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Kopmar NE, Othus M, Quach K, Rasmussen A, Schonhoff K, Becker PS, Walter RB, Halpern AB, Salit R, Cassaday RD, Shustov A, Stewart FM, Oehler VG, Scott BL, Sandmaier BM, Lee SJ, Estey EH, Percival MEM. Intensive Reinduction Chemotherapy Followed by Early Allogeneic Hematopoietic Cell Transplantation for Relapsed/Refractory High-Grade Myeloid Neoplasms. Transplant Cell Ther 2024:S2666-6367(24)00376-2. [PMID: 38710302 DOI: 10.1016/j.jtct.2024.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 03/01/2024] [Accepted: 05/03/2024] [Indexed: 05/08/2024]
Abstract
Outcomes for adults with relapsed/refractory (R/R) high-grade myeloid neoplasms remain poor, with allogeneic hematopoietic cell transplantation (HCT) the sole therapy likely to result in cure. We conducted the present study to determine the feasibility of early HCT-within 60 days of beginning reinduction chemotherapy-to see whether getting patients to HCT in an expeditious manner would expand the number of patients being offered this curative option. In this proof-of-principle feasibility study, we included adults age 18 to 75 years with R/R myeloid malignancies with ≥10% blood/marrow blasts at diagnosis who were eligible for a reduced-intensity HCT. Subjects received reinduction chemotherapy with cladribine, cytarabine, mitoxantrone, and filgrastim (CLAG-M) and proceeded to HCT with reduced-intensity conditioning (fludarabine/ melphalan). We enrolled 30 subjects, all of whom received CLAG-M reinduction, although only 9 underwent HCT within 60 days (<15, the predetermined threshold for feasibility "success"), with a median time to HCT of 48 days (range, 42 to 60 days). Eleven additional subjects received HCT beyond the target 60 days (off-study), with a median time to transplantation of 83 days (range, 53 to 367 days). Barriers to early HCT included infection, physician preference, lack of an HLA-matched donor, logistical delays, and disease progression, all of which may limit the real-world uptake of such early-to-transplantation protocols.
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Affiliation(s)
- Noam E Kopmar
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Megan Othus
- Public Health Sciences, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Kim Quach
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Allegra Rasmussen
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Kelda Schonhoff
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | | | - Roland B Walter
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington; Translational Science and Therapeutics Division, Fred Hutchinson Cancer Center, Seattle, Washington; Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington; Department of Epidemiology, University of Washington, Seattle, Washington
| | - Anna B Halpern
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Rachel Salit
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Ryan D Cassaday
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | | | | | - Vivian G Oehler
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington; Translational Science and Therapeutics Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Bart L Scott
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Brenda M Sandmaier
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington; Translational Science and Therapeutics Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Stephanie J Lee
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Elihu H Estey
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Mary-Elizabeth M Percival
- Division of Hematology and Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington; Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington.
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2
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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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Orozco JJ, Vo PT, Gooley TA, Haaf RL, Lundberg SJ, Hamlin DK, Wilbur DS, Matesan MC, Fisher DR, Gopal AK, Green DJ, Pagel JM, Sandmaier BM. Targeted Radiation Delivery before Haploidentical HCT for High-risk Leukemia or MDS Patients Yields Long-term Survivors. Clin Cancer Res 2024; 30:274-282. [PMID: 37939122 PMCID: PMC10843688 DOI: 10.1158/1078-0432.ccr-23-1200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 08/23/2023] [Accepted: 11/02/2023] [Indexed: 11/10/2023]
Abstract
PURPOSE Hematopoietic cell transplantation (HCT) has curative potential for myeloid malignancies, though many patients cannot tolerate myeloablative conditioning with high-dose chemotherapy alone or with total-body irradiation (TBI). Here we report long-term outcomes from a phase I/II study using iodine-131 (131I)-anti-CD45 antibody BC8 combined with nonmyeloablative conditioning prior to HLA-haploidentical HCT in adults with high-risk relapsed/ refractory acute myeloid or lymphoid leukemia (AML or ALL), or myelodysplastic syndrome (MDS; ClinicalTrials.gov, NCT00589316). PATIENTS AND METHODS Patients received a tracer diagnostic dose before a therapeutic infusion of 131I-anti-CD45 to deliver escalating doses (12-26 Gy) to the dose-limiting organ. Patients subsequently received fludarabine, cyclophosphamide (CY), and 2 Gy TBI conditioning before haploidentical marrow HCT. GVHD prophylaxis was posttransplant CY plus tacrolimus and mycophenolate mofetil. RESULTS Twenty-five patients (20 with AML, 4 ALL and 1 high-risk MDS) were treated; 8 had ≥ 5% blasts by morphology (range 9%-20%), and 7 had previously failed HCT. All 25 patients achieved a morphologic remission 28 days after HCT, with only 2 patients showing minimal residual disease (0.002-1.8%) by flow cytometry. Median time to engraftment was 15 days for neutrophils and 23 days for platelets. Point estimates for overall survival and progression-free survival were 40% and 32% at 1 year, and 24% at 2 years, respectively. Point estimates of relapse and nonrelapse mortality at 1 year were 56% and 12%, respectively. CONCLUSIONS 131I-anti-CD45 radioimmunotherapy prior to haploidentical HCT is feasible and can be curative in some patients, including those with disease, without additional toxicity.
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Affiliation(s)
- Johnnie J Orozco
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
- Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Phuong T Vo
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
- Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Ted A Gooley
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Robyn L Haaf
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Sally J Lundberg
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Donald K Hamlin
- Radiation Oncology, University of Washington School of Medicine, Seattle, Washington
| | - D Scott Wilbur
- Radiation Oncology, University of Washington School of Medicine, Seattle, Washington
| | - Manuela C Matesan
- Nuclear Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Darrell R Fisher
- Versant Medical Physics and Radiation Safety, Richland, Washington
| | - Ajay K Gopal
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
- Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Damian J Green
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
- Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - John M Pagel
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Brenda M Sandmaier
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
- Division of Medical Oncology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
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4
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Fan Y, Wang L, Chen B, Zhang J, Yang L, Qiu X, Jiang H, Zhu L, Wang C, Xu Y. Long-term survival in a patient with primary refractory AML after salvage allogeneic hematopoietic transplantation and post-transplant localized irradiation and venetoclax maintenance: a case report. Front Oncol 2023; 13:1329858. [PMID: 38162505 PMCID: PMC10756059 DOI: 10.3389/fonc.2023.1329858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 11/14/2023] [Indexed: 01/03/2024] Open
Abstract
For patients with primary refractory AML, allogeneic hematopoietic cell transplantation (allo-HCT) is considered the only curative approach. However, the therapeutic efficacy of salvage transplantation in the non-remission (NR) state remains controversial. We present a patient with primary refractory AML and concomitant central nervous system (CNS) leukemia, who received salvage allo-HCT, localized radiotherapy and venetoclax maintenance. Although he experienced systemic chronic graft-versus-host disease (cGVHD), he remained disease-free for 2 years. We propose that salvage transplantation is a feasible for primary refractory AML and discuss strategies to prevent relapse after allo-HCT, including maintenance therapy and donor lymphocyte infusion (DLI). Finally, we highlight the importance of radiotherapy, which can exert immunomodulatory effects to enhance immune responses against leukemia.
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Affiliation(s)
- Yili Fan
- Department of Hematology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Luyao Wang
- Department of Hematology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Boxiao Chen
- Department of Hematology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jiawei Zhang
- Department of Hematology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Luyu Yang
- Department of Hematology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xi Qiu
- Department of Hematology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Huawei Jiang
- Department of Hematology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Lei Zhu
- Department of Laboratory Medicine, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chao Wang
- Department of Radiology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yang Xu
- Department of Hematology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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Mozaffari Jovein M, Ihorst G, Duque-Afonso J, Wäsch R, Bertz H, Wehr C, Duyster J, Zeiser R, Finke J, Scherer F. Long-term follow-up of patients with acute myeloid leukemia undergoing allogeneic hematopoietic stem cell transplantation after primary induction failure. Blood Cancer J 2023; 13:179. [PMID: 38071327 PMCID: PMC10710471 DOI: 10.1038/s41408-023-00953-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 11/16/2023] [Accepted: 11/20/2023] [Indexed: 12/18/2023] Open
Abstract
Primary induction failure (PIF) in acute myeloid leukemia (AML) patients is associated with poor outcome, with allogeneic hematopoietic stem cell transplantation (HCT) being the sole curative therapeutic option. Here, we retrospectively evaluated long-term outcomes of 220 AML patients undergoing allogeneic HCT after PIF who never achieved remission, and identified clinical and molecular risk factors associated with treatment response and ultimate prognosis. In this high-risk population, disease-free survival was 25.2% after 5 years and 18.7% after 10 years, while overall survival rates were 29.8% and 21.6% after 5 and 10 years of HCT, respectively. 10-year non-relapse mortality was 32.5%, and 48.8% of patients showed disease relapse within 10 years after allogeneic HCT. Adverse molecular risk features determined at initial diagnosis, poor performance status at the time of allogeneic HCT, and long diagnosis-to-HCT intervals were associated with unfavorable prognosis. Collectively, our data suggests that immediate allogeneic HCT after PIF offers long-term survival and cure in a substantial subset of cases and that high-risk AML patients who never achieved complete response during induction might benefit from early donor search.
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Affiliation(s)
- Miriam Mozaffari Jovein
- Department of Medicine I, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Gabriele Ihorst
- Clinical Trials Unit, Biometry and Statistics, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jesús Duque-Afonso
- Department of Medicine I, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ralph Wäsch
- Department of Medicine I, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Hartmut Bertz
- Department of Medicine I, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Claudia Wehr
- Department of Medicine I, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Justus Duyster
- Department of Medicine I, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Robert Zeiser
- Department of Medicine I, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jürgen Finke
- Department of Medicine I, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Florian Scherer
- Department of Medicine I, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
- German Cancer Consortium (DKTK) partner site Freiburg and German Cancer Research Center (DKFZ), Heidelberg, Germany.
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Darwish C, Farina K, Tremblay D. The core concepts of core binding factor acute myeloid leukemia: Current considerations for prognosis and treatment. Blood Rev 2023; 62:101117. [PMID: 37524647 DOI: 10.1016/j.blre.2023.101117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 07/04/2023] [Accepted: 07/21/2023] [Indexed: 08/02/2023]
Abstract
Core binding factor acute myeloid leukemia (CBF AML), defined by t(8;21) or inv(16), is a subset of favorable risk AML. Despite its association with a high complete remission rate after induction and relatively good prognosis overall compared with other subtypes of AML, relapse risk after induction chemotherapy remains high. Optimizing treatment planning to promote recurrence free survival and increase the likelihood of survival after relapse is imperative to improving outcomes. Recent areas of research have included evaluation of the role of gemtuzumab in induction and consolidation, the relative benefit of increased cycles of high dose cytarabine in consolidation, the utility of hypomethylating agents and kinase inhibitors, and the most appropriate timing of stem cell transplant. Surveillance with measurable residual disease testing is increasingly being utilized for monitoring disease in remission, and ongoing investigation seeks to determine how to use this tool for early identification of patients who would benefit from proceeding to transplant. In this review, we outline the current therapeutic approach from diagnosis to relapse while highlighting the active areas of investigation in each stage of treatment.
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Affiliation(s)
- Christina Darwish
- Tisch Cancer Institute, Division of Hematology/Oncology, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1079, New York, NY 10029, USA
| | - Kyle Farina
- Department of Pharmacy Practice, The Mount Sinai Hospital, New York, NY 10029, USA
| | - Douglas Tremblay
- Tisch Cancer Institute, Division of Hematology/Oncology, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1079, New York, NY 10029, USA.
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Zhang C, Gao D, Wang X, Sun X, Yan Y, Yang Y, Zhang J, Yan J. Effectiveness of chemotherapy using bortezomib combined with homoharringtonine and cytarabine in refractory or relapsed acute myeloid leukemia: a phase II, multicenter, prospective clinical trial. Front Oncol 2023; 13:1142449. [PMID: 37664023 PMCID: PMC10472935 DOI: 10.3389/fonc.2023.1142449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 06/28/2023] [Indexed: 09/05/2023] Open
Abstract
Background Refractory/relapsed acute myeloid leukemia (R/R AML) has unsatisfactory outcomes even after allogeneic hematopoietic stem cell transplantation. Long-term survival is mainly influenced by complete remission (CR) rates after induction therapies. Objectives To investigate CR/CR with incomplete hematologic recovery (CRi) rates and adverse events with a new induction therapy (bortezomib, homoharringtonine, and cytarabine [BHA]) for patients with R/R AML. Methods We enrolled 21 patients with R/R AML (median age, 42 [range, 30-62] years), who received BHA for remission induction (bortezomib, 1.3 mg/m2/day on days 1 and 4; homoharringtonine, 4 mg/m2/day for 5 days, and cytarabine, 1.5 g/m2/day for 5 days). CR and adverse events were assessed. Results After one course of BHA, the CR/CRi and partial remission rates were 38.1% and 14.3%, respectively, with an overall response rate (ORR) of 52.4% in 21 patients. 9 of 21 patients harbored FLT3-ITD or FLT3-TKD mutations, and achieved either CR/CRi or ORR of 66.7% (P=0.03) by comparison with that in R/R AML without FLT3 mutation. After induction therapy, consolidation chemotherapy or allogeneic hematopoietic stem cell transplantation led to a one-year overall survival of 27.8% in all patients. One-year relapse-free survival was 50% in 8 patients who had achieved CR/CRi after one course of BHA. During induction, non-hematologic adverse events (grade 3/4) commonly were infection (90.5%), hypokalemia (14.4%), hypocalcemia (14.3%), and mucositis (9.5%). In patients achieving CR, the median time to neutrophil count >0.5×109/L and time to platelet count >20×109/L were 15 (13-17) days and 13 (13-18) days, respectively. Conclusion BHA chemotherapy regimen was safe and tolerable to serve as an induction therapy for R/R AML, particularly with FLT3 mutation. The higher CR/CRi rate will give a clue to determine a potentialeffectiveness of BHA for AML patients carrying FLT3 mutation in a further investigation. Clinical trial registration https://www.chictr.org.cn/, identifier ChiCTR2000029841.
