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Parekh D, Lin H, Batajoo A, Peckham-Gregory E, Karri V, Stanton W, Scull B, Fleishmann R, El-Mallawany N, Eckstein OS, Prudowsky ZD, Gulati N, Agrusa JE, Ahmed AZ, Chu R, Dietz MS, Goldman SC, Hogarty MD, Imran H, Intzes S, Kim JM, Kopp LM, Levy CF, Neff P, Pillai PM, Sisk BA, Schiff DE, Trobaugh-Lotrario AD, Walkovich K, McClain KL, Allen CE. Clofarabine monotherapy in aggressive, relapsed and refractory Langerhans cell histiocytosis. Br J Haematol 2024; 204:1888-1893. [PMID: 38501389 DOI: 10.1111/bjh.19376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 02/14/2024] [Accepted: 02/20/2024] [Indexed: 03/20/2024]
Abstract
Over 50% of patients with systemic LCH are not cured with front-line therapies, and data to guide salvage options are limited. We describe 58 patients with LCH who were treated with clofarabine. Clofarabine monotherapy was active against LCH in this cohort, including heavily pretreated patients with a systemic objective response rate of 92.6%, higher in children (93.8%) than adults (83.3%). BRAFV600E+ variant allele frequency in peripheral blood is correlated with clinical responses. Prospective multicentre trials are warranted to determine optimal dosing, long-term efficacy, late toxicities, relative cost and patient-reported outcomes of clofarabine compared to alternative LCH salvage therapy strategies.
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Affiliation(s)
- Deevyashali Parekh
- Texas Children's Cancer Center, Texas Children's Hospital, Houston, Texas, USA
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Howard Lin
- Texas Children's Cancer Center, Texas Children's Hospital, Houston, Texas, USA
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Akanksha Batajoo
- Texas Children's Cancer Center, Texas Children's Hospital, Houston, Texas, USA
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Erin Peckham-Gregory
- Texas Children's Cancer Center, Texas Children's Hospital, Houston, Texas, USA
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Vivekanudeep Karri
- Texas Children's Cancer Center, Texas Children's Hospital, Houston, Texas, USA
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Whitney Stanton
- Texas Children's Cancer Center, Texas Children's Hospital, Houston, Texas, USA
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Brooks Scull
- Texas Children's Cancer Center, Texas Children's Hospital, Houston, Texas, USA
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Ryan Fleishmann
- Texas Children's Cancer Center, Texas Children's Hospital, Houston, Texas, USA
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Nader El-Mallawany
- Texas Children's Cancer Center, Texas Children's Hospital, Houston, Texas, USA
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Olive S Eckstein
- Texas Children's Cancer Center, Texas Children's Hospital, Houston, Texas, USA
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Zachary D Prudowsky
- Texas Children's Cancer Center, Texas Children's Hospital, Houston, Texas, USA
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Nitya Gulati
- Texas Children's Cancer Center, Texas Children's Hospital, Houston, Texas, USA
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Baylor College of Medicine, Houston, Texas, USA
- Department of Pediatrics, Weill Cornell Medical College, New York, New York, USA
| | - Jennifer E Agrusa
- Texas Children's Cancer Center, Texas Children's Hospital, Houston, Texas, USA
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Baylor College of Medicine, Houston, Texas, USA
- Division of Pediatric Hematology/Oncology, C.S. Mott Children's Hospital, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Asra Z Ahmed
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Roland Chu
- Division of Hematology/Oncology/BMT, Central Michigan University College of Medicine, Children's Hospital of Michigan, Detroit, Michigan, USA
| | - Matthew S Dietz
- Division of Pediatric Hematology and Oncology, University of Utah, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Stanton C Goldman
