1
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Shah NP, Bhatia R, Altman JK, Amaya M, Begna KH, Berman E, Chan O, Clements J, Collins RH, Curtin PT, DeAngelo DJ, Drazer M, Maness L, Metheny L, Mohan S, Moore JO, Oehler V, Pratz K, Pusic I, Rose MG, Shomali W, Smith BD, Styler M, Talpaz M, Tanaka TN, Tantravahi S, Thompson J, Tsai S, Vaughn J, Welborn J, Yang DT, Sundar H, Gregory K. Chronic Myeloid Leukemia, Version 2.2024, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2024; 22:43-69. [PMID: 38394770 DOI: 10.6004/jnccn.2024.0007] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
Chronic myeloid leukemia (CML) is defined by the presence of Philadelphia chromosome resulting from a reciprocal translocation between chromosomes 9 and 22 [t9;22] that gives rise to a BCR::ABL1 fusion gene. CML occurs in 3 different phases (chronic, accelerated, and blast phase) and is usually diagnosed in the chronic phase in developed countries. Tyrosine kinase inhibitor (TKI) therapy is a highly effective treatment option for patients with chronic phase-CML. The primary goal of TKI therapy in patients with chronic phase-CML is to prevent disease progression to accelerated phase-CML or blast phase-CML. Discontinuation of TKI therapy with careful monitoring is feasible in selected patients. This manuscript discusses the recommendations outlined in the NCCN Guidelines for the diagnosis and management of patients with chronic phase-CML.
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MESH Headings
- Humans
- Blast Crisis/chemically induced
- Blast Crisis/drug therapy
- Blast Crisis/genetics
- Protein Kinase Inhibitors/adverse effects
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/diagnosis
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Philadelphia Chromosome
- Leukemia, Myeloid, Chronic-Phase/drug therapy
- Fusion Proteins, bcr-abl/genetics
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Affiliation(s)
- Neil P Shah
- 1UCSF Helen Diller Family Comprehensive Cancer Center
| | | | - Jessica K Altman
- 3Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | | | | | | | | | | | | | | | | | | | - Leland Metheny
- 14Case Comprehensive Cancer Center University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | | | | | - Keith Pratz
- 18Abramson Cancer Center at the University of Pennsylvania
| | - Iskra Pusic
- 19Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | | | | | - B Douglas Smith
- 22The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | | | | | | | | | | | | | - Jennifer Vaughn
- 29The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
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Ozga M, Nicolet D, Mrózek K, Yilmaz AS, Kohlschmidt J, Larkin KT, Blachly JS, Oakes CC, Buss J, Walker CJ, Orwick S, Jurinovic V, Rothenberg-Thurley M, Dufour A, Schneider S, Sauerland MC, Görlich D, Krug U, Berdel WE, Woermann BJ, Hiddemann W, Braess J, Subklewe M, Spiekermann K, Carroll AJ, Blum WG, Powell BL, Kolitz JE, Moore JO, Mayer RJ, Larson RA, Uy GL, Stock W, Metzeler KH, Grimes HL, Byrd JC, Salomonis N, Herold T, Mims AS, Eisfeld AK. Sex-associated differences in frequencies and prognostic impact of recurrent genetic alterations in adult acute myeloid leukemia (Alliance, AMLCG). Leukemia 2024; 38:45-57. [PMID: 38017103 PMCID: PMC10776397 DOI: 10.1038/s41375-023-02068-8] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 09/25/2023] [Accepted: 10/09/2023] [Indexed: 11/30/2023]
Abstract
Clinical outcome of patients with acute myeloid leukemia (AML) is associated with demographic and genetic features. Although the associations of acquired genetic alterations with patients' sex have been recently analyzed, their impact on outcome of female and male patients has not yet been comprehensively assessed. We performed mutational profiling, cytogenetic and outcome analyses in 1726 adults with AML (749 female and 977 male) treated on frontline Alliance for Clinical Trials in Oncology protocols. A validation cohort comprised 465 women and 489 men treated on frontline protocols of the German AML Cooperative Group. Compared with men, women more often had normal karyotype, FLT3-ITD, DNMT3A, NPM1 and WT1 mutations and less often complex karyotype, ASXL1, SRSF2, U2AF1, RUNX1, or KIT mutations. More women were in the 2022 European LeukemiaNet intermediate-risk group and more men in adverse-risk group. We found sex differences in co-occurring mutation patterns and prognostic impact of select genetic alterations. The mutation-associated splicing events and gene-expression profiles also differed between sexes. In patients aged <60 years, SF3B1 mutations were male-specific adverse outcome prognosticators. We conclude that sex differences in AML-associated genetic alterations and mutation-specific differential splicing events highlight the importance of patients' sex in analyses of AML biology and prognostication.
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Affiliation(s)
- Michael Ozga
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Deedra Nicolet
- The Ohio State University Comprehensive Cancer Center, Clara D. Bloomfield Center for Leukemia Outcomes Research, Columbus, OH, USA
- Alliance Statistics and Data Management Center, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Krzysztof Mrózek
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA.
- The Ohio State University Comprehensive Cancer Center, Clara D. Bloomfield Center for Leukemia Outcomes Research, Columbus, OH, USA.
| | - Ayse S Yilmaz
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
- The Ohio State University Comprehensive Cancer Center, Clara D. Bloomfield Center for Leukemia Outcomes Research, Columbus, OH, USA
| | - Jessica Kohlschmidt
- The Ohio State University Comprehensive Cancer Center, Clara D. Bloomfield Center for Leukemia Outcomes Research, Columbus, OH, USA
- Alliance Statistics and Data Management Center, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Karilyn T Larkin
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
- The Ohio State University Comprehensive Cancer Center, Clara D. Bloomfield Center for Leukemia Outcomes Research, Columbus, OH, USA
| | - James S Blachly
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
- The Ohio State University Comprehensive Cancer Center, Clara D. Bloomfield Center for Leukemia Outcomes Research, Columbus, OH, USA
| | - Christopher C Oakes
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
- The Ohio State University Comprehensive Cancer Center, Clara D. Bloomfield Center for Leukemia Outcomes Research, Columbus, OH, USA
| | - Jill Buss
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
- The Ohio State University Comprehensive Cancer Center, Clara D. Bloomfield Center for Leukemia Outcomes Research, Columbus, OH, USA
| | - Christopher J Walker
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
- The Ohio State University Comprehensive Cancer Center, Clara D. Bloomfield Center for Leukemia Outcomes Research, Columbus, OH, USA
| | - Shelley Orwick
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Vindi Jurinovic
- Laboratory for Leukemia Diagnostics, Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Maja Rothenberg-Thurley
- Laboratory for Leukemia Diagnostics, Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Annika Dufour
- Laboratory for Leukemia Diagnostics, Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
| | - Stephanie Schneider
- Laboratory for Leukemia Diagnostics, Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- Institute of Human Genetics, University Hospital, LMU Munich, Munich, Germany
| | | | - Dennis Görlich
- Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany
| | - Utz Krug
- Department of Medicine 3, Klinikum Leverkusen, Leverkusen, Germany
| | - Wolfgang E Berdel
- Department of Medicine, Hematology and Oncology, University of Münster, Münster, Germany
| | | | - Wolfgang Hiddemann
- Laboratory for Leukemia Diagnostics, Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jan Braess
- Department of Oncology and Hematology, Hospital Barmherzige Brüder, Regensburg, Germany
| | - Marion Subklewe
- Laboratory for Leukemia Diagnostics, Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Karsten Spiekermann
- Laboratory for Leukemia Diagnostics, Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Andrew J Carroll
- Department of Genetics, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Bayard L Powell
- Wake Forest University Health Sciences, Winston-Salem, NC, USA
| | - Jonathan E Kolitz
- Monter Cancer Center, Hofstra Northwell School of Medicine, Lake Success, NY, USA
| | - Joseph O Moore
- Duke Cancer Institute, Duke University Health System, Durham, NC, USA
| | - Robert J Mayer
- Department of Medical Oncology, Dana-Farber/Partners CancerCare, Boston, MA, USA
| | | | - Geoffrey L Uy
- Division of Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Wendy Stock
- University of Chicago Medical Center, Chicago, IL, USA
| | - Klaus H Metzeler
- Department of Hematology, Cellular Therapy, and Hemostaseology, Leipzig University Hospital, Leipzig, Germany
| | - H Leighton Grimes
- Division of Immunobiology, Cincinnati Children's Hospital, University of Cincinnati, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - John C Byrd
- Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Nathan Salomonis
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
- Division of Biomedical Informatics, Cincinnati Children's Hospital, University of Cincinnati, Cincinnati, OH, USA
| | - Tobias Herold
- Laboratory for Leukemia Diagnostics, Department of Medicine III, University Hospital, LMU Munich, Munich, Germany
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Alice S Mims
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
- The Ohio State University Comprehensive Cancer Center, Clara D. Bloomfield Center for Leukemia Outcomes Research, Columbus, OH, USA
| | - Ann-Kathrin Eisfeld
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA.
- The Ohio State University Comprehensive Cancer Center, Clara D. Bloomfield Center for Leukemia Outcomes Research, Columbus, OH, USA.
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3
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Winn AN, Atallah E, Cortes J, Deininger MWN, Kota V, Larson RA, Moore JO, Mauro MJ, Oehler VG, Pinilla-Ibarz J, Radich JP, Shah NP, Thompson JE, Flynn KE. Estimated Savings After Stopping Tyrosine Kinase Inhibitor Treatment Among Patients With Chronic Myeloid Leukemia. JAMA Netw Open 2023; 6:e2347950. [PMID: 38109114 PMCID: PMC10728762 DOI: 10.1001/jamanetworkopen.2023.47950] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 11/02/2023] [Indexed: 12/19/2023] Open
Abstract
Importance Patients with chronic myeloid leukemia (CML) who have a sustained deep molecular response using tyrosine kinase inhibitors (TKIs) can safely attempt to stop their use. As these medications are very costly, this change in treatment protocols may result in large savings. Objective To estimate future savings from attempting to stop TKI use among patients with CML who have deep molecular response. Design, Setting, and Participants A microsimulation model was developed for this decision analytical modeling study to estimate costs for US adults moving from using a TKI, to attempting discontinuation and then reinitiating TKI therapy, if clinically appropriate. Estimates were calculated for US patients who currently have CML and simulated newly diagnosed cohorts of patients over the next 30 years. Exposure Attempting to stop using a TKI. Main Outcomes and Measures Estimated savings after attempted discontinuation of TKI use. Results A simulated population of individuals with CML in 2018 and future populations were created using estimates from the SEER*Explorer website. The median age at diagnosis was 66 years for men and 65 years for women. Between 2022 and 2052, the savings associated with eligible patients attempting discontinuation of TKI therapy was estimated at more than $30 billion among those currently diagnosed and over $15 billion among those who will develop CML in the future, for a total savings of over $54 billion by 2052 for drug treatment and polymerase chain reaction testing. The estimate is conservative as it does not account for complications and other health care-associated costs for patients continuing TKI therapy. Conclusions and Relevance The findings of this decision analytical modeling study of patients with CML suggest that attempting discontinuation of TKI therapy could save over $54 billion during the next 30 years. Further education for patients and physicians is needed to safely increase the number of patients who can successfully attain treatment-free remission.
