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Gabellier L, Peterlin P, Thepot S, Hicheri Y, Paul F, Gallego-Hernanz MP, Bertoli S, Turlure P, Pigneux A, Guieze R, Ochmann M, Malfuson JV, Cluzeau T, Thomas X, Tavernier E, Jourdan E, Bonnet S, Tudesq JJ, Raffoux E. Hypomethylating agent monotherapy in core binding factor acute myeloid leukemia: a French multicentric retrospective study. Ann Hematol 2024; 103:759-769. [PMID: 38273140 PMCID: PMC10867066 DOI: 10.1007/s00277-024-05623-0] [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: 10/26/2023] [Accepted: 01/10/2024] [Indexed: 01/27/2024]
Abstract
Very few data are available about hypomethylating agent (HMA) efficiency in core binding factor acute myeloid leukemias (CBF-AML). Our main objective was to evaluate the efficacy and safety of HMA in the specific subset of CBF-AML. Here, we report the results of a multicenter retrospective French study about efficacy of HMA monotherapy, used frontline or for R/R CBF-AML. Forty-nine patients were included, and received a median of 5 courses of azacitidine (n = 46) or decitabine (n = 3). ORR was 49% for the whole cohort with a median time to response of 112 days. After a median follow-up of 72.3 months, median OS for the total cohort was 10.6 months. In multivariate analysis, hematological relapse of CBF-AML at HMA initiation was significantly associated with a poorer OS (HR: 2.13; 95%CI: 1.04-4.36; p = 0.038). Responders had a significantly improved OS (1-year OS: 75%) compared to non-responders (1-year OS: 15.3%; p < 0.0001). Hematological improvement occurred for respectively 28%, 33% and 48% for patients who were red blood cell or platelet transfusion-dependent, or who experienced grade 3/4 neutropenia at HMA initiation. Adverse events were consistent with the known safety profile of HMA. Our study highlights that HMA is a well-tolerated therapeutic option with moderate clinical activity for R/R CBF-AML and for patients who cannot handle intensive chemotherapy.
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Affiliation(s)
- Ludovic Gabellier
- Département d'Hématologie Clinique, CHU Montpellier, Université Montpellier-Nîmes, 80, Avenue Augustin Fliche, 34090, Montpellier, France.
| | - Pierre Peterlin
- Département d'Hématologie Clinique, CHU Nantes, Université de Nantes, Nantes, France
| | - Sylvain Thepot
- Département d'Hématologie Clinique, CHU Angers, Université d'Angers, Angers, France
| | - Yosr Hicheri
- Département d'Hématologie Clinique, Institut Paoli-Calmettes, Marseille, France
| | - Franciane Paul
- Département d'Hématologie Clinique, CHU Montpellier, Université Montpellier-Nîmes, 80, Avenue Augustin Fliche, 34090, Montpellier, France
| | | | - Sarah Bertoli
- Service d'Hématologie Clinique, CHU Toulouse, Institut Universitaire du Cancer de Toulouse - Oncopôle, Université Toulouse III - Paul Sabatier, Toulouse, France
| | - Pascal Turlure
- Département d'Hématologie Clinique, CHU Limoges, Université de Limoges, Limoges, France
| | - Arnaud Pigneux
- Département d'Hématologie Clinique, CHU Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Romain Guieze
- Département d'Hématologie Clinique, CHU Clermont-Ferrand, Université de Clermont-Ferrand, Clermont-Ferrand, France
| | - Marlène Ochmann
- Département d'Hématologie Clinique, Orléans, Orléans, CH, France
| | - Jean-Valère Malfuson
- Département d'Hématologie Clinique, Hôpital d'instruction Des Armées, Percy, France
| | - Thomas Cluzeau
- Département d'Hématologie Clinique, CHU Nice, Université de Nice, Nice, France
| | - Xavier Thomas
- Département d'Hématologie Clinique, Hospices Civils de Lyon, CHU Lyon, Université de Lyon, Lyon, France
| | - Emmanuelle Tavernier
- Département d'Hématologie Clinique, Institut de Cancérologie Lucien Neuwirth, Université de Saint-Etienne, Saint-Etienne, France
| | - Eric Jourdan
- Département d'Hématologie Clinique, CHU Nîmes, Université de Montpellier-Nîmes, Nîmes, France
| | - Sarah Bonnet
- Département d'Hématologie Clinique, CHU Montpellier, Université Montpellier-Nîmes, 80, Avenue Augustin Fliche, 34090, Montpellier, France
| | - Jean-Jacques Tudesq
- Département d'Hématologie Clinique, CHU Montpellier, Université Montpellier-Nîmes, 80, Avenue Augustin Fliche, 34090, Montpellier, France
| | - Emmanuel Raffoux
- Département d'Hématologie Clinique Adultes, Hôpital Saint-Louis, APHP, Université Paris Diderot, Paris, France
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Prognosis of older patients with newly diagnosed AML undergoing antileukemic therapy: A systematic review. PLoS One 2022; 17:e0278578. [PMID: 36469519 PMCID: PMC9721486 DOI: 10.1371/journal.pone.0278578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 11/20/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND OBJECTIVE The prognostic value of age and other non-hematological factors in predicting outcomes in older patients with newly diagnosed acute myeloid leukemia (AML) undergoing antileukemic therapy is not well understood. We performed a systematic review to determine the association between these factors and mortality and health-related quality of life or fatigue among these patients. METHODS We searched Medline and Embase through October 2021 for studies in which researchers quantified the relationship between age, comorbidities, frailty, performance status, or functional status; and mortality and health-related quality of life or fatigue in older patients with AML receiving antileukemic therapy. We assessed the risk of bias of the included studies using the Quality in Prognostic Studies tool, conducted random-effects meta-analyses, and assessed the quality of the evidence using the Grading of Recommendations, Assessment, Development and Evaluation approach. RESULTS We included 90 studies. Meta-analysis showed that age (per 5-year increase, HR 1.16 95% CI 1.11-1.21, high-quality evidence), comorbidities (Hematopoietic Cell Transplantation-specific Comorbidity Index: 3+ VS less than 3, HR 1.60 95% CI 1.31-1.95, high-quality evidence), and performance status (Eastern Cooperative Oncology Group/ World Health Organization (ECOG/WHO): 2+ VS less than 2, HR 1.63 95% CI 1.43-1.86, high-quality evidence; ECOG/WHO: 3+ VS less than 3, HR 2.00 95% CI 1.52-2.63, moderate-quality evidence) were associated with long-term mortality. These studies provided inconsistent and non-informative results on short-term mortality (within 90 days) and quality of life. CONCLUSION High-quality or moderate-quality evidence support that age, comorbidities, performance status predicts the long-term prognosis of older patients with AML undergoing antileukemic treatment.
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Cortes JE, Mehta P. Determination of fitness and therapeutic options in older patients with acute myeloid leukemia. Am J Hematol 2021; 96:493-507. [PMID: 33368536 PMCID: PMC7986910 DOI: 10.1002/ajh.26079] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 12/15/2020] [Accepted: 12/20/2020] [Indexed: 12/11/2022]
Abstract
Treatment of older patients with AML remains challenging. Although age, performance status, and comorbidities are commonly employed to determine fitness for intensive treatment, several studies have demonstrated improved outcomes with treatment in older and classically unfit patients, highlighting the importance of other disease-related and patient-related factors that have prognostic value for treatment outcome in AML. However, consistent and objective assessments for fitness are lacking. Multi-parameter geriatric assessment tools offer more comprehensive evaluation, but are limited by the required resources and lack of standardization and consensus regarding prognostic value. These assessments are particularly important considering the emerging new AML therapies that represent a spectrum of intensities. Patients should therefore be evaluated holistically for fitness to receive a specific treatment, with the aim of providing individualized care, and such definitions of fitness should also consistently be applied to clinical trials. This review will examine evolving criteria for the determination of fitness among AML patients and discuss treatment options for older and/or unfit patients with AML.
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Affiliation(s)
- Jorge E. Cortes
- Georgia Cancer Center Augusta University Augusta Georgia USA
| | - Priyanka Mehta
- Department of Haematology University Hospitals Bristol, NHS Foundation Trust Bristol UK
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Benchmarking treatment effects for patients over 70 with acute myeloid leukemia: A systematic review and meta-analysis. J Geriatr Oncol 2020; 11:1293-1308. [PMID: 32665186 DOI: 10.1016/j.jgo.2020.06.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 04/20/2020] [Accepted: 06/15/2020] [Indexed: 01/02/2023]
Abstract
OBJECTIVES The majority of patients with acute myeloid leukemia (AML) are aged 70 and over. However, there is uncertainty about how and whether older patients with AML should receive cytotoxic treatment. MATERIALS AND METHODS Medline and Cochrane library search was performed for studies in newly diagnosed AML which enrolled at least 20 patients per arm (for randomized controlled trials), or 50 patients (for non-randomized studies) over the age of 70. References were hand searched for additional eligible studies. Study investigators were contacted to maximize relevant data. Dual independent data extraction was done using standardized data collection forms. Data was collected on study and treatment characteristics, baseline patient information, and outcomes. Study methodological quality was assessed. The primary outcome was 1 year overall survival (OS). Impact of treatment [intensive chemotherapy (INT), low-dose chemotherapy (LOW), hypomethylating agents (HMA), or best supportive care (BSC)], cytogenetics, performance status, and comorbidity were assessed. RESULTS The search produced 11,846 references of which 38 randomized controlled trials and 30 non-randomized studies met inclusion criteria, representing 13,381 patients, with a worldwide distribution. One-year OS with INT was 37% (31-42%), with LOW 11% (6-18%), with HMA 35% (18-54%) and with BSC 17%(13-21%). Two-year OS was 22% (18-26%), 11% (7-15%), 22% (16-28%), 6% (2-12%), respectively. We present subgroup data based on the studies including cytogenetics, performance status, and comorbidity. Formal direct comparisons with adjustment for all prognostic factors were not possible. CONCLUSIONS In this largest to date series of AML patients aged 70 and older, we provide benchmarks for treatment efficacy and effectiveness that may be used for decision analysis models and for the future development of clinical trials focusing on these patients.