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Affiliation(s)
- Chengtao Zhang
- Department of Hematology, Liaoning Key Laboratory of Hematopoietic Stem Cell Transplantation and Translational Medicine, Liaoning Medical Center for Hematopoietic Stem Cell Transplantation, The Second Hospital of Dalian Medical University, Dalian, China
| | - Da Gao
- Department of Hematology, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Xiaohong Wang
- Department of Hematology, The ChaoYang Central Hospital, Liaoning, China
| | - Xiuli Sun
- Department of Hematology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yan Yan
- Department of Hematology, Bayannur Hospital, Bayannur, Inner Mongolia, China
| | - Yan Yang
- Department of Hematology, Liaoning Key Laboratory of Hematopoietic Stem Cell Transplantation and Translational Medicine, Liaoning Medical Center for Hematopoietic Stem Cell Transplantation, The Second Hospital of Dalian Medical University, Dalian, China
| | - Jingjing Zhang
- Department of Hematology, Liaoning Key Laboratory of Hematopoietic Stem Cell Transplantation and Translational Medicine, Liaoning Medical Center for Hematopoietic Stem Cell Transplantation, The Second Hospital of Dalian Medical University, Dalian, China
| | - Jinsong Yan
- Department of Hematology, Liaoning Key Laboratory of Hematopoietic Stem Cell Transplantation and Translational Medicine, Liaoning Medical Center for Hematopoietic Stem Cell Transplantation, The Second Hospital of Dalian Medical University, Dalian, China
- Blood Stem Cell Transplantation Institute of Dalian Medical University, Dalian, China
- Pediatric Oncology and Hematology Center of the Second Hospital of Dalian Medical University, Dalian, China
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8
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Tong X, Jin J, Xu B, Su S, Li L, Li M, Peng Y, Mao X, Huang W, Zhang D. Real-world experience with selinexor-containing chemotherapy-free or low-dose chemotherapy regimens for patients with relapsed/refractory acute myeloid leukemia and myeloid sarcoma. Front Pharmacol 2023; 14:1217701. [PMID: 37601075 PMCID: PMC10436481 DOI: 10.3389/fphar.2023.1217701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 07/24/2023] [Indexed: 08/22/2023] Open
Abstract
Introduction: Treatment of relapsed or refractory acute myeloid leukemia (R/R AML) and myeloid sarcoma (MS) has presented challenges for decades. Studies on selinexor in combination with various standard or intensive chemotherapy regimens for the treatment of R/R AML have demonstrated promising results. This study aimed to evaluate the efficacy and safety of chemotherapy-free or low-dose chemotherapy regimens with selinexor for R/R AML and MS patients. Methods: Ten patients with R/R AML or MS who received chemotherapy-free or low-dose chemotherapy regimens in combination with selinexor at Tongji Hospital from October 2021 to August 2022 were included in this study. The primary endpoint was overall response rate (ORR) and secondary endpoints included complete remission (CR), CR with incomplete hematological recovery (CRi), partial remission (PR), transplantation rate, and safety. Results: All patients were evaluable for response, achieving CR in four (40.0%) patients and CRi in two (20.0%) patients for a total CR/CRi of 60.0%. The ORR was 80.0% when patients with PR were included. Five (50.0%) patients underwent allogeneic hematopoietic stem cell transplantation (allo-HSCT) after treatment with selinexor-containing regimens. At the end of the follow-up, seven (70.0%) patients were alive, and three patients died of transplant-related complications or disease progression. The most frequently reported nonhematologic adverse events (AEs) in patients were grade 1 or 2 asymptomatic hyponatremia. Conclusion: The chemotherapy-free or low-dose chemotherapy regimens in combination with selinexor for R/R AML are feasible and tolerable and provide an opportunity for patients to receive transplantation.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Donghua Zhang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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9
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Kopińska A, Węglarz P, Koclęga A, Wieczorkiewicz-Kabut A, Woźniczka K, Armatys A, Spałek A, Grygoruk-Wiśniowska I, Grosicki S, Butrym A, Czyż J, Obara A, Gromek T, Helbig G. Allogeneic Hematopoietic Stem Cell Transplantation for Relapsed/Refractory Acute Myeloid Leukemia: A Single-Centre Experience. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:28-39. [PMID: 36323603 DOI: 10.1016/j.clml.2022.08.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 08/21/2022] [Accepted: 08/24/2022] [Indexed: 10/14/2022]
Abstract
INTRODUCTION Patients with relapsed/refractory acute myeloid leukemia (r/r AML) are characterized as having a poor prognosis. The only viable option of treatment for these patients is allogenic stem cell transplantation (allo-HSCT). Therefore, we have attempted to analyse factors related to both the disease itself and the transplantation procedure that could have an influence on the improvement of outcomes in this group of patients. PATIENTS AND METHODS Sixty-four patients with r/r AML underwent allo-HSCT at our center in 2012 to 2021. Fifty-two had active disease at the beginning of theallo-HSCT procedure, with amedian number of blasts in bone marrow (BM) of 18, and 12 had therapeutic aplasia after the last reinduction (blasts < 5% in BM). RESULTS The probability of overall survival (OS) at 2 years was 25%. The median follow-up for survivors was 21.5 months. Progression-free survival (PFS) estimates were above 46%. The main cause of death was disease progression (49%). A statistically significant effect on premature death was reported for the diagnosis of secondary AML (sAML) and cytomelovirus (CMV) reactivation post allo-HSCT. On the other hand, chronic graft versus host disease (cGVHD) decreased the risk of disease progression. sAML and CMV reactivation were found to have opposite effects.
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Affiliation(s)
- Anna Kopińska
- Department of Hematology and Bone Marrow Transplantation, Silesian Medical University, Katowice Poland.
| | - Patryk Węglarz
- Department of Hematology and Bone Marrow Transplantation, Silesian Medical University, Katowice Poland
| | - Anna Koclęga
- Department of Hematology and Bone Marrow Transplantation, Silesian Medical University, Katowice Poland
| | | | - Krzysztof Woźniczka
- Department of Hematology and Bone Marrow Transplantation, Silesian Medical University, Katowice Poland
| | - Anna Armatys
- Department of Hematology and Bone Marrow Transplantation, Silesian Medical University, Katowice Poland
| | - Adrianna Spałek
- Department of Hematology and Bone Marrow Transplantation, Silesian Medical University, Katowice Poland
| | - Iwona Grygoruk-Wiśniowska
- Department of Hematology and Bone Marrow Transplantation, Silesian Medical University, Katowice Poland
| | - Sebastian Grosicki
- Department of Hematology and Cancer Prevention, Silesian Medical University, Katowice, Poland
| | - Aleksandra Butrym
- Department of Cancer Prevention and Therapy, Wroclaw Medical University, Wroclaw, Poland
| | - Jarosław Czyż
- Department of Hematology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Bydgoszcz, Poland
| | - Agata Obara
- Departament of Hematology, Świętokrzyskie Cancer Centre, Kielce, Poland
| | - Tomasz Gromek
- Department of Haematooncology and Bone Marrow Transplantation, Medical University of Lublin, Poland
| | - Grzegorz Helbig
- Department of Hematology and Bone Marrow Transplantation, Silesian Medical University, Katowice Poland
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10
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Benton C, Grunwald MR, Safah H, Kasner M. Co-management strategies for acute myeloid leukemia patients in the community setting. Front Oncol 2022; 12:1060912. [PMID: 36578924 PMCID: PMC9791081 DOI: 10.3389/fonc.2022.1060912] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 11/15/2022] [Indexed: 12/14/2022] Open
Abstract
The treatment landscape for acute myeloid leukemia (AML) has changed substantially in recent years. The introduction of newer therapies, including oral agents, less myelosuppressive agents, and parenteral regimens suitable for outpatient administration, has made it feasible for select patients to receive therapy in the outpatient setting and in community practices. Thorough patient evaluation (including molecular testing), planned supportive care (eg, transfusion support, antimicrobial prophylaxis), and vigilant patient monitoring (for tumor lysis syndrome and adverse events) by a multidisciplinary team are required for successful management of patients both in the community and at specialized leukemia centers. Some patients are unable or unwilling to travel to larger academic centers for treatment, and treatment of AML in the community setting may have potential advantages compared to less conveniently located academic/leukemia centers. This includes reduction of financial hardship for patients and their families and often better opportunities for family/caregiver support. Additionally, partnership between community practices and academic/leukemia centers is often crucial to optimizing AML management for many patients, as collaboration may facilitate access to additional expertise and trials, multidisciplinary teams for supportive care, easier transition to hematopoietic cell transplantation, and access to sophisticated molecular testing. In this review, we discuss AML treatment and management in the community setting, available therapies, and circumstances in which a referral to and co-management with an academic/leukemia center is more strongly recommended.
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Affiliation(s)
- Christopher Benton
- Rocky Mountain Cancer Centers, US Oncology Network, Denver, CO, United States
| | - Michael R. Grunwald
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, NC, United States
| | - Hana Safah
- Tulane Cancer Center, Tulane University School of Medicine, New Orleans, LA, United States
| | - Margaret Kasner
- Department of Medical Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, United States,*Correspondence: Margaret Kasner,
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11
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Begna KH, Kittur J, Gangat N, Alkhateeb H, Patnaik MS, Al-Kali A, Elliott MA, Hogan WJ, Litzow MR, Pardanani A, Hanson CA, Ketterling RP, Tefferi A. European LeukemiaNet-defined primary refractory acute myeloid leukemia: the value of allogeneic hematopoietic stem cell transplant and overall response. Blood Cancer J 2022; 12:7. [PMID: 35039473 PMCID: PMC8764050 DOI: 10.1038/s41408-022-00606-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 10/19/2021] [Accepted: 11/03/2021] [Indexed: 11/15/2022] Open
Abstract
We sought to appraise the value of overall response and salvage chemotherapy, inclusive of allogeneic hematopoietic stem cell transplant (AHSCT), in primary refractory acute myeloid leukemia (prAML). For establishing consistency in clinical practice, the 2017 European LeukemiaNet (ELN) defines prAML as failure to attain CR after at least 2 courses of intensive induction chemotherapy. Among 60 consecutive patients (median age 63 years) correspondent with ELN-criteria for prAML, salvage was documented in 48 cases, 30/48 (63%) being administered intensive chemotherapy regimens and 2/48 consolidated with AHSCT as first line salvage. 13/48 (27%) attained response: CR, 7/13 (54%), CRi, 2/13 (15%), MLFS, 4/13 (31%). The CR/CRi rate was 9/48 (19%), with CR rate of 7/48 (15%). On univariate analysis, intermediate-risk karyotype was the only predictor of response (44% vs 17% in unfavorable karyotype; P = 0.04). Administration of any higher-dose (>1 g/m2) cytarabine intensive induction (P = 0.50), intensive salvage chemotherapy (P = 0.72), targeted salvage (FLT3 or IDH inhibitors) (P = 0.42), greater than 1 salvage regimen (P = 0.89), age < 60 years (P = 0.30), and de novo AML (P = 0.10) did not enhance response achievement, nor a survival advantage. AHSCT was performed in 12 patients with (n = 8) or without (n = 4) CR/CRi/MLFS. 1/2/5-year overall survival (OS) rates were 63%/38%/33% in patients who received AHSCT (n = 12) vs 27%/0%/0% in those who achieved CR/CRi/MLFS but were not transplanted (n = 5), vs 14%/0%/0% who were neither transplanted nor achieved CR/CRi/MLFS (n = 43; P < 0.001); the median OS was 18.6, 12.6 and 5.6 months, respectively. Although CR/CRi/MLFS bridged to AHSCT (n = 8), appeared to manifest a longer median OS (20 months), vs (13.4 months) for those with no response consolidated with AHSCT (n = 4), the difference was not significant P = 0.47. We conclude AHSCT as indispensable for securing long-term survival in prAML (p = 0.03 on multivariate analysis), irrespective of response achievement.
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Affiliation(s)
- K H Begna
- Division of Hematology and Department of Internal Medicine, Rochester, MN, USA
| | - J Kittur
- Division of Hematology and Department of Internal Medicine, Rochester, MN, USA
| | - N Gangat
- Division of Hematology and Department of Internal Medicine, Rochester, MN, USA
| | - H Alkhateeb
- Division of Hematology and Department of Internal Medicine, Rochester, MN, USA
| | - M S Patnaik
- Division of Hematology and Department of Internal Medicine, Rochester, MN, USA
| | - A Al-Kali
- Division of Hematology and Department of Internal Medicine, Rochester, MN, USA
| | - M A Elliott
- Division of Hematology and Department of Internal Medicine, Rochester, MN, USA
| | - W J Hogan
- Division of Hematology and Department of Internal Medicine, Rochester, MN, USA
| | - M R Litzow
- Division of Hematology and Department of Internal Medicine, Rochester, MN, USA
| | - A Pardanani
- Division of Hematology and Department of Internal Medicine, Rochester, MN, USA
| | - C A Hanson
- Division of Hematopathology, Department of Laboratory Medicine, Mayo Clinic, Rochester, MN, USA
| | - R P Ketterling
- Division of Cytogenetics, Department of Laboratory Medicine, Mayo Clinic, Rochester, MN, USA
| | - A Tefferi
- Division of Hematology and Department of Internal Medicine, Rochester, MN, USA.