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Affiliation(s)
- Aaron N. Winn
- Department of Health Systems, Outcomes and Policy, School of Pharmacy, University of Illinois at Chicago
| | - Ehab Atallah
- Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Jorge Cortes
- Georgia Cancer Center, Augusta University Medical Center, Augusta
| | | | - Vamsi Kota
- Georgia Cancer Center, Augusta University Medical Center, Augusta
| | - Richard A. Larson
- Department of Medicine and Comprehensive Cancer Center, University of Chicago, Chicago, Illinois
| | | | | | | | | | | | - Neil P. Shah
- Department of Medicine, University of California at San Francisco
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4
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Larkin KT, Nicolet D, Kelly BJ, Mrózek K, LaHaye S, Miller KE, Wijeratne S, Wheeler G, Kohlschmidt J, Blachly JS, Mims AS, Walker CJ, Oakes CC, Orwick S, Boateng I, Buss J, Heyrosa A, Desai H, Carroll AJ, Blum W, Powell BL, Kolitz JE, Moore JO, Mayer RJ, Larson RA, Stone RM, Paskett ED, Byrd JC, Mardis ER, Eisfeld AK. High early death rates, treatment resistance, and short survival of Black adolescents and young adults with AML. Blood Adv 2022; 6:5570-5581. [PMID: 35788257 PMCID: PMC9577622 DOI: 10.1182/bloodadvances.2022007544] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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: 03/10/2022] [Accepted: 04/20/2022] [Indexed: 11/20/2022] Open
Abstract
Survival of patients with acute myeloid leukemia (AML) is inversely associated with age, but the impact of race on outcomes of adolescent and young adult (AYA; range, 18-39 years) patients is unknown. We compared survival of 89 non-Hispanic Black and 566 non-Hispanic White AYA patients with AML treated on frontline Cancer and Leukemia Group B/Alliance for Clinical Trials in Oncology protocols. Samples of 327 patients (50 Black and 277 White) were analyzed via targeted sequencing. Integrated genomic profiling was performed on select longitudinal samples. Black patients had worse outcomes, especially those aged 18 to 29 years, who had a higher early death rate (16% vs 3%; P=.002), lower complete remission rate (66% vs 83%; P=.01), and decreased overall survival (OS; 5-year rates: 22% vs 51%; P<.001) compared with White patients. Survival disparities persisted across cytogenetic groups: Black patients aged 18 to 29 years with non-core-binding factor (CBF)-AML had worse OS than White patients (5-year rates: 12% vs 44%; P<.001), including patients with cytogenetically normal AML (13% vs 50%; P<.003). Genetic features differed, including lower frequencies of normal karyotypes and NPM1 and biallelic CEBPA mutations, and higher frequencies of CBF rearrangements and ASXL1, BCOR, and KRAS mutations in Black patients. Integrated genomic analysis identified both known and novel somatic variants, and relative clonal stability at relapse. Reduced response rates to induction chemotherapy and leukemic clone persistence suggest a need for different treatment intensities and/or modalities in Black AYA patients with AML. Higher early death rates suggest a delay in diagnosis and treatment, calling for systematic changes to patient care.
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Affiliation(s)
- Karilyn T. Larkin
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
- Clara D. Bloomfield Center for Leukemia Outcomes Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Deedra Nicolet
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
- Clara D. Bloomfield Center for Leukemia Outcomes Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH
- Alliance Statistics and Data Center, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Benjamin J. Kelly
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH
| | - Krzysztof Mrózek
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
- Clara D. Bloomfield Center for Leukemia Outcomes Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Stephanie LaHaye
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH
| | - Katherine E. Miller
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
| | - Saranga Wijeratne
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH
| | - Gregory Wheeler
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH
| | - Jessica Kohlschmidt
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
- Clara D. Bloomfield Center for Leukemia Outcomes Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH
- Alliance Statistics and Data Center, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - James S. Blachly
- Clara D. Bloomfield Center for Leukemia Outcomes Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Alice S. Mims
- Clara D. Bloomfield Center for Leukemia Outcomes Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Christopher J. Walker
- Clara D. Bloomfield Center for Leukemia Outcomes Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Christopher C. Oakes
- Clara D. Bloomfield Center for Leukemia Outcomes Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Shelley Orwick
- Clara D. Bloomfield Center for Leukemia Outcomes Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Isaiah Boateng
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Jill Buss
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
- Clara D. Bloomfield Center for Leukemia Outcomes Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Adrienne Heyrosa
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
- Clara D. Bloomfield Center for Leukemia Outcomes Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Helee Desai
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
- Clara D. Bloomfield Center for Leukemia Outcomes Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Andrew J. Carroll
- Department of Genetics, University of Alabama at Birmingham, Birmingham, AL
| | - William Blum
- Emory University School of Medicine, Atlanta, GA
| | - Bayard L. Powell
- Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC
| | - Jonathan E. Kolitz
- Monter Cancer Center, Hofstra Northwell School of Medicine, Lake Success, NY
| | - Joseph O. Moore
- Duke Cancer Institute, Duke University Medical Center, Durham, NC
| | - Robert J. Mayer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | | | - Richard M. Stone
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Electra D. Paskett
- Division of Cancer Prevention and Control, Department of Internal Medicine, College of Medicine, The Ohio State University, Columbus, OH
- The Center for Cancer Health Equity, The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - John C. Byrd
- Department of Internal Medicine, University of Cincinnati, Cincinnati, OH
| | - Elaine R. Mardis
- The Steve and Cindy Rasmussen Institute for Genomic Medicine, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
| | - Ann-Kathrin Eisfeld
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
- Clara D. Bloomfield Center for Leukemia Outcomes Research, The Ohio State University Comprehensive Cancer Center, Columbus, OH
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, Columbus, OH
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5
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Atallah E, Schiffer CA, Radich JP, Weinfurt KP, Zhang MJ, Pinilla-Ibarz J, Kota V, Larson RA, Moore JO, Mauro MJ, Deininger MWN, Thompson JE, Oehler VG, Wadleigh M, Shah NP, Ritchie EK, Silver RT, Cortes J, Lin L, Visotcky A, Baim A, Harrell J, Helton B, Horowitz M, Flynn KE. Assessment of Outcomes After Stopping Tyrosine Kinase Inhibitors Among Patients With Chronic Myeloid Leukemia: A Nonrandomized Clinical Trial. JAMA Oncol 2021; 7:42-50. [PMID: 33180106 DOI: 10.1001/jamaoncol.2020.5774] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Importance Tyrosine kinase inhibitors (TKIs) have been associated with improved survival of patients with chronic myeloid leukemia (CML) but are also associated with adverse effects, especially fatigue and diarrhea. Discontinuation of TKIs is safe and is associated with the successful achievement of treatment-free remission (TFR) for some patients. Objective To evaluate molecular recurrence (MRec) and patient-reported outcomes (PROs) after TKI discontinuation for US patients with CML. Design, Setting, and Participants The Life After Stopping TKIs (LAST) study was a prospective single-group nonrandomized clinical trial that enrolled 172 patients from 14 US academic medical centers from December 18, 2014, to December 12, 2016, with a minimum follow-up of 3 years. Participants were adults with chronic-phase CML whose disease was well controlled with imatinib, dasatinib, nilotinib, or bosutinib. Statistical analysis was performed from August 13, 2019, to March 23, 2020. Intervention Discontinuation of TKIs. Main Outcomes and Measures Molecular recurrence, defined as loss of major molecular response (BCR-ABL1 International Scale ratio >0.1%) by central laboratory testing, and PROs (Patient-Reported Outcomes Measurement Information System computerized adaptive tests) were monitored. Droplet digital polymerase chain reaction (ddPCR) was performed on samples with undetectable BCR-ABL1 by standard real-time quantitative polymerase chain reaction (RQ-PCR). Results Of 172 patients, 89 were women (51.7%), and the median age was 60 years (range, 21-86 years). Of 171 patients evaluable for molecular analysis, 112 (65.5%) stayed in major molecular response, and 104 (60.8%) achieved TFR. Undetectable BCR-ABL1 by either ddPCR or RQ-PCR at the time of TKI discontinuation (hazard ratio, 3.60; 95% CI, 1.99-6.50; P < .001) and at 3 months (hazard ratio, 5.86; 95% CI, 3.07-11.1; P < .001) was independently associated with MRec. Molecular recurrence for patients with detectable BCR-ABL1 by RQ-PCR was 50.0% (14 of 28), undetectable BCR-ABL1 by RQ-PCR but detectable by ddPCR was 64.3% (36 of 56), and undetectable BCR-ABL1 by both ddPCR and RQ-PCR was 10.3% (9 of 87) (P ≤ .001). Of the 112 patients in TFR at 12 months, 90 (80.4%) had a clinically meaningful improvement in fatigue, 39 (34.8%) had a clinically meaningful improvement in depression, 98 (87.5%) had a clinically meaningful improvement in diarrhea, 24 (21.4%) had a clinically meaningful improvement in sleep disturbance, and 5 (4.5%) had a clinically meaningful improvement in pain interference. Restarting a TKI resulted in worsening of PROs. Conclusions and Relevance In this study, TKI discontinuation was safe, and 60.8% of patients remained in TFR. Discontinuation of TKIs was associated with improvements in PROs. These findings should assist patients and physicians in their decision-making regarding discontinuation of TKIs. Detectable BCR-ABL1 by RQ-PCR or ddPCR at the time of TKI discontinuation was associated with higher risk of MRec; clinical application of this finding should be confirmed in other studies. Trial Registration ClinicalTrials.gov Identifier: NCT02269267.
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Affiliation(s)
- Ehab Atallah
- Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Charles A Schiffer
- Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, Michigan
| | - Jerald P Radich
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Kevin P Weinfurt
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Mei-Jie Zhang
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee
| | - Javier Pinilla-Ibarz
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | - Vamsi Kota
- Georgia Cancer Center, Augusta University Medical Center, Augusta
| | - Richard A Larson
- Department of Medicine and Comprehensive Cancer Center, University of Chicago, Chicago, Illinois
| | | | - Michael J Mauro
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael W N Deininger
- Division of Hematology and Hematologic Malignancies, Huntsman Cancer Institute, The University of Utah, Salt Lake City
| | - James E Thompson
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, New York
| | - Vivian G Oehler
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Martha Wadleigh
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Neil P Shah
- Department of Medicine, University of California at San Francisco, San Francisco
| | - Ellen K Ritchie
- Division of Medicine, Department of Medical Oncology and Hematology, Weill Medical College of Cornell University, New York, New York
| | - Richard T Silver
- Division of Medicine, Department of Medical Oncology and Hematology, Weill Medical College of Cornell University, New York, New York
| | - Jorge Cortes
- Georgia Cancer Center, Augusta University Medical Center, Augusta
| | - Li Lin
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Alexis Visotcky
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee
| | - Arielle Baim
- Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Jill Harrell
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Bret Helton
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Mary Horowitz
- Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Kathryn E Flynn
- Department of Medicine, Medical College of Wisconsin, Milwaukee
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6
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Deininger MW, Shah NP, Altman JK, Berman E, Bhatia R, Bhatnagar B, DeAngelo DJ, Gotlib J, Hobbs G, Maness L, Mead M, Metheny L, Mohan S, Moore JO, Naqvi K, Oehler V, Pallera AM, Patnaik M, Pratz K, Pusic I, Rose MG, Smith BD, Snyder DS, Sweet KL, Talpaz M, Thompson J, Yang DT, Gregory KM, Sundar H. Chronic Myeloid Leukemia, Version 2.2021, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2020; 18:1385-1415. [PMID: 33022644 DOI: 10.6004/jnccn.2020.0047] [Citation(s) in RCA: 121] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Chronic myeloid leukemia (CML) is defined by the presence of Philadelphia chromosome (Ph) which results from a reciprocal translocation between chromosomes 9 and 22 [t(9;22] that gives rise to a BCR-ABL1 fusion gene. CML occurs in 3 different phases (chronic, accelerated, and blast phase) and is usually diagnosed in the chronic phase. Tyrosine kinase inhibitor therapy is a highly effective first-line treatment option for all patients with newly diagnosed chronic phase CML. This manuscript discusses the recommendations outlined in the NCCN Guidelines for the diagnosis and management of patients with chronic phase CML.
