF) ≥50%, and no history of congestive heart failure (CHF) or myocardial infarction (MI); “ineligible” patients failed to meet one or more of these criteria. We included 372 patients who received chemotherapy. Ineligible patients represented 40% of the population and had a 1.79-fold greater risk of death (95% Confidence Interval [CI]: 1.37-2.33) than eligible patients. Very few patients had cardiac comorbidities, including 2% with low EF, 4% with prior CHF, and 5% with prior MI. In multivariable analysis, ineligibility was associated with decreased survival (Hazard ratio [HR] 1.44; 95% CI: 1.07-1.93). Allogeneic transplantation, performed in 150 patients (40%), was associated with improved survival (HR 0.66, 95% CI: 0.48-0.91). Therefore, standard eligibility characteristics identify a patient population with improved survival. Further treatment options are needed for patients considered ineligible for clinical trials.

Financial Implications of Early Hospital Discharge After AML-Like Induction Chemotherapy: A 4-Year Retrospective Analysis

BACKGROUND

Early hospital discharge (EHD) after intensive acute myeloid leukemia (AML) induction chemotherapy has become routine at the University of Washington/Seattle Cancer Care Alliance over the past several years. We assessed the financial implications of EHD over the first 4 years after its broad adoption for patients with AML and other high-grade myeloid neoplasms undergoing AML-like induction chemotherapy.

PATIENTS AND METHODS

We retrospectively compared charges between 189 patients with EHD who received all postinduction inpatient/outpatient care within our care system between August 2014 and July 2018 and 139 medically matched control patients who remained hospitalized for logistical reasons. Charges from the day of initial discharge (patients with EHD) or end of chemotherapy (control patients) until blood count recovery, additional chemotherapy or care transition, hospital discharge (for control patients only), an elapse of 42 days, or death were extracted from financial databases and separated into categories: facility/provider, emergency department, transfusions, laboratory, imaging, pharmacy, and miscellaneous.

RESULTS

Combined charges averaged $4,157/day (range, $905-$13,119/day) for patients with EHD versus $9,248/day (range, $4,363-$48,522/day) for control patients (P<.001). The EHD cohort had lower mean facility/provider, transfusion, laboratory, and pharmacy charges but not imaging or miscellaneous charges. During readmissions, there was no statistically significant difference in daily inpatient charges between the EHD and control cohorts. After multivariable adjustment, average charges were $3,837/day lower for patients with EHD (P<.001).

CONCLUSIONS

Together with previous data from our center showing that EHD is safe and associated with reduced healthcare resource utilization, this study further supports this care approach for AML and other high-grade myeloid neoplasms if infrastructure is available to enable close outpatient follow-up.

Practice patterns and outcomes for adults with acute myeloid leukemia receiving care in community vs academic settings

Consistent with observations in other disease settings, retrospective studies have indicated that treatment outcomes for adults with acute myeloid leukemia (AML) are better in higher- vs lower-volume hospitals and academic vs nonacademic centers, with greatest benefits noted in acute promyelocytic leukemia. Younger age, more frequent receipt of chemotherapy and hematopoietic cell transplantation, and differences in comorbidities and socioeconomic factors may partially account for these differences. With new therapeutic options including oral small molecule inhibitors and parenteral drugs suitable for outpatient administration, there is increasing interest from patients and physicians in treating AML in the community setting and avoiding referral to academic centers. This may be particularly true for older adults, for whom treatment rates in the community have historically been low, and for those with comorbidities, because treatment benefits are estimated to be low, and thus travel to academic centers is perceived as especially burdensome. How the volume-outcome relationship is affected by the shift of the treatment landscape in AML over the last few years is unknown. Additionally, improvements in supportive care (transfusion support, broad-spectrum oral antimicrobials), resulting in gradually decreasing early death rates over time, and the growing focus on the impact of AML therapy on quality of life and treatment cost concerns further fuel the larger trend toward an increasing proportion of care delivered in the outpatient setting. Here, we examine whether the current shift of administering chemotherapy and supportive care to the outpatient setting can be translated to the community setting without compromising patient outcomes.