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12
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Austin AE, Byrne M. Detecting and preventing post-hematopoietic cell transplant relapse in AML. Curr Opin Hematol 2021; 28:380-388. [PMID: 34534984 DOI: 10.1097/moh.0000000000000686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Relapsed disease is the primary cause of mortality for acute myeloid leukemia (AML) patients after allogeneic hematopoietic cell transplantation (HCT). This review outlines the most recent advances in the detection and prevention of AML relapse following allogeneic HCT. RECENT FINDINGS Conventional methods for predicting post-HCT relapse rely on the molecular and cytogenetics features present at diagnosis. These methods are slow to reflect a growing understanding of the molecular heterogeneity of AML and impact of new therapies on post-HCT outcomes. The use of measurable residual disease (MRD) techniques, including multiparameter flow cytometry and molecular testing, may improve the prognostic ability of these models and should be incorporated into post-HCT surveillance whenever possible.In the post-HCT setting, FLT3 inhibitor maintenance data indicate that effective therapies can improve post-HCT outcomes. Maintenance data with DNA methyltransferase inhibitor monotherapy is less compelling and outcomes may improve with combinations. Early interventions directed at preemptive management of MRD may further improve post-HCT outcomes. SUMMARY Post-HCT AML relapse prevention has evolved to include more sensitive measures of disease detection and novel therapies that may improve outcomes of poor-risk AML patients. Additional work is needed to maintain this progress.
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Affiliation(s)
| | - Michael Byrne
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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13
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Hirabayashi S, Uozumi R, Kondo T, Arai Y, Kawata T, Uchida N, Marumo A, Ikegame K, Fukuda T, Eto T, Tanaka M, Wake A, Kanda J, Kimura T, Tabuchi K, Ichinohe T, Atsuta Y, Yanada M, Yano S. Personalized prediction of overall survival in patients with AML in non-complete remission undergoing allo-HCT. Cancer Med 2021; 10:4250-4268. [PMID: 34132501 PMCID: PMC8267144 DOI: 10.1002/cam4.3920] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/25/2021] [Accepted: 04/08/2021] [Indexed: 12/24/2022] Open
Abstract
Allogenic hematopoietic stem cell transplantation (allo‐HCT) is the standard treatment for acute myeloid leukemia (AML) in non‐complete remission (non‐CR); however, the prognosis is inconsistent. This study aimed to develop and validate nomograms and a web application to predict the overall survival (OS) of patients with non‐CR AML undergoing allo‐HCT (cord blood transplantation [CBT], bone marrow transplantation [BMT], and peripheral blood stem cell transplantation [PBSCT]). Data from 3052 patients were analyzed to construct and validate the prognostic models. The common significant prognostic factors among patients undergoing allo‐HCT were age, performance status, percentage of peripheral blasts, cytogenetic risk, chemotherapy response, and number of transplantations. The conditioning regimen was a significant prognostic factor only in patients undergoing CBT. Compared with cyclophosphamide/total body irradiation, a conditioning regimen of ≥3 drugs, including fludarabine, with CBT exhibited the lowest hazard ratio for mortality (0.384; 95% CI, 0.266–0.554; p < 0.0001). A conditioning regimen of ≥3 drugs with CBT also showed the best leukemia‐free survival among all conditioning regimens. Based on the results of the multivariable analysis, we developed prognostic models showing adequate calibration and discrimination (the c‐indices for CBT, BMT, and PBSCT were 0.648, 0.600, and 0.658, respectively). Our prognostic models can help in assessing individual risks and designing future clinical studies. Furthermore, our study indicates the effectiveness of multi‐drug conditioning regimens in patients undergoing CBT.
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Affiliation(s)
- Shigeki Hirabayashi
- Department of Hematology and Oncology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ryuji Uozumi
- Department of Biomedical Statistics and Bioinformatics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Tadakazu Kondo
- Department of Hematology and Oncology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yasuyuki Arai
- Department of Hematology and Oncology, Kyoto University Graduate School of Medicine, Kyoto, Japan.,Department of Transfusion Medicine and Cell Therapy, Kyoto University Hospital, Kyoto, Japan
| | - Takahito Kawata
- Department of Hematology and Oncology, Kyoto University Graduate School of Medicine, Kyoto, Japan.,Department of Hematology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Naoyuki Uchida
- Department of Hematology, Federation of National Public Service Personnel Mutual Aid Associations Toranomon Hospital, Tokyo, Japan
| | - Atsushi Marumo
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Kazuhiro Ikegame
- Division of Hematology, Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan
| | - Takahiro Fukuda
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Tetsuya Eto
- Department of Hematology, Hamanomachi Hospital, Fukuoka, Japan
| | - Masatsugu Tanaka
- Department of Hematology, Kanagawa Cancer Center, Yokohama, Japan
| | - Atsushi Wake
- Department of Hematology, Federation of National Public Service Personnel Mutual Aid Associations, Toranomon Hospital Kajigaya, Kawasaki, Japan
| | - Junya Kanda
- Department of Hematology and Oncology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Takafumi Kimura
- Preparation Department, Japanese Red Cross Kinki Block Blood Center, Osaka, Japan
| | - Ken Tabuchi
- Department of Pediatrics, Tokyo Metropolitan Cancer and Infectious Disease Center, Komagome Hospital, Tokyo, Japan.,Tokyo Cancer Registry, Bureau of Social Welfare and Public Health, Tokyo Metropolitan Government, Tokyo, Japan
| | - Tatsuo Ichinohe
- Department of Hematology and Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Yoshiko Atsuta
- Japanese Data Center for Hematopoietic Cell Transplantation, Nagoya, Japan.,Department of Healthcare Administration, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masamitsu Yanada
- Department of Hematology and Cell Therapy, Aichi Cancer Center, Nagoya, Japan
| | - Shingo Yano
- Division of Clinical Oncology and Hematology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
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14
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Su Q, Fan Z, Huang F, Xu N, Nie D, Lin D, Guo Z, Shi P, Wang Z, Jiang L, Sun J, Jiang Z, Liu Q, Xuan L. Comparison of Two Strategies for Prophylactic Donor Lymphocyte Infusion in Patients With Refractory/Relapsed Acute Leukemia. Front Oncol 2021; 11:554503. [PMID: 33747904 PMCID: PMC7966710 DOI: 10.3389/fonc.2021.554503] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 01/11/2021] [Indexed: 11/27/2022] Open
Abstract
Prophylactic donor lymphocyte infusion (pDLI) could reduce relapse in patients with refractory/relapsed acute leukemia (RRAL) undergoing allogeneic hematopoietic stem cell transplantation (allo-HSCT), but optimal timing of pDLI remains uncertain. We compared the outcomes of two strategies for pDLI based on time from transplant and minimal residual disease (MRD) status in patients with RRAL. For patients without grade II–IV acute graft-versus-host disease (aGVHD) on day +60, pDLI was given on day +60 regardless of MRD in cohort 1, and was given on day +90 unless MRD was positive on day +60 in cohort 2. A total of 161 patients with RRAL were enrolled, including 83 in cohort 1 and 78 in cohort 2. The extensive chronic GVHD (cGVHD) incidence in cohort 2 was lower than that in cohort 1 (10.3% vs. 27.9%, P = 0.006) and GVHD-free/relapse-free survival (GRFS) in cohort 2 was superior to that in cohort 1 (55.1% vs. 41.0%, P = 0.042). The 2-year relapse rate, overall and leukemia-free survival were comparable between the two cohorts (29.0% vs. 28.2%, P = 0.986; 63.9% vs. 64.1%, P = 0.863; 57.8% vs. 61.5%, P = 0.666). Delaying pDLI to day +90 based on MRD for patients with RRAL undergoing allo-HSCT could lower extensive cGVHD incidence and improve GRFS without increasing incidence of leukemia relapse compared with pDLI on day +60.
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Affiliation(s)
- Qiongqiong Su
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhiping Fan
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Fen Huang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Na Xu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Danian Nie
- Department of Hematology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Dongjun Lin
- Department of Hematology, The Third Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Ziwen Guo
- Department of Hematology, Zhongshan People's Hospital, Zhongshan, China
| | - Pengcheng Shi
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhixiang Wang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ling Jiang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Jing Sun
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zujun Jiang
- Department of Hematology, Guangzhou General Hospital of Guangzhou Military Command, Guangzhou, China
| | - Qifa Liu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Li Xuan
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou, China
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15
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Dholaria B, Savani BN, Hamilton BK, Oran B, Liu HD, Tallman MS, Ciurea SO, Holtzman NG, Ii GLP, Devine SM, Mannis G, Grunwald MR, Appelbaum F, Rodriguez C, El Chaer F, Shah N, Hashmi SK, Kharfan-Dabaja MA, DeFilipp Z, Aljurf M, AlShaibani A, Inamoto Y, Jain T, Majhail N, Perales MA, Mohty M, Hamadani M, Carpenter PA, Nagler A. Hematopoietic Cell Transplantation in the Treatment of Newly Diagnosed Adult Acute Myeloid Leukemia: An Evidence-Based Review from the American Society of Transplantation and Cellular Therapy. Transplant Cell Ther 2021; 27:6-20. [PMID: 32966881 DOI: 10.1016/j.bbmt.2020.09.020] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 09/10/2020] [Indexed: 12/31/2022]
Abstract
The role of hematopoietic cell transplantation (HCT) in the management of newly diagnosed adult acute myeloid leukemia (AML) is reviewed and critically evaluated in this evidence-based review. An AML expert panel, consisting of both transplant and nontransplant experts, was invited to develop clinically relevant frequently asked questions covering disease- and HCT-related topics. A systematic literature review was conducted to generate core recommendations that were graded based on the quality and strength of underlying evidence based on the standardized criteria established by the American Society of Transplantation and Cellular Therapy Steering Committee for evidence-based reviews. Allogeneic HCT offers a survival benefit in patients with intermediate- and high-risk AML and is currently a part of standard clinical care. We recommend the preferential use of myeloablative conditioning in eligible patients. A haploidentical related donor marrow graft is preferred over a cord blood unit in the absence of a fully HLA-matched donor. The evolving role of allogeneic HCT in the context of measurable residual disease monitoring and recent therapeutic advances in AML with regards to maintenance therapy after HCT are also discussed.
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Affiliation(s)
- Bhagirathbhai Dholaria
- Department of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Bipin N Savani
- Department of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Betty K Hamilton
- Blood and Marrow Transplant Program, Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio
| | - Betul Oran
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Hien D Liu
- Department of Blood and Marrow Transplant and Cellular Immunotherapy, Moffitt Cancer Center, Tampa, Florida
| | | | | | - Noa G Holtzman
- Center for Cancer Research, National Cancer Institute, Bethesda, Maryland
| | | | - Steven M Devine
- National Marrow Donor Program and Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota
| | - Gabriel Mannis
- Department of Medicine, Division of Hematology, Stanford University, Stanford, California
| | - Michael R Grunwald
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health, Charlotte, North Carolina
| | - Frederick Appelbaum
- Fred Hutchinson Cancer Research Center; Department of Medicine, University of Washington, Seattle, Washington
| | - Cesar Rodriguez
- Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Firas El Chaer
- Division of Hematology/Oncology, University of Virginia, Charlottesville, Virginia
| | - Nina Shah
- Division of Hematology-Oncology, Department of Medicine, University of California San Francisco, San Francisco, California
| | | | - Mohamed A Kharfan-Dabaja
- Division of Hematology-Oncology and Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, Florida
| | - Zachariah DeFilipp
- Blood and Marrow Transplant Program, Massachusetts General Hospital, Boston, Massachusetts
| | - Mahmoud Aljurf
- Department of Oncology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - AlFadel AlShaibani
- Department of Oncology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Yoshihiro Inamoto
- Fred Hutchinson Cancer Research Center; Department of Medicine, University of Washington, Seattle, Washington; Division of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Tokyo, Japan
| | - Tania Jain
- Sidney Kimmel Cancer Center, John Hopkins Hospital, Baltimore, Maryland
| | - Navneet Majhail
- Blood and Marrow Transplant Program, Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, Ohio
| | - Miguel-Angel Perales
- Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Mohamad Mohty
- Saint Antoine Hospital, INSERM UMR 938, Université Pierre et Marie Curie, TC, Paris, France; EBMT Paris Study Office, Paris, France
| | - Mehdi Hamadani
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Paul A Carpenter
- Fred Hutchinson Cancer Research Center; Department of Medicine, University of Washington, Seattle, Washington
| | - Arnon Nagler
- EBMT Paris Study Office, Paris, France; Chaim Sheba Medical Center, Tel Hashomer, Israel
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16
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FLAMSA-Based Reduced-Intensity Conditioning versus Myeloablative Conditioning in Younger Patients with Relapsed/Refractory Acute Myeloid Leukemia with Active Disease at the Time of Allogeneic Stem Cell Transplantation: An Analysis from the Acute Leukemia Working Party of the European Society for Blood and Marrow Transplantation. Biol Blood Marrow Transplant 2020; 26:2165-2173. [DOI: 10.1016/j.bbmt.2020.07.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/07/2020] [Accepted: 07/15/2020] [Indexed: 12/20/2022]
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17
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Tachibana T, Kanda J, Ishizaki T, Najima Y, Tanaka M, Doki N, Fujiwara SI, Kimura SI, Onizuka M, Takahashi S, Saito T, Mori T, Fujisawa S, Sakaida E, Miyazaki T, Aotsuka N, Gotoh M, Watanabe R, Shono K, Usuki K, Tsukada N, Kanamori H, Kanda Y, Okamoto S. Clinical Benefits of Preconditioning Intervention in Patients with Relapsed or Refractory Acute Myelogenous Leukemia Who Underwent Allogeneic Hematopoietic Cell Transplantation: A Kanto Study of Group for Cell Therapy Multicenter Analysis. Transplant Cell Ther 2020; 27:70.e1-70.e8. [PMID: 33007494 DOI: 10.1016/j.bbmt.2020.09.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 09/21/2020] [Accepted: 09/21/2020] [Indexed: 10/23/2022]
Abstract
A multicenter retrospective study was conducted to evaluate the clinical significance of preconditioning intervention (PCI) before allogeneic hematopoietic cell transplantation (HCT) in patients with acute myelogenous leukemia (AML) not in remission. The study cohort consisted of 519 patients classified according to the intensity (intensive/moderate) of PCI and their response to PCI. The group treated with PCI had higher blast counts in the peripheral blood (PB) and had a lower overall survival (OS) rate (P < .001) and higher nonrelapse mortality (NRM) rate (P = .035) compared with those without PCI (no PCI group). Approximately 40% of the patients (68 of 236) achieved a good response to PCI (good PCI group), and those patients had lower blast counts in the PB compared with the group with poor response to PCI (poor PCI group). OS in the good PCI group was comparable to that in the no PCI group and significantly better than that in the poor PCI group (hazard ratio, .54; 95% confidence interval, .39 to .77; P < .001). However, OS was significantly lower in patients with intensive/moderate PCI compared with the no PCI group. These results suggest that PCI increases NRM without decreasing the post-transplantation relapse rate, but may be beneficial for patients with lower blast counts in PB irrespective of its intensity.
