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Maffini E, Labopin M, Kröger N, Finke J, Stelljes M, Schroeder T, Einsele H, Tischer J, Bornhäuser M, Bethge W, Brecht A, Rösler W, Dreger P, Schäfer-Eckart K, Passweg J, Blau IW, Nagler A, Ciceri F, Mohty M. Allogeneic hematopoietic cell transplantation for older patients with AML with active disease. A study from the Acute Leukemia Working Party of the European Society for Blood and Marrow Transplantation (EBMT). Bone Marrow Transplant 2024:10.1038/s41409-024-02275-6. [PMID: 38555412 DOI: 10.1038/s41409-024-02275-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 03/20/2024] [Accepted: 03/21/2024] [Indexed: 04/02/2024]
Abstract
Older adults with acute myeloid leukemia (AML) refractory to initial or reinduction chemotherapy have a dismal prognosis if they do not undergo hematopoietic stem-cell transplantation (HCT). However, data assessing HCT outcomes from different donors are scarce. We evaluated results from a retrospective analysis on patients aged ≥70 years, with AML not in remission who received an allogeneic HCT from HLA-matched sibling donor (MSD), HLA-10/10 matched unrelated donor (MUD), or T-cell replete haploidentical (Haplo) donor, from 2010 to 2021, reported to the ALWP-EBMT database. A total of 360 patients (median age 72 years, range 70-79) were included in the analysis. Median follow-up for the entire population was 35.5 months. Donors were MSD (n = 58), 10/10 HLA-MUD (n = 228), and Haplo (n = 74). A total of 213 (59.2%) patients were primary induction failures, while 147 (40.8%) were in first or subsequent relapse. Graft source was peripheral blood in 92% of the patients. Patients transplanted from Haplo donors more frequently received marrow grafts (p < 0.01) and presented the combination female donor to male recipient (p < 0.01). The overall 2-year rates of overall survival (OS) and leukemia-free survival (LFS) were: 62.4% (95% CI 47.2-74.3) and 47.6% (95% CI 33.1-60.8) for MSD, 43% (95% CI 35.8-49.9), and 37.5% (95% CI 30.7-44.4) for MUD, and 25.9% (95% CI 15.8-37.2), and 26.5% (95% CI 16.3-37.8) for recipients of Haplo transplants. The 2-year cumulative incidence of relapse (RI) was slightly lower for Haplo recipients at 29.6% (95% CI 19-40.9), for MUD it was 30.2% (95% CI 23.9-36.7), and for MSD 34.9% (95% CI 22-48.2); counterbalanced by a higher incidence of non-relapse mortality (NRM) of 43.9% (95% CI 31.6-55.6) for Haplo recipients, 32.2% (95% CI 26-33.1) for MUD and 17.5% (95% CI 8.4-29.3) for MSD. Graft-versus-host disease (GVHD-free, relapse-free survival (GRFS) was 35.3% (95% CI 22.3-48.5) for MSD, 29.6% (95% CI 23.2-36.2) for MUD, and 19.2% (95% CI 10.7-29.6) for Haplo patients. In the multivariate model, compared to the referent group of MSD recipients, the risk of NRM was higher among patients transplanted from Haplo donors ([hazard ratio] HR 5.1, 95% CI 2.23-11.61, p < 0.001) and MUD (HR 3.21, 95% CI 1.48-0.6.94, p = 0.003). Furthermore, both Haplo and MUD were associated with inferior OS, (HR 3.6, 95% CI 1.98-0.6.56, p < 0.001, and HR 2.3, 95% CI 1.37-0.3.88, p = 0.002, respectively), and LFS (HR 2.24, 95% CI 1.31-0.3.84, p = 0.003, and HR 1.64, 95% CI 1.04-0.2.60, p = 0.034, respectively). Patients transplanted from Haplo donors were also associated with worse GFRS (HR 1.72, 95% CI 1.07-2.77, p:0.025) compared with MSD patients. Older adult AML patients with active disease transplanted from MSD experienced prolonged OS and LFS compared to 10/10 MUD and Haplo due to lower NRM. Prospective clinical trials are warranted.