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Affiliation(s)
| | - Neil P Shah
- UCSF Helen Diller Family Comprehensive Cancer Center
| | - Jessica K Altman
- Robert H. Lurie Comprehensive Cancer Center of Northwestern University
| | | | | | - Bhavana Bhatnagar
- The Ohio State University Comprehensive Cancer Center - James Cancer Hospital and Solove Research Institute
| | | | | | | | | | | | - Leland Metheny
- Case Comprehensive Cancer Center/University Hospitals Seidman Cancer Center and Cleveland Clinic Taussig Cancer Institute
| | | | | | - Kiran Naqvi
- The University of Texas MD Anderson Cancer Center
| | - Vivian Oehler
- Fred Hutchinson Cancer Research Center/Seattle Cancer Care Alliance
| | - Arnel M Pallera
- St. Jude Children's Research Hospital/The University of Tennessee Health Science Center
| | | | - Keith Pratz
- Abramson Cancer Center at the University of Pennsylvania
| | - Iskra Pusic
- Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine
| | | | - B Douglas Smith
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins
| | | | | | | | | | - David T Yang
- University of Wisconsin Carbone Cancer Center; and
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7
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Radich JP, Deininger M, Abboud CN, Altman JK, Berman E, Bhatia R, Bhatnagar B, Curtin P, DeAngelo DJ, Gotlib J, Hobbs G, Jagasia M, Kantarjian HM, Maness L, Metheny L, Moore JO, Pallera A, Pancari P, Patnaik M, Purev E, Rose MG, Shah NP, Smith BD, Snyder DS, Sweet KL, Talpaz M, Thompson J, Yang DT, Gregory KM, Sundar H. Chronic Myeloid Leukemia, Version 1.2019, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2019; 16:1108-1135. [PMID: 30181422 DOI: 10.6004/jnccn.2018.0071] [Citation(s) in RCA: 145] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Chronic myeloid leukemia (CML) is defined by the presence of Philadelphia chromosome (Ph), resulting from a reciprocal translocation between chromosomes 9 and 22 [t(9;22] that gives rise to a BCR-ABL1 fusion gene. CML occurs in 3 different phases (chronic, accelerated, and blast phase) and is usually diagnosed in the chronic phase. Tyrosine kinase inhibitor (TKI) therapy is a highly effective first-line treatment option for all patients with newly diagnosed chronic phase CML (CP-CML). The selection TKI therapy should be based on the risk score, toxicity profile of TKI, patient's age, ability to tolerate therapy, and the presence of comorbid conditions. This manuscript discusses the recommendations outlined in the NCCN Guidelines for the diagnosis and management of patients with CP-CML.
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MESH Headings
- Antineoplastic Combined Chemotherapy Protocols/pharmacology
- Antineoplastic Combined Chemotherapy Protocols/standards
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Biomarkers, Tumor/antagonists & inhibitors
- Biomarkers, Tumor/genetics
- Biomarkers, Tumor/isolation & purification
- Bone Marrow/pathology
- Clinical Trials as Topic
- Disease Progression
- Dose-Response Relationship, Drug
- Drug Resistance, Neoplasm/genetics
- Fusion Proteins, bcr-abl/antagonists & inhibitors
- Fusion Proteins, bcr-abl/genetics
- Fusion Proteins, bcr-abl/isolation & purification
- Humans
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/diagnosis
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/mortality
- Medical Oncology/methods
- Medical Oncology/standards
- Patient Selection
- Philadelphia Chromosome
- Prognosis
- Progression-Free Survival
- Protein Kinase Inhibitors/pharmacology
- Protein Kinase Inhibitors/standards
- Protein Kinase Inhibitors/therapeutic use
- Real-Time Polymerase Chain Reaction/standards
- Risk Assessment/methods
- Risk Assessment/standards
- Societies, Medical/standards
- United States
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8
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Friedman DR, Guadalupe E, Volkheimer A, Moore JO, Weinberg JB. Clinical outcomes in chronic lymphocytic leukaemia associated with expression of CD5, a negative regulator of B-cell receptor signalling. Br J Haematol 2018; 183:747-754. [PMID: 30407619 DOI: 10.1111/bjh.15632] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 09/07/2018] [Indexed: 11/30/2022]
Abstract
Chronic lymphocytic leukaemia (CLL) is characterized by expression of CD5 on clonal B cells, and is partly driven by activated B-cell receptor (BCR) signalling. While CD5 is known to be a negative regulator of BCR signalling, it is unknown if variability in CD5 expression exists among patients and whether CLL cell CD5 expression affects CLL clinical outcomes. We assessed the extent to which CD5 expression is correlated with clinical outcomes, and whether this information adds to currently used prognostic markers. We evaluated CD5 expression from 1275 blood samples, established prognostic markers and time to event data from 423 CLL patients followed at the Duke University and Durham VA Medical Centers. CD5 median fluorescence intensity (MFI) was largely stable over time in individual patients, but ranged between 0·5 and 760 in the entire cohort. Lower CD5 MFI was significantly associated with a shorter time to first therapy. CD5 MFI, combined with established clinical and molecular prognostic markers, significantly improved risk-stratification. CD5 may affect disease outcomes by suppressing signalling through the BCR. Thus, a strategy to modulate CLL cell CD5 expression or function could be a therapeutic approach in CLL.
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Affiliation(s)
- Daphne R Friedman
- Division of Medical Oncology, Duke University Medical Center, Durham, NC, USA.,Medicine Service, Durham VA Medical Center, Durham, NC, USA
| | - Eross Guadalupe
- Medicine Service, Durham VA Medical Center, Durham, NC, USA.,Division of Hematology, Duke University Medical Center, Durham, NC, USA
| | - Alicia Volkheimer
- Medicine Service, Durham VA Medical Center, Durham, NC, USA.,Division of Hematology, Duke University Medical Center, Durham, NC, USA
| | - Joseph O Moore
- Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, NC, USA
| | - J Brice Weinberg
- Medicine Service, Durham VA Medical Center, Durham, NC, USA.,Division of Hematology, Duke University Medical Center, Durham, NC, USA
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9
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Atallah E, Schiffer CA, Weinfurt KP, Zhang MJ, Radich JP, Oehler VG, Pinilla-Ibarz J, Deininger MWN, Lin L, Larson RA, Mauro MJ, Moore JO, Ritchie EK, Shah NP, Silver RT, Wadleigh M, Cortes J, Thompson J, Guhl J, Horowitz MM, Flynn KE. Design and rationale for the life after stopping tyrosine kinase inhibitors (LAST) study, a prospective, single-group longitudinal study in patients with chronic myeloid leukemia. BMC Cancer 2018; 18:359. [PMID: 29609532 PMCID: PMC5879565 DOI: 10.1186/s12885-018-4273-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 03/20/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Treatment of chronic myeloid leukemia with a tyrosine kinase inhibitor (TKI) offers significant improvements over previous treatments in terms of survival and toxicity yet nevertheless is associated with reduced health-related quality of life and very high cost. Several small studies from Europe and Australia suggested that discontinuing TKIs with regular monitoring was safe. METHODS The Life After Stopping TKIs (LAST) study is a large, U.S.-based study that aims to improve the evidence for clinical decision making regarding TKI discontinuation with monitoring in patients with chronic myeloid leukemia who have a deep molecular response to TKI therapy. The LAST study is a non-randomized, prospective, single-group longitudinal study of 173 patients. The co-primary objectives are to determine the proportion of patients who develop molecular recurrence (> 0.1% BCR-ABLIS) after discontinuing one of four TKIs (imatinib, dasatinib, nilotinib, or bosutinib) and to compare the patient-reported health status of patients before and after stopping TKIs. Outcomes are assessed at baseline and throughout the 36-month study follow-up period with a central laboratory used for blood samples. All samples with undetectable BCR-ABL are also examined using digital polymerase chain reaction, which is a more sensitive nanofluidic polymerase chain reaction system. DISCUSSION Because of their high cost and side effects, discontinuation of TKIs for patients with chronic myeloid leukemia who have a deep molecular response to TKI therapy is a promising approach to treatment. The LAST study is the largest U.S.-based TKI discontinuation study. It is the first to allow participation from patients on any of 4 first- and second-generation TKIs, includes a robust approach to measurement of clinical and patient-reported outcomes, and is using digital polymerase chain reaction to explore better prediction of safe discontinuation. TRIAL REGISTRATION This study was registered prospectively on October 21, 2014 and assigned trial number NCT02269267 .
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MESH Headings
- Antineoplastic Agents/therapeutic use
- Clinical Protocols
- Fusion Proteins, bcr-abl/genetics
- Humans
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/diagnosis
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/genetics
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/psychology
- Longitudinal Studies
- Molecular Targeted Therapy
- Patient Reported Outcome Measures
- Protein Kinase Inhibitors/therapeutic use
- Quality of Life
- Recurrence
- Research Design
- Watchful Waiting
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Affiliation(s)
- Ehab Atallah
- Department of Medicine, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226 USA
| | - Charles A. Schiffer
- Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI USA
| | - Kevin P. Weinfurt
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC USA
| | - Mei-Jie Zhang
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, WI USA
| | - Jerald P. Radich
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA USA
| | - Vivian G. Oehler
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA USA
| | - Javier Pinilla-Ibarz
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL USA
| | - Michael W. N. Deininger
- Division of Hematology and Hematologic Malignancies, Huntsman Cancer Institute, The University of Utah, Salt Lake City, UT USA
| | - Li Lin
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC USA
| | - Richard A. Larson
- Department of Medicine and Comprehensive Cancer Center, University of Chicago, Chicago, IL USA
| | | | | | | | - Neil P. Shah
- Department of Medicine, University of California at San Francisco, San Francisco, CA USA
| | | | - Martha Wadleigh
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA USA
| | - Jorge Cortes
- University of Texas MD Anderson Cancer Center, Houston, TX USA
| | | | - Jessica Guhl
- Cancer Center, Medical College of Wisconsin, Milwaukee, WI USA
| | - Mary M. Horowitz
- Department of Medicine, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226 USA
| | - Kathryn E. Flynn
- Department of Medicine, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226 USA
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10
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Hoppe RT, Advani RH, Ai WZ, Ambinder RF, Aoun P, Armand P, Bello CM, Benitez CM, Bierman PJ, Chen R, Dabaja B, Dean R, Forero A, Gordon LI, Hernandez-Ilizaliturri FJ, Hochberg EP, Huang J, Johnston PB, Kaminski MS, Kenkre VP, Khan N, Maddocks K, Maloney DG, Metzger M, Moore JO, Morgan D, Moskowitz CH, Mulroney C, Rabinovitch R, Seropian S, Tao R, Winter JN, Yahalom J, Burns JL, Ogba N. NCCN Guidelines Insights: Hodgkin Lymphoma, Version 1.2018. J Natl Compr Canc Netw 2018. [DOI: 10.6004/jnccn.2018.0013] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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11
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Hudson KE, Rizzieri D, Thomas SM, LeBlanc TW, Powell Z, Diehl L, Moore JO, DeCastro C, Beaven AW. Dose-intense chemoimmunotherapy plus radioimmunotherapy in high-risk diffuse large B-cell lymphoma and mantle cell lymphoma: a phase II study. Br J Haematol 2018; 184:647-650. [PMID: 29468651 DOI: 10.1111/bjh.15138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
| | | | - Samantha M Thomas
- Duke University Medical Center, Durham, NC, USA.,Department of Biostatistics & Bioinformatics, Duke University, Durham, NC, USA
| | | | | | - Louis Diehl
- Duke University Medical Center, Durham, NC, USA
| | | | | | - Anne W Beaven
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
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12
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Hoppe RT, Advani RH, Ai WZ, Ambinder RF, Aoun P, Bello CM, Benitez CM, Bernat K, Bierman PJ, Blum KA, Chen R, Dabaja B, Forero A, Gordon LI, Hernandez-Ilizaliturri FJ, Hochberg EP, Huang J, Johnston PB, Kaminski MS, Kenkre VP, Khan N, Maloney DG, Mauch PM, Metzger M, Moore JO, Morgan D, Moskowitz CH, Mulroney C, Poppe M, Rabinovitch R, Seropian S, Smith M, Winter JN, Yahalom J, Burns J, Ogba N, Sundar H. Hodgkin Lymphoma Version 1.2017, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2017; 15:608-638. [PMID: 28476741 DOI: 10.6004/jnccn.2017.0064] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This portion of the NCCN Guidelines for Hodgkin lymphoma (HL) focuses on the management of classical HL. Current management of classical HL involves initial treatment with chemotherapy or combined modality therapy followed by restaging with PET/CT to assess treatment response using the Deauville criteria (5-point scale). The introduction of less toxic and more effective regimens has significantly advanced HL cure rates. However, long-term follow-up after completion of treatment is essential to determine potential long-term effects.