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Affiliation(s)
| | - Junya Kanda
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Saitama, Japan; Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takuma Ishizaki
- Department of Hematology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Yuho Najima
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Masatsugu Tanaka
- Department of Hematology, Kanagawa Cancer Center, Yokohama, Japan
| | - Noriko Doki
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Shin-Ichiro Fujiwara
- Division of Hematology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Shun-Ichi Kimura
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Makoto Onizuka
- Department of Hematology and Oncology, Tokai University School of Medicine, Isehara, Japan
| | - Satoshi Takahashi
- Division of Molecular Therapy, The Advanced Clinical Research Center, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Takeshi Saito
- Division of Clinical Oncology and Hematology, Department of Internal Medicine, the Jikei University School of Medicine, Tokyo, Japan
| | - Takehiko Mori
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shin Fujisawa
- Department of Hematology, Yokohama City University Medical Center, Yokohama, Japan
| | - Emiko Sakaida
- Department of Hematology, Chiba University Hospital, Chiba, Japan
| | - Takuya Miyazaki
- Department of Hematology and Clinical Immunology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Nobuyuki Aotsuka
- Division of Hematology-Oncology, Japanese Red Cross Society Narita Hospital, Narita, Japan
| | - Moritaka Gotoh
- First Department of Internal Medicine, Tokyo Medical University, Tokyo, Japan
| | - Reiko Watanabe
- Department of Hematology, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
| | - Katsuhiro Shono
- Department of Hematology, Chiba Aoba Municipal Hospital, Chiba, Japan
| | - Kensuke Usuki
- Department of Hematology, NTT Medical Center Tokyo, Tokyo, Japan
| | - Nobuhiro Tsukada
- Department of Hematology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Heiwa Kanamori
- Department of Hematology, Kanagawa Cancer Center, Yokohama, Japan
| | - Yoshinobu Kanda
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Saitama, Japan; Division of Hematology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Shinichiro Okamoto
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
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18
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Olson AL, Saliba RM, Oran B, Chen J, Alousi A, Ahmed S, Bashir Q, Ciurea SO, Hosing C, Seon Im J, Kebriaei P, Khouri IF, Mehta R, Nieto Y, Parmar S, Rezvani K, Shah N, Shpall E, Srour SA, Qazilbash M, Andersson BS, Champlin R, Popat UR. Cytogenetics and Blast Count Determine Transplant Outcomes in Patients with Active Acute Myeloid Leukemia. Acta Haematol 2020; 144:74-81. [PMID: 32604096 DOI: 10.1159/000507012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 02/17/2020] [Indexed: 12/17/2022]
Abstract
Acute myeloid leukemia (AML) patients not in remission and beyond first or second complete remission are considered allogeneic stem cell transplant (SCT) candidates. We present 361 patients who underwent SCT from matched related or unrelated donors between 2005 and 2013. The purpose was to identify a subgroup of patients with active disease at the time of transplant that benefit. Cox proportional hazards regression analysis was used for univariate and multivariate analyses to predict overall survival (OS). Variables considered were age, sex, SWOG cytogenetic risk group, bone marrow (BM) and peripheral blood (PB) blast percentage, regimen intensity, and type of AML. At a median of 26 months after transplantation, OS, progression-free survival (PFS), non-relapse mortality, and relapse rates were 26, 24, 23, and 48%, respectively. In a univariate analysis, risk cytogenetics (p < 0.001) and BM blasts >4% (p = 0.006) or any blasts in PB (p < 0.001) indicated worse OS. In a multivariate analysis, patients with <5% BM blasts or absence of circulating blasts and good or intermediate risk cytogenetics had significantly superior OS (46%), PFS (44%), and disease progression at 3 years. Based on these findings, patients not in remission with good or intermediate risk cytogenetics and low blast counts should be considered for SCT.
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MESH Headings
- Adolescent
- Adult
- Aged
- Biomarkers, Tumor
- Biopsy
- Bone Marrow/pathology
- Chromosome Aberrations
- Cytogenetic Analysis
- Female
- Graft vs Host Disease/diagnosis
- Graft vs Host Disease/etiology
- Hematopoietic Stem Cell Transplantation
- Humans
- Leukemia, Myeloid, Acute/diagnosis
- Leukemia, Myeloid, Acute/genetics
- Leukemia, Myeloid, Acute/mortality
- Leukemia, Myeloid, Acute/therapy
- Male
- Middle Aged
- Prognosis
- Time Factors
- Transplantation, Homologous
- Treatment Outcome
- Young Adult
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Affiliation(s)
- Amanda L Olson
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA,
| | - Rima M Saliba
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Betul Oran
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Julianne Chen
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Amin Alousi
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sairah Ahmed
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Qaiser Bashir
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Stefan O Ciurea
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Chitra Hosing
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jin Seon Im
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Partow Kebriaei
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Issa F Khouri
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Rohtesh Mehta
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Yago Nieto
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Simrit Parmar
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Katy Rezvani
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nina Shah
- Department of Medicine, UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California, USA
| | - Elizabeth Shpall
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Samer A Srour
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Muzaffar Qazilbash
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Borje S Andersson
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Richard Champlin
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Uday R Popat
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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19
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McDaniel Mims B, Jones-Hall Y, Dos Santos AP, Furr K, Enriquez J, Grisham MB. Induction of acute graft vs. host disease in lymphopenic mice. ACTA ACUST UNITED AC 2019; 26:233-244. [PMID: 31248669 DOI: 10.1016/j.pathophys.2019.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 06/04/2019] [Accepted: 06/13/2019] [Indexed: 12/30/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) is a potentially life-saving treatment for refractory/relapsing hematological malignancies, blood disorders or autoimmune diseases. However, approximately 40-50% of patients undergoing allogeneic HSCT will develop a multi-organ, inflammatory disorder called acute graft vs. host disease (aGVHD). Experimental and clinical studies suggest that intestinal injury due to toxic, pre-transplant conditioning protocols (e.g. lethal irradiation and/or chemotherapy) may play a major role in the development of aGVHD. However, recent studies from our laboratory suggest that this may not be the case. The objective of this study was to quantify and compare the onset and severity of aGVHD induced by the adoptive transfer of allogeneic T cells into untreated lymphopenic mice. Four million allogeneic or syngeneic CD4+CD62L+CD25- T cells were transferred (i.p.) into NK cell-depleted RAG1-/- mice or RAG2-/-IL2rγ-/-double knock-out (DKO) mice and assessed daily for signs of aGVHD. We found that adoptive transfer of allogeneic but not syngeneic T cells into NK cell-depleted RAG1-/- or DKO mice induced many of the clinical and histological features of aGVHD including weight loss, inflammatory cytokine production and tissue inflammation. In addition, adoptive transfer of allogeneic T cells into each recipient induced severe anemia as well as dramatic reductions in bone marrow and spleen cellularity. Taken together, we conclude that allogeneic CD4+ T cells are both necessary and sufficient to induce aGVHD in lymphopenic recipients in the absence of toxic, pre-transplant conditioning.
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Affiliation(s)
- Brianyell McDaniel Mims
- Department of Immunology and Molecular Microbiology, Texas Tech University Health, Sciences Center, Lubbock, TX 79430, United States
| | - Yava Jones-Hall
- Purdue University, College of Veterinary Medicine, Department of Comparative Pathobiology, West Lafayette, IN 47907, United States
| | - Andrea Pires Dos Santos
- Purdue University, College of Veterinary Medicine, Department of Comparative Pathobiology, West Lafayette, IN 47907, United States
| | - Kathryn Furr
- Department of Immunology and Molecular Microbiology, Texas Tech University Health, Sciences Center, Lubbock, TX 79430, United States
| | - Josue Enriquez
- Department of Immunology and Molecular Microbiology, Texas Tech University Health, Sciences Center, Lubbock, TX 79430, United States
| | - Matthew B Grisham
- Department of Immunology and Molecular Microbiology, Texas Tech University Health, Sciences Center, Lubbock, TX 79430, United States.
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20
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Tachibana T, Kanda J, Ishizaki T, Najima Y, Tanaka M, Doki N, Fujiwara SI, Kimura SI, Onizuka M, Takahashi S, Saito T, Mori T, Fujisawa S, Sakaida E, Matsumoto K, Aotsuka N, Goto M, Watanabe R, Shono K, Usuki K, Tsukada N, Kanamori H, Kanda Y, Okamoto S. Prognostic index for patients with relapsed or refractory acute myeloid leukemia who underwent hematopoietic cell transplantation: a KSGCT multicenter analysis. Leukemia 2019; 33:2610-2618. [PMID: 31147621 DOI: 10.1038/s41375-019-0494-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 03/20/2019] [Accepted: 04/10/2019] [Indexed: 11/09/2022]
Abstract
A multicenter retrospective study was performed to explore a prognostic scoring index in order to identify a population who are least likely to benefit from allogeneic hematopoietic cell transplantation (HCT) in patients with relapsed or refractory acute myeloid leukemia (AML). The cohort included 519 patients with AML, who received HCT between 2005 and 2015 at a status of relapse or primary induction failure. Multivariate analysis demonstrated five independent predictors for OS, including C-reactive protein ≥ 1 mg/dL, peripheral blood blast fraction ≥ 20%, poor-risk karyotype, performance status ≥ 2, and bone marrow unrelated donor as a stem cell source. A prognostic scoring index was explored based on these predictors, and successfully separated the cohort into four groups. At 2 years, OS was 47%, 24%, 8%, and 0% for Good (Score 0, 1: n = 118), Intermediate-1 (Score 2: n = 75), Intermediate-2 (Score 3: n = 39), and Poor (Score 4: n = 24), respectively (P < 0.001). The predicting value of the index was confirmed in a validation cohort. Although a further validation study is warranted, the scoring index may be useful to predict survival and to identify the population with the lowest survival prior to HCT in patients with relapsed or refractory AML.