- Pediatric Hematology/Oncology, Medical City Children's Hospital, Dallas, Texas, USA
| | - Michael D Hogarty
- Division of Oncology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hamayun Imran
- Department of Pediatrics, University of South Alabama, Mobile, Alberta, USA
| | - Stefanos Intzes
- Department of Pediatric Hematology/Oncology, Sacred Heart Children's Hospital, Spokane, Washington, USA
| | - Jenny M Kim
- Department of Pediatrics, Division of Hematology/Oncology, University of California San Diego School of Medicine, Rady Children's Hospital, San Diego, California, USA
| | - Lisa M Kopp
- Department of Pediatrics, University of Arizona, Mel and Enid Zuckerman College of Public Health, Tucson, Arizona, USA
| | - Carolyn Fein Levy
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Cohen Children's Medical Center, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Philip Neff
- Children's Blood and Cancer Center, The University of Texas at Austin, Dell Children's Medical Center of Central Texas, Austin, Texas, USA
| | - Pallavi M Pillai
- Jack Martin Division of Pediatric Hematology-Oncology, Jack and Lucy Clark Department of Pediatrics, Mount Sinai Kravis Children's Hospital, New York, New York, USA
| | - Bryan A Sisk
- Division of Pediatric Hematology and Oncology, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Deborah E Schiff
- Department of Pediatrics, Division of Hematology/Oncology, University of California San Diego School of Medicine, Rady Children's Hospital, San Diego, California, USA
| | | | - Kelly Walkovich
- Division of Pediatric Hematology/Oncology, C.S. Mott Children's Hospital, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Kenneth L McClain
- Texas Children's Cancer Center, Texas Children's Hospital, Houston, Texas, USA
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Carl E Allen
- Texas Children's Cancer Center, Texas Children's Hospital, Houston, Texas, USA
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, Baylor College of Medicine, Houston, Texas, USA
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Saito T, Hatta Y, Hayakawa F, Takahashi T, Hagihara M, Iida H, Minauchi K, Yamazaki E, Sugiura I, Murayama T, Sakura T, Mori N, Imai K, Yahagi Y, Atsuta Y, Saito AM, Hirakawa A, Kiyoi H, Matsumura I, Miyazaki Y. Combination of clofarabine, etoposide, and cyclophosphamide in adult relapsed/refractory acute lymphoblastic leukemia: a phase 1/2 dose-escalation study by the Japan Adult Leukemia Study Group. Int J Hematol 2020; 113:395-403. [PMID: 33230647 DOI: 10.1007/s12185-020-03032-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 10/24/2020] [Accepted: 10/27/2020] [Indexed: 11/25/2022]
Abstract
This phase 1/2 study aimed to identify the maximum tolerated dose, the recommended phase 2 dose (RP2D), and efficacy of the clofarabine, etoposide, and cyclophosphamide combination regimen in adult patients with relapsed/refractory acute lymphoblastic leukemia (ALL). Patients aged ≥ 15 years with relapsed/refractory ALL were enrolled. Escalating doses of clofarabine (20-30 mg/m2/day × 5 days), etoposide (50-100 mg/m2/day × 5 days), and cyclophosphamide (200-440 mg/m2/day × 5 days) were administered. Dose-limiting toxicity was defined as Grade 3 or more non-hematological toxicities and others. A total of 18 patients (B-ALL; n = 13, T-ALL; n = 5) were recruited in phase 1; however, the protocol was amended to close study without proceeding to phase 2. Three patients were enrolled in cohort 1, three in cohort 2, six in cohort 3, and six in cohort 4. The RP2D of clofarabine, etoposide, and cyclophosphamide was 30, 100, and 440 mg/m2 daily, respectively. Complete remission (CR) was achieved in four patients (22%) and CR without platelet recovery in four patients (22%), with an overall response rate of 44%. The RP2D of the combination therapy was successfully determined in this study.
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Affiliation(s)
- Takeshi Saito
- Division of Clinical Oncology and Hematology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan.