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13
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O'Donnell MR, Tallman MS, Abboud CN, Altman JK, Appelbaum FR, Arber DA, Bhatt V, Bixby D, Blum W, Coutre SE, De Lima M, Fathi AT, Fiorella M, Foran JM, Gore SD, Hall AC, Kropf P, Lancet J, Maness LJ, Marcucci G, Martin MG, Moore JO, Olin R, Peker D, Pollyea DA, Pratz K, Ravandi F, Shami PJ, Stone RM, Strickland SA, Wang ES, Wieduwilt M, Gregory K, Ogba N. Acute Myeloid Leukemia, Version 3.2017, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2017; 15:926-957. [DOI: 10.6004/jnccn.2017.0116] [Citation(s) in RCA: 277] [Impact Index Per Article: 39.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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14
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Tuchman SA, Moore JO, DeCastro CD, Li Z, Sellars E, Kang Y, Long G, Gasparetto CG. Phase II study of dose-attenuated bortezomib, cyclophosphamide and dexamethasone (“VCD-Lite”) in very old or otherwise toxicity-vulnerable adults with newly diagnosed multiple myeloma. J Geriatr Oncol 2017; 8:165-169. [DOI: 10.1016/j.jgo.2017.02.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 01/11/2017] [Accepted: 02/09/2017] [Indexed: 10/20/2022]
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15
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Pallera A, Altman JK, Berman E, Abboud CN, Bhatnagar B, Curtin P, DeAngelo DJ, Gotlib J, Hagelstrom RT, Hobbs G, Jagasia M, Kantarjian HM, Kropf P, Metheny L, Moore JO, Ontiveros E, Purev E, Quiery A, Reddy VV, Rose MG, Shah NP, Smith BD, Snyder DS, Sweet KL, Tibes R, Yang DT, Gregory K, Sundar H, Deininger M, Radich JP. NCCN Guidelines Insights: Chronic Myeloid Leukemia, Version 1.2017. J Natl Compr Canc Netw 2016; 14:1505-1512. [DOI: 10.6004/jnccn.2016.0162] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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16
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O'Brien S, Radich JP, Abboud CN, Akhtari M, Altman JK, Berman E, Curtin P, DeAngelo DJ, Deininger M, Devine S, Fathi AT, Gotlib J, Jagasia M, Kropf P, Moore JO, Pallera A, Reddy VV, Shah NP, Smith BD, Snyder DS, Wetzler M, Gregory K, Sundar H. Chronic myelogenous leukemia, version 1.2015. J Natl Compr Canc Netw 2015; 12:1590-610. [PMID: 25361806 DOI: 10.6004/jnccn.2014.0159] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Chronic myelogenous leukemia (CML) is usually diagnosed in the chronic phase. Untreated chronic phase CML will eventually progress to advanced phase (accelerated or blast phase) CML. Tyrosine kinase inhibitors (TKIs) have been shown to induce favorable response rates in patients with accelerated and blast phase CML. The addition of TKIs to chemotherapy has also been associated with improved outcomes in patients with blast phase CML. Allogeneic hematopoietic stem cell transplant remains a potentially curative option for patients with advanced phase CML, although treatment with a course of TKIs will be beneficial as a bridge to transplant. This manuscript discusses the recommendations outlined in the NCCN Guidelines for the diagnosis and management of patients with advanced phase CML.
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MESH Headings
- Antineoplastic Agents/therapeutic use
- Guidelines as Topic
- Hematopoietic Stem Cell Transplantation/methods
- Humans
- Leukemia, Myeloid, Accelerated Phase/diagnosis
- Leukemia, Myeloid, Accelerated Phase/drug therapy
- Leukemia, Myeloid, Accelerated Phase/surgery
- Leukemia, Myeloid, Chronic-Phase/diagnosis
- Leukemia, Myeloid, Chronic-Phase/drug therapy
- Leukemia, Myeloid, Chronic-Phase/surgery
- Protein Kinase Inhibitors/therapeutic use
- Protein-Tyrosine Kinases/antagonists & inhibitors
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17
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Hoppe RT, Advani RH, Ai WZ, Ambinder RF, Aoun P, Bello CM, Benitez CM, Bierman PJ, Blum KA, Chen R, Dabaja B, Forero A, Gordon LI, Hernandez-Ilizaliturri FJ, Hochberg EP, Huang J, Johnston PB, Khan N, Maloney DG, Mauch PM, Metzger M, Moore JO, Morgan D, Moskowitz CH, Mulroney C, Poppe M, Rabinovitch R, Seropian S, Tsien C, Winter JN, Yahalom J, Burns JL, Sundar H. Hodgkin lymphoma, version 2.2015. J Natl Compr Canc Netw 2015; 13:554-86. [PMID: 25964641 PMCID: PMC4898052 DOI: 10.6004/jnccn.2015.0075] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Hodgkin lymphoma (HL) is an uncommon malignancy involving lymph nodes and the lymphatic system. Classical Hodgkin lymphoma (CHL) and nodular lymphocyte-predominant Hodgkin lymphoma are the 2 main types of HL. CHL accounts for most HL diagnosed in the Western countries. Chemotherapy or combined modality therapy, followed by restaging with PET/CT to assess treatment response using the Deauville criteria (5-point scale), is the standard initial treatment for patients with newly diagnosed CHL. Brentuximab vedotin, a CD30-directed antibody-drug conjugate, has produced encouraging results in the treatment of relapsed or refractory disease. The potential long-term effects of treatment remain an important consideration, and long-term follow-up is essential after completion of treatment.
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18
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Niederwieser C, Kohlschmidt J, Volinia S, Whitman SP, Metzeler KH, Eisfeld AK, Maharry K, Yan P, Frankhouser D, Becker H, Schwind S, Carroll AJ, Nicolet D, Mendler JH, Curfman JP, Wu YZ, Baer MR, Powell BL, Kolitz JE, Moore JO, Carter TH, Bundschuh R, Larson RA, Stone RM, Mrózek K, Marcucci G, Bloomfield CD. Prognostic and biologic significance of DNMT3B expression in older patients with cytogenetically normal primary acute myeloid leukemia. Leukemia 2015; 29:567-75. [PMID: 25204569 PMCID: PMC4351165 DOI: 10.1038/leu.2014.267] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Revised: 08/26/2014] [Accepted: 08/29/2014] [Indexed: 02/06/2023]
Abstract
DNMT3B encodes a DNA methyltransferase implicated in aberrant epigenetic changes contributing to leukemogenesis. We tested whether DNMT3B expression, measured by NanoString nCounter assay, associates with outcome, gene and microRNA expression and DNA methylation profiles in 210 older (⩾60 years) adults with primary, cytogenetically normal acute myeloid leukemia (CN-AML). Patients were dichotomized into high versus low expressers using median cut. Outcomes were assessed in the context of known CN-AML prognosticators. Gene and microRNA expression, and DNA methylation profiles were analyzed using microarrays and MethylCap-sequencing, respectively. High DNMT3B expressers had fewer complete remissions (CR; P=0.002) and shorter disease-free (DFS; P=0.02) and overall (OS; P<0.001) survival. In multivariable analyses, high DNMT3B expression remained an independent predictor of lower CR rates (P=0.04) and shorter DFS (P=0.04) and OS (P=0.001). High DNMT3B expression associated with a gene expression profile comprising 363 genes involved in differentiation, proliferation and survival pathways, but with only four differentially expressed microRNAs (miR-133b, miR-148a, miR-122, miR-409-3p) and no differential DNA methylation regions. We conclude that high DNMT3B expression independently associates with adverse outcome in older CN-AML patients. Gene expression analyses suggest that DNMT3B is involved in the modulation of several genes, although the regulatory mechanisms remain to be investigated to devise therapeutic approaches specific for these patients.
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MESH Headings
- Age Factors
- Aged
- Aged, 80 and over
- Cytarabine/therapeutic use
- DNA (Cytosine-5-)-Methyltransferases/genetics
- DNA Methylation
- Daunorubicin/therapeutic use
- Female
- Gene Expression Profiling
- Gene Expression Regulation, Leukemic
- Humans
- Induction Chemotherapy
- Karyotyping
- Leukemia, Myeloid, Acute/diagnosis
- Leukemia, Myeloid, Acute/drug therapy
- Leukemia, Myeloid, Acute/genetics
- Leukemia, Myeloid, Acute/mortality
- Male
- MicroRNAs/genetics
- Microarray Analysis
- Middle Aged
- Prognosis
- Survival Analysis
- DNA Methyltransferase 3B
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Affiliation(s)
| | - Jessica Kohlschmidt
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
- Alliance for Clinical Trials in Oncology Statistics and Data Center, Mayo Clinic, Rochester, MN
| | - Stefano Volinia
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Susan P. Whitman
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | | | | | - Kati Maharry
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
- Alliance for Clinical Trials in Oncology Statistics and Data Center, Mayo Clinic, Rochester, MN
| | - Pearlly Yan
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | | | - Heiko Becker
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | | | | | - Deedra Nicolet
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
- Alliance for Clinical Trials in Oncology Statistics and Data Center, Mayo Clinic, Rochester, MN
| | - Jason H. Mendler
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - John P. Curfman
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Yue-Zhong Wu
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Maria R. Baer
- Greenebaum Cancer Center, University of Maryland, Baltimore, MD
| | - Bayard L. Powell
- Comprehensive Cancer Center of Wake Forest University, Winston-Salem, NC
| | - Jonathan E. Kolitz
- Monter Cancer Center, Hofstra North Shore-Long Island Jewish School of Medicine, Lake Success, NY
| | | | | | - Ralf Bundschuh
- Departments of Physics and Chemistry & Biochemistry, The Ohio State University, Columbus, OH
| | | | | | - Krzysztof Mrózek
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Guido Marcucci
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
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19
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Shi Y, Rand AJ, Crow JH, Moore JO, Lagoo AS. Blast phase in chronic myelogenous leukemia is skewed toward unusual blast types in patients treated with tyrosine kinase inhibitors: a comparative study of 67 cases. Am J Clin Pathol 2015; 143:105-19. [PMID: 25511149 DOI: 10.1309/ajcpwex5yy4phscn] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES To compare the features of the blast phase of chronic myelogenous leukemia (CML) in patients treated with tyrosine kinase inhibitors (TKIs) with those in the pre-TKI era. METHODS Sixty-seven patients with blast phase CML were identified in the Duke Pathology database from 1991 to 2011. The morphology and immunophenotype of blasts were evaluated, along with cytogenetic studies and associated findings in the peripheral blood and bone marrow. RESULTS In the TKI era, the blasts were more frequently of a type other than the usual myeloid or lymphoid types when compared with the pre-TKI era. Blast phase in TKI-treated patients was associated with a higher peripheral WBC count and a lower blast percentage in the bone marrow. Of the 23 patients with cytogenetic studies during blast phase, additional cytogenetic changes more frequently occurred in patients with an unusual blast type, and some patients showed these changes months before the onset of blast phase. CONCLUSIONS Blast phase CML in TKI- and non-TKI-treated patients differs in the morphology and immunophenotype of blasts, cytogenetic findings, and associated findings in the peripheral blood and bone marrow.