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Affiliation(s)
- Enrico Maffini
- IRCCS Azienda Ospedaliero-Universitaria di Bologna; Istituto "L. e A. Seràgnoli", Bologna, Italy.
| | | | - Nicolaus Kröger
- University Medical Center Hamburg, Department for Stem Cell Transplantation, Hamburg, Germany
| | - Jürgen Finke
- Department of Medicine -Hematology Oncology, University of Freiburg, Freiburg, Germany
| | - Matthias Stelljes
- Department of Medicine A, Hematology, Oncology, and Pneumology, University Hospital Münster, Münster, Germany
| | - Thomas Schroeder
- University Hospital, Department of Bone Marrow Transplantation, Essen, Germany
| | - Herman Einsele
- Universitaetsklinikum Wuerzburg, Med. Klinik und Poliklinik II, Wuerzburg, Germany
| | - Johanna Tischer
- Klinikum Grosshadern, Medizinische Klinik III, Munich, Germany
| | - Martin Bornhäuser
- Universitaetsklinikum Dresden, Medizinische Klinik und Poliklinik I, Dresden, Germany
| | - Wolfgang Bethge
- Universitaet Tuebingen Medizinische Klinik, Tuebingen, Germany
| | - Arne Brecht
- Deutsche Klinik fuer Diagnostik, KMT Zentrum, Wiesbaden, Germany
| | - Wolf Rösler
- University Hospital Erlangen, Department of Internal Medicine 5, Erlangen, Germany
| | - Peter Dreger
- University of Heidelberg, Medizinische Klinik u. Poliklinik V, Heidelberg, Germany
| | | | | | - Igor Wolfgang Blau
- Medizinische Klinik m. S. Hämatologie, Onkologie und Tumorimmunologie, Charité Universitätsmedizin, Berlin, Germany
| | - Arnon Nagler
- Sheba Medical Center, Tel-Hashomer, Tel-Aviv University, Ramat-Gan, Israel
| | - Fabio Ciceri
- Ospedale San Raffaele s.r.l., Haematology and BMT, Milano, Italy
| | - Mohamad Mohty
- Sorbonne University, Clinical Hematology and Cellular Therapy Department, Saint Antoine Hospital, INSERM UMRs 938, Paris, France
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2
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Weisdorf DJ, Millard HR, Horowitz MM, Hyare PS, Champlin R, Ho V, Mielcarek M, Rezvani A, Stockerl-Goldstein K, Khoury HJ, De Lima M, Saber W, Sandmaier B, Zhang MJ, Eapen M. Allogeneic transplantation for advanced acute myeloid leukemia: The value of complete remission. Cancer 2017; 123:2025-2034. [PMID: 28117884 DOI: 10.1002/cncr.30536] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 10/25/2016] [Accepted: 12/09/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND Patients with acute myeloid leukemia (AML) without complete remission (CR) or in first relapse (Rel1) can have extended leukemia control and survival after allogeneic hematopoietic cell transplantation (HCT). For patients in Rel1 or primary induction failure (PIF), transplantation versus treatment to achieve a second CR (CR2) and subsequent HCT might yield similar outcomes, but available comparative data are scarce. METHODS Survival was analyzed in 4682 HCT recipients according to disease status: PIF (N = 1440), Rel1 (failing ≥1 reinduction; N = 1256), and CR2 (N = 1986). RESULTS Patient, disease, and transplantation characteristics were similar, except that patients in CR2 more often had performance scores of 90% to 100%, de novo AML, and longer CR1 duration. Adverse cytogenetics were more common in patients who experienced PIF. The 5-year survival rate adjusted for performance score, cytogenetic risk, and donor type for CR2 was 39% (95% confidence interval [CI], 37%-41%) compared with 18% (95% CI, 16%-20%) for HCT in Rel1 and 21% (95% CI, 19%-23%) in PIF (P < .0001). CONCLUSIONS Although survival is superior for patients who undergo HCT in CR2, transplantation for selected patients in Rel1 or PIF may still be valuable. These data can guide decision making about additional salvage therapy versus prompt HCT for patients not in CR, but they also highlight that AML is intrinsically more treatable in patients who have favorable-risk cytogenetics, those with longer CR1 duration, and younger patients with better performance status. Cancer 2017;123:2025-2034. © 2017 American Cancer Society.