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Talati C, Dhulipala VC, Extermann MT, Ali NA, Kim J, Komrokji R, Sweet K, Kuykendall A, Sehovic M, Reljic T, Djulbegovic B, Lancet JE. Comparisons of commonly used front-line regimens on survival outcomes in patients aged 70 years and older with acute myeloid leukemia. Haematologica 2020; 105:398-406. [PMID: 31073071 PMCID: PMC7012500 DOI: 10.3324/haematol.2018.208637] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 05/07/2019] [Indexed: 12/03/2022] Open
Abstract
In older patients with acute myeloid leukemia, the more frequent presence of biologically inherent therapy-resistant disease and increased comorbidities translate to poor overall survival and therapeutic challenges. Optimal front-line therapies for older patients with acute myeloid leukemia remain controversial. We retrospectively evaluated survival outcomes in 980 elderly (≥70 years) acute myeloid leukemia patients from a single institution between 1995 and 2016. Four treatment categories were compared: high-intensity (daunorubicin/cytarabine or equivalent), hypomethylating agent, low-intensity (low-dose cytarabine or similar without hypomethylating agents), and supportive care therapy (including hydroxyurea). At a median follow up of 20.5 months, the median overall survival for the entire cohort was 7.1 months. Multivariate analysis identified secondary acute myeloid leukemia, poor-risk cytogenetics, performance status, front-line therapy, age, white blood cell count, platelet count, and hemoglobin level at diagnosis as having an impact on survival. High-intensity therapy was used in 360 patients (36.7%), hypomethylating agent in 255 (26.0%), low-intensity therapy in 91 (9.3%), and supportive care in 274 (28.0%). Pairwise comparisons between hypomethylating agent therapy and the three other treatment groups demonstrated statistically significant superior median overall survival with hypomethylating agent [14.4 months) vs. high-intensity therapy 10.8 months, hazard ratio 1.35, 95% confidence interval (CI): 1.10-1.65; P =0.004], low-intensity therapy (5.9 months, hazard ratio 2.01, 95%CI: 1.53-2.62; P<0.0001), and supportive care (2.1 months, hazard ratio 2.94, 95%CI: 2.39-3.61; P<0.0001). Our results indicate a significant survival benefit with hypomethylating agents compared to high-intensity, low-intensity, or supportive care. Additionally, high-intensity chemotherapy resulted in superior overall outcomes compared to low-intensity therapy and supportive care. Results from this study highlight the need for novel therapeutic approaches besides utilization of intensive chemotherapy in this specific aged population.
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Affiliation(s)
- Chetasi Talati
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | | | - Mar Tine Extermann
- Senior Adult Oncology Program, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL.,Department of Oncology Sciences, University of South Florida, Tampa, FL
| | - Najla Al Ali
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Jongphil Kim
- Maur y Regional Cancer Center, Columbia, TN.,Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, FL
| | - Rami Komrokji
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL.,Malignant Hematology Department, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Kendra Sweet
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL.,Malignant Hematology Department, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Andrew Kuykendall
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL.,Maur y Regional Cancer Center, Columbia, TN
| | - Marina Sehovic
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
| | - Tea Reljic
- Maur y Regional Cancer Center, Columbia, TN
| | - Benjamin Djulbegovic
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL.,Maur y Regional Cancer Center, Columbia, TN
| | - Jeffrey E Lancet
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL.,Malignant Hematology Department, H Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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Tremblay G, Rousseau B, Marquis M, Beaubois C, Sauvageau G, Hébert J. Cost-Effectiveness Analysis of a HMGA2 Prognostic Test for Acute Myeloid Leukemia in a Canadian Setting. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2019; 17:827-839. [PMID: 31392669 PMCID: PMC6885508 DOI: 10.1007/s40258-019-00503-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Current strategies for risk stratification of patients with acute myeloid leukemia assign approximately 40% of patients to the intermediate-risk group, where uncertainty about optimal therapy still persists. OBJECTIVE The objective of this study was to assess the cost effectiveness of a HMGA2 prognostic test based on HMGA2+/HMGA2- expression, which improves genetic risk stratification in acute myeloid leukemia, and compare this test with the current standard of care in Canada. METHODS A cost-effectiveness model was developed from the Canadian National Healthcare Service and societal perspective using data from the Quebec Leukemia Cell Bank, published literature, and physician surveys. The model includes a lifetime horizon assessing the HMGA2 test vs. standard of care. RESULTS The HMGA2 test outperformed the standard of care at all time horizons culminating with estimated improvements of 1.92 and 3.12 months in leukemia-free survival and overall survival, respectively. Costs associated with the HMGA2 test were consistently lower, except diagnostic costs, routine medical costs, and costs related to infections and false positives. From a societal perspective, total lifetime costs were $161,358 CAD and $151,908 CAD with the standard of care and the HMGA2 test, respectively. The incremental quality-adjusted life-year gain was 0.138, which led to dominance over the standard of care. Deterministic sensitivity analyses confirmed the results of the base-case scenario. Probabilistic sensitivity analyses revealed that for a willingness-to-pay threshold of $100,000 CAD, the probability of cost effectiveness was 87.19%. CONCLUSIONS The HMGA2 test is estimated to improve leukemia-free survival and overall survival outcomes, and yield costs savings from a healthcare system and societal perspective.
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Affiliation(s)
- Gabriel Tremblay
- Purple Squirrel Economics, New York, NY, USA.
- Geneconomics Inc, 1372 rue Du crépuscule, Lévis, QC, Canada, G7A 4K3.
| | | | - Miriam Marquis
- The Leucegene Project, Université de Montréal, Montreal, QC, Canada
- Quebec Leukemia Cell Bank, Research Centre, Maisonneuve-Rosemont Hospital, 5415 l'Assomption Blvd, Montreal, QC, H1T 2M4, Canada
| | - Cyrielle Beaubois
- The Leucegene Project, Université de Montréal, Montreal, QC, Canada
- Quebec Leukemia Cell Bank, Research Centre, Maisonneuve-Rosemont Hospital, 5415 l'Assomption Blvd, Montreal, QC, H1T 2M4, Canada
| | - Guy Sauvageau
- The Leucegene Project, Université de Montréal, Montreal, QC, Canada
- Quebec Leukemia Cell Bank, Research Centre, Maisonneuve-Rosemont Hospital, 5415 l'Assomption Blvd, Montreal, QC, H1T 2M4, Canada
- Division of Hematology-Oncology, Maisonneuve-Rosemont Hospital, Montreal, QC, Canada
- Department of Medicine, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Josée Hébert
- The Leucegene Project, Université de Montréal, Montreal, QC, Canada.
- Quebec Leukemia Cell Bank, Research Centre, Maisonneuve-Rosemont Hospital, 5415 l'Assomption Blvd, Montreal, QC, H1T 2M4, Canada.
- Division of Hematology-Oncology, Maisonneuve-Rosemont Hospital, Montreal, QC, Canada.
- Department of Medicine, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada.
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Inhibition of Proliferation in U937 Cells Treated by Blue Light Irradiation and Combined Blue Light Irradiation/Drug. Int J Mol Sci 2018; 19:ijms19051464. [PMID: 29762467 PMCID: PMC5983758 DOI: 10.3390/ijms19051464] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 05/09/2018] [Accepted: 05/09/2018] [Indexed: 02/06/2023] Open
Abstract
The cell viability and apoptosis of tumor U937 cells treated by blue light (BL) irradiation have been examined. BL irradiation can specially inhibit the proliferation and promote the apoptosis of U937 cells, relating to the production of reactive oxygen species (ROS) and the decline of mitochondrial membrane potential (ΔΨm). The apoptosis is further associated with varying downregulated B-cell lymphoma-extra large (Bcl-XL) and B-cell lymphoma 2 (Bcl-2) genes, upregulated Bcl-2-associated X (Bax) gene, the activation of caspase-3 and caspase-9, and the cleavage of poly (ADP-ribose) polymerase (PARP) by the BL irradiation process. Moreover, BL irradiation induced proliferation inhibition is higher than that treated by a common chemotherapeutic drug of homoharringtonine (HHT). When we synergize BL irradiation with HHT (BL-HHT), a higher proliferation inhibition is obtained than that treated by BL irradiation or HHT alone. These results are helpful for establishing a low toxicity and high efficiency strategy of BL irradiation for clinical treatment of acute myeloid leukemia, not limited to U937 cells.
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Lerch E, Espeli V, Zucca E, Leoncini L, Scali G, Mora O, Bordoni A, Cavalli F, Ghielmini M. Prognosis of Acute Myeloid Leukemia in the General Population: Data from Southern Switzerland. TUMORI JOURNAL 2018; 95:303-10. [DOI: 10.1177/030089160909500306] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aims and background To evaluate the outcome of adult patients with de novo acute myeloid leukemia in the Italian-speaking part of Switzerland and to identify prognostic factors, time to progression and overall survival. Methods and study design Data of all adult patients diagnosed with acute myeloid leukemia from January 1984 to December 2003 were collected retrospectively. Univariate and multivariate analysis for time to progression and overall survival were performed. Results The incidence of acute myeloid leukemia in the adult population in southern Switzerland is 2.6/100,000 per year. Complete clinical and pathological data and follow-up information were available for 128 patients. The median age was 67 years (range, 18 to 94). The median follow-up was 97 months. Median overall survival was 6 months, with a 2-year overall survival of 16%. Median time to progression was 3 months. Thirty-five patients (median age, 80 years) were given best supportive care and/or palliative chemotherapy. The median survival in this subset was 2 months. Of the 93 patients treated with a curative intent, 48 were older than 60 years. The complete remission rate after induction chemotherapy was 80% for patients younger than 60 years and 31% for those older than 60 years (P <0.0001). Overall survival at 2 years was 40% and 12%, respectively (P <0.0005). The relapse rate was 61%, and only 28% of the patients who were given reinduction chemotherapy reached a second complete remission. Of the patients treated with curative intent, 52% were treated in a clinical trial. Their median age was significantly lower than those not included in a trial: 57 vs 66 years (P <00001). Patients treated in a trial had a significantly better prognosis than those not so treated (median survival, 12 vs 6 months). Patients treated with high-dose cytarabine as first-line therapy (given to 25 of 93 patients treated with a curative intent) had a better survival than those given standard cytarabine doses (P <0.0005). The outcome of the patients treated after 1993 was significantly better (P = 0.026) than that of the previously treated cohort. In multivariate analysis (not including cytogenetic data), only age (P = 0.005), performance status >1 (P = 0.001) and treatment given before/after 1993 (P = 0.044) were found to be independent prognostic factors for both overall survival and time to progression. Conclusions Most patients with acute myeloid leukemia are older than 60 years, and their outcome is still disappointing. For younger patients, the prognosis is better if they receive high-dose cytarabine as post-remission therapy and if they are treated in the setting of a clinical trial.