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Affiliation(s)
- Yang Shi
- Department of Pathology, Duke University Medical Center, Durham, NC
| | - Andrew J. Rand
- Department of Pathology, Duke University Medical Center, Durham, NC
| | - Jennifer H. Crow
- Department of Pathology, Duke University Medical Center, Durham, NC
| | - Joseph O. Moore
- Department of Medicine, Duke University Medical Center, Durham, NC
| | - Anand S. Lagoo
- Department of Pathology, Duke University Medical Center, Durham, NC
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O’Brien S, Radich JP, Abboud CN, Akhtari M, Altman JK, Berman E, DeAngelo DJ, Deininger M, Devine S, Fathi AT, Gotlib J, Jagasia M, Kropf P, Moore JO, Pallera A, Pinilla-Ibarz J, Reddy VVB, Shah NP, Smith BD, Snyder DS, Wetzler M, Gregory K, Sundar H. Chronic Myelogenous Leukemia, Version 1.2014. J Natl Compr Canc Netw 2013; 11:1327-40. [DOI: 10.6004/jnccn.2013.0157] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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O’Donnell MR, Tallman MS, Abboud CN, Altman JK, Appelbaum FR, Arber DA, Attar E, Borate U, Coutre SE, Damon LE, Lancet J, Maness LJ, Marcucci G, Martin MG, Millenson MM, Moore JO, Ravandi F, Shami PJ, Smith BD, Stone RM, Strickland SA, Wang ES, Gregory KM, Naganuma M. Acute Myeloid Leukemia, Version 2.2013. J Natl Compr Canc Netw 2013; 11:1047-55. [DOI: 10.6004/jnccn.2013.0127] [Citation(s) in RCA: 121] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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22
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Friedman DR, Lanasa MC, Davis PH, Allgood SD, Matta KM, Brander DM, Chen Y, Davis ED, Volkheimer AD, Moore JO, Gockerman JP, Sportelli P, Weinberg JB. Perifosine treatment in chronic lymphocytic leukemia: results of a phase II clinical trial and in vitro studies. Leuk Lymphoma 2013; 55:1067-75. [PMID: 23863122 DOI: 10.3109/10428194.2013.824080] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract Because of the importance of the phosphoinositide 3-kinase (PI3K)/AKT pathway in chronic lymphocytic leukemia (CLL), we evaluated in vitro cytotoxicity induced by perifosine, an AKT inhibitor, in CLL lymphocytes and found that the mean 50% effective dose (ED50) was 313 nM. We then performed a phase II trial of perifosine in patients with relapsed/refractory CLL to assess response, outcomes, toxicity and ex vivo correlative measures. After 3 months of treatment, six of eight patients showed stable disease, one achieved a partial response and one had progressive disease. Median event-free survival and overall survival in all patients treated were 3.9 and 9.7 months. Adverse events included hematologic, infectious/fever, pain, gastrointestinal and constitutional toxicities. Unexpectedly, AKT phosphorylation in CLL lymphocytes from treated patients was not correlated with response. Additionally, perifosine did not inhibit AKT phosphorylation in cultured CLL lymphocytes. Perifosine is cytotoxic to CLL cells in vitro, and largely induces stabilized disease in vivo, with an AKT-independent mechanism.
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Affiliation(s)
- Daphne R Friedman
- Department of Medicine, Duke University Medical Center , Durham, NC , USA
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Mendler JH, Maharry K, Becker H, Eisfeld AK, Senter L, Mrózek K, Kohlschmidt J, Metzeler KH, Schwind S, Whitman SP, Khalife J, Caligiuri MA, Klisovic RB, Moore JO, Carter TH, Marcucci G, Bloomfield CD. In rare acute myeloid leukemia patients harboring both RUNX1 and NPM1 mutations, RUNX1 mutations are unusual in structure and present in the germline. Haematologica 2013; 98:e92-4. [PMID: 23753029 DOI: 10.3324/haematol.2013.089904] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Brander D, Rizzieri D, Gockerman J, Diehl L, Shea TC, Decastro C, Moore JO, Beaven A. Phase II open label study of the oral vascular endothelial growth factor-receptor inhibitor PTK787/ZK222584 (vatalanib) in adult patients with refractory or relapsed diffuse large B-cell lymphoma. Leuk Lymphoma 2013; 54:2627-30. [PMID: 23488610 DOI: 10.3109/10428194.2013.784969] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PTK787/ZK222584 (vatalanib), an orally active inhibitor of vascular endothelial growth factor receptors (VEGFRs), was evaluated in this phase II study of 20 patients with relapsed/refractory diffuse large B-cell lymphoma (DLBCL). Patients received once-daily PTK787/ZK222584 at a target dose of 1250 mg. Eighteen patients were evaluable for response: one patient had a complete response (CR), six patients had stable disease but subsequently progressed, 10 patients had progressive disease by three cycles and one subject withdrew before response evaluation. The patient who attained a CR underwent autologous stem cell transplant and remains disease-free 76 months after study completion. There were no grade 4 toxicities. Grade 3 thrombocytopenia occurred in 20% and grade 3 hypertension occurred in 10%. There were no episodes of grade 3 proteinuria. In conclusion, PTK787/ZK222584 was well tolerated in a heavily pretreated population of patients with DLBCL, although its therapeutic potential as a single agent in DLBCL appears limited.
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Affiliation(s)
- Danielle Brander
- Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke Cancer Institute , Durham, NC , USA
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Held LA, Rizzieri D, Long GD, Gockerman JP, Diehl LF, de Castro CM, Moore JO, Horwitz ME, Chao NJ, Gasparetto C. A Phase I study of arsenic trioxide (Trisenox), ascorbic acid, and bortezomib (Velcade) combination therapy in patients with relapsed/refractory multiple myeloma. Cancer Invest 2013; 31:172-6. [PMID: 23406188 DOI: 10.3109/07357907.2012.756109] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE This Phase I study assessed the feasibility of concomitant arsenic trioxide (ATO), ascorbic acid (AA), and bortezomib (Velcade™) (AAV) for patients with relapsed/refractory multiple myeloma. EXPERIMENTAL DESIGN ATO (0.25 mg/kg) and AA (1 g) were given with an escalating dose of bortezomib (1 mg/m(2) or 1.3 mg/m(2) IV bolus on days 1 and 8 of a 21-day cycle). RESULTS Ten patients (median age 62 years), with a median of 3 prior regimens, were enrolled. Four (40%) patients achieved clinical benefit, with one patient achieving a durable partial response. No formal DLTs were encountered. CONCLUSION AAV combination was feasible and demonstrated some benefits in this heavily pretreated population.
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Affiliation(s)
- Lauren A Held
- Division of Cellular Therapy, Duke University Medical Center, Durham, North Carolina 27710, USA
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26
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Rizzieri D, Moore JO. Implementation of management guidelines for chronic myeloid leukemia: perspectives in the United States. P T 2012; 37:640-8. [PMID: 23204819 PMCID: PMC3498990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 05/01/2012] [Indexed: 11/05/2023]
Abstract
Clinical practice guidelines are developed to improve the quality of care and outcomes for patients. Guidelines facilitate clinical decisions, promote efficient use of health care resources, and provide guidance to practitioners. For chronic myeloid leukemia (CML), tyrosine kinase inhibitors (TKIs) have changed the paradigm of therapy by lowering the disease burden and by providing more precise monitoring of response. These advances affect treatment guidelines for CML and inform CML clinical trial protocols.Guidelines developed by the National Comprehensive Cancer Network (NCCN) and European LeukemiaNet (ELN) synthesize the best available evidence to support decision-making in the management of CML patients. Both guidelines recognize specific milestones for treatment response. At each time point, the ELN guidelines define overall response benchmarks, and the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) provide an algorithm that specifies the timing for evaluations of cytogenetic and molecular parameters during therapy. The NCCN Guidelines also include strategies for providing supportive care and for managing toxicities. Molecular monitoring now plays a greater role in CML management. Molecular response as a milestone is currently recommended by the ELN but has not yet been adopted by the NCCN. As evidence continues to accumulate, the NCCN and ELN Guidelines are likely to evolve to reflect new data and standards of care.
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Morris TA, DeCastro CM, Diehl LF, Gockerman JP, Lagoo AS, Li Z, Moore JO, Rizzieri DA, Rao AV. Re-induction therapy decisions based on day 14 bone marrow biopsy in acute myeloid leukemia. Leuk Res 2012; 37:28-31. [PMID: 23046833 DOI: 10.1016/j.leukres.2012.09.016] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Revised: 09/17/2012] [Accepted: 09/18/2012] [Indexed: 11/29/2022]
Abstract
PURPOSE The decision to re-induce patients with acute myeloid leukemia (AML) based on results of the day 14 bone marrow (BM) biopsy is variable and lacks evidence based data. The aim of our review was to evaluate the accuracy of a day 14 BM biopsy in determining the need for re-induction chemotherapy. METHODS Seventy-four patients with newly diagnosed de novo AML treated with induction chemotherapy were retrospectively reviewed for the purpose of evaluating treatment decisions and outcomes based on their day 14 BM biopsy. Response to therapy in this analysis was based on morphology alone. RESULTS Of the 74 patients undergoing standard induction, 45 patients (61%) had no evidence of leukemia on their day 14 BM biopsy. Eighteen patients (24%) had definitive residual disease (RD), and 11 patient's (15%) were classified as indeterminate response (IR). Fifteen patients with RD and one with IR underwent re-induction chemotherapy. However, thirteen patients (3 RD and 10 IR) were observed until count recovery without any re-induction therapy. Eleven of these 13 patients who were observed eventually attained a morphologic complete remission (CR), including two patients with RD. CONCLUSIONS A day 14 BM biopsy may have suboptimal sensitivity for the detection of residual leukemia. Some patients with an IR on day 14 may not require re-induction chemotherapy, but instead, may benefit from careful observation until count recovery to avoid the mortality and morbidity associated with re-induction chemotherapy.
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Affiliation(s)
- Tod A Morris
- Division of Medical Oncology, Duke University Health System, Durham, NC, USA
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Mrózek K, Marcucci G, Nicolet D, Maharry KS, Becker H, Whitman SP, Metzeler KH, Schwind S, Wu YZ, Kohlschmidt J, Pettenati MJ, Heerema NA, Block AW, Patil SR, Baer MR, Kolitz JE, Moore JO, Carroll AJ, Stone RM, Larson RA, Bloomfield CD. Prognostic significance of the European LeukemiaNet standardized system for reporting cytogenetic and molecular alterations in adults with acute myeloid leukemia. J Clin Oncol 2012; 30:4515-23. [PMID: 22987078 DOI: 10.1200/jco.2012.43.4738] [Citation(s) in RCA: 315] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
PURPOSE To evaluate the prognostic significance of the international European LeukemiaNet (ELN) guidelines for reporting genetic alterations in acute myeloid leukemia (AML). PATIENTS AND METHODS We analyzed 1,550 adults with primary AML, treated on Cancer and Leukemia Group B first-line trials, who had pretreatment cytogenetics and, for cytogenetically normal patients, mutational status of NPM1, CEBPA, and FLT3 available. We compared complete remission (CR) rates, disease-free survival (DFS), and overall survival (OS) among patients classified into the four ELN genetic groups (favorable, intermediate-I, intermediate-II, adverse) separately for 818 younger (age < 60 years) and 732 older (age ≥ 60 years) patients. RESULTS The percentages of younger versus older patients in the favorable (41% v 20%; P < .001), intermediate-II (19% v 30%; P < .001), and adverse (22% v 31%; P < .001) genetic groups differed. The favorable group had the best and the adverse group the worst CR rates, DFS, and OS in both age groups. Both intermediate groups had significantly worse outcomes than the favorable but better than the adverse group. Intermediate-I and intermediate-II groups in older patients had similar outcomes, whereas the intermediate-II group in younger patients had better OS but not better CR rates or DFS than the intermediate-I group. The prognostic significance of ELN classification was confirmed by multivariable analyses. For each ELN group, older patients had worse outcomes than younger patients. CONCLUSION The ELN classification clearly separates the genetic groups by outcome, supporting its use for risk stratification in clinical trials. Because they have different proportions of genetic alterations and outcomes, younger and older patients should be reported separately when using the ELN classification.
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Affiliation(s)
- Krzysztof Mrózek
- The Ohio State University Comprehensive Cancer Center, Columbus, OH 43210-1228, USA.
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29
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O'Donnell MR, Abboud CN, Altman J, Appelbaum FR, Arber DA, Attar E, Borate U, Coutre SE, Damon LE, Goorha S, Lancet J, Maness LJ, Marcucci G, Millenson MM, Moore JO, Ravandi F, Shami PJ, Smith BD, Stone RM, Strickland SA, Tallman MS, Wang ES, Naganuma M, Gregory KM. NCCN Clinical Practice Guidelines Acute myeloid leukemia. J Natl Compr Canc Netw 2012; 10:984-1021. [PMID: 22878824 DOI: 10.6004/jnccn.2012.0103] [Citation(s) in RCA: 198] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Acute myeloid leukemia (AML) remains the most common form of acute leukemia among adults and accounts for the largest number of annual deaths due to leukemias in the United States. The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for AML provide recommendations on the diagnostic evaluation and workup for AML, risk assessment based on cytogenetic and molecular features, treatment options for induction and consolidation therapies for younger and older (age ≥ 65 years) adult patients, and key supportive care considerations.
