1
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Paterno G, Palmieri R, Tesei C, Nunzi A, Ranucci G, Mallegni F, Moretti F, Meddi E, Tiravanti I, Marinoni M, Page C, Fagiolo S, Buzzatti E, Secchi R, Gurnari C, Maurillo L, Buccisano F, Venditti A, Del Principe MI. The ISTH DIC-score predicts early mortality in patients with non-promyelocitic acute myeloid leukemia. Thromb Res 2024; 236:30-36. [PMID: 38387301 DOI: 10.1016/j.thromres.2024.02.017] [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: 12/06/2023] [Revised: 02/13/2024] [Accepted: 02/15/2024] [Indexed: 02/24/2024]
Abstract
Coagulation disorders frequently complicate the clinical course of acute myeloid leukemia (AML) patients. This study examined the frequency and prognostic significance, with regards of early mortality, of the presence of overt disseminated intravascular coagulation (DIC) at AML diagnosis and its correlation with clinical and biological characteristics. A retrospective analysis of 351 newly diagnosed non-promyelocytic AML patients was conducted, utilizing the 2018 ISTH DIC-Score criteria to evaluate the presence of overt DIC at AML onset. The study cohort had a median age of 65 years with a predominance of male gender (59 %). Overt DIC was present in 21 % of cases and was associated with advanced age, comorbidities, poor performance status, hyperleukocytosis, LDH levels, NPM1 mutations, expression of CD33 and CD4, and lack of expression of CD34. With a median follow-up of 72 months (3-147 months), the 6-year overall survival (OS) was 17.4 %, with patients having overt DIC showing significantly poorer outcomes (7.2 % compared to 20.3 % of those without DIC, p < 0.001). Patients with overt DIC showed markedly high early mortality rates at 30 (42.5 % vs 8 %), 60 (49.3 % vs 16.9 %), and 120 days (64.4 % vs 25.6 %) from disease onset. In multivariate analysis overt DIC retained its independent prognostic value for early mortality. In conclusion, the prevalence and clinical relevance of DIC in non-promyelocytic AML is not negligible, underlining its potential as an unfavorable prognostic marker. In newly diagnosed patients with AML, early recognition and measure to counteract coagulation disturbances might help mitigate the elevated mortality risk associated with DIC.
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Affiliation(s)
| | - Raffaele Palmieri
- Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Cristiano Tesei
- Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Andrea Nunzi
- Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Giorgia Ranucci
- Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Flavia Mallegni
- Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Federico Moretti
- Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Elisa Meddi
- Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Ilaria Tiravanti
- Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Massimiliano Marinoni
- Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Camilla Page
- Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Solaria Fagiolo
- Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Elisa Buzzatti
- Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Roberto Secchi
- Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Carmelo Gurnari
- Hematology, Fondazione Policlinico Tor Vergata, Rome, Italy; Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy; Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Luca Maurillo
- Hematology, Fondazione Policlinico Tor Vergata, Rome, Italy
| | - Francesco Buccisano
- Hematology, Fondazione Policlinico Tor Vergata, Rome, Italy; Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Adriano Venditti
- Hematology, Fondazione Policlinico Tor Vergata, Rome, Italy; Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy.
| | - Maria Ilaria Del Principe
- Hematology, Fondazione Policlinico Tor Vergata, Rome, Italy; Hematology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
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2
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White O, Kennedy E, Huckabee JB, Rogers E, LeBlanc TW, Dillon M, Li Z, Hanna D. Isavuconazonium or posaconazole for antifungal prophylaxis in patients with acute myeloid leukemia. J Oncol Pharm Pract 2024; 30:527-534. [PMID: 37186784 DOI: 10.1177/10781552231175825] [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: 05/17/2023]
Abstract
BACKGROUND Invasive fungal infection (IFI) prophylaxis is recommended in patients with acute myeloid leukemia (AML) during induction chemotherapy. Posaconazole (POSA) is the recommended agent of choice; however, this medication can be associated with QTc prolongation, hepatotoxicity, and drug-drug interactions. Furthermore, there is conflicting evidence for the role of isavuconazole (ISAV) in this setting as an alternative to POSA. OBJECTIVE The primary objective of this study was to evaluate the use of ISAV prophylaxis for primary IFI prevention in patients with AML undergoing induction. Additionally, the study investigated the use of ISAV trough concentration monitoring and compared these results to the efficacy of POSA therapeutic drug monitoring (TDM). Other secondary objectives included assessing the rates of toxicities associated with either prophylactic agent. This study analyzed the impact these toxicities had on patient outcomes by examining the need to hold or discontinue therapy. The final endpoint considered the efficacy associated with multiple dosing strategies employed at the study institution. Specifically, this included the use of loading doses or foregoing these when initiating prophylaxis. METHODS This was a retrospective, single-center, cohort study. Patients included in this study were adults with AML admitted to Duke University Hospital between June 30, 2016 and June 30, 2021, who received induction chemotherapy and primary IFI prophylaxis for at least 7 days. Exclusion criteria included patients who received concomitant antifungal agents and patients who received antifungal agents as secondary prophylaxis. RESULTS 241 patients met inclusion criteria with 12 (4.98%) participants in the ISAV group and 229 (95.02%) participants in the POSA group. The IFI incidence in the POSA group was 14.5%, while the ISAV group did not have any occurrences of IFI. No significant difference was found in the rate of IFI occurrence between the two treatment groups (p = 0.3805). Furthermore, it was demonstrated that the use of a loading dose when initiating prophylaxis could impact rates of IFI for this patient population. CONCLUSION Due to no difference in incidence, patient specific factors such as concomitant medications and baseline QTc should influence the choice between prophylactic agent.