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Affiliation(s)
- Erika Lerch
- Istituto Oncologico della Svizzera Italiana (IOSI), Bellinzona, Switzerland
| | - Vittoria Espeli
- Istituto Oncologico della Svizzera Italiana (IOSI), Bellinzona, Switzerland
| | - Emanuele Zucca
- Istituto Oncologico della Svizzera Italiana (IOSI), Bellinzona, Switzerland
| | - Leda Leoncini
- Istituto Oncologico della Svizzera Italiana (IOSI), Bellinzona, Switzerland
| | | | - Oreste Mora
- Istituto Oncologico della Svizzera Italiana (IOSI), Bellinzona, Switzerland
| | - Andrea Bordoni
- Registro dei Tumori del Canton Ticino, Locarno, Switzerland
| | - Franco Cavalli
- Istituto Oncologico della Svizzera Italiana (IOSI), Bellinzona, Switzerland
| | - Michele Ghielmini
- Istituto Oncologico della Svizzera Italiana (IOSI), Bellinzona, Switzerland
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Goyal G, Gundabolu K, Vallabhajosyula S, Silberstein PT, Bhatt VR. Reduced-intensity conditioning allogeneic hematopoietic-cell transplantation for older patients with acute myeloid leukemia. Ther Adv Hematol 2016; 7:131-41. [PMID: 27247754 PMCID: PMC4872178 DOI: 10.1177/2040620716643493] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Elderly patients (>60 years) with acute myeloid leukemia have a poor prognosis with a chemotherapy-alone approach. Allogeneic hematopoietic-cell transplantation (HCT) can improve overall survival (OS). However, myeloablative regimens can have unacceptably high transplant-related mortality (TRM) in an unselected group of older patients. Reduced-intensity conditioning (RIC) or nonmyeloablative (NMA) conditioning regimens preserve the graft-versus-leukemia effects but reduce TRM. NMA regimens result in minimal cytopenia and may not require stem cell support for restoring hematopoiesis. RIC regimens, intermediate in intensity between NMA and myeloablative regimens, can cause prolonged myelosuppresion and usually require stem cell support. A few retrospective and prospective studies suggest a possibility of lower risk of relapse with myeloablative HCT in fit older patients with lower HCT comorbidity index; however, RIC and NMA HCTs have an important role in less-fit patients and those with significant comorbidities because of lower TRM. Whether early tapering of immunosuppression, monitoring of minimal residual disease, and post-transplant maintenance therapy can improve the outcomes of RIC and NMA HCT in elderly patients will require prospective trials.
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Affiliation(s)
- Gaurav Goyal
- Creighton University Medical Center, 601 North 30th Street, Ste 5850, Omaha, NE 68131, USA
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Takahashi K, Kantarjian H, Garcia-Manero G, Borthakur G, Kadia T, DiNardo C, Jabbour E, Pierce S, Estrov Z, Konopleva M, Andreeff M, Ravandi F, Cortes J. Clofarabine Plus Low-Dose Cytarabine Is as Effective as and Less Toxic Than Intensive Chemotherapy in Elderly AML Patients. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2015; 16:163-8.e1-2. [PMID: 26752456 DOI: 10.1016/j.clml.2015.11.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 11/16/2015] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Most patients with acute myeloid leukemia (AML) age ≥ 60 years are not offered intensive induction because of high mortality. Phase 2 studies of clofarabine plus low-dose cytarabine (CLDA) as frontline therapy for elderly AML patients demonstrated high response and acceptable toxicity. PATIENTS AND METHODS We hypothesized that induction therapy with CLDA provides equivalent outcomes to but is less toxic than intensive induction in these patients. To test this hypothesis, we conducted a propensity score-matched comparison of AML patients age ≥ 60 years given induction CLDA versus idarubicin and cytarabine (IA). Ninety-five patients in both groups were matched according to their propensity score. RESULTS We did not observe statistically significant differences in response, overall survival, or mortality rate between the two induction regimens. However, CLDA produced significantly fewer grade 3 or worse toxicities (46% for CLDA vs. 62% for IA; P = .03). Furthermore, among responders, the median response duration was significantly longer with CLDA when we censored patients who underwent stem cell transplantation (15.9 months for CLDA vs. 7.0 months for IA; P = .033). CONCLUSION Compared with intensive induction, CLDA offers equivalent responses and survival but less toxicity in clinically well-matched cohorts of elderly AML patients. Prospective randomized trials to confirm these findings are warranted.
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Affiliation(s)
- Koichi Takahashi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX; Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Gautam Borthakur
- 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
| | - Courtney DiNardo
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sherry Pierce
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Zeev Estrov
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Marina Konopleva
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Michael Andreeff
- 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
| | - Jorge Cortes
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX.
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Arahata M, Shimizu Y, Asakura H, Nakao S. Persistent molecular remission of refractory acute myeloid leukemia with inv(16)(p13.1q22) in an elderly patient induced by cytarabine ocfosfate hydrate. J Hematol Oncol 2015; 8:5. [PMID: 25652695 PMCID: PMC4332927 DOI: 10.1186/s13045-014-0100-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2014] [Accepted: 12/27/2014] [Indexed: 11/10/2022] Open
Abstract
The prognosis of relapsed acute myeloid leukemia (AML) in elderly patients is dismal, even if the AML exhibits a good prognostic karyotype, such as inv(16)(p13.1q22). We present a 72-year-old female with AML with inv(16)(p13.1q22) who suffered five episodes of relapse with temporary complete remission. Maintenance chemotherapy with oral cytarabine ocfosfate hydrate eventually produced persistent molecular complete remission of her AML that had not been induced by conventional regimens including intensive chemotherapy and low dose cytarabine therapy. The high level of tolerability to oral cytarabine ocfosfate hydrate may offer elderly patients with this type of AML a good chance for a cure.
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Affiliation(s)
- Masahisa Arahata
- Department of Internal Medicine, Nanto Municipal Hospital, 938 Inami, Nanto, Toyama, 932-0211, Japan.
| | - Yukihiro Shimizu
- Department of Internal Medicine, Nanto Municipal Hospital, 938 Inami, Nanto, Toyama, 932-0211, Japan.
| | - Hidesaku Asakura
- Department of Internal Medicine (III), Kanazawa University Graduate School of Medical Science, Kanazawa, Japan.
| | - Shinji Nakao
- Department of Cellular Transplantation Biology, Division of Cancer Medicine, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan.
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12
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Budziszewska BK, Pluta A, Sulek K, Wierzbowska A, Robak T, Giebel S, Holowiecka-Goral A, Sawicki W, Ejduk A, Patkowska E, Manko J, Gajkowska-Kulik J, Piszcz J, Mordak-Domagala M, Madry K, Holowiecki J, Kyrcz-Krzemien S, Nowakowska-Domagala M, Dmoszynska A, Calbecka M, Kloczko J, Wiktor Jędrzejczak W, Lange A, Razny M, Bilinski P, Warzocha K, Lech-Maranda E. Treatment of elderly patients with acute myeloid leukemia adjusted for performance status and presence of comorbidities: a Polish Adult Leukemia Group study. Leuk Lymphoma 2015; 56:2331-8. [PMID: 25393675 DOI: 10.3109/10428194.2014.985672] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
This prospective study estimated outcomes in 509 elderly patients with acute myeloid leukemia (AML) with different treatment approaches depending on Eastern Cooperative Oncology Group (ECOG) performance status and Charlson Comorbidity Index (CCI). Patients were stratified into fit (ECOG 0-2 and CCI 0-2) or frail (ECOG>2 and/or CCI>2) groups. Fit patients with CCI 0 received intensive chemotherapy whilst reduced-intensive chemotherapy (R-IC) was given to those with CCI 1-2. Frail patients received best supportive therapy. Fit patients presented a longer overall survival (OS) than frail subjects, but 8-week mortality rates were similar. The complete response (CR) rate between fit CCI 0 and CCI 1-2 subgroups was significantly different. Both of the fit subgroups showed similar 8-week mortality rates and OS probabilities. Allocating fit patients with CCI 1-2 to R-IC enabled an increase in the group of elderly patients who could be treated with the intention of inducing remission.