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Mendler JH, Maharry K, Radmacher MD, Mrózek K, Becker H, Metzeler KH, Schwind S, Whitman SP, Khalife J, Kohlschmidt J, Nicolet D, Powell BL, Carter TH, Wetzler M, Moore JO, Kolitz JE, Baer MR, Carroll AJ, Larson RA, Caligiuri MA, Marcucci G, Bloomfield CD. RUNX1 mutations are associated with poor outcome in younger and older patients with cytogenetically normal acute myeloid leukemia and with distinct gene and MicroRNA expression signatures. J Clin Oncol 2012; 30:3109-18. [PMID: 22753902 DOI: 10.1200/jco.2011.40.6652] [Citation(s) in RCA: 203] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
PURPOSE To determine the association of RUNX1 mutations with therapeutic outcome in younger and older patients with primary cytogenetically normal acute myeloid leukemia (CN-AML) and with gene/microRNA expression signatures. PATIENTS AND METHODS Younger (< 60 years; n = 175) and older (≥ 60 years; n = 225) patients with CN-AML treated with intensive cytarabine/anthracycline-based first-line therapy on Cancer and Leukemia Group B protocols were centrally analyzed for RUNX1 mutations by polymerase chain reaction and direct sequencing and for established prognostic gene mutations. Gene/microRNA expression profiles were derived using microarrays. RESULTS RUNX1 mutations were found in 8% and 16% of younger and older patients, respectively (P = .02). They were associated with ASXL1 mutations (P < .001) and inversely associated with NPM1 (P < .001) and CEBPA (P = .06) mutations. RUNX1-mutated patients had lower complete remission rates (P = .005 in younger; P = .006 in older) and shorter disease-free survival (P = .058 in younger; P < .001 in older), overall survival (P = .003 in younger; P < .001 in older), and event-free survival (P < .001 for younger and older) than RUNX1 wild-type patients. Because RUNX1 mutations were more common in older patients and almost never coexisted with NPM1 mutations, RUNX1 mutation-associated expression signatures were derived in older, NPM1 wild-type patients and featured upregulation of genes normally expressed in primitive hematopoietic cells and B-cell progenitors, including DNTT, BAALC, BLNK, CD109, RBPMS, and FLT3, and downregulation of promoters of myelopoiesis, including CEBPA and miR-223. CONCLUSION RUNX1 mutations are twice as common in older than younger patients with CN-AML and negatively impact outcome in both age groups. RUNX1-mutated blasts have molecular features of primitive hematopoietic and lymphoid progenitors, potentially leading to novel therapeutic approaches.
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Affiliation(s)
- Jason H Mendler
- The Ohio State University, Comprehensive Cancer Center, 1216 James Cancer Hospital, 300 West 10th Ave, Columbus, OH 43210, USA
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Rao AV, Rizzieri DA, DeCastro CM, Diehl LF, Lagoo AS, Moore JO, Gockerman JP. Phase I study of dose dense induction and consolidation with gemtuzumab ozogamicin and high dose cytarabine in older adults with AML. J Geriatr Oncol 2012. [DOI: 10.1016/j.jgo.2012.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Hoppe RT, Advani RH, Ai WZ, Ambinder RF, Aoun P, Bello CM, Bierman PJ, Blum KA, Chen R, Dabaja B, Duron Y, Forero A, Gordon LI, Hernandez-Ilizaliturri FJ, Hochberg EP, Maloney DG, Mansur D, Mauch PM, Metzger M, Moore JO, Morgan D, Moskowitz CH, Poppe M, Pro B, Winter JN, Yahalom J, Sundar H. Hodgkin Lymphoma, Version 2.2012 Featured Updates to the NCCN Guidelines. J Natl Compr Canc Netw 2012; 10:589-97. [DOI: 10.6004/jnccn.2012.0061] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Advani AS, Shadman M, Ali-Osman F, Barker A, Rybicki L, Kalaycio M, Sekeres MA, de Castro CM, Diehl LF, Moore JO, Beaven A, Copelan E, Sobecks R, Talea P, Rizzieri DA. A Phase II trial of gemcitabine and mitoxantrone for patients with acute myeloid leukemia in first relapse. Clin Lymphoma Myeloma Leuk 2012; 10:473-6. [PMID: 21156465 DOI: 10.3816/clml.2010.n.082] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION We evaluated the complete remission (CR) rate in patients with acute myeloid leukemia (AML) in first relapse treated with fixed-dose-rate gemcitabine and mitoxantrone. In addition, we measured multidrug resistance (MDR) proteins on pretreatment bone marrows and correlated expression with outcome. PATIENTS AND METHODS The study was performed in a 2-stage design. Pretreatment bone marrows were assayed for the MDR proteins (LRP, MDR1, MRP1, SLC28-29A1/A2, ABCC4/C5, and GSTP1) by immunohistochemistry and reverse-transcriptase polymerase chain reaction (RT-PCR). RESULTS Only 5 of the first 24 patients (21%) achieved CR; therefore, the study was terminated. Eleven patients (46%) had poor-risk cytogenetics and the median duration of first CR was 7.3 months. Patients had significant expression of the various MDR genes, with 70% of patients expressing moderate to high levels of GSTP1 by immunohistochemistry. Higher sum total of ABCC4 and SLC29A2 expression measured by RT-PCR was associated with not achieving CR (20.6 vs. 12.1; P = .006). In addition, there was a trend for higher expression of the sum total of the 10 MDR genes (measured by RT-PCR) and not achieving CR (P = .06). CONCLUSION The CR rate in this study was comparable to other regimens used in poor-risk patients. Of interest, ABCC4 and SLC29A2 expression were predictive of achieving CR. The high expression of GSTP1 suggests that this may be a therapeutic target for relapsed AML. Finally, the rapidity and ease of using RT-PCR to quantify MDR in this study may have clinical utility in future trials.
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Affiliation(s)
- Anjali S Advani
- Hematologic Oncology and Blood Disorders, Taussig Cancer Center, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Marcucci G, Metzeler KH, Schwind S, Becker H, Maharry K, Mrózek K, Radmacher MD, Kohlschmidt J, Nicolet D, Whitman SP, Wu YZ, Powell BL, Carter TH, Kolitz JE, Wetzler M, Carroll AJ, Baer MR, Moore JO, Caligiuri MA, Larson RA, Bloomfield CD. Age-related prognostic impact of different types of DNMT3A mutations in adults with primary cytogenetically normal acute myeloid leukemia. J Clin Oncol 2012; 30:742-50. [PMID: 22291079 DOI: 10.1200/jco.2011.39.2092] [Citation(s) in RCA: 216] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To determine the frequency of DNMT3A mutations, their associations with clinical and molecular characteristics and outcome, and the associated gene- and microRNA-expression signatures in primary cytogenetically normal acute myeloid leukemia (CN-AML). PATIENTS AND METHODS Four hundred fifteen previously untreated adults were analyzed for DNMT3A mutations and established prognostic gene mutations and expression markers. Gene- and microRNA-expression profiles were derived using microarrays. RESULTS Younger (< 60 years; n = 181) and older (≥ 60 years; n = 234) patients had similar frequencies of DNMT3A mutations (35.3% v 33.3%). Missense mutations affecting arginine codon 882 (R882-DNMT3A) were more common (n = 92; 62%) than those affecting other codons (non-R882-DNMT3A). DNMT3A-mutated patients did not differ regarding complete remission rate, but had shorter disease-free survival (DFS; P = .03) and, by trend, overall survival (OS; P = .07) than DNMT3A-wild-type patients. In multivariable analyses, DNMT3A mutations remained associated with shorter DFS (P = .01), but not with shorter OS. When analyzed separately, the two DNMT3A mutation types had different significance by age group. Younger patients with non-R882-DNMT3A mutations had shorter DFS (P = .002) and OS (P = .02), whereas older patients with R882-DNMT3A mutations had shorter DFS (P = .005) and OS (P = .002) after adjustment for other clinical and molecular prognosticators. Gene- and microRNA-expression signatures did not accurately predict DNMT3A mutational status. CONCLUSION DNMT3A mutations are frequent in CN-AML, and their clinical significance seems to be age dependent. DNMT3A-R882 mutations are associated with adverse prognosis in older patients, and non-R882-DNMT3A mutations are associated with adverse prognosis in younger patients. Low accuracy of gene- and microRNA-expression signatures in predicting DNMT3A mutation status suggested that the role of these mutations in AML remains to be elucidated.
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Affiliation(s)
- Guido Marcucci
- The Ohio State University Comprehensive Cancer Center, Columbus, OH 43210, USA.
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O'Brien S, Abboud CN, Akhtari M, Altman J, Berman E, DeAngelo DJ, Devine S, Fathi AT, Gotlib J, Jagasia M, Moore JO, Pinilla-Ibarz J, Radich JP, Reddy VVB, Shah NP, Shami PJ, Smith BD, Snyder DS, Wetzler M, Yunus F. Chronic myelogenous leukemia. J Natl Compr Canc Netw 2012; 10:64-110. [PMID: 22223870 DOI: 10.6004/jnccn.2012.0009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Becker H, Maharry K, Radmacher MD, Mrózek K, Metzeler KH, Whitman SP, Schwind S, Kohlschmidt J, Wu YZ, Powell BL, Carter TH, Kolitz JE, Wetzler M, Carroll AJ, Baer MR, Moore JO, Caligiuri MA, Larson RA, Marcucci G, Bloomfield CD. Clinical outcome and gene- and microRNA-expression profiling according to the Wilms tumor 1 (WT1) single nucleotide polymorphism rs16754 in adult de novo cytogenetically normal acute myeloid leukemia: a Cancer and Leukemia Group B study. Haematologica 2011; 96:1488-95. [PMID: 21659357 PMCID: PMC3186310 DOI: 10.3324/haematol.2011.041905] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [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: 02/07/2011] [Revised: 05/12/2011] [Accepted: 06/06/2011] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The alleles of the Wilms tumor 1 (WT1) polymorphism rs16754 harbor adenine (A) or guanine (G). Recently, rs16754 has been reported to affect the outcome of patients with cytogenetically normal acute myeloid leukemia. To validate this finding, we investigated pretreatment features and outcome associated with rs16754 in a large cohort of patients with cytogenetically normal acute myeloid leukemia. DESIGN AND METHODS Four-hundred and thirty-three intensively treated and molecularly characterized cytogenetically normal patients with de novo acute myeloid leukemia (18-83 years old) were analyzed for rs16754. To gain biological insights, we studied the gene- and microRNA-expression profiles for associations with rs16754. RESULTS Three-hundred and nine (71%) patients were homozygous for A (WT1(AA)), 112 (26%) were heterozygous (WT1(AG)) and 12 (3%) were homozygous for G (WT1(GG)). For comparison with previous studies, we grouped WT1(AG) and WT1(GG) patients and compared them with WT1(AA) patients divided into younger (<60 years) and older (≥60 years) adults. We found no independent prognostic impact of WT1(AA). However, WT1(GG) patients, who were less often Caucasian than WT1(AG) (P=0.001) or WT1(AA) (P=0.008) patients, and had TET2 mutations more often than WT1(AG) (P=0.02) patients, had, among patients with FLT3-internal tandem duplication and/or NPM1 wild-type, better disease-free (P=0.02) and overall survival (P=0.04) than WT1(AA) and WT1(AG) patients combined. Unsupervised and supervised analyses of the gene- and microRNA-expression profiles suggested that there were no distinct expression patterns associated with any rs16754 genotype. CONCLUSIONS We did not observe the previously reported adverse impact of WT1(AA) but found favorable outcomes associated with the homozygous WT1(GG). Considering its low frequency, confirmatory studies are necessary. The biological significance of rs16754 remains questionable as no distinct expression profiles were associated with the genotypes.