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Affiliation(s)
- Olivia White
- Department of Pharmacy, Duke University Hospital, Durham, North Carolina, USA
| | - Erin Kennedy
- Department of Pharmacy, Duke University Hospital, Durham, North Carolina, USA
| | - Jordan B Huckabee
- Department of Pharmacy, Duke University Hospital, Durham, North Carolina, USA
| | - Elizabeth Rogers
- Department of Pharmacy, Duke University Hospital, Durham, North Carolina, USA
| | - Thomas W LeBlanc
- Department of Hematologic Malignancies, Duke University Hospital, Durham, North Carolina, USA
| | - Mairead Dillon
- Department of Biostatistics and Bioinformatics, Duke University Hospital, Durham, North Carolina, USA
| | - Zhiguo Li
- Department of Biostatistics and Bioinformatics, Duke University Hospital, Durham, North Carolina, USA
| | - Desirae Hanna
- Department of Pharmacy, Duke University Hospital, Durham, North Carolina, USA
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3
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Bhatt VR, Uy GL, Klepin HD. Determining treatment tolerance and fitness for intensive chemotherapy in older adults with AML: a call to action. Blood 2024; 143:483-487. [PMID: 38048592 PMCID: PMC10950471 DOI: 10.1182/blood.2023022611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 11/06/2023] [Accepted: 11/20/2023] [Indexed: 12/06/2023] Open
Abstract
ABSTRACT Determining fitness for intensive chemotherapy in an older adult with acute myeloid leukemia (AML) is an unanswered age-old question. Geriatric assessment captures any variation in multidimensional health, which can influence treatment tolerance. A prospective study is necessary to validate fitness criteria, determine whether geriatric assessment-based fitness performs superiorly to other criteria, and what components of geriatric assessment are associated with treatment tolerance. A validation study should enroll diverse patients from both academic and community centers and patients receiving intensive and lower-intensity chemotherapy. Geriatric assessment should include at minimum measures of comorbidity burden, cognition, physical function, and emotional health, which in previous smaller studies have shown to be associated with mortality in AML. These assessments should be completed before or within a few days of initiation of chemotherapy to reduce the influence of chemotherapy on the assessment results. Treatment tolerance has been measured by rates of toxicities in patients with solid malignancies; however, during the initial treatment of AML, rates of toxicities are very high regardless of treatment intensity. Early mortality, frequently used in previous studies, can provide a highly consequential and easily identifiable measure of treatment tolerance. The key end point to assess treatment tolerance, thus, should include early mortality. Other end points may include decline in function and quality of life and treatment modifications or cessation due to toxicities. Validating fitness criteria can guide treatment selection and supportive care interventions and are crucial to guide fitness-based trial eligibility, inform the interpretation of trial results, and facilitate drug labeling.
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Affiliation(s)
- Vijaya Raj Bhatt
- Fred & Pamela Buffett Cancer Center, Division of Hematology-Oncology, University of Nebraska Medical Center, Omaha, NE
| | - Geoffrey L. Uy
- Division of Oncology, Washington University School of Medicine, St. Louis, MO
| | - Heidi D. Klepin
- Department of Internal Medicine, Section on Hematology and Oncology, Wake Forest University Health System, Winston-Salem, NC
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4
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Sasaki K, Ravandi F, DiNardo C, Welch MA, Kadia T, Kantarjian H. Early Mortality as a Quality Indicator in Frontline and Salvage Acute Myeloid Leukemia. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:905-910. [PMID: 37730483 DOI: 10.1016/j.clml.2023.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 08/16/2023] [Accepted: 08/18/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Early mortality is a historical measure of the quality of care incorporated into many quality measure algorithms that mostly account for patient comorbidities but do not incorporate disease characteristics and treatment status which independently increase early mortality. This is particularly significant in leukemia, especially in the refractory and salvage settings. STUDY AIM To define the independent adverse effect of leukemia salvage vs. frontline therapy on early mortality in acute myeloid leukemia (AML) after accounting for the pretreatment independent adverse effects associated with early mortality. PATIENTS AND METHODS A total of 4151 patients with AML were analyzed, 2893 newly diagnosed and 1258 in salvage. Univariate and multivariate analyses (MVA) were conducted to determine the independent adverse effects associated with 8-week mortality. RESULTS The 8-week mortality was 13% in frontline therapy and 18% in salvage therapy. By MVA, older age; therapy-related AML; prior history of myelodysplastic syndrome; poorer performance status; high white blood cell count; lower platelet count; higher percent of peripheral blasts; lower albumin levels; higher bilirubin, creatinine, and lactate dehydrogenase levels; and adverse cytogenetic risk groups were independently associated with a higher 8-week mortality rate. Adding treatment status after accounting for the independent adverse variables still selected salvage status as significantly adverse for 8-week mortality (hazard ratio 1.954; P-value < .001). CONCLUSIONS Quality measure algorithms should incorporate a risk mortality index related to leukemia vs. other tumors and benign conditions and a risk mortality index related to the treatment status of leukemia (salvage vs. frontline therapy).
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Affiliation(s)
- Koji Sasaki
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Courtney DiNardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mary Alma Welch
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Tapan Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX.
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5
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Kantarjian H, Welch MA, Sasaki K. Early mortality after chemotherapy as a quality indicator-the leukemia perspective. Blood Cancer J 2023; 13:176. [PMID: 38040680 PMCID: PMC10692074 DOI: 10.1038/s41408-023-00956-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 11/16/2023] [Accepted: 11/21/2023] [Indexed: 12/03/2023] Open
Affiliation(s)
- Hagop Kantarjian
- From the Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, USA.
| | - Mary Alma Welch
- From the Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Koji Sasaki
- From the Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, USA
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6
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Ramos F, Hermosín ML, Fuertes-Núñez M, Martínez P, Rodriguez-Medina C, Barrios M, Ibáñez F, Bernal T, Olave MT, Álvarez MÁ, Vahí M, Caballero-Velázquez T, González B, Altés A, García L, Fernández P, Durán MA, López R, Rafel M, Serrano J. Survival Outcomes and Health-Related Quality of Life in Older Adults Diagnosed with Acute Myeloid Leukemia Receiving Frontline Therapy in Daily Practice. J Pers Med 2023; 13:1667. [PMID: 38138894 PMCID: PMC10744855 DOI: 10.3390/jpm13121667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 10/25/2023] [Accepted: 11/14/2023] [Indexed: 12/24/2023] Open
Abstract
Acute myeloid leukemia has a poor prognosis in older adults, and its management is often unclear due to its underrepresentation in clinical trials. Both overall survival (OS) and health-related quality-of-life (HRQoL) are key outcomes in this population, and patient-reported outcomes may contribute to patient stratification and treatment assignment. This prospective study included 138 consecutive patients treated in daily practice with the currently available non-targeted therapies (intensive chemotherapy [IC], attenuated chemotherapy [AC], hypomethylating agents [HMA], or palliative care [PC]). We evaluated patients' condition at diagnosis (Life expectancy [Lee Index for Older Adults], Geriatric Assessment in Hematology [GAH scale], HRQoL [EQ-5D-5L questionnaire], and fatigue [fatigue items of the QLQ-C30 scale]), OS, early death (ED), treatment tolerability (TT) and change in HRQoL over 12 months follow-up. The median OS was 7.1 months (IC not reached, AC 5.9, HMA 8.8, and PC 1.0). Poor risk AML category and receiving just palliative care, as well as a higher Lee index score in the patients receiving active therapy, independently predicted a shorter OS. The Lee Index and GAH scale were not useful for predicting TT. The white blood cell count was a valid predictor for ED. Patients' HRQoL remained stable during follow-up.