Accuracy of SIE/SIES/GITMO Consensus Criteria for Unfitness to Predict Early Mortality After Intensive Chemotherapy in Adults With AML or Other High-Grade Myeloid Neoplasm

PURPOSE

With increasing therapeutic alternatives available, there is growing interest in tools that accurately identify patients most suitable for intensive acute myeloid leukemia (AML) chemotherapy. Nowadays, conceptual criteria proposed by an Italian panel of experts are widely used for this purpose. How accurately these Ferrara criteria predict fitness for intensive chemotherapy is unknown.

PATIENTS AND METHODS

We assessed the fitness of adults undergoing intensive AML therapy based on Ferrara criteria and determined the accuracy of this assessment for early mortality and survival prediction.

RESULTS

Among 655 adults who received curative-intent induction or reinduction chemotherapy with 7 days of standard-dose cytarabine and 3 days of an anthracycline ("7+3") CLAG-M (cladribine, high-dose cytarabine, granulocyte colony-stimulating factor, and mitoxantrone), or reduced-dose CLAG-M, 197 (30%) met at least one of the criteria defining unfitness for intensive chemotherapy (F-unfit). Compared with F-fit patients, the overall survival of F-unfit patients was significantly shorter (median, 4.8 months; 95% CI, 3.6 to 6.5 months v 36.8 months; 95% CI, 27.4 to 73.0 months; P < .001). When used alone, the Ferrara unfitness assessment was more accurate in predicting day 28 and day 100 mortality than the treatment-related mortality score we developed previously (used binary, ≤ 13.1 v > 13.1), as indicated by area under the receiver operating characteristic curve (AUC) values of 0.76 and 0.79 versus 0.66 and 0.62. The predictive accuracy of the Ferrara unfitness assessment could be significantly improved by including additional covariates such as performance status and albumin, yielding AUCs as high as 0.84-0.85 for the prediction of day 28 or day 100 mortality. Prediction of overall survival was less accurate, yielding a c-statistic value as high as 0.75 in multivariable models.

CONCLUSION

Ferrara unfitness criteria provide a good prediction tool for shorter-term mortality after intensive AML chemotherapy. Our data may serve as a benchmark for expected outcomes with intensive chemotherapy in F-fit and F-unfit patients.

Considerations for Managing Patients With Hematologic Malignancy During the COVID-19 Pandemic: The Seattle Strategy

In January 2020, the first documented patient in the United States infected with severe acute respiratory syndrome coronavirus 2 was diagnosed in Washington State. Since that time, community spread of coronavirus disease 2019 (COVID-19) in the state has changed the practice of oncologic care at our comprehensive cancer center in Seattle. At the Seattle Cancer Care Alliance, the primary oncology clinic for the University of Washington/Fred Hutchinson Cancer Consortium, our specialists who manage adult patients with hematologic malignancies have rapidly adjusted clinical practices to mitigate the potential risks of COVID-19 to our patients. We suggest that our general management decisions and modifications in Seattle are broadly applicable to patients with hematologic malignancies. Despite a rapidly changing environment that necessitates opinion-based care, we provide recommendations that are based on best available data from clinical trials and collective knowledge of disease states.