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Affiliation(s)
- Heiko Becker
- Division of Hematology, Department of Internal Medicine, Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Kati Maharry
- Division of Hematology, Department of Internal Medicine, Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
- The Cancer and Leukemia Group B Statistical Center, Duke University Medical Center, Durham, NC, USA
| | - Michael D. Radmacher
- Division of Hematology, Department of Internal Medicine, Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
- The Cancer and Leukemia Group B Statistical Center, Duke University Medical Center, Durham, NC, USA
| | - Krzysztof Mrózek
- Division of Hematology, Department of Internal Medicine, Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Klaus H. Metzeler
- Division of Hematology, Department of Internal Medicine, Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Susan P. Whitman
- Division of Hematology, Department of Internal Medicine, Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Sebastian Schwind
- Division of Hematology, Department of Internal Medicine, Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Jessica Kohlschmidt
- Division of Hematology, Department of Internal Medicine, Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
- The Cancer and Leukemia Group B Statistical Center, Duke University Medical Center, Durham, NC, USA
| | - Yue-Zhong Wu
- Division of Hematology, Department of Internal Medicine, Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Bayard L. Powell
- Comprehensive Cancer Center, Wake Forest University, Winston-Salem, NC, USA
| | | | | | | | | | | | | | - Michael A. Caligiuri
- Division of Hematology, Department of Internal Medicine, Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | | | - Guido Marcucci
- Division of Hematology, Department of Internal Medicine, Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
| | - Clara D. Bloomfield
- Division of Hematology, Department of Internal Medicine, Comprehensive Cancer Center, The Ohio State University, Columbus, OH, USA
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Lanasa MC, Davis PH, Datto M, Li Z, Gockerman JP, Moore JO, DeCastro CM, Friedman DR, Diehl LF, Rehder C, Cook H, Daugherty FJ, Matta KMB, Weinberg JB, Rizzieri D. Phase II study of cenersen, an antisense inhibitor of p53, in combination with fludarabine, cyclophosphamide and rituximab for high-risk chronic lymphocytic leukemia. Leuk Lymphoma 2011; 53:218-24. [PMID: 21827374 DOI: 10.3109/10428194.2011.610012] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Patients with chronic lymphocytic leukemia (CLL) with deletion or mutation of TP53 have exceedingly poor clinical outcomes. Cenersen, an oligonucleotide targeting TP53, has been shown to abrogate the activity of TP53 gain-of-function mutants and to increase sensitivity of lymphoma cells to cytotoxic chemotherapy in vitro. We combined cenersen with fludarabine, cyclophosphamide and rituximab (FCR) as treatment for patients with high-risk CLL. The purpose of this phase II study was to determine the overall response rate, response duration and toxicity of cenersen administered in combination with FCR. Twenty patients with relapsed or high-risk CLL were evaluated. Nineteen patients were previously treated. The complete response rate was 18%; the overall response rate was 53%. Median progression-free and overall survival was 5.3 and 10.6 months, respectively. The most common serious adverse events were neutropenia and thrombocytopenia. In this single arm phase II study, cenersen combined with FCR yielded clinical responses with acceptable toxicity in patients with high-risk CLL.
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Affiliation(s)
- Mark C Lanasa
- Duke University Medical Center, Durham, NC 27710, USA.
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Hoppe RT, Advani RH, Ai WZ, Ambinder RF, Bello CM, Bierman PJ, Blum KA, Dabaja B, Duron Y, Forero A, Gordon LI, Hernandez-Ilizaliturri FJ, Hochberg EP, Maloney DG, Mansur D, Mauch PM, Metzger M, Moore JO, Morgan D, Moskowitz CH, Poppe M, Pro B, Weiss L, Winter JN, Yahalom J. Hodgkin Lymphoma. J Natl Compr Canc Netw 2011; 9:1020-58. [DOI: 10.6004/jnccn.2011.0086] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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O'Donnell MR, Abboud CN, Altman J, Appelbaum FR, Coutre SE, Damon LE, Foran JM, Goorha S, Maness LJ, Marcucci G, Maslak P, Millenson MM, Moore JO, Ravandi F, Shami PJ, Smith BD, Stone RM, Strickland SA, Tallman MS, Wang ES. Acute myeloid leukemia. J Natl Compr Canc Netw 2011; 9:280-317. [PMID: 21393440 DOI: 10.6004/jnccn.2011.0027] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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40
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Metzeler KH, Maharry K, Radmacher MD, Mrózek K, Margeson D, Becker H, Curfman J, Holland KB, Schwind S, Whitman SP, Wu YZ, Blum W, Powell BL, Carter TH, Wetzler M, Moore JO, Kolitz JE, Baer MR, Carroll AJ, Larson RA, Caligiuri MA, Marcucci G, Bloomfield CD. TET2 mutations improve the new European LeukemiaNet risk classification of acute myeloid leukemia: a Cancer and Leukemia Group B study. J Clin Oncol 2011; 29:1373-81. [PMID: 21343549 DOI: 10.1200/jco.2010.32.7742] [Citation(s) in RCA: 254] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
PURPOSE To determine the frequency of TET2 mutations, their associations with clinical and molecular characteristics and outcome, and the associated gene- and microRNA-expression signatures in patients with primary cytogenetically normal acute myeloid leukemia (CN-AML). PATIENTS AND METHODS Four-hundred twenty-seven patients with CN-AML were analyzed for TET2 mutations by polymerase chain reaction and direct sequencing and for established prognostic gene mutations. Gene- and microRNA-expression profiles were derived using microarrays. RESULTS TET2 mutations, found in 23% of patients, were associated with older age (P < .001) and higher pretreatment WBC (P = .04) compared with wild-type TET2 (TET2-wt). In the European LeukemiaNet (ELN) favorable-risk group (patients with CN-AML who have mutated CEBPA and/or mutated NPM1 without FLT3 internal tandem duplication [FLT3-ITD]), TET2-mutated patients had shorter event-free survival (EFS; P < .001) because of a lower complete remission (CR) rate (P = .007), and shorter disease-free survival (DFS; P = .003), and also had shorter overall survival (P = .001) compared with TET2-wt patients. TET2 mutations were not associated with outcomes in the ELN intermediate-I-risk group (CN-AML with wild-type CEBPA and wild-type NPM1 and/or FLT3-ITD). In multivariable models, TET2 mutations were associated with shorter EFS (P = .004), lower CR rate (P = .03), and shorter DFS (P = .05) only among favorable-risk CN-AML patients. We identified a TET2 mutation-associated gene-expression signature in favorable-risk but not in intermediate-I-risk patients and found distinct mutation-associated microRNA signatures in both ELN groups. CONCLUSION TET2 mutations improve the ELN molecular-risk classification in primary CN-AML because of their adverse prognostic impact in an otherwise favorable-risk patient subset. Our data suggest that these patients may be candidates for alternative therapies.
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Affiliation(s)
- Klaus H Metzeler
- The Ohio State University Comprehensive Cancer Center, 1216 James Cancer Hospital, 300 West 10th Ave, Columbus, OH 43210, USA
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O'Brien S, Berman E, Moore JO, Pinilla-Ibarz J, Radich JP, Shami PJ, Smith BD, Snyder DS, Sundar HM, Talpaz M, Wetzler M. NCCN Task Force report: tyrosine kinase inhibitor therapy selection in the management of patients with chronic myelogenous leukemia. J Natl Compr Canc Netw 2011; 9 Suppl 2:S1-25. [PMID: 21335443 PMCID: PMC4234100 DOI: 10.6004/jnccn.2011.0125] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The advent of imatinib has dramatically improved outcomes in patients with chronic myelogenous leukemia (CML). It has become the standard of care for all patients with newly diagnosed chronic-phase CML based on its successful induction of durable responses in most patients. However, its use is complicated by the development of resistance in some patients. Dose escalation might overcome this resistance if detected early. The second-generation tyrosine kinase inhibitors (TKIs) dasatinib and nilotinib provide effective therapeutic options for managing patients resistant or intolerant to imatinib. Recent studies have shown that dasatinib and nilotinib provide quicker and potentially better responses than standard-dose imatinib when used as a first-line treatment. The goal of therapy for patients with CML is the achievement of a complete cytogenetic response, and eventually a major molecular response, to prevent disease progression to accelerated or blast phase. Selecting the appropriate TKI depends on many factors, including disease phase, primary or secondary resistance to TKI, the agent's side effect profile and its relative effectiveness against BCR-ABL mutations, and the patient's tolerance to therapy. In October 2010, NCCN organized a task force consisting of a panel of experts from NCCN Member Institutions with expertise in the management of patients with CML to discuss these issues. This report provides recommendations regarding the selection of TKI therapy for the management of patients with CML based on the evaluation of available published clinical data and expert opinion among the task force members.
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Cortes J, Moore JO, Maziarz RT, Wetzler M, Craig M, Matous J, Luger S, Dey BR, Schiller GJ, Pham D, Abboud CN, Krishnamurthy M, Brown A, Laadem A, Seiter K. Control of plasma uric acid in adults at risk for tumor Lysis syndrome: efficacy and safety of rasburicase alone and rasburicase followed by allopurinol compared with allopurinol alone--results of a multicenter phase III study. J Clin Oncol 2010; 28:4207-13. [PMID: 20713865 DOI: 10.1200/jco.2009.26.8896] [Citation(s) in RCA: 138] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
PURPOSE Rasburicase is effective in controlling plasma uric acid in pediatric patients with hematologic malignancies. This study in adults evaluated safety of and compared efficacy of rasburicase alone with rasburicase followed by oral allopurinol and with allopurinol alone in controlling plasma uric acid. PATIENTS AND METHODS Adults with hematologic malignancies at risk for hyperuricemia and tumor lysis syndrome (TLS) were randomly assigned to rasburicase (0.20 mg/kg/d intravenously days 1-5), rasburicase plus allopurinol (rasburicase 0.20 mg/kg/d days 1 to 3 followed by oral allopurinol 300 mg/d days 3 to 5), or allopurinol (300 mg/d orally days 1 to 5). Primary efficacy variable was plasma uric acid response rate defined as percentage of patients achieving or maintaining plasma uric acid ≤ 7.5 mg/dL during days 3 to 7. RESULTS Ninety-two patients received rasburicase, 92 rasburicase plus allopurinol, and 91 allopurinol. Plasma uric acid response rate was 87% with rasburicase, 78% with rasburicase plus allopurinol, and 66% with allopurinol. It was significantly greater for rasburicase than for allopurinol (P = .001) in the overall study population, in patients at high risk for TLS (89% v 68%; P = .012), and in those with baseline hyperuricemia (90% v 53%; P = .015). Time to plasma uric acid control in hyperuricemic patients was 4 hours for rasburicase, 4 hours for rasburicase plus allopurinol, and 27 hours for allopurinol. CONCLUSION In adults with hyperuricemia or at high risk for TLS, rasburicase provided control of plasma uric acid more rapidly than allopurinol. Rasburicase was well tolerated as a single agent and in sequential combination with allopurinol.
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Affiliation(s)
- Jorge Cortes
- MD Anderson Cancer Center, Houston, TX 77030, USA.
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Crout CA, Koh LP, Gockerman JP, Moore JO, Decastro C, Long GD, Diehl L, Gasparetto C, Niedzwiecki D, Edwards J, Prosnitz L, Horwitz M, Chute J, Morris A, Davis P, Beaven A, Chao NJ, Ali-Osman F, Rizzieri DA. Overcoming drug resistance in mantle cell lymphoma using a combination of dose-dense and intense therapy. Cancer Invest 2010; 28:654-60. [PMID: 20521909 DOI: 10.3109/07357901003631015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We present a study of the prevalence of genetic polymorphisms and expression of genes encoding the drug-resistance proteins glutathione S-transferases (GSTs) in order to gain insights into the pattern of failure evident in mantle cell lymphoma. We note a high preponderance of genetic alterations conferring resistance to standard chemotherapy in this illness. Concurrent with this investigation, we present a series of patients who were provided dose-dense and intense chemotherapy to circumvent these drug-resistance mechanisms. High responses were noted, though durable remissions were few, indicating non-traditional chemotherapy options are important to investigate in this illness.