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Affiliation(s)
- Fernando Ramos
- Department of Hematology, Hospital Universitario de León, 24008 Leon, Spain
| | - María Lourdes Hermosín
- Department of Hematology, Hospital Universitario de Jerez de la Frontera, 11407 Jerez de la Frontera, Spain
| | | | - Pilar Martínez
- Department of Hematology, Hospital Universitario 12 de Octubre, 28041 Madrid, Spain
| | - Carlos Rodriguez-Medina
- Department of Hematology, Hospital Universitario de Gran Canaria Dr. Negrín, 35010 Las Palmas de Gran Canaria, Spain
| | - Manuel Barrios
- Department of Hematology, Hospital Regional Universitario de Málaga, 29010 Malaga, Spain
| | - Francisco Ibáñez
- Department of Hematology, Hospital General Universitario de Valencia, 46014 Valencia, Spain
| | - Teresa Bernal
- Department of Hematology, Hospital Universitario Central de Asturias, 33011 Oviedo, Spain
| | - Maria Teresa Olave
- Department of Hematology, Hospital Clinico Lozano Blesa, 50009 Zaragoza, Spain
| | | | - María Vahí
- Department of Hematology, Hospital Universitario Virgen de Valme, 41014 Sevilla, Spain
| | - Teresa Caballero-Velázquez
- Department of Hematology, Instituto de Biomedicina de Sevilla, IBiS/Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, 41013 Sevilla, Spain
| | - Bernardo González
- Department of Hematology, Hospital Universitario de Canarias, 38320 La Laguna, Spain
| | - Albert Altés
- Department of Hematology, Hospital Sant Joan de Deu de Manresa—Fundació Althaia, 08243 Manresa, Spain
| | - Lorena García
- Department of Hematology, Complejo Hospitalario Universitario A Coruña (CHUAC), 15006 A Coruña, Spain
| | - Pascual Fernández
- Department of Hematology, Hospital General Universitario de Alicante, 03010 Alicante, Spain
| | - María Antonia Durán
- Department of Hematology, Hospital Universitario Son Espases, 07120 Palma de Mallorca, Spain
| | - Rocío López
- Medical Department, Hematology Area, Bristol Myers Squibb Company, Celgene, 28050 Madrid, Spain
| | - Montserrat Rafel
- Medical Department, Hematology Area, Bristol Myers Squibb Company, Celgene, 28050 Madrid, Spain
| | - Josefina Serrano
- Department of Hematology, Hospital Universitario Reina Sofía, IMIBIC UCO, 14004 Cordoba, Spain
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Lee H, Han JH, Kim JK, Yoo J, Yoon JH, Cho BS, Kim HJ, Lim J, Jekarl DW, Kim Y. Machine Learning Predicts 30-Day Outcome among Acute Myeloid Leukemia Patients: A Single-Center, Retrospective, Cohort Study. J Clin Med 2023; 12:5940. [PMID: 37762881 PMCID: PMC10531920 DOI: 10.3390/jcm12185940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 09/04/2023] [Accepted: 09/06/2023] [Indexed: 09/29/2023] Open
Abstract
Acute myeloid leukemia (AML) is a clinical emergency requiring treatment and results in high 30-day (D30) mortality. In this study, the prediction of D30 survival was studied using a machine learning (ML) method. The total cohort consisted of 1700 survivors and 130 non-survivors at D30. Eight clinical and 42 laboratory variables were collected at the time of diagnosis by pathology. Among them, six variables were selected by a feature selection method: induction chemotherapy (CTx), hemorrhage, infection, C-reactive protein, blood urea nitrogen, and lactate dehydrogenase. Clinical and laboratory data were entered into the training model for D30 survival prediction, followed by testing. Among the tested ML algorithms, the decision tree (DT) algorithm showed higher accuracy, the highest sensitivity, and specificity values (95% CI) of 90.6% (0.918-0.951), 70.4% (0.885-0.924), and 92.1% (0.885-0.924), respectively. DT classified patients into eight specific groups with distinct features. Group 1 with CTx showed a favorable outcome with a survival rate of 97.8% (1469/1502). Group 6, with hemorrhage and the lowest fibrinogen level at diagnosis, showed the worst survival rate of 45.5% (25/55) and 20.5 days. Prediction of D30 survival among AML patients by classification of patients with DT showed distinct features that might support clinical decision-making.
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Affiliation(s)
- Howon Lee
- Department of Laboratory Medicine, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 07345, Republic of Korea
| | - Jay Ho Han
- Department of Laboratory Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Jae Kwon Kim
- Department of Laboratory Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Jaeeun Yoo
- Department of Laboratory Medicine, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Incheon 21431, Republic of Korea;
| | - Jae-Ho Yoon
- Division of Hematology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Byung Sik Cho
- Division of Hematology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Hee-Je Kim
- Division of Hematology, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Jihyang Lim
- Department of Laboratory Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 03312, Republic of Korea
| | - Dong Wook Jekarl
- Department of Laboratory Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
- Research and Development Institute for In Vitro Diagnostic Medical Devices, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Yonggoo Kim
- Department of Laboratory Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea
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8
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Bazinet A, Kantarjian H, Arani N, Popat U, Bataller A, Sasaki K, DiNardo CD, Daver N, Yilmaz M, Abbas HA, Short NJ, Issa G, Jabbour E, Pierce SA, Chen J, Garcia R, Konopleva M, Garcia-Manero G, Alousi A, Shpall EJ, Champlin RE, Borthakur G, Ravandi F, Kadia T. Evolving trends and outcomes in older patients with acute myeloid leukemia including allogeneic stem cell transplantation. Am J Hematol 2023; 98:1383-1393. [PMID: 37334870 DOI: 10.1002/ajh.26997] [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: 04/18/2023] [Revised: 05/26/2023] [Accepted: 06/07/2023] [Indexed: 06/21/2023]
Abstract
Outcomes in older patients with acute myeloid leukemia (AML) have historically been poor. Given advances in low-intensity therapy (LIT) and stem cell transplantation (SCT), we performed a retrospective single-center study to evaluate the contemporary outcomes of this population. We reviewed all patients ≥60 years with newly diagnosed AML between 2012 and 2021 and analyzed treatment and SCT-related trends and outcomes. We identified 1073 patients with a median age of 71 years. Adverse clinical and cytomolecular findings were frequent within this cohort. In total, 16% of patients were treated with intensive chemotherapy, 51% with LIT alone, and 32% with LIT plus venetoclax. The composite complete remission rate with LIT plus venetoclax was 72%, which was higher than with LIT alone (48%, p < .0001) and comparable to intensive chemotherapy (74%, p = .6). The median overall survival (OS) with intensive chemotherapy, LIT, and LIT plus venetoclax was 20.1, 8.9, and 12.1 months, respectively. 18% of patients received SCT. SCT rates were 37%, 10%, and 22% in patients treated with intensive chemotherapy, LIT, and LIT plus venetoclax, respectively. The 2-year OS, relapse-free survival (RFS), cumulative incidence (CI) of relapse, and CI of treatment-related mortality with frontline SCT (n = 139) were 59%, 52%, 27%, and 22%, respectively. By landmark analysis, patients undergoing frontline SCT had superior OS (median 39.6 vs. 21.4 months, p < .0001) and RFS (30.9 vs. 12.1 months, p < .0001) compared with responding patients who did not. Outcomes in older patients with AML are improving with more effective LIT. Measures should be pursued to increase access to SCT in older patients.