Relation between measurable residual disease and morphologic relapse in AML

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Background: Measurable residual disease (MRD) in AML portends a poor prognosis. The outcomes and treatments of MRD after an initial MRD negative complete remission (MRD- CR) are unclear. Methods: We retrospectively identified 432 patients ≥ 18 years of age treated for AML or high grade myeloid neoplasm (10-19% blasts in blood and/or marrow) at University of Washington/Seattle Cancer Care Alliance from 2008-2017 who achieved MRD- CR after initial treatment. Next disease recurrence was recorded, with patients either developing MRD ( < 5% blasts via multiparameter flow cytometry; n = 44) or developing morphologic relapse (≥5% blasts; n = 100). The remaining patients remained in MRD- CR (n = 288, median follow up time 3.7 years). A landmark analysis at one year was performed to compare overall survival (OS). Results: Patients who developed MRD tended to be older (p = 0.009), but baseline characteristics were otherwise similar. Therapies for MRD included allogeneic transplant, low intensity chemotherapy, and high intensity chemotherapy; no significant associations were found between type MRD directed therapy and survival. Landmark OS at 1 year after MRD- CR was significantly different for patients without relapse at 1 year compared to those with MRD or morphologic relapse (median OS was 8.5 years for no relapse, 2.2 years for MRD, and 1.0 years for morphologic relapse). A multivariable Cox regression model among patients alive at 1 year showed patients without relapse had significantly improved OS compared to those with morphologic relapse [HR 0.18 (95% CI 0.1-0.31)]. Although there was a trend towards improved OS, we did not identify a significant difference between patients with MRD relapse compared to morphologic relapse [HR 0.54 (95% CI 0.27-1.11)]. There were no significant differences in patient characteristics for patients with MRD vs morphologic relapse matched by time of relapse (days 30-90, 90-150, 150-210). Conclusions: Following MRD- CR, development of either MRD or morphologic relapse were both associated with decreased OS. Notably, no significant differences in terms of survival were seen between patients who presented with MRD as opposed to morphologic relapse. No clear predictors were identified for MRD vs morphologic relapse. In this cohort, development of MRD carried a poor OS prognosis, similar to the prognosis of developing morphologic relapse. Future clinical trials should focus on MRD directed therapies, as no consensus exists about optimal treatment of MRD.

Impact of clinical, cytogenetic, and molecular profiles on long-term survival after transplantation in patients with chronic myelomonocytic leukemia

Chronic myelomonocytic leukemia (CMML) is a heterogeneous group of clonal hematopoietic malignancies with variable clinical and molecular features. We analyzed long-term results of allogeneic hematopoietic cell transplantation in patients with CMML and determined clinical and molecular risk factors associated with outcomes. Data from 129 patients, aged 7-74 (median 55) years, at various stages of the disease and transplanted from related or unrelated donors were analyzed. Using a panel of 75 genes somatic mutations present before hematopoietic cell transplantation were identified In 52 patients. The progression-free survival rate at 10 years was 29%. The major cause of death was relapse (32%), which was significantly associated with adverse cytogenetics (hazard ratio, 3.77; P=0.0002), CMML Prognostic Scoring System (hazard ratio, 14.3, P=0.01), and MD Anderson prognostic scores (hazard ratio, 9.4; P=0.005). Mortality was associated with high-risk cytogenetics (hazard ratio, 1.88; P=0.01) and high Hematopoietic Cell Transplantation Comorbidity Index (score ≥4: hazard ratio, 1.99; P=0.01). High overall mutation burden (≥10 mutations: hazard ratio, 3.4; P=0.02), and ≥4 mutated epigenetic regulatory genes (hazard ratio 5.4; P=0.003) were linked to relapse. Unsupervised clustering of the correlation matrix revealed distinct high-risk groups with unique associations of mutations and clinical features. CMML with a high mutation burden appeared to be distinct from high-risk groups defined by complex cytogenetics. New transplant strategies must be developed to target specific disease subgroups, stratified by molecular profiling and clinical risk factors.

A comparison of patients with acute myeloid leukemia and high-risk myelodysplastic syndrome treated on versus off study

Patients with newly diagnosed (ND) and relapsed/refractory (RR) acute myeloid leukemia (AML) and high-risk myelodysplastic syndrome (MDS, ≥10% blasts) often receive intensive chemotherapy at diagnosis and relapse. We retrospectively identified 365 patients and categorized the reasons for receiving treatment off study (medical, logistical, or unclear). The pretreatment characteristics of the on and off study groups were similar. Rates of the complete remission (CR) without measurable residual disease were significantly higher for ND patients treated on versus off study (61% versus 35%), but CR rates and survival were low for all RR patients regardless of study assignment. The subset of ND patients treated off study for medical reasons had significantly decreased overall survival and relapse-free survival. Standard, stringent study eligibility criteria may delineate a population of ND, but not RR, patients with improved outcomes with intensive induction chemotherapy.

Impact of region of diagnosis, ethnicity, age, and gender on survival in acute myeloid leukemia (AML)

Aim: Acute myeloid leukemia (AML) is an aggressive hematopoietic clonal disorder characterized by the increased blasts and poor survival outcome, which is mainly driven by cytogenetic and molecular abnormalities. Here, we investigated the prognostic impact of other demographic parameters on the survival outcomes in AML patients.