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Affiliation(s)
- Bozena Katarzyna Budziszewska
- a Hematology Department, Institute of Hematology and Transfusion Medicine , Warsaw , Poland.,b Center of Postgraduate Medical Education , Warsaw , Poland
| | - Agnieszka Pluta
- c Hematology Department, Medical University of Lodz , Lodz , Poland
| | - Kazimierz Sulek
- d Hematology Department, Military Medical Institute , Warsaw , Poland
| | | | - Tadeusz Robak
- c Hematology Department, Medical University of Lodz , Lodz , Poland
| | - Sebastian Giebel
- e Department of Bone Marrow Transplantation , Comprehensive Cancer Center, M. Sklodowska-Curie Memorial Institute , Gliwice , Poland
| | | | - Waldemar Sawicki
- d Hematology Department, Military Medical Institute , Warsaw , Poland
| | - Anna Ejduk
- a Hematology Department, Institute of Hematology and Transfusion Medicine , Warsaw , Poland
| | - Elzbieta Patkowska
- a Hematology Department, Institute of Hematology and Transfusion Medicine , Warsaw , Poland.,b Center of Postgraduate Medical Education , Warsaw , Poland
| | - Joanna Manko
- f Hematology Department, Medical University of Lublin , Lublin , Poland
| | | | - Jaroslaw Piszcz
- h Hematology Department, Medical University of Bialystok , Bialystok , Poland
| | | | - Krzysztof Madry
- j Hematology and Oncology Department, Warsaw Medical University , Warsaw , Poland
| | - Jerzy Holowiecki
- e Department of Bone Marrow Transplantation , Comprehensive Cancer Center, M. Sklodowska-Curie Memorial Institute , Gliwice , Poland
| | | | | | - Anna Dmoszynska
- f Hematology Department, Medical University of Lublin , Lublin , Poland
| | | | - Janusz Kloczko
- h Hematology Department, Medical University of Bialystok , Bialystok , Poland
| | | | - Andrzej Lange
- i Lower Silesian Centrum for Cellular Transplantation , Wroclaw , Poland
| | - Malgorzata Razny
- m Hematology Department, Rydygier Memorial Hospital , Krakow , Poland
| | - Przemyslaw Bilinski
- a Hematology Department, Institute of Hematology and Transfusion Medicine , Warsaw , Poland
| | - Krzysztof Warzocha
- a Hematology Department, Institute of Hematology and Transfusion Medicine , Warsaw , Poland
| | - Ewa Lech-Maranda
- a Hematology Department, Institute of Hematology and Transfusion Medicine , Warsaw , Poland.,b Center of Postgraduate Medical Education , Warsaw , Poland
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13
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Dukka S, Bowen DT. An intensive approach to treatment for older patients with relapsed isolated NPM1 mutated AML. Leuk Res Rep 2015; 4:18-20. [PMID: 25709893 PMCID: PMC4327759 DOI: 10.1016/j.lrr.2015.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 01/08/2015] [Accepted: 01/11/2015] [Indexed: 11/26/2022] Open
Abstract
We present a short case series of elderly patients with NK-AML and isolated NPM1 mutation who were treated with intensive chemotherapy, achieving significant CRs multiple times on reinduction, even with a single course.We hope to highlight the NPM1 as a molecular marker in elderly for consideration of aggressive treatment, even if abridged, as this subset may achieve a durable, good quality responses at diagnosis or subsequent relapses. Three case reports of elderly AML with NPM1 mutation treated with intensive chemotherapy. Multiple relapses managed with reinduction with intensive regimens with good clinical response, even with a single course. NPM1 mutation may be used as a molecular marker in elderly patients for consideration of aggressive treatment.
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Affiliation(s)
- Srivasavi Dukka
- Specialist Registrar in Haematology, Department of Haematology, Level 3 Bexley Wing, St. James׳s University Hospital, Leeds LS9 7TF, United Kingdom
| | - David T Bowen
- Honorary Professor of Myeloid Leukaemia Studies and Consultant Haematologist, St James׳s Institute of Oncology, Bexley Wing, Beckett Street, Leeds LS9 7TF, United Kingdom
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14
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Kim DS, Kang KW, Yu ES, Kim HJ, Kim JS, Lee SR, Park Y, Sung HJ, Yoon SY, Choi CW, Kim BS. Selection of elderly acute myeloid leukemia patients for intensive chemotherapy: effectiveness of intensive chemotherapy and subgroup analysis. Acta Haematol 2014; 133:300-9. [PMID: 25470986 DOI: 10.1159/000362777] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Accepted: 04/09/2014] [Indexed: 01/02/2023]
Abstract
BACKGROUND Despite the advances in acute myeloid leukemia (AML) treatment, the prognosis of elderly patients remains poor and no definitive treatment guideline has been established. In the present study, we aimed to evaluate the effectiveness of intensive chemotherapy in elderly AML patients and to determine which subgroup of patients would be most responsive to the therapy. METHODS We retrospectively analyzed 84 elderly patients: 35, 19, and 30 patients were administered intensive chemotherapy, low-dose chemotherapy, and supportive care, respectively. RESULTS Among those who received intensive chemotherapy, there were 17 cases of remission after induction chemotherapy; treatment-related mortality was 22.9%. The median overall survival was 7.9 months. Multivariate analysis indicated that the significant prognostic factors for overall survival were performance status, fever before treatment, platelet count, blast count, cytogenetic risk category, and intensive chemotherapy. Subgroup analysis showed that intensive chemotherapy was markedly effective in the relatively younger patients (65-70 years) and those with de novo AML, better-to-intermediate cytogenetic risk, no fever before treatment, high albumin levels, and high lactate dehydrogenase levels. CONCLUSIONS Elderly AML patients had better outcomes with intensive chemotherapy than with low-intensity chemotherapy. Thus, appropriate subgroup selection for intensive chemotherapy is likely to improve therapeutic outcome.
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Affiliation(s)
- Dae Sik Kim
- Division of Oncology and Hematology, Department of Internal Medicine, Korea University Medical Center, Seoul, South Korea
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15
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Walter RB, Estey EH. Management of older or unfit patients with acute myeloid leukemia. Leukemia 2014; 29:770-5. [PMID: 25005246 DOI: 10.1038/leu.2014.216] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 05/01/2014] [Accepted: 05/19/2014] [Indexed: 12/21/2022]
Abstract
Acute myeloid leukemia (AML) is primarily a disease of older adults, for whom optimal treatment strategies remain controversial. Because of the concern for therapeutic resistance and, in particular, excessive toxicity or even treatment-related mortality, many older or medically unfit patients do not receive AML-directed therapy. Yet, evidence suggests that outcomes are improved if essentially all of these patients are offered AML therapy, ideally at a specialized cancer center. Medical fitness for tolerating intensive chemotherapy can be estimated relatively accurately with multiparameter assessment tools; this information should serve as basis for the assignment to intensive or non-intensive therapy. Until our accuracy in predicting the success of individual therapies improves, all patients should be considered for participation in a randomized controlled trial. Comparisons between individual trials will be facilitated once standardized, improved response criteria are developed, and standard treatment approaches have been defined against which novel therapies can be tested.
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Affiliation(s)
- R B Walter
- 1] Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA [2] Division of Hematology, Department of Medicine, University of Washington, Seattle, WA, USA [3] Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - E H Estey
- 1] Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA [2] Division of Hematology, Department of Medicine, University of Washington, Seattle, WA, USA
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16
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Hirsch P, Qassa G, Marzac C, Tang R, Perrot JY, Isnard F, Mohty M, Marie JP, Legrand O. Acute myeloid leukemia in patients older than 75: prognostic impact of FLT3-ITD and NPM1 mutations. Leuk Lymphoma 2014; 56:147-50. [PMID: 24724782 DOI: 10.3109/10428194.2014.913288] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The benefit associated with chemotherapy in older patients with acute myeloid leukemia (AML) is debated. The prognostic impact of molecular mutations in these patients is unknown. We identified 79 patients with AML aged 75 years or over. Forty-two received chemotherapy and 37 supportive care only. In intensively treated patients, overall survival was longer (p < 0.001). Achieving complete remission was associated with longer survival (p < 0.001). NPM1 mutations tended to be associated with a higher complete remission rate (p = 0.12). In multivariate analysis, FLT3-ITD was associated with poorer survival (p = 0.049). Patients harboring FLT3-ITD and no NPM1 mutation had a poorer prognosis than others (p = 0.02). Intensive treatments can benefit a portion of elderly patients. FLT3-ITD and NPM1 mutational status might be useful for prognosis stratification.
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Affiliation(s)
- Pierre Hirsch
- Service d'hématologie clinique et de thérapie cellulaire, Hôpital Saint-Antoine, APHP , Paris , France
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17
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Abstract
Cloretazine is a new sulfonylhydrazine alkylating agent with antileukemic activity. Phase I studies have shown myelosuppression to be the dose limiting toxicity in both solid tumors and leukemias. A large Phase II study of single agent cloretazine (600 mg/m2) confirmed its activity in patients with relapsed acute myeloid leukemia, and in elderly patients with previously untreated acute myeloid leukemia or myelodysplastic syndrome. It also confirmed the limited nonhematological toxicity, even in elderly patients. Cloretazine can be safely combined with cytarabine, and this combination regimen is currently being tested in a large Phase III study in patients with relapsed acute myeloid leukemia. Cloretazine is a promising new antileukemic agent that may be incorporated into an intensive combination regimen.
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Affiliation(s)
- Norbert Vey
- Department of Hematology, Institut Paoli-Calmettes, 232 Blvd Sainte Marguerite, 13009 Marseille, France.