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Affiliation(s)
| | - Junya Kanda
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Saitama, Japan.,Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takuma Ishizaki
- Department of Medicine and Clinical Science, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Yuho Najima
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Masatsugu Tanaka
- Department of Hematology, Kanagawa Cancer Center, Yokohama, Japan
| | - Noriko Doki
- Hematology Division, Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | - Shin-Ichiro Fujiwara
- Division of Hematology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Shun-Ichi Kimura
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Makoto Onizuka
- Department of Hematology and Oncology, Tokai University School of Medicine, Isehara, Japan
| | - Satoshi Takahashi
- Division of Molecular Therapy, The Advanced Clinical Research Center, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Takeshi Saito
- Division of Clinical Oncology and Hematology, Department of Internal Medicine, Jikei University School of Medicine, Tokyo, Japan
| | - Takehiko Mori
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shin Fujisawa
- Department of Hematology, Yokohama City University Medical Center, Yokohama, Japan
| | - Emiko Sakaida
- Department of Hematology, Chiba University Hospital, Chiba, Japan
| | - Kenji Matsumoto
- Department of Hematology and Clinical Immunology, Yokohama City University School of Medicine, Yokohama, Japan
| | - Nobuyuki Aotsuka
- Division of Hematology-Oncology, Japanese Red Cross Society Narita Hospital, Narita, Japan
| | - Moritaka Goto
- First Department of Internal Medicine, Tokyo Medical University, Tokyo, Japan
| | - Reiko Watanabe
- Department of Hematology, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
| | - Katsuhiro Shono
- Department of Internal Medicine, Chiba Aoba Municipal Hospital, Chiba, Japan
| | - Kensuke Usuki
- Department of Hematology, NTT Medical Center Tokyo, Tokyo, Japan
| | - Nobuhiro Tsukada
- Department of Hematology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Heiwa Kanamori
- Department of Hematology, Kanagawa Cancer Center, Yokohama, Japan
| | - Yoshinobu Kanda
- Division of Hematology, Saitama Medical Center, Jichi Medical University, Saitama, Japan.,Division of Hematology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Shinichiro Okamoto
- Division of Hematology, Department of Medicine, Keio University School of Medicine, Tokyo, Japan
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21
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Brissot E, Labopin M, Ehninger G, Stelljes M, Brecht A, Ganser A, Tischer J, Kröger N, Afanasyev B, Finke J, Elmaagacli A, Einsele H, Mohty M, Nagler A. Haploidentical versus unrelated allogeneic stem cell transplantation for relapsed/refractory acute myeloid leukemia: a report on 1578 patients from the Acute Leukemia Working Party of the EBMT. Haematologica 2018; 104:524-532. [PMID: 30361416 PMCID: PMC6395335 DOI: 10.3324/haematol.2017.187450] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Accepted: 10/19/2018] [Indexed: 12/14/2022] Open
Abstract
Primary refractory or relapsed acute myeloid leukemia is associated with a dismal prognosis. Allogeneic stem cell transplantation is the only therapeutic option that offers prolonged survival and cure in this setting. In the absence of a matched sibling donor, transplantation from unrelated 10/10 HLA allele-matched or 9/10 HLA allele-mismatched donors and haploidentical donors are potential alternatives. The current study aimed to compare the outcomes of acute myeloid leukemia patients with active disease who received allogeneic stem cell transplantation from a haploidentical donor with post-transplant cyclophosphamide (n=199) versus an unrelated 10/10-matched donor (n=1111) and versus an unrelated 9/10-mismatched donor (n=383) between 2007 and 2014 and who were reported to the European Society for Blood and Marrow Transplantation registry. Propensity score weighted analysis was conducted in order to control for disease risk imbalances between the groups. The leukemia-free survival rates at 2 years of recipients of grafts from a haploidentical donor, an unrelated 10/10-matched donor and an unrelated 9/10-mismatched donor were 22.8%, 28% and 22.2%, respectively (P=NS). In multivariate analysis, there were no significant differences in leukemia-free survival, overall survival, relapse incidence, non-relapse mortality, or graft-versus-host-disease-free relapse-free survival between the three groups. Two predictive factors were associated with a higher relapse incidence: transplantation during first or second relapse compared to primary refractory acute myeloid leukemia and poor cytogenetics. Allogeneic stem cell transplantation may rescue about 25% of acute myeloid leukemia patients with active disease. Importantly, the outcomes of transplants from haploidentical donors were comparable to those from 10/10-matched and 9/10-mismatched unrelated donors. Therefore, a haploidentical donor is a valid option for acute myeloid leukemia patients with active disease.
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Affiliation(s)
- Eolia Brissot
- Service d'Hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint Antoine, APHP, Paris, France
| | - Myriam Labopin
- Service d'Hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint Antoine, APHP, Paris, France.,Acute Leukemia Working Party office, Hôpital Saint Antoine, APHP, Paris, France
| | - Gerhard Ehninger
- Universitaetsklinikum Dresden, Medizinische Klinik und Poliklinik I, Germany
| | - Matthias Stelljes
- University of Münster, Department of Medicine A / Hematology and Oncology, Germany
| | - Arne Brecht
- Deutsche Klinik für Diagnostik, KMT Zentrum, Wiesbaden, Germany
| | - Arnold Ganser
- Hannover Medical School, Department of Haematology, Hemostasis, Oncology, and Stem Cell Transplantation, Germany
| | | | - Nicolaus Kröger
- University Hospital Eppendorf, Bone Marrow Transplantation Centre, Hamburg, Germany
| | - Boris Afanasyev
- First State Pavlov Medical University of St. Petersburg, Raisa Gorbacheva Memorial Research Institute for Pediatric Oncology, Hematology, and Transplantation, Russia
| | - Jürgen Finke
- University of Freiburg, Faculty of Medicine and Department of Medicine -Hematology, Oncology and Stem Cell Transplantation, Germany
| | - Ahmet Elmaagacli
- Asklepios Klinik St. Georg, Department of Hematology, Hamburg, Germany
| | - Herman Einsele
- Universitaetsklinikum Würzburg, Med. Klinik und Poliklinik II, Germany
| | - Mohamad Mohty
- Service d'Hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint Antoine, APHP, Paris, France.,Acute Leukemia Working Party office, Hôpital Saint Antoine, APHP, Paris, France
| | - Arnon Nagler
- Acute Leukemia Working Party office, Hôpital Saint Antoine, APHP, Paris, France.,Hematology Division, Chaim Sheba Medical Center and Tel Aviv University, Tel-Hashomer, Ramat-Gan, Israel
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22
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McMahon CM, Perl AE. Management of primary refractory acute myeloid leukemia in the era of targeted therapies. Leuk Lymphoma 2018; 60:583-597. [PMID: 30234399 DOI: 10.1080/10428194.2018.1504937] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Primary refractory acute myeloid leukemia (AML), or primary induction failure, represents a continued challenge in clinical management. This review presents an overview of primary refractory disease and a discussion of risk factors for induction failure, including current evidence regarding the impact of karyotype and molecular mutation status on responsiveness to chemotherapy. We review the evidence for various treatment options for refractory AML including salvage chemotherapy regimens, allogeneic hematopoietic stem cell transplantation, targeted agents, and non-intensive therapies such as hypomethylating agents. A therapeutic approach to this patient population is presented, and several new and emerging therapies are reviewed.
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Affiliation(s)
- Christine M McMahon
- a Department of Medicine, Division of Hematology and Oncology , Perelman School of Medicine at the University of Pennsylvania , Philadelphia , PA , USA
| | - Alexander E Perl
- a Department of Medicine, Division of Hematology and Oncology , Perelman School of Medicine at the University of Pennsylvania , Philadelphia , PA , USA
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23
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Gu B, Zhang X, Chen G, Wu X, Ma X, Chen S, Wu D. Efficacy of haploidentical hematopoietic stem cell transplantation compared to HLA-matched transplantation for primary refractory acute myeloid leukemia. Ann Hematol 2018; 97:2185-2194. [PMID: 30039296 DOI: 10.1007/s00277-018-3428-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 06/30/2018] [Indexed: 01/30/2023]
Abstract
Newly diagnosed acute myeloid leukemia (AML) failed to achieve complete remission after two courses of intensive chemotherapy. This was considered as primary refractory AML (PRR-AML), and still has a dismal prognosis. Allogeneic hematopoietic stem cell transplantation could be the only cure for these patients. However, the role of haploidentical hematopoietic stem cell transplantation (HID-HCT) for PRR-AML is still undetermined. We retrospectively analyzed the outcomes of 45 adult patients with PRR-AML who underwent HID-HCT, and compared it with the result of 53 patients who received HLA-matched related or unrelated donor transplantation (MD-HCT) during the same treatment period. The 3-year overall survival (OS), leukemia-free survival (LFS), cumulative incidence of relapse (CIR), and non-relapse mortality (NRM) rates in the HID-HCT group were 19.0, 16.5, 70.0, and 35.2%, respectively, but showed no significant differences from the results of MD-HCT. Multivariate analysis showed that complex karyotype with del(7) and time > 6 months from diagnosis to transplantation were associated with lower OS and LFS, and chronic GVHD demonstrated better OS and LFS in the entire cohort. Complex karyotype with del(7) was related with higher CIR and chronic GVHD with lower CIR. In conclusion, HID-HCT could be an alternative treatment strategy to improve the long-term survival in PRR-AML adult patients who have no HLA-matched donors.
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Affiliation(s)
- Bin Gu
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Hematology, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
| | - Xiang Zhang
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Hematology, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
| | - Guanghua Chen
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Hematology, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
| | - Xiaojin Wu
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Hematology, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
| | - Xiao Ma
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Hematology, Suzhou, China.,Institute of Blood and Marrow Transplantation, Suzhou, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
| | - Suning Chen
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Hematology, Suzhou, China. .,Institute of Blood and Marrow Transplantation, Suzhou, China. .,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China. .,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China.
| | - Depei Wu
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Hematology, Suzhou, China. .,Institute of Blood and Marrow Transplantation, Suzhou, China. .,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China. .,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China.
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24
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Decroocq J, Itzykson R, Vigouroux S, Michallet M, Yakoub-Agha I, Huynh A, Beckerich F, Suarez F, Chevallier P, Nguyen-Quoc S, Ledoux MP, Clement L, Hicheri Y, Guillerm G, Cornillon J, Contentin N, Carre M, Maillard N, Mercier M, Mohty M, Beguin Y, Bourhis JH, Charbonnier A, Dauriac C, Bay JO, Blaise D, Deconinck E, Jubert C, Raus N, Peffault de Latour R, Dhedin N. Similar outcome of allogeneic stem cell transplantation after myeloablative and sequential conditioning regimen in patients with refractory or relapsed acute myeloid leukemia: A study from the Société Francophone de Greffe de Moelle et de Thérapie Cellulaire. Am J Hematol 2018; 93:416-423. [PMID: 29226497 DOI: 10.1002/ajh.25004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Revised: 12/05/2017] [Accepted: 12/07/2017] [Indexed: 01/22/2023]
Abstract
Patients with acute myeloid leukemia (AML) in relapse or refractory to induction therapy have a dismal prognosis. Allogeneic hematopoietic stem cell transplantation is the only curative option. In these patients, we aimed to compare the results of a myeloablative transplant versus a sequential approach consisting in a cytoreductive chemotherapy followed by a reduced intensity conditioning regimen and prophylactic donor lymphocytes infusions. We retrospectively analyzed 99 patients aged 18-50 years, transplanted for a refractory (52%) or a relapsed AML not in remission (48%). Fifty-eight patients received a sequential approach and 41 patients a myeloablative conditioning regimen. Only 6 patients received prophylactic donor lymphocytes infusions. With a median follow-up of 48 months, 2-year overall survival was 39%, 95% confidence interval (CI) (24-53) in the myeloablative group versus 33%, 95% CI (21-45) in the sequential groups (P = .39), and 2-year cumulative incidence of relapse (CIR) was 57% versus 50% respectively (P = .99). Nonrelapse mortality was not higher in the myeloablative group (17% versus 15%, P = .44). In multivariate analysis, overall survival, CIR and nonrelapse mortality remained similar between the two groups. However, in multivariate analysis, sequential conditioning led to fewer acute grade II-IV graft versus host disease (GVHD) (HR for sequential approach = 0.37; 95% CI: 0.21-0.65; P < .001) without a significant impact on chronic GVHD (all grades and extensive). In young patients with refractory or relapsed AML, myeloablative transplant and sequential approach offer similar outcomes except for a lower incidence of acute GvHD after a sequential transplant.
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Affiliation(s)
| | | | | | | | - Ibrahim Yakoub-Agha
- Hematology department; CHU de Lille, LIRIC INSERM U995, Université Lille 2, Lille; France
| | - Anne Huynh
- Hematology department; IUCT Oncopole; Toulouse France
| | | | - Felipe Suarez
- Hematology department; Hôpital Necker Enfants malades; Paris France
| | | | | | | | | | - Yosr Hicheri
- Hematology department; CHU Lapeyronie; Montpellier France
| | | | | | | | - Martin Carre
- Hematology department; CHU Grenoble; Grenoble France
| | | | | | - Mohamad Mohty
- Hematology department; Hôpital Saint Antoine; Paris France
| | - Yves Beguin
- Hematology department; CHU Liège; Liège Belgium
| | | | | | | | | | - Didier Blaise
- Hematology department; Institut Paoli Calmettes; Marseille France
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Rashidi A, Weisdorf DJ, Bejanyan N. Treatment of relapsed/refractory acute myeloid leukaemia in adults. Br J Haematol 2018; 181:27-37. [PMID: 29318584 DOI: 10.1111/bjh.15077] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The prognosis of relapsed acute myeloid leukaemia (AML) is poor and treatment is challenging. While the most potent treatment modality for patients who achieve a complete remission after relapse is still allogeneic haematopoietic cell transplantation (allo-HCT), both transplant-related mortality and relapse rates are high and many patients are not candidates for this approach. After a few decades of relative stasis in this field, a large number of novel approaches have become available to tackle this highly fatal disease. This is mostly due to our improved understanding of disease pathogenesis (including targetable mutations) and the anti-leukaemia potential of the immune system. Several small-molecule inhibitors and immunotherapeutic options are being explored in clinical trials and many more are in pre-clinical phase. Future studies will focus on novel and mechanistically driven combinations, sequential treatments, and low-toxicity maintenance strategies. While cure of relapsed/refractory AML without allo-HCT is currently unlikely, treatments are becoming less toxic and remissions are lasting longer.