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Affiliation(s)
- Alexandre Bazinet
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Naszrin Arani
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Uday Popat
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Alex Bataller
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Koji Sasaki
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Courtney D DiNardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Naval Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Musa Yilmaz
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Hussein A Abbas
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
- Department of Genomic Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ghayas Issa
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sherry A Pierce
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Julianne Chen
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ricky Garcia
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Marina Konopleva
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Guillermo Garcia-Manero
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Amin Alousi
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Elizabeth J Shpall
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Richard E Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gautam Borthakur
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Tapan Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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9
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Jimbu L, Valeanu M, Trifa AP, Mesaros O, Bojan A, Dima D, Parvu A, Rus IC, Tomuleasa C, Torok T, Urian L, Vasilache A, Zdrenghea M. A Survival Analysis of Acute Myeloid Leukemia Patients Treated With Intensive Chemotherapy: A Single Center Experience. Cureus 2023; 15:e43794. [PMID: 37731446 PMCID: PMC10508193 DOI: 10.7759/cureus.43794] [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] [Accepted: 08/20/2023] [Indexed: 09/22/2023] Open
Abstract
INTRODUCTION Acute myeloid leukaemia (AML) is a haematological disease associated with a dismal prognosis, despite major progress made in recent years in terms of antileukemic agents and supportive care. METHODS We investigated the results of the intensive treatment of 133 fit AML patients (de novo and secondary) from a referral cancer centre in Romania, treated between January 2015 and December 2021. RESULTS We included 79 male and 54 female patients with a median age of 53 years (range 18-70). Molecular biology analysis was available for 82.7% of patients, whereas karyotype analysis was only available for 33% of patients. The median overall survival (OS) was 8.7 months, and the disease-free survival rate was 26.3% at a median follow-up of 33.7 months. The complete remission (CR) rate after induction was 48.9% for all patients and 61.9% for patients who were assessable (excluding patients who died before being assessed for response). Twelve patients underwent allogeneic bone marrow transplantation (BMT), with the median OS not reached. Early mortality (EM), defined as death during the first 30 days after admission, was 17.3%, with the main cause of death being septic shock (78.3%). Elderly patients (≥60 years of age) had a lower OS, more primary refractory disease, and higher rates of early mortality. CONCLUSION Complete remission rates and OS in our cohort were lower than in other reports. Early mortality was unexpectedly high, mainly due to infections, which were the main causes of death in our cohort.
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Affiliation(s)
- Laura Jimbu
- Hematology, 'Ion Chiricuta' Oncology Institute, Cluj-Napoca, ROU
- Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, ROU
| | - Madalina Valeanu
- Statistics, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, ROU
| | - Adrian P Trifa
- Genetics, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj Napoca, ROU
- Genetics, 'Ion Chiricuta' Oncology Institute, Cluj-Napoca, ROU
| | - Oana Mesaros
- Hematology, 'Ion Chiricuta' Oncology Institute, Cluj-Napoca, ROU
- Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, ROU
| | - Anca Bojan
- Hematology, 'Ion Chiricuta' Oncology Institute, Cluj, ROU
- Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, ROU
| | - Delia Dima
- Hematology, 'Ion Chiricuta' Oncology Institute, Cluj-Napoca, ROU
| | - Andrada Parvu
- Hematology, 'Ion Chiricuta' Oncology Institute, Cluj-Napoca, ROU
- Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, ROU
| | - Ioana C Rus
- Hematology, 'Ion Chiricuta' Oncology Institute, Cluj-Napoca, ROU
| | - Ciprian Tomuleasa
- Hematology, 'Ion Chiricuta' Oncology Institute, Cluj Napoca, ROU
- Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, ROU
| | - Tunde Torok
- Hematology, 'Ion Chiricuta' Oncology Institute, Cluj-Napoca, ROU
- Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, ROU
| | - Laura Urian
- Hematology, 'Ion Chiricuta' Oncology Institute, Cluj-Napoca, ROU
- Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, ROU
| | - Anca Vasilache
- Hematology, 'Ion Chiricuta' Oncology Institute, Cluj-Napoca, ROU
| | - Mihnea Zdrenghea
- Hematology, 'Ion Chiricuta' Oncology Institute, Cluj-Napoca, ROU
- Hematology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, ROU
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10
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DiNardo CD, Erba HP, Freeman SD, Wei AH. Acute myeloid leukaemia. Lancet 2023; 401:2073-2086. [PMID: 37068505 DOI: 10.1016/s0140-6736(23)00108-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 11/09/2022] [Accepted: 01/12/2023] [Indexed: 04/19/2023]
Abstract
Progress in acute myeloid leukaemia treatment is occurring at an unprecedented pace. The past decade has witnessed an increasingly improved scientific understanding of the underlying biology of acute myeloid leukaemia, leading to enhanced prognostication tools and refined risk assessments, and most especially incorporating measurable residual disease (MRD) into longitudinal risk assessments. The classification of acute myeloid leukaemia has recently been updated by WHO and the International Consensus Classification (ICC). Recommendations for prognostic stratification, response assessment, and MRD determination have also been updated by the European LeukemiaNet. Treatment options have evolved substantially in the last 5 years for patients with newly diagnosed acute myeloid leukaemia, leading to improved outcomes in intensively treated patients and those more appropriate for non-intensive chemotherapy. More effective targeted treatment options in the relapsed setting are also available, further advancing the treatment armamentarium and improving patient outcomes.