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18
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Wetzler M, Mrózek K, Kohlschmidt J, Dombret H, Döhner H, Pilorge S, Krug U, Carroll AJ, Larson RA, Marcucci G, Hiddemann W, Büchner T, Bloomfield CD. Intensive induction is effective in selected octogenarian acute myeloid leukemia patients: prognostic significance of karyotype and selected molecular markers used in the European LeukemiaNet classification. Haematologica 2013; 99:308-13. [PMID: 24097631 DOI: 10.3324/haematol.2013.092072] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
We investigated whether octogenarian patients with acute myeloid leukemia enrolled onto Cooperative Group clinical trials and treated with intensive induction therapy could be cured, and whether karyotype and selected molecular markers had any prognostic significance in these patients. Among 138 patients with cytogenetic information, normal karyotype was the most common (47.1%) followed by complex karyotype (14.5%) and sole +8 (9.4%). Among these patients, the relapse-free survival rate at 1 year was 37% and 13% at 3 years, and the respective overall survival rates were 24% and 8%. Whereas the 90 patients who survived beyond 30 days had the same relapse-free survival rates, their 1-year and 3-year overall survival rates were 36% and 11%, respectively. Of the 66 patients surviving beyond 30 days who could be classified into European LeukemiaNet genetic groups, those in the intermediate-I group had better overall survival than patients in the adverse group (P=0.01). Among patients with cytogenetically normal acute myeloid leukemia who were tested for the European LeukemiaNet-associated molecular alterations, FLT3-internal tandem duplication and NPM1 mutations, it was found that FLT3-internal tandem duplication (detected in 29% of patients) did not associate with overall survival (P=0.31), whereas NPM1 mutations (30%) were associated with a significantly longer overall survival (P=0.002). We conclude that intensive induction is effective and indicated in selected octogenarians with acute myeloid leukemia, that their overall survival varies among the European LeukemiaNet genetic groups and that NPM1 mutations may be of prognostic significance among octogenarian patients with cytogenetically normal acute myeloid leukemia.
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19
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DiNardo CD, O'Brien S, Gandhi VV, Ravandi F. Elacytarabine (CP-4055) in the treatment of acute myeloid leukemia. Future Oncol 2013; 9:1073-82. [PMID: 23902239 DOI: 10.2217/fon.13.130] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Elacytarabine (formerly CP-4055) is a lipid-conjugated derivative of the nucleoside analog cytarabine. Elacytarabine was rationally designed to circumvent cytarabine resistance related to decreased cellular uptake, due to the ability of the lipophilic drug moiety to enter the cell without the requirement of specialized nuclear transport proteins, including the hENT1. In preclinical and clinical studies, elacytarabine has demonstrated both safety and efficacy in acute myeloid leukemia (AML), with noteworthy activity among the cytarabine-refractory AML population. Elacytarabine was granted orphan drug designation status from the European Commission in 2007 and from the US FDA in 2008, with a fast-track approval designation from the FDA in 2010. Results of a recent randomized Phase III clinical trial, however, failed to show superiority of elacytarabine over the investigator's choice of therapy for relapsed or refractory AML.
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Affiliation(s)
- Courtney D DiNardo
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
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20
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Kim I, Koh Y, Yoon SS, Park S, Kim BK, Kim DY, Lee JH, Lee KH, Cheong JW, Lee HK, Kim SH, Kim H, Joo YD, Lee SM, Won JH, Park SK, Hong DS, Kim SH, Sohn SK, Kim CS, Park E, Kim MK, Park MR, Lee JH, Min YH. Fludarabine, cytarabine, and attenuated-dose idarubicin (m-FLAI) combination therapy for elderly acute myeloid leukemia patients. Am J Hematol 2013; 88:10-5. [PMID: 23077109 DOI: 10.1002/ajh.23337] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Revised: 08/29/2012] [Accepted: 08/30/2012] [Indexed: 12/11/2022]
Abstract
We performed a phase II trial to evaluate the efficacy and safety of the modified fludarabine, cytarabine, and attenuated-dose idarubicin (m-FLAI) regimen in elderly acute myeloid leukemia (AML) patients. Elderly (≥60 years) AML patients who had not previously received chemotherapy were enrolled in the study. Patients received two consecutive cycles of m-FLAI chemotherapy as an induction. The m-FLAI regimen comprised fludarabine (25 mg/m(2) , days 1-4), cytarabine (1,000 mg/m(2) , days 1-4), and attenuated-dose idarubicin (5 mg/m(2) , days 1-3). The primary end point was complete remission (CR) rate. Secondary end points were overall survival (OS), event-free survival (EFS), and treatment-related mortality (TRM). There were 108 patients (median age 68.4 years, M:F = 64:44) enrolled in the study. CR was achieved in 56.5% of patients, and the TRM rate was 21.3%. Median OS and median EFS were 10.2 and 6.6 months, respectively. The mortality at 30 and 60 days was 15 and 21%, respectively. Performance status and comorbidity did not have prognostic value in this patient cohort. Bone marrow expression of CD117 was associated with increased EFS and OS. m-FLAI is an effective induction regimen for previously untreated AML in elderly patients. In addition, bone-marrow CD117 expression is an independent favorable prognostic factor in elderly AML patients. (ClinicalTrials.gov number, NCT01247493).
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Affiliation(s)
- Inho Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Korea
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21
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Alvarado Y, Swords R, Kelly KR, Giles FJ. Clinical activity of laromustine (Onrigin™) in hematologic malignancies. Expert Rev Hematol 2011; 2:481-8. [PMID: 21083013 DOI: 10.1586/ehm.09.38] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Laromustine (Onrigin™), formerly known as Cloretazine(®) (VNP40101M), belongs to a novel class of alkylating agents--the sulfonylhydrazines--and was selected for clinical development based on its broad anti-tumor activity in preclinical models. Laromustine is metabolized to yield 90CE and methylisocyanate, the former rapidly produces an alkylating, chloroethylating species, similar to the chloroethylating species generated by carmustine. However, several features distinguish laromustine from carmustine and possibly account for their biological differences in vitro and in vivo. The chloroethylating species responsible for laromustine's alkylator effect is relatively specific for guanine and forms a crosslink after incorporation into DNA. Laromustine has significant activity in both older patients with previously untreated acute myeloid leukemia or high-risk myelodysplastic syndrome, including those with very poor-risk disease, and in patients with relapsed disease. Further clinical studies are required with laromustine to evaluate its place as an anticancer agent in other hematological malignancies.
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Affiliation(s)
- Yesid Alvarado
- Institute for Drug Development, Cancer Therapy and Research Center at the UT Health Science Center, University of Texas, San Antonio, TX 78229, USA
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22
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Abe S, Kanaya K, Kikukawa M, Sakai M, Akai T, Takata Y, Sakurai H, Shin K, Mori M, Iwamoto T. Clinical results and issues of acute myeloid leukemia in elderly patients aged 75 years and older. Geriatr Gerontol Int 2011; 11:290-6. [PMID: 21303435 DOI: 10.1111/j.1447-0594.2010.00682.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
AIM Clinical outcomes of acute myeloid leukemia (AML) in elderly patients still remain unsatisfactory and the optimal treatment has yet to be clearly established. This report describes the results of a retrospective study of clinical outcomes and prognostic factors of AML in patients aged 75 years and older. In addition, we aimed to elucidate the situation of patients with AML accompanied by dementia, which has been largely ignored in previous studies. METHODS The subjects consisted of 31 patients with untreated AML (including previous myelodysplastic syndrome: AML/MDS). All patients underwent chemotherapy, with 25 undergoing conventional therapy and six undergoing low-intensity therapy. RESULTS Complete remission was obtained in 16 of the 31 cases (51.6%), with a 3-year survival rate of 11.5%. However, in seven cases, Alzheimer's disease (AD) was observed. Although we were able to perform induction therapy in each of these cases, consolidation therapy was difficult in cases of moderate AD. CONCLUSION The results of this study suggest that even very elderly patients can benefit from chemotherapy. However, it is thought that the treatment selection for cases which are complicated by moderate to severe dementia should be determined carefully while considering the patient's quality of life.
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Affiliation(s)
- Shine Abe
- Department of Geriatric Medicine, Hachioji Medical Center, Tokyo, Japan.
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23
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Klepin HD, Danhauer SC, Tooze JA, Stott K, Daley K, Vishnevsky T, Powell BL, Mihalko SL. Exercise for older adult inpatients with acute myelogenous leukemia: A pilot study. J Geriatr Oncol 2011; 2:11-17. [PMID: 23843929 DOI: 10.1016/j.jgo.2010.10.004] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Acute myelogenous leukemia (AML) largely affects older adults. Few interventions have sought to improve functional status and health-related quality of life (HRQL) during treatment. The objective of this study is to examine the feasibility of an exercise intervention among older adults with AML undergoing induction chemotherapy. MATERIALS AND METHODS Pilot study of adults ≥50 years of age hospitalized for AML chemotherapy. The four week exercise intervention included stretching, walking, and strength exercises. Feasibility measures included recruitment, retention, number of exercise sessions completed, and barriers to participation. Physical function, HRQL, depression, and distress were assessed at baseline (week 1), upon completion of intervention (week 5), and during follow-up (weeks 9-13). Exploratory analyses used repeated measures ANCOVA to model changes over time. RESULTS Among 55 eligible inpatients, 24 enrolled (43.6%). Mean age was 65.1 years (SD 7.8). 87.5% of participants completed baseline measures; 70.8% attended ≥1 exercise sessions, and 50.0% completed post-intervention assessment. Among baseline characteristics, only higher physical performance was associated with greater number of exercise sessions attended (p=0.001). Post intervention, HRQL and depressive symptoms improved (p <0.05). CONCLUSIONS Recruitment to an exercise intervention was feasible. Exercise shows promise to maintain physical function and enhance HRQL. Strategies to enhance adherence to exercise are needed to maximize benefit.