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Affiliation(s)
- Daniel J Weisdorf
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Heather R Millard
- Center for International Blood and Marrow Transplantation (CIBMTR), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mary M Horowitz
- Center for International Blood and Marrow Transplantation (CIBMTR), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Richard Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Vincent Ho
- Center for Hematologic Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Marco Mielcarek
- Adult Blood and Marrow Transplant Program, Fred Hutchinson Cancer Research Center, Seattle Cancer Care Alliance, Seattle, Washington
| | - Andrew Rezvani
- Division of Blood and Marrow Transplantation, Stanford Health Care, Stanford, California
| | | | - Hanna J Khoury
- Hematology/Oncology, Emory University School of Medicine, Emory University Hospital, Atlanta, Georgia
| | - Marcos De Lima
- Department of Medicine, Seidman Cancer Center, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Wael Saber
- Center for International Blood and Marrow Transplantation (CIBMTR), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Brenda Sandmaier
- Division of Medical Oncology, University of Washington and Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Mei Jie Zhang
- Center for International Blood and Marrow Transplantation (CIBMTR), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin.,Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mary Eapen
- Center for International Blood and Marrow Transplantation (CIBMTR), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
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3
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Liu N, Ning HM, Hu LD, Jiang M, Xu C, Hu JW, Wang J, Li YH, Li BT, Lou X, Yang F, Chen JL, Su YF, Li M, Wang HY, Ren J, Feng YQ, Zhang B, Wang DH, Chen H. Outcome of myeloablative allogeneic peripheral blood hematopoietic stem cell transplantation for refractory/relapsed AML patients in NR status. Leuk Res 2015; 39:1375-81. [PMID: 26530539 DOI: 10.1016/j.leukres.2015.10.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 10/13/2015] [Accepted: 10/14/2015] [Indexed: 10/22/2022]
Abstract
To further find effective method to improve the long term survival of refractory or relapsed acute myeloid leukemia (AML) patients, we retrospectively analyzed the outcomes of myeloablative hematopoietic stem cell transplantation (HSCT) for 133 consecutive patients with acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS) therapy related AML(t-AML) in not remission status. The overall 3-year OS and DFS were 40.9% and 35.6% respectively. The variables associated with improved long term DFS were a bone marrow blast cell count less than 20% and an intensified conditioning regimen. In addition, the t-AML group had higher rates of relapse and III-IV acute GVHD than the primary AML group. The unrelated donor group had similar OS and DFS with sibling groups. Our study suggested that decreasing bone marrow blast cell counts before HSCT and strengthening the conditioning regimen may improve long-term DFS for refractory/relapsed AML patients, and unrelated donor group can get similar effect when compared to the sibling group.
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Affiliation(s)
- Na Liu
- Department of Hematopoietic Stem Cell Transplantation Center, Affiliated Hospital to Academy of Military Medical Science (307Hospital, PLA), China
| | - Hong-Mei Ning
- Department of Hematopoietic Stem Cell Transplantation Center, Affiliated Hospital to Academy of Military Medical Science (307Hospital, PLA), China
| | - Liang-Ding Hu
- Department of Hematopoietic Stem Cell Transplantation Center, Affiliated Hospital to Academy of Military Medical Science (307Hospital, PLA), China
| | - Min Jiang
- Department of Hematopoietic Stem Cell Transplantation Center, Affiliated Hospital to Academy of Military Medical Science (307Hospital, PLA), China
| | - Chen Xu
- Department of Hematopoietic Stem Cell Transplantation Center, Affiliated Hospital to Academy of Military Medical Science (307Hospital, PLA), China
| | - Jiang-Wei Hu
- Department of Hematopoietic Stem Cell Transplantation Center, Affiliated Hospital to Academy of Military Medical Science (307Hospital, PLA), China
| | - Jun Wang