| | - Yoshihiro Hatta
- Division of Hematology and Rheumatology, Nihon University School of Medicine, Tokyo, Japan
| | - Fumihiko Hayakawa
- Division of Cellular and Genetic Sciences, Department of Integrated Health Sciences, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tsutomu Takahashi
- Department of Oncology/Hematology, Shimane University Hospital, Izumo, Japan
| | - Maki Hagihara
- Department of Hematology and Clinical Immunology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Hiroatsu Iida
- National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | | | - Etsuko Yamazaki
- Clinical Laboratory Department, Yokohama City University Hospital, Yokohama, Japan
| | - Isamu Sugiura
- Division of Hematology and Oncology, Toyohashi Municipal Hospital, Toyohashi, Japan
| | - Tohru Murayama
- Department of Hematology, Hyogo Cancer Center, Akashi, Japan
| | - Toru Sakura
- Leukemia Research Center, Saiseikai Maebashi Hospital, Maebashi, Japan
| | - Naoki Mori
- Department of Hematology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Kiyotoshi Imai
- Department of Hematology, Otaru General Hospital, Otaru, Japan
| | - Yuichi Yahagi
- Division of Clinical Oncology and Hematology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Yoshiko Atsuta
- Japanese Data Center for Hematopoietic Cell Transplantation, Nagoya, Japan
| | - Akiko Moriya Saito
- Clinical Research Center, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Akihiro Hirakawa
- Division of Biostatics and Data Science, Clinical Research Center, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hitoshi Kiyoi
- Department of Hematology and Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Itaru Matsumura
- Department of Hematology and Rheumatology, Kindai University Hospital, Faculty of Medicine, Osaka, Japan
| | - Yasushi Miyazaki
- Department of Hematology, Atomic Bomb Disease Institute, Nagasaki University, Nagasaki, Japan
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Salzer WL, Burke MJ, Devidas M, Chen S, Gore L, Larsen EC, Borowitz M, Wood B, Heerema NA, Carroll AJ, Hilden JM, Loh ML, Raetz EA, Winick NJ, Carroll WL, Hunger SP. Toxicity associated with intensive postinduction therapy incorporating clofarabine in the very high-risk stratum of patients with newly diagnosed high-risk B-lymphoblastic leukemia: A report from the Children's Oncology Group study AALL1131. Cancer 2018; 124:1150-1159. [PMID: 29266189 PMCID: PMC5839964 DOI: 10.1002/cncr.31099] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 08/25/2017] [Accepted: 09/20/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND Children, adolescents, and young adults with very high-risk (VHR) B acute lymphoblastic leukemia (B-ALL) have poor outcomes, and novel therapies are needed for this subgroup. The AALL1131 study evaluated postinduction therapy using cyclophosphamide (CPM), etoposide (ETOP), and clofarabine (CLOF) for patients with VHR B-ALL. METHODS Patients who were 1 to 30 years old and had VHR B-ALL received modified Berlin-Frankfurt-Münster therapy after induction and were randomized to 1) CPM, cytarabine, mercaptopurine, vincristine (VCR), and pegaspargase (control arm), 2) CPM, ETOP, VCR, and pegaspargase (experimental arm 1), or 3) CPM, ETOP, CLOF (30 mg/m2 /d × 5), VCR, and pegaspargase (experimental arm 2) during the second half of consolidation and delayed intensification. RESULTS The rates of grade 4/5 infections and grade 3/4 pancreatitis were significantly increased in experimental arm 2. The dose of CLOF was, therefore, reduced to 20 mg/m2 /d × 5, and myeloid growth factor was required after CLOF administration. Despite these changes, 4 of 39 patients (10.3%) developed grade 4 infections, with 1 of these patients developing a grade 5 acute kidney injury attributed to CLOF, whereas only 1 of 46 patients (2.2%) in experimental arm 1 developed grade 4 infections, and there were no grade 4/5 infections in the control arm (n = 20). Four patients in experimental arm 2 had prolonged cytopenias for >60 days, whereas none did in the control arm or experimental arm 1. Counts failed to recover for 2 of these patients, one having a grade 5 acute kidney injury and the other removed from protocol therapy; both events occurred 92 days after the start of consolidation part 2. CONCLUSIONS In AALL1131, CLOF, administered with CPM and ETOP, was associated with unacceptable toxicity. Cancer 2018;124:1150-9. © 2017 American Cancer Society.