Method: We reviewed the Surveillance, Epidemiology, and End Result (SEER) database to collect demographic information, including age, diagnosis, gender, race, and geographic region in patients with non-acute promyelocytic leukemia AML, between 2004–2008. The primary end-point of our study was 3-year overall survival (OS), which was estimated by the Kaplan–Meier method and Cox regression model.

Results: A total of 13,282 patients were included in our analyses. Increasing age (HR 1.2, p < .0001), male gender (HR 1.05, p = .01), and geographic region of Midwest (HR 1.07, p = .002) were associated with inferior 3-year OS in univariate analysis, and these parameters remained independent prognostic factors in multivariate analyses.

Conclusions: AML is a heterogeneous myeloid neoplasm with patient outcomes largely dictated by the cytogenetics and somatic mutations. In our study, additional demographic factors, including advanced age, male gender, and geographic region of AML diagnosis were associated with OS outcome in non-APL AML patients.

Mitoxantrone, etoposide and cytarabine following epigenetic priming with decitabine in adults with relapsed/refractory acute myeloid leukemia or other high-grade myeloid neoplasms: a phase 1/2 study

DNA methyltransferase inhibitors sensitize leukemia cells to chemotherapeutics. We therefore conducted a phase 1/2 study of mitoxantrone, etoposide, and cytarabine following “priming” with 5-10 days of decitabine (dec/MEC) in 52 adults (median age 55 [range: 19-72] years) with relapsed/refractory acute myeloid leukemia (AML) or other high-grade myeloid neoplasms. During dose escalation in cohorts of 6-12 patients, all dose levels were well-tolerated. As response rates appeared similar with 7 and 10-days of decitabine, a 7-day course was defined as the recommended phase 2 dose (RP2D). Among 46 patients treated at/above the RP2D, 10 (22%) achieved a complete remission (CR), 8 without measurable residual disease; five additional patients achieved CR with incomplete platelet recovery, for an overall response rate of 33%. Seven patients (15%) died within 28 days of treatment initiation. Infection/neutropenic fever, nausea, and mucositis were the most common adverse events. While the CR rate compared favorably to a matched historic control population (observed/expected CR ratio=1.77), CR rate and survival were similar to two contemporary salvage regimens used at our institution (G-CLAC and G-CLAM). Thus, while meeting the pre-specified efficacy goal, we found no evidence that dec/MEC is substantially better than other cytarabine-based regimens currently used for relapsed/refractory AML.

Association of Risk Factors, Mortality, and Care Costs of Adults With Acute Myeloid Leukemia With Admission to the Intensive Care Unit

Importance

Adults with acute myeloid leukemia (AML) commonly require support in the intensive care unit (ICU), but risk factors for admission to the ICU and adverse outcomes remain poorly defined.

Objective

To examine risk factors, mortality, length of stay, and cost associated with admission to the ICU for patients with AML.

Design, Setting, and Participants

This study extracted information from the University HealthSystem Consortium database on patients 18 years or older with AML who were hospitalized for any cause between January 1, 2004, and December 31, 2012. The University HealthSystem Consortium database contains demographic, clinical, and cost variables prospectively abstracted by certified coders from discharge summaries. Outcomes were analyzed using univariate and multivariable statistical techniques. Data analysis was performed from November 15, 2013, to August 15, 2016.

Main Outcomes and Measures

Primary outcomes were admission to the ICU and inpatient mortality among patients requiring ICU care. Secondary outcomes included length of stay in the ICU, total hospitalization length of stay, and cost.