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Affiliation(s)
| | - Harry P Erba
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Sylvie D Freeman
- Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Andrew H Wei
- Department of Haematology, Peter MacCallum Cancer Centre, Royal Melbourne Hospital, University of Melbourne and Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
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11
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Oshikawa G, Sasaki K. Optimizing Treatment Options for Newly Diagnosed Acute Myeloid Leukemia in Older Patients with Comorbidities. Cancers (Basel) 2023; 15:cancers15082399. [PMID: 37190327 DOI: 10.3390/cancers15082399] [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: 03/19/2023] [Revised: 04/05/2023] [Accepted: 04/12/2023] [Indexed: 05/17/2023] Open
Abstract
Traditionally, the goal of AML therapy has been to induce remission through intensive chemotherapy, maintain long-term remission using consolidation therapy, and achieve higher rates of a cure by allogeneic transplantation in patients with a poor prognosis. However, for the elderly patients and those with comorbidities, the toxicity often surpasses the therapeutic benefits of intensive chemotherapy. Consequently, low-intensity therapies, such as the combination of a hypomethylating agent with venetoclax, have emerged as promising treatment options for elderly patients. Given the rise of low-intensity therapies as the leading treatment option for the elderly, it is increasingly important to consider patients' age and comorbidities when selecting a treatment option. The recently proposed comorbidity-based risk stratification for AML allows prognosis stratification not only in patients undergoing intensive chemotherapy, but also in those receiving low-intensity chemotherapy. Optimizing treatment intensity based on such risk stratification is anticipated to balance treatment efficacy and safety, and will ultimately improve the life expectancy for patients with AML.
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Affiliation(s)
- Gaku Oshikawa
- Department of Hematology, Japanese Red Cross Musashino Hospital, 1-26-1 Kyonan-cho Musashino-shi, Tokyo 180-8610, Japan
| | - Koji Sasaki
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 428, Houston, TX 77030, USA
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12
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Desprez C, Kouatchet A, Marchand T, Mear JB, Tadié JM, Peterlin P, Chevalier P, Canet E, Couturier MA, Guillerm G, Bodenes L, Gyan E, Villate A, Ehrmann S, Lebreton A, Lester MA, Fronteau C, Larhantec G, André V, Riou J, Hunault-Berger M, Schmidt-Tanguy A, Orvain C. Outcome of patients with newly diagnosed AML admitted to the ICU, including preemptive admission - a multi-center study. Ann Hematol 2023; 102:1383-1393. [PMID: 37039874 DOI: 10.1007/s00277-023-05205-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 03/29/2023] [Indexed: 04/12/2023]
Abstract
Acute myeloid leukemia (AML) can lead to life-threatening complications that may require intensive care unit (ICU) management. It has been advocated that early preemptive (ePE) ICU admission, before the onset of organ failure, could benefit some high-risk patients such as those with hyperleukocytosis. The aim of this study was to retrospectively analyze the outcome of newly diagnosed AML patients who required ICU admission in five academic centers with a special focus on patients with an ePE admission strategy, i.e., those transferred to the ICU without any organ failure (modified SOFA score ≤ 2 [omitting thrombocytopenia] and no life-sustaining intervention in the first 24 h following ICU admission) before the start of induction therapy. Between January 2017 and December 2019, 428 patients were included among which 101 were admitted to the ICU. Among patients requiring life-sustaining interventions (n = 83), 18 (22%) died while in the ICU but ICU survivors had the same survival as those not admitted to the ICU. Patients with an ePE admission (n = 18) had more comorbidities and high-risk disease features such as hyperleukocytosis but required no life-sustaining interventions while in the ICU. In a subgroup analysis of patients with hyperleukocytosis ≥ 50 G/l at diagnosis (n = 85), patients not admitted to the ICU and those admitted with an ePE strategy had similar outcomes. This study provides encouraging results about ICU outcome in AML patients during induction therapy but the potential benefit of an ePE strategy must be confirmed prospectively.
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Affiliation(s)
- Christophe Desprez
- Service des maladies du sang, CHU d'Angers, 4 rue LarreyAngers Cedex 9, F-49933, Angers, France
- Service de médecine intensive et réanimation et de médecine hyperbare, CHU d'Angers, Angers, France
| | - Achille Kouatchet
- Service de médecine intensive et réanimation et de médecine hyperbare, CHU d'Angers, Angers, France
| | - Tony Marchand
- Service d'hématologie clinique, CHU de Rennes, Rennes, France
- INSERM U1236, Université Rennes 1, Rennes, France
- Federation hospitalo-universitaire « Grand Ouest against Leukemia », Nantes, France
| | | | - Jean Marc Tadié
- Maladies Infectieuses et Réanimation Médicale, CHU Rennes, Rennes, France
| | - Pierre Peterlin
- Federation hospitalo-universitaire « Grand Ouest against Leukemia », Nantes, France
- Service d'hématologie clinique, CHU de Nantes, Nantes, France
| | - Patrice Chevalier
- Federation hospitalo-universitaire « Grand Ouest against Leukemia », Nantes, France
- Service d'hématologie clinique, CHU de Nantes, Nantes, France
| | | | - Marie-Anne Couturier
- Federation hospitalo-universitaire « Grand Ouest against Leukemia », Nantes, France
- Service d'Hématologie Clinique, Hôpital Morvan, CHU de Brest, Brest, France
| | - Gaelle Guillerm
- Federation hospitalo-universitaire « Grand Ouest against Leukemia », Nantes, France
- Service d'Hématologie Clinique, Hôpital Morvan, CHU de Brest, Brest, France
| | - Laetitia Bodenes
- Médecine Intensive et Réanimation, CHU de Brest, Hôpital de la Cavale Blanche, Brest, France
| | - Emmanuel Gyan
- Federation hospitalo-universitaire « Grand Ouest against Leukemia », Nantes, France
- Service d'Hématologie et Thérapie Cellulaire, CHRU de Tours, Hôpital Bretonneau, Tours, France
| | - Alban Villate
- Federation hospitalo-universitaire « Grand Ouest against Leukemia », Nantes, France
- Service d'Hématologie et Thérapie Cellulaire, CHRU de Tours, Hôpital Bretonneau, Tours, France
| | - Stephan Ehrmann
- Service de Médecine Intensive et Réanimation, CHRU de Tours, Hôpital Bretonneau, Tours, France
| | | | | | | | - Gaelle Larhantec
- Pharmacie Oncologique, CHU de Brest, Hôpital Morvan, Brest, France
| | | | - Jérémie Riou
- Inserm, CNRS, MINT, SFR ICAT, Univ Angers, CHU Angers, Angers, France
| | - Mathilde Hunault-Berger
- Service des maladies du sang, CHU d'Angers, 4 rue LarreyAngers Cedex 9, F-49933, Angers, France
- Federation hospitalo-universitaire « Grand Ouest against Leukemia », Nantes, France
- Inserm UMR 1307, CNRS UMR 6075, Nantes Université, CRCI2NA, Université d'Angers, F-49000, Angers, France
| | - Aline Schmidt-Tanguy
- Service des maladies du sang, CHU d'Angers, 4 rue LarreyAngers Cedex 9, F-49933, Angers, France
- Federation hospitalo-universitaire « Grand Ouest against Leukemia », Nantes, France
- Inserm UMR 1307, CNRS UMR 6075, Nantes Université, CRCI2NA, Université d'Angers, F-49000, Angers, France
| | - Corentin Orvain
- Service des maladies du sang, CHU d'Angers, 4 rue LarreyAngers Cedex 9, F-49933, Angers, France.