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Affiliation(s)
- Heidi D Klepin
- Comprehensive Cancer Center of Wake Forest University, Department of Internal Medicine, Section on Hematology and Oncology, Winston-Salem, NC
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24
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25
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Breccia M, Frustaci AM, Cannella L, Stefanizzi C, Latagliata R, Cartoni C, Diverio D, Guarini A, Nanni M, Rago A, Cimino G, Alimena G. Comorbidities and FLT3-ITD abnormalities as independent prognostic indicators of survival in elderly acute myeloid leukaemia patients. Hematol Oncol 2009; 27:148-53. [PMID: 19274612 DOI: 10.1002/hon.889] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Elderly acute myeloid leukaemia (AML) patients have a dismal prognosis due to biological features of disease in itself and to presence of comorbidities. Aim of this study was to evaluate the prognostic impact of comorbidity prognostic score systems applied in our population of patients. as well as other clinical-biological features. We retrospectively considered the outcome of 120 patients aged >65 years diagnosed as having AML between January 2001 and December 2005. Comorbidities were evaluated by using Charlson comorbidity index (CCI), Hematopoietic cell transplantation comorbidity index (HCTCI) and a score proposed by Dombret et al. in 2007. Median patient age was 67 years. Forty-six patients were treated with intensive chemotherapy and 23 reached a complete remission. Seventy-four patients received only supportive therapies or low-dose chemotherapy. Multivariate analysis showed the effects of leukocytosis (p = 0.0013), antecedent Myelodysplastic syndrome (MDS) (p = 0.011), FLT3 abnormalities (p = 0.032), CCI (p = 0.0037) and Dombret et al. score (p = 0.045) as independent prognostic parameters for survival. Based on these variables we were able to stratify patients in low and high risk, with different median overall survival: patients were considered as low risk if they had none or only one of the above mentioned adverse factors for survival, with a median overall survival of 447 days. Patients with two or more adverse factors were categorized as high risk: this subgroup had a median overall survival of 227 days (p = 0.001). Comorbidities are independent factors that influence survival. Application of CCI and Dombret score may help to better identify patients at diagnosis who can benefit from intensive chemotherapy.
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Affiliation(s)
- Massimo Breccia
- Department of Cellular Biotechnology and Hematology, University La Sapienza, 00161 Rome, Italy.
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26
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Prébet T, Boissel N, Reutenauer S, Thomas X, Delaunay J, Cahn JY, Pigneux A, Quesnel B, Witz F, Thépot S, Ugo V, Terre C, Recher C, Tavernier E, Hunault M, Esterni B, Castaigne S, Guilhot F, Dombret H, Vey N. Acute myeloid leukemia with translocation (8;21) or inversion (16) in elderly patients treated with conventional chemotherapy: a collaborative study of the French CBF-AML intergroup. J Clin Oncol 2009; 27:4747-53. [PMID: 19720919 DOI: 10.1200/jco.2008.21.0674] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Acute myeloid leukemia (AML) with translocation (t) (8;21) or inversion (inv) (16) is associated with a favorable prognosis when treated with intensive chemotherapy. In elderly patients, these AML types are rare, and intensive treatments are much less tolerated. We conducted a retrospective study to evaluate the characteristics and outcome of AML with t(8;21) or inv(16) in the elderly. PATIENTS AND METHODS Patients with t(8;21) or inv(16) AML who were age 60 years or older and who received at least one course of induction chemotherapy were included. Postremission therapy consisted of low-dose maintenance chemotherapy (n = 72) or intensive consolidation (n = 56). RESULTS A total of 147 patients were analyzed. The median age was 67 years. Sixty patients had t(8;21), and 87 patients had inv(16). A total of 129 patients achieved complete response (CR) after one or two induction courses (ie, 88% CR rate), and 15 patients (10%) died early (ie, during the 8 weeks after induction). During a median follow-up of 48 months, the 5-year probabilities of overall survival (OS) and leukemia-free survival (LFS) were 31% and 27%, respectively. Multivariate analysis showed a negative impact of high WBC, impaired performance status, and deletion (9q) on OS and LFS. Administration of intensive consolidation was associated with better LFS only in patients with t(8;21). In addition, the need for critical care during induction independently predicted lower LFS. CONCLUSION Because of a high CR rate, induction chemotherapy should be considered systematically for elderly patients who have AML with t(8;21) or inv(16). The high risk of relapse suggests that alternative strategies of postremission therapy are warranted.
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Wang J, Lü S, Yang J, Song X, Chen L, Huang C, Hou J, Zhang W. A homoharringtonine-based induction regimen for the treatment of elderly patients with acute myeloid leukemia: a single center experience from China. J Hematol Oncol 2009; 2:32. [PMID: 19642997 PMCID: PMC2731035 DOI: 10.1186/1756-8722-2-32] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2009] [Accepted: 07/30/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND AND PURPOSE The response to remission induction in elderly patients with acute myeloid leukemia (AML) remains poor. The purpose of this paper is to evaluate the efficacy and toxicity of a plant alkaloid, homoharringtonine, in combination with cytarabine as an induction therapy for AML in elderly patients (> or =60 years). RESULTS Twenty-three patients were treated with the HA regimen consisting of homoharringtonine (2 mg/m2/day for 7 days) and cytarabine (Ara-C, 100 mg/m2/day for 7 days). The overall response rate was 56.5% with complete remission (CR) rate of 39.1% and partial remission of 17.4%. There was no early death in this cohort of patients. The estimated median overall survival (OS) time of all patients was (12.0 +/- 3.0) months. The estimated OS time of the CR patients was 15 months. The estimated one-year OS rate of all patients treated with HA protocol was (49.3 +/- 13.5) %. The estimated one-year OS rate of the CR patients was (62.5 +/- 17.1) %. CONCLUSION HA is a suitable induction regimen for elderly patients with AML, with relatively low toxicity and reasonable response rate.
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Affiliation(s)
- Jianmin Wang
- Department of Hematology, Changhai Hospital, Second Military Medical University, Shanghai, PR China.
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28
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Mori M, Ohta M, Miyata A, Higashihara M, Oshimi K, Kimura H, Yagasaki F, Sunami K. Treatment of acute myeloid leukemia patients aged more than 75 years: Results of the E-AML-01 trial of the Japanese Elderly Leukemia and Lymphoma Study Group (JELLSG). Leuk Lymphoma 2009; 47:2062-9. [PMID: 17071477 DOI: 10.1080/10428190600733317] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The feasibility and effects of combination chemotherapy for very elderly patients with acute myeloid leukemia was examined in 65 patients (including previous myelodysplastic syndrome) aged 76 years or morewith a performance status of 0 - 3. Induction chemotherapy was performed with 30 mg/m2 daunorubicin on days 1 - 3, 150 mg/m2 behenoyl cytosine arabinoside on days 1 - 7, and 70 mg/m2 6-mercaptopurine with 300 mg allopurinol taken orally on days 1 - 7 (BHAC-DM). The complete remission (CR) rate was 38.5%, whereas overall survival at 2 and 5 years was 22.0% and 4.7%, respectively. Two- and 5-year survival of CR patients was 41.8% and 11.2%, respectively. The relapse rate of the 25 CR patients was 64.0% and disease-free survival at 2 and 5 years was 21.0% and 11.2%, respectively. The therapy-related mortality rate at induction was 13.8%. BHAC-DM is feasible and effective for selected very elderly acute myeloid leukemia patients.
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Affiliation(s)
- Mayumi Mori
- Division of Hematology, Tokyo Metropolitan Geriatric Hospital, Sakaecho, Tokyo, Japan.
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29
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Ferrara F, Palmieri S, Celentano M, De Simone M, Pollio F, D'Amico MR, Copia C, Mele G. Feasibility of autologous peripheral blood stem cell transplantation in elderly patients with acute myeloid leukemia. Leuk Lymphoma 2009; 47:1593-8. [PMID: 16966271 DOI: 10.1080/10428190600624730] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Most studies showing that autologous stem cell transplantation (ASCT) is feasible in older patients with acute myeloid leukemia (AML) referred to highly selected patients considered as eligible after complete remission (CR) achievement and bone marrow or peripheral blood stem cell (PBSC) collection. This study evaluated the feasibility of ASCT from 155 consecutive AML patients aged over 60 years (median age 72 years, range 61 - 94) programmed to receive ASCT by using PBSCs after CR achievement. Overall, 90 out of 155 patients (58%) were judged as eligible for aggressive chemotherapy and 45 (50%) achieved CR. Among these, 36 (80%) received consolidation and 32 (89% of consolidated) were monitored for PBSC mobilization. A successful collection was registered in 25/32 patients (78% of monitored). Finally, 20 patients received ASCT. Reasons for not autografting five mobilizing patients included relapse pre-ASCT, toxicity, and refusal. Median survival was 4 months for the whole patient population and 19 months for patients actually autografted. Overall, 20 out of 90 patients accrued into intensive chemotherapy (22%) and 20 out of the entire patient population (13%) underwent ASCT. It is concluded that APBSCT can result in an improvement of therapeutic results in AML of the elderly, but it is feasible in a minority of selected patients.
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Affiliation(s)
- Felicetto Ferrara
- Division of Haematology and Stem cell Transplantation Unit, Cardarelli Hospital, Naples, Italy.
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30
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A randomized phase 3 study of tipifarnib compared with best supportive care, including hydroxyurea, in the treatment of newly diagnosed acute myeloid leukemia in patients 70 years or older. Blood 2009; 114:1166-73. [PMID: 19470696 DOI: 10.1182/blood-2009-01-198093] [Citation(s) in RCA: 100] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
This phase 3, multicenter, open-label study evaluated the efficacy and safety of tipifarnib compared with best supportive care (BSC), including hydroxyurea, as first-line therapy in elderly patients (>or=70 years) with newly diagnosed, de novo, or secondary acute myeloid leukemia. A total of 457 patients were enrolled with 24% 80 years of age or older. Tipifarnib 600 mg orally twice a day was administered for the first 21 consecutive days, in 28-day cycles. The primary endpoint was overall survival. The median survival was 107 days for the tipifarnib arm and 109 days for the BSC arm. The hazard ratio (tipifarnib vs BSC) for overall survival was 1.02 (P value by stratified log-rank test, .843). The complete response rate for tipifarnib in this study (8%) was lower than that observed previously, but with a similar median duration of 8 months. The most frequent grade 3 or 4 adverse events were cytopenias in both arms, slightly more infections (39% vs 33%), and febrile neutropenia (16% vs 10%) seen in the tipifarnib arm. The results of this randomized study showed that tipifarnib treatment did not result in an increased survival compared with BSC, including hydroxyurea. This trial was registered at www.clinicaltrials.gov as #NCT00093990.