Results

Of the 43 249 patients with AML (mean [SD] age, 59.5 [16.6] years; 23 939 men and 19 310 women), 11 277 (26.1%) were admitted to the ICU. On multivariable analysis (with results reported as odds ratios [95% CIs]), independent risk factors for admission to the ICU included age younger than 80 years (1.56 [1.42-1.70]), hospitalization in the South (1.81 [1.71-1.92]), hospitalization at a low- or medium-volume hospital (1.25 [1.19-1.31]), number of comorbidities (10.64 [8.89-12.62] for 5 vs none), sepsis (4.61 [4.34-4.89]), invasive fungal infection (1.24 [1.11-1.39]), and pneumonia (1.73 [1.63-1.82]). In-hospital mortality was higher for patients requiring ICU care (4857 of 11 277 [43.1%] vs 2959 of 31 972 [9.3%]). On multivariable analysis, independent risk factors for death in patients requiring ICU care included age 60 years or older (1.16 [1.06-1.26]), nonwhite race/ethnicity (1.18 [1.07-1.30]), hospitalization on the West coast (1.19 [1.06-1.34]), number of comorbidities (18.76 [13.7-25.67] for 5 vs none), sepsis (2.94 [2.70-3.21]), invasive fungal infection (1.20 [1.02-1.42]), and pneumonia (1.13 [1.04-1.24]). Mean costs of hospitalization were higher for patients requiring ICU care ($83 354 vs $41 973) and increased with each comorbidity, from $50 543 for patients with no comorbidities to $124 820 for those with 5 or more comorbidities.

Conclusions and Relevance

Admission to the ICU is associated with high mortality and cost that increase proportionally with the comorbidity burden in adults with AML. Several demographic factors and medical characteristics identify patients at risk for admission to the ICU and mortality and provide an opportunity for testing primary prevention strategies.

Pre- and post-transplant quantification of measurable ('minimal') residual disease via multiparameter flow cytometry in adult acute myeloid leukemia

Measurable (“minimal”) residual disease (MRD) before or after hematopoietic cell transplantation (HCT) identifies adults with AML at risk of poor outcomes. Here, we studied whether peri-transplant MRD dynamics can refine risk assessment. We analyzed 279 adults receiving myeloablative allogeneic HCT in first or second remission who survived at least 35 days and underwent 10-color multiparametric flow cytometry (MFC) analyses of marrow aspirates before and 28±7 days after transplantation. MFC-detectable MRD before (n=63) or after (n=16) transplantation identified patients with high relapse risk and poor survival. Forty-nine patients cleared MRD with HCT conditioning, whereas 2 patients developed new evidence of disease. The 214 MRD^neg/MRD^neg patients had excellent outcomes, whereas both MRD^neg/MRD^pos patients died within 100 days following transplantation. For patients with pre-HCT MRD, outcomes were poor regardless of post-HCT MRD status, although survival beyond 3 years was observed among the 58 patients with decreasing but not the 7 patients with increasing peri-HCT MRD levels. In multivariable models, pre-HCT but not post-HCT MRD was independently associated with OS and RR. These data indicate that MRD^pos patients before transplantation have a high relapse risk regardless of whether or not they clear MFC-detectable disease with conditioning and should be considered for pre-emptive therapeutic strategies.

Allogeneic Hematopoietic Cell Transplantation for Acute Myeloid Leukemia: Time to Move Toward a Minimal Residual Disease-Based Definition of Complete Remission?

PURPOSE

Patients with acute myeloid leukemia (AML) who are in morphologic complete remission are typically considered separately from patients with active disease (ie, ≥ 5% marrow blasts by morphology) in treatment algorithms for allogeneic hematopoietic cell transplantation (HCT), which implies distinct outcomes for these two groups. It is well recognized that the presence of minimal residual disease (MRD) at the time of transplantation is associated with adverse post-HCT outcome for those patients in morphologic remission. This effect of pre-HCT MRD prompted us to compare outcomes in consecutive patients in MRD-positive remission with patients with active AML who underwent myeloablative allogeneic HCT at our institution.

PATIENTS AND METHODS

We retrospectively studied 359 consecutive adults with AML who underwent myeloablative allogeneic HCT from a peripheral blood or bone marrow donor between 2006 and 2014. Pre-HCT disease staging included 10-color multiparametric flow cytometry on bone marrow aspirates in all patients. Any level of residual disease was considered to be MRD positive.

RESULTS

Three-year relapse estimates were 67% in 76 patients in MRD-positive morphologic remission and 65% in 48 patients with active AML compared with 22% in 235 patients in MRD-negative remission. Three-year overall survival estimates were 26%, 23%, and 73% in these three groups, respectively. After multivariable adjustment, MRD-negative remission status remained statistically significantly associated with longer overall and progression-free survival as well as lower risk of relapse compared with MRD-positive morphologic remission status or having active disease, with similar outcomes between the latter two groups.