- Federation hospitalo-universitaire « Grand Ouest against Leukemia », Nantes, France.
- Inserm UMR 1307, CNRS UMR 6075, Nantes Université, CRCI2NA, Université d'Angers, F-49000, Angers, France.
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13
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St Martin EC, Zhang TY, Mannis GN. The Goldilocks Dilemma in AML: Too Young and Fit, but Not Young and Fit Enough. CLINICAL LYMPHOMA MYELOMA AND LEUKEMIA 2023; 23:410-412. [PMID: 37076365 DOI: 10.1016/j.clml.2023.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/21/2023] [Accepted: 03/23/2023] [Indexed: 04/04/2023]
Affiliation(s)
| | - Tian Yi Zhang
- Division of Hematology, Department of Medicine, Stanford Cancer Institute, Stanford University, Stanford, CA
| | - Gabriel N Mannis
- Division of Hematology, Department of Medicine, Stanford Cancer Institute, Stanford University, Stanford, CA.
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14
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Sasaki K, Ravandi F, Kadia TM, Borthakur G, Short NJ, Jain N, Daver NG, Jabbour EJ, Garcia-Manero G, Loghavi S, Patel KP, Montalban-Bravo G, Masarova L, DiNardo CD, Kantarjian HM. Prediction of survival with lower intensity therapy among older patients with acute myeloid leukemia. Cancer 2023; 129:1017-1029. [PMID: 36715486 DOI: 10.1002/cncr.34609] [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: 08/02/2022] [Revised: 10/05/2022] [Accepted: 10/21/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND The aim of this study was to develop a prognostic model for survival in older/unfit patients with newly diagnosed acute myeloid leukemia (AML) who were treated with lower-intensity chemotherapy regimens. METHODS The authors reviewed all older/unfit patients with newly diagnosed AML who received lower-intensity chemotherapy from 2000 until 2020 at their institution. A total of 1462 patients were included. They were divided (3:1 basis) into a training (n = 1088) and a validation group (n = 374). RESULTS In the training cohort of 1088 patients (median age, 72 years), the multivariate analysis identified 11 consistent independent adverse factors associated with survival: older age, therapy-related myeloid neoplasm, existence of previous myelodysplastic syndrome or myeloproliferative neoplasms, poor performance status, pulmonary comorbidity, anemia, thrombocytopenia, elevated lactate dehydrogenase, cytogenetic abnormalities, and the presence of infection at diagnosis, and therapy not containing venetoclax. The 3-year survival rates were 52%, 24%, 10%, and 1% in favorable, intermediate, poor, and very poor risk, respectively. This survival model was validated in an independent cohort. In a subset of patients in whom molecular mutation profiles were performed in more recent times, adding the mutation profiles after accounting for the effects of previous factors identified IDH2 (favorable), NPM1 (favorable), and TP53 (unfavorable) mutations as molecular prognostic factors. CONCLUSION The proposed survival model with lower-intensity chemotherapy in older/unfit patients with newly diagnosed AML may help to advise patients on their expected outcome, to propose different strategies in first complete remission, and to compare the results of different existing or future investigational therapies. PLAIN LANGUAGE SUMMARY Lower intensity therapy can be considered for older patients to avoid severe toxicities and adverse events. However, survival prediction in AML was commonly developed in patients who received intensive chemotherapy. In this study, we have proposed a survival model to guide therapeutic approach in older patients who received lower-intensity therapy.
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Affiliation(s)
- Koji Sasaki
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Tapan M Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gautam Borthakur
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Naval G Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Elias J Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Guillermo Garcia-Manero
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sanam Loghavi
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Keyur P Patel
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Lucia Masarova
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Courtney D DiNardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Hagop M Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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15
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Bazinet A, Kantarjian HM. Moving toward individualized target-based therapies in acute myeloid leukemia. Ann Oncol 2023; 34:141-151. [PMID: 36423744 DOI: 10.1016/j.annonc.2022.11.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 10/24/2022] [Accepted: 11/09/2022] [Indexed: 11/22/2022] Open
Abstract
Acute myeloid leukemia (AML) is a heterogeneous disease at the genetic level. The field of AML therapy is increasingly shifting away from uniform approaches based solely on intensive chemotherapy (such as '7 + 3') toward personalized therapy. The treatment of AML can now be individualized based on patient characteristics and cytogenetic/molecular disease features. In this review, we provide a comprehensive updated summary of personalized, target-directed therapy in AML. We first discuss the selection of intensive versus low-intensity treatment approaches based on the patient's age and/or comorbidities. We follow with a detailed review of specific molecularly defined AML subtypes that benefit from the addition of targeted agents. In this context, we highlight the urgent need for novel therapies in tumor protein p53 (TP53)-mutated AML. We then propose approaches to optimize AML therapy in patients without directly actionable mutations. We conclude with a discussion on the emerging role of using measurable residual disease to modify therapy based on the quality of response.
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Affiliation(s)
- A Bazinet
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - H M Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, USA.