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Affiliation(s)
- Christopher A Crout
- Duke University Medical Center, Department of Medicine, Division of Oncology and Stem Cell Transplantation, Adult Bone Marrow Transplantation Program, Durham, NC, USA
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44
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Friedman DR, Weinberg JB, Barry WT, Goodman BK, Volkheimer AD, Bond KM, Chen Y, Jiang N, Moore JO, Gockerman JP, Diehl LF, Decastro CM, Potti A, Nevins JR. A genomic approach to improve prognosis and predict therapeutic response in chronic lymphocytic leukemia. Clin Cancer Res 2009; 15:6947-55. [PMID: 19861443 DOI: 10.1158/1078-0432.ccr-09-1132] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Chronic lymphocytic leukemia (CLL) is a B-cell malignancy characterized by a variable clinical course. Several parameters have prognostic capabilities but are associated with altered response to therapy in only a small subset of patients. EXPERIMENTAL DESIGN We used gene expression profiling methods to generate predictors of therapy response and prognosis. Genomic signatures that reflect progressive disease and responses to chemotherapy or chemoimmunotherapy were created using cancer cell lines and patient leukemia cell samples. We validated and applied these three signatures to independent clinical data from four cohorts, representing a total of 301 CLL patients. RESULTS A genomic signature of prognosis created from patient leukemic cell gene expression data coupled with clinical parameters significantly differentiated patients with stable disease from those with progressive disease in the training data set. The progression signature was validated in two independent data sets, showing a capacity to accurately identify patients at risk for progressive disease. In addition, genomic signatures that predict response to chlorambucil or pentostatin, cyclophosphamide, and rituximab were generated and could accurately distinguish responding and nonresponding CLL patients. CONCLUSIONS Thus, microarray analysis of CLL lymphocytes can be used to refine prognosis and predict response to different therapies. These results have implications for standard and investigational therapeutics in CLL patients.
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Affiliation(s)
- Daphne R Friedman
- Divisions of Hematology, Oncology, and Cellular Therapy, Duke Institute for Genome Sciences and Policy, Durham VA Medical Center, Durham, North Carolina, USA
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O'Brien S, Berman E, Borghaei H, Deangelo DJ, Devetten MP, Devine S, Erba HP, Gotlib J, Jagasia M, Moore JO, Mughal T, Pinilla-Ibarz J, Radich JP, Shah Md NP, Shami PJ, Smith BD, Snyder DS, Tallman MS, Talpaz M, Wetzler M. NCCN clinical practice guidelines in oncology: chronic myelogenous leukemia. J Natl Compr Canc Netw 2009; 7:984-1023. [PMID: 19878641 DOI: 10.6004/jnccn.2009.0065] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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O'Brien S, Moore JO, Boyd TE, Larratt LM, Skotnicki AB, Koziner B, Chanan-Khan AA, Seymour JF, Gribben J, Itri LM, Rai KR. 5-year survival in patients with relapsed or refractory chronic lymphocytic leukemia in a randomized, phase III trial of fludarabine plus cyclophosphamide with or without oblimersen. J Clin Oncol 2009; 27:5208-12. [PMID: 19738118 DOI: 10.1200/jco.2009.22.5748] [Citation(s) in RCA: 128] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE A randomized trial of oblimersen plus fludarabine/cyclophosphamide (OBL-FC; n = 120) versus FC (n = 121) was conducted in patients with relapsed/refractory chronic lymphocytic leukemia (CLL). The primary end point was met: the complete response (CR) rate, defined as complete or nodular partial response, was significantly greater with OBL-FC than with FC (17% v 7%; P = .025). Among patients with CR, response duration was significantly longer with OBL-FC than with FC (median not reached; > 36 months v 22 months; P = .03). Maximum benefit with OBL-FC, including a four-fold increase in CR rate and a survival benefit with 3 years of follow-up (hazard ratio, 0.53; P = .05), was observed in patients with fludarabine-sensitive disease. We evaluated long-term survival and poststudy CLL therapy among all randomly assigned patients. METHODS Poststudy CLL treatment information was collected. Patients were observed for survival for up to 5 years from the date of random assignment. RESULTS Poststudy CLL treatment was balanced between arms. Intent-to-treat analysis of 5-year survival showed no significant between-treatment difference (hazard ratio, 0.87; P = .34). Among the greater than 40% of patients with complete or partial remission, a significant 5-year survival benefit was observed with OBL-FC (hazard ratio, 0.60; P = .038). Among patients with fludarabine-sensitive disease who had previously demonstrated maximum benefit with OBL-FC, the previously observed survival benefit improved: a 50% reduction in the risk of death was observed (P = .004). CONCLUSION In relapsed/refractory CLL, OBL combined with FC offers patients who achieve complete or partial remission, as well as those who have fludarabine-sensitive disease, a significant survival benefit.
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Affiliation(s)
- Susan O'Brien
- Division of Hematology, The University of Texas M. D. Anderson Cancer Center, Houston, TX 77030, USA.
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Gasparetto C, Gockerman JP, Diehl LF, de Castro CM, Moore JO, Long GD, Horwitz ME, Keogh G, Chute JP, Sullivan KM, Neuwirth R, Davis PH, Sutton LM, Anderson RD, Chao NJ, Rizzieri D. "Short course" bortezomib plus melphalan and prednisone as induction prior to transplant or as frontline therapy for nontransplant candidates in patients with previously untreated multiple myeloma. Biol Blood Marrow Transplant 2009; 16:70-7. [PMID: 19733251 DOI: 10.1016/j.bbmt.2009.08.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2009] [Accepted: 08/30/2009] [Indexed: 10/20/2022]
Abstract
The purpose of this study was to evaluate the efficacy and safety of short-course bortezomib, melphalan, prednisone (VMP) in previously untreated multiple myeloma as frontline therapy for transplant-ineligible patients and induction prior to autologous stem cell transplantation (ASCT). Patients received up to 6 28-day cycles of bortezomib 1.3 mg/m(2), days 1, 4, 8, and 11, plus melphalan 6 mg/m(2) and prednisone 60 mg/m(2), days 1-7. After 2-6 cycles, eligible and consenting patients could proceed to ASCT. Responses were assessed by International Uniform Response Criteria. The primary endpoint was complete response (CR) rate with VMP. Forty-five patients were enrolled. Among 44 evaluable patients, response rate was 95%, including 18% >or=CR (9% stringent CR), 27% very good partial responses (VGPR), and 50% partial responses (PR). Twenty patients proceeded to ASCT. Stem cell collection was successful in all; median yield was 5.6 x 10(6) CD34(+) cells/kg. Posttransplant response rates were 30% >or=CR (10% stringent CR), 65% VGPR, and 5% PR. After median follow-up of 14.0/14.6 months, median time to progression and progression-free survival were both 19.8/27.9 months in non-ASCT/ASCT patients. Seven patients have died; 1-year survival rates were 82%/95% in non-ASCT/ASCT patients. The most common grade 3/4 toxicities were thrombocytopenia (20%), neutropenia (28%), and infection (9%). Peripheral neuropathy grade 2-4 was the most common nonhematopoietic side effect occurring 17 patients (38%), although it was typically reversible, and only 5 patients (11%) discontinued therapy as a result of it. Short-course VMP is highly effective and generally well tolerated, both as initial treatment in non-ASCT patients and induction prior to ASCT. VMP did not negatively affect stem cell collection. Longer follow-up and prospective phase III trials are required to validate these initial observations.
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Affiliation(s)
- Cristina Gasparetto
- Department of Cellular Therapy, Duke University Medical Center, Durham, NC 27710, USA.
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Rizzieri DA, O'Brien JA, Broadwater G, Decastro CM, Dev P, Diehl L, Beaven A, Lagoo A, Gockerman JP, Chao NJ, Moore JO. Outcomes of patients who undergo aggressive induction therapy for secondary acute myeloid leukemia. Cancer 2009; 115:2922-9. [PMID: 19452542 DOI: 10.1002/cncr.24379] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Response and survival in 96 patients with secondary acute myeloid leukemia (sAML) who received aggressive induction chemotherapy was reviewed. METHODS The median follow-up of survivors was 2.3 years. A total of 70 (73%) patients achieved a morphologic complete remission (CR) confirmed by absence of leukemic blasts by flow cytometry. RESULTS For all 96 patients, the median event-free survival (EFS) was 8 months, and overall survival (OS) was 13.6 months (range, 1-119 months). Eight patients died shortly after induction therapy because of disease or side effects, and 13 are currently in continuous first remission. The median disease-free survival (DFS) for all 70 patients who achieved a morphologic CR was 9 months (range, 1-51 months), with a 64% chance of surviving 1 year. Patients with AML after previous chemotherapy or radiation therapy had a higher morphologic remission rate compared with those arising from myelodysplastic syndrome or myeloproliferative disease (82% vs 62%; P = .027). However, among the patients from the 2 groups who attained a morphologic remission, there was no difference in terms of CR rate (P = .94), DFS, EFS, or OS (P = .55, .83, and .71, respectively). This is a similar DFS to the group of 7 patients who went directly to ablative allogeneic transplant rather than having induction therapy first. In this population of patients who received aggressive chemotherapy, Charlson comorbidity index or a higher number of factors recognized as high risk in leukemia patients did not affect the chance of OS, DFS, and EFS, although having more recognized leukemia risk factors was related to a lower chance of surviving 1 year. However, it is important to note that those with higher comorbidity indexes were underrepresented in this aggressively treated cohort. CONCLUSIONS The data from the current study demonstrate that many patients with sAML can tolerate aggressive induction therapy and attain remission, but duration of response and the chance of long-term survival remain poor.
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Affiliation(s)
- David A Rizzieri
- Department of Medicine, Division of Cellular Therapy, Duke University Medical Center, Durham, North Carolina 27710, USA.
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Rao AV, Younis IR, Sand GJ, Spasojevic I, Adams DJ, Decastro CM, Gockerman JP, Peterson BL, Petros WP, Moore JO, Rizzieri DA. Phase I evaluation of gemcitabine, mitoxantrone, and their effect on plasma disposition of fludarabine in patients with relapsed or refractory acute myeloid leukemia. Leuk Lymphoma 2008; 49:1523-9. [PMID: 18766965 DOI: 10.1080/10428190802210700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Our aim was to estimate the duration of maximum tolerated dose (MTD) duration for gemcitabine given as a continuous infusion in combination with fludarabine and mitoxantrone and to evaluate potential pharmacokinetic (PK) interactions in 17 patients with refractory or relapsed acute myeloid leukaemia (AML). Gemcitabine was administered at 10 mg/m(2)/min for 3-15 h, fludarabine at 25 mg/m(2) daily for days 1-5 and mitoxantrone at 10 mg/m(2) daily on days 1-3. PK studies revealed that fludarabine clearance was not affected by gemcitabine but mean terminal half-life and volume of distribution of fludarabine were slightly increased. The duration of MTD for gemcitabine was 12 h. Our previous in vitro work has demonstrated the binary combination of gemcitabine + fludarabine is most synergistic at a molar ratio around 0.002. However, with MTD dosing this drug ratio is not optimal to produce synergy and future studies using ratiometric dosing are required to confirm these findings.
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Affiliation(s)
- Arati V Rao
- Department of Medicine, Divisions of Medical Oncology, Pharmacology, and Cellular Therapy, Duke University Medical Center, Durham, NC 27710, USA.
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O'Donnell MR, Appelbaum FR, Coutre SE, Damon LE, Erba HP, Foran J, Lancet J, Maness LJ, Marcucci G, Maslak PG, Millenson M, Moore JO, Ravandi F, Schuening F, Shami P, Smith BD, Stone RM, Tallman MS, Wang E, White FL. Acute myeloid leukemia. J Natl Compr Canc Netw 2008; 6:962-93. [PMID: 19176196 DOI: 10.6004/jnccn.2008.0074] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Approximately 13,290 people will be diagnosed with acute myeloid leukemia (AML) in 2008, and 8820 patients will die of the disease. As the population ages, the incidence of AML, along with myelodysplasia, appears to be rising. Clinical trials have led to significant treatment improvements in some areas, primarily acute promyelocytic leukemia. However, recent large clinical trials have highlighted the need for new, innovative strategies, because outcomes for AML patients have not substantially changed in the past 3 decades. The NCCN AML Panel has focused on outlining reasonable treatment options based on recent clinical trials and data from basic science, which may identify new risk factors and treatment approaches. These guidelines attempt to provide a rationale for including several treatment options in some categories, as divergent opinions about the relative risks and benefits of various treatment options have surfaced. Updates for 2009 include new clarifications of some treatment recommendations as well as for defining polymerase chain reaction positivity.
For the most recent version of the guidelines, please visit NCCN.org
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