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Affiliation(s)
- Armin Rashidi
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Daniel J Weisdorf
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Nelli Bejanyan
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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26
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Brissot E, Labopin M, Stelljes M, Ehninger G, Schwerdtfeger R, Finke J, Kolb HJ, Ganser A, Schäfer-Eckart K, Zander AR, Bunjes D, Mielke S, Bethge WA, Milpied N, Kalhs P, Blau IW, Kröger N, Vitek A, Gramatzki M, Holler E, Schmid C, Esteve J, Mohty M, Nagler A. Comparison of matched sibling donors versus unrelated donors in allogeneic stem cell transplantation for primary refractory acute myeloid leukemia: a study on behalf of the Acute Leukemia Working Party of the EBMT. J Hematol Oncol 2017; 10:130. [PMID: 28646908 PMCID: PMC5483262 DOI: 10.1186/s13045-017-0498-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 06/16/2017] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Primary refractory acute myeloid leukemia (PRF-AML) is associated with a dismal prognosis. Allogeneic stem cell transplantation (HSCT) in active disease is an alternative therapeutic strategy. The increased availability of unrelated donors together with the significant reduction in transplant-related mortality in recent years have opened the possibility for transplantation to a larger number of patients with PRF-AML. Moreover, transplant from unrelated donors may be associated with stronger graft-mediated anti-leukemic effect in comparison to transplantations from HLA-matched sibling donor, which may be of importance in the setting of PRF-AML. METHODS The current study aimed to address the issue of HSCT for PRF-AML and to compare the outcomes of HSCT from matched sibling donors (n = 660) versus unrelated donors (n = 381), for patients with PRF-AML between 2000 and 2013. The Kaplan-Meier estimator, the cumulative incidence function, and Cox proportional hazards regression models were used where appropriate. RESULTS HSCT provide patients with PRF-AML a 2-year leukemia-free survival and overall survival of about 25 and 30%, respectively. In multivariate analysis, two predictive factors, cytogenetics and time from diagnosis to transplant, were associated with lower leukemia-free survival, whereas Karnofsky performance status at transplant ≥90% was associated with better leukemia-free survival (LFS). Concerning relapse incidence, cytogenetics and time from diagnosis to transplant were associated with increased relapse. Reduced intensity conditioning regimen was the only factor associated with lower non-relapse mortality. CONCLUSIONS HSCT was able to rescue about one quarter of the patients with PRF-AML. The donor type did not have any impact on PRF patients' outcomes. In contrast, time to transplant was a major prognostic factor for LFS. For patients with PRF-AML who do not have a matched sibling donor, HSCT from an unrelated donor is a suitable option, and therefore, initiation of an early search for allocating a suitable donor is indicated.
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Affiliation(s)
- Eolia Brissot
- Service d’Hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint Antoine, APHP, 184 rue du faubourg Saint-Antoine, 75571 Paris, Cedex 12 France
| | - Myriam Labopin
- Service d’Hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint Antoine, APHP, 184 rue du faubourg Saint-Antoine, 75571 Paris, Cedex 12 France
- Acute Leukemia Working Party Office, Hôpital Saint Antoine, APHP, Paris, France
| | - Matthias Stelljes
- Department of Medicine A/Hematology and Oncology, University of Muenster, Muenster, Germany
| | - Gerhard Ehninger
- Medizinische Klinik und Poliklinik I, Universitätsklinikum, Dresden, Germany
| | | | - Jürgen Finke
- Faculty of Medicine and Medical Center, Hematology, Oncology and Stem Cell Transplantation, University of Freiburg, Freiburg im Breisgau, Germany
| | | | - Arnold Ganser
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | | | - Axel R. Zander
- Bone Marrow Transplantation Center, University Hospital Eppendorf, Hamburg, Germany
| | - Donald Bunjes
- Klinik fuer Innere Medizin III, Universtätklinikum, Ulm, Germany
| | - Stephan Mielke
- Department of Internal Medicine II, Würzburg University Medical Center, Würzburg, Germany
| | - Wolfgang A. Bethge
- Medical Department, Hematology and Oncology, University of Tuebingen, Tübingen, Germany
| | | | - Peter Kalhs
- Department of Internal Medicine I, Bone Marrow Transplantation Unit, Medical University of Vienna, Vienna, Austria
| | - Igor-Woflgang Blau
- Charite-Campus Benjamin Franklin Universitaetsmedizin Berlin Klinik III- Hematologie u Onkologie, Hindenburgdamm, Berlin, Germany
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Antonin Vitek
- Department of Clinical Hematology, Institute of Hematology and Blood Transfusion, Prague, Czech Republic
| | - Martin Gramatzki
- Division of Stem Cell Transplantation and Immunotherapy, University of Kiel, Kiel, Germany
| | - Ernst Holler
- Department of Haematology/Oncology, University Hospital Regensburg, Regensburg, Germany
| | | | - Jordi Esteve
- Hospital Clinic Institut d’investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Mohamad Mohty
- Service d’Hématologie Clinique et de Thérapie Cellulaire, Hôpital Saint Antoine, APHP, 184 rue du faubourg Saint-Antoine, 75571 Paris, Cedex 12 France
- Acute Leukemia Working Party Office, Hôpital Saint Antoine, APHP, Paris, France
| | - Arnon Nagler
- Acute Leukemia Working Party Office, Hôpital Saint Antoine, APHP, Paris, France
- Chaim Sheba Medical Center, Tel Hashomer, Israel
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Farshchi Zarabi S, Chan S, Gupta V, Khalaf D, Lutynski A, Minden MD, Rostom A, Rydlewski A, Schuh AC, Sibai H, Yee KWL, Schimmer AD. Remissions after third induction chemotherapy for primary non-responders with acute myeloid leukemia (AML) are uncommon and short-lived. Leuk Lymphoma 2017; 59:237-240. [PMID: 28595467 DOI: 10.1080/10428194.2017.1323273] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
| | - Steven Chan
- a Princess Margaret Cancer Centre , Toronto , Ontario , Canada
| | - Vikas Gupta
- a Princess Margaret Cancer Centre , Toronto , Ontario , Canada
| | - Dina Khalaf
- a Princess Margaret Cancer Centre , Toronto , Ontario , Canada
| | | | - Mark D Minden
- a Princess Margaret Cancer Centre , Toronto , Ontario , Canada
| | - Amr Rostom
- a Princess Margaret Cancer Centre , Toronto , Ontario , Canada
| | - Anna Rydlewski
- a Princess Margaret Cancer Centre , Toronto , Ontario , Canada
| | - Andre C Schuh
- a Princess Margaret Cancer Centre , Toronto , Ontario , Canada
| | - Hassan Sibai
- a Princess Margaret Cancer Centre , Toronto , Ontario , Canada
| | - Karen W L Yee
- a Princess Margaret Cancer Centre , Toronto , Ontario , Canada
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28
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Allogeneic hematopoietic cell transplantation in patients with AML not achieving remission: potentially curative therapy. Bone Marrow Transplant 2017; 52:1083-1090. [DOI: 10.1038/bmt.2017.8] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 11/29/2016] [Accepted: 01/03/2017] [Indexed: 12/22/2022]
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29
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O'Hare P, Lucchini G, Cummins M, Veys P, Potter M, Lawson S, Vora A, Wynn R, Peniket A, Kirkland K, Pearce R, Perry J, Amrolia PJ. Allogeneic stem cell transplantation for refractory acute myeloid leukemia in pediatric patients: the UK experience. Bone Marrow Transplant 2017; 52:825-831. [DOI: 10.1038/bmt.2017.3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 10/26/2016] [Accepted: 11/02/2016] [Indexed: 12/28/2022]
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30
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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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31
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Yoo SH, Koh Y, Kim DY, Lee JH, Lee JH, Lee KH, Yoon SS, Park S, Park SK, Hong DS, Yi HG, Kim CS, Jang JE, Cheong JW, Moon J, Min YH, Sohn SK, Kim I. Salvage therapy for acute chemorefractory leukemia by allogeneic stem cell transplantation: the Korean experience. Ann Hematol 2017; 96:605-615. [PMID: 28091736 DOI: 10.1007/s00277-017-2919-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 12/29/2016] [Indexed: 10/20/2022]
Abstract
Little is known about the characteristics that make patients with acute leukemia suitable for undergoing salvage therapy by allogeneic hematopoietic stem cell transplantation (allo-HSCT). Here, we analyzed the clinical outcomes of 223 patients with acute leukemia who underwent allo-HSCT while not in complete remission (CR). The primary end points were overall survival (OS) and CR rate. CR was achieved in 79.8% of patients after allo-HSCT. Acute graft-versus-host disease (GVHD) was significantly associated with CR (P = 0.045). During a median follow-up of 30.1 months, the median OS was 6.1 months. OS was significantly longer in patients with good or standard risk cytogenetic characteristics than in those with poor risk cytogenetic characteristics (P = 0.029, P = 0.030, respectively). Patients who received allo-HSCT from a matched sibling donor had better survival than those with unrelated donors (P = 0.015). Primary chemorefractoriness was not associated with poor survival (P = 0.071). The number of chemotherapies before allo-HSCT was significantly correlated with outcome (P = 0.006). Chronic GVHD was a strong predictor of a longer OS (P = 0.025). In conclusion, survival of patients with primary chemorefractory acute leukemia is not lower when treated upfront with allo-HSCT. Hence, allo-HSCT should be actively considered in such patients. Acute and chronic GVHD is associated with better outcomes patients with acute leukemia who have undergone allo-HSCT and not achieved CR.
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Affiliation(s)
- Shin Hye Yoo
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Chongno-gu, Seoul, 110-744, South Korea
| | - Youngil Koh
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Chongno-gu, Seoul, 110-744, South Korea
| | - Dae-Young Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jung-Hee Lee
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Je-Hwan Lee
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Kyoo-Hyung Lee
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sung-Soo Yoon
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Chongno-gu, Seoul, 110-744, South Korea
| | - Seonyang Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Chongno-gu, Seoul, 110-744, South Korea
| | - Sung-Kyu Park
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, South Korea
| | - Dae-Sik Hong
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Bucheon, South Korea
| | - Hyeon Gyu Yi
- Department of Internal Medicine, Inha University College of Medicine, Incheon, South Korea
| | - Chul-Soo Kim
- Department of Internal Medicine, Inha University College of Medicine, Incheon, South Korea
| | - Ji Eun Jang
- Department of Internal Medicine, Yonsei University Severance Hospital, 250 Sungsan-ro, Seodaemun-gu, Seoul, 120-752, South Korea
| | - June-Won Cheong
- Department of Internal Medicine, Yonsei University Severance Hospital, 250 Sungsan-ro, Seodaemun-gu, Seoul, 120-752, South Korea
| | - Joonho Moon
- Department of Internal Medicine, Kyung-Pook University Hospital, Daegu, South Korea
| | - Yoo Hong Min
- Department of Internal Medicine, Yonsei University Severance Hospital, 250 Sungsan-ro, Seodaemun-gu, Seoul, 120-752, South Korea.
| | - Sang Kyun Sohn
- Department of Internal Medicine, Kyung-Pook University Hospital, Daegu, South Korea. .,Department of Internal Medicine, Kyungpook National University Hospital, Kyungpook National University School of Medicine, 200 Dongduk-ro, Jung-gu, Daegu, 700-721, South Korea.
| | - Inho Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Chongno-gu, Seoul, 110-744, South Korea.
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32
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Kovach AE, Brunner AM, Fathi AT, Chen YB, Hasserjian RP. Prognostic Significance of Residual Acute Myeloid Leukemia in Bone Marrow Samples Taken Prior to Allogeneic Hematopoietic Cell Transplantation. Am J Clin Pathol 2017; 147:50-59. [PMID: 28108471 DOI: 10.1093/ajcp/aqw203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES We sought to identify features in routine evaluation of pre-hematopoietic cell transplantation (HCT) bone marrow samples from patients with acute myeloid leukemia (AML) that influenced patient outcome. METHODS Of 140 patients, evidence of residual leukemia (RL) was identified in 38 (27%) of pre-HCT samples, as defined by 5% or more aspirate blasts, increased blood blasts, clustered or necrotic blasts on biopsy specimens, and/or leukemia-associated karyotypic abnormalities. RESULTS Morphologic or karyotypic evidence of RL was significantly associated with shorter leukemia-free survival (LFS) compared with cases without identifiable RL (median, 7.1 vs 28.3 months; P < .0001). Upon multivariable analysis, RL, prior relapse, age, high-risk karyotype, and alternate donor source were each independently associated with shorter LFS. RL in pre-HCT samples was more strongly associated with shorter LFS in patients with intermediate or favorable-risk AML karyotype ( P = .001) than secondary or adverse karyotype-risk AML ( P = .04). CONCLUSIONS Rigorous morphologic and karyotypic evaluation of pretransplant marrows is practical and important for posttransplant prognosis.
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Affiliation(s)
- Alexandra E Kovach
- From the Department of Pathology, Microbiology & Immunology, Vanderbilt University Medical Center, Nashville, TN; and Departments of
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33
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Diagnosis and management of AML in adults: 2017 ELN recommendations from an international expert panel. Blood 2016; 129:424-447. [PMID: 27895058 DOI: 10.1182/blood-2016-08-733196] [Citation(s) in RCA: 3901] [Impact Index Per Article: 487.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 11/15/2016] [Indexed: 12/13/2022] Open
Abstract
The first edition of the European LeukemiaNet (ELN) recommendations for diagnosis and management of acute myeloid leukemia (AML) in adults, published in 2010, has found broad acceptance by physicians and investigators caring for patients with AML. Recent advances, for example, in the discovery of the genomic landscape of the disease, in the development of assays for genetic testing and for detecting minimal residual disease (MRD), as well as in the development of novel antileukemic agents, prompted an international panel to provide updated evidence- and expert opinion-based recommendations. The recommendations include a revised version of the ELN genetic categories, a proposal for a response category based on MRD status, and criteria for progressive disease.