- Department of Hematopoietic Stem Cell Transplantation Center, Affiliated Hospital to Academy of Military Medical Science (307Hospital, PLA), China
| | - Yu-Hang Li
- Department of Hematopoietic Stem Cell Transplantation Center, Affiliated Hospital to Academy of Military Medical Science (307Hospital, PLA), China
| | - Bo-Tao Li
- Department of Hematopoietic Stem Cell Transplantation Center, Affiliated Hospital to Academy of Military Medical Science (307Hospital, PLA), China
| | - Xiao Lou
- Department of Hematopoietic Stem Cell Transplantation Center, Affiliated Hospital to Academy of Military Medical Science (307Hospital, PLA), China
| | - Fan Yang
- Department of Hematopoietic Stem Cell Transplantation Center, Affiliated Hospital to Academy of Military Medical Science (307Hospital, PLA), China
| | - Jian-Lin Chen
- Department of Hematopoietic Stem Cell Transplantation Center, Affiliated Hospital to Academy of Military Medical Science (307Hospital, PLA), China
| | - Yong-Feng Su
- Department of Hematopoietic Stem Cell Transplantation Center, Affiliated Hospital to Academy of Military Medical Science (307Hospital, PLA), China
| | - Meng Li
- Department of Hematopoietic Stem Cell Transplantation Center, Affiliated Hospital to Academy of Military Medical Science (307Hospital, PLA), China
| | - Hong-Ye Wang
- Department of Hematopoietic Stem Cell Transplantation Center, Affiliated Hospital to Academy of Military Medical Science (307Hospital, PLA), China
| | - Jing Ren
- Department of Hematopoietic Stem Cell Transplantation Center, Affiliated Hospital to Academy of Military Medical Science (307Hospital, PLA), China
| | - Yue-Qian Feng
- Department of Hematopoietic Stem Cell Transplantation Center, Affiliated Hospital to Academy of Military Medical Science (307Hospital, PLA), China
| | - Bin Zhang
- Department of Hematopoietic Stem Cell Transplantation Center, Affiliated Hospital to Academy of Military Medical Science (307Hospital, PLA), China
| | - Dan-Hong Wang
- Department of Hematopoietic Stem Cell Transplantation Center, Affiliated Hospital to Academy of Military Medical Science (307Hospital, PLA), China
| | - Hu Chen
- Department of Hematopoietic Stem Cell Transplantation Center, Affiliated Hospital to Academy of Military Medical Science (307Hospital, PLA), China.
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4
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Jabbour E, Daver N, Champlin R, Mathisen M, Oran B, Ciurea S, Khouri I, Cornelison AM, Ghanem H, Cardenas- Turanzas M, Popat U, Ravandi F, Giralt S, Garcia-Manero G, Cortes J, Kantarjian H, de Lima M. Allogeneic stem cell transplantation as initial salvage for patients with acute myeloid leukemia refractory to high-dose cytarabine-based induction chemotherapy. Am J Hematol 2014; 89:395-8. [PMID: 24375514 DOI: 10.1002/ajh.23655] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Revised: 12/16/2013] [Accepted: 12/19/2013] [Indexed: 11/06/2022]
Abstract
Outcomes of patients with acute myeloid leukemia (AML) who are refractory to high-dose Cytarabine (HiDAC)-based induction are dismal. Allogeneic hematopoietic stem cell transplantation (AHSCT) as initial salvage may be effective and potentially superior to conventional salvage chemotherapy. Eighteen percent (285 of 1597) of AML patients were primary refractory to HiDAC-based regimens at the MD Anderson Cancer Center between 1995 and 2009. AHSCT was the initial salvage in 28 cases. These patients were compared against 149 patients who received salvage chemotherapy, but never received AHSCT. Patients receiving salvage chemotherapy were older, had higher bone marrow blasts percentage, and higher incidence of unfavorable cytogenetics (P < 0.001). Median time from induction to AHSCT was 76 days. Objective response was achieved in 23 of 28 patients (82%) undergoing AHSCT. The incidence of grade III/IV acute and chronic graft versus-host-disease was 11% and 29%, respectively. Median follow up for living patients is 80 months. Median overall survival (OS) was 15.7 months and 2.9 months for AHSCT and chemotherapy, respectively (P < 0.001); the 3-year OS rates were 39% and 2%, respectively. ASHCT as initial salvage therapy was identified as an independent prognostic factor for survival in multivariate analysis (HR = 3.03; P < 0.001). Initial salvage therapy with AHSCT in patients with primary HiDAC refractory AML is feasible and may yield superior outcomes to salvage chemotherapy.