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Abstract
The incidence of acute myelogenous leukemia (AML) increases with age. Older AML patients, generally defined by age > or = 60 years, have worse treatment outcomes than younger patients. While selected older patients can benefit from standard therapies, as a group they experience greater treatment-related toxicity, lower remission rates, shorter disease-free survival times, and shorter overall survival times. Outcome disparity is in part explained by age-related biologic features. Older patients are more likely to present with unfavorable cytogenetic abnormalities, multidrug resistance phenotypes, and secondary AML. However, even older adults with favorable tumor biology have a worse prognosis than younger patients. Patient-specific factors, including impaired physical function and comorbidity, independently predict greater treatment toxicity and shorter survival. Improving patient assessment strategies is critical to identify those patients who are most likely to benefit from induction and postremission therapies. In addition, continued efforts to identify more effective and tolerable induction and postremission strategies are needed for this population. Investigations of hypomethylating agents and signal transduction inhibitors hold promise for the treatment of AML patients. Steady advances in the field of hematopoietic transplantation, including use of reduced intensity transplants, may result in additional curative options available to selected older adults. Finally, improved supportive care strategies are needed to maximize treatment outcomes.
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Affiliation(s)
- Heidi D Klepin
- Wake Forest University Comprehensive Cancer Center, Winston-Salem, NC 27157, USA.
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32
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Kwon JH, Kim JW, Park JH, Koh Y, Kim JH, Bang SM, Song J, Lee JS. Long-term Complete Remission in a 71-year-old Patient with AML-M7 after Low-dose Cytarabine Induction and Intermediate-dose Cytarabine Consolidation Treatment. THE KOREAN JOURNAL OF HEMATOLOGY 2009. [DOI: 10.5045/kjh.2009.44.4.244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Ji Hyun Kwon
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Ji Won Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jin Hyun Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Youngil Koh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jee Hyun Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Su Mi Bang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Junghan Song
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jong-Seok Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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33
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Age and acute myeloid leukemia: real world data on decision to treat and outcomes from the Swedish Acute Leukemia Registry. Blood 2008; 113:4179-87. [PMID: 19008455 DOI: 10.1182/blood-2008-07-172007] [Citation(s) in RCA: 693] [Impact Index Per Article: 43.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Acute myeloid leukemia (AML) is most common in the elderly, and most elderly are thought to be unfit for intensive treatment because of the risk of fatal toxicity. The Swedish Acute Leukemia Registry covers 98% of all patients with AML (nonacute promyelocytic leukemia) diagnosed in 1997 to 2005 (n = 2767), with a median follow-up of 5 years, and reports eligibility for intensive therapy, performance status (PS), complete remission rates, and survival. Outcomes were strongly age and PS dependent. Early death rates were always lower with intensive therapy than with palliation only. Long-term survivors were found among elderly given intensive treatment despite poor initial PS. Total survival of elderly AML patients was better in the geographic regions where most of them were given standard intensive therapy. This analysis provides unique real world data from a large, complete, and unselected AML population, both treated and untreated, and gives background to treatment decisions for the elderly. Standard intensive treatment improves early death rates and long-term survival compared with palliation. Most AML patients up to 80 years of age should be considered fit for intensive therapy, and new therapies must be compared with standard induction.
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34
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Ferrara F, Palmieri S, Leoni F. Clinically useful prognostic factors in acute myeloid leukemia. Crit Rev Oncol Hematol 2008; 66:181-93. [DOI: 10.1016/j.critrevonc.2007.09.008] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2006] [Revised: 08/31/2007] [Accepted: 09/28/2007] [Indexed: 11/30/2022] Open
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35
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Hussein K, Jahagirdar B, Gupta P, Burns L, Larsen K, Weisdorf D. Day 14 bone marrow biopsy in predicting complete remission and survival in acute myeloid leukemia. Am J Hematol 2008; 83:446-50. [PMID: 18247382 DOI: 10.1002/ajh.21133] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
We retrospectively analyzed 194 previously untreated acute myeloid leukemia (AML) patients to evaluate the role of Day 14 bone marrow (BM) biopsy in predicting complete remission (CR). Sixty-seven percent received induction therapy. Achieving Day 14 BM < or =5% blasts was strongly predictive of Day 28 CR with 90% sensitivity and 79% positive predictive value; but weak 43% specificity and 29% negative predictive value. Day 14 BM biopsy is highly sensitive in predicting CR, but did not predict overall survival. Some patients with BM blast >5% at Day 14 may still achieve a Day 28 CR, and not necessarily need reinduction therapy though high risk cytochemical or cytogenetic phenotype predicts a need for retreatment.
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Affiliation(s)
- Kebede Hussein
- Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota 55455, USA
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36
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Craig CM, Schiller GJ. Acute myeloid leukemia in the elderly: conventional and novel treatment approaches. Blood Rev 2008; 22:221-34. [PMID: 18433953 DOI: 10.1016/j.blre.2008.03.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Acute Myeloid Leukemia (AML) is a disorder affecting primarily elderly individuals and poses significant treatment challenges. Much has been learned about the underlying immunologic, cytogenetic and molecular features of AML in recent years, and many features have been identified that portend a poor prognosis for elderly patients with newly diagnosed AML. Despite this, treatment outcomes for elderly patients remain poor for both newly diagnosed and relapsed disease. While conventional treatment approaches may be appropriate for some elderly patients, the vast majority do not tolerate intensive chemotherapy well, thus alternative strategies have been investigated. Here we review both conventional and novel treatment approaches for elderly patients with AML, including agents in early clinical trials. Treatment options have been divided into several discussions, including conventional treatments, agents complementary to conventional treatments, alternatives to conventional induction therapies, post-induction treatment, and relapsed disease. Current and developing research focuses upon identifying subgroups of patients that benefit more from specific chemotherapeutic agents. Treating elderly patients with AML requires an organized, multidisciplinary approach, taking into account individual patient characteristics, preferences, and comorbidities when formulating treatment plans.
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Affiliation(s)
- Chad M Craig
- Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles, CA, United States.
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37
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Kessler T, Mohr M, Müller-Tidow C, Krug U, Brunnberg U, Mohr B, Schliemann C, Sauerland C, Serve H, Büchner T, Berdel WE, Mesters RM. Amsacrine containing induction therapy in elderly AML patients: Comparison to standard induction regimens in a matched-pair analysis. Leuk Res 2008; 32:491-4. [PMID: 17675230 DOI: 10.1016/j.leukres.2007.06.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2007] [Revised: 06/24/2007] [Accepted: 06/25/2007] [Indexed: 10/23/2022]
Abstract
Many elderly patients with newly diagnosed acute myeloid leukemia (AML) present with cardiac comorbidity precluding the use of anthracycline containing chemotherapy regimens. Amsacrine, a topoisomerase II inhibitor, has been proposed as possible alternative to anthracyclines. Here, we report about the combination of amsacrine (210 mg/m(2)), in replacement for daunorubicin (DNR), with standard dose cytarabine and thioguanine (TAA) to elderly patients (>or=60 years of age) with impaired cardiac function. The outcome of 16 patients with a median age of 66 years treated between 1997 and 2003 was compared with standard treatment regimens of the AMLCG study group in a matched-pair analysis. There were no statistically significant differences in response rate, relapse free survival or overall survival between TAA treated patients or standard therapy. In conclusion, replacing anthracyclines with amsacrine for induction therapy of AML patients with significant cardiac comorbidities represents a treatment option without compromising the potential curability of the disease.
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Affiliation(s)
- T Kessler
- Department of Medicine/Hematology and Oncology, Universityclinic of Münster, Albert-Schweitzer-Str. 33, D-48129 Münster, Germany
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38
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Etienne A, Esterni B, Charbonnier A, Mozziconacci MJ, Arnoulet C, Coso D, Puig B, Gastaut JA, Maraninchi D, Vey N. Comorbidity is an independent predictor of complete remission in elderly patients receiving induction chemotherapy for acute myeloid leukemia. Cancer 2007; 109:1376-83. [PMID: 17326052 DOI: 10.1002/cncr.22537] [Citation(s) in RCA: 128] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND : Elderly patients with acute myeloid leukemia (AML) have a poor prognosis, which is explained by the disease itself and by host-related factors. The objective of this study was to determine the prognostic role of comorbidities in this population. METHODS : For this single-center, retrospective study, the authors analyzed the outcome of 133 patients aged >/=70 years who received induction chemotherapy for nonpromyelocytic AML between 1995 and 2004. Comorbidities were evaluated by using an adapted form of the Charlson comorbidity index (CCI). RESULTS : The median patient age was 73 years. The CCI score was 0 for 83 patients (68%), 1 for 16 patients (13%), and >1 for 23 patients (19%). The complete remission (CR) rate was 56%, and the median overall survival was 9 months. In multivariate analysis, 4 adverse prognostic factors for CR were identified: unfavorable karyotype, leukocytosis >/=30 g/L, CD34 expression on leukemic cells, and CCI >1. A score could be generated to allow the stratification of patients into low-, intermediate-, and high-risk groups with CR rates of 87%, 63%, and 37%, respectively. The risk of early mortality and the probability of survival also were different in the 3 risk groups (P = .02 and P = .01, respectively). CONCLUSIONS : The results from this study indicated that associated comorbidities are independent factors that may influence achievement of CR in elderly patients with AML. Such a scoring system may be useful in the prognostic staging systems that are used to identify patients with AML who can benefit from induction chemotherapy.