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Ferguson P, Hills RK, Grech A, Betteridge S, Kjeldsen L, Dennis M, Vyas P, Goldstone AH, Milligan D, Clark RE, Russell NH, Craddock C. An operational definition of primary refractory acute myeloid leukemia allowing early identification of patients who may benefit from allogeneic stem cell transplantation. Haematologica 2016; 101:1351-1358. [PMID: 27540133 DOI: 10.3324/haematol.2016.148825] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 08/10/2016] [Indexed: 11/09/2022] Open
Abstract
Up to 30% of adults with acute myeloid leukemia fail to achieve a complete remission after induction chemotherapy - termed primary refractory acute myeloid leukemia. There is no universally agreed definition of primary refractory disease, nor have the optimal treatment modalities been defined. We studied 8907 patients with newly diagnosed acute myeloid leukemia, and examined outcomes in patients with refractory disease defined using differing criteria which have previously been proposed. These included failure to achieve complete remission after one cycle of induction chemotherapy (RES), less than a 50% reduction in blast numbers with >15% residual blasts after one cycle of induction chemotherapy (REF1) and failure to achieve complete remission after two courses of induction chemotherapy (REF2). 5-year overall survival was decreased in patients fulfilling any criteria for refractory disease, compared with patients achieving a complete remission after one cycle of induction chemotherapy: 9% and 8% in patients with REF1 and REF2 versus 40% (P<0.0001). Allogeneic stem cell transplantation improved survival in the REF1 (HR 0.58 (0.46-0.74), P=0.00001) and REF2 (HR 0.55 (0.41-0.74), P=0.0001) cohorts. The utilization of REF1 criteria permits the early identification of patients whose outcome after one course of induction chemotherapy is very poor, and informs a novel definition of primary refractory acute myeloid leukemia. Furthermore, these data demonstrate that allogeneic stem cell transplantation represents an effective therapeutic modality in selected patients with primary refractory acute myeloid leukemia.
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Affiliation(s)
- Paul Ferguson
- Queen Elizabeth Hospital Birmingham NHS Foundation Trust, UK
| | | | | | | | | | | | - Paresh Vyas
- University of Oxford and Oxford University Hospitals NHS Trust, UK
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Damiani D, Tiribelli M, Raspadori D, Sirianni S, Meneghel A, Cavalllin M, Michelutti A, Toffoletti E, Geromin A, Simeone E, Bocchia M, Fanin R. Clinical impact of CD200 expression in patients with acute myeloid leukemia and correlation with other molecular prognostic factors. Oncotarget 2016; 6:30212-21. [PMID: 26338961 PMCID: PMC4745791 DOI: 10.18632/oncotarget.4901] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 08/07/2015] [Indexed: 01/25/2023] Open
Abstract
CD200, a protein belonging to the immunoglobulin superfamily, has been associated with a poor prognosis in lymphoproliferative disorders and in acute leukemia. We studied the expression of CD200 in a series of 244 patients with diagnosis of acute myeloid leukemia (AML), to evaluate its impact on outcome and its possible association with other known prognostic factors. CD200 was found in 136/244 (56%) patients, in 41 of whom (30%) with high intensity of expression (MFI ≥ 11). CD200 was more frequent in secondary compared to de novo leukemia (p = 0.0006), in CD34 positive cases (p = 0.00001), in Bcl2 overexpressing cases (p = 0.01), in those wild-type Flt3 (p = 0.004) and with favorable or unfavorable compared to intermediate karyotype (p = 0.0003). CD200+ patients have a two-fold lower probability to attain complete remission, both in univariate (p = 0.006) and multivariate (p = 0.04) analysis. The negative impact of CD200 was found also in overall survival (p = 0.02) and was correlated with the intensity of expression of the molecule (p = 0.024). CD200 has an additive negative impact on survival in patients with unfavorable cytogenetic (p = 0.046) and in secondary leukemia (p = 0.05), and is associate with a worsening of outcome in patients with favorable biological markers, such as mutated NPM (p = 0.02), wild-type Flt3 (p = 0.034), negativity of CD34 (p = 0.03) and of CD56 (p = 0.03). In conclusion, CD200 is emerging as both a prognostic factor and a potential target of novel therapeutic approaches for AML, aiming to reverse the “do not eat me” signal of CD200 or to manipulate the suppressive immune microenvironment induced by CD200 binding to its receptor.
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Affiliation(s)
- Daniela Damiani
- Division of Hematology and Bone Marrow Transplantation, Azienda Ospedaliero-Universitaria di Udine, Udine, Italy
| | - Mario Tiribelli
- Division of Hematology and Bone Marrow Transplantation, Azienda Ospedaliero-Universitaria di Udine, Udine, Italy
| | | | | | - Alessia Meneghel
- Division of Hematology and Bone Marrow Transplantation, Azienda Ospedaliero-Universitaria di Udine, Udine, Italy
| | - Margherita Cavalllin
- Division of Hematology and Bone Marrow Transplantation, Azienda Ospedaliero-Universitaria di Udine, Udine, Italy
| | - Angela Michelutti
- Division of Hematology and Bone Marrow Transplantation, Azienda Ospedaliero-Universitaria di Udine, Udine, Italy
| | - Eleonora Toffoletti
- Division of Hematology and Bone Marrow Transplantation, Azienda Ospedaliero-Universitaria di Udine, Udine, Italy
| | - Antonella Geromin
- Division of Hematology and Bone Marrow Transplantation, Azienda Ospedaliero-Universitaria di Udine, Udine, Italy
| | - Erica Simeone
- Division of Hematology and Bone Marrow Transplantation, Azienda Ospedaliero-Universitaria di Udine, Udine, Italy
| | - Monica Bocchia
- Division of Hematology, University of Siena, Siena, Italy
| | - Renato Fanin
- Division of Hematology and Bone Marrow Transplantation, Azienda Ospedaliero-Universitaria di Udine, Udine, Italy
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Avni B, Shapira MY, Resnick IB, Stepensky P, Or R, Grisariu S. Active acute leukaemia: should transplant be offered to all patients? Hematol Oncol 2016; 35:797-803. [PMID: 27338621 DOI: 10.1002/hon.2308] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 04/29/2016] [Indexed: 11/06/2022]
Abstract
The probability of achieving long term remission for patients with refractory acute leukaemia is very low. Allogeneic stem cell transplantation (SCT) is offered to these patients in order to improve their dismal outcome. We retrospectively analyzed 361 acute leukaemia patients, who underwent allogeneic SCT in the Hadassah's bone marrow transplantation department between the years 2005 and 2012 and identified 84 patients with active leukaemia at transplantation. Median age was 34 years. Sixty four patients were diagnosed with acute myeloid leukaemia (AML), 18 patients with acute lymphoblastic leukaemia and two with biphenotypic leukaemia. The majority of patients were diagnosed with de-novo AML and transplanted at relapse. In the surviving patients, median follow up was 15 months. One year OS was 20%. At time of last follow up, 13 patients were alive (15.5%): ten patients with AML and two patients with acute lymphoblastic leukaemia. In the univariate analysis, factors associated with significantly better overall survival were as follows: matched unrelated donor (p = 0.006), matched donor (p = 0.014) and occurrence of acute graft-versus-host disease (aGVHD) (p = 0.019). Karnofsky performance score at SCT and occurrence of cGVHD were found to be borderline significant. Only matched unrelated donor and aGVHD were found to affect overall survival significantly in the multivariate analysis. Other than performance score at SCT, none of the pretransplant patients' characteristics were found to influence survival. In conclusion, as none of the pretransplant characteristics were found to influence the ability to select the patients that will benefit from HSC transplantation, this work supports offering HSCT to all active leukaemia eligible patients with reasonable performance status. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Batia Avni
- Hadassah-Hebrew University Medical Center, Bone Marrow Transplantation and Cancer Immunotherapy Department, Jerusalem, Israel
| | - Michael Y Shapira
- Hadassah-Hebrew University Medical Center, Bone Marrow Transplantation and Cancer Immunotherapy Department, Jerusalem, Israel
| | - Igor B Resnick
- Hadassah-Hebrew University Medical Center, Bone Marrow Transplantation and Cancer Immunotherapy Department, Jerusalem, Israel
| | - Polina Stepensky
- Hadassah-Hebrew University Medical Center, Bone Marrow Transplantation and Cancer Immunotherapy Department, Jerusalem, Israel
| | - Reuven Or
- Hadassah-Hebrew University Medical Center, Bone Marrow Transplantation and Cancer Immunotherapy Department, Jerusalem, Israel
| | - Sigal Grisariu
- Hadassah-Hebrew University Medical Center, Bone Marrow Transplantation and Cancer Immunotherapy Department, Jerusalem, Israel
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Are we curing more older adults with acute myeloid leukemia with allogeneic transplantation in CR1? Curr Opin Hematol 2016; 23:95-101. [PMID: 26825695 DOI: 10.1097/moh.0000000000000220] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Despite the fact that acute myeloid leukemia (AML) is most common in older adults aged at least 60 years, curative therapy remains elusive in this population. Here we examine the data for predicting which patients are candidates for 'curative therapy', available therapeutic options, and the utilization of reduced intensity allogeneic stem cell transplantation in first remission. RECENT FINDINGS Incorporation of geriatric assessment tools to assess patient frailty, in addition to evaluation of comorbid conditions, improves patient selection for intense therapy. The majority of patients eligible for and treated with induction chemotherapy achieve complete remission, and overall survival in the older AML population is superior after allogeneic stem cell transplant. However, population-based studies continue to demonstrate the undertreatment or lack of treatment of older AML patients. SUMMARY New patient assessment tools, ability to offer more successful outcomes after induction chemotherapy, and improved survival after allogeneic transplantation has not yet translated to increased 'curative' treatment on a population level of older AML patients. It is critical that the tools and therapies available be put into practice while older patient enrollment in well designed therapeutic clinical trials which include the option of allogeneic transplantation is increased.
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38
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Lu QS, Xu N, Zhou X, Huang JX, Li L, Li YL, Lu ZY, Cao R, Liao LB, Liu XL. Prognostic Significance of Monosomal Karyotype in Adult Patients With Acute Myeloid Leukemia Treated With Risk-Adapted Protocols. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2015; 15:790-6. [PMID: 26482108 DOI: 10.1016/j.clml.2015.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 09/01/2015] [Accepted: 09/11/2015] [Indexed: 02/05/2023]
Abstract
BACKGROUND The monosomal karyotype (MK) is a well-known adverse prognostic factor and has been found to be related to poor outcome in patients with acute myeloid leukemia (AML). However, the outcome in MK-positive AML patients undergoing different therapies has not been well investigated. PATIENTS AND METHODS We retrospectively analyzed clinical and laboratory features in 225 MK-positive AML patients. Clinical outcome of overall survival (OS) and disease-free survival (DFS) was evaluated in patients according to age group and in patients who received different therapy protocols. RESULTS The proportion of MK-positive patients increased along with age. Also, patients who were treated with high-dose cytarabine (HD-Ara-C) as consolidation therapy followed by allogeneic hematopoietic stem cell transplantation (allo-HSCT) demonstrated longer OS and DFS compared to allo-HSCT or HD-Ara-C alone. Patients treated with allo-HSCT alone exhibited longer DFS compared to patients treated with HD-Ara-C alone. No difference in OS was discovered between these 2 single protocols. CONCLUSION MK was associated with a lower complete remission rate. HD-Ara-C therapy followed by allo-HSCT could improve the prognosis of MK-positive AML patients.
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Affiliation(s)
- Qi-Si Lu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou Dadao North Street, Guangzhou, China
| | - Na Xu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou Dadao North Street, Guangzhou, China
| | - Xuan Zhou
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou Dadao North Street, Guangzhou, China
| | - Ji-Xian Huang
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou Dadao North Street, Guangzhou, China
| | - Lin Li
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou Dadao North Street, Guangzhou, China
| | - Yu-Ling Li
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou Dadao North Street, Guangzhou, China
| | - Zi-Yuan Lu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou Dadao North Street, Guangzhou, China
| | - Rui Cao
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou Dadao North Street, Guangzhou, China
| | - Li-Bin Liao
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou Dadao North Street, Guangzhou, China
| | - Xiao-Li Liu
- Department of Hematology, Nanfang Hospital, Southern Medical University, Guangzhou Dadao North Street, Guangzhou, China.