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Affiliation(s)
- Elias Jabbour
- Department of Leukemia; U.T. M.D. Anderson Cancer Center; Houston Texas
| | - Naval Daver
- Department of Leukemia; U.T. M.D. Anderson Cancer Center; Houston Texas
| | - Richard Champlin
- Department of Cellular therapy and stem cell transplantation; U.T. M.D. Anderson Cancer Center; Houston Texas
| | - Michael Mathisen
- Department of Leukemia; U.T. M.D. Anderson Cancer Center; Houston Texas
| | - Betul Oran
- Department of Cellular therapy and stem cell transplantation; U.T. M.D. Anderson Cancer Center; Houston Texas
| | - Stefan Ciurea
- Department of Cellular therapy and stem cell transplantation; U.T. M.D. Anderson Cancer Center; Houston Texas
| | - Issa Khouri
- Department of Cellular therapy and stem cell transplantation; U.T. M.D. Anderson Cancer Center; Houston Texas
| | - A Megan Cornelison
- Department of Cellular therapy and stem cell transplantation; U.T. M.D. Anderson Cancer Center; Houston Texas
| | - Hady Ghanem
- Department of Leukemia; U.T. M.D. Anderson Cancer Center; Houston Texas
| | | | - Uday Popat
- Department of Cellular therapy and stem cell transplantation; U.T. M.D. Anderson Cancer Center; Houston Texas
| | - Farhad Ravandi
- Department of Leukemia; U.T. M.D. Anderson Cancer Center; Houston Texas
| | - Sergio Giralt
- Department of Cellular therapy and stem cell transplantation; U.T. M.D. Anderson Cancer Center; Houston Texas
| | | | - Jorge Cortes
- Department of Leukemia; U.T. M.D. Anderson Cancer Center; Houston Texas
| | - Hagop Kantarjian
- Department of Leukemia; U.T. M.D. Anderson Cancer Center; Houston Texas
| | - Marcos de Lima
- University Hospitals Seidman Cancer Center, Case Western Reserve University; Cleveland Ohio
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5
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Bacher U, Klyuchnikov E, Wiedemann B, Kroeger N, Zander AR. Safety of conditioning agents for allogeneic haematopoietic transplantation. Expert Opin Drug Saf 2009; 8:305-15. [DOI: 10.1517/14740330902918273] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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6
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Oyekunle AA, Kröger N, Zabelina T, Ayuk F, Schieder H, Renges H, Fehse N, Waschke O, Fehse B, Kabisch H, Zander AR. Allogeneic stem-cell transplantation in patients with refractory acute leukemia: a long-term follow-up. Bone Marrow Transplant 2005; 37:45-50. [PMID: 16258531 DOI: 10.1038/sj.bmt.1705207] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
We examined retrospectively 44 patients with refractory acute leukemia (acute myeloid leukemia (AML)/acute lymphoblastic leukemia=25/19) who underwent allogeneic transplantation at our center between 11/1990 and 04/2004. The median leukemic blasts was 25% and age 28 years (range, 3-56). Twenty-one patients had untreated relapse, 13 failed reinduction, eight in partial remission and two aplastic. Conditioning was myeloablative using cyclophosphamide, busulfan, total-body irradiation and etoposide (Bu/Cy/VP, n=22; TBI/Cy/VP, n=17; others, n=5) followed by marrow or peripheral blood transplant (n=23/21) from unrelated or related donors (n=28/16). All patients had graft-versus-host disease (GVHD) prophylaxis with cyclosporin and methotrexate. One patient experienced late graft failure. Severe acute-GVHD and chronic-GVHD appeared in eight and 14 patients, respectively. Thirteen patients (30%) remain alive after a median of 25.3 months (range, 2.4-134.1); with 31 deaths, mostly from relapse (n=15) and infections (n=12). Overall survival (OS) and progression-free survival (PFS) at 5 years was 28 and 26%, respectively. OS and PFS were significantly better with blasts < or =20% and time to transplant < or =1 year while transplant-related mortality was less with the use of TBI. We conclude that patients with refractory leukemia can benefit from allogeneic BMT, especially with < or =20% marrow blast.