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Affiliation(s)
- Anne Etienne
- Department of Hematology, Paoli-Calmettes Institute, Marseille, France
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39
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Abstract
Improvements in survival in adult acute myeloid leukaemia (AML) have yet to be gleaned from either refinements in the understanding of the pathophysiology of the disease or from the expanding pool of targeted therapies. Outcomes have remained particularly dismal in older patients. Ongoing and planned trials will assess the effects of drugs targeting biological pathways whose clinical importance may vary as a function of the unique genotype and phenotype of each case of AML. The success of these ventures will ultimately require well-designed clinical trials in subsets of patients with risk being dependent not only on age and cytogenetics, but on additional, increasingly quantifiable biological variables. Inhibitors of fms-like tyrosine kinase-3, farnesyl transferase, apoptotic and angiogenic pathways are being studied alone and in combination with chemotherapy. Biological therapies, including monoclonal antibodies, peptide vaccines and interleukin-2, are undergoing evaluation. The role of autologous as well as allogeneic myeloablative and reduced-intensity transplantation continues to be defined. Several potentially useful new cytotoxic agents are being introduced. Critically important to advancing the field in light of such an increasing number of choices is a reassessment of traditional phase II trial designs so that more efficient evaluation of new therapies may take place, even as well-designed phase III trials continue to be performed.
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Affiliation(s)
- Jonathan E Kolitz
- Leukemia Service, Monter Cancer Center, North Shore University Hospital, New York University School of Medicine, Lake Success, NY, USA.
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40
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Brosens RP, Oomen JL, Glas AS, van Bochove A, Cuesta MA, Engel AF. POSSUM predicts decreased overall survival in curative resection for colorectal cancer. Dis Colon Rectum 2006; 49:825-32. [PMID: 16550320 DOI: 10.1007/s10350-005-0284-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Poor condition at operation determined by the physiologic POSSUM score is related to postoperative mortality and morbidity of colorectal cancer surgery. This study was designed to analyze the relationship between condition of patients with colorectal cancer at operation and long-term overall survival. METHODS A total of 542 patients survived a radical resection for Stages I, II, or III colorectal cancer. Physiologic POSSUM score at surgery, exclusive of age, was calculated for all patients. Mean physiologic POSSUM score was used as cutoff point to determine low-risk and high-risk group patients. A Cox proportional hazard analysis was performed to study the effect of low-risk and high-risk group on overall survival and to identify independent risk factors. RESULTS Five-year overall survival was significantly higher in low-risk group patients than in high-risk group patients (low-risk group 66.6 percent vs. high-risk group 48.5 percent; P < 0.001). Differences in overall survival also were found when patients in Stages I, II, and III were analyzed separately. Risk factors for overall survival were advanced stage of disease, poor tumor differentiation, mucinous adenocarcinoma, older than age 70 years, and poor condition of the patient at time of operation. CONCLUSIONS Poor condition at operation, as determined by physiologic POSSUM score, is a risk indicator for long-term overall survival in colorectal cancer patients.
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Affiliation(s)
- Rebecca P Brosens
- Department of Surgery, Zaans Medical Centre, Zaandam, The Netherlands.
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41
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Abstracts from the Chemotherapy Foundation Symposium XXIV: Innovative Cancer Therapy for Tomorrow, November 8-11, 2006, New York, New York, USA. Cancer Invest 2006; 24 Suppl 1:1-59. [PMID: 16546846 DOI: 10.1080/07357900600560838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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42
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Faderl S, Verstovsek S, Cortes J, Ravandi F, Beran M, Garcia-Manero G, Ferrajoli A, Estrov Z, O'Brien S, Koller C, Giles FJ, Wierda W, Kwari M, Kantarjian HM. Clofarabine and cytarabine combination as induction therapy for acute myeloid leukemia (AML) in patients 50 years of age or older. Blood 2006; 108:45-51. [PMID: 16403905 DOI: 10.1182/blood-2005-08-3294] [Citation(s) in RCA: 115] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Outcome of patients with acute myeloid leukemia (AML) who are older than 60 years of age remains unsatisfactory, with low remission rates and poor overall survival. We have previously established the activity of clofarabine plus cytarabine in AML relapse. We have now conducted a phase 2 study of clofarabine plus cytarabine in patients aged 50 years or older with previously untreated AML. Clofarabine was given at 40 mg/m2 as a 1-hour intravenous infusion for 5 days (days 2 to 6) followed 4 hours later by cytarabine at 1 g/m2/d as a 2-hour intravenous infusion for 5 days (days 1 to 5). Of 60 patients, 29 (48%) had secondary AML, 30 (50%) had abnormal karyotypes (monosomy 5 and/or 7 in 15 [25%]), and 11 (21%) showed FLT3 abnormalities. The overall response (OR) rate was 60% (52% CR, 8% CRp). Four patients (7%) died during induction. Adverse events were mainly grade 2 or lower and included diarrhea, nausea, vomiting, mucositis, skin reactions, liver test abnormalities, and infusion-related facial flushing and headaches. Myelosuppression was common. Clofarabine plus cytarabine has activity in adult AML, achieving a good CR rate. However, survival does not appear to be improved compared with other regimens. Modifications of this combination in AML therapy of older patients warrant further evaluation.
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Affiliation(s)
- Stefan Faderl
- Department of Leukemia, University of Texas M. D. Anderson Cancer Center, Houston, TX 77230-1402, USA.
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Amadori S, Suciu S, Stasi R, Willemze R, Mandelli F, Selleslag D, Denzlinger C, Muus P, Stauder R, Berneman Z, Pruijt J, Nobile F, Cassibba V, Marie JP, Beeldens F, Baila L, Vignetti M, de Witte T. Gemtuzumab ozogamicin (Mylotarg®) as single-agent treatment for frail patients 61 years of age and older with acute myeloid leukemia: final results of AML-15B, a phase 2 study of the European Organisation for Research and Treatment of Cancer and Gruppo Italiano Malattie Ematologiche dell'Adulto Leukemia Groups. Leukemia 2005; 19:1768-73. [PMID: 16079891 DOI: 10.1038/sj.leu.2403901] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The therapeutic activity and toxicity profile of gemtuzumab ozogamicin were assessed in 40 patients >60 years of age with acute myeloid leukemia (AML) who were not considered eligible for conventional chemotherapy because of advanced age or poor performance status. The drug was administered at the dose of 9 mg/m2 as a single 2-h i.v. infusion on days 1 and 15. Patients who achieved a complete remission (CR/CRp) were to receive a consolidation with two additional injections of the immunotoxin at the same dose. The overall CR/CRp rate was 17% (95% CI, 8-32%). The CR/CRp rate in patients 61-75 years old was 33% (6/18), and 5% (1/22) in patients older than 75 years. Induction death occurred in seven patients (17%), all aged above 75 years. Overall survival was significantly longer in patients aged 61-75 years than in older individuals (P=0.05), and in CD33+ cases than in CD33- cases (P=0.05). We conclude that the dose/schedule of gemtuzumab ozogamicin used in this trial is too toxic in the age group over 75 years. For these patients, additional studies with reduced doses of the immunotoxin are warranted.
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Affiliation(s)
- S Amadori
- Department of Hematology, University Tor Vergata, Rome, Italy.
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Abstract
Standard induction chemotherapy, depending on patient tolerability, is at present the treatment of choice in patients with acute myeloid leukaemia (AML) under the age of 75 years. Since AML is a disease primarily of the elderly, a large proportion of patients do not receive this therapy; therefore, novel treatment modalities are warranted. In addition, younger patients with poor-risk cytogenetics often have unsatisfactory results with conventional chemotherapy, so novel treatment options would represent a significant advancement in the management of this disease. The encouraging results of low-dose schedules of demethylating agents in myelodysplastic syndromes (MDS) have stimulated interest in the use of these agents in patients with AML. The DNA methylator phenotype of MDS and AML offers a biological rationale for treating these patients with doses of demethylating agents which act by reverting the hypermethylated state to an unmethylated state rather than by "classic" cytotoxicity mechanisms typically associated with higher doses. However, many issues surrounding this therapy need to be unravelled, including the role of different target genes that may become demethylated, and the potential use of combination therapy of hypomethylating agents with other drugs. This review will provide a summary of epigenetic processes in AML and the role of the demethylating agent 5-aza-2'-deoxycytidine (decitabine; Dacogen, MGI Pharma, Inc, Bloomington, MN).
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Affiliation(s)
- Michael Lübbert
- Department of Medicine, Division of Hematology/Oncology, University of Freiburg Medical Center, Freiburg, Germany.
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Chen CC, Yang CF, Yang MH, Lee KD, Kwang WK, You JY, Yu YB, Ho CH, Tzeng CH, Chau WK, Hsu HC, Gau JP. Pretreatment prognostic factors and treatment outcome in elderly patients with de novo acute myeloid leukemia. Ann Oncol 2005; 16:1366-73. [PMID: 15956039 DOI: 10.1093/annonc/mdi259] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Elderly patients with acute myeloid leukemia (AML) generally have an unfavorable clinical course and are under-represented in clinical trials. The aim of this study was to analyze the prognosis and treatment outcome of elderly AML patients. PATIENTS AND METHODS We studied 205 AML patients aged 65 years or older at our hospital. Prior to study initiation, we designated 13 variables to be analyzed for their impact on complete remission (CR) rate and overall survival (OS). RESULTS Induction regimen (standard chemotherapy) and good performance status (PS) (Eastern Cooperative Oncology Group PS 0-1) independently influenced the achievement of CR. Multivariate analysis also determined five poor prognostic factors for OS: poor PS (score 2-4), presence of comorbidities, elevated serum lactate dehydrogenase level (> or =2x upper normal limit), extreme leukocytosis (> or =100 x 10(9)/l) and marked thrombocytopenia (< or =20 x 10(9)/l). Age was not an independent contributing factor in terms of either CR attainment or OS duration. Low-risk patients, who possessed one or less non-leukocytosis poor prognostic factor, had significantly longer disease-free survival and OS than their high-risk counterparts. CONCLUSIONS Elderly AML patients should be risk-stratified at diagnosis. Anthracycline-based induction chemotherapy would be the best therapeutic option for such patients.
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Affiliation(s)
- C-C Chen
- Division of Hematology Oncology, Department of Medicine, Chang Gung Memorial Hospital, Taipei, Taiwan
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