CONCLUSION

The similarities in outcomes between patients in MRD-positive morphologic remission and those with active disease at the time of HCT support the use of treatment algorithms that use MRD- rather than morphology-based disease assessments.

Single center experience treating adults with FLT3-mutated acute myeloid leukemia (AML)

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Background: Activating mutations of the fms-like tyrosine kinase-3 (FLT3) gene are common in AML. Depending upon the allele mutation fraction, these mutations have been associated with poor outcomes in prospective multi-center trials. Methods: We studied a consecutive series of adults with FLT3-mutated leukemia at our institution since we began testing in 2006 through Sept 2011. Clinical characteristics and patient (pt) outcomes were extracted through a retrospective chart review and analyzed using logistic regression and Cox proportional hazard models. Results: We identified 73 pts with a FLT3 mutation (71 with AML and 2 with myelodysplasia with <20% blasts). 62 (85%) presented to our institution at initial diagnosis; 11 (15%) were diagnosed elsewhere and seen by us only at relapse. 44 (60%) were men and 51 (70%) were white. Median age was 62 yrs (range, 19-90); 48% were <60 yrs old. 63 (86%) had an internal tandem duplication (ITD) mutation, 9 (12%) had the D835 point mutation (TKD), and 1 had both. An NPM1 mutation was also present in 26 (36%). Median white blood cell count at diagnosis was 53 x 103/µL (range, 0.8 - 466). 34 (47%) had monocytic morphology (M4 or M5). 8 (11%) pts had favorable karyotypes; 50 (68%) had normal karyotypes; 13 (18%) had unfavorable karyotypes. 58 (79%) received standard induction therapy (anthracycline + cytarabine for most; ATRA + arsenic trioxide for 3 with APL); 46/58 (79%) achieved a complete remission (CR). Including the 15 pts who received only low intensity therapies, 40/64 (63%) with an ITD and 6/9 (67%) with a TKD mutation achieved CR. 31 (42%) pts received an allogeneic transplant, 21 in first CR (CR1) and 10 after relapse. Median overall survival (OS) for the whole group was 417 days (95% CI: 291-780); it was 684 days for those diagnosed at our institution and 285 days for those seen only after relapse. Median disease-free survival (DFS) in CR1 was 417 days. Median OS for pts transplanted in CR1 was 1262 days from initial diagnosis and 416 days for those transplanted after relapse. DFS did not differ with or without a transplant (median, 526 vs 305 days; p=.64). Conclusions: FLT3-mutated AML is heterogeneous. Our single center experience is similar to that reported from multi-center trials.

Factors associated with clinical benefit from epidermal growth factor receptor inhibitors in recurrent and metastatic squamous cell carcinoma of the head and neck

Single agent epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKI) have demonstrated reproducible response rates of 5-15% in treatment of squamous cell carcinomas of the head and neck (SCCHN). The subset of patients that benefits most from these agents remains unknown. We reviewed individual patient data from five clinical trials of erlotinib, lapatinib, or gefitinib to determine if there are clinical characteristics that are associated with clinical benefit defined as complete response (CR), partial response (PR), and stable disease (SD) >4months. Secondary endpoints included progression-free survival (PFS) and overall survival (OS). Three-hundred and nineteen subjects were included. Observed responses were: 1% CR, 6% PR, 24% SD >4months, 18% SD <4months, 45% progressive disease (PD), 7% not evaluable (NE). The median OS was 6.4months and the median PFS was 2.7months. The most common toxicities observed were rash (grade 1 in 37%, grade 2 in 33%, grade 3+ in 6%) and diarrhea (grade 1 in 30%, grade 2 in 10%, grade 3+ in 5%). Performance status (PS) (p=0.04), older age (p=0.02), and development of rash (p<0.01), diarrhea (p=0.03), or oral side effects (p=0.02) were independently associated with clinical benefit. Older age, better PS, and development of rash were associated with longer PFS and OS. Clinical parameters that appear to predict response to EGFR TKI include PS and age. EGFR mechanistic toxicities that develop during therapy are also highly associated with benefit and suggest a relationship between drug exposure and outcome.