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MESH Headings
- Adolescent
- Adult
- Blast Crisis/complications
- Blast Crisis/mortality
- Blast Crisis/pathology
- Blast Crisis/therapy
- Busulfan/administration & dosage
- Child
- Child, Preschool
- Cyclophosphamide/administration & dosage
- Disease-Free Survival
- Female
- Graft vs Host Disease/etiology
- Graft vs Host Disease/prevention & control
- Humans
- Leukemia, Myeloid, Acute/complications
- Leukemia, Myeloid, Acute/mortality
- Leukemia, Myeloid, Acute/pathology
- Leukemia, Myeloid, Acute/therapy
- Male
- Middle Aged
- Myeloablative Agonists/administration & dosage
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/complications
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/mortality
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/pathology
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/therapy
- Retrospective Studies
- Stem Cell Transplantation
- Transplantation Conditioning
- Transplantation, Homologous
- Whole-Body Irradiation/methods
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Affiliation(s)
- A A Oyekunle
- Department of Bone Marrow Transplantation, University-Hospital Hamburg-Eppendorf, Hamburg, Germany.
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7
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Song KW, Lipton J. Is it appropriate to offer allogeneic hematopoietic stem cell transplantation to patients with primary refractory acute myeloid leukemia? Bone Marrow Transplant 2005; 36:183-91. [PMID: 15937497 DOI: 10.1038/sj.bmt.1705038] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Although continued advances have been made in the treatment of acute myeloid leukemia (AML), approximately 20-30% of patients will never achieve a remission. For these patients with primary refractory AML, the only curative option remains an allogeneic stem cell transplant. Allogeneic transplantation provides the ability to administer myeloablative doses of chemotherapy or chemoradiotherapy, as well as the advantage of a possible graft-versus-leukemia effect. Difficulty in interpreting the literature is due to selection bias, in particular, the varying definitions of primary refractory disease with respect to the morphological criteria and the number of induction regimen required before being defined as being refractory. Regardless, it is a procedure with high treatment-related mortality and risk of relapse. Most studies demonstrate an event-free survival of 10-20% at 5 years. Predictive factors of outcome include blast cell count in the marrow, karyotype, the number of prior regimen, age, performance status and availability of a related donor. These prognostic factors should be considered prior to offering allogeneic transplantation for primary refractory AML. Those patients with many favorable prognostic factors and an HLA-matched related donor available would be the best candidate for the procedure. Those with many poor prognostic factors and only an unrelated donor available may be better served by being offered palliation or being enrolled in investigational studies.
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Affiliation(s)
- K W Song
- The Leukemia/Bone Marrow Transplantation Program of British Columbia, Vancouver Hospital and Health Sciences Center, British Columbia Cancer Agency, University of British Columbia, Vancouver, British Columbia, Canada.
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8
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Abstract
Although the cure of acute leukaemia has improved significantly, many patients will still relapse and die. The unraveling of the molecular pathogenesis of acute leukaemia has lead to the identification of new prognostic factors and improved the detection of minimal residual disease. The treatment of relapsed acute leukaemia with chemotherapy remains unsatisfactory. Allogeneic or autologous blood and marrow transplant (BMT) can cure a subset of patients with relapsed acute leukaemia. The identification of the graft-vs-leukaemia (GVL) effect has lead to the development of donor lymphocyte infusions to re-induce remission in patients with relapsed leukaemia after allogeneic BMT and also stimulated the development of the less toxic nonmyeloablative allogeneic transplant approach. The identification of molecular targets of therapy and the development of monoclonal antibody-directed therapy has generated optimism. It is possible that combinations of chemotherapy, molecularly directed therapy, and immunotherapy may be combined to cure an increasing proportion of patients with acute leukaemia.
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Affiliation(s)
- Mark R Litzow
- Division of Hematology, Mayo Clinic and Mayo Medical School, 200 First Streeet, SW, Rochester, MN 55905, USA.