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Affiliation(s)
- Wanda L. Salzer
- U.S. Army Medical Research and Materiel Command, Fort Detrick, MD
| | - Michael J. Burke
- Department of Pediatrics, Medical College of Wisconsin, Children’s Hospital of Wisconsin, Milwaukee, WI
| | - Meenakshi Devidas
- Department of Biostatistics, Colleges of Medicine and Public Health & Health Professions, University of Florida, Gainesville, FL
| | - Si Chen
- Department of Biostatistics, Colleges of Medicine and Public Health & Health Professions, University of Florida, Gainesville, FL
| | - Lia Gore
- Center for Cancer and Blood Disorders, Children’s Hospital Colorado and The University of Colorado School of Medicine, Aurora, CO
| | | | - Michael Borowitz
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD
| | - Brent Wood
- Department of Laboratory Medicine, University of Washington, Seattle, WA
| | - Nyla A. Heerema
- Department of Pathology, The Ohio State University School of Medicine, Columbus, OH
| | | | - Joanne M. Hilden
- Children’s Hospital Colorado and the Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Mignon L. Loh
- Department of Pediatrics, Benioff Children’s Hospital, University of California at San Francisco, CA
| | | | - Naomi J. Winick
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - William L. Carroll
- Department of Pediatrics, Perlmutter Cancer Center, New York University Medical Center, New York, NY
| | - Stephen P Hunger
- Children’s Hospital of Philadelphia and The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Foss FM, Parker T. A Phase I Dose-Escalation Study of Clofarabine in Patients with Relapsed or Refractory Low-Grade or Intermediate-Grade B-Cell or T-Cell Lymphoma. Oncologist 2018; 23:397-e30. [PMID: 29438091 PMCID: PMC5896711 DOI: 10.1634/theoncologist.2017-0658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 11/06/2017] [Indexed: 11/17/2022] Open
Abstract
LESSONS LEARNED Clofarabine can be active in relapsed and refractory lymphoid malignancies on a weekly dosing schedule.Responses were seen in patients with T-cell lymphomas, including cutaneous T-cell lymphoma, but not in patients with aggressive B-cell lymphomas. BACKGROUND Clofarabine is a second-generation purine nucleoside analog currently approved for the treatment of pediatric relapsed or refractory acute lymphoblastic leukemia. In adults, clofarabine has been investigated in several phase I and II trials as a single agent and in combination for relapsed or refractory acute leukemia. These studies have shown that clofarabine has activity and an acceptable safety profile in patients with hematological malignancies. In this phase I dose escalation trial, clofarabine was evaluated in patients with relapsed or refractory, low-grade or intermediate-grade, B-cell or T-cell lymphoma. METHODS The starting dose of 10 mg/m2 per week was administered intravenously (IV) for 3 consecutive weeks every 28 days, and doses were escalated in cohorts of three. The study objectives were to determine the maximum tolerated dose (MTD), characterize and quantify the toxicity profile, and determine the overall response rate of clofarabine administered once a week for 3 weeks and repeated every 4 weeks. Eligible patients were over the age of 18, had a histologically confirmed low-grade or intermediate-grade B-cell or T-cell lymphoma, and must have previously been treated with one standard chemotherapy regimen, excluding single-agent rituximab. The primary objectives included in statistical analyses were MTD, toxicity, and overall response rate (ORR). Four patients were enrolled in cohort 1 (clofarabine 10 mg/m2), four in cohort 2 (clofarabine 15 mg/m2), three in cohort 3 (clofarabine 20 mg/m2), two in cohort 4 (clofarabine 30 mg/m2), and one in cohort 5 (clofarabine 40 mg/m2) (Table 2). RESULTS MTD was not reached in the study. The most common toxicity observed was myelosuppression. A total of four (29%) patients experienced grade 3 leukopenia, with three (21%) patients experiencing grade 4 neutropenia. The myelosuppression was not considered to be a dose-limiting toxicity, as it resolved within 7 days.Fourteen patients were enrolled: 10 patients with T-cell non-Hodgkin lymphoma (NHL) and 4 patients with B-cell NHL (see Table 1). All 14 patients received at least one dose of clofarabine and were evaluable for response. One patient with cutaneous T-cell lymphoma (CTCL) had a partial response; five (36%) had stable disease, and eight patients (57%) had no response. The one patient with a response had stage III erythroderma and was treated in the 10 mg/m2 cohort; a nodal complete response by positron emission tomography scan was observed with a partial response of the skin. CONCLUSION In this study, weekly administration of clofarabine was demonstrated to be safe and associated with minimal hematologic toxicity at doses ranging from 10-40 mg/m2. In prior studies when dosed daily for 5 consecutive days, the MTD was shown to be 4 mg/m2. Weekly dosing within this dose range did not result in dose modifications, and the MTD was not reached. Clinical efficacy was observed in one patient with CTCL who was treated in the lowest-dose cohort.
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MESH Headings
- Aged
- Aged, 80 and over
- Antimetabolites, Antineoplastic/administration & dosage
- Antimetabolites, Antineoplastic/adverse effects
- Clofarabine/administration & dosage
- Clofarabine/adverse effects
- Drug Administration Schedule
- Drug Resistance, Neoplasm
- Female
- Humans
- Lymphoma, B-Cell/drug therapy
- Lymphoma, B-Cell/pathology
- Lymphoma, Non-Hodgkin/drug therapy
- Lymphoma, Non-Hodgkin/pathology
- Lymphoma, T-Cell/drug therapy
- Lymphoma, T-Cell/pathology
- Male
- Maximum Tolerated Dose
- Middle Aged
- Recurrence
- Treatment Outcome
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Affiliation(s)
| | - Terri Parker
- Yale University School of Medicine, New Haven, Connecticut, USA
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