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16
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Kim K, Ong F, Sasaki K. Current Understanding of DDX41 Mutations in Myeloid Neoplasms. Cancers (Basel) 2023; 15:344. [PMID: 36672294 PMCID: PMC9857085 DOI: 10.3390/cancers15020344] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 12/22/2022] [Accepted: 12/23/2022] [Indexed: 01/06/2023] Open
Abstract
The DEAD-box RNA helicase 41 gene, DDX41, is frequently mutated in hereditary myeloid neoplasms, identified in 2% of entire patients with AML/MDS. The pathogenesis of DDX41 mutation is related to the defect in the gene's normal functions of RNA and innate immunity. About 80% of patients with germline DDX41 mutations have somatic mutations in another allele, resulting in the biallelic DDX41 mutation. Patients with the disease with DDX41 mutations reportedly often present with the higher-grade disease, but there are conflicting reports about its impact on survival outcomes. Recent studies using larger cohorts reported a favorable outcome with a better response to standard therapies in patients with DDX41 mutations to patients without DDX41 mutations. For stem-cell transplantation, it is important for patients with DDX41 germline mutations to identify family donors early to improve outcomes. Still, there is a gap in knowledge on whether germline DDX41 mutations and its pathology features can be targetable for treatment, and what constitutes an appropriate screening/surveillance strategy for identified carriers. This article reviews our current understanding of DDX41 mutations in myeloid neoplasms in pathologic and clinical features and their clinical implications.
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Affiliation(s)
| | | | - Koji Sasaki
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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17
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Sahasrabudhe K, Huang Y, Rebechi M, Elder P, Mims A, Wall S. Survival, response rates, and post-transplant outcomes in patients with Acute Myeloid Leukemia aged 60-75 treated with high intensity chemotherapy vs. lower intensity targeted therapy. Front Oncol 2022; 12:1017194. [PMID: 36263213 PMCID: PMC9574198 DOI: 10.3389/fonc.2022.1017194] [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: 08/11/2022] [Accepted: 09/05/2022] [Indexed: 12/01/2022] Open
Abstract
The United States Food and Drug Administration has approved several oral, targeted therapies for the treatment of Acute Myeloid Leukemia (AML) in recent years. These agents are approved in patients with relapsed/refractory disease or as frontline therapy in patients who are ineligible for intensive chemotherapy based on age, performance status, or comorbidities. They are also being increasingly utilized frontline in patients of all ages and fitness levels through clinical trials and off label prescribing, but comparative treatment outcomes associated with intensive versus targeted therapy have not been extensively studied. We conducted a single center, retrospective analysis to address the impact of treatment intensity on survival in patients with AML aged 60-75 at diagnosis. This study included 127 patients, 73 of whom received high intensity chemotherapy at any point during treatment (any HiC) and 54 of whom received only low intensity targeted therapy (LITT only). Overall survival (OS) from treatment initiation did not differ significantly between the any HiC and LITT only groups (hazard ratio (HR) for death, 0.67; 95% CI, 0.41 to 1.09; P=0.11). The only three variables that were independently associated with superior OS were lower European Leukemia Net (ELN) risk classification, TP53 unmutated status, and receipt of transplant. Our data suggest that baseline genomic features and receipt of transplant are more important than treatment intensity in predicting survival in this patient population. They also highlight the vital role of transplant in older patients with AML regardless of treatment intensity utilized for remission induction. Larger studies are needed to further address this question, including prospective randomized trials.
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Affiliation(s)
- Kieran Sahasrabudhe
- Division of Hematology, Department of Internal Medicine, Comprehensive Cancer Center, The Ohio State University, Columbus, OH, United States
| | - Ying Huang
- Division of Hematology, Department of Internal Medicine, Comprehensive Cancer Center, The Ohio State University, Columbus, OH, United States
| | - Melanie Rebechi
- Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University, Columbus, OH, United States
| | - Patrick Elder
- Division of Hematology, Department of Internal Medicine, Comprehensive Cancer Center, The Ohio State University, Columbus, OH, United States
| | - Alice Mims
- Division of Hematology, Department of Internal Medicine, Comprehensive Cancer Center, The Ohio State University, Columbus, OH, United States
| | - Sarah Wall
- Division of Hematology, Department of Internal Medicine, Comprehensive Cancer Center, The Ohio State University, Columbus, OH, United States
- *Correspondence: Sarah Wall,
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18
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Desprez C, Riou J, Peterlin P, Marchand T, Couturier MA, Villate A, Mear JB, Chevalier P, Guillerm G, Gyan E, Schmidt-Tanguy A, Walter RB, Hunault-Berger M, Orvain C. Comparison of scoring systems evaluating suitability for intensive chemotherapy in adults with acute myeloid leukemia-a Grand Ouest Against Leukemia (GOAL) study. Leukemia 2022; 36:2408-2417. [PMID: 35962057 DOI: 10.1038/s41375-022-01677-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/28/2022] [Accepted: 08/01/2022] [Indexed: 11/09/2022]
Abstract
Several scoring systems have been developed to assess suitability of individual patients for intensive acute myeloid leukemia (AML) therapy. We sought to compare the performance of these scores in a cohort of 428 consecutive adults with AML who received conventional induction chemotherapy in five academic centers in France. All scoring systems identified a subset of patients with increased 28 and 56-day mortality although the prediction accuracy was overall limited with C-statistics of ranging from 0.61 to 0.71 Overall survival (OS) prediction was more limited and restricted to scoring systems that include AML-related parameters. The outcome of 104 patients (24%) considered unsuitable for intensive chemotherapy based on criteria used in recent randomized trials was similar to that of the other 324 patients (28-day mortality, odds ratio [OR] = 1.88, P = 0.2; 56-day mortality, OR = 1.71, P = 0.21; event-free survival, hazard ratio [HR] = 1.08, P = 0.6; OS, HR = 1.25, P = 0.14) with low discrimination (C-statistic: 0.57, 0.56, 0.50, and 0.52 for 28-day, 56-day mortality, EFS, and OS, respectively). Together, our findings indicate that the accuracy of currently available approaches to identify patients at increased risk of early mortality and shortened survival after intensive AML therapy is relatively limited. Caution regarding the use of available scoring systems should be warranted in clinical decision-making.