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Singhal S, Powles R, Henslee-Downey PJ, Chiang KY, Treleaven J, Godder K, Kulkarni S, van Rhee F, Sirohi B, Pinkerton CR, Meller S, Mehta J. Allogeneic transplantation from HLA-matched sibling or partially HLA-mismatched related donors for primary refractory acute leukemia. Bone Marrow Transplant 2002; 29:291-5. [PMID: 11896425 DOI: 10.1038/sj.bmt.1703373] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2001] [Accepted: 11/06/2001] [Indexed: 11/09/2022]
Abstract
Allogeneic transplantation is successful in a minority of patients with primary refractory acute leukemia (PRAL). An HLA-matched sibling donor (MSD) is available only in 30-40% of the patients, whereas a partially mismatched related donor (PMRD) is available for most. We compared the outcome of 24 MSD (median age 24 years) and 19 PMRD (median age 34 years; P = 0.04) allograft recipients with PRAL. All MSD patients received non-T cell-depleted marrow whereas all PMRD patients received partially T cell-depleted marrow. All evaluable PMRD patients and 90% of the evaluable MSD patients attained CR. Six patients in each group with recurrent/persistent disease died. Ten PMRD (3-year probability 70%) and 14 MSD (3-year probability 63%) patients died of treatment-related causes. At the last follow-up, three PMRD (18-50 months; 3-year probability 14%) and four MSD (20-166 months; 3-year probability 20%) patients were alive and well. We conclude that allogeneic transplantation is a viable therapeutic option for PRAL. PMRD transplantation is a reasonable alternative in patients with no MSD, and results in similar outcome. In terms of identifying a donor and harvesting cells, a PMRD transplant is significantly quicker than an unrelated donor transplant - a point of great practical importance in the setting of failed induction chemotherapy where time is of the essence.
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10
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Link H, Kolb HJ, Ebell W, Hossfeld DK, Zander A, Niethammer D, Wandt H, Grosse-Wilde H, Schaefer UW. [Transplantation of hematopoietic stem cells. II: Indications for transplantation of hematopoietic stem cells after myeloablative therapy]. MEDIZINISCHE KLINIK (MUNICH, GERMANY : 1983) 1997; 92:534-45. [PMID: 9411202 DOI: 10.1007/bf03044929] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The destruction of hematopoiesis and lymphopoiesis by total body irradiation or high dose chemotherapy for the treatment of malignancy can be reversed by the transplantation of allogeneic or autologous hematopoietic stem cells. In primary disorders of bone marrow or immune system, allogeneic stem cells replace deficient cells. Acute leukemias can be cured, with in 50 to 80% disease free survival after 5 to 8 years. The allogeneic graft versus leukemia effect by immunoreactive cells reduces the relapse rate in myeloid and lymphoid malignancies. 40 to 70% of patients with chronic myeloid leukemia remain disease free after more than 5 years. Patients with malignant lymphoma have a 40 to 70% chance of cure with autologous transplantation, which is not increased by allogeneic cells, because of a higher incidence of severe complications. An increasing number of patients without option for cure is treated with the aim of prolonging remission or retarding disease progression, such as in chronic myeloid leukemia, multiple myeloma and certain solid tumors. New studies suggest in breast cancer with axillary lymph node metastases, that adjuvant high dose chemotherapy with autologous stem cell support will significantly improve disease free survival from 30 to over 60% after 3 to 5 years. In congenital metabolic and storage diseases deficient enzymes are substituted by the allogeneic cells. Clinical trials explore the use of stem cell transplantation after myeloablative therapy in autoimmune disorders as well as in gene therapy with transfected hematopoietic stem cells.
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Affiliation(s)
- H Link
- Abteilung Hämatologie und Onkologie, Zentrum Innere Medizin, Medizinische Hochschule Hannover
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11
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Dimopoulos MA, Yau JC, Huan SD, Jagannath S, Spitzer G, Spinolo JA, Zagars GK, LeMaistre CF, Dicke KA, Zander AR. Allogeneic bone marrow transplantation for leukemia following piperazinedione and fractionated total body irradiation. Am J Hematol 1994; 46:82-6. [PMID: 8172200 DOI: 10.1002/ajh.2830460205] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Between 1980 and 1988, 126 patients with leukemia were treated with piperazinedione and fractionated total body irradiation (TBI) followed by allogeneic bone marrow transplantation from HLA matched siblings. Sixty-one patients had acute myelogenous leukemia, 46 acute lymphoblastic leukemia, and 19 chronic myelogenous leukemia. Patients with acute leukemia in first complete remission were transplanted only if perceived to have a low probability of remaining in remission with conventional therapy. The toxicity from the preparative regimen was similar to that of cyclophosphamide and TBI except that none of the patients in the study had hemorrhagic cystitis or veno-occlusive disease. After a median follow up of 114 months, 29 patients (23%) are still alive without relapse. The survival of patients with acute myelogenous or lymphoblastic leukemia transplanted in their first remission were 35% and 43%, respectively. The survival of patients transplanted in their first chronic phase of chronic myelogenous leukemia was 60%. The results of this preparative regimen are comparable to those of cyclophosphamide and TBI.