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Nagler A, Savani BN, Labopin M, Polge E, Passweg J, Finke J, Kyrcz-Krzemien S, Volin L, Anagnostopoulos A, Aljurf M, Beelen DW, Vigouroux S, Milpied N, Suarez F, Mohty M. Outcomes after use of two standard ablative regimens in patients with refractory acute myeloid leukaemia: a retrospective, multicentre, registry analysis. LANCET HAEMATOLOGY 2015; 2:e384-92. [DOI: 10.1016/s2352-3026(15)00146-5] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 07/24/2015] [Accepted: 08/03/2015] [Indexed: 11/29/2022]
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40
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Lazzarotto D, Candoni A, Nadali G, Pavan L, Lessi F, Mosna F, Simeone E, Ventura G, Gherlinzoni F, Semenzato G, Pizzolo G, Fanin R. Multicentre survey to explore current survival of patients with acute myeloid leukaemia who failed induction chemotherapy. Eur J Haematol 2015; 96:586-92. [PMID: 26186084 DOI: 10.1111/ejh.12635] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Acute myeloid leukaemia not responsive to first induction chemotherapy (PIF-AML) still remains a challenge, and there are only few recent epidemiological data regarding the outcome of these patients. In this multicentre survey, we evaluate the prognosis and outcome of patients with PIF-AML, who were diagnosed and treated in the last 5 yrs in four Italian institutions. RESULTS One hundred PIF-AML were recorded, 57 males and 43 females, with a median age of 63 yrs (19-79), 42% were younger than 60 yrs; 42% had a secondary AML and 40% had an adverse karyotype. According to cytogenetic/molecular risk stratification at diagnosis, 33% of patients were classified as favourable/intermediate-1 risk and 56% as intermediate-2/adverse risk. After a median follow-up of 11 months (1-49), 77% of patients died, while 23% were alive (with 12/23 in cCR). Thirty-six patients underwent allogeneic SCT, and of these, 11 of 36 (31%) were alive at last follow-up. The 12- and 24-month OS probability of the whole population was 45% and 21%, respectively. In multivariate analysis, the probability of OS of the whole population was significantly improved by Allo-SCT procedure (12-month OS probability 60% vs. 35%; P < 0.0001) and was better in patients with favourable/intermediate-1 risk at diagnosis (12-month OS probability 58% vs. 40%; P = 0.028). In transplanted cases, a pretransplant responsive disease was the only significant factor to predict a favourable outcome after Allo-SCT (P = 0.006). CONCLUSION Treatment options of PIF-AML still are limited and the prognosis, even recently, remains extremely poor. This survey shows that PIF-AML is still rarely cured without Allo-SCT and confirms the importance of initiating an urgent unrelated donor search in cases without a matched sibling donor. Moreover, the outcome of Allo-SCT is better in patients who achieve a good AML debulking before transplant. To reach this goal, new predictive scores and new protocols of salvage therapy (with target drugs or combinations) need to be explored urgently in PIF-AML.
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Affiliation(s)
- Davide Lazzarotto
- Division of Hematology and SCT, University Hospital of Udine, Udine, Italy
| | - Anna Candoni
- Division of Hematology and SCT, University Hospital of Udine, Udine, Italy
| | | | - Laura Pavan
- Division of Hematology, University of Padua, Padua, Italy
| | - Federica Lessi
- Division of Hematology, University of Padua, Padua, Italy
| | - Federico Mosna
- Division of Hematology, Hospital of Treviso, Treviso, Italy
| | - Erica Simeone
- Division of Hematology and SCT, University Hospital of Udine, Udine, Italy
| | - Giovanna Ventura
- Division of Hematology and SCT, University Hospital of Udine, Udine, Italy
| | | | | | | | - Renato Fanin
- Division of Hematology and SCT, University Hospital of Udine, Udine, Italy
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41
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Mussai F, Egan S, Higginbotham-Jones J, Perry T, Beggs A, Odintsova E, Loke J, Pratt G, U KP, Lo A, Ng M, Kearns P, Cheng P, De Santo C. Arginine dependence of acute myeloid leukemia blast proliferation: a novel therapeutic target. Blood 2015; 125:2386-96. [PMID: 25710880 PMCID: PMC4416943 DOI: 10.1182/blood-2014-09-600643] [Citation(s) in RCA: 112] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 02/11/2015] [Indexed: 12/14/2022] Open
Abstract
Acute myeloid leukemia (AML) is one of the most common acute leukemias in adults and children, yet significant numbers of patients relapse and die of disease. In this study, we identify the dependence of AML blasts on arginine for proliferation. We show that AML blasts constitutively express the arginine transporters CAT-1 and CAT-2B, and that the majority of newly diagnosed patients' blasts have deficiencies in the arginine-recycling pathway enzymes argininosuccinate synthase and ornithine transcarbamylase, making them arginine auxotrophic. BCT-100, a pegylated human recombinant arginase, leads to a rapid depletion in extracellular and intracellular arginine concentrations, resulting in arrest of AML blast proliferation and a reduction in AML engraftment in vivo. BCT-100 as a single agent causes significant death of AML blasts from adults and children, and acts synergistically in combination with cytarabine. Using RNA sequencing, 20 further candidate genes which correlated with resistance have been identified. Thus, AML blasts are dependent on arginine for survival and proliferation, as well as depletion of arginine with BCT-100 of clinical value in the treatment of AML.
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MESH Headings
- Adolescent
- Aged
- Animals
- Antimetabolites, Antineoplastic/therapeutic use
- Arginase/therapeutic use
- Arginine/metabolism
- Child
- Child, Preschool
- Cytarabine/therapeutic use
- Enzyme Therapy
- Female
- Humans
- Infant
- Leukemia, Myeloid, Acute/drug therapy
- Leukemia, Myeloid, Acute/enzymology
- Leukemia, Myeloid, Acute/metabolism
- Leukemia, Myeloid, Acute/pathology
- Male
- Mice, SCID
- Middle Aged
- Recombinant Proteins/therapeutic use
- Tumor Cells, Cultured
- Young Adult
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Affiliation(s)
- Francis Mussai
- School of Cancer Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Sharon Egan
- School of Veterinary Medicine and Science, University of Nottingham, Nottingham, United Kingdom
| | | | - Tracey Perry
- School of Cancer Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Andrew Beggs
- School of Cancer Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Elena Odintsova
- School of Cancer Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Justin Loke
- School of Cancer Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Guy Pratt
- School of Cancer Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Kin Pong U
- Bio-cancer Treatment International Ltd, Hong Kong Science Park, Shatin, New Territories, Hong Kong; and
| | - Anthony Lo
- Department of Anatomic Pathology, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Margaret Ng
- Department of Anatomic Pathology, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Pamela Kearns
- School of Cancer Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Paul Cheng
- Bio-cancer Treatment International Ltd, Hong Kong Science Park, Shatin, New Territories, Hong Kong; and
| | - Carmela De Santo
- School of Cancer Sciences, University of Birmingham, Birmingham, United Kingdom
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Ramos NR, Mo CC, Karp JE, Hourigan CS. Current Approaches in the Treatment of Relapsed and Refractory Acute Myeloid Leukemia. J Clin Med 2015; 4:665-95. [PMID: 25932335 PMCID: PMC4412468 DOI: 10.3390/jcm4040665] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 03/20/2015] [Indexed: 01/07/2023] Open
Abstract
The limited sensitivity of the historical treatment response criteria for acute myeloid leukemia (AML) has resulted in a different paradigm for treatment compared with most other cancers presenting with widely disseminated disease. Initial cytotoxic induction chemotherapy is often able to reduce tumor burden to a level sufficient to meet the current criteria for "complete" remission. Nevertheless, most AML patients ultimately die from their disease, most commonly as clinically evident relapsed AML. Despite a variety of available salvage therapy options, prognosis in patients with relapsed or refractory AML is generally poor. In this review, we outline the commonly utilized salvage cytotoxic therapy interventions and then highlight novel investigational efforts currently in clinical trials using both pathway-targeted agents and immunotherapy based approaches. We conclude that there is no current standard of care for adult relapsed or refractory AML other than offering referral to an appropriate clinical trial.
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Affiliation(s)
- Nestor R. Ramos
- Myeloid Malignancies Section, Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD 20892-1583, USA; E-Mail:
- Department of Hematology-Oncology, John P. Murtha Cancer Center, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA; E-Mail:
| | - Clifton C. Mo
- Department of Hematology-Oncology, John P. Murtha Cancer Center, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA; E-Mail:
| | - Judith E. Karp
- Division of Hematologic Malignancies, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA; E-Mail:
| | - Christopher S. Hourigan
- Myeloid Malignancies Section, Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD 20892-1583, USA; E-Mail:
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43
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Percival MEM, Tao L, Medeiros BC, Clarke CA. Improvements in the early death rate among 9380 patients with acute myeloid leukemia after initial therapy: A SEER database analysis. Cancer 2015; 121:2004-12. [PMID: 25739348 DOI: 10.1002/cncr.29319] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 01/19/2015] [Accepted: 01/20/2015] [Indexed: 01/28/2023]
Abstract
BACKGROUND Acute myeloid leukemia (AML) is treated with conventional induction chemotherapy shortly after diagnosis for the majority of patients aged ≤ 65 years. A recent report suggested a substantial decline in the early, or 1-month, mortality rate in patients treated on clinical trials over the past 2 decades. It is unknown whether a similar improvement has been observed in the general population. METHODS The authors examined the 1-month mortality rate in a large population-based series of 9380 patients with AML who were aged ≤ 65 years and were diagnosed and treated with chemotherapy between 1973 and 2010. RESULTS A significant decline was observed in the 1-month mortality rate from 18.7% among patients diagnosed from 1973 through 1977 (95% confidence interval [95% CI], 16.4%-21.2%) to 5.8% for those diagnosed between 2008 and 2010 (95% CI, 4.5%-7.6%) (P <.001). The median overall survival improved significantly from 6 months (95% CI, 5 months-7 months) in 1973 to 1977 to 23 months (95% CI, 16 months-20 months) in 2008 to 2010 (P <.001). Although age and geographic variation were found to significantly influence the 1-month mortality for the period between 1973 and 1977, these differences in 1-month mortality were no longer significant among patients with AML who were treated more recently (2008-2010). CONCLUSIONS Over the past 4 decades, early mortality has become uncommon in younger patients (aged ≤ 65 years) with newly diagnosed AML undergoing induction chemotherapy. It is encouraging that the improvements noted in 1-month mortality rate among a selective cohort of patients in clinical trials have also been observed in a population-based analysis.
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Affiliation(s)
| | - Li Tao
- Cancer Prevention Institute of California, Fremont, California
| | - Bruno C Medeiros
- Division of Hematology, Stanford University School of Medicine, Stanford, California
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44
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45
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Sasine JP, Schiller GJ. Emerging strategies for high-risk and relapsed/refractory acute myeloid leukemia: Novel agents and approaches currently in clinical trials. Blood Rev 2015; 29:1-9. [DOI: 10.1016/j.blre.2014.07.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Revised: 06/17/2014] [Accepted: 07/11/2014] [Indexed: 01/26/2023]
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46
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Roboz GJ. Epigenetic targeting and personalized approaches for AML. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2014; 2014:44-51. [PMID: 25696833 DOI: 10.1182/asheducation-2014.1.44] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Acute myeloid leukemia (AML) is a genetically heterogeneous clonal hematopoietic stem cell disorder and the majority of patients with AML die from their disease. The treatment paradigms for AML were developed decades ago and, although there have been improvements in the outcomes of selected younger patients and those with specific cytogenetic and molecular genetic characteristics, the overall survival for older patients remains dismal. Over the last few years, next-generation sequencing technologies have identified recurrent mutations in genes encoding proteins involved in the epigenetic regulation of transcription in most patients with AML. This discovery has led to new insights into the role of the epigenome in AML and opens the possibility of epigenetically targeted therapies. This chapter describes how epigenetic dysregulation plays a role in AML and highlights current and future treatment strategies that attempt to exploit epigenetic targets.
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Affiliation(s)
- Gail J Roboz
- Leukemia Program, Weill Medical College of Cornell University and New York Presbyterian Hospital, New York, NY
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47
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[Current indications of allogeneic stem cell transplant in adults with acute myeloid leukemia]. Bull Cancer 2014; 101:856-65. [PMID: 25296413 DOI: 10.1684/bdc.2014.1944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Allogeneic stem cell transplantation (SCT) is an increasingly important therapeutic option for the treatment of adult patients with acute myeloid leukemia. Here we review the current indications of SCT in this disease. While patients with favorable cytogenetics should receive consolidation chemotherapy, patients with unfavorable karyotype are prime candidates for SCT or new approaches to SCT (which should be done in first complete remission). Patients with intermediate prognoses should also receive SCT in first complete remission. In the absence of a suitable matched related donor, most patients will be able to find an alternative donor to proceed to a potentially curative allogeneic transplantation. The use of reduced-intensity conditioning regimens before SCT has allowed patients in the sixth or seventh decades of life to be routinely transplanted. Despite major differences among transplant centers in the intensity and composition of the conditioning regimen and immunosuppression, choice of graft source, postgraft immune-modulation, and supportive care, there has been a dramatic improvement in terms of tolerance. Although it is presumed to be a curative strategy, major complications of SCT remain graft-versus-host disease, delayed immune recovery, multiple comorbidities, and relapse after transplant.
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48
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Medeot M, Tiribelli M, Patriarca F, Sperotto A, Geromin A, Fanin R. Factors affecting outcome of allogeneic stem cell transplantation as salvage in patients with acute myeloid leukemia primary refractory to intensive induction therapy. Am J Hematol 2014; 89:933-4. [PMID: 24861480 DOI: 10.1002/ajh.23769] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2014] [Accepted: 05/21/2014] [Indexed: 11/10/2022]
Affiliation(s)
- Marta Medeot
- Division of Hematology and Bone Marrow Transplantation; Department of Clinical and Experimental Medical Sciences; AOU Udine Udine Italy
| | - Mario Tiribelli
- Division of Hematology and Bone Marrow Transplantation; Department of Clinical and Experimental Medical Sciences; AOU Udine Udine Italy
| | - Francesca Patriarca
- Division of Hematology and Bone Marrow Transplantation; Department of Clinical and Experimental Medical Sciences; AOU Udine Udine Italy
| | - Alessandra Sperotto
- Division of Hematology and Bone Marrow Transplantation; Department of Clinical and Experimental Medical Sciences; AOU Udine Udine Italy
| | - Antonella Geromin
- Division of Hematology and Bone Marrow Transplantation; Department of Clinical and Experimental Medical Sciences; AOU Udine Udine Italy
| | - Renato Fanin
- Division of Hematology and Bone Marrow Transplantation; Department of Clinical and Experimental Medical Sciences; AOU Udine Udine Italy
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