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Affiliation(s)
| | - Jérémie Riou
- Univ Angers, CHU Angers, Inserm, CNRS, MINT, SFR ICAT, Angers, France
| | - Pierre Peterlin
- Service d'hématologie clinique, CHU de Nantes, Rennes, France.,Federation hospitalo-universitaire « Grand Ouest against Leukemia », Angers, France
| | - Tony Marchand
- Federation hospitalo-universitaire « Grand Ouest against Leukemia », Angers, France.,Service d'hématologie clinique, CHU de Rennes, Rennes, France.,INSERM U1236, Université Rennes 1, Rennes, France
| | - Marie-Anne Couturier
- Federation hospitalo-universitaire « Grand Ouest against Leukemia », Angers, France.,Service d'Hématologie Clinique, Hôpital Morvan, CHU de Brest, Rennes, France
| | - Alban Villate
- Federation hospitalo-universitaire « Grand Ouest against Leukemia », Angers, France.,Service d'Hématologie et Thérapie Cellulaire, Hôpital Bretonneau, CHRU de Tours, CNRS EMR7001 LNOx, Université de Tours, Rennes, France
| | - Jean-Baptiste Mear
- Federation hospitalo-universitaire « Grand Ouest against Leukemia », Angers, France.,Service d'hématologie clinique, CHU de Rennes, Rennes, France
| | - Patrice Chevalier
- Service d'hématologie clinique, CHU de Nantes, Rennes, France.,Federation hospitalo-universitaire « Grand Ouest against Leukemia », Angers, France
| | - Gaelle Guillerm
- Federation hospitalo-universitaire « Grand Ouest against Leukemia », Angers, France.,Service d'Hématologie Clinique, Hôpital Morvan, CHU de Brest, Rennes, France
| | - Emmanuel Gyan
- Federation hospitalo-universitaire « Grand Ouest against Leukemia », Angers, France.,Service d'Hématologie et Thérapie Cellulaire, Hôpital Bretonneau, CHRU de Tours, CNRS EMR7001 LNOx, Université de Tours, Rennes, France
| | - Aline Schmidt-Tanguy
- Service des maladies du sang, CHU d'Angers, Angers, France.,Federation hospitalo-universitaire « Grand Ouest against Leukemia », Angers, France.,Université d'Angers, Inserm UMR 1307, CNRS UMR 6075, Nantes Université, CRCI2NA, F-49000, Angers, France
| | - Roland B Walter
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA, USA.,Department of Medicine, Division of Hematology/Oncology, University of Washington, Seattle, WA, USA.,Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Mathilde Hunault-Berger
- Service des maladies du sang, CHU d'Angers, Angers, France.,Federation hospitalo-universitaire « Grand Ouest against Leukemia », Angers, France.,Université d'Angers, Inserm UMR 1307, CNRS UMR 6075, Nantes Université, CRCI2NA, F-49000, Angers, France
| | - Corentin Orvain
- Service des maladies du sang, CHU d'Angers, Angers, France. .,Federation hospitalo-universitaire « Grand Ouest against Leukemia », Angers, France. .,Université d'Angers, Inserm UMR 1307, CNRS UMR 6075, Nantes Université, CRCI2NA, F-49000, Angers, France.
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19
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Sasaki K, Ravandi F, Kadia T, DiNardo C, Borthakur G, Short N, Jain N, Daver N, Jabbour E, Garcia-Manero G, Khoury J, Konoplev S, Loghavi S, Patel K, Montalban-Bravo G, Masarova L, Konopleva M, Kantarjian H. Prediction of survival with intensive chemotherapy in acute myeloid leukemia. Am J Hematol 2022; 97:865-876. [PMID: 35384048 DOI: 10.1002/ajh.26557] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 03/29/2022] [Accepted: 03/31/2022] [Indexed: 12/15/2022]
Abstract
Progress with intensive chemotherapy and supportive care measures has improved survival in newly diagnosed acute myeloid leukemia (AML). Predicting outcome helps in treatment decision making. We analyzed survival as the treatment endpoint in 3728 patients with newly diagnosed AML treated with intensive chemotherapy from 1980 to 2021. We divided the total study group (3:1 basis) into a training (n = 2790) and a validation group (n = 938). The associations between survival and 27 characteristics were investigated. In the training cohort, the multivariate analysis identified 12 consistent adverse prognostic variables independently associated with worse survival: older age, therapy-related myeloid neoplasm, worse performance status, cardiac comorbidity, leukocytosis, anemia, thrombocytopenia, elevated creatinine and lactate dehydrogenase, cytogenetic abnormalities, and the presence of infection at diagnosis except fever of unknown origin. We categorized patients into four prognostic groups, favorable (7%), intermediate (43%), poor (39%), and very poor (11%) with estimated 5-year survival rates of 69%, 36%, 13%, and 3% respectively (p < .001). The predictive model was validated in an independent cohort. In a subset of patients with molecular mutation profiles, adding the mutation profiles after accounting for the effects of previous factors identified NPM1 (favorable), PTPN11, and TP53 (both unfavorable) mutations as molecular prognostic factors. The new proposed predictive model for survival with intensive chemotherapy in patients with AML is robust and can be used to advise patients regarding their prognosis, to modify therapy in remission (e.g., proposing allogeneic stem cell transplantation in first remission), and to compare outcome and benefits on future investigational therapies.
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Affiliation(s)
- Koji Sasaki
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Tapan Kadia
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Courtney DiNardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gautam Borthakur
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nicholas Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Naval Daver
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Guillermo Garcia-Manero
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Joseph Khoury
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sergej Konoplev
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sanam Loghavi
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Keyur Patel
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Lucia Masarova
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Marina Konopleva
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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20
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Short NJ, Kantarjian H. Choosing between intensive and less intensive front-line treatment approaches for older patients with newly diagnosed acute myeloid leukaemia. Lancet Haematol 2022; 9:e535-e545. [PMID: 35772432 DOI: 10.1016/s2352-3026(22)00167-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 05/12/2022] [Accepted: 05/17/2022] [Indexed: 06/15/2023]
Abstract
The outcomes of older patients with acute myeloid leukaemia are inferior to their younger counterparts, because, in part, of a more aggressive disease biology and poorer tolerance of cytotoxic chemotherapy. Although intensive chemotherapy was historically considered the only effective treatment for these patients, many older patients are not suitable for intensive chemotherapy owing to comorbidities or general frailty. Determination of patient fitness for intensive chemotherapy is imperfect, and even older patients who appear to be suitable (also known as fit) for intensive chemotherapy can have high rates of morbidity and early and late mortality with this approach. Fortunately, the outcomes of older or unfit patients with acute myeloid leukaemia have substantially improved with the use of a hypomethylating agent plus venetoclax in the front-line setting. Although the formal approval of this combination is limited to patients aged 75 years or older, or those with a clinically significant comorbidity, the high response rates and survival improvement in these patients have led many practitioners to consider this low-intensity regimen in older patients without significant comorbidities and even in younger patients with high-risk disease features for whom the expected outcomes with intensive chemotherapy are poor. Modifications to the hypomethylating agent plus venetoclax backbone might further improve the outlook for these patients, particularly in some acute myeloid leukaemia subsets with a targetable mutation. In this Viewpoint, we review the retrospective and prospective data supporting both intensive chemotherapy and low-intensity venetoclax-based approaches in older patients with acute myeloid leukaemia. We also discuss our own approach to the management of older or unfit patients with acute myeloid leukaemia, including how cytomolecular features have a role in establishing the optimal front-line therapy.
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Affiliation(s)
- Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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