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Affiliation(s)
- M A Dimopoulos
- University of Texas M.D. Anderson Cancer Center, Houston
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12
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Yau JC, LeMaistre CF, Andersson BS, Huan SD, Wallerstein RO, Woo SY, Spitzer G, Spinolo JA, Spencer V, Brunner LJ. Allogeneic bone marrow transplantation for hematological malignancies following etoposide, cyclophosphamide, and fractionated total body irradiation. Am J Hematol 1992; 41:40-4. [PMID: 1503097 DOI: 10.1002/ajh.2830410108] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Forty-three patients received etoposide, cyclophosphamide, and fractionated total body irradiation before allogeneic marrow transplantation. Fifteen patients had chronic myelogenous leukemia in chronic phase or acute leukemia in first remission (standard risk) and twenty-eight patients with more advanced disease (high risk). All patients received etoposide 1,500 mg/m2 intravenously on day -8, cyclophosphamide 60 mg/kg/day intravenously on days -7 and -6, and total body irradiation at 170 cGy twice a day on days -3, -2, and -1. During the first 100 days 12 high risk patients (43%) died from causes unrelated to relapse while none of the standard risk patients died. Renal and hepatic dysfunction were also significantly increased during the first 14 days in the high risk group. The addition of 1,500 mg/m2 of etoposide to the cyclophosphamide and total body irradiation was well tolerated for patients with standard risk. However, the regimen was poorly tolerated with high mortality in patients with more advanced disease.
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MESH Headings
- Acute Disease
- Adolescent
- Adult
- Bone Marrow Transplantation
- Carmustine/therapeutic use
- Combined Modality Therapy
- Cyclophosphamide/administration & dosage
- Cyclophosphamide/therapeutic use
- Drug Therapy, Combination
- Etoposide/administration & dosage
- Etoposide/therapeutic use
- Female
- Humans
- Injections, Intravenous
- Leukemia/drug therapy
- Leukemia/radiotherapy
- Leukemia/surgery
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/radiotherapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/surgery
- Male
- Middle Aged
- Transplantation, Homologous
- Whole-Body Irradiation
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Affiliation(s)
- J C Yau
- Ottawa Regional Cancer Center, Ontario, Canada
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13
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Abstract
Seventeen patients who had a relapse at a median of 9 months after marrow transplant (14 allogeneic and three syngeneic) received second transplants. Eight patients were in remission when transplanted. Of the nine patients with active disease at the time of transplant, six had complete remissions, and one converted from blastic to chronic phase of chronic myelogenous leukemia. The median survival was 9 months (95% confidence interval, 4 to 17 months). Four patients died within 100 days of transplantation, and three were disease-free. Ten patients died after 100 days, all except two of disease relapse. Five patients had remissions that were greater than 12 months and longer than the remission after their first transplant (inversions). Three patients remain alive and disease-free at 37+, 55+, and 61+ months, the former two despite remissions of less than 1 year after their first transplant. Second transplants with a different cytoreductive regimen can eradicate disease resistant to prior myeloablative treatment; some patients may benefit from second transplants, even if the first transplant only achieves a short remission.
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Affiliation(s)
- J A Spinolo
- M. D. Anderson Cancer Center, Houston, Texas
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14
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Martin PJ, Hansen JA, Storb R, Thomas ED. Human marrow transplantation: an immunological perspective. Adv Immunol 1987; 40:379-438. [PMID: 2884832 DOI: 10.1016/s0065-2776(08)60243-6] [Citation(s) in RCA